Table 2.

Therapeutic options for treatment of achalasia.

Therapy	Success rate	Complications	Target patients
Oral pharmacological therapy			Patients who cannot undergo definitive treatment with either PD, POEM or HM and have failed botulinum toxin therapy
Calcium channel blockers	55–75%	Bradycardia Hypotension Pedal edema
Isosorbide dinitrate	49–87%	Headache Hypotension
Endoscopic botulinum toxin injection	>75% at 1 month 35–40% at 12 months	Chest pain (16–25%) Mediastinitis (rare)	Patients who cannot undergo definitive treatment with either PD, POEM or HM Adjunctive therapy in patients with residual spastic contractions after HM or POEM
Pneumatic dilation (PD)	50–93%	Esophageal perforation (median 1.9%) GERD (15–35%)	Recommended initial therapy for most patients who do not wish to undergo surgical myotomy. Patients must be surgical candidates, in case of perforation
Heller myotomy (HM) with Dor fundoplication	60–94%	GERD (~10%)	Recommended initial therapy for patients who are good surgical candidates and willing to undergo surgical myotomy
Peroral endoscopic myotomy (POEM)	>90% Long-term efficacy data beyond 1 year lacking	GERD (10–50%) Rare (<1–2%): – Mucosal injury – Hemorrhage – GE junction leaks – Pneumothorax	Evolving role Recommended for patients in whom HM is technically difficult, such as prior major upper abdominal surgery, prior HM and morbid obesity
Esophagectomy	>80%	Mortality (up to 5.4%) Postop dysphagia requiring dilation (up to 50%)	Patients unresponsive to all other forms of therapy

GERD, gastroesophageal reflux disease; GE, gastroesophageal.