The following surgical procedures are used in the treatment of achalasia:
- Extramucosal myotomy (muscle splitting) of the lower esophageal sphincter (UES) (Gottstein-Heller operation) – can be performed surgically or laparoscopically (laparoscopic myotomy, LHM).
- Indication: alternative to balloon dilatation or after several dilatations have been performed with only short-term success.
- Success rate: up to 90%
- Lethality (mortality related to the total number of people suffering from the disease): < 0.3%.
- Complication: in about 10% of cases, the operation may be followed by occlusive insufficiency of the UES with subsequent reflux disease (frequent reflux (backflow) of acid gastric juice and other gastric contents into the esophagus (esophagus)).Note: In LHM, transection of the sphincter is combined with antireflux surgery.
- Peroral endoscopic myotomy (POEM) – endoscopic transection of the circular muscle fibers in both the tubular esophagus and the high-pressure zone of the lower esophageal sphincter (LES).
- High clinical efficacy and a low procedural complication rate (complication during the procedure).
- Complications: Study indicates a high rate of gastroesophageal reflux (post-POEM GERD; reflux (Latin refluere = to flow back) of acidic gastric juice and other gastric contents into the esophagus (esophagus)); see also under “Additional Notes.”
- Injection of botulinum toxin (BTX) into the lower esophageal sphincter (UES) – performed endoscopically during gastroscopy (gastroscopy).
- Paralysis of the esophageal sphincter widens the opening to the stomach.
- Indication: patients with high comorbidity (concomitant diseases).
- Disadvantage: short duration of action (about 6 months).
- Esophagectomy (removal of the esophagus) – rarely required.
Further notes
- Laparoscopic Heller myotomy (LHM) usually includes Dor’s fundoplicatio (= gastric fundus is wrapped around the lower section of the esophagus (esophagus) and sutured). To reduce the risk of scarring, the sphincter (sphincter muscle) is cut from inside the esophagus. The procedure is called peroral endoscopic myotomy (POEM). The disadvantage of this procedure is that no fundoplicatio is possible, therefore gastroesophageal reflux (see above. ) must be expected: after 24 months, reflux esophagitis (esophagitis due to reflux) was more frequent after POEM (44 versus 29%, odds ratio 2.00; 95% confidence interval 1.03 to 3.85); patients also had to take proton pump inhibitors (proton pump inhibitors, PPI, acid blockers) more often (52.8% 27.2%).
