Although not a common disease, the last several years have had exciting breakthroughs in better defining the pathophysiology of achalasia, classifying the disease with high-resolution manometry and potentially exciting new treatments.
The introduction of high-resolution manometry with detailed assessment of lower esophageal sphincter function and peristalsis has made it possible to classify achalasia into three subtypes. This becomes clinically important as patients with type II achalasia do best with both pneumatic dilation and surgical myotomy, whereas type III achalasia may respond better to surgery. The first multicenter randomized controlled trial published by the European Achalasia Trial group reported similar excellent outcomes over a 2-year follow-up with both pneumatic dilation and laparoscopic myotomy in a study involving nearly 200 achalasia patients. Although longer follow-up is required, this supports the continued use of pneumatic dilation for treating achalasia. Finally, the novel endoscopic technique of peroral endoscopic myotomy is a promising new treatment option for achalasia, but it requires increased experiences and careful evaluation before widespread application.
These are exciting times in the diagnosis and treatment of achalasia, which will definitely improve patient treatment outcomes. However, we still await breakthroughs in the basic science arena to identify the actual cause of achalasia.
Joy McCann Culverhouse, Center for Esophageal and Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
Correspondence to Joel E. Richter, MD, FACP, MACG, Professor of Medicine, Hugh F. Culverhouse Chair for Esophageal Disorders, Director, Division of Digestive Diseases & Nutrition, Director, Joy McCann Culverhouse, Center for Esophageal and Swallowing Disorders, University of South Florida Morsani College of Medicine, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL 33612, USA. E-mail: Jrichte1@health.usf.edu