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Treatments for Achalasia

Tuesday, July 14, 2009 @ 10:07 AM
posted by: admin

by Pankaj J Pasricha, MD
Source: Up to Date Patient Preview

 

Several options are available for the treatment of achalasia. Unfortunately, none can stop or reverse the underlying problem. However, all of the treatments are effective for improving symptoms.

Two of these treatments (drug therapy and botulinum toxin injection) work by reducing the LES (lower esophageal sphincter) pressure while two other treatments, balloon dilatation and surgery (myotomy), work by mechanically weakening the muscle fibers of the LES.

Drug therapy — Two classes of drugs, nitrates and calcium channel blockers, have muscle-relaxing effects. These drugs can relax the LES and decrease symptoms in people with achalasia. They are usually taken by placing a pill under the tongue 10 to 30 minutes before meals.

Drug therapy is the least invasive option for treating achalasia. However, most people find that long-term drug therapy is inconvenient, ineffective, and sometimes associated with side effects, such as headache and low blood pressure. Furthermore, these drugs tend to become less effective over time. For these reasons, medications are recommended for patients who are not interested in or not healthy enough for other treatments.

 Balloon dilatation (pneumatic dilatation)  — Balloon dilatation stretches the contracted LES. This procedure is effective for relieving symptoms of achalasia in two-thirds of people, although chest pain persists in some people. Up to half of patients may require more than one treatment for adequate relief. The person is given general anesthesia and is generally able to go home at the end of the day.

Procedure — If you have balloon dilatation, you will be asked to drink only liquids for 12 hours to two days in advance (a longer period is recommended if you have a great deal of food in the esophagus). Using fluoroscopy, a physician advances a guide wire down the esophagus and positions it inside the LES. A deflated balloon is then advanced along this guide wire, positioned inside the LES, and inflated for about 60 seconds. The balloon is then deflated and withdrawn, and you are monitored in a recovery area for five to six hours to detect any complications. If there are no complications, you can usually resume eating after six hours. If your day-to-day symptoms do not improve, additional dilatations can be performed.

Success rate — A single balloon dilatation session continues to relieve symptoms of achalasia in about 60 percent of people one year after the procedure and in about 25 percent of people five years after the procedure. Higher success rates have been reported in some studies. The success rate after longer periods has not been well studied, but some people have remained symptom-free for as long as 25 years.

Complications — About 15 percent of people experience severe chest pain immediately after balloon dilatation and some experience fever.

The most significant complication of balloon dilatation is creation of a hole (perforation) in the wall of the esophagus; this complication occurs in about 2 to 6 percent of people undergoing the procedure, and it is most likely to occur during the first dilatation session. Symptoms of persistent or worsening pain in the hours after the procedure may indicate a perforation. Some doctors routinely an check x-ray and/or swallow tests immediately after the procedure to check for a perforation.

Most perforations are small, and some heal on their own with antibiotics and intravenous feeding. However, many doctors recommend surgery to repair these tears, regardless of their size. There is no way to predict perforation; however, it is sensible to choose a doctor who experience performing balloon dilatation procedures.

Other possible complications of balloon dilatation include bruising of the esophageal wall, damage to the esophageal lining, the development of small pockets (diverticula) in the esophagus or upper stomach, and the development of gastroesophageal reflux disease (GERD). Because the LES is the principal barrier that prevents the reflux of stomach contents into the esophagus, its disruption can lead to acid reflux. GERD occurs in about 2 percent of people after balloon dilatation, but is usually easily controlled with acid-reducing medications. (See "Patient information: Gastroesophageal reflux disease in adults".)

Surgery (myotomy) — Myotomy is a surgical procedure that can be used to directly cut the muscle fibers of the LES. The most common surgical technique is called the Heller myotomy. In the past, surgery was performed through an open incision in the chest or abdomen; surgery can now be performed through a tiny incision using a thin, lighted tube (a laparoscope or thoracoscope). This new approach is less traumatic and shortens recovery time. People who undergo laparoscopic myotomy are given general anesthesia, and generally stay in the hospital for one to two nights. Some post-operative pain is expected, which can be controlled with pain medications.

Success rate — Surgery relieves symptoms in 70 to 90 percent of people. Symptom relief is sustained in about 85 percent of people 10 years after surgery and in about 65 percent of people 20 years after the surgery. Thus, surgery is a more permanent solution for achalasia than balloon dilatation or botulinum toxin injection (see below). However, surgery can also be associated with complications, and is more invasive and more expensive than balloon dilatation.

Complications — Like balloon dilatation, there is a risk of acid reflux following myotomy, which can cause damage to the esophagus over time. Surgeons generally perform a fundoplication (wrapping a portion of the stomach around the esophagus to prevent regurgitation of stomach contents) at the time of surgery; however this does not always prevent reflux. Patients should be regularly monitored for this complication, and may require acid suppressing medications. (See "Patient information: Gastroesophageal reflux disease in adults".)

Botulinum toxin injection — Botulinum toxin injections temporarily paralyze the nerves that signal the LES to contract, thereby helping to relieve the obstruction. Botulinum toxin injection may also be used as a diagnostic test in people with suspected achalasia who have inconclusive test results.

Procedure — The injection procedure is performed during routine endoscopy, while the person is sedated. The botulinum toxin is injected directly into the LES.

Success rate — A single botulinum toxin injection session relieves symptoms in 65 to 90 percent of people in the short term (three months to approximately one year). Additional injections can relieve symptoms in patients whose symptoms return. Botulinum toxin injection is more likely to be effective in people over the age of 50 years and in people who have the vigorous form of achalasia.

When compared with balloon dilatation, botulinum toxin has a similar effectiveness for relieving symptoms in the first one to two years after the procedure; however, prolonged effectiveness requires multiple botulinum toxin injections in 40 to 50 percent of people because the paralyzing effect of the toxin is temporary. The long-term safety and effectiveness of botulinum toxin injection is unknown.

Complications — About 25 percent of people have chest pain for a few hours after the procedure and about 5 percent develop heartburn. Damage to the esophageal wall and lining are rare. The short-term safety of botulinum toxin injection appears to be greater than the short-term safety of both balloon dilatation and surgery; this greater short-term safety may make botulinum toxin injection a better choice for people with other medical conditions who must avoid more invasive procedures. Because the amount of botulinum toxin used is very small, there is virtually no risk of botulism poisoning from this procedure.

 

 

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