Surgical and endoscopic approaches to achalasia: what does the evidence say

Achalasia is a rare primary esophageal motility disorder characterized by failure of the lower esophageal sphincter (LES) to relax and absence of normal peristalsis in the esophagus. Patients typically present with progressive dysphagia to both solids and liquids, regurgitation, chest pain, and weight loss. Diagnosis is confirmed by high-resolution manometry demonstrating incomplete LES relaxation and aperistalsis, with supportive findings on barium esophagram (e.g. “bird’s beak” narrowing) and endoscopy to exclude pseudo achalasia. Achalasia is subdivided into three manometric subtypes (I–III) based on esophageal pressure patterns, which have prognostic significance. Treatment is directed at relieving the distal esophageal obstruction, with options including pneumatic balloon dilation, laparoscopic Heller myotomy (LHM) with partial fundoplication, and peroral endoscopic myotomy (POEM). Botulinum toxin injection is reserved for high-risk patients. Current evidence from guidelines and recent studies indicates that LHM and pneumatic dilation have comparable efficacy in appropriate candidates, and POEM offers similar symptomatic relief to LHM. Manometric subtype guides therapy—type II achalasia responds best to any therapy, whereas type III often benefits from a tailored myotomy approach. The addition of fundoplication to Heller myotomy significantly reduces post-treatment reflux without compromising achalasia symptom control. In pediatric achalasia, Heller myotomy yields superior long-term outcomes compared to dilations. Robotic-assisted Heller myotomy is an emerging technique showing comparable efficacy to LHM with a potential reduction in perforation risk. An individualized, patient-centered approach - considering achalasia subtype, patient age/comorbidity, and available expertise is essential to optimize outcomes. This review synthesizes the current evidence on achalasia management, highlighting the role of Heller myotomy relative to other therapies in light of recent clinical guidelines and studies.