Current Treatment Options in Gastroenterology

, Volume 4, Issue 1, pp 89–100 | Cite as


  • Peter M. Dunaway
  • Roy K. H. Wong

Opinion statement

The optimal treatment of achalasia includes several options and presents a challenge for most gastroenterologists. There are numerous patient variables that must be assessed including age, degree of symptoms, duration of disease, desires of each patient, and related comorbidities. Treatment includes both medical and surgical options, with medical therapy further subclassified into pharmacologic and pneumatic dilation. Pneumatic dilations with a polyethylene dilator (sizes of 3.0, 3.5, and 4.0 cm) and laparoscopic myotomy represent the most common forms of therapy. A graduated increase in dilator size, based on symptomatic response, minimizes complications and is successful in more than 90% of patients. Further dilations or adjustment of pharmacologic therapy should be based on symptoms, weight gain, and a timed barium meal. Referral for myotomy should be considered for patients who do not respond to medical therapy or individuals that do not desire pneumatic dilations. Most patients responding to botulinum toxin (Botox; Allergan, Irvine, CA) injections will require repeat treatment at 3- to 6-month intervals. Due to cost constraints, Botox therapy should be reserved for patients who are at an increased risk from possible complications of a dilation or surgery, or those with less than 2 years of life expectancy. The most cost-effective course of therapy per patient cured over a 5-year period is pneumatic dilation, then Botox, and finally laparoscopic myotomy.


Botulinum Toxin Achalasia Main Drug Interaction Esophageal Perforation Lower Esophageal Sphincter Pressure 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Birgisson S, Richter JE: Achalasia: what’s new in diagnosis and treatment? Dig Dis 1997, 15(suppl):1–27.PubMedGoogle Scholar
  2. 2.
    Howard PJ, Maher L, Pryde A, et al.: Five year prospective study of the incidence, clinical features, and diagnosis of achalasia in Edinburgh. Gut 1992, 33:1011–1015.PubMedGoogle Scholar
  3. 3.
    Mayberry JF, Rhodes J: Achalasia in the city of Cardiff from 1926 to 1977. Digestion 1980, 20:248–252.PubMedCrossRefGoogle Scholar
  4. 4.
    Wong RKH, Maydonovitch CL: Achalasia. In The Esophagus, edn 3. Edited by Castell DO. Philadelphia, Philadelphia: Lippincott Williams & Wilkins; 1999:185–213. A thorough chapter discussing the demographics, pathology, and pathophysiology of achalasia in addition to a broad and extensive review of the literature on different treatment options.Google Scholar
  5. 5.
    Goldblum JR, Whyte RI, Orringer MB, et al.: Achalasia: a morphologic study of 42 resected specimens. Am J Surg Pathol 1994, 18:327–337. This is a good reference article discussing the spectrum of histologic findings that can be seen in achalasia. This also a good reference base for reviewing the pathophysiology of this condition.PubMedCrossRefGoogle Scholar
  6. 6.
    Katz PO, Richter JE, Cowan R, et al.: Apparent complete lower esophageal sphincter relaxation in achalasia. Gastroenterology 1986, 90:978–983.PubMedGoogle Scholar
  7. 7.
    Goldenberg SP, Burrell M, Fette GG, et al.: Classic and vigorous achalasia: a comparison of manometric, radiographic, and clinical findings. Gastroenterology 1991, 101:743–748.PubMedGoogle Scholar
  8. 8.
    Miller LS, Liu JB, Barbarevech CA, et al.: High-resolution endoluminal sonography in achalasia. Gastrointest Endosc 1995, 42:545–549.PubMedCrossRefGoogle Scholar
  9. 9.
    Kahrilas PJ, Kishk SM, Helm JF, et al.: Comparison of pseudoachalasia and achalasia. Am J Med 1987, 82:439–446.PubMedCrossRefGoogle Scholar
  10. 10.
    Tucker HJ, Snape WJ Jr, Cohen S: Achalasia secondary to carcinoma: manometric and clinical features. Ann Intern Med 1978, 89:315–318.PubMedGoogle Scholar
  11. 11.
    Woodfield CA, Levine MS, Rubesin SE, et al.: Diagnosis of primary versus secondary achalasia: reassessment of clinical and radiographic criteria. Am J Roentgenol 2000, 175:727–731.Google Scholar
  12. 12.
    Tracey JP, Traube M: Difficulties in the diagnosis of pseudoachalasia. Am J Gastroenterol 1994, 89:2014–2018.PubMedGoogle Scholar
  13. 13.
    Vaezi MF, Richter JE: Current therapies for achalasia. Comparison and efficacy. J Clin Gastroenterol 1998, 27:21–35. This article is one of the most thorough review articles on the discussion and comparison of the three main treatment options for achalasia. An extensive discussion of historic and recent literature is presented.PubMedCrossRefGoogle Scholar
  14. 14.
    Imperiale TF, O’Connor JB, Vaezi MF, et al.: A cost-minimization analysis of alternative treatment strategies for achalasia. Am J Gastroenterol 2000, 95:2737–2745. This article presents a comprehensive cost assessment treatment model for the management of achalasia.PubMedCrossRefGoogle Scholar
  15. 15.
    Panaccione R, Gregor JC, Reynolds RP, Preiksaitis HG: Intersphincteric botulinum toxin versus pneumatic dilatation for achalasia: a cost minimization analysis. Gastrointest Endosc 1999, 50:492–498.PubMedCrossRefGoogle Scholar
  16. 16.
    Vaezi MF, Richter JE, Wilcox CM, et al.: Botulinum toxin versus pneumatic dilatation in the treatment of achalasia: a randomised trial. Gut 1999, 44:231–239. One the landmark articles comparing Botox to pneumatic dilation and objectively assessing the 1-year treatment response rate.PubMedCrossRefGoogle Scholar
  17. 17.
    Fishman VM, Parkman HP, Schiano TD, et al.: Symptomatic improvement in achalasia after botulinum toxin injection of the lower esophageal sphincter. Am J Gastroenterol 1996, 91:1724–1730.PubMedGoogle Scholar
  18. 18.
    Abid S, Champion G, Richter JE, et al.: Treatment of achalasia: the best of both worlds. Am J Gastroenterol 1994, 89:979–985.PubMedGoogle Scholar
  19. 19.
    Vaezi MF, Achkar E, Rice TW, et al.: Laparoscopic myotomy may offer improved outcome in younger patients compared to pneumatic dilation [abstract]. Am J Gastroenterol 2000, 95:2438. This abstract is the first study comparing pneumatic dilation to laparoscopic myotomy. The main outcome is symptomatic relapse rate at 1 year for different age groups and pneumatic dilation treatment arms.CrossRefGoogle Scholar
  20. 20.
    Pasricha PJ, Kalloo AN: Recent advances in the treatment of achalasia. Gastrointest Endosc Clin N Am 1997, 7:191–206. A extensive review and discussion of the different treatment options for achalasia.PubMedGoogle Scholar
  21. 21.
    Vaezi MF: Achalasia: diagnosis and management. Semin Gastrointest Dis 1999, 10:103–112.PubMedGoogle Scholar
  22. 22.
    Pasricha PJ, Ravich WJ, Hendrix TR, Kalloo AN: Botulinum toxin for achalasia: long-term outcome and predictors of response. Gastroenterology 1996, 110:1410–1415. This article follows patients for an extended period with multiple Botox injections. The failure rate from Botox is quite significant over time.PubMedCrossRefGoogle Scholar
  23. 23.
    Annese V, Bassotti G, Coccia G, et al.: A multicentre randomised study of intrasphincteric botulinum toxin in patients with oesophageal achalasia. Gut 2000, 46:597–600. This randomized study presents a comparison of different Botox treatment dosages. Objective data are obtained and patients are followed for a mean of 1 year.PubMedCrossRefGoogle Scholar
  24. 24.
    Vaezi MF, Richter JE: Diagnosis and management of achalasia. American College of Gastroenterology Practice Parameter Committee. Am J Gastroenterol 1999, 94:3406–3412. A concise summary of necessary aspects to successfully manage patients with achalasia.PubMedCrossRefGoogle Scholar
  25. 25.
    Patti MG, Feo CV, Arcerito M, et al.: Effects of previous treatment on results of laparoscopic Heller myotomy for achalasia. Dig Dis Sci 1999, 44:2270–2276.PubMedCrossRefGoogle Scholar
  26. 26.
    Kessler KR, Skutta M, Benecke R: Long-term treatment of cervical dystonia with botulinum toxin A: efficacy, safety, and antibody frequency. German Dystonia Study Group. J Neurol 1999, 246:265–274.PubMedCrossRefGoogle Scholar
  27. 27.
    Gordon JM: Prospective study of esophageal botulinum toxin injection in high-risk achalasia patients. Am J Gastroenterol 1997, 92:1812–1817.PubMedGoogle Scholar
  28. 28.
    Muehldorfer SM, Schneider TH, Hochberger J, et al.: Esophageal achalasia: intrasphincteric injection of botulinum toxin A vs balloon dilation. Endoscopy 1999, 31:517–521.PubMedCrossRefGoogle Scholar
  29. 29.
    Gideon RM, Castell DO, Yarze J: Prospective randomized comparison of pneumatic dilatation technique in patients with idiopathic achalasia. Dig Dis Sci 1999, 44:1853–1857.PubMedCrossRefGoogle Scholar
  30. 30.
    Meshkinpour H, Kaye L, Elias A, Glick ME: Manometric and radiologic correlations in achalasia. Am J Gastroenterol 1992, 87:1567–1570.PubMedGoogle Scholar
  31. 31.
    Kadakia SC, Wong RKH: Graded pneumatic dilation using Rigiflex achalasia dilators in patients with primary esophageal achalasia. Am J Gastroenterol 1993, 88:34–38. This is one of the main evidence-based articles supporting the current treatment recommendation of graduated pneumatic dilation.PubMedGoogle Scholar
  32. 32.
    Pricolo VE, Park CS, Thompson WR: Surgical repair of esophageal perforation due to pneumatic dilatation for achalasia. Is myotomy really necessary? Arch Surg 1993, 128:540–5444.PubMedGoogle Scholar
  33. 33.
    Ellis FH: Oesophagomyotomy for achalasia: a 22-year experience. Br J Surg 1993, 80:882–885.PubMedCrossRefGoogle Scholar
  34. 34.
    Di Simone MP, Felice V, D’Errico A, et al.: Onset timing of delayed complications and criteria of follow-up after operation for esophageal achalasia. Ann Thorac Surg 1996, 61:1106–1111.PubMedCrossRefGoogle Scholar
  35. 35.
    Patti MG, Pellegrini CA, Horgan S, et al.: Minimally invasive surgery for achalasia. An 8-year experience with 168 patients. Ann Surg 1999, 230:587–594. This study presents pertinent data supporting the use of laparoscopic Heller myotomy and also includes a thorough discussion on the necessity of a antireflux procedure after myotomy.PubMedCrossRefGoogle Scholar
  36. 36.
    Stewart KC, Finley RJ, Clifton JC, et al.: Thorascopic versus laparoscopic modified Heller myotomy for achalasia: efficacy and safety in 87 patients. J Am Coll Surg 1999, 189:164–170.PubMedCrossRefGoogle Scholar
  37. 37.
    Zaninotto G, Constantini M, Molena D, et al.: Treatment of esophageal achalasia with laparoscopic Heller myotomy and Dor partial anterior fundoplication: prospective evaluation of 100 consecutive patients. J Gastrointest Surg 2000, 4:282–289. This prospective study presents objective data on the incidence of GERD after laparoscopic Heller myotomy. A detailed review of the literature on this area also is included.PubMedCrossRefGoogle Scholar
  38. 38.
    Vogt D, Curet M, Pitcher D, et al.: Successful treatment of esophageal achalasia with laparoscopic Heller myotomy and Toupet fundoplication. Am J Surg 1997, 174:709–714.PubMedCrossRefGoogle Scholar
  39. 39.
    Bowrey DJ, Peters JH: Laparoscopic esophageal surgery. Surg Clin N Am 2000, 80:1213–1242.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc 2001

Authors and Affiliations

  • Peter M. Dunaway
    • 1
  • Roy K. H. Wong
    • 1
  1. 1.Gastroenterology ServiceWalter Reed Army Medical CenterWashingtonUSA

Personalised recommendations