Drugs have a limited role in the treatment of achalasia. Nitrates and calcium channel blockers may reduce LES pressure and relieve relief in some patients.
Sausage toxin (Botox), which is injected directly into LES under endoscopic guidance, has been shown to significantly reduce LES pressure in humans and animals. The duration of the effect of the sausage toxin varies and many patients undergo repeated injections as needed.
Esophageal dilatation has been a key approach in the treatment of achalasia for literally hundreds of years. LES dilation for achalasia can be performed under endoscopic and / or fluoroscopic guidance with solid or pneumatic dilators that are significantly larger than standard esophageal dilators. Expanders or balloons of increasing size can be used during the same session, but caution should be exercised due to the risk of perforation and bleeding. The reported clinical response to dilation therapy varies widely, but approximately 60% to 80% of patients will improve after 1 session. The duration of the response is also highly variable and many patients need intermittent dilation indefinitely.
Endoscopic Myotomy (POEM)
Oral endoscopic myotomy, or POEM, is a modern minimally invasive method in which a tunnel is created under the mucosa of the lower esophagus separating it from the underlying muscle. This results in excellent access to the smooth muscle of the esophagus as well as to the lower esophageal sphincter which are the main problem of achalasia. The endoscope then performs the myotomy using a flexible endoscope, which means that the whole procedure can be done without external incisions.
Originally described by Heller, LES surgical myotomy has been modified in recent decades and can now be performed laparoscopically. During this operation, one or more incisions are made in the gastroesophageal junction to cut the muscle fibers that cause esophageal obstruction. Modern myotomies are sometimes performed at the same time as a fundoplication to prevent long-term complications.