Achalasia: Dilation, injection or surgery? PRINCIPLES OF THERAPY

14 Jan

Current treatment modalities for achalasia are palliative and aim at improving esophageal emptying by reducing lower esophageal sphincter resistance to passage of the bolus. This effect can be achieved endoscopically by means of either pneumatic dilation or botulinum toxin injection, and surgically by extramucosal myotomy. No firm consensus has been reached yet regarding the choice of the initial treatment. Retrospective studies have shown better results with myotomy performed by an experienced surgeon, and in the only prospective randomized trial myotomy gave better long term results compared with pneu­matic dilation. Uncontrolled studies show that both procedures have equal success rates if skilled operators are available, and, therefore, the patient should be allowed to make his or her own decision. In the only controlled trial of botulinum toxin injection versus pneumatic dilation, both procedures were effective at one-year follow-up.

Two randomized, double-blind, placebo controlled trials have shown that chronic treatment with calcium-channel blockers, such as nifedipine or verapamil, does not signifi­cantly improve symptoms despite a marked decrease of lower esophageal sphincter pressure in up to 50% of the patients. This form of therapy may be considered for short term management in individuals with relatively mild symp­toms or as a temporary measure when more invasive proce­dures are contraindicated.


Rigiflex balloon dilation of the esophagus is effective in more than two-thirds of patients. In up to 50% of the cases additional dilations are required to maintain symptomatic remission; the risk of perforation is estimated to be 1% to 6% in expert hands. Twenty-four hour esophageal pH monitoring shows gastroesophageal reflux in approxi­mately one-third of the patients after dilation.

The effectiveness of dilation does not appear to depend on balloon size, dilation pressure, rapidity of inflation, dura­tion of inflation, number of inflations per session or use of pre- medication. Patients who do not significantly respond to the first two dilations are unlikely to benefit from subsequent ses­sions, which may increase the risk of perforation.
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