Treating achalasia & dysmotility disorders
Per-oral endoscopic myotomy for the treatment of achalasia and dysmotility disorders of the oesophagus and stomach
by Dr Farzan Bahin
From Ezra N Teitelbaum and Lee Swanstrom – Lancet Gastroenterology & Hepatology 2018
Dr Farzan Bahin is a gastrointestinal endoscopy specialist and is the current Head of Department of Gastroenterology and Hepatology at Blacktown and Mount Druitt Hospital. Well known in his field for his research efforts, science publications, and efforts to keep up with the latest patient-care improvements, Dr. Bahin is passionate about improving healthcare quality in the community. His strong academic background includes extensive publications, peer review of journals and participation in numerous research trials. Dr Bahin has won numerous prestigious academic awards and his special areas of interest include colorectal cancer screening and prevention, therapeutic endoscopy including advanced tissue resection, ERCP, luminal stenting and dilatation. Here, he takes us through a case study of a POEM procedure (per oral endoscopic myotomy) on a 20 year old patient.
GL is a 20 year old girl with significant progressive dysphagia to solids and liquids for 4 months. This has resulted in 10% weight loss and significant decrease in quality of life and productivity. The patient had a gastroscopy which didn’t show any obvious abnormalities although there was some oeosphageal dilatation and difficulty to scope passage into the stomach. A barium swallow was suspicious for achalasia and a manometry confirmed the diagnosis. After discussing options of medical therapy, botox injections, and surgical myotomy the patient elected to go ahead with the POEM procedure (per oral endoscopic myotomy). The patient has had an excellent functional response with ability to regain weight after 3 months and minimal reflux symptoms.
The oesophageal mucosa is incised after submucosal injection. Using endoscopic knives a tunnel is created within the submucosa and extends beyond the gastro-oesophageal junction. Subsequently the circular (and occasionally longitudinal) oesophageal muscle fibres are cut as part of the myotomy. The myotomy cuts the lower oesophageal sphincter. The total length of the myotomy is determined by the underlying type of achalasia. Following the myotomy the incised mucosa is closed with clips.
The procedure is generally well tolerated and most patients are able to be discharged one day after the procedure. Symptom improvement occurs in over 90% of patients and remains so in over 75% of patients in longer term follow up of up to 5 years. The main immediate risks relate to pneumoperitoneum which is usually easily treated by needle decompression. The longer term main risk is reflux symptoms and reflux oesophagitis which can occur in up to 30% of patients and is usually treatable with lifestyle changes and medications.
POEM has emerged as a very effective, safe and minimally invasive intervention for achalasia and related disorders. It is also used for the treatment of gastroparesis and Zenker’s diverticulum. The role of POEM and its limitations have to be carefully discussed with patients and placed in the context of existing medical and surgical interventions. Results of randomised studies comparing POEM with Heller’s myotomy for achalasia are still awaited.
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Dr Farzan Bahin
MBBS (Hons), FRACP, PhD, MPhil (Med)
Consulting from his rooms in Bella Vista, Dr Bahin specializes in diagnosing and treating all digestive disorders in both adults, and children. He is a member of the Gastroenterological Society of Australia, the American Society for Gastrointestinal Endoscopy, and a Fellow of the Royal Australasian College. Dr Bahin is the current Head of Department of Gastroenterology and Hepatology at Blacktown and Mount Druitt Hospital and is actively involved in clinical trials to improve treatment modalities in the field, Dr. Bahin is the recipient of an impressive number of research-related prizes, including recognition through the National Health and Medical Research Council scholarship.
Dr. Bahin has proven himself passionate about his patients’ health. He continues to conduct his own research on how to achieve better outcomes in gastrointestinal procedures.