Bridging the Gap between Advancements in the Evolution of Diagnosis and Treatment towards Better Outcomes in Achalasia

Abstract

Over the past few decades, there was an encouraging breakthrough in bridging the gap between advancements in the evolution of diagnosis and treatment towards a better outcome in achalasia. The purpose of this review is to provide updated knowledge on how the current evidence has bridged the gap between advancements in the evolution of diagnosis and treatment of esophageal achalasia. The advent of high-resolution manometry and standardization based on the Chicago classification has increased early recognition of the disease. These 3 clinical subtypes of achalasia can predict the outcomes of patients, and the introduction of POEM has revolutionized the choice of treatment. Previous evidence has shown that laparoscopic Heller myotomy (LHM) and anterior fundoplication were considered the most durable treatments for achalasia. Based on the current evidence, POEM has been evolving as a promising strategy and is effective against all 3 types of achalasia, but the efficacy of POEM is based on short- and medium-term outcome studies from a limited number of centers. Types I and II achalasia respond well to POEM, LHM, and PD, while most studies have shown that type III achalasia responds better to POEM than to LHM and PD. In general, among the 3 subtypes of achalasia, type II achalasia has the most favorable outcomes after medical or surgical therapies. The long-term efficacy of POEM is still unknown. The novel ENDOFLIP measures the changes in intraoperative esophagogastric junction dispensability, which enables a quantitative assessment of luminal patency and sphincter distension; however, this technology is in its infancy with little data to date supporting its intraoperative use. In the future, identifying immunomodulatory drugs and the advent of stem cell therapeutic treatments, including theoretically transplanting neuronal stem cells, may achieve a functional cure. In summary, it is important to identify the clinical subtype of achalasia to initiate target therapy for these patients.

Spectrum and Clinical Outcome of Motility Disorders on High-Resolution Esophageal Manometry: A Study From a Tertiary Center on Patients With Dysphagia in Pakistan

“…By creating a submucosal tunnel, endoscopic access to the mediastinum is established through the walls of the esophagus, rather than through skin incisions in the traditional laparoscopic method [ 14 ]. Despite having promising short-term results, long-term prospective studies are required for establishing safety and durability of the procedure in long term [ 22 ]. EndoFLIP can be used to measure the EGJ distensibility intraoperatively and is a useful tool in ensuring that adequate myotomy is performed.…”

“…EndoFLIP can be used to measure the EGJ distensibility intraoperatively and is a useful tool in ensuring that adequate myotomy is performed. This technique involves the use of a balloon electrode and functional imaging luminal probe for the measurement of the diameter of the esophagogastric junction [ 22 ]. Despite being a useful modality in predicting outcome of surgical procedures for achalasia, it is still a relatively newer procedure and not very widely used.…”

An update on endoscopic treatment for achalasia: From per oral endoscopic myotomy to endolumenal functional lumen imaging probe

“…Traditional endoscopic treatment of achalasia includes endoscopic local injection of botulinum toxin into the lower esophageal sphincter (LES) muscle, endoscopic balloon dilations. 1,2 Injection of botulinum toxin is safe and only may be associated with minor complications but the main drawback is the short duration of maintaining successful treatment which lasts only for 9 months or less. It is therefore recommended for elderly patients with concomitant comorbid disease who are at high risks to receive other treatment modalities.…”

“…3 In addition, although the incidence rate of perforation was approximately 0% to 2% but could be disaster if not properly handled. 1,2 In the past, surgery is always an encouraging treatment of choice because of the reported higher long-term results with myotomy of the LES and a concomitant antireflux procedure in minimally invasive laparoscopic Heller myotomy (LHM) to reduce postoperative reflux. 3,4 The utilization of per oral endoscopic myotomy (POEM) has changed the backdrop for the treatment of achalasia.…”

“…This is in contrast to LHM by most surgeons who generally choose a length of myotomy of 4-5 cm into the esophagus (shorter than the length dissected by POEM) and 2-3 cm into the stomach. 2 One other advantage of POEM is that patients with advanced disease and severe fibrosis can also be successfully performed by this endoscopic skill. In this circumstance, it could be harder for the surgeons to extend the length of the myotomy to the thoracic esophagus by LHM.…”