Treatment Options In Achalasia

The main line of treatment of achalsia is reducing the LES pressure, which may be achieved by medical, endoscopic or surgical therapies. Medical therapy (including Nitrates, Ca- channel blockers, Anticholinergics, Theophylline and b 2 - agonists) is indicated in patients with mild symptoms, as a temporary measure before a more definitive form of therapy, surgically high-risk patients and those not responding to botulinum toxin injections. Botulinum toxin, a potent inhibitor of the release of acetylcholine from nerve terminals, is indicated in patients at high risk for complications with balloon dilation or myotomy. It needs to be repeated at roughly annual intervals. Balloon (Pneumatic) dilation is considered the treatment of choice for most patients of achalasia. In a 7 years follow-up study, 50-75% success rate was seen with single dilation. The major complication of pneumatic dilation is esophageal perforation. Sclerotherapy is an effective alternative to the pneumatic dilatation. The margin of error between too short myotomy (persistent dysphagia) and too long myotomy (post -op reflux) is very narrow 2. Best strategy is a long myotomy to prevent residual dysphagia accompanied by a fundoplication procedure to prevent GE reflux, however, the most common open procedure is an anterior myotomy through a thoracotomy or laparoscopy. Instances of post myotomy severe esophagitis, strictures, Barrett metaplasia and adenocarcinoma associated with Barrett metaplasia have all been observed.