Treatment of Gastric and Esophageal Movement Disorder - Achalasia and Poem Procedure

ACHALASIA IS A RARE DISORDER IN WHICH YOUR ESOPHAGUS IS UNABLE TO MOVE 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 sphincter achalasia it will not relax, and by doing so prevents the food from passing into your stomach.
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Who can have achalasia?

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 condition does not run 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 left untreated. If you suffer from achalasia, you will gradually experience increased difficulty eating solid foods and drinking fluids. 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 achalasia?

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 coronavirus we will witness an increase in the number of patients with achalasia, but this is hypothesized and not yet proven. THE BODY'S IMMUNE SYSTEM ATTACKS THE NERVE CELLS IN THE MUSCLE LAYERS OF THE ESOPHAGUS WALLS THAT CONTROL MUSCLE FUNCTION, WHICH SUBSEQUENTLY DEGENERATE FOR REASONS THAT ARE NOT UNDERSTOOD TODAY. 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 achalasia?

Symptoms of achalasia develop slowly, lasting 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 due to difficulty eating. This is a late symptom.

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

• 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), and as a result can cause pneumonia.

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

3 tests are commonly used to diagnose achalasia:
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Ingestion of barium:

In this examination, you will ingest a barium preparation (liquid or other) 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 examination, a flexible, narrow tube with a camera on it -- called an endoscope -- is passed 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 achalasia.
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Menometry:

This test measures the timing and strength of esophageal muscle contractions and relaxation of the lower esophageal sphincter. Failure in healing of the lower esophageal sphincter as a response to swallowing and lack of muscle spasms along the walls of the esophagus supports the diagnosis of achalasia. 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 blur with the introduction of a pressure gauge during Gastroscopy examination.
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How is achalasia treated?

Several treatments exist for achalasia including non-surgical options (balloon dilation, 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

process POEM 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 patients with achalasia.
Endoscopic oral myotomy of the patient (POEM) is an excellent sexually 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 relax the muscles, allowing the return to a normal or near-normal state of passage of food and fluid 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 procedure POEM is the treatment of choice in case of unsuccessful surgery or recurrence of symptoms.
A procedure can be carried out POEM New as a post-procedure treatment POEM First if symptoms recur.
process POEM It is considered a complex procedure at the medical level and requires experience, skill and manual abilities from the operating endoscopist.
Dr. Vosko is considered a senior endoscopist and has extensive experience in the procedure POEM.
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Heller's analysis

The surgery used to treat achalasia is called laparoscopic esophagectomy or laparoscopic Heller 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 DO NOT WISH TO PERFORM SURGERY, BUT NOW THIS OPTION HAS BEEN PUSHED DUE TO ONLY TEMPORARY IMPROVEMENT OF SYMPTOMS AND A BETTER ENDOSCOPIC OPTION THAT IS POEM.

If you are not a candidate for balloon dilation or surgery or have chosen not to undergo these procedures, you may benefit from Botox® (Botulinum Toxin) injections. 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. The injections must be repeated to maintain control of symptoms.

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

Esophagectomy Esophagectomy Removal 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 needed after treatment?

Long-term follow-up care is needed regardless of the treatment you receive. This is because the treatments are palliative -- meaning they relieve symptoms -- and do not cure achalasia or stop its progression. Symptoms can recur. Gastroesophageal reflux can also develop.

What result can be expected from the different treatment options?

Endoscopic procedure POEM 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 achalasia. The procedure may need to be repeated to maintain improvement in the symptom. Repeated dilation increases the risk of causing a hole/perforation in the esophagus. Complications up to 2-4% during extension.

Heller's 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 relaxing the lower esophageal sphincter. 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 achalasia.
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Living with achalasia

To begin with, 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 by 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 highlights:

Cutting the 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 the supine position - this will increase your risk of inhaling food into your lungs.
Sleep with your head held high.
Avoiding eating solid foods before going to bed.

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Information on the treatment of achalasia using an endoscopic procedure POEM

In the last decade, a method has developed (POEM) FOR ORAL ENDOSCOPIC MYOTOMY.

Since its spread there has been a dramatic change when it comes to treating movement disorders.

The operation performed by an endoscope with oral access for patients with a problem of esophageal motility (ACHALASIA, ESOPHAGEAL SECTION, DES) Also 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 muscles of the wall. The trench is built to a length of from 6 to 20 cm. The muscle fibers that cause the disorder are cut while preserving the mucosa. At the end of the operation, the initial incision is closed with clips.

The operation is performed without incisions in the abdominal wall and without tissue separation. 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 as PPI.

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.

Continue to follow up

Continued follow-up is often clinical, involving improvement in swallowing indices and patient satisfaction.

How to prepare for the procedure POEM?
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Preparation for the procedure POEM REQUIRES PRIOR PLANNING BECAUSE IT IS ONLY FEASIBLE PROVIDED THE ESOPHAGUS IS CLEAN OF FOOD. To do this, one or two days before the procedure, the patient will be required to adhere to a liquid diet (soups, porridges, etc.), and on the day of the procedure, or about a few hours before its implementation, the patient will be required to be in complete fasting.

If blood thinners are taken, their use should be stopped before the procedure, and sometimes there may be special changes or instructions for additional chronic drugs.

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After completion of the procedure POEM The doctor's instructions should be followed when it comes to taking medication and adhering to a soft diet for about a week. It should be remembered that the recovery time depends on the condition of the specific person and the severity of the condition from which he suffered.

In any case, the doctor's instructions should be followed, including taking medication and setting regular follow-up appointments. It is also necessary to rest, drink plenty of fluids and eat a balanced diet.

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