Current Endoscopic Management of Achalasia Cardia: Review Article
Abstract:
The management of achalasia cardia can be categorized into endoscopic and surgical approaches. Endoscopic management encompasses pneumatic dilatation and botulinum toxin injection. Additionally, peroral endoscopic myotomy is included within endoscopic therapy, although some scholars have classified it under surgical therapy for achalasia. Surgical management involves the implementation of Heller myotomy and esophagectomy. In this review, we will examine the role of botulinum toxin, pneumatic dilatation, and peroral endoscopic myotomy in the management of achalasia cardia, focusing on their indications and associated complications.
KeyWords:
Achalasia, Botulinum toxin, Endoscopy, Medical, Pneumatic dilatation, POEM.
References:
- Annese, V., Bassotti, G., Coccia, G., Dinelli, M., D'Onofrio, V., Gatto, G., Leandro, G., Repici, A., Testoni, P. A., & Andriulli, A. (2000). A multicenter randomized study of intrasphincteric botulinum toxin in patients with oesophageal achalasia. GISMAD Achalasia Study Group. Gut, 46(5), 597–600. https://doi.org/10.1136/gut.46.5.597
- Aiolfi, A., Bona, D., Riva, C. G., Micheletto, G., Rausa, E., Campanelli, G., Olmo, G., Bonitta, G., & Bonavina, L. (2020). Systematic review and Bayesian network meta-analysis comparing laparoscopic Heller myotomy, pneumatic dilatation, and peroral endoscopic myotomy for esophageal Achalasia. Journal of Laparoendoscopic and Advanced Surgical Techniques, 30(2), 1–9. https://doi.org/10.1089/lap.2019.0432
- Aljebreen, A. M., Samarkandi, S., Al-Harbi, T., Al-Radhi, H., & Almadi, M. A. (2014). Efficacy of pneumatic dilatation in Saudi achalasia patients. Saudi Journal of Gastroenterology, 20(1), 43–47. https://doi.org/10.4103/1319-3767.126317
- Allaix, M. E., & Patti, M. G. (2015). Endoscopic Dilatation, Heller Myotomy, and Peroral Endoscopic Myotomy: Treatment Modalities for Achalasia. In Surgical Clinics of North America (Vol. 95, Issue 3, pp. 567–578). W.B. Saunders. https://doi.org/10.1016/j.suc.2015.02.009
- Bechara, R., Ikeda, H., & Inoue, H. (2015). Peroral endoscopic myotomy: An evolving treatment for Achalasia. In Nature Reviews Gastroenterology and Hepatology (Vol. 12, Issue 7, pp. 410–426). Nature Publishing Group. https://doi.org/10.1038/nrgastro.2015.87
- Boeckxstaens, G. E. E. (2007). Achalasia. Best Practice and Research in Clinical Gastroenterology, 21(4), 595–608. https://doi.org/10.1016/j.bpg.2007.03.004
- Bonifácio, P., De Moura, D. T. H., Bernardo, W. M., De Moura, E. T. H., Farias, G. F. A., Neto, A. C. M., Lordello, M., Korkischko, N., Sallum, R., & De Moura, E. G. H. (2019). Pneumatic dilation versus laparoscopic Heller’s myotomy in the treatment of Achalasia: Systematic review and meta-analysis based on randomized controlled trials. In Diseases of the Esophagus (Vol. 32, Issue 2). Oxford University Press. https://doi.org/10.1093/dote/doy105
- Bredenoord, A. J., Rösch, T., & Fockens, P. (2014). Peroral endoscopic myotomy for achalasia. Neurogastroenterology and Motility, 26(1), 3–12. https://doi.org/10.1111/nmo.12257
- Costantini, M., & Costantini, A. (2026). Clinical Evaluation, Etiology and Classification of Esophageal Achalasia (pp. 147–155). https://doi.org/10.1007/978-3-031-90570-4_17
- Cuilliere, C., Ducrotte, P., Zerbib, F., Metman, E. H., De Looze, D., Guillemot, F., Hudziak, H., Lamouliatte, H., Grimaud, J. C., Ropert, A., Dapoigny, M., Bost, R., Lemann, M., Bigard, M. A., Denis, P., Auget, J. L., Galmiche, J. P., & Bruley Des Varannes, S. (1997). Achalasia: outcome of patients treated with intrasphincteric injection of botulinum toxin. In Gut (Vol. 41).
- Dirks, R. C., Kohn, G. P., Slater, B., Whiteside, J., Rodriguez, N. A., Docimo, S., Pryor, A., & Stefanidis, D. (2021). Is peroral endoscopic myotomy (POEM) more effective than pneumatic dilation and Heller myotomy? A systematic review and meta-analysis. In Surgical Endoscopy (Vol. 35, Issue 5, pp. 1949–1962). Springer. https://doi.org/10.1007/s00464-021-08353-w
- Dobrowolsky, A., & Fisichella, P. M. (2014). The management of esophageal achalasia: From diagnosis to surgical treatment. In Updates in Surgery (Vol. 66, Issue 1, pp. 23–29). https://doi.org/10.1007/s13304-013-0224-1
- Drexel, S., Kishawi, S., & Marks, J. (2020). Peroral Esophageal Myotomy. In Surgical Clinics of North America (Vol. 100, Issue 6, pp. 1183–1192). W.B. Saunders. https://doi.org/10.1016/j.suc.2020.08.004
- Eckardt, V. F., Gockel, I., & Bernhard, G. (2004). Pneumatic dilation for achalasia: Late results of a prospective follow up investigation. Gut, 53(5), 629–633. https://doi.org/10.1136/gut.2003.029298
- Familiari, P., Greco, S., Volkanovska, A., Gigante, G., Cali, A., Boškoski, I., & Costamagna, G. (2015). Achalasia: Current treatment options. In Expert Review of Gastroenterology and Hepatology (Vol. 9, Issue 8, pp. 1101–1114). Taylor and Francis Ltd. https://doi.org/10.1586/17474124.2015.1052407
- Ghoshal, U. C., Rangan, M., & Misra, A. (2012). Pneumatic dilation for achalasia cardia: Reduction in lower esophageal sphincter pressure in assessing response and factors associated with recurrence during long-term follow-up. Digestive Endoscopy, 24(1), 7–15. https://doi.org/10.1111/j.1443-1661.2011.01159.x
- Heddle, R., & Cock, C. (2020). Role of botulinum toxin injection in the treatment of achalasia. In Annals of Esophagus (Vol. 3). AME Publishing Company. https://doi.org/10.21037/aoe-2019-ach-09
- Howard, J. M., Mongan, A. M., Manning, B. J., Byrne, P., Lawler, P., Ravi, N., & Reynolds, J. V. (2010). Outcomes in achalasia from a surgical unit where pneumatic dilatation is first-line therapy. Diseases of the Esophagus, 23(6), 465–472. https://doi.org/10.1111/j.1442-2050.2010.01055.x
- Hulselmans, M., Vanuytsel, T., Degreef, T., Sifrim, D., Coosemans, W., Lerut, T., & Tack, J. (2010). Long-term Outcome of Pneumatic Dilation in the Treatment of Achalasia. Clinical Gastroenterology and Hepatology, 8(1), 30–35. https://doi.org/10.1016/j.cgh.2009.09.020
- Inoue, H., Sato, H., Ikeda, H., Onimaru, M., Sato, C., Minami, H., Yokomichi, H., Kobayashi, Y., Grimes, K. L., & Kudo, S. E. (2015). Per-Oral Endoscopic Myotomy: A Series of 500 Patients. Journal of the American College of Surgeons, 221(2), 256–264. https://doi.org/10.1016/j.jamcollsurg.2015.03.057
- Katsinelos, P., Kountouras, J., Paroutoglou, G., Beltsis, A., Zavos, C., Papaziogas, B., Elsevier, K. M., & Mimidis, K. (2005). Long-term results of pneumatic dilation for achalasia: A 15 years’ experience. World J Gastroenterol, 11(36), 5701–5705. www.wjgnet.comhttp://www.wjgnet.com/1007-9327/11/5701.asp
- Kohn, G. P., Dirks, R. C., Ansari, M. T., Clay, J., Dunst, C. M., Lundell, L., Marks, J. M., Molena, D., Rooker, C., Saxena, P., Swanstrom, L., Wong, R. K., Pryor, A. D., & Stefanidis, D. (2021). SAGES guidelines for the use of peroral endoscopic myotomy (POEM) for the treatment of achalasia. Surgical Endoscopy, 35(5), 1931–1948. https://doi.org/10.1007/s00464-020-08282-0
- Leyden, J. E., Moss, A. C., & Macmathuna, P. (2014). Endoscopic pneumatic dilation versus botulinum toxin injection in the management of primary achalasia. In Cochrane Database of Systematic Reviews (Vol. 2014, Issue 12). John Wiley and Sons Ltd. https://doi.org/10.1002/14651858.CD005046.pub3
- Martínek, J., Siroký, M., Plottová, Z., Bures, J., Hep, A., & Spicák, J. (2003). Treatment of patients with achalasia with botulinum toxin: a multicenter prospective cohort study. Diseases of the esophagus: official journal of the International Society for Diseases of the Esophagus, 16(3), 204–209. https://doi.org/10.1046/j.1442-2050.2003.00329.x
- Mikaeli, J., Fazel, A., Montazeri, G., Yaghoobi, M., & Malekzadeh, R. (2001). Randomized controlled trial comparing botulinum toxin injection to pneumatic dilatation for the treatment of achalasia. Alimentary pharmacology & therapeutics, 15(9), 1389–1396. https://doi.org/10.1046/j.1365-2036.2001.01065.x
- Miranda-García, P., Casals-Seoane, F., Gonzalez, J. M., Barthet, M., & Santander-Vaquero, C. (2017). Per-oral endoscopic myotomy (POEM): A new endoscopic treatment for achalasia. In Revista Espanola de Enfermedades Digestivas (Vol. 109, Issue 10, pp. 719–726). ARAN Ediciones S.A. https://doi.org/10.17235/reed.2017.4732/2016
- Müller, M., Keck, C., Eckardt, A. J., Werling, S., Wehrmann, T., König, J., & Gockel, I. (2018). Outcomes of pneumatic dilation in achalasia: Extended follow-up of more than 25 years with a focus on manometric subtypes. Journal of Gastroenterology and Hepatology (Australia), 33(5), 1067–1074. https://doi.org/10.1111/jgh.14044
- Neubrand, M., Scheurlen, C., Schepke, M., & Sauerbruch, T. (2002). Long-term results and prognostic factors in the treatment of achalasia with botulinum toxin. Endoscopy, 34(7), 519–523. https://doi.org/10.1055/s-2002-33225
- Oude Nijhuis, R. A. B., Zaninotto, G., Roman, S., Boeckxstaens, G. E., Fockens, P., Langendam, M. W., Plumb, A. A., Smout, A. J. P. M., Targarona, E. M., Trukhmanov, A. S., Weusten, B. L. A. M., & Bredenoord, A. J. (2020). European Guideline on Achalasia – UEG and ESNM recommendations. In United European Gastroenterology Journal (Vol. 8, Issue 1, pp. 13–34). SAGE Publications Ltd. https://doi.org/10.1177/2050640620903213
- Pandolfino, J. E., & Gawron, A. J. (2015). Achalasia: A systematic review. JAMA - Journal of the American Medical Association, 313(18), 1841–1852. https://doi.org/10.1001/jama.2015.2996
- Pasricha, P. J., Ravich, W. J., Hendrix, T. R., Sostre, S., Jones, B., & Kalloo, A. N. (1995). Intrasphincteric botulinum toxin for the treatment of achalasia. The New England journal of medicine, 332(12), 774–778. https://doi.org/10.1056/NEJM199503233321203
- Ramchandani, M., Reddy, D. N., Darisetty, S., Kotla, R., Chavan, R., Kalpala, R., Galasso, D., Lakhtakia, S., & Rao, G. V. (2016). Peroral endoscopic myotomy for achalasia cardia: Treatment analysis and follow up of over 200 consecutive patients at a single center. Digestive Endoscopy, 28(1), 19–26. https://doi.org/10.1111/den.12495
- Ramzan, Z., & Nassri, A. B. (2013). The role of Botulinum toxin injection in the management of achalasia. In Current Opinion in Gastroenterology (Vol. 29, Issue 4, pp. 468–473). https://doi.org/10.1097/MOG.0b013e328362292a
- Riccio, F., Costantini, M., & Salvador, R. (2022). Esophageal Achalasia: Diagnostic Evaluation. World Journal of Surgery, 46(7), 1516–1521. https://doi.org/10.1007/s00268-022-06483-3
- Richards, W. O., Torquati, A., & Lutfi, R. (2005). The current treatment of achalasia. Advances in surgery, 39, 285–314. https://doi.org/10.1016/j.yasu.2005.04.002
- Richter, J. E. (2013). Esophageal motility disorder: achalasia. In Current Opinion in Otolaryngology and Head and Neck Surgery (Vol. 21, Issue 6, pp. 535–542). https://doi.org/10.1097/MOO.0b013e3283658f4f
- Stavropoulos, S. N., Desilets, D. J., Fuchs, K. H., Gostout, C. J., Haber, G., Inoue, H., Kochman, M. L., Modayil, R., Savides, T., Scott, D. J., Swanstrom, L. L., & Vassiliou, M. C. (2014). Per-oral endoscopic myotomy white paper summary. Gastrointestinal Endoscopy, 80(1), 1–15. https://doi.org/10.1016/j.gie.2014.04.014
- Talukdar, R., Inoue, H., & Reddy, D. N. (2015). Efficacy of peroral endoscopic myotomy (POEM) in the treatment of achalasia: a systematic review and meta-analysis. Surgical Endoscopy, 29(11), 3030–3046. https://doi.org/10.1007/s00464-014-4040-6
- Tuset, J. A., Luján, M., Huguet, J. M., Canelles, P., & Medina, E. (2009). Endoscopic pneumatic balloon dilation in primary achalasia: Predictive factors, complications, and long-term follow-up. Diseases of the Esophagus, 22(1), 74–79. https://doi.org/10.1111/j.1442-2050.2008.00874.x
- Vaezi, M. F., Pandolfino, J. E., & Vela, M. F. (2013). ACG clinical guideline: Diagnosis and management of achalasia. American Journal of Gastroenterology, 108(8), 1238–1249. https://doi.org/10.1038/ajg.2013.196
- van Hoeij, F. B., Prins, L. I., Smout, A. J. P. M., & Bredenoord, A. J. (2019). Efficacy and safety of pneumatic dilation in achalasia: A systematic review and meta-analysis. In Neurogastroenterology and Motility (Vol. 31, Issue 7). Blackwell Publishing Ltd. https://doi.org/10.1111/nmo.13548
- Vespa, E., Pellegatta, G., Chandrasekar, V. T., Spadaccini, M., Patel, H., Maselli, R., Galtieri, P. A., Carlani, E., Sharma, P., Hassan, C., & Repici, A. (2023). Long-term outcomes of peroral endoscopic myotomy for achalasia: a systematic review and meta-analysis. In Endoscopy (Vol. 55, Issue 2, pp. 167–175). Georg Thieme Verlag. https://doi.org/10.1055/a-1894-0147
- Walzer, N., & Hirano, I. (2008). Achalasia. In Gastroenterology Clinics of North America (Vol. 37, Issue 4, pp. 807–825). https://doi.org/10.1016/j.gtc.2008.09.002
- Zhong, C., Tan, S., Ren, Y., Lü, M., Peng, Y., Fu, X., & Tang, X. (2020). Quality of life following peroral endoscopic myotomy for esophageal achalasia: A systematic review and meta-analysis. In Annals of Thoracic and Cardiovascular Surgery (Vol. 26, Issue 3, pp. 113–124). Japanese Association for Coronary Artery Surgery. https://doi.org/10.5761/atcs.ra.19-00273