Management of achalasia: surgery or pneumatic dilation

Abstract

Achalasia is an esophageal motility disorder of unknown cause, characterised by aperistalsis of the esophageal body and impaired lower esophageal sphincter relaxation. Patients present at all ages, primarily with dysphagia for solids/liquids and bland regurgitation. The diagnosis is suggested by barium esophagram or endoscopy and confirmed by esophageal manometry. Achalasia cannot be cured. Instead, our goal is to relieve symptoms, improve esophageal emptying and prevent the development of megaesophagus. The most successful therapies are pneumatic dilation and surgical myotomy. The advantages of pneumatic dilation include an outpatient procedure, minimal pain, return to work the next day, mild if any GERD, and can be performed in any age group and even during pregnancy. Pneumatic dilation does not hinder future myotomy, and all cost analyses find it less expensive than Heller myotomy. Laparoscopic myotomy with a partial fundoplication has the advantage of being a single procedure, dysphagia relief is longer at the cost of more troubling heartburn, and a myotomy may be more effective treatment in adolescents and younger adults, especially men. Over a two year horizon, the clinical success of pneumatic dilation and laparoscopic myotomy are comparable in a recent large European randomised trial. The prognosis for achalasia patients to return to near-normal swallowing and good quality of life are excellent, but few are "cured" with a single treatment and intermittent "touch up" procedures may be required.

Association Between Gastroesophageal Reflux Disease After Pneumatic Balloon Dilatation and Clinical Course in Patients With Achalasia

“…3,4 Achalasia is not curable, which leads to be a chronic condition. Currently pneumatic balloon dilatation (PD), surgical myotomy, per-oral endoscopic myotomy (POEM) and botulinum toxin injection have been performed as initial treatment for achalasia depending on patient's condition and center expertise.…”

“…Currently pneumatic balloon dilatation (PD), surgical myotomy, per-oral endoscopic myotomy (POEM) and botulinum toxin injection have been performed as initial treatment for achalasia depending on patient's condition and center expertise. [4][5][6][7] All these treatment options aimed at reducing the elevated pressure of LES. 1,[8][9][10] However, the LES hypertonicity returns over time and repeated interventions are needed.…”

Laparoscopic heller myotomy is equally efficient and safe in patients who had pre-myotomy endoscopic interventions when compared with those with no interventions

“…There are studies for balloon dilatation as a first line technique and show the same pattern as well. From a clinical point, this variation in response to treatment, low morbidity and mortality and possibility of equally safe surgery after endoscopic treatment forms the rationale for a trial of endoscopic treatment as a first line option for many gastroenterologists [4]. The outcome from laparoscopic Heller myotomy is shown to be durable beyond 1 year (86% vs 76%) with very low relapse rates when compared with balloon dilatation [9].…”

“…Currently treatment strategies offer symptomatic and functional relief through relaxation of LES barrier, there is also evidence of partial return of the peristaltic function of the esophagus after long term resolution of the outflow obstruction [3]. Endoscopic treatments like balloon dilatation and botulinum toxin injection can provide quick relief with low morbidity and mortality but repeated attempts may be needed to maintain quality of life [4]. Myotomy on the other hand, can be achieved either by minimally invasive surgery or per oral endoscopic myotomy (POEM).…”

Is Heller Myotomy Better than Balloon Dilation? A Meta-Analysis

“…The most serious complication is perforation, which occurred in about 1-3% of the cases [5,11], and 50% of those patients required surgical intervention [12]. Other complications following pneumatic dilation are usually minor (mucosal tear, fever, bleeding, chest pain) [32].…”