REVIEW

URRENT
C
OPINION

Treatment of the patient with achalasia

Wout O. Rohof a and Guy E. Boeckxstaens a,b

Purpose of review
In recent years, several studies on the treatment and follow-up of achalasia have been published. This
review aims at highlighting interesting publications from the recent years.
Recent findings
Treatment of achalasia aims at relieving functional obstruction at the level of the esophagogastric junction.
Several treatment options such as pneumodilation and laparoscopic Heller myotomy (LHM) are available
for this purpose. A large prospective randomized trial comparing pneumodilation and LHM demonstrated
comparable success rates and quality of life for the two treatment options. Long-term data demonstrate
comparable treatment success rates, when redilation in case of recurrent symptoms after pneumodilation is
accepted. The most important risk factor for treatment failure is the manometric subtype, with a worse
outcome for type I and type III compared with type II achalasia. Recently, peroral endoscopic myotomy
(POEM) has been described with high success rates. Comparative studies with longer follow-up are
awaited. A prospective study assessing the risk of esophageal carcinoma in patients with achalasia
showed a 28-fold increased risk to develop carcinoma.
Summary
Either LHM or pneumodilation have high comparable short-term clinical success rates. Based on the
increased risk to develop esophageal carcinoma, a screening program may be indicated. POEM is a new
interesting treatment but longer follow-up data are awaited.
Keywords
achalasia, high-resolution manometry, laparoscopic Heller myotomy, peroral endoscopic myotomy,
pneumatic dilation

INTRODUCTION

INITIAL TREATMENT

Achalasia is a primary esophageal motor disorder

characterized by the absence of peristalsis and a
defective relaxation of the lower esophageal sphincter (LES), resulting in impaired bolus transport and
stasis of food in the esophagus [1]. A patient with
achalasia typically presents with dysphagia for solids and liquids, regurgitation of undigested food,
weight loss and retrosternal pain. It is now generally
accepted that esophageal manometry, preferably
high-resolution manometry, is the gold standard
to diagnose achalasia [2].
To date, mainly due to a lack in pathophysiological insight, treatment is confined to mechanical
disruption of the LES. Treatment modalities available for this purpose include mainly pneumatic
dilation, laparoscopic Heller myotomy (LHM) and,
recently, peroral endoscopic myotomy (POEM). In
this review, we will discuss recent publications and
new insights into the initial treatment and followup of patients with achalasia.

Mainly due to the lack of understanding in the

mechansims underlying the loss of neurons in
achalasia, treatment is still confined to disruption
of the LES. For many years, pneumodilation had
been considered the treatment of choice. Since the
introduction of minimally invasive surgery, however, the surgical treatment option has become
increasingly popular. Excellent results have been
reported for laparoscopic Heller myotomy (LHM,
a

Department of Gastroenterology and Hepatology, Academic Medical

Center, Amsterdam, The Netherlands and bDepartment of Gastroenterology, University Hospital of Leuven and Catholic University of Leuven,
Leuven, Belgium
Correspondence to Professor Dr Guy E. Boeckxstaens, Department of
Gastroenterology, Translational Research Center for Gastrointestinal
Disorders, University Hospital Leuven, Catholic University Leuven, Herestraat 49, 3000 Leuven, Belgium. Tel: +32 16 347075
Curr Opin Gastroenterol 2012, 28:389394
DOI:10.1097/MOG.0b013e328353af8f

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Esophagus

KEY POINTS
 The characteristic feature of achalasia is the loss of
enteric neurons in the myenteric plexus, leading to
severely disturbed esophageal motility and typical
symptoms such as dysphagia, regurgitation and
weight loss.
 Due to a lack in pathophysiological insight, treatment is
currently confined to mechanical disruption of the lower
esophageal sphincter, aimed at relieving functional
obstruction at the esophagogastric junction.
 Pneumatic dilation and laparoscopic Heller myotomy
are the most commonly used treatment modalities and
have comparable success rates.
 Treatment success depends on the manometric subtype
defined on pretreatment high-resolution manometry.
 Patients with achalasia should be monitored on a
regular basis to prevent possible complications such as
sigmoid like esophagus and esophageal squamous
cell carcinoma.

were diagnosed by an esophagogram with watersoluble contrast. The most important risk factor
for esophageal perforation was age (age >60 years,
hazard ratio 3.4 compared with
60 years), a finding
consistent with that of previous studies. In a large
European study, the risk for perforation was also
significantly higher if the first dilation was performed with a 35 mm balloon rather than a
30 mm balloon (31 vs. 4%) [6 ,8 ]. Although perforation is a potentially life-threatening complication, as evidenced by the death of one patient
who had perforation further complicated bymediastinal hemorrhage, most of the patients who experienced perforation in this study (69%) were treated
successfully with conservative (nonoperative) treatment (i.e. antibiotics and nothing by mouth). Four
of 16 (25%) patients needed drainage of pleural
effusion, but none required surgery to close the
perforation. Notably, the long-term outcome after
esophageal perforation was reported to be excellent
in 69% of patients after a follow-up of 84 months,
which is comparable to treatment success reported
for patients without perforation [7 ].
Recently, Katzka and Castell [8 ] performed a
meta-analysis of 29 studies evaluating pneumatic
dilation regarding efficacy, rate of perforation and
dilation technique. Pooled results of studies with
the currently used Rigiflex balloons showed an 88%
1-year efficacy, gradually declining with time to 70
and 29% after 5 and 10 years, respectively, with a
combined perforation rate of 2%. Efficacy and durability of clinical success were increased by applying
repeated or graded dilations rather than just a single
dilation. In case of recurrent symptoms, redilation
leads to a further increase of the success rate to
8193% after 610 years [3,4]. Based on these numbers, one can conclude that pneumodilation has a
high rate of success when a graded distension protocol and redilation in case of recurrent symptoms are
used. Nevertheless, a clinician should always be
aware of the risk of perforation, and of the need to
evaluate and treat possible perforations promptly. It
is important to stress that early diagnosis of esophageal perforation is crucial, either by assessment of
pain evoked by ingestion of water 12 h after the
procedure, or by routinely performing a postdilation
radiograph of the esophagus using water-soluble
contrast.
&&

&

&

&

with or without an antireflux procedure) and, as a

result, many authorities began to consider operative
therapy to be the treatment of choice. As discussed
below, however, randomized trials are required to
objectively compare different treatment modalities
before one can decide on the superiority of any
treatment option.

Pneumodilation
Pneumodilation disrupts the LES by forceful
inflation of an air-filled balloon. Briefly, a noncompliant Rigiflex balloon (Boston Scientific, Nanterre,
France) is inserted over an endoscopically placed
guidewire, and positioned at the level of the LES.
Under fluoroscopic guidance, the balloon is inflated
until the waist caused by the impression of the
esophaogastric junction is completely obliterated.
Usually, a graded distension protocol with increasing balloon sizes (30, 35 and 40 mm) is used, leading
to success rates of 7080%. Treatment success further increases to more than 90% when redilation is
allowed in case of recurrent symptoms [35]. Pneumatic dilation should preferentially start with the
smallest Rigiflex balloon (30 mm) to lower the risk of
esophageal perforation [6 ]. Perforation is the most
serious complication of pneumatic dilation, and
therefore one of the major drawbacks for clinicians.
In a recent retrospective study by Vanuytsel et al.
[7 ], pneumodilation was complicated by transmural esophageal perforation in 16 of 830 (1.9%) procedures [or 16 of 372 (4.3%) patients]. Perforations
&&

&

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Laparoscopic Heller myotomy

During LHM, the esophagogastric junction is visualized laparoscopically, and the surgeon cuts both
muscle layers of the LES, extending the incision
distally (over the proximal stomach) by 23 cm
[9]. Patients are usually hospitalized for 35 days.
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Treatment of the patient with achalasia Rohof and Boeckxstaens

Complications include conversion to an open procedure (2%) and mucosal perforation, on average
observed in 6.9% of patients [9,10]. However, most
perforations are noticed during surgery and immediately closed, such that these perforations cause
clinical problems only in approximately 0.7% of
patients [10].
A Heller myotomy is usually combined with
an antireflux procedure, lowering the incidence
of gastroesophageal reflux disease after treatment
from 32 to 8.8% [10]. The type of fundoplication
used differs among centers. In a study comparing
Dor (anterior 1808) and Nissen (3608) fundoplication, efficacy in preventing abnormal reflux was
similar, but dysphagia was more frequently observed
after Nissen fundoplication (2.8 vs. 15%, P < 0.001)
[11], arguing against the use of a total fundoplication.
Success rates for LHM reported in retrospective,
single-center studies are high, which resulted in
increasing enthusiasm for the surgical approach.
In a recent meta-analysis including 3086 patients
by Campos et al. [10], success rates were as high
as 89% (range 77100%) after a mean follow-up of
35 months. However, similar to pneumatic dilation,
treatment success rates for LHM decline over time
to 60%, as demonstrated in several studies with a
follow-up of 610 years [1214]. In patients with
recurrent symptoms following LHM, both pneumodilation and redo myotomy lead to acceptable
treatment success rates, ranging from 50 to 67%
for pneumodilation and from 58 to 87% for redo
myotomy [1517].

Pneumodilation versus laparoscopic Heller

myotomy
For many years, repeated endoscopic pneumodilation had been the treatment of choice. Since the
introduction of laparoscopic surgery, however, the
enthusiasm for the surgical approach has markedly
increased. It should be emphasized that direct comparison of reported success rates for pneumodilation
and LHM is difficult because different groups of
investigators often use different outcome measures.
Moreover, available data are rather conflicting. In
one retrospective, longitudinal study of 1181
patients with a follow-up period of 10 years, patients
treated with pneumodilation had to undergo
retreatment far more often than those who had
LHM (64 vs. 38%) [18]. In contrast, a cross-sectional
follow-up study by Vela et al. [12] showed similar
success rates for pneumodilation and LHM. Finally
and most importantly, randomized studies with
sufficient statistical power comparing these two
major treatment options were lacking.

&&

Recently, Boeckxstaens et al. [6 ] reported the

results of a prospective, multicenter trial in which
201 patients were randomized to receive either
graded pneumodilation (n 95) or LHM (n 106).
Therapeutic success was defined as a reduction in
the Eckardt symptom score below 4. After 2 years of
follow-up, comparable therapeutic success rates of
86 and 90% were observed for pneumodilation and
LHM, respectively [6 ]. Redilation, allowed once
during the first 2 years of follow-up, was performed
in 23 of 95 patients after pneumodilation (25%). No
difference in the level of esophageal stasis or in the
quality of life measured by SF-36 was observed.
Based on these data, the authors concluded that
LHM does not achieve superior rates of therapeutic
success compared with pneumodilation as primary
treatment for achalasia, at least after a mean followup of 43 months and, therefore, either can be
advised as initial therapy.
&&

Individualized treatment for the patients with

achalasia?
By defining risk factors for failure/success, in
particular age, gender and manometric subtype, it
might perhaps be possible to design an individualized therapy for the patient with achalasia. In
patients treated with pneumodilation, redilation
is more often needed in younger and male patients
(<40 years) [6 ,19], suggesting that LHM might be
offered preferentially to younger, male patients who
have low surgical risks [5]. In addition, data have
been reported that clinical outcome might be predicted by the manometric subtype of achalasia.
Recently, Pandolfino et al. [20] identified three such
manometric subtypes based on the residual esophageal wave pattern: in type I only minimal contractility is observed in the esophageal body; in type II,
intermittent periods of compartmentalized esophageal pressurization are recorded; and in type III,
spastic contractions are measured in the distal
esophagus. In 83 patients, most of whom were
treated with pneumodilation, success rates were
significantly higher for type II achalasia (96%) compared with type I (56%) and type III (29%) achalasia.
In a subsequent study reporting on 246 patients
treated with LHM, differences in treatment success
among the achalasia subtypes also were noted, with
success rates of 85, 95 and 70% for type I, II and III,
respectively [21]. Potentially, achalasia subtype
classification might be used to determine the choice
of treatment. However, currently available studies
have used different definitions of treatment success
and patients have not been followed up prospectively [2022]. In the randomized European trial
[6 ], both type I and II patients had similar success

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&&

&&

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Esophagus

rates after either LHM or pneumodilation. Patients

with type III, however, had a lower response rate, in
particular those who underwent pneumodilation
[23]. Based on these results, one could argue that
LHM might be the preferred treatment option in
patients with type III achalasia, although the number of patients studied so far is rather small.

Peroral endoscopic myotomy

POEM is a recently developed endoscopic technique
used to treat achalasia. In brief, the endoscopist
creates a submucosal tunnel to reach the LES and
to dissect the circular muscle fibers over a 7 cm
esophageal and 2 cm gastric length. The procedure
is performed under general anesthesia and patients
remain hospitalized for a median of 5 days [24].
Inoue et al. [24] reported a success rate of 100%
and a significant reduction in LES pressure in 17
patients. A recent European study reporting on their
experience in 16 patients confirmed the high success rate (94%), even following multiple previous
pneumodilations [25]. It should be emphasized
though, that follow-up of both studies is still short
(5 and 3 months, respectively) and that longer follow-up is needed before accepting this new technique. In addition, randomized studies comparing
POEM to pneumodilation or LHM should be performed, and such studies are presently in progress
[25].

FOLLOW-UP
Follow-up of patients with achalasia is not only
important to ensure optimal symptom control,
but also to prevent possible complications such as
esophageal decompensation [5,9]. Furthermore,
patients with achalasia have an increased risk to
develop dysplasia and eventually even esophageal
squamous carcinoma [26,27]. Current guidelines do
not provide guidance on follow-up of patients with
achalasia [28,29]. However, several studies have
proposed that regular follow-up should be performed to decide on retreatment, preferably based
on the results of a functional test such as a timed
barium esophagogram [3,30].

Retreatment
As discussed above, treatment success gradually
decreases in patients with longstanding disease
(10 year) to 4060% [4,18,31,32]. Importantly,
however, additional treatment, both after initial
pneumodilation or LHM, has satisfactory results
with success rates of 6080% and improvement of
esophageal emptying [4,9,12,16]. The decision to
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retreat patients may be a clinical challenge, especially as symptoms and functional data (e.g. stasis on a
barium swallow, LES pressure measurements) do not
always match. Furthermore, patients often learn to
tolerate a certain level of symptoms or adapt their
diet accordingly. However, timely detection of
patients in need for additional treatment may be
important to avoid long-term complications such as
esophageal decompensation.
Multiple studies have assessed risk factors for the
need for retreatment after therapy. Vaezi et al. [33]
have demonstrated that 90% of patients with esophageal stasis need additional treatment within a year,
even if they have few or no symptoms shortly after
initial treatment. The data from the European achalasia trial confirm that monitoring esophageal emptying after treatment is a helpful tool for predicting
recurrence [6 ]. Therefore, 24 weeks after treatment, a timed barium esophagogram should be
performed, and this can be repeated during follow-up visits. In case esophageal stasis recurs,
additional treatment may be indicated.
&&

Screening for esophageal carcinoma

A potential long-term complication of achalasia is
the development of esophageal squamous cell carcinoma. Several studies have shown that the relative
risk of developing esophageal carcinoma with achalasia is increased, ranging from 0-fold to 50-fold
[26,27,34]. Recently, a long-term prospective trial
demonstrated a hazard ratio of 28 for esophageal
carcinoma in patients with achalasia compared with
matched controls [26]. In line with this, we observed
a mortality rate of 19% due to esophageal carcinoma
in a cohort of patients with longstanding achalasia
in a retrospective study [31]. Symptoms of esophageal carcinoma in these patients often are misinterpreted as merely symptoms of achalasia, resulting
in late diagnosis and advanced esophageal cancer at
the time of diagnosis. This experience highlights the
need for early detection of curable, dysplastic lesions
in patients with achalasia. Conventional endoscopy
of the esophagus is, however, not sensitive for the
detection of dysplasia in achalasia, and most neoplastic lesions are detected in an advanced stage
[26]. Potentially, brush cytology, advanced imaging
techniques or the use of dyes such as Lugols staining might be used to detect early dysplastic lesions
[35]. Lugols staining has been shown to have sensitivity as high as 96% for the detection of dysplastic
lesions in squamous epithelium [36]. Therefore, it
could be an excellent tool to use for repetitive
screening in patients with achalasia.
To increase probability for detection during
screening, and thereby cost-effectiveness, risk
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Treatment of the patient with achalasia Rohof and Boeckxstaens

factors for dysplasia need to be recognized. In a

prospective study by Leeuwenburgh et al. [26]
patients who developed esophageal cancer had
achalasia for more than 24 years. In addition,
patients with esophageal stasis have a higher
risk for the development of dysplasia and neoplasia [35,37], probably because dysplasia can be
a consequence of chronic inflammation [38].
These data suggest that screening for dysplasia
should be performed in patients with a long history
of dysphagia (>1520 years), especially those with
long-term esophageal stasis. However, further
studies are needed to determine the benefit of
such screening.

CONCLUSION
Due to a lack of understanding of the pathogenesis
of achalasia, initial treatment still focuses on
mechanical disruption of the LES, rather than on
restoring esophageal motility. As demonstrated
in a recent prospective, randomized trial, a graded
pneumodilation protocol with the possibility
for redilation in case of recurrent symptoms is as
successful as LHM, and leads to comparable drop
in LES pressure, reduction in esophageal stasis
and improved quality of life. Ideally, the choice
of treatment should be based on risk factors such
as achalasia subtype and age in order to generate
an individualized therapeutic strategy. Follow-up
of the patient with achalasia should aim at
relieving recurrent symptoms and preventing
possible complications. POEM has generated great
enthusiasm among endoscopists, but longer
follow-up data and randomized comparative trials
are required before widespread acceptance of this
new approach.
Acknowledgements
None.
Conflicts of interest
GEB is supported by a grant (Odysseus program,
G.0905.07) of the Flemish Fonds Wetenschappelijk
Onderzoek (FWO).
There are no conflicts of interest.

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&
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