Modern management of achalasia.

PURPOSE OF REVIEW: Achalasia is a chronic esophageal motility disorder characterized by incomplete lower esophageal sphincter relaxation and aperistalsis resulting in delayed esophageal emptying. Management is aimed at palliation of symptoms and improvement in quality of life. Multiple factors including demographics, severity of disease, and existing comorbidities influence management options. RECENT FINDINGS: Given its low rates of complications, surgical myotomy has become the preferred primary treatment, particularly in young males. However, recent studies describing favorable long-term outcomes for pneumatic dilation make this a reasonable option to consider as first-line therapy for achalasia. SUMMARY: Pneumatic dilation and surgical myotomy are the most effective therapeutic options for achalasia. Depending on local expertise, either option is acceptable as first-line therapy. There continues to be a limited role for other treatment modalities such as pharamacologic agents and botulinum toxin in certain patient populations.

Stents for Esophageal Disease.

Esophageal malignancies presenting with dysphagia from luminal obstruction generally are not resectable for cure, and palliative therapy is the primary focus. Self-expandable metal stents (SEMS) have replaced plastic stents as a primary mode of palliation for malignant esophageal obstruction because of the relative ease of insertion, lower initial morbidity, and larger stent diameter. Self-expandable metal stents are ideal for patients with midesophageal tumors. A majority of patients experience relief of dysphagia with SEMS and dietary modification, but the initial cost is high and early morbidity may be significant. The placement of SEMS across the gastroesophageal junction may result in free reflux that may improve with a stent containing a one-way gastric flap valve. The placement of SEMS in the cervical esophagus, although more difficult, less effective, and less well tolerated, also may be successful. Coated SEMS are a treatment of choice for individuals with tracheoesophageal fistula. Delayed complications occur in up to 40% of patients and include stent migration, bleeding, perforation, fistula formation, and occlusion. Most complications can be managed endoscopically and additional stents may be placed for tumor overgrowth. The comparison of three currently available SEMS for esophageal malignancy show no statistically significant differences with regard to ease of placement, effectiveness, complications, and mortality. The use of SEMS for patients with benign disease is still considered experimental.