gastrointestinal disorders
Achalasia
Treatment of Achalasia
Pneumatic balloon dilation of the LES Surgical myotomy of the LES Peroral endoscopic myotomy Sometimes botulinum toxin injection No therapy restores peristalsis; treatment of achalasia is aimed at reducing the pressure at the LES. Pneumatic balloon dilation of the LES and surgical or peroral endoscopic myotomy appear similarly effective. In 2016, a randomized, controlled trial involving achalasia patients found that at 5-year follow-up pneumatic balloon dilation had comparable efficacy to laparoscopic Heller myotomy ( Treatment references ). A posthoc analysis of these data according to achalasia subtypes found better results with pneumatic balloon dilation for patients with type II achalasia (swallowing increases pressure in the entire esophagus) and better results with Heller myotomy for type III achalasia (spastic achalasia; swallowing often results in lumen-obliterating contractions). Both procedures produced similar outcomes in patients with type I achalasia (classic achalasia; swallowing results in no change in esophageal pressure) ( In patients who are not candidates for these treatment options, chemical denervation of cholinergic nerves in the distal esophagus by direct endoscopic injection of botulinum toxin type A into the LES may be tried. Clinical improvement occurs in 70 to 80% of patients; results may last 6 months to over 1 year. Drugs such as nitrates or calcium channel blockers have been used in the past but have not been shown to be effective. 1.Moonen A, Annese V, Belmans A, et al: Long-term results of the European achalasia trial: A multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy.Gut65(5):732–739, 2016. doi: 10.1136/gutjnl-2015-310602 2.Pandolfino JE, Kwiatek MA, Nealis T, et al: Achalasia: A new clinically relevant classification by high-resolution manometry.Gastroenterology135(5):1526–1533, 2008. doi: 10.1053/j.gastro.2008.07.022 3.Lynch KL, Pandolfino JE, Howden CW, et al: Major complications of pneumatic dilation and Heller myotomy for achalasia: Single-center experience and systematic review of the literature.Am J Gastroenterol107(12):1817–1825, 2012. doi: 10.1038/ajg.2012.332 4.Rentein DV, Fuchs K-H, Fockens P, et al: Peroral endoscopic myotomy for the treatment of achalasia: An international prospective multicenter study.Gastroenterology145(2):272–273, 2013. doi: 10.1053/j.gastro.2013.04.057 