Endoscopic approaches to treatment of achalasia

Abstract

Endoscopic therapy for achalasia is directed at disrupting or weakening the lower esophageal sphincter (LES). The two most commonly utilized endoscopic interventions are large balloon pneumatic dilation (PD) and botulinum toxin injection (BTI). These interventions have been extensively scrutinized and compared with each other as well as with surgical disruption (myotomy) of the LES. PD is generally more effective in improving dysphagia in achalasia than BTI, with the latter reserved for infirm older people, and PD may approach treatment results attained with myotomy. However, PD may need to be repeated. Small balloon dilation and endoscopic stent placement for achalasia have only been used in select centers. Per oral endoscopic myotomy is a newer endoscopic modality that will likely change the treatment paradigm for achalasia. It arose from the field of natural orifice transluminal endoscopic surgery and represents a scarless endoscopic approach to Heller myotomy. This is a technique that requires extensive training and preparation and thus there should be rigorous accreditation and monitoring of outcomes to ensure safety and efficacy.

Per-oral endoscopic myotomy white paper summary

“…44 An alternative technique, possibly more accessible to those with modest ESD experience, uses a through-the-scope dilation balloon such as a short-nosed biliary extraction balloon or a longer esophageal dilation balloon (CRE; Boston Scientific, Natick, Mass) to dissect the submucosal tunnel without electrosurgery. 9,23 The group at Zhongshan Hospital, Shanghai, compared the T-type hybrid knife and triangular tip knife in a head-to-head, prospective, randomized study of 100 patients, which revealed shorter procedure time, lower bleeding rate, and less frequent use of coagulation forceps to control bleeding with the T-type hybrid knife. 44 No other comparative data exist regarding tunnel dissection techniques.…”

“…11 Indications, contraindications, and pre-procedural evaluation and preparation POEM appears to be a safe and effective alternative for the treatment of classic achalasia. [12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30] However, its role and efficacy in patients with other hypertensive motor disorders, prior conventional achalasia treatments, end-stage achalasia, age extremes, and significant comorbid diseases is not clear.…”

Peroral endoscopic myotomy: a literature review and the first UK case series

“…13 There is no current age limit for the procedure: the youngest patient to date being 3 years and the oldest 93 years old. 14,15 Of particular note is the versatility and efficacy in patients who have undergone previous endoscopic therapy or LHM, and indications for the procedure have expanded to include a spectrum of spastic oesophageal motility disorders. [16][17][18] Contraindications to POEM include refractory achalasia with mega-oesophagus, significant oesophageal scarring secondary to oesophageal radiation therapy, oesophageal mucosal resection or ablation.…”

The last innovation in achalasia treatment; per-oral endoscopic myotomy

“…Until 2010, there were 4 different treatment modalities for patients with achalasia, including medical treatment with drugs such as calcium channel blockers, botulinum toxin injections, pneumatic dilatation, and surgical myotomy (2). In 2007, submucosal endoscopy and transesophageal mediastinoscopy were performed with "mucosal flap safety valve (SEMF) technique" on the basis of natural orifice transluminal endoscopic surgery (NOTES) by Sumiyama et al (3).…”

“…Esophageal manometry findings are characteristic (1). Although there are different treatment options for achalasia, they all aim to improving the passage of solids and liquids through the gastroesophageal junction (GEJ) (2).…”