1. Updates on management of achalasia
Hung Sze Wing Dorothy

2. Achalasia
Achalasia is a primary esophageal motility disorder characterised by absence of esophageal peristalsis, impaired lower esophageal sphincter response
Peak incidence years old
Equally common among men and women
1 in 100,000 incidence per year
ACG Clinical Guideline: Diagnosis and Management of Achalasia Michael F. Vaezi , MD, PhD, MSc, FACG 1 , John E. Pandolfi no , MD, MSCI 2 and Marcelo F. Vela , MD, MSCR 3

3. Presenting symptoms: Dysphagia (most common) Regurgitation Chest pain
Weight loss

4. Investigations OGD Ba swallow: bird’s beak appearance
Grossly normal
Tight lower esophageal sphincter (LES)
Dilated sigmoid esophagus with retained food and saliva
Ba swallow: bird’s beak appearance
High resolution manometry (HRM) =gold standard
Radiology, St Vincent’s university hospital

5. Normal HRM Proximal esophagus Distal esophagus Lower pressure
Higher pressure
The University Hospital, Cincinnati

6. Chicago classification
Developed by investigators at Northwestern University of Chicago
facilitate the diagnosis of achalasia
classify achalasia
Integrated relaxation pressure (IRP) = mean pressure of LES during the 4 seconds of maximal relaxation in the 10-second window beginning at UES relaxation
Normal IRP ≤ 15 mmHg
Achalasia = ↑ IRP + failed peristalsis or spasm 
The Chicago Classification of esophageal motility disorders, v3.0 P.J. Kahrilas et al. Neurogastroenterology and motility. Dec 2014

7. Chicago classification
Type I (“classic achalasia”): minimal pressure in esophagus
Type II: pan-esophageal pressurization (most common)
Type III: Spasm. At least 20% of swallows reveal rapidly propagating or spastic simultaneous contraction
Type I
Type II
Per oral endoscopic myotomy (POEM) for all spastic esophageal disorders? Endosc Int Open 2015 Jun; 3(3): E202–E204.
Type III

8. Prognosis
Response to pneumatic dilatation or laparoscopic Heller myotomy
Type I intermediate response (~81%)
Type II has best response (~96%)
Type III has the least favorable response (~66%)
JAMA. 2015;313(18):1841. Achalasia: a systematic review

9. Eckardt Score for achalasia severity
Sign/symptoms
Score 1 2 3
Recent weight loss (kg)
None
<5
5-10
>10
Dysphagia
Occasional
Daily
Each meal
Chest pain
Several times a day
Regurgitation
Score: 0-12
Eckardt AJ, Eckardt VF. Treatment and surveillance strategies in achalasia: an update. Nat Rev Gastroenterol Hepatol. 2011;8(6):

10. Treatment options
Pharmacological
Endoscopic
Surgical

11. Pharmacological options
Calcium channel blockers and nitrates
Least effective
Side effects e.g. dizziness, headache
Symptomatic improvement 53 to 87%
Achalasia: a new clinically relevant classification by high-resolution manometry. Pandolfino JE, Kwiatek MA, Nealis T, Bulsiewicz W, Post J, Kahrilas PJ. Gastroenterology Nov; 135(5):

12. Endoscopic Botulinum toxin Pneumatic dilatation Durability 6-12months
1 month response rate >75%
Pneumatic dilatation
Annese V, Bassotti G, Coccia G et al. A multicentre randomised study of intrasphincteric botulinum toxin in patients with oesophageal achalasia. GISMAD Achalasia Study Group. Gut 2000;46:597–600

13. Pneumatic dilatation Endoscopic, graded dilatation
Good short term results
No GA
Requires repeated dilatation
Risk of perforation ~5%
Pneumatic dilation versus laparoscopic Heller’s myotomy for idiopathic achalasia. Boeckxstaens GE et al. N Eng J Med, May 2011

14. Surgical options New options Laparoscopic Heller myotomy
Per-oral endoscopic myotomy (POEM)

15. Heller myotomy Divide circular and longitudinal muscles
Extended 6-8cm on the esophagus and 1.5-3cm on gastric cardia
+ Fundoplication to reduce reflux
Dor/Toupet
87% success after 2 years
Boeckxstaens GE, Annese V, des Varannes SB et al. Pneumatic dilation versus laparoscopic Heller’s myotomy for idiopathic achalasia. N Engl J Med 2011;364:1807–181
Surgical treatment for achalasia – GI motility online – Nature. Jedediah A. Kaufman at al

16. POEM Submucosal tunneling Tunneling beyond GE junction
Circular muscles divided
Closure of mucosal entry
Per-Oral Endoscopic Myotomy: A Series of 500 Patients. H Inoue et al. Journal of the American College of Surgeons, august 2015.

17. POEM vs Heller: systemic review and meta-analysis
Author
Journal
Number of patients
Improvement in dysphagia
GERD
Schlottmann et al
Annals of surgery 2018
74 studies
>7000 patients
POEM better than Heller
More GERD in POEM
Talukdar R, Inoue H et al
Surgical Endoscopy 2015
19 studies
>1000 patients
No difference
Marano L et al.
Medicine (Baltimore) 2016
11 studies
486 patients
Trend towards less GERD in Heller

18. HK data POEM vs Heller

19. Retrospective cohort study
2001 to 2014
33 patients POEM
23 patients laparoscopic Heller myotomy
Similar post-operative dysphagia score at 4 weeks, 3 months, 6 months
GERD symptoms similar (25% Heller, 15.2% POEM p = 0.311)

20. POEM vs Heller
Similar efficacy
?more GERD post-op in POEM patients

21. Longer myotomy = better?
Theoretical advantage of a longer myotomy in POEM = ?better outcome
Incision limited superiorly by hiatus

22. Prognosis
Response to pneumatic dilatation or laparoscopic Heller myotomy
Type I intermediate prognosis(~81%)
Type II has best prognosis (~96%)
Type III has the least favorable response to treatment (~66%)
JAMA. 2015;313(18):1841. Achalasia: a systematic review

23. Endoscopy International Open, Jun 2015
75 patients with type III achalasia
49 underwent POEM
26 underwent laparoscopic Heller’s myotomy
POEM better response (98.0 % vs 80.8 %; P =0.01) and significantly shorter OT time

24. Update in American gastroenterological association (AGA) guideline 2017
If expertise available:
POEM should be considered as primary therapy for type III achalasia
POEM should be considered a treatment option comparable to laparoscopic Heller myotomy for any of the achalasia syndromes

25. Dilatation vs Heller vs POEM
Pros
Cons
Pneumatic dilatation
No GA
No skin incisions
Repeated dilatation
Perforation Lower efficacy
Heller myotomy
One off procedure
Good long term results
Requires GA
POEM
One-off procedure
Short term comparable to Heller
?best option for type 3 achalasia
No long term results
?more GERD

26. Conclusion Treatment options
Botox and oral medications for unfit patients
Pneumatic dilatation
Heller, POEM
Fitness for OT
Patient’s preference $
Expertise
Type of achalasia

27. Thank you

28. Fit for OT Yes No Type 3 achalasia Types 1 or 2 achalasia
Botulinum toxin
Fail
Expertise available
financially accept
POEM or Heller
Yes No
Calcium channel blockers
Nitrates
POEM
Heller