COMPARE AND CONTRAST THE TREATMENT OPTIONS - PNEUMATIC DILATION, HELLER'S MYOTOMY(LAPROSCOPIC), POEM ( PERORAL ENDOSCOPIC MYOTOMY) AND BOTULINUM TOXIN INJECTION - INCLUDING INDICATIONS, OUTCOMES AND COMPLICATIONS Botulinum toxin Botulinum toxin is a potent presynaptic inhibitor of acetylcho- line release from nerve endings. When injected endoscopically into the LOS, it interferes with the LOS cholinergic excitatory neural activity and paralyses the sphincter muscle. The reported symptom relief decreased from 70% in 3 months to around 40% in a year. The injection usually has to be repeated after a few months. Because the e! ect is temporary, it is sometimes used when the diagnosis of achalasia is in doubt. Repeated injection may result in scarring, making subsequent treatments more di#cult. It should not be o!ered as first-line treatment in patients who are suitable for myotomy or pneumatic dilatation and its indication is usually restricted to elderly patients with comorbidities. Pneumatic dilatation This involves stretching the LOS with a non-compliant balloon to disrupt the sphincter muscle and render it less competent. Plastic (polyethene) balloons with a precisely controlled exter- nal diameter are used. If the pressure in the balloon is too high, the balloon is designed to split along its length rather than expanding further. Balloons of 30–40 mm in diameter are available and are inserted over a guidewire. There is no standardised dilatation protocol. Generally, it is preferred to have serial dilatations in a graded manner, from 30 mm to 35 mm and 40 mm. Serial pneumatic dilatation has similar e#cacy to surgical myotomy in selected patients. Features that predict optimal response are: patients older than 45 years, female, those with an undilated oesophagus, those who have responded to first dil- atation and those with type II achalasia. Perforation is uncom- mon; the reported incidence averaged about 1.9% (0–16%). With a 30-mm balloon, the chance of perforation should be less than 0.5%. The risk of perforation increases with big- ger balloons, which should be used cautiously for progressive dilatation over weeks. It is important to have an experienced endoscopist performing the procedure and surgical back-up in case of perforation. Heller’s myotomy This involves cutting the muscle of the lower oesophagus and gastric cardia (Figure 66.26).Typically, anterior myotomy isperformed for at least 6 cm proximally at the oesophageal side and 2–3 cm distally into the gastric cardia. Transabdominal or transthoracic approaches have been advocated. Currently, the standard procedure is a laparoscopic approach. The major complication is GORD, which can occur in up to 40% of patients. The addition of a partial fundoplication (anterior Dor or posterior Toupet) has been shown to be e!ective in reducing the incidence of GORD. A complete 360° fundoplication (Nissen) is considered contraindicated because the increase in outflow resistance against an aperistaltic oesophageal body will probably result in postoperative dysphagia. Laparoscopic myotomy is superior to single pneumatic dilatation in e#cacy and durability. The surgical outcome is better in types I and II achalasia than in type III. For the latter, a longer extended proximal myotomy is often needed for adequate treatment. Peroral endoscopic myotomy Peroral endoscopic myotomy (POEM) involves opening the mucosa at a short distance proximal to the intended myotomy site. Entrance is gained into the submucosal plane, which is extended distally to about 2–3 cm into the gastric cardia. The circular +/– longitudinal muscles are then cut using ESD instruments. Typically, the myotomy extends a minimum of 6 cm in the oesophagus proximally and 2 cm into the gastric cardia distally (Figure 66.27). The mucosal opening is then closed with endoclips. In type III achalasia, there is a spastic component at the distal oesophagus that responds less well to pneumatic dilatation and Heller’s myotomy. POEM has the advantage in that it can extend the length of the myotomy proximally, tailored to preoperative HRM and barium swallow parameters. POEM can also be utilised to treat other types of ‘spastic’ oesophageal motility disorders such as distal oesoph- ageal spasm and hypercontractile oesophagus. Randomised controlled trials have demonstrated similar e#cacy of POEM to pneumatic dilatation and Heller’s myotomy in relieving dysphagia. Without any antireflux procedure, the incidence of GORD is expectedly higher in POEM compared with Heller’s myotomy with partial fundoplication. The incidence of oesophagitis at 3 months after POEM can be as high as 57%, which may subject patients to lifelong acid suppression therapy or subsequent antireflux operation. Oesophagectomy Oesophagectomy is reserved only for the treatment of patients with ‘end-stage’ achalasia with a sigmoidal or megaoesopha- gus that is not responding to other methods (Figure 66.28). Depending on the chronicity of the disease, the symptoms of achalasia may be tolerated. However, a grossly dilated oesoph- agus predisposes to regurgitation and aspiration pneumonia. Balancing the risk of an oesophagectomy with the patient’s quality of life and risk of aspiration complication, surgery can be a reasonable option for surgically fit patients.Follow-up Treatment success is usually defined by symptom relief. The Eckardt score is quantified and compared with the preoperative score. Patients should be counselled on a post-treatment diet as the oesophageal body motility remains defective. Ideally,HRM, barium contrast study, endoscopy and 24-hour pH monitoring should be performed postoperatively to objectively assess LOS function, bolus retention, response to treatment, presence of oesophagitis and acid reflux. This depends on the availability of resources and patients’ preference. Use this content