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.

Keywords: Endoscopic Submucosal Dissection; Endoscopic Surgery; Esophagus; Foregut Surgery; Motility.

Figure 1:

Diagnostic modalities for patients with achalasia. (A) Esophageal pressure topography plot from a high-resolution manometry study of a patient with Type 1 achalasia. (B) Timed barium esophagram from the same patient. (C) EndoFLIP® 2.0 System (Medtronic, Minneapolis, MN).

Figure 2:

Animated and endoscopic depictions of per-oral esophageal myotomy. (A) A 1–2 cm mucosotomy is made with an electrocautery knife. (B) Within the submucosal tunnel, the muscle layers are oriented anteriorly and the mucosa is oriented posteriorly. (C) An electrocautery knife is used to fashion a selective circular myotomy, producing the cut circular muscle edges (purple dashes) and revealing the underlying longitudinal muscle (orange dashed lines). (D) Completed myotomy. Note the cut circular muscle edges and intervening longitudinal muscle, which may splay in segments of the myotomy. Animations reprinted with permission of Eric Hungness and David Botts, Northwestern University (25).