 | |  | |  | |  | |  |
management of achalasia.
Treatments for achalasia include oral medications, dilation or stretching of the lower esophageal sphincter, surgery to cut the sphincter
(esophagomyotomy), and the injection of botulinum toxin (Botox) into the sphincter. All four treatments reduce the pressure within the lower
esophageal sphincter to allow easier passage of food from the esophagus into the stomach.
Home treatments
Here is a list of some home remedies that work for some that suffer from NCCP (non cardiac chest pains or spasms)
Oral medications
Oral medications that help to relax the lower esophageal sphincter include groups of drugs called nitrates, e.g., isosorbide dinitrate (Isordil) and
calcium-channel blockers, e.g., nifedipine (Procardia) and verapamil (Calan). Although some patients with achalasia, particularly early in the
disease, have improvement of symptoms with medications, most do not. By themselves, oral medications are likely to provide only short-term and
not long-term relief of the symptoms of achalasia, and many patients experience side-effects from the medications.
Botulinum toxin- BOTOX
The newest treatment for achalasia is the endoscopic injection of botulinum toxin into the lower sphincter to weaken it. Injection is fast,
nonsurgical, and requires no hospitalization. Treatment with botulinum toxin is safe, but the effects on the sphincter often last only for months,
and additional injections with botulinum toxin may be necessary. Injection is a good option for patients who are very elderly or are at high risk for
surgery, e.g., patients with severe heart or lung disease. It also allows patients who have lost substantial weight to eat and improve their
nutritional status prior to “permanent” treatment with surgery. This may reduce post-surgical complications. This treatment option can leave
some scar tissue, making further difficulties for future surgeries and other procedures.
Dilation
The lower esophageal sphincter also may be treated directly by forceful dilation. Dilation of the lower esophageal sphincter is done by having the
patient swallow a tube with a balloon on the end. The balloon is placed across the lower sphincter with the help of x-ray, and the balloon is blown
up suddenly. The goal is to stretch--actually to tear--the sphincter. The success of forceful dilation has been reported to be between 60 and
95%. Patients in whom dilation is not successful can undergo further dilations, but the rate of success decreases with each additional dilation. If
dilation is not successful, the sphincter may still be treated surgically. The main complication of forceful dilation is rupture of the esophagus,
which occurs 5% of the time. Half of the ruptures heal without surgery, though patients with rupture who do not require surgery still must be
followed closely and treated with antibiotics. The other half of ruptures require surgery. (Although surgery carries additional risk for the patient,
surgery can repair the rupture as well as permanently treat the achalasia with esophagomyotomy.) Death following forceful dilation is rare.
Dilation is fast, inexpensive compared with surgery, and requires only a short hospital stay. This treatment option can leave some scar tissue,
making further difficulties for future surgeries and other procedures.
Esophagomyotomy
The sphincter also can be cut surgically, a procedure called esophagomyotomy or sometimes refereed to as a "Heller Myotomy". The surgery
can be done using a large abdominal incision or laparoscopically through small punctures in the abdomen. In general, the laparoscopic
approach is used with uncomplicated achalasia. Alternatively, the surgery can be done with a large incision or laparoscopically through the
chest. Esophagomyotomy is more successful than forceful dilation, probably because the pressure in the lower sphincter is reduced to a greater
extent and more reliably; 80-90% of patients have good results. With prolonged follow-up, however, some patients develop recurrent dysphagia.
Thus, esophagomyotomy does not guarantee a permanent cure. The most important side effect from the more reliable and greater reduction in
pressure with esophagomyotomy, is reflux of acid (gastroesophageal reflux disease or GERD). In order to prevent this, the esophagomyotomy
may be modified so that it doesn’t completely cut the sphincter or the esophagomyotomy may be combined with anti-reflux surgery
(fundoplication). There are different types of fundoplications. This is usually either an anterior (Dor) or posterior (Toupet) fundoplication. Please
see the prior link for further explanation of these. Whichever surgical procedure is done, some physicians recommend life-long treatment with
oral medications for acid reflux. Others recommend 24 hour esophageal acid testing with lifelong medication only if acid reflux is found.
Esophagectomy?
Esophagectomy (partial or full removal of the esophagus surgically) is typically ONLY recommended as a treatment for high-grade dysplasia or
cancer in Barrett's esophagus. This is because most patients who have Barrett's esophagus never develop cancer and the risk of complications
from the surgery is too great to justify removing the esophagus of all patients who have Barrett's esophagus.
In patients who have high-grade dysplasia, the goal of surgery is to remove all of the Barrett's lining to completely eliminate the risk of developing
a large and incurable esophageal adenocarcinoma (Barrett's associated cancer). Additionally, if the patient is found at surgery to have an
unsuspected cancer, early surgical treatment gives the patient the best chance for cure and the only treatment that allows patients to safely stop
endoscopic biopsy surveillance because all of the Barrett's lining at risk for cancer is removed along with the esophagus. The diagnosis of high-
grade dysplasia should always be confirmed by an experienced GI pathologist prior to recommending esophagectomy as treatment for high-
grade dysplasia.
Because not all patients who have high-grade dysplasia develop cancer when followed for many years by endoscopic biopsy surveillance, other
options for these patients include ablation therapies or remaining in endoscopic biopsy surveillance without treatment. All patients who elect
either of these options should undergo frequent endoscopic biopsy surveillance and if cancer is detected, esophagectomy is usually
recommended. Strong consideration should be given to referring all patients with a diagnosis of high-grade dysplasia to a large specialty center
that has esophageal surgeons and gastroenterologists experienced in the management of these patients.
In patients who have esophageal cancer without metastatic disease (spread of cancer to other organs) and who are good surgical candidates,
surgery is performed with the intention of a possible cure and to allow the patient to swallow. In some patients, chemotherapy and radiation
therapy may also be recommended. Most patients who have developed esophageal cancer come to the doctor because they are having
problems swallowing food. Very few patients who develop esophageal cancer were in an endoscopic surveillance program and had their cancer
detected early. Patients who have surgery for a cancer found in Barrett's esophagus have all of the Barrett's lining removed as well as the
cancer to eliminate the risk of developing another cancer in the future or missing an unsuspected second cancer that can also be present in the
Barrett's tissue.
Surgical techniques
Two commonly performed surgical techniques are the "transhiatal esophagectomy" and the "transthoracic esophagectomy" (Ivor-Lewis
Procedure). Both of these surgeries involve removing the patient's esophagus and top part of the stomach. A portion of the stomach is then
pulled up into the chest and connected to the remaining normal portion of the esophagus. The patient then has a "new" esophagus made up of
the normal portion of the esophagus not removed at surgery connected to a portion of the stomach pulled up into the chest.
Both of these esophagectomy surgeries have similar cure rates and complication rates and these should be discussed with the surgeon prior to
the operation. There are advantages and disadvantages in using either surgical technique. In general, the type of surgery performed depends
on many factors. Some of these factors are: age of the patient; size and location of the cancer; whether the cancer has grown into other
structures in the chest, such as the lungs or large blood vessels; overall health of the patient, and even the experience of the surgeon in
performing a particular surgical technique. Therefore, the type of surgery chosen should be individualized to meet the needs of the patient being
treated. It is desirable for the surgeon to be flexible and experienced with both techniques.
Some centers are now performing minimally invasive esophageal surgery. Minimally invasive esophageal surgery may offer the advantage of a
quicker recovery and fewer complications, but , how it compares to conventional surgical techniques is unknown. The experience in performing
this procedure is limited to very few specialty centers. Studies comparing minimally invasive surgery to conventional esophagectomy with longer
follow-up are needed to confirm that there are advantages of minimally invasive esophagectomy as compared to conventional esophagectomy.
At the present time, conventional surgical approaches remain the standard operations in most specialty centers.
Surgeon experience and rate of mortality
Several large studies now confirm that whether a patient has a good result from the esophagectomy surgery is highly dependent on the number
of esophagectomies performed at the medical center where the surgeon operates. In the hands of an experienced esophageal surgeon who
performs these surgeries in a center experienced in the care of patients who undergo esophagectomy, the mortality (rate of death) is around 3-
8%. On the other hand, the surgical mortality in low volume centers is in the range of 16-23%. Because esophagectomy is a technically difficult
surgery, the surgeon needs to be a specialist in esophageal surgery and be regularly performing these procedures in a medical center with
experience in the care of these patients. Therefore, one should undergo esophagectomy only in the hands of an EXPERIENCED esophageal
surgeon who has a surgical mortality of no greater than 5% and who is regularly performing these procedures in a large specialty center.
Any procedure and or surgery are only to improve how food and liquids travel down the esophagus and enter the stomach. They
are NOT a cure and they do NOT return peristalsis to normal.