TREATMENT DECISION
Achalasia Treatments: Endoscopic and Surgical Options
Treatment aims to reduce resistance at the lower oesophageal sphincter. There is no single “best” option for everyone; subtype, age, anatomy, prior treatment, reflux risk, patient preference and centre expertise all matter.
Editorial draft · physician review required before publicationCore principle
The goal is not to apply one procedure to everyone, but to compare options according to confirmed diagnosis and subtype.
| Feature | POEM | Heller + Fundoplication | Pneumatic Dilation | Botulinum Toxin |
|---|---|---|---|---|
| Approach | Endoscopic myotomy | Laparoscopic surgical myotomy | Endoscopic balloon disruption | Endoscopic injection |
| External incision | None | Small laparoscopic incisions | None | None |
| Muscle division / myotomy | Yes; length can be tailored | Yes; surgical myotomy | No; balloon disruption | No |
| Type I | Strong option | Strong option | Option in selected patients | Not a durable first-line option |
| Type II | Strong option | Strong option | Effective in selected patients | Usually temporary |
| Type III | Favoured in SAGES 2025 guidance | Alternative; myotomy length matters | Generally more limited | Temporary / selected patient |
| Anti-reflux procedure | No routine fundoplication | Partial fundoplication usually added | — | — |
| Post-treatment reflux follow-up | Especially important | Still relevant; fundoplication aims to reduce risk | As needed | As needed |
| Need for repeat intervention | Possible with recurrence | Possible with recurrence | Serial/graded sessions may be needed | Repeat injection is often needed |
| Key risk / follow-up issue | Reflux; procedural adverse events including mucosal injury/perforation can occur | Surgical adverse events and reflux | Perforation risk | Effect may diminish over time |
| Decision factors | Subtype · oesophageal anatomy · previous treatment · age/comorbidity · reflux priorities · patient preference · centre expertise | |||
Medical safety note
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