Achalasia- Gastroenterology

Achalasia is a digestive disorder that makes swallowing food and liquids difficult, with regurgitation occurring in about one-third of patients with this condition. Achalasia develops when the nervous tissue in the esophagus becomes damaged in some way, altering muscular contractions. This results in food and drink not being able to move down into the stomach.

Left untreated, achalasia can lead to complications. Patients can become malnourished, develop anemia or even pneumonia from aspirated food and drink.

Whom to see for achalasia?

Gastroenterologists diagnose and help formulate a treatment plan for achalasia.

Diagnosis

Diagnostic tests are performed to determine the type of achalasia and help establish which treatment method will work best for you. The tests include the following:

• Upper endoscopy: A flexible tube with a camera is used to examine your esophagus
• Barium esophagram: An X-ray is performed after you swallow barium to assess the functioning of the esophagus
• Esophageal manometry: This test assesses the functioning of the muscles in your esophagus

Treatment options for achalasia

There are broadly two ways in which achalasia can be treated. The choice of technique will depend on an individual’s age, how severe the problem is, and their general state of health. Achalasia cannot be cured, but treatments can help alleviate the symptoms. There are both surgical and non-surgical options for treating achalasia.

Non-surgical Options

Non-surgical options include the following:

Medication

Achalasia is usually treated with nitroglycerin and nifedipine. These two drugs help relax the muscles and are taken before meals. However, medication is not always effective.

Botox injections

The Botulinum toxin type A can be injected into the affected tissues of the lower esophageal sphincter to help relax the muscles. The injections are administered through an endoscope into the muscles of the lower esophageal sphincter (LES). This treatment has shown success, with up to 80% of patients experiencing an improvement in their symptoms.

Pneumatic dilation (PD)

This procedure is performed under sedation. It utilizes an endoscope with a balloon attached to it. Once the endoscope is inserted into the esophagus through the mouth, the balloon is expanded to widen the esophagus. The procedure generally works well, but most of the time, you need to have it done again (usually in about five years). Patients with type II achalasia often benefit the most from this procedure.

Surgical Options

The surgical treatment options for achalasia include the following:

Heller myotomy and partial fundoplication

This procedure works well for people with type III achalasia, which is also known as spastic achalasia. Heller myotomy is best done as a laparoscopic surgical procedure. However, an open procedure may be needed if the esophagus has a protruding pouch, known as epiphrenic diverticula, slightly above the lower esophageal sphincter (LES).

The patient is put under general anesthesia. The open procedure involves a large incision, whereas the laparoscopic method utilizes two or three small incisions to access the area. In myotomy, the surgeon cuts the muscle at the LES, enabling the food to enter the stomach.

After the myotomy is done, the surgeon often partially wraps the top section of the stomach around the LES in a technique known as partial fundoplication to avoid problems with GERD. The Heller myotomy and partial fundoplication procedure have a 90% success rate.

Post-operative care

The procedure generally gives good results, helping alleviate the symptoms. Patients often stay in the hospital for about 4 to 6 days.

• Barium esophagram: Follow-up X-rays, specifically a barium esophagram, are done to check that the procedure has worked as expected. With a barium esophagram, you need to swallow barium first, then X-rays are done.
• Medication for pain and nausea may be given.
• Post-surgery, your diet will start off with liquids and then gradually incorporate soft foods, progressing to more solid foods.

Complications

Although uncommon, there are possible complications of Heller myotomy, including:

• Barrett’s esophagus
• GERD: Unlikely if the procedure includes a partial fundoplication
• Esophagitis: Inflamed and infected esophagus
• Perforation of the esophagus
• Esophageal cancer

Peroral endoscopic myotomy (POEM)

This surgical procedure is not as invasive as Heller myotomy since POEM accesses the area through the mouth, meaning that no surgical incisions over the esophagus are needed. In this procedure, an endoscope is used, and certain muscles inside the esophagus, by the LES, are cut. The procedure is done entirely through an endoscope and is, therefore, considered less invasive than a Heller myotomy. The aim of POEM is to loosen the esophagus to improve swallowing. The overall success rate is about 90%.

Post-operative care

The procedure works well for most patients who have type I and II achalasia.

• Patients usually stay from two to three days in the hospital after undergoing a POEM
• You will be given medicine for nausea and pain
• An esophagram is usually done to check that there are no leaks from the surgical site
• You can only consume liquids and pureed foods for two weeks after the procedure

Complications

There are some potential complications of the procedure, which are listed below:

• GERD: This can be a side effect of the procedure. Patients may want a fundoplication procedure later if GERD becomes very problematic
• Esophagitis
• Pneumothorax: In this condition, the lung collapses
• Pneumomediastinum: Air becomes trapped between the lungs
• Bleeding

Esophagectomy 

This involves removing a portion or the entire length of the esophagus. This is not a common treatment for achalasia. Generally, this procedure is only done when the other methods have failed during end-stage achalasia and the esophagus is irreparably damaged and non-functional. The laparoscopic method of esophagectomy is preferred over open surgery.

Post-operative care

• Patients will often have a nasogastric (NG) tube in place for about a day after surgery
• There might be some discomfort if you had a laparoscopic procedure because of the carbon dioxide
• You will be treated for pain and discharged 1 to 3 days after surgery, depending on your recovery

Complications

The possibility of complications with an esophagectomy includes the following:

• Pulmonary complications: Lung problems such as pneumonia can occur
• Mediastinal bleeding: Bleeding in the chest cavity
• Anastomotic leak: a leak where a surgical connection fails
• Chylothorax: accumulation of lymph in the chest

References:

• Eckardt, A. J., & Eckardt, V. F. (2011). Treatment and surveillance strategies in achalasia: an update. Nature reviews Gastroenterology & hepatology, 8(6), 311-319.
• Moonen, A., Annese, V., Belmans, A., Bredenoord, A. J., Des Varannes, S. B., Costantini, M., ... & Boeckxstaens, G. E. (2016). Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut, 65(5), 732-739.
• Nurczyk, K., & Patti, M. G. (2020). Surgical management of achalasia. Annals of gastroenterological surgery, 4(4), 343-351.
• Orringer, M. B., & Stirling, M. C. (1989). Esophageal resection for achalasia: indications and results. The Annals of Thoracic Surgery, 47(3), 340-345.
• Vaezi, M. F., Pandolfino, J. E., Yadlapati, R. H., Greer, K. B., & Kavitt, R. T. (2020). ACG clinical guidelines: diagnosis and management of achalasia. Official journal of the American College of Gastroenterology| ACG, 115(9), 1393-1411.

To learn more about Achalasia, please check our blog on ACHALASIA TREATMENT OPTIONS (WITH AND WITHOUT SURGERY).

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