Modern Treatment for Achalasia: Endoscopic and Surgical therapies.

Abstract

Achalasia is a rare, progressive oesophageal motility disorder defined by impaired lower oesophageal sphincter relaxation and absent peristalsis, leading to dysphagia, regurgitation, chest pain, weight loss, and increased long-term risks of aspiration and malignancy. Management has evolved from open surgical myotomy to minimally invasive laparoscopic and robotic techniques and, more recently, peroral endoscopic myotomy (POEM). This review summarises contemporary diagnostic strategies, including high-resolution manometry, timed barium oesophagram, endoscopy, and emerging applications of impedance planimetry, and critically appraises current endoscopic and surgical therapies. The review compares outcomes of pneumatic dilation, botulinum toxin injection, minimally invasive Heller myotomy with fundoplication, POEM, POEM with fundoplication, and newer approaches for advanced disease such as per-oral oesophageal plication and oesophagectomy, integrating data from randomised trials and long-term cohort studies. Key issues including post-treatment gastroesophageal reflux, cancer surveillance, and management of recurrent or refractory symptoms are addressed. Treatment selection is emphasised as individualised, incorporating manometric subtype, oesophageal morphology, patient comorbidity, institutional expertise, procedural durability, complication profiles, and evolving guideline recommendations across international expert consensus groups. Contemporary multimodal therapy enables durable symptom control and meaningful quality-of-life improvement for most patients, while ongoing innovation and longer-term follow-up will continue to refine treatment algorithms and standards of care.