Achalasia: new diagnostic tests and treatments

Introduction: The past several years have seen exciting breakthroughs leading to a better understanding of the pathogenesis of achalasia, classifying the disease more accurately by high-resolution manometry (HRM), defining better predictors of achalasia treatment success and to the introduction of exciting new treatments. Areas covered: PubMed and the Cochrane library were searched with no date limits for 'achalasia' and appropriate treatment modalities. This review summarizes the current state-of-the-art treatment and technology in achalasia. Emphasis is placed on the role of HRM with detailed assessment of lower esophageal sphincter function and peristalsis making it possible to classify achalasia into three subsets. These subsets seem to predict treatment success: type II achalasia does best with any form of treatment, whereas type III may respond better to surgery. The multicenter, randomized controlled European Achalasia Trial now gives us confidence that either pneumatic dilation or surgical myotomy are equivalent treatments for achalasia over a 2-year period. Finally, the novel endoscopic technique of peroral endoscopicmyotomy is a promising newincision-less treatment for achalasia, although troubling acid reflux is a potential drawback. Expert opinion: These are exciting times in the diagnosis and treatment of achalasia, which will definitely improve patient treatment outcomes. However, achalasia is never cured, re-treatment may be required over time and there is a slight risk of developing esophageal squamous cancer, particularly in those patients with megaesophagus.