TREATMENT OF GASTROESOPHAGEAL MOVEMENT DISORDER - ACHALASIA AND POEM PROCEDURE

Achalasia is a rare disorder where your esophagus is unable to transport food and fluids into your stomach. The esophagus is the muscular tube that carries food from the mouth to the stomach. In the area where the esophagus meets the stomach is a muscle ring called the lower esophageal sphincter .
This muscle relaxes (opens) to allow food to enter your stomach and contracts (tightens to close) to prevent stomach contents from returning to the esophagus. If you have Achalasia this sphincter does not relax, thereby preventing food from passing into your stomach.
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Who can have an achlazia?

Achalasia develops in about 1 in 100,000 people each year. It is usually diagnosed in adults between the ages of 25 and 60, but can also occur in children (less than 5% of cases are in children under 16 years of age). No particular race or ethnic group is more affected than others, and the situation does not work in families (except perhaps in a rare form of the disorder). Men and women are equally affected.
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Is achalasia dangerous?

Yes, achalasia can be dangerous, especially if it is not treated. If you suffer from achlasia, you will gradually experience increased difficulty eating solid foods and drinking liquids. Achalasia can cause considerable weight loss and malnutrition. People with achalasia also have an increased risk of developing esophageal cancer, especially if the condition has been present for a long time.

What causes achlasia?

The reason why your esophageal muscles fail to contract and relax normally is unknown. One theory is that Achalasia is an autoimmune disease (the body attacks itself) triggered by a virus, it is possible that following the global outbreak of the coronavirus we will witness an increase in the number of patients with Achalasia, but this is a hypothesis and has not yet been proven. The body's immune system attacks nerve cells in the muscle layers of the esophageal walls that control muscle function, which subsequently degenerate for reasons that are not currently understood. This results in excessive contractions in the lower sphincter in the body which interferes with the proper passage of food and fluids into your stomach.

What are the symptoms of achlasia?

Achlasia symptoms develop slowly, last for months or years.

Symptoms include:

• Difficulty swallowing (dysphagia). This is the most common early symptom.

• Increase (regurgitation) of undigested food upwards.

• Chest pain that comes and goes; The pain can be strong.

•Heartburn.

• Nocturnal cough.

• Weight loss/malnutrition as a result of eating difficulties. This is a late symptom.

• Hiccups, belching (less common symptoms).
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What are the complications of achlasia?

• Weight loss and malnutrition.

•Depression.

Some of the complications of Achalasia are the result of food rising from the stomach into the esophagus and then into your trachea (aspiration), resulting in pneumonia.

• Increased risk of esophageal cancer.
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How is achlasia diagnosed?

3 tests are commonly used to diagnose achlasia:
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Barium ingestion:

In this test, a barium preparation (liquid or other) will be swallowed and its movement through the esophagus is assessed using X-rays. The barium swallow will show narrowing of the esophagus in the lower esophageal sphincter
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Gastroscopy:

In this test, a flexible, narrow tube with a camera on it – called an endoscope – is moved down the esophagus. The camera projects images of the inside of the esophagus onto a screen for evaluation. This examination helps to rule out cancerous (malignant) lesions as well as to assess achlasia.
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Menometry:

This test measures the timing and strength of esophageal muscle contractions and relaxation of the lower esophageal sphincter. Failure to heal the lower esophageal sphincter in response to swallowing and lack of muscle spasms along the walls of the esophagus supports the diagnosis of achlesiasia. This is the main test for diagnosing Achalasia.
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It is important to note that the test can now be done under sedation with the insertion of a pressure gauge during gastroscopy.
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How is achlasia treated?

There are several treatments for Achelasia including non-surgical options (balloon expansion, medication and botulinum toxin injection) and surgical options. The goal of treatment is to relieve your symptoms by relaxing the lower esophageal sphincter.
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POEM

The POEMprocedure was first performed in Tokyo Japan in 2008.
This is a proven procedure that has accumulated many years of experience and documentation in medical research as an effective solution for Achalasia patients.
Patient's oral endoscopic myotomy (POEM) is an excellent mini-invasive alternative to Heller's laparoscopic myotomy, which is laparoscopic surgery. In this procedure, the muscles on the side of the esophagus are cut with a knife from the inside, without the need for external cuts or scars.

The incisions in these areas loosen the muscles, allowing a return to a normal or almost normal state of passage of food and fluids through the esophagus to the stomach. Recovery and recovery times are much faster compared to laparoscopic surgery and the results are excellent with over 90% clinical improvement, we emphasize - these results are maintained over time.
It is important to note that the POEM procedure is the treatment of choice in case of unsuccessful surgery or recurrence of symptoms.
POEMcan be performed as treatment afterprevious POEMif symptoms recur.
The POEMprocedure is considered a complex procedure at the medical level and requires experience, skill and mental abilities from the performing endoscopist.
Dr. Vosko is considered a senior endoscopist with extensive experience in POEM procedures.
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Heller analysis

The surgery used to treat Achalasia is called laparoscopic esophagectomy or Heller laparoscopic myotomy. In this surgery, an instrument called a laparoscope, is inserted through an incision in the abdomen. A laparoscope is connected to a video camera that projects a view of the surgical site onto video monitors located in the operating room. In this operation, the muscle fibers of the lower esophageal sphincter are cut.
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Balloon expansion

In this non-surgical procedure, a balloon is inserted through the lower sphincter of the esophagus and then inflated. The procedure relaxes the sphincter, which allows food to enter the stomach. Balloon dilation used to be the option of choice for patients who did not wish to have surgery, but now this option has been pushed back due to only temporary improvement of symptoms and a better endoscopic option which isPOEM.

If you are not a candidate for balloon expansion or surgery or have chosen not to undergo these procedures, you may benefit from Botox® injections (botulinum toxin). Botox is a protein produced by the bacteria that cause botulism. When injected into the muscles in very small amounts, Botox can relax spastic muscles. It works by blocking the signal from the nerves to the sphincter muscles that tell them to contract. Injections should be repeated to maintain symptom control.

Other pharmacological treatments include medications that relax the spasticity esophageal muscles by decompression These treatments are less effective than other options and provide only short-term relief of your symptoms.

Esophagectomy surgery Removal of the esophagus is a treatment of last resort.
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What are the complications of achalasia treatments?

Complications of achalasia treatments include:

• Creating a hole in the esophagus.

• Lack of success and recurrence of symptoms.

• Gastroesophageal reflux disease.

•Swelling.

What follow-up is required after treatment?

Long-term follow-up is needed regardless of the treatment you receive. This is because the treatments are palliative – that is, relieve the symptoms – and do not cure achalasia or stop its progression. Symptoms can recur. Also can develop gastroesophageal reflux.

What result can be expected from the different treatment options?

The POEMendoscopic procedure is effective in over 91% of people with Achalasia It is important to remember that up to 20% of people experience symptoms of gastroesophageal reflux after surgery.  The percentage of complications during surgery is less than 1%.

Balloon dilation improves symptoms in 50% to 93% of people with chalice. It may be necessary to repeat the procedure to maintain an improvement in the symptom. Repeated dilation increases the risk of causing a hole/perforation in the esophagus.  Complications up to 2-4% during expansion.

Heller laparoscopic myotomy surgery is effective in 76% to 90% of people with achalasia It is important to remember that up to 30% of people experience symptoms of gastroesophageal reflux after surgery.  Complications during surgery 5-10%

Botox injection - Up to 35% of people with achalasia will feel an improvement in the relaxation of the lower sphincter of the esophagus. The injections should be repeated every six to 12 months to maintain symptom relief.

Medications can improve symptoms in 0% to 25% of people with achlesia.
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Living with Achalasia

First, you will need to understand that achalasia is a lifelong condition. It is important to have realistic expectations about the results of the different treatment procedures. No treatment cures achalasia 100%.

It is important to discuss all treatment options and their success rates for controlling symptoms, the need for repeated procedures and frequency, and the risks and benefits of each procedure.

Patients diagnosed with Achalasia and undergoing treatment are recommended to assimilate the habits and work on the following beneficial emphases:

Cutting food into small bite-sized pieces and eating in an upright position - this will allow gravity to help move food through your esophagus.
Avoid eating in a supine position – this will increase your risk of inhaling food into your lungs.
Sleep with your head held high.
Avoid eating solid foods before bedtime.

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INFORMATION ON TREATMENT OF ACHALASIA USING POEM ENDOSCOPIC PROCEDURE

IN THE LAST DECADE, THE PERORAL ENDOSCOPIC MYOTOMY (POEM) METHOD HAS DEVELOPED.

Since its development, there has been a dramatic change in the treatment of movement disorders.

THE OPERATION PERFORMED BY AN ORAL ENDOSCOPE FOR PATIENTS SUFFERING FROM ESOPHAGEAL MOTILITY PROBLEMS (ACHLASIA, ESOPHAGUS SECTION, DES) AS WELL AS IN THE STOMACH (GASTROPARESIS).

In this surgery, an endoscope is inserted into the esophagus or stomach depending on the existing disorder. After cutting the mucosa, the endoscope is inserted into the canal between the mucosa and the wall muscles. The canal is built up to a length of between 6 and 20 cm. Muscle fibers causing the disorder are cut while preserving the mucosa. At the end of the operation, the initial incision closes with clips.

The operation is performed without incisions in the abdominal wall and without separation of tissues. The results of the method are similar to the results and even better in some cases than traditional laparoscopic surgery.

Risks

In the case of cutting of the lower esophageal muscle that separates the stomach from the esophagus, one of the main complications is reflux disease of up to 20%, which can be treated very effectively by antacids such asPPI.

In the rest of the cases complications are rare and include bleeding, perforation and infection. Most often these complications can only be treated with conservative therapy.

Follow up

Follow-up is usually clinical, which includes improving swallowing and patient satisfaction metrics.

How do I prepare for the POEM procedure?
Preparation for the POEM procedure requires prior planning because it can only be carried out on condition that the esophagus is free of food. For this purpose, a day or two before the procedure, the patient will be required to follow a liquid diet (soups, porridges, etc.), and on the day of the procedure, or a few hours before its execution, the patient will be required to be completely fasting. If blood thinners are taken, they should be discontinued before the procedure, and sometimes there may be changes or special instructions for additional chronic medications.

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