ASGE Esophagology: Tailoring Management from Testing to Treatment (Live and Virtual) | July 2022-Draganov

Draganov_Individualizing Management in Achalasia

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The management of achalasia can be individualized based on the specific needs of each patient. Current treatment options for achalasia include pneumatic dilation (PD), laparoscopic Heller myotomy (LHM), per-oral endoscopic myotomy (POEM), and botulinum toxin (Botox) injections. Botox injections are easy to administer but do not provide long-lasting relief and may require multiple treatments. PD is less invasive but may require serial treatments and can lead to long-term recurrent symptoms. LHM is a durable option but is more invasive and has a higher complication rate. POEM is a minimally invasive procedure with shorter recovery time and fewer complications compared to PD and LHM, but it may increase the risk of gastroesophageal reflux disease (GERD).<br /><br />Recent studies have compared the effectiveness of POEM with PD and LHM. A randomized controlled trial found that POEM had a higher treatment success rate compared to PD and resulted in fewer serious complications. Another multicenter study found that POEM had similar treatment success rates as LHM but had a higher incidence of reflux esophagitis.<br /><br />The approach to treatment should be individualized based on the patient's specific characteristics and needs. POEM may be the primary choice for most patients, particularly those with type III achalasia, a history of abdominal surgeries, and who are morbidly obese. LHM may be preferred for patients unwilling to take long-term proton pump inhibitors (PPIs), those with gastroparesis, and those who are morbidly obese. PD may be suitable for older patients, patients with recurrent symptoms after LHM or POEM, and those who are morbidly obese. Botox injections may be considered for patients with comorbidities, those unable to stop anticoagulation, advanced age, or pregnancy.<br /><br />It is important to note that GERD can occur after POEM, but most cases can be managed with lifestyle modifications and PPIs. Ongoing improvements in the POEM technique and the development of new management strategies, such as functional POEM (F-POEM) and transoral incisionless fundoplication (TIF), may help address GERD-related issues. While POEM is becoming the preferred first-line therapy for achalasia, LHM, PD, and Botox injections still have their place in the management of the condition.

Keywords

achalasia

management

pneumatic dilation

laparoscopic Heller myotomy

per-oral endoscopic myotomy

botulinum toxin injections

treatment options

GERD

treatment success rate

reflux esophagitis