What are the current treatment options for achalasia, and how do they differ based on disease severity?

Current treatment options for achalasia vary based on disease severity and patient factors, focusing on relieving symptoms by reducing lower oesophageal sphincter (LOS) pressure.

For mild to moderate achalasia, initial management often includes pneumatic balloon dilation or pharmacological therapy such as calcium channel blockers or nitrates, which provide temporary symptom relief but are less durable long-term options ¹.

In more severe or refractory cases, or when less invasive treatments fail, laparoscopic Heller myotomy combined with partial fundoplication is considered the gold standard surgical treatment, offering durable symptom control by mechanically disrupting the LOS muscle fibers ¹.

Peroral endoscopic myotomy (POEM) has emerged as a less invasive alternative to surgery, particularly effective in severe achalasia or type III achalasia subtypes, providing comparable efficacy to Heller myotomy with potentially fewer complications (Zaninotto et al., 2018).

Botulinum toxin injection into the LOS is generally reserved for patients who are unfit for surgery or endoscopic interventions due to comorbidities, as its effects are temporary and symptoms often recur (Zaninotto et al., 2018) ¹.

Choice of treatment is influenced by achalasia subtype (determined by high-resolution manometry), patient age, comorbidities, and local expertise, with more aggressive interventions favored in severe disease to improve long-term outcomes ¹ (Zaninotto et al., 2018).