There are several treatment options for patients with achalasia. Surgical correction provides the most definitive results, and has the best long term outcome, however occasionally in patients with serious medical conditions, non surgical therapy may be preferable. Occasionally patients may get mild temporary relief from medications that relax smooth muscle such as nitrates or calcium channel blockers, however that relief is often minimal and short lived.
Botulinum toxin (Botox) injected into the lower esophageal sphincter (LES) under endoscopic guidance can be used to temporarily relax the muscle and improve swallowing. Symptom relief after botox therapy usually last 4 to 6 months.
Using a specially designed balloon placed into the esophagus, the lower sphincter can be forcefully dilated. This technique splits some of the muscle fibers in the lower sphincter. Approximately 60% of patients experience some improvement in their swallowing after dilation. The procedure is best performed by a gastroenterologist who specializes in achalasia and who has performed many esophageal dilations, because there is a risk of perforating the esophagus, which has to be repaired with surgery.
Because the results of pneumatic dilatation are unpredictable, laparoscopic myotomy is a far better treatment option. Laparoscopic myotomy is safe and results are more predictable.
Laparoscopic Heller Myotomy and Fundoplication
The most effective treatment for achalasia is Heller myotomy (esophagomyotomy), a procedure in which the muscle fibers of the lower esophageal sphincter (LES) are divided. After completing the myotomy, a partial fundoplication or "wrap" at the area of the LES is added in order to prevent acid reflux, which may cause esophagitis and lead to serious damage to the esophagus over time.
Although Heller myotomy can done through the chest, today it is always performed laparoscopically through small incisions in the abdomen, which affords a faster recovery and return to normal activities. Long term studies have shown over 90% of patients still have improved swallowing, eating, and quality of life, ten years after a laparoscopic Heller myotomy.
Per Oral Endoscopic Myotomy (POEM)
Per Oral Endoscopic Myotomy (POEM) is a new and emerging endoscopic technique to treat achalasia. During POEM, the muscle is cut from inside the esophagus without surgery. Data so far indicate that over 90% of patients experience short-term relief of symptoms after the procedure. POEM may prove to combine the benefits of minimally invasive endoscopy with the long-term benefits of surgical myotomy; the technique is currently under careful study at this time.