Achalasia of the oesophagus

This is mainly accomplished by reducing the lower oesophageal sphincter pressure because peristalsis rarely returns with therapy. This can be done with drugs, endoscopic dilatation, surgical myotomy and the latest treatment POEM (per-oral endoscopic myotomy).

No drugs give long term improvement. Those tried include nitrates, theophylline, calcium channel blockers, particularly nifedipine and botulinum toxin.

Endoscopic dilatation to a diameter of 30 mm is needed to tear the muscle in the lower oesophageal sphincter and achieve long lasting reduction of sphincter pressure in these patients. Studies suggest resolution of dysphagia in 32-98% of patients with younger patients and those with a shorter duration of symptoms doing less well than older patients. If initial success is achieved, only small numbers will need repeat dilatation at a later stage. In the last few years, it has become clear that doing two dilatations a few weeks apart, the first to 30mm and the second to 35mm diameter gives a better functional outcome.

Surgical myotomy (dividing the muscle in the oesophageal wall) is associated with good functional improvement in 65-92% of patients. Gastroesophageal reflux may occur after surgery in anything up to a half of patients. Myotomy and endoscopic dilation can both be used in the same patient at different times. So if a patient has initially benefited from dilation and later on the problem returns, surgery can be considered. Similarly, if surgery has worked initially but symptoms return, endoscopic dilation can be considered at that time.

POEM is a relatively new treatment. This is a hybrid between traditional endoscopic and surgical techniques. It appears to be as good as either of the more established techniques and may have a particular benefit in patients with type 3 achalasia.

If you wish to discuss achalasia and its treatments in London with one of our specialists, please do get in touch.