Treatment of achalasia in the era of high-resolution manometry

Esophageal achalasia is a primary motility disorder characterized by impaired lower esophageal sphinc ter relaxation and absence of esophageal peristalsis leading to impa ired bolus transit, manifested with symptoms such as dysphagia, regurgitation, retrosternal pain, and weight loss. Th e standard diagnostic tool is esophageal manometry which demonstrates incomplete relaxation of the lower esophageal sphincter and impaired esophageal peristalsis. Recently, a new advanced technique, high-resolution manometry (HRM) with the addition of pressure topography plotting, using multip le sensors to capture the manometric data as a spatial continuum, allows a detailed pressure recording of the esophageal motility. Th is technique, currently th e gold standard for the diagnosis of achalasia, has led to a subclassifi cation of three manometric types that seem to have diff erent responsiveness to treatment. Because its pathogenesis is as yet unknown, achalasia treatment options are not curativ e. Type II achalasia patients respond better to treatment compared to those with types I and III. Low-risk patients with type I or II achalasia have good outcome with both graded pneumatic dilatations and laparoscopic Heller myotomy, while type III achalasia patients respond better to laparoscopic Heller myotomy. Although, type III achalasia patients responds less in comparison to types I and II to laparoscopic Heller myotomy. Peroral endoscopic myotomy is a promising new technique but long-term follow-up studies for its safety and effi cacy must be performed. Th is article reviews the current therapeutic options, highlighting the impact of HRM to predict the outcome and the new insights for the treatment of achalasia