Peroral endoscopic myotomy (POEM) for achalasia

Peroral endoscopic myotomy (POEM) is a minimally invasive intervention that aims to treat achalasia. It is regarded as the endoscopic equivalent of Heller myotomy.

 Why These Two Words Now Shape My Life With Achalasia Disorder

I never expected these two words would ever describe my life, and now they have become a massive part of it in the last 11 months – “rare” and “incurable.” I was diagnosed with Achalasia disorder in November 2017, after six weeks of not being able to swallow solids or liquids. I was dismissed by doctors for weeks, as I continued to lose weight everyday and become dehydrated drastically.

Stuck in the Middle - An Approach to Achalasia

In this episode, we review the pathophysiology, history, work-up and management of Achalasia. Our medicine minute discusses the trial "Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia" published in NEJM in 2019.

A minimally invasive solution to an uncomfortable issue

POEM is a surgical treatment, and, as with all treatments, there are pros and cons to consider. There are less invasive treatments, such as Botox® injections to the muscle and balloon dilation, but surgical options can have longer, sustained effects. In the past, the surgery was only done through external laparoscopic incisions, referred to as “Heller myotomy”. With POEM, we make those incisions internally, which has obvious advantages in recovery. Additionally, the surgery can be tailored to the subtype of achalasia and the patient’s anatomy.

Achalasia - An Update

Achalasia is an esophageal motility disorder of unknown cause, characterized by aperistalsis of the esophageal body and impaired lower esophageal sphincter relaxation. Patients present at all ages, primarily with dysphagia for solids/liquids and bland regurgitation. The diagnosis is suggested by barium esophagram and confirmed by esophageal manometry.

Achalasia in a 16-Year-Old: Diagnostic Dilemma

Achalasia is a rare disorder that usually presents between the age of 25 and 40. Establishing an early diagnosis in children can be challenging since more than half of the cases are diagnosed at an older age creating a diagnostic dilemma for pediatricians and gastroenterologists.

Achalasia—an unnecessary long way to diagnosis

Dysphagia, regurgitation, atypical chest pain, and weight loss are patients’ complaints in the daily practice of gastroenterologists and foregut surgeons... However, apparently only few physicians consider other rare diseases, such as achalasia, although the symptoms mentioned above represent the most common complaints found in idiopathic achalasia.

An Overview of Achalasia and Its Subtypes

Achalasia is one of the most studied esophageal motility disorders. However, the pathophysiology and reasons that patients develop achalasia are still unclear. Patients often present with dysphagia to solids and liquids, regurgitation, and varying degrees of weight loss. There is significant latency prior to diagnosis, which can have nutritional implications.

An Unusual Case of Dysphagia

Regurgitation of undigested food is an important diagnostic feature of esophageal achalasia, and rarely causes aspiration pneumonia. Some patients may also have heartburn, weight loss, cough, or chest pain.

Controversies in management of achalasia

Achalasia is the best characterized primary esophageal motility disorder of the esophagus and typically presents with absent peristalsis of the esophageal body and a failure of the lower esophageal sphincter to relax upon swallowing on manometry, associated with progressively severe dysphagia, regurgitation, aspiration, chest pain, and weight loss.

FAQs about Achalasia, Heller Myotomy, and POEM

Achalasia is believed to be caused by a loss of Auerbach's nerve plexus, which results in the lower esophageal sphincter failing to relax during swallowing. In most achalasia patients, their esophagus will have poor motility, and the esophagus will not push the food down toward the stomach.

Management of achalasia

Several theories on the etiology and pathophysiology of achalasia have been reported but, to date, it is widely accepted that loss of peristalsis and absence of swallow-induced relaxation of the lower esophageal sphincter are the main functional abnormalities. Treatment of achalasia often aims to alleviate the symptoms of achalasia and not to correct the underlying disorder. Medical therapy has poor efficacy, so patients who are good surgical candidates should be offered either laparoscopic myotomy or pneumatic balloon dilatation.

Mystery Solved: Jim's Story About Disease of Esophagus

Acha-What? Achalasia is a relatively rare disease, occurring in only one of 100,000 people. With achalasia, two problems occur: the esophagus fails to propel food down, and the sphincter where the esophagus meets the stomach fails to relax enough to let food through.

The Pathogenesis and Management of Achalasia: Current Status and Future Directions

Pneumatic dilation and surgical myotomy are the only definitive treatment options for patients with achalasia who can undergo surgery. Botulinum toxin injection into the lower esophageal sphincter should be reserved for those who cannot undergo definitive therapy.

Treatment challenges of sigmoid-shaped esophagus and severe achalasia

Achalasia is a chronic motility disorder which may require surgical interventions to effectively manage patients’ symptoms and improve functional status. In late stage achalasia, patients may present with sigmoid-shaped esophagus which complicates traditional treatment approaches for achalasia as the esophagus is massively dilated and dysfunctional with delicate tissue integrity.