February 26, 2018
A Promising New Surgical Technique for Achalasia
Matthew Brengman, MD, FACS
Achalasia is a relatively rare disorder of the muscle of the esophagus. The esophagus is a muscular tube that carries food and liquids from the mouth to the stomach. In achalasia, the muscle at the bottom of the esophagus doesn't open appropriately. Achalasia makes it difficult for food and liquid to pass into the stomach from the esophagus. There are traditional surgical and non-surgical treatment options for the disorder, as well as a newer surgical alternative, called Peroral Esophageal Myotomy (POEM).
What causes achalasia?
A muscle called the lower esophageal sphincter (LES) is located where the esophagus meets the stomach. When not swallowing, the LES remains closed to keep food, liquid, and stomach acid from moving back into the esophageal tube. When swallowing, nerve signals control the muscles in order to push food down the esophagus, and telling the LES to open. This process is called peristalsis.
In people with achalasia, the nerve cells in the lower esophageal tube and the LES do not work correctly. This results in missing peristaltic (muscular) activity and failure of the LES to open completely. While achalasia is associated with the loss of nerve cells in the esophagus, the cause is unknown.
What are the symptoms of achalasia?
Symptoms of achalasia usually occur between the ages of 25 and 60, and rarely develop in children. Symptoms tend to be mild at first, and then grow worse over months or years. The main symptom is difficulty swallowing solids and, as the condition progresses, liquids. Nearly all people with achalasia eventually have difficulty swallowing both solids and liquids.
Other symptoms may include:
- Discomfort or pain in the chest, especially after meals.
- Coughing, especially when lying down.
- Weight loss, especially as the condition progresses.
- Vomiting or regurgitating food or liquids. This may occur during sleep, and can cause a person to inhale food particles or liquid, leading to aspiration pneumonia or other respiratory infections.
- Heartburn (Reflux Disease).
Are there risk factors for developing achalasia?
A risk factor is something that increases your chances of developing a certain disease or condition. In the case of achalasia, there are no known risk factors. Because there are no known risk factors, there currently is no protocol for preventing achalasia.
How is achalasia diagnosed?
The doctor will review a patient’s medical history, and a physical exam will be performed. Tests be performed, including:
- Manometry: A tube is inserted down the throat to test the pressure in the esophagus and the stomach when swallowing.
- Upper GI Series: X-rays are taken with contrast material (also called a barium swallow).
- Upper GI Endoscopy: The esophagus is viewed directly through a fiberoptic tube with a camera on it that is inserted into the esophagus to look for other causes of the symptoms.
What are traditional treatment options for achalasia?
The goal of treating achalasia is to make it easier for the lower esophageal sphincter to open. Traditional treatment options include:
- Pneumatic Dilation (PD): This treatment stretches the LES muscle. A thin tube with an uninflated balloon is inserted into the throat. When the tube reaches the LES muscle, the balloon is inflated. Pneumatic dilation has a high success rate and is a widespread treatment for achalasia, although the procedure frequently needs to be repeated.
- Laparoscopic Heller Myotomy (LHM) Surgery: The circular lower esophageal sphincter muscle is divided to open the sphincter. Because the LES is divided, some people experience gastroesophageal reflux symptoms after surgery, and the procedure sometimes has to be repeated.
- Botulinum Toxin: Tiny amounts of botulinum toxin type A are injected into the LES. Botulinum causes the LES to relax, which makes it easier to open. Since the effect is temporary, repeat injections are almost always needed, but the response decreases with each injection.
- Medication: Certain medications may help those that cannot tolerate surgery and do not have success with botulinum therapy. The symptom relief is temporary.
Are there newer treatment options for achalasia?
Peroral Esophageal Myotomy (POEM) is a newer treatment for achalasia, and is considered an important advance in gastroesophageal surgery. POEM combines the use of an endoscope, a thin tube with a camera on the end, with a more minimally invasive surgical technique than Laparoscopic Heller Myotomy (LHM). As a result, it has quickly been adopted by many surgeons and gastroenterologists as a safe, effective option for those suffering from achalasia.
Compared to more traditional techniques, POEM has a high success rate. Benefits include:
- Minimally invasive compared to other techniques.
- Allows for a longer myotomy (cut) than LHM, likely improving the long-term outcome, and reducing the need for repeated surgery.
- Fewer complications than LHM surgery.
- Minimal discomfort after surgery.
- Successful treatment in cases where other treatments failed.
While POEM has many advantages, there are some other considerations, such as general anesthesia and length of hospital stay. As with any medical procedure, you should check with your provider to weight all circumstances and health factors before determining a course of treatment.
Jama Surgical Innovation
National Institutes of Health (NIH)