Achalasia: A review of Western and Iranian experiences

Abstract

Achalasia is a primary motor disorder of the eso phagus, in which esophageal emptying is impaired. Diagnosis of achalasia is based on clinical findings. The diagnosis is confirmed by radiographic, endoscopic, and manometric evaluations. Several treatments for achalasia have been introduced. We searched the PubMed Database for original articles and meta analyses about achalasia to summarize the current knowledge regarding this disease, with particular focus on different procedures that are used for treatment of achalasia. We also report the Iranian experience of treatment of this disease, since it could be considered as a model for mediumresource countries. Myotomy, particularly laparoscopic myotomy with fundoplication, i s t h e m o s t e ffe c t i ve t re a t m e n t fo r a c h a l a s i a . Compared to other treatments, however, the initial cost of myotomy is usually higher and the recovery period is longer. When performing myotomy is not indicated or not possible, graded pneumatic dilation with slow rate of balloon inflation seems to be an effective and safe initial alternative. Injection of botulinum toxin into the lower esophageal sphincter before pneumatic dilation may increase remission rates. However, this needs to be confirmed in further studies. Due to lack of adequate information regarding the role of expandable stents in the treatment of achalasia, insertion of stents does not currently seem to be a recommended treatment. In summary, laparoscopic myotomy can be considered as the procedure of choice for treatment of achalasia. Graded pneumatic dilation is an effective alternative when the performance of myotomy is not possible for any reason.

High-resolution manometry is comparable to timed barium esophagogram for assessing response to pneumatic dilation in patients with achalasia

“…These patients may be picked up early by objective assessments by HRM and TBE. This early detection has clinical significance, as these patients can be prognosticated and planned for further sessions of PD or alternative treatment such as Heller's myotomy [29]. In our study, both HRM and TBE performed well after 1 month of PD and had similar concordance rate of response estimation with clinical evaluation (symptom scoring).…”

Pneumatic Dilation for Achalasia Cardia: Reduction in Lower Esophageal Sphincter Pressure in Assessing Response and Factors Associated With Recurrence During Long‐term Follow Up

“…Previously, repeated PD with increasing size of balloon starting at 30 mm was recommended as the treatment strategy for achalasia 31,32 . Although most authorities believed that failure of response to three sessions of PD should be considered as treatment failure and therefore should be an indication for alternative treatment such as Heller's myotomy, 33 this was based more on opinion than on appropriate scientific evidence. In fact, whether laparoscopic Heller's myotomy should be considered as the initial option for achalasia is being debated 6,9,19 .…”

Reasons and Prevalence of Reoperations After Esophagomyotomy for Achalasia

“…3,[5][6][7][8] Surgical division of the circular muscle at the cardia or cardiomyotomy was proposed in 1901 by Gottstein, and was first performed in 1913 by Heller using anterior and posterior esophageal incisions. It has the lowest rate of recurrence when compared with pharmacological therapy, botulinum toxin injection, and pneumatic dilation.…”