Treatment of idiopathic achalasia with per-oral esophageal myotomy

Abstract

Achalasia is a rare esophageal motility disorder that necessitates the disruption of the lower esophageal sphincter. Patients with achalasia should be evaluated in a systematic, multidisciplinary fashion. Workup should include upper endoscopy, esophagography, and high-resolution manometry. The gold standard for surgical treatment is laparoscopic Heller myotomy with partial fundoplication. Per-oral esophageal myotomy is a novel endoscopic technique that has gained considerable traction over the past decade. The procedure includes the creation of a submucosal tunnel and a selective circular myotomy of the lower esophageal sphincter. Common intra-operative hazards include bleeding within the submucosal tunnel and capnoperitoneum. Significant complications are rare. Patients experience excellent dysphagia relief that is on par with laparoscopic Heller myotomy at moderate-term follow up. Post-operative gastroesophageal reflux disease occurs in greater than one-third of patients, and the vast majority of cases are readily controlled with an anti-secretory medication. Although data is sparse, there is a growing body of literature that supports the long-term durability of per-oral esophageal myotomy.

Outcomes of 100 Patients More Than 4 Years After POEM for Achalasia

“…Our operative technique has been described in detail. 18,19 Briefly, after mucosotomy (in an anterior, 12 to 1 o'clock position) and submucosal tunnel creation, a selective myotomy of the circular fibers is completed along the esophagus, esophagogastric junction (EGJ), and stomach. The extent of our standard myotomy is 6 cm proximal to the EGJ and 2 to 3 cm distal to the EGJ.…”