Achalasia: A gentle therapy is as successful as surgery

Achalasia can be successfully managed with gentle endoscopic treatment. The method is as successful as a surgical intervention, previously considered the standard procedure for the condition.

The finding is the result of a  multicenter clinical trial

According to the latest findings, achalasia can be managed to great success with gentle endoscopic treatment. The method is just as successful as a surgical intervention, which was previously considered to be the standard procedure for the condition.

Achalasia is a rare disease of the esophagus that can cause considerable difficulty in swallowing. "The cause is permanent cramping of the sphincter muscle located at the lower end of the esophagus. Food, therefore, does not or only partially reach the stomach," explains Prof. Dr. Thomas Rösch, Director of the Clinic for Interdisciplinary Endoscopy at the UKE (Universitätsklinikum Hamburg-Eppendorf), Germany. Conventional treatment methods are either repeated endoscopic balloon dilatation, which is carried out under X-ray control or keyhole surgery in which the oesophageal’ sphincter muscle is severed.

The endoscopic procedure improves esophageal function and quality of life

"Peroral endoscopic myotomy, called POEM, is a newly developed treatment that allows the separation of the esophageal sphincter muscle exclusively during an endoscopy, i.e. without surgical intervention," explains study leader Dr. Yuki Werner. What is unusual about this new procedure is that, despite the severing of the muscular barrier, hardly any bacteria can pass from the esophagus into the abdominal cavity, so that severe and life-threatening inflammations do not occur.

In a clinical study conducted at eight treatment centers in six European countries, endoscopy and surgery were compared in 221 patients. The group was monitored for two years. Both procedures were almost equally successful (endoscopy 83.0% versus surgery 81.7%), resulting in almost identical improvements in esophageal function and quality of life. Acute complications occurred less frequently with the endoscopic treatment (2.7%) than with the surgical procedure (7.3%). Dr. Werner: "However, after two years the reflux rate was higher in patients treated endoscopically. We will have to investigate this further".

Prof. Rösch concluded that “the introduction of the endoscopic working technique POEM has triggered a worldwide innovation push in the gastroenterological and visceral surgical fields. Comparative studies with established therapeutic procedures are of great importance for clinical practice and thus for the patients treated".

Werner Y, Rösch Th, et al. Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia, N Engl J Med 2019; 381:2219-29. DOI: 10.1056/NEJMoa1905380