Current trends in the management of achalasia

Despite the recent advances in the understanding of the pathophysiology of achalasia, aetiology remains obscure and this primary oesophageal motor dis order is still considered "idiopathic" in nature. As a consequence, the the rapeutic approach remains palliative. Since there is little or no chance of improving the motor abnormalities of the oesophageal body, treatment of ac halasia is aimed at symptomatic relief of functional lower oesophageal sphi ncter obstruction. Pharmacologic treatment induces only a limited and brief improvement. It may be used to treat early cases of achalasia without sign ificant oesophageal dilatation and to manage patients exhibiting some but n ot all the characteristics of achalasia (e.g. transitional forms). In any e vent, drug therapy should be seen as a short-term measure and be considered as an alternative only in patients unfit to undergo pneumatic dilatation o r surgery. Pneumatic dilatation and surgical myotomy (now increasingly carr ied out through a minimally invasive approach) remain, therefore, the two m ain approaches which guarantee long-lasting symptomatic relief. Unfortunate ly, both pneumatic dilatation and Heller cardiomyotomy are only palliative as neither reliably reverses oesophageal aperistalsis not corrects the inco mplete postdeglutition relaxation of the lower oesophageal sphincter. They do, however, improve symptoms by lowering lower oesophageal sphincter press ure thus enhancing oesophageal emptying by gravity. Recently a third approa ch, consisting in perendoscopic injection of botulinum toxin into the lower oesophageal sphincter is gaining acceptance. Indeed, more endoscopists are finding this kind of treatment attractive because it does not carry the ri sk of perforation that can occur with pneumatic dilatation. However: since symptomatic improvement with botulinum toxin only lasts a few months, eithe r repeated injections are required or the patient must be switched to other therapy. There may be, however: subsets of patients for whom BoTox (R) inj ection is the preferred approach. They probably include elderly patients or patients with multiple medical problems who are poor candidates for more i nvasive procedures as well as those unwilling to have either surgery or pne umatic dilatation. Future approaches to achalasia may markedly change from the suggested algorithm depending on the long-term efficacy and safety as w ell as cost analysis of BoTox (R) injection and of minimally invasive surge ry.