New Treatments for Achalasia: Novel Ideas, but Are They Ready for Prime Time?
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EDITORIAL
New Treatments for Achalasia: Novel Ideas, but Are They Ready for Prime Time? Joel E. Richter
Published online: 8 January 2013 Ó Springer Science+Business Media New York 2013
Achalasia is a rare disorder (1/100,000 people per year) without any age or gender predilection [1]. Patients typically present with dysphagia for solids and liquids, regurgitation of undigested food, nocturnal coughing, chest pain, and weight loss. These symptoms result from impaired, usually absent, peristalsis and incomplete relaxation of the lower esophageal sphincter (LES) leading to stasis of food in the esophagus and esophageal dilation. Why the enteric esophageal neurons gradually disappear in patients with achalasia remains unknown. Evidence is accumulating that an autoimmune response targeted against these neurons, triggered by an infectious agent, possibly HSV-1, may be involved [2]. The diagnosis is made by a combination of tests including barium esophagram, esophageal manometry, and upper endoscopy. No treatment for achalasia can restore muscular activity to the denervated esophagus; as a consequence, esophageal aperistalsis is rarely reversed. All treatments are thus directed at reducing the gradient across the LES with three goals [3]: 1. 2. 3.
Relieving patients symptoms, especially dysphagia and bland regurgitation Improving esophageal emptying Preventing the long term development of megaesophagus.
In the modern era of achalasia treatment, LES disruption is best accomplished by pneumatic dilation using Rigiflex
J. E. Richter (&) Division of Digestive Diseases and Nutrition, Department of Internal Medicine, Center for Esophageal and Swallowing Disorders, University of South Florida College of Medicine, 12901 Bruce B. Downs Blvd., MDC 72, Tampa, FL 33612, USA e-mail: [email protected]
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balloons or laparoscopic myotomy, and, less effectively, by pharmacological agents, such as intrasphincteric botulinum toxin injection (Botox) or systemic calcium channel blockers. Symptoms of dysphagia and regurgitation are the easiest to treat; chest pain relief is more unpredictable [4]. Overall, using single or multiple treatment modalities, over 90 % of achalasia patients will do well [5]. Nevertheless, achalasia is never ‘‘cured’’ by our current treatments. Therefore, recurrences will occur requiring ‘‘touch up’’ treatments with higher recurrence rates with longer periods of follow-up. This editorial will review the currently available treatments and potential new endoscopic treatments for achalasia. Nitrates and calcium channel blockers decrease resting LES pressure in a dose-dependent manner, with a maximum effect of 50 %, thereby temporarily relieving dysphagia. These drugs are taken 15–30 min before meals, but improvement is incomplete and short-lived, efficacy decreases with time and adverse effects (headaches, dizziness, pedal edema) are common [6]. Primary pharmacologic therapy for achalasia now is endoscopic intrasphincteric Botox injection. As a potent inhibitor of acetylcholine release from nerve endings, B
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