Journal Review in Minimally Invasive Surgery: Achalasia

Jul 31, 2025

Explore the complexities of achalasia, a condition hindering swallowing. Delve into the latest treatment options like POEM, pneumatic dilation, and Heller myotomy. Discover how the Chicago Classification defines achalasia subtypes, influencing tailored therapies. The hosts highlight long-term outcomes, including a unique analysis of 10-year data comparing treatments. Gain insights into the trade-offs between dysphagia relief and managing post-treatment GERD. Plus, look ahead at emerging therapies shaping the future of achalasia management.

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INSIGHT

Core Diagnostic Criteria

Achalasia diagnosis requires failed LES relaxation, absent organized peristalsis, and exclusion of structural causes.
High-resolution manometry plus EGD are the diagnostic gold standard.

INSIGHT

Chicago Classification Simplified

The Chicago Classification defines three achalasia subtypes by manometry patterns and IRP.
Type 1: failed peristalsis; Type 2: panesophageal pressurization; Type 3: spastic distal contractions.

INSIGHT

Subtype Drives Treatment Choice

Achalasia subtype guides therapy selection and outcomes.
POEM is preferred for type 3; types 1–2 can be treated with Heller myotomy or POEM.

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Today, we’re diving into a condition that’s as fascinating as it is complex: Achalasia—where the esophagus stops playing nice, and swallowing becomes a daily challenge.

We’re breaking down the latest evidence, comparing POEM, pneumatic dilation, and Heller myotomy, and digging into what actually matters when deciding how to treat each achalasia subtype.

Join show hosts Drs. Jake Greenberg, Dana Portenier, Zach Weitzner, and Joey Lew as they discuss the past, present, and future of Achalasia management. Whether you're a medical student or a seasoned attending, this episode will arm you with the tools to think critically about diagnosis, tailor your treatment strategy, and stay ahead of the curve on the future of achalasia care.

Hosts:
· Jacob Greenberg, MD, EdM, MIS Division Chief and Vice Chair for Education, Duke University
· Dana Portenier, MD, MIS Fellowship Director, Duke University
· Zachary Weitzner, MD, Minimally Invasive and Bariatric Surgery Fellow, Duke University, @ZachWeitznerMD
· Joey Lew, MD, MFA, Surgical resident PGY-3, Duke University, @lew__actually

Learning Goals:
By the end of this episode, listeners will be able to:
· Describe the pathophysiology and key diagnostic criteria for achalasia, including the role of manometry, EGD, and esophagram.
· Differentiate between the three subtypes of achalasia based on the Chicago Classification and understand the clinical significance of each.
· Compare treatment options for achalasia—pneumatic dilation, Lap Heller myotomy, and POEM—including indications, efficacy, and long-term outcomes.
· Interpret landmark studies (e.g., European Achalasia Trial, JAMA POEM trial) and their impact on treatment decision-making.
· Recognize patient-specific factors (age, comorbidities, achalasia subtype) that influence the choice of therapy.
· Discuss evolving technologies and future directions in achalasia management, including endoluminal robotics, ARMS, and combined anti-reflux strategies.
· Outline a basic treatment algorithm for newly diagnosed achalasia, incorporating diagnostic steps and tailored interventions.
· Appreciate the multidisciplinary approach to achalasia care, including the roles of MIS surgeons, gastroenterologists, and emerging procedural skillsets.

References:
· Boeckxstaens G, Elsen S, Belmans A, Annese V, Bredenoord AJ, Busch OR, Costantini M, Fumagalli U, Smout AJPM, Tack J, Vanuytsel T, Zaninotto G, Salvador R; European Achalasia Trial Investigators. 10‑year follow-up results of the European Achalasia Trial: a multicentre randomised controlled trial comparing pneumatic dilation with laparoscopic Heller myotomy. Gut. 2024 Mar;73(4):582‑589. doi: 10.1136/gutjnl‑2023‑331374. PMID: 38050085 https://pubmed.ncbi.nlm.nih.gov/38050085/
· He J, Yin Y, Tang W, Jiang J, Gu L, Yi J, Yan L, Chen S, Wu Y, Liu X.
Objective Outcomes of an Extended Anti‑reflux Mucosectomy in the Treatment of PPI‑Dependent Gastroesophageal Reflux Disease (with Video). J Gastrointest Surg. 2022 Aug;26(8):1566–1574. doi:10.1007/s11605‑022‑05396‑9. PMID: 35776296 https://pubmed.ncbi.nlm.nih.gov/35776296/
· Modayil RJ, Zhang X, Rothberg B, et al. Peroral endoscopic myotomy: 10-year outcomes from a large, single-center U.S. series with high follow-up completion and comprehensive analysis of long-term efficacy, safety, objective GERD, and endoscopic functional luminal assessment. Gastrointest Endosc. 2021;94(5):930-942. doi:10.1016/j.gie.2021.05.014. PMID: 33989646. https://pubmed.ncbi.nlm.nih.gov/33989646/
· Ponds FA, Fockens P, Lei A, Neuhaus H, Beyna T, Kandler J, Frieling T, Chiu PWY, Wu JCY, Wong VWY, Costamagna G, Familiari P, Kahrilas PJ, Pandolfino JE, Smout AJPM, Bredenoord AJ.
Effect of peroral endoscopic myotomy vs pneumatic dilation on symptom severity and treatment outcomes among treatment-naive patients with achalasia: a randomized clinical trial. JAMA. 2019 Jul 9;322(2):134–144. doi:10.1001/jama.2019.8859. PMID: 31287522. https://pubmed.ncbi.nlm.nih.gov/31287522/
· Vaezi MF, Pandolfino JE, Yadlapati RH, Greer KB, Kavitt RT; ACG Clinical Guidelines Committee.
ACG clinical guidelines: Diagnosis and management of achalasia. Am J Gastroenterol. 2020 Sep;115(9):1393–1411. doi:10.14309/ajg.0000000000000731. PMID: 32773454; PMCID: PMC9896940 https://pubmed.ncbi.nlm.nih.gov/32773454/
· West RL, Hirsch DP, Bartelsman JF, de Borst J, Ferwerda G, Tytgat GN, Boeckxstaens GE. Long term results of pneumatic dilation in achalasia followed for more than 5 years. Am J Gastroenterol. 2002;97(6):1346-1351. doi:10.1111/j.1572-0241.2002.05771.x. PMID:12094848. https://pubmed.ncbi.nlm.nih.gov/12094848/

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