Advances in Management of Esophageal Motility Disorders

Peter J. Kahrilas; Albert J. Bredenoord; Dustin A. Carlson; John E. Pandolfino


Clin Gastroenterol Hepatol. 2018;16(11):1692-1700. 

In This Article


High-resolution manometry and the CC have led to a major restructuring in the classification of esophageal motility disorders. Along with this has come the recognition that a defining feature of the major esophageal motility disorders is obstructive physiology, whether the EGJ, the distal esophagus, or both (Figure 1). Although the CC has helped crystallize esophageal motility diagnoses, especially the varied phenotypes of achalasia, it has also led to the realization that there are circumstances beyond types I, II, and III achalasia in which therapies once reserved for achalasia are beneficial. Furthermore, because no HRM pattern or metric is absolutely sensitive or specific for idiopathic achalasia, complementary assessments with provocative maneuvers during HRM or interrogating the EGJ with the FLIP during endoscopy can be useful in clarifying equivocal or inexplicable HRM findings. The emerging methodology of FLIP Panometry (Figure 2) is also promising in this regard. Recognizing obstructive physiology as a primary target of therapy has become particularly relevant with the development of a minimally invasive technique for performing a calibrated myotomy of the esophageal circular muscle, the POEM procedure. With the widespread adoption of POEM, there has come a shift in management strategy toward rendering treatment in a phenotype-specific manner, eg, POEM calibrated to patient-specific physiology as defined by HRM for the spastic disorders and PD for the disorders limited to the LES. Table 2 details important treatment considerations for therapeutic interventions for the major esophageal motility disorders as defined by CC v3.0 from the perspectives of the authors. Clearly, there are substantial limitations to the current data set in defining the optimal treatment for esophageal motility disorders as currently conceptualized, and there are often major issues with the available expertise, but all things being equal, this is what we glean from the best evidence currently available.