Self-expandable metal stents for achalasia: Thinking out of the box!

Achalasia is a primary motor disorder of the esophagus diagnosed manometrically in the clinical setting of dysphagia to both solids and liquids. Currently established treatment options include pneumatic dilation, laparoscopic Heller myotomy, botulinum toxin injection performed endoscopically, oral agents that relax the lower esophageal sphincter and esophagectomy for refractory, end-stage disease. Despite their effectiveness, a significant proportion of patients eventually relapses and needs retreatment. In this setting, several new techniques are under investigation promising future enrichment of our therapeutic armamentarium for achalasic patients. Among them, peroral endoscopic myotomy and self-expandable metal stents placed across the gastro-esophageal junction represent the most encouraging modalities, as initial studies assessing their efficacy and safety indicate. This review highlights the role of self-expandable metal stents in the management of patients with achalasia. Their possible position in the therapeutic algorithm of achalasia along with established and novel techniques is also assessed. Finally, the need for large prospective randomized trials is underlined in order to elucidate the numerous relevant issues.