Abstract
Achalasia is a rare neurodegenerative disorder causing dysphagia and is characterized by abnormal esophageal motor function as well as the loss of lower esophageal sphincter (LES) relaxation. The assessment and management of achalasia has significantly progressed in recent years due to the advances in high-resolution manometry (HRM) technology along with the improvements and innovations of therapeutic endoscopy procedures. The recent evolution of HRM technology with the inclusion of an adjunctive test, fluoroscopy, and EndoFLIP has enabled more precise diagnoses of achalasia to be made and the subgrouping into therapeutically meaningful subtypes. Current management possibilities include endoscopic treatments such as Botulinum toxin injected to the LES and pneumatic balloon dilation. Surgical treatment includes laparoscopic Heller myotomy and esophagectomy. Furthermore, in recent years, per oral endoscopic myotomy (POEM) has established itself as a principal endoscopic therapeutic alternative to the traditional laparoscopic Heller myotomy. The latest randomized trials report that POEM, pneumatic balloon dilatation, and laparoscopic Heller’s myotomy have comparable effectiveness and complications rates. The aim of the current review is to provide a practical clinical approach to dysphagia and to shed light on the most recent improvements in diagnostics and treatment of achalasia over the last two years.
Highlights
Achalasia originates from the Greek word a-khalasis, meaning lack of relaxation
All treatment options target lower esophageal sphincter (LES) tearing, allowing a bolus to pass through the esophago-gastric junction (EGJ) [6]
A post-hoc analysis by Rohof et al of the European achalasia registry study found an association between achalasia subtype and treatment outcomes; the efficacy of pneumatic dilation was outstandingly excellent in type II achalasia but significantly decreased to 40% in type III achalasia [66]
Summary
Achalasia originates from the Greek word a-khalasis, meaning lack of relaxation It is characterized by a spastic lower esophageal sphincter and a lack of esophageal peristalsis resulting in esophageal outflow obstruction [1,2]. The natural history of achalasia is characterized by a chronic, life-long, but rarely life-threatening disease that seriously affects patients’ morbidity and quality of life [5]. The quality of life almost returns to near normal for a long time; on the other hand, when untreated, the course is usually progressive, leading to esophageal lumen dilatation, which, over time, leads to a burned-out, decompensated sigmoid esophagus with its clinical related consequences, including malnutrition [5,6]. An endoscopy every three years is considered an acceptable practical surveillance approach for esophageal cancer in longstanding achalasia. All treatment options target lower esophageal sphincter (LES) tearing, allowing a bolus to pass through the esophago-gastric junction (EGJ) [6]
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