Surgical treatment for achalasia: when should it be performed, and for which patients?

Abstract

Achalasia is a rare motor disorder of the esophagus, characterized by the absence of peristalsis and impaired swallow-induced relaxation. In the past decade, evidence has been accumulated suggesting that achalasia may be an immune-mediated inflammatory disorder. With the advent of minimally invasive surgery, laparoscopic Heller myotomy (LHM) has slowly shifted the treatment of achalasia toward the greater use of surgical therapy. The goal of both surgical and nonsurgical treatment is to eliminate the outflow obstruction afforded by a nonrelaxing sphincter, relieving dysphagia and maintaining a barrier against gastroesophageal reflux (GER). Endoscopic botulinum toxin injection (EBTI) is safe, easy to perform, inexpensive, and effective in aged patients, and it is especially effective when the lower esophageal pressure is hypertonic. This therapeutic option is reserved for patients too ill to undergo any surgical procedure. Pneumatic dilation (PD) has been shown to be an effective and inexpensive treatment with few adverse effects. The long-term success rate of PD seems to drop progressively over time. Heller myotomy (HM) has shown the best clinical efficacy in achalasia as a first-line treatment. Multiple endoscopic treatments are associated with poorer outcomes after HM. EBTI also makes LHM more difficult and results in a worse surgical outcome. The inferior symptomatic outcomes after thoracoscopic HM may be caused by the difficulty in extending an adequate myotomy onto the stomach from the chest and the inability to create a fundoplication. LHM with Dor's fundoplication (LHM + Dor) is effective and is safer procedure for avoiding GER, dysphagia, mucosal perforation, and a pseudodiverticulum. LHM + Dor is also effective in the presence of sigmoid achalasia, but the clinical result is not as good as nonsigmoid achalasia. A few patients need esophagectomy for surgical failure of HM. However, considering the risk of esophagectomy, LHM + Dor is the first treatment option for patients with achalasia regardless of the degree of esophageal dilatation. This procedure is therefore considered to be an effective and safe treatment for patients of any age or with any condition.

Comparison of conventional versus Hybrid knife peroral endoscopic myotomy methods for esophageal achalasia: a case–control study

“…Achalasia is a rare disorder of esophagus, with an estimated incidence of 1 in 100,000 per year [15]. Despite an increasing understanding of its pathophysiology, the etiology of achalasia still remains unknown [16].…”

Training in peroral endoscopic myotomy (POEM) for esophageal achalasia

“…Therapy has focused mainly on the forced relaxation of the lower esophageal sphincter (LES) by endoscopic or surgical means 7–17. As few randomized control trials have tried to determine the optimal strategy, treatment still varies widely 18,19…”

Cervical oesophagostomy in patients with severe dysphagia following radiotherapy for nasopharyngeal carcinoma

“…Severe dysphagia indicates a requirement for feeding tube placement. Moderate dysphagia can be relieved by such procedures as cervical oesophageal balloon dilatation, 8 cricopharyngeal myotomy 9 , 10 and laryngeal elevation 11 . However, severe oropharyngeal dysphagia is difficult to ameliorate, even using laryngotracheal closure 12 or laryngectomy; patients with severe trismus and bilateral hypoglossal nerve palsy are especially difficult to treat.…”