Achalasia: Physician versus Surgeon

May 16, 2019 By: Paul Fockens and Giovanni Zaninotto

Achalasia: Physician versus Surgeon

Two European experts give their opposing views on the best treatment option for achalasia

Oesophageal achalasia is a rare motility disorder, in which peristalsis is impaired or absent and the lower oesophageal sphincter fails to relax. Symptoms of achalasia include dysphagia, regurgitation of undigested food, coughing and choking, chest pain and chest infections.


We invited two European experts to give their opposing viewpoints—physician versus surgeon—on the best treatment option for achalasia.





A Physician's Viewpoint—Paul Fockens

Although the title of this blog quickly attracted your attention, it is actually not a choice between physician and surgeon but a choice between peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM). From a patient's point of view, the natural orifice approach will be preferred as it diminishes complications and reduces recovery time. But are both treatments equal in their efficacy and safety profile? There are many studies that suggest the efficacy of both POEM and LHM is excellent, but POEM has not been around very long so less evidence is available. Two large randomized controlled trials presented in abstract form and awaiting full publication both demonstrate the high efficacy of POEM, which seems equal to LHM and superior to a set of two pneumatic dilations. But how about safety? POEM is significantly less invasive, and thereby safer, than LHM; complications are very rare and usually mild. Therefore, with comparable efficacy and improved safety when compared with LHM, POEM seems to have a bright future. Is there any disadvantage to POEM? Yes, there is one issue and that is reflux. POEM can currently not be combined with an endoscopic antireflux procedure, so a significant percentage of patients will have to use proton pump inhibitors after POEM. It is up to the patient, after care has been taken to inform them about all available treatment options, to come to a shared decision with their doctor. Without a doubt in my mind, I believe POEM will frequently be the patient's favourite choice!



A Surgeon's Viewpoint—Giovanni Zaninotto

Surgical treatment of oesophageal achalasia divides the muscle fibresof the distal oesophagus and cardia, leaving the underlying mucosa intact. Consequently, resistance of the lower oesophageal sphincter to the flow of the bolus is diminished. Heller myotomy, named for the German surgeon who performed it first (in 1913), has been completed laparoscopically (LHM) since 1990, with a partial wrap of the fundus added to prevent iatrogenic gastro-oesophageal reflux disease (GORD). LHM has gained vast popularity because of its efficacy in reducing dysphagia (89% and 85% of patients are asymptomatic at 5 and 10 years, respectively) while maintaining a very good safety profile (mortality <0.1%, morbidity <7%). Postoperative reflux is observed in 10–20% of patients when a partial fundoplication is added to LHM. Three randomized controltrials and three meta-analyses have compared the efficacy of LHM with that of pneumatic dilation, revealing that pneumatic dilation can achieve the same efficacy as LHM only after multiple, sequential dilations. Moreover, LHM is more effective than pneumatic dilation for treatment of type III spastic achalasia. There are no randomized control trials published in full that compare LHM with POEM, though two meta-analyses show that POEM achieves slightly (but significantly) better symptomatic control than LHM, especially for type III achalasia. However, the duration of the patient follow-up was shorter for POEM, and POEM presented a higher risk of postoperative reflux (20–40%). I believe five small abdominal scars are preferable to an increased risk of GORD, and that LHM remains the 'single-shot' better option for achalasia patients.


About the Authors

Paul Fockens is Professor and Chair of Gastroenterology & Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands. His clinical and research interests regard interventional endoscopy as well as oncology. He is the current UEG President. Follow Paul on Twitter @PaulFockens.

Giovanni Zaninotto is currently Visiting Professor in the Department of Surgery & Cancer at Imperial College, London, UK, and Editor of Diseases of the Esophagus. His clinical and research interests include all diseases of the oesophagus and laparoscopic surgery of the upper gastrointestinal tract.



Dmitry Haurilenka, June 19, 2019 16:33
Really interesting topic. and predictable bipolar views))
What method was used to diagnose achalasia. Are physician and surgeon unanimous regarding the method of diagnosis of achalasia?
Ivan Lyutakov, June 18, 2019 19:10
Hello, my name is Ivan Lyutakov (Gastroenterologist) and I am from Bulgaria. In our hospital (center) we don't have thoracic surgery. We only have abdominal surgeons and they perform LHM, but is it feasible we gastroenterologists to start doing POEMS without a thoracic surgery around? Very good topic and idea for discussion! Thank you!