Treatment and surveillance strategies in achalasia: an update

Peroral endoscopic myotomy for treatment of achalasia cardia: Our experience with 7 cases

AIM: To evaluate the clinical efficacy of peroral endoscopic myotomy (POEM) in the treatment of achalasia cardia (AC).

METHODS: The clinical data for 7 patients who were diagnosed with AC and received POEM at our center from May 16, 2011 to May 30, 2013 were reviewed. They ranged in age from 20 to 48 years old, with a mean value of 30.4 years. The disease courses lasted for 2 to 15 years. Key procedures of POEM were esophageal mucosal incision, submucosal tunneling by endoscopic submucosal dissection, endoscopic myotomy of the circular muscle and closure of mucosal entry using hemostatic clips.

RESULTS: POEM was successful in all the patients. Mean operation time was 114 min (range, 55-180 min). Mean submucosal tunneling length was 11.7 cm (range, 10-13 cm). Mean length of endoscopic myotomy of the circular muscle was 9.2 cm (range, 8-11 cm). Two cases underwent full-thickness myotomy. Patients were followed for one year. Five cases of dysphagia were cured, and no obvious effect was observed in two cases.

CONCLUSION: POEM has good short-term efficacy in relieving dysphagia. Further observation is needed to evaluate long-term efficacy and complications.

Botulinum toxin reduces Dysphagia in patients with nonachalasia primary esophageal motility disorders

BACKGROUND & AIMS

Endoscopic injection of botulinum toxin (BTX) has shown benefits for patients with diffuse esophageal spasm (DES) and nutcracker esophagus (NE) in small uncontrolled trials. We investigated the effect of BTX on symptoms of patients with DES or NE and assessed manometry findings in a prospective, double-blind, randomized, controlled study.

METHODS

We assessed 22 patients with dysphagia-predominant, manometry-confirmed DES or NE (6 men; age, 63 ± 2 y) at a tertiary care medical center. Patients were given injections of BTX (8 × 12.5 U) or saline (8 × 0.5 mL) in 4 quadrants, at 2 and 7 cm above the esophagogastric junction. After 1 month, patients crossed over between groups and received endoscopic injections of BTX or saline. When the study began and 4 weeks after each injection, the patients were assessed by esophageal manometry and completed a symptom questionnaire (to determine solid and liquid dysphagia, chest pain, and regurgitation and heartburn; all scored 0-4). Responders were defined based on modified Vantrappen criteria for achalasia.

RESULTS

After BTX injections, patients had significant decreases in total symptom scores (sum of solid and liquid dysphagia and chest pain; from 7.6 ± 0.7 to 4.8 ± 0.8; P = .01); this decrease was not observed in patients who received saline injections. Moreover, BTX injection stabilized unintentional weight loss (weight gain of 0.3 ± 0.3 after BTX injection vs further weight loss of 1.6 ± 0.5 kg after saline injection; P = .01). Fifty percent of patients had a response 1 month after BTX injection, compared with 10% after saline injection (P = .04); 30% still had a response 1 year after BTX injection. BTX injection also caused a significant decrease in the mean esophagogastric junction pressure, compared with baseline (15.8 ± 1.7 vs 24.0 ± 2.8 mm Hg; P = .02).

CONCLUSIONS

In a prospective controlled study of patients with DES and NE, injections of BTX reduced symptoms and stabilized unintentional weight loss.

TRIAL REGISTRY

http://www.targid.eu, ML2669, ML6294.

Endoscopic approach to achalasia

Achalasia is a primary esophageal motor disorder. The etiology is still unknown and therefore all treatment options are strictly palliative with the intention to weaken the lower esophageal sphincter (LES). Current established endoscopic therapeutic options include pneumatic dilation (PD) or botulinum toxin injection. Both treatment approaches have an excellent symptomatic short term effect, and lead to a reduction of LES pressure. However, the long term success of botulinum toxin (BT) injection is poor with symptom recurrence in more than 50% of the patients after 12 mo and in nearly 100% of the patients after 24 mo, which commonly requires repeat injections. In contrast, after a single PD 40%-60% of the patients remain asymptomatic for ≥ 10 years. Repeated on demand PD might become necessary and long term remission can be achieved with this approach in up to 90% of these patients. The main positive predictors for a symptomatic response to PD are an age > 40 years, a LES-pressure reduction to < 15 mmHg and/or an improved radiological esophageal clearance post-PD. However PD has a significant risk for esophageal perforation, which occurs in about 2%-3% of cases. In randomized, controlled studies BT injection was inferior to PD and surgical cardiomyotomy, whereas the efficacy of PD, in patients > 40 years, was nearly equivalent to surgery. A new promising technique might be peroral endoscopic myotomy, although long term results are needed and practicability as well as safety issues must be considered. Treatment with a temporary self expanding stent has been reported with favorable outcomes, but the data are all from one study group and must be confirmed by others before definite recommendations can be made. In addition to its use as a therapeutic tool, endoscopy also plays an important role in the diagnosis and surveillance of patients with achalasia.

ACG clinical guideline: diagnosis and management of achalasia

Achalasia is a primary motor disorder of the esophagus characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. This results in patients' complaints of dysphagia to solids and liquids, regurgitation, and occasional chest pain with or without weight loss. Endoscopic finding of retained saliva with puckered gastroesophageal junction or barium swallow showing dilated esophagus with birds beaking in a symptomatic patient should prompt appropriate diagnostic and therapeutic strategies. In this ACG guideline the authors present an evidence-based approach in patients with achalasia based on a comprehensive review of the pertinent evidence and examination of relevant published data.

Peroral endoscopic myotomy for the treatment of achalasia: a clinical comparative study of endoscopic full-thickness and circular muscle myotomy

BACKGROUND

A circular muscle myotomy preserving the longitudinal outer esophageal muscular layer is often recommended during peroral endoscopic myotomy (POEM) for achalasia. However, because the longitudinal muscle fibers of the esophagus are extremely thin and fragile, and completeness of myotomy is the basis for the excellent results of conventional surgical myotomy, this modification needs to be further debated. Here, we retrospectively analyzed our prospectively maintained POEM database to compare the outcomes of endoscopic full-thickness and circular muscle myotomy.

STUDY DESIGN

According to the myotomy depth, 103 patients with full-thickness myotomy were assigned to group A, while 131 patients with circular muscle myotomy were assigned to group B. Symptom relief, procedure-related parameters and adverse events, manometry outcomes, and reflux complications were compared between groups.

RESULTS

The mean operation times were significantly shorter in group A compared with group B (p = 0.02). There was no increase in any procedure-related adverse event after full-thickness myotomy (all p < 0.05). During follow-up, treatment success (Eckardt score ≤ 3) persisted for 96.0% (95 of 99) of patients in group A and for 95.0% (115 of 121) of patients in group B (p = 0.75). There were no statistically significant differences in pre- and post-treatment D-value of symptom scores and lower esophageal sphincter pressures between groups (both p > 0.05). The overall clinical reflux complication rates were also similar (21.2% vs 16.5%, p = 0.38).

CONCLUSIONS

Short-term symptom relief and manometry outcomes of each method were comparable. Full-thickness myotomy significantly reduced the procedure time but did not increase the procedure-related adverse events or clinical reflux complications.

The role of Botulinum toxin injection in the management of achalasia

PURPOSE OF REVIEW

Botulinum toxin injection into the lower esophageal sphincter is an established therapy for the treatment of achalasia. This review will highlight recent studies that shed light on the role of Botulinum toxin injection in the management of achalasia.

RECENT FINDINGS

Recent studies have shown that Botulinum toxin injection is the most common initial endoscopic therapy for achalasia, most likely due to its safety and ease of administration. However, this trend represents a deviation from recent guidelines which consider Botulinum toxin injection less efficacious than alternative treatments like pneumatic dilation and laparoscopic Heller myotomy. Over the past decade, multiple commercial formulations of Botulinum toxin injection have been introduced, but the techniques, indications, and therapeutic efficacy for Botulinum toxin have largely remained unchanged. This review will evaluate recent guidelines, consensus articles, meta-analyses, and landmark studies to expound on the short and long-term efficacy of Botulinum toxin, injection dosages, and technique, as well as its efficacy compared to pneumatic dilation, myotomy, and combination therapy.

SUMMARY

Despite its relatively poor long-term efficacy, Botulinum toxin injection continues to play an important role in elderly patients with comorbidities and as salvage therapy for achalasia.

Fluoroscopically guided balloon dilatation for the treatment of achalasia: long-term outcomes

To report the immediate and long-term outcomes following the fluoroscopically guided balloon dilatations performed in our department for the treatment of achalasia. We reviewed retrospectively all patients that underwent a fluoroscopically guided balloon dilatation because of achalasia in our department between April 2007 and September 2010. The follow-up was performed by interviews and/or investigation of the patient's medical and imaging records. The primary endpoints of the study were technical success, clinical success, major complication rates, and repeat dilatation rates because of recurrence of clinical symptomatology. Secondary endpoints were the rate of minor complications and the dilatation-free interval. Various parameters that could affect the clinical outcome were also analyzed. Thirty-nine consecutive patients (20 female) with a mean age 44 ± 17 years underwent 69 dilatations, while 10/39 (25.6%) patients had a history of a previous laparoscopic myotomy. The most common symptom was dysphagia (64/69, 92.7%), while regurgitation and/or retrosternal pain were present in 12/39 (30.7%) and 9/39 (23%) of the cases, respectively. Technical success was achieved in 98.5% (68/69). There were no procedure-related major complications. The mean balloon diameter used was 30 ± 3.9 mm, and the mean period of follow-up was 27.7 ± 16.0 months. Excellent or good initial responses were noted in 54/66 cases (81.8%). A repeated dilatation to deal with recurrence of symptoms was performed in 69.4% of the cases (25/36). In the majority of the cases, two dilatations were needed in order to achieve long-term relief from symptoms. A dilatation-free interval of 4 years was observed in 26.4%. Clinical success was achieved in 30/36 patients (83.3%). Subgroup analysis did not detect significantly different recurrence rates in patients with and without previous laparoscopic myotomy (50% vs. 69% respectively), those of young age (75% < 21 years vs. 68.8% > 21 years), and male gender (71.4% male vs. 55.0% females). The high redilatation rate was attributed to the utilization of smaller balloons by less experienced operators. Fluoroscopically guided balloon dilatation is a safe and effective method for the treatment of achalasia. Young age and prior Heller's laparoscopic myotomy were not associated with increased rates of recurrence rate or clinical failure.

A comparison of symptom severity and bolus retention with Chicago classification esophageal pressure topography metrics in patients with achalasia

BACKGROUND & AIMS

We compared findings from timed barium esophagrams (TBEs) and esophageal pressure topography studies among achalasia subtypes and in relation to symptom severity.

METHODS

We analyzed data from 50 patients with achalasia (31 men; age, 20-79 y) who underwent high-resolution manometry (HRM), had TBE after a 200-mL barium swallow, and completed questionnaires that determined Eckardt Scores. Twenty-five patients were not treated, and 25 patients were treated (11 by pneumatic dilation, 14 by myotomy). Nonparametric testing was used to assess differences among groups of treated patients (10 had type 1 achalasia and 15 had type 2 achalasia), and the Pearson correlation was used to assess their relationship.

RESULTS

There were no significant differences in TBE measurements between patient groups. Of the 25 patients who received treatment, 10 had a manometric pattern consistent with persistent achalasia after treatment (6 patients with type 1 and 4 patients with type 2 achalasia), whereas 15 appeared to have resolved the achalasia pattern (peristalsis was absent in 8 patients and weak in 7 patients). The height of the barium column at 5 minutes and Eckardt Scores were reduced significantly in patients who had resolved their achalasia pattern, based on HRM. The integrated relaxation pressure and the TBE column height correlated at 5 minutes (r = 0.422; P < .05).

CONCLUSIONS

Patients who resolved their achalasia pattern, based on HRM, showed improved emptying based on TBE measurements and improved symptom scores. There was no significant difference between patients with type 1 or type 2 achalasia in TBEs. These findings indicate that normalization of the integrated relaxation pressure on HRM is a clinically relevant objective of treatment for achalasia.

Recent progress in treatment of achalasia

Achalasia is a rare primary esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter, absent or decreased esophageal peristaltic waves and synchronous contractions. As the exact pathogenesis of the disease remains unclear, treatment options focus on the alleviation of the functional obstruction caused by lower esophageal sphincter and prevention of gastroesophageal reflux disease at the same time. Treatment modalities include pharmacological therapy, interventional therapy, surgical treatment and spinal rotation massage. This article reviews the latest progress in treatment of achalasia, with particular emphasis on the evolution of main treatments which include endoscopic pneumatic dilation, Heller myotomy and per-oral endoscopic myotomy (POEM).

Training in peroral endoscopic myotomy (POEM) for esophageal achalasia

Peroral endoscopic myotomy (POEM) has been developed in the context of natural orifice transluminal endoscopic surgery (NOTES) as a minimally invasive endoscopic treatment for symptomatic esophageal achalasia, which is a chronic progressive benign disease with severe morbidity and difficult management. Since September 2008, POEM has been successfully performed in more than 200 consecutive patients with symptomatic achalasia at the Digestive Disease Center of Showa University, Northern Yokohama Hospital, Yokohama, Japan, with excellent short- and long-term results and absence of serious complications. International experience of POEM within clinical studies is also promising. According to these results, POEM is considered as a safe procedure that can be applied to all achalasia patients. However, the low incidence of achalasia (0.3%-1% per 100,000 population), in combination with the potential serious complications related to the technically demanding POEM procedure, has made training difficult. There is therefore an urgent need for an animal model for training to decrease the learning curve. Further, there are other ethical and training issues to address. The pig is the most appropriate animal model for training in POEM due to its anatomy being similar to that of humans. The porcine esophagus has the advantage of easy mobilization due to absence of tight junctions to surrounding organs. A non-survival porcine model would be a simple, inexpensive, and reproducible animal model for training in POEM, without the need for concern about complications. A possible training process might first involve observation of POEM performed by specialists, then training on non-survival and survival porcine models, followed by training in humans under specialist guidance and finally, performance of POEM in humans.

Training in peroral endoscopic myotomy (POEM) for esophageal achalasia

Peroral endoscopic myotomy (POEM) has been developed in the context of natural orifice transluminal endoscopic surgery (NOTES) as a minimally invasive endoscopic treatment for symptomatic esophageal achalasia, which is a chronic progressive benign disease with severe morbidity and difficult management. Since September 2008, POEM has been successfully performed in more than 200 consecutive patients with symptomatic achalasia at the Digestive Disease Center of Showa University, Northern Yokohama Hospital, Yokohama, Japan, with excellent short- and long-term results and absence of serious complications. International experience of POEM within clinical studies is also promising. According to these results, POEM is considered as a safe procedure that can be applied to all achalasia patients. However, the low incidence of achalasia (0.3%-1% per 100,000 population), in combination with the potential serious complications related to the technically demanding POEM procedure, has made training difficult. There is therefore an urgent need for an animal model for training to decrease the learning curve. Further, there are other ethical and training issues to address. The pig is the most appropriate animal model for training in POEM due to its anatomy being similar to that of humans. The porcine esophagus has the advantage of easy mobilization due to absence of tight junctions to surrounding organs. A non-survival porcine model would be a simple, inexpensive, and reproducible animal model for training in POEM, without the need for concern about complications. A possible training process might first involve observation of POEM performed by specialists, then training on non-survival and survival porcine models, followed by training in humans under specialist guidance and finally, performance of POEM in humans.