Treatment of Achalasia Without Surgery
Achalasia is an esophageal disorder that makes it difficult to swallow food and drinks. This rare condition affects the lower esophageal sphincter, the muscle located at the bottom of the esophagus between the esophagus and the stomach. A spasm occurs in this muscle, preventing it from relaxing properly, due to the degeneration of nerve connections in the esophageal wall.
When swallowing food, it passes from the mouth into the esophagus, where the muscles contract to push the food down toward the stomach. The food reaches the lower esophageal sphincter (LES) at the end of the esophagus, where it meets the stomach. This sphincter is a ring of muscles that relaxes to open and allow the food to pass into the stomach.
In dysphagia (achalasia), the esophageal muscles do not contract properly, hindering food movement down to the stomach. At the same time, the lower esophageal sphincter fails to relax correctly, meaning that food cannot pass into the stomach and remains in the esophagus.
Symptoms of Achalasia:
Patients with achalasia may experience any or all of the following symptoms:
• Difficulty swallowing while eating, often requiring the patient to drink water to help push food down the esophagus to the stomach.
• Bad breath, despite good oral hygiene, due to food accumulation and fermentation in the esophagus.
• Chest pain resulting from esophageal dilation or abnormal contractions in the esophageal muscles is associated with achalasia. Some may confuse this pain with heart problems like angina, but it actually originates from the esophagus.
• Regurgitation of food into the mouth, In advanced cases, persistent vomiting may occur, leading to a feeling of choking and suffocation, especially during sleep.
• Noticeable weight loss due to the inability to deliver food to the stomach for digestion, preventing it from reaching the intestines for calorie absorption.
Three diagnostic methods for achalasia:
1. Endoscopy: Endoscopy, which involves inserting a flexible tube through the mouth, is a non-surgical method used for the initial diagnosis of achalasia. A thin, illuminated tube is inserted through the mouth, throat, and esophagus to examine the internal condition of the esophagus and evaluate any changes indicating the presence of achalasia. The goal of endoscopy is to rule out other causes, such as tumors, that may be responsible for similar symptoms.
2. Upper Gastrointestinal Barium Contrast Radiography: This involves conducting X-rays after drinking a white, non-colored substance. The descent of this substance through the esophagus is photographed to assess any delays in reaching the stomach. Barium X-rays evaluate the esophagus above the lower esophageal sphincter and examine its dilation.
3. High-Resolution Manometry: This test is essential for confirming the diagnosis of achalasia, as it accurately measures pressure within the esophagus and the length of the lower esophageal sphincter and it determines the type of achalasia. It also diagnoses other esophageal motility disorders.
Types of Achalasia:
Achalasia is classified into three types, not grades, and is determined through high-resolution manometry. Identifying the type of achalasia is vital for selecting the appropriate treatment:
• Type 1: Characterized by the lack of relaxation of the lower esophageal sphincter and the absence of contractions in the upper esophagus, known as classic achalasia.
• Type 2: Characterized by the lack of relaxation of the lower esophageal sphincter, along with contractions from the esophageal muscles overall.
• Type 3: Characterized by the lack of relaxation of the lower esophageal sphincter, along with severe contractions along the esophagus. This rare type of achalasia often affects older adults the most.
Treatment methods for Achalasia:
Less common methods:
• Medication: This includes muscle relaxants, heart medications, and antihypertensive drugs such as nitrates or calcium channel blockers, which allow the lower esophageal sphincter to relax. However, the effects of medication are usually temporary, requiring repeated treatments as they provide only immediate relief.
• Botox Injections: This causes temporary paralysis of the sphincter muscle, but symptoms of difficulty swallowing typically return within weeks or months as the effects of Botox wear off.
Three basic methods of treatment:
The therapeutic approaches aim to relax or open the lower esophageal sphincter, allowing food and liquids to pass more easily from the esophagus to the stomach. There are three known methods for treating achalasia:
1. Balloon Dilatation via Endoscopy:
This procedure uses a guidewire inserted through the endoscope, followed by the insertion of a dilation balloon after locating the lower esophageal sphincter with imaging guidance. The balloon is gradually inflated to achieve dilation. Balloon dilation is for Type 1 achalasia and some cases of Type 2 only.
One issue with this procedure is the lack of complete control over the muscle's response, which can vary from patient to patient. There is a 5% risk of perforating the esophageal wall, which requires prompt intervention to close the perforation, potentially necessitating a surgical procedure. The patient may also require multiple dilation sessions, and in some cases, doctors may resort to performing a myotomy on the sphincter muscle.
2. Esophageal Myotomy (Heller’s Myotomy):
This procedure involves cutting the lower esophageal sphincter and a small portion of the lower esophageal muscle through a surgical abdominal incision or using laparoscopic surgery. This allows for easier passage of food through the sphincter and enables the patient to resume his normal diet within two weeks after the surgery. This method is suitable for Type 1 achalasia and some cases of Type 2 only.
This traditional approach was the most common solution for achalasia until 2010; however, it presents challenges such as its surgical nature, which exposes the patient to surgical complications, a longer recovery time, the risk of infection, and external wounds. It also requires a specialized gastrointestinal surgeon for the procedure.
3. Per Oral Endoscopic Myotomy (POEM):
The modern and advanced "POEM" technique is the latest global method for treating achalasia endoscopically without surgical incisions, utilizing third-space endoscopy. This helps patients regain their normal lives and completely overcome swallowing issues. This method was first introduced in 2010.
POEM is similar to surgical myotomy in that it involves cutting the lower esophageal sphincter and adjacent muscles, but it is:
• Less invasive as the procedure is performed orally.
• Without surgical intervention.
• Superior to surgery for Type 2 and Type 3 achalasia cases.
• Without external incisions or drains.
• Patients can drink the day after the procedure and resume normal activities within 4 to 5 days.
• Shorter hospital stay.
Steps to treat difficulty swallowing without surgery:
1. The patient is placed under general anesthesia.
2. Dr. Shaimaa El Kholy inserts an endoscope—a thin, flexible tube equipped with a camera and surgical instruments—into the patient's mouth and directs it to the esophagus.
3. The endoscope can be passed through a temporary tunnel created in the middle layer of the esophageal tissue, specifically in the third layer, which has the property of expansion, allowing sufficient space for the endoscope to pass through. Dr. Shaimaa guides the endoscope through this tunnel until it reaches about 2-3 cm below the lower esophageal sphincter as a safety margin.
4. Once there, Dr. Shaimaa uses precise instruments to make an incision of appropriate length in the muscle layer, using an electrocautery knife to cut the tissue and seal any blood vessels.
5. The small opening, which does not exceed 1 cm, is then closed using clips that will dissolve spontaneously within ten days.
This modern method is the optimal solution for treating various types of achalasia (Types 1, 2, and 3). It is a last-resort option for patients who have not responded to all previous treatment methods, including surgery. It is safe for patients of all ages, including children and the elderly. Global studies have shown that the POEM technique is extremely secure and achieves a technical success rate approaching 100%.
Dr. Shaimaa El Kholy, Associate Professor of Advanced Interventional Gastrointestinal Endoscopy (ESD & Third Space Endoscopy), Faculty of Medicine, Cairo University, has extensive experience in this field and was part of the pioneering team that introduced this innovative technique to Egypt and the Arab world, achieving significant success and establishing it as a trusted center both in Egypt and internationally.