Unfortunately, there is no way to fix or replace the oesophagus. The only thing that can be done is to weaken the lower oesophageal sphincter so that food and fluid is not blocked on its way into the stomach. The oesophagus remains the same, so food and liquid has to rely on the weak peristalsis and gravity to go down. The problem with this is that with a broken LOS, patient may then get reflux symptoms.
The LOS can be weakened by endoscopy. A balloon can be used to stretch and then tear the LOS muscle fibres (pneumatic balloon dilatation). This does give good relief of symptoms, but over time the muscle heals with scarring, meaning that procedure needs to be repeated. Each time this happens, the improvement is less effective and lasting. There is also the risk of rupturing the oesophagus during this intervention, which again increases the more times the procedure is performed.
Another option endoscopically is to inject Botox into the LOS which causes it relax. Again, relief is only temporary, and so procedure needs to be repeated, each time being less effective, causing scarring and risking damage to the oesophagus.
Recently, a new technique per-oral endoscopic myotomy (POEM) has been introduced. Here, via endoscopy, the LOS muscle fibres are cut directly after the inner lining of the lower oesophagus (mucosa) has been lifted. Following myotomy, the mucosa is replaced. There is a risk of making a hole in the oesophagus (perforation). This does appear to give a more permanent relief of symptoms. However, the longer-term results are not yet known. It is also a very highly specialised technique, and currently only Units in Japan, Europe and the United States have published reasonable results.
Paradoxically, if an endoscopic technique succeeds, then achalasia symptoms may be replaced with very bad reflux symptoms, again impacting on quality of life and requiring further management with permanent drug therapy.
Following my Heller Cardiomyotomy I am pleased to tell you that at this moment it would appear to be 100% successful. It is no exaggeration to say it has transformed my life.
Keyhole surgery can be used to divide the abnormal LOS muscles (laparoscopic myotomy). This will enable un-obstructed passage of food and liquid into the stomach with weak peristalsis and gravity improving swallowing function. A fundoplication can also be performed at the same time which will prevent excessive reflux.
The balance of a myotomy and fundoplication seems to offer the best option an overall and long-term resolution of the symptoms of achalasia.
