Tailoring Therapy for Achalasia.

Achalasia is a rare esophageal motility disorder with impaired lower esophageal sphincter (LES) opening and aperistalsis. The disease cannot be cured and aperistalsis cannot be corrected, but good long-term symptom relief results from some degree of destruction to the obstruction of the LES. The presence of multiple treatment options with excellent scientific efficacy now offers the opportunity to tailor therapy for patients with achalasia. Drug therapy, especially botulinum toxin A, should be reserved for elderly patients with short life expectancy. Pneumatic dilation and surgical myotomy are equally effective for patients with types I and II achalasia. Pneumatic dilation offers a less morbid, cheaper outpatient procedure, especially for older patients and women, but redilation may be needed. Surgical myotomy is effective across all groups, especially young men. Laparoscopic Heller myotomy with fundoplication is preferred in patients with megaesophagus, diverticulum, or hiatal hernia. Peroral endoscopic myotomy is the treatment of choice for patients with type III achalasia, but requires advanced endoscopic skills, and the risk of gastroesophageal reflux disease is high. This article reviews the various treatments currently available for achalasia and discusses how to tailor therapy for patients.