Achalasia: Treatment options revisited

The aim of all current forms of treatment of achalasia is to enable the pat ient to eat without disabling symptoms such as dysphagia, regurgitation, co ughing or choking. Historically, this has been accomplished by mechanical d isruption of the lower esophageal sphincter fibres, either by means of pneu matic dilation (PD) or by open surgical myotomy. The addition of laparoscop ic myotomy and botulinum toxin (BTX) injection to the therapeutic armamenta rium has triggered a recent series of reviews to determine the optimal ther apeutic approach. Both PD and BTX have excellent short term (less than thre e months) efficacy in the majority of patients. New data have been publishe d that suggest that PD and BTX (with repeat injections) can potentially obt ain long term efficacy. PD is still considered the first-line treatment by most physicians; its main disadvantage is risk of perforation. BTX injectio n is evolving as an excellent, safe option for patients who are considered high risk for more invasive procedures. Laparoscopic myotomy with combined antireflux surgery is an increasingly attractive option in younger patients with achalasia, but long term follow-up studies are required to establish its efficacy and the potential for reflux-related sequelae.