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Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Oct 21, 2016; 22(39): 8670-8683
Published online Oct 21, 2016. doi: 10.3748/wjg.v22.i39.8670
Update on the endoscopic treatments for achalasia
Dushant S Uppal, Andrew Y Wang
Dushant S Uppal, Andrew Y Wang, Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA 22908, United States
Author contributions: Uppal DS and Wang AY contributed equally to this manuscript.
Conflict-of-interest statement: The authors have no conflicts of interest, financial or otherwise, to report with respect to this manuscript. Dr. Wang discloses that he has received research funding from Cook Medical on the topic of metal biliary stents.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Andrew Y Wang, MD, AGAF, FACG, FASGE, Associate Professor of Medicine, Section Chief of Interventional Endoscopy, Division of Gastroenterology and Hepatology, University of Virginia Health System, Box 800708, Charlottesville, VA 22908, United States. ayw7d@virginia.edu
Telephone: +1-434-9241653 Fax: +1-434-2447590
Received: March 28, 2016
Peer-review started: March 29, 2016
First decision: May 12, 2016
Revised: August 20, 2016
Accepted: September 14, 2016
Article in press: September 14, 2016
Published online: October 21, 2016
Processing time: 206 Days and 2.3 Hours
Abstract

Achalasia is the most common primary motility disorder of the esophagus and presents as dysphagia to solids and liquids. It is characterized by impaired deglutitive relaxation of the lower esophageal sphincter. High-resolution manometry allows for definitive diagnosis and classification of achalasia, with type II being the most responsive to therapy. Since no cure for achalasia exists, early diagnosis and treatment of the disease is critical to prevent end-stage disease. The central tenant of diagnosis is to first rule out mechanical obstruction due to stricture or malignancy, which is often accomplished by endoscopic and fluoroscopic examination. Therapeutic options include pneumatic dilation (PD), surgical myotomy, and endoscopic injection of botulinum toxin injection. Heller myotomy and PD are more efficacious than pharmacologic therapies and should be considered first-line treatment options. Per oral endoscopic myotomy (POEM) is a minimally-invasive endoscopic therapy that might be as effective as surgical myotomy when performed by a trained and experienced endoscopist, although long-term data are lacking. Overall, therapy should be individualized to each patient’s clinical situation and based upon his or her risk tolerance, operative candidacy, and life expectancy. In instances of therapeutic failure or symptom recurrence re-treatment is possible and can include PD or POEM of the wall opposite the site of prior myotomy. Patients undergoing therapy for achalasia require counseling, as the goal of therapy is to improve swallowing and prevent late manifestations of the disease rather than to restore normal swallowing, which is unfortunately impossible.

Keywords: Per oral endoscopic myotomy; Dilation; Achalasia; Treatment; Endoscopy; Myotomy; Per oral

Core tip: Achalasia can be classified into three subtypes based on high-resolution manometry, with type 2 being the most responsive to therapy. Since no cure for achalasia exists, early diagnosis and treatment of the disease are critical. Pre-treatment counseling is paramount, as the goal of therapy is to improve swallowing and prevent late manifestations of the disease, rather than to restore normal swallowing and function. Pneumatic dilation and surgical or endoscopic myotomy are efficacious and reasonable first-line treatment options in appropriate candidates. In instances of therapeutic failure or symptom recurrence, different treatment modalities might need to be applied.