Effectiveness and complication of achalasia treatment: A systematic review and network meta-analysis of randomized controlled trials

Integrating psychological assessment in achalasia management: addressing mental health to enhance patient outcomes

Achalasia is a chronic esophageal disorder with a generally favorable prognosis; however, approximately 20% of patients experience persistent or recurrent symptoms despite therapeutic interventions. These ongoing symptoms can significantly diminish both disease-specific and overall quality of life. Although the physical manifestations of achalasia, such as regurgitation, dysphagia, chest pain, and weight loss, are well-documented and assessed using the Eckardt score, the psychological burden of the disease remains underexplored. Individuals with achalasia are at an increased risk of mental health issues, including depression, anxiety, and somatization, exacerbated by the emotional strain and social limitations imposed by the disease. Despite this, psychological impacts are often overlooked in clinical settings, leading to inadequate mental health support for these patients. This article underscores the necessity for prompt psychological assessments during the diagnosis of achalasia to better address these mental health challenges and improve overall patient care.

[Esophageal Motility Disorders - What's New?]

Esophageal motor disorders are an important cause of dysphagia but can also be associated with retrosternal pain and heartburn as well as regurgitation. In extreme cases, patients are not able to eat appropriately and lose weight. Repetitive aspiration can occur and may cause pulmonological complications. Achalasia represents the most important and best-defined esophageal motor disorder and is characterized by insufficient relaxation of the lower esophageal sphincter in combination with typical disturbances of esophageal peristalsis. Additional defined motor disorders are distal esophageal spasm, hypercontractile esophagus, absent contractility and ineffective peristalsis. Patients with appropriate symptoms should primarily undergo esophagogastroduodenoscopy for exclusion of e.g., tumors and esophagitis. Esophageal high-resolution manometry is the reference method for diagnosis and characterization of motor disorders in non-obstructive dysphagia. An esophagogram with barium swallow may deliver complementary information or may be used if manometry is not available. Balloon dilatation and Heller myotomy are long established and more or less equally effective therapeutic options for patients with achalasia. Peroral endoscopic myotomy (POEM) enhances the therapeutic armamentarium for achalasia and hypertensive/spastic motor disorders since 2010. For hypotensive motor disorders, which may occur as a complication of e.g., rheumatological diseases or idiopathically, therapeutic options are still limited.

Clinical effects of peroral endoscopic myotomy in treatment of achalasia

BACKGROUND

Peroral endoscopic myotomy (POEM) is a safe and effective method for the treatment of achalasia of cardia (AC), which can significantly improve the clinical symptoms in a short term. However, there are few studies on its long-term efficacy.

AIM

To observe and analyze the clinical effects of POEM in the treatment of AC.

METHODS

The data of 28 patients diagnosed with AC and treated by POEM at the Department of Gastroenterology, Yunnan First People's Hospital from July 2013 to January 2019 were collected. The clinical symptom score and endoscopic and esophageal motility changes of the patients before and after POEM were analyzed to evaluate the clinical efficacy of POEM in the treatment of AC.

RESULTS

Among the 28 patients included, the duration of disease ranged from 2 to 360 mo, the success rate of surgery was 100.0%, and the follow-up time ranged from 1 to 36 mo. There was a significant difference in Eckardt score before and after POEM (P < 0.001). The total Eckardt scores in patients with types I and II AC after POEM were significantly lower than those before operation (P < 0.05). Postoperative follow-up gastroscopy showed no significant resistance through the cardia, improved esophageal dilatation, and no large amount of food retention in the lumen. The resting lower esophageal sphincter pressure and integrated relaxation pressure of the lower esophageal sphincter after operation were significantly lower than those before operation, and the differences in overall and type II patients were statistically significant (P < 0.05), while the differences in type I patients were not statistically significant. There was no significant difference in resting upper esophageal sphincter pressure or lower esophageal sphincter length after operation compared with before operation.

CONCLUSION

POEM is an effective treatment for AC, with definite short-term efficacy and relatively high safety. Some esophageal motility indexes are improved, but its long-term complications and effectiveness need further follow-up with large samples.

Evaluating the Non-conventional Achalasia Treatment Modalities

Introduction

Achalasia is a primary esophageal dysmotility disorder. Despite the high volume of studies addressing the conventional treatments for achalasia, few are debated regarding the non-conventional treatments, such as cardiectomy, cardioplasty, endoluminal substances injection (ethanolamine oleate, polidocanol, botulinum toxin), stents, and certain drugs (beta-agonists, anticholinergic, nitrates, calcium channel blockers, and phosphodiesterase inhibitors).

Methods

A critical review was performed.

Results

Endoscopic, surgical, and pharmacological treatments were included. A qualitative synthesis was presented.

Conclusion

Non-conventional therapeutic options for treating achalasia encompass medical, endoscopic, and surgical procedures. Clinicians and patients need to know all the tools for the management of achalasia. However, several currently available studies of non-conventional treatments lack high-quality evidence, and future randomized trials are still needed.