Surgical treatment of achalasia and spastic esophageal disorders

Abstract

Achalasia is the most common primary esophageal motility disorder that is characterized by the inability of the LES to relax and by absence of esophageal body peristalsis due to the inflammatory loss of ganglion cells in the myenteric plexus of the esophageal body and LES, causing dysphagia for solids and liquids, regurgitation of retained food, and chest pain. Pharmacological treatments such as smooth muscle relaxants and botulinum toxin injection are mainly reserved for patients who cannot tolerate more invasive interventions due to severe comorbidities or as a bridge to a more definite treatment option. Pneumatic dilation and laparoscopic Heller myotomy with a partial fundoplication are the most commonly performed to treat achalasia. Recent randomized controlled study to compare these two treatment options demonstrated the similar efficacy in the therapeutic success during the short-term follow-up. However, further modifications of the treatment protocol have the potential for improvement in the outcomes of each option. Since the widespread acceptance of laparoscopic Heller myotomy, the efficacy of pneumatic dilation has been probably underestimated, and gastroenterologists should be trained to successfully perform pneumatic dilation. Note that all treatment options are palliative and none of the treatment options can restore the impaired muscle function of the esophageal body and LES, and it is more important to stratify patients to the optimal initial treatment to accomplish long-term symptom control rather than to simply achieve initial success. For this purpose, the predictors of treatment outcomes should be considered. Other spastic esophageal motility disorders such as diffuse esophageal spasm (DES), nutcracker esophagus, and hypertensive LES are diagnosed based on well-defined manometric criteria. It is important to evaluate these patients for the presence of GERD as symptoms of spasticity may subside when reflux is properly treated. Myotomy should be considered when GERD has been adequately treated, and symptoms persist despite appropriate reassurance and medical therapy. The outcomes of surgical treatment in this setting are variable.