Achalasia

 

The oesophagus is a muscular tube which transmits food into the stomach. When food passes from the lower end of the oesophagus into the stomach, it encounters a muscular ring known as   the lower oesophageal sphincter (LOS). The LOS relaxes to allow food into the stomach and tightens to prevent the reflux of food and acid back into the oesophagus.

Individuals with achalasia have 2 primary abnormalities:
1.        Tight LOS
2.         Absent peristalsis (contraction) of the oesophagus

Common Symptoms

• Difficulty swallowing
• Food regurgitation
• Coughing at night
• Chest pain
• Weight loss

Tests and Procedures

• Endoscopy
• Barium meal
• High-resolution manometry (HRM)

 

Treatment Options

• Balloon Dilatation

A balloon is inserted into the LOS under endoscopic guidance. Upon inflation of the balloon, the force will tear the LOS muscle fibres and consequently reduce the LOS pressure. This procedure may need to be repeated if there is a relapse of symptoms.

• Laparoscopic Myotomy

The LOS muscle fibres are divided under direct vision via keyhole surgery. This procedure has excellent long-term outcomes and has also been the treatment of choice for the last decade. It is performed under general anaesthesia.

• Peroral Endoscopic Myotomy (POEM)

POEM is the next generation treatment modality for achalasia. It is performed endoscopically, with the aid of a high-resolution endoscope and requires no external surgical incisions. Similar to laparoscopic myotomy, it is done with the aim to relax the LOS in order to allow food to pass through.

POEM is now a popular treatment for achalasia with good outcomes and low risks.

 

Peroral Endoscopic Myotomy (POEM)

Step 1  An endoscope is placed in the oesophagus. Under direct vision, a small cut is made in the lining of the oesophagus.	Step 2  Through the small cut, the endoscope is   tunnelled   to the level of the oesophageal sphincter.
Mucosal incision toward submucosal space	Creation of submucosal tunnel
Step 3 The sphincter muscle is then cut, without penetrating the outer layer. This allows the sphincter to relax.	Step 4 The defect in the oesophageal lining is closed with surgical clips.
Myotomy	Closure of mucosal entry

 

Recent Publications

• Gastro-esophageal reflux disease (GERD) after peroral endoscopic myotomy (POEM)
  Teh JL, Tham HY, Soh AYS, Chee C, Kim G, Shabbir A, Wong RKM, So JBY.
  Surg Endosc. 2021 Jul 29. doi: 10.1007/s00464-021-08644-2. Epub ahead of print. PMID: 34327547.

• A Training Model for Introducing a Novel Surgical Procedure into Clinical Practice: Our Experience on Peroral Endoscopic Myotomy for Achalasia

Chan DK1, Wong RK, Phua JN, Shabbir A, Ho KY, Chiu PW, So JB.
Ann Acad Med Singapore. 2017 Mar;46(3):111-114.
PMID: 28417135

• Removal of a large, 40-mm, submucosal leiomyoma using submucosal tunneling endoscopic resection and extraction of specimen using a distal mucosal incision.
  Ng JJ, Chiu PW, Shabbir A, So JB.
  Endoscopy. 2015;47. doi: 10.1055/s-0034-1391904. Epub 2015 Jun 12.
  PMID: 26069978

 

• Per-Oral Endoscopic Myotomy (POEM) for Achalasia: Techniques, Outcomes and Clinical Applications
  KM Chue, JL Teh, JBY So
  Surgery Open Digestive Advance. February 2021;1:100007.
  doi:10.1016/j.soda.2021.100007