Introduction
Achalasia of cardia (AC) is a primary esophageal motility disorder. Due to poor relaxation of the lower esophageal sphincter (LES) and lack of esophageal peristalsis, food retention results in dysphagia and reaction. Clinical symptoms such as bleeding, chest pain and weight loss. The prevalence is approximately 32.58/100,000.
The treatment of achalasia mainly includes non-surgical treatment, dilation therapy and surgical treatment.
01Medical Treatement
The mechanism of drug treatment is to reduce LES pressure in the short term. There is no obvious evidence that drugs can continuously and effectively improve the symptoms of AC. Currently commonly used drugs include nitrates, calcium channel blockers, and β-receptor agonists.
(1) Nitrates, such as nitroglycerin, amyl nitrate, and isosorbide dinitrate
(2) Calcium channel blockers, such as nifedipine, verapamil, and diltiazem
(3)β-receptor agonists, such as cabuterol
02Endoscopic Botulinum Toxin Injection (BTI)
Endoscopic botulinum toxin injection(BTl) can be used to treat AC, but it can only provide short-term effects and can be used in elderly patients with high risks of surgery and anesthesia.
1) Indications: middle-aged and elderly patients (>40 years old); those who cannot tolerate endoscopic balloon dilation (PD) or surgical treatment; those with multiple PD treatments or poor surgical treatment results; those with esophageal perforation during PD treatment For those with high risk, it can also be used in combination with PD; it can be used as a transition to surgery or PD treatment.
(2) Contraindications: It is not recommended for first-line treatment of AC in young patients (≤40 years old).
03Endoscopic Balloon Dilation (PD)
Balloon dilatation has certain effects on AC, but requires multiple treatments and carries the risk of serious complications.
(1) Indications: AC patients without cardiopulmonary insufficiency, coagulation dysfunction, etc.; men over 50 years old and women over 35 years old; patients who have failed surgery. It can be used as the first choice treatment method.
(2) Contraindications: Severe cardiopulmonary insufficiency, coagulation dysfunction and high risk of esophageal perforation.
04Peroral Endoscopic Myotomy (POEM)
In recent years, with the large-scale implementation of peroral endoscopic myotomy (POEM), the success rate of clinical treatment of AC has increased significantly. POEM treatment of AC is very consistent with the concept of "super minimally invasive surgery", that is, only lesions are removed/removed during the treatment process, and organs are not removed. The integrity and functionality of the anatomical structure is maintained, and the patient's postoperative quality of life is basically not affected. The emergence of POEM has made the treatment of AC super minimally invasive.
Figure: POEM surgery steps
The mid- and long-term efficacy of POEM in the treatment of AC is consistent with that of laparoscopic Heller myotomy (LHM) can be used as first-line treatment option. Some patients may develop gastroesophageal reflux symptoms after POEM surgery
(1) Absolute indications: AC without severe submucosal adhesion, gastric functional emptying disorder and huge diverticulum.
(2) Relative indications: Diffuse esophageal spasm, nutcracker esophagus and other esophageal motility diseases, patients with failed POEM or Heller surgery, and AC with some esophageal submucosal adhesions.
(3) Contraindications: Patients with severe coagulation dysfunction, severe cardiopulmonary disease, poor general condition, etc. who cannot tolerate surgery.
05Laparoscopic Heller Myotomy (LHM)
LHM has good long-term efficacy in treating AC, and has been basically replaced by POEM in places where conditions permit.
06Surgical Esophagectomy
If AC is combined with lower esophageal scar stenosis, tumors, etc., surgical esophagectomy may be considered.
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Post time: Jul-09-2024