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Treatment and surveillance strategies in achalasia: an update

Abstract

Controversy exists with regard to the optimal treatment for achalasia and whether surveillance for early recognition of late complications is indicated. Currently, surgical myotomy and pneumatic dilation are the most effective treatments for patients with idiopathic achalasia, and a multicenter, randomized, international trial has confirmed similar efficacy of these treatments, at least in the short term. Clinical predictors of outcome, patient preferences and local expertise should be considered when making a decision on the most appropriate treatment option. Owing to a lack of long-term benefit, endoscopic botulinum toxin injection and medical therapies are reserved for patients of advanced age and those with clinically significant comorbidites. The value of new endoscopic, radiologic or surgical treatments, such as peroral endoscopic myotomy, esophageal stenting and robotic-assisted myotomy has not been fully established. Finally, long-term follow-up data in patients with achalasia support the notion that surveillance strategies might be beneficial after a disease duration of more than 10–15 years.

Key Points

  • There is controversy with regard to the optimal treatment for and surveillance of achalasia

  • The most effective treatment modalities for achalsia are pneumatic dilation and surgical myotomy

  • Comparative studies show equal efficacy of pneumatic dilation and surgical myotomy in the short term

  • Patients undergoing pneumatic dilation require more frequent re-interventions than patients undergoing surgical myotomy

  • Surveillance may lead to early recognition of cancer or late complications and should be considered after a disease duration of >10–15 years

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Figure 1: Radiographic images of two patients with achalasia after a barium swallow.
Figure 2: High-resolution manometry of the esophagus showing three different types of achalasia.
Figure 3: Esophageal resection specimens from patients with achalasia who developed esophageal cancer.

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A. J. Eckardt contributed to all aspects of the article. V. F. Eckardt made a substantial contribution to the discussion of content and the review/editing of the manuscript before submission.

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Eckardt, A., Eckardt, V. Treatment and surveillance strategies in achalasia: an update. Nat Rev Gastroenterol Hepatol 8, 311–319 (2011). https://doi.org/10.1038/nrgastro.2011.68

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