151
|
Öter V, Bostancı EB, Karaman K, Sümer F, Özer İ. Effects of preoperative endoscopic pneumatic balloon dilatation on postoperative achalasia symptoms after Heller esophageal myotomy plus Dor fundoplication. TURKISH JOURNAL OF GASTROENTEROLOGY 2019; 29:543-548. [PMID: 30260775 DOI: 10.5152/tjg.2018.17822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND/AIMS Currently, forceful endoscopic pneumatic balloon dilatation (PBD), laparoscopic Heller myotomy (LHM) with or without an anti-reflux procedure, and peroral endoscopic myotomy are the preferred treatment options for achalasia. The aim of the present study was to retrospectively compare postoperative outcomes after LHM plus Dor fundoplication (DF) between patients who underwent prior endoscopic balloon dilatation and those who did not. MATERIALS AND METHODS Sixty-five patients who underwent HM+DF between January 2008 and December 2016 were retrospectively analyzed. Of these, 45 had a history of endoscopic PBD. Pre- and postoperative achalasia symptoms, including weight loss, dysphagia, heartburn, and regurgitation, were evaluated using the Eckardt score. RESULTS Fifty (76.9%) patients underwent laparoscopic surgery and 15 (23.1%) underwent open surgery. When patients were compared according to the presence of preoperative endoscopic PBD, no significant difference were observed in terms of age, sex, preoperative lower esophageal sphincter pressure, operation time, hospitalization period, and follow-up period (p>0.05). The mean Eckardt score at the first postoperative year was significantly lower than the preoperative Eckardt score (4.51±1.8 vs. 0.52±0.7; p<0.001). In contrast, no significant difference was found between patients with and without previous PBD on the pre- and postoperative Eckardt scores (p=0.43). CONCLUSION HM+DF is an effective procedure in relieving achalasia symptoms as a first-line therapy as well as in individuals unresponsive to repeated endoscopic PBDs.
Collapse
Affiliation(s)
- Volkan Öter
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Erdal Birol Bostancı
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Kerem Karaman
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Fatih Sümer
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - İlter Özer
- Department of Gastroenterological Surgery, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| |
Collapse
|
152
|
Lee Y, Brar K, Doumouras AG, Hong D. Peroral endoscopic myotomy (POEM) for the treatment of pediatric achalasia: a systematic review and meta-analysis. Surg Endosc 2019; 33:1710-1720. [PMID: 30767141 DOI: 10.1007/s00464-019-06701-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/06/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Achalasia is a rare primary esophageal dysmotility disorder in children. Peroral endoscopic myotomy (POEM) is a novel endoscopic technique which has shown promising results for treating achalasia in adults. However, limited data on efficacy and safety in pediatric patients are available. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of POEM in pediatric achalasia. METHODS We searched MEDLINE, Embase, PubMed, and Web of Science databases through July 2018. Studies were eligible for inclusion if they conducted POEM in pediatric patients. Main outcomes were Eckardt score and lower esophageal sphincter (LES) pressure before and after POEM. Secondary outcomes were clinical success rate and adverse events associated with POEM. Two reviewers independently reviewed the studies, collected data, and assessed quality of evidence using Methodological Index for Non-Randomized Studies (MINORS). Pooled estimates were calculated using random effects meta-analyses. Heterogeneity was quantified using the inconsistency statistic, and funnel plot was used to assess publication bias. RESULTS A total of 12 studies with 146 pediatric patients (53.68% female) underwent POEM for the treatment of achalasia (mean duration of disease of 19.48 months). There was a significant reduction in Eckardt score by 6.88 points (Mean Difference (MD) 6.88, 95% confidence interval (CI), 6.28-7.48, P < .001) and LES pressure by 20.73 mmHg (MD 20.73, 95% CI, 15.76-25.70, P < .001) following POEM. At least 93% of the patients experienced improvement or resolution of achalasia symptoms both short and long terms after POEM, with small proportion of patients experiencing minor adverse effects which could be managed conservatively. CONCLUSIONS POEM is efficacious and safe for treating achalasia in pediatric populations. Large comparative or randomized trials are warranted to confirm the efficacy and safety of POEM compared to other surgical procedures for achalasia.
Collapse
Affiliation(s)
- Yung Lee
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.,Centre for Minimal Access Surgery (CMAS), Division of General Surgery, Department of Surgery, McMaster University St. Joseph's Healthcare, 50 Charlton Avenue East Hamilton, Hamilton, ON, L8N 4A6, Canada
| | - Karanbir Brar
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Aristithes G Doumouras
- Centre for Minimal Access Surgery (CMAS), Division of General Surgery, Department of Surgery, McMaster University St. Joseph's Healthcare, 50 Charlton Avenue East Hamilton, Hamilton, ON, L8N 4A6, Canada
| | - Dennis Hong
- Centre for Minimal Access Surgery (CMAS), Division of General Surgery, Department of Surgery, McMaster University St. Joseph's Healthcare, 50 Charlton Avenue East Hamilton, Hamilton, ON, L8N 4A6, Canada.
| |
Collapse
|
153
|
Ishii T, Akaishi T, Abe M, Takayama S, Koseki K, Kamei T, Nakano T. Importance of Barium Swallow Test and Chest CT Scan for Correct Diagnosis of Achalasia in the Primary Care Setting. TOHOKU J EXP MED 2019; 247:41-49. [PMID: 30662021 DOI: 10.1620/tjem.247.41] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Esophageal achalasia is a disease characterized by the impaired esophageal peristalsis and non-relaxation of the lower esophageal sphincter muscle with unknown causes. Clinical manifestation of the disease is nonspecific (e.g., weight loss, vomiting, and persistent cough); namely, early diagnosis of the disease is often difficult. Delayed diagnosis of the disease is known to impair the patients' quality of life. Identifying the diagnostic factors that could cause diagnostic delay is needed. In this study, we collected data from 38 patients with achalasia and searched for diagnostic factors associated with delayed diagnosis (i.e., ≥ 6 months from the first hospital visit to diagnosis). The enrolled patients, diagnosed with achalasia based on esophageal manometry findings, had undergone surgical myotomy. As a result, the diagnosis of achalasia was likely to be delayed when the physician who had first contacted the patient did not perform a barium swallow test (p < 0.0001) or chest CT scan (p < 0.01) in a timely fashion. Among the patients with a delayed diagnosis (n = 15), none underwent a barium swallow test or chest CT within 6 months from their first hospital visit. The estimated sensitivities of diagnostic examinations for achalasia based on the enrolled 38 patients were higher than 80% for the barium swallow test and chest CT scan, but only 50-81% for endoscopy. To avoid the delayed diagnosis of achalasia, performing a barium swallow test or chest CT scan in a timely fashion, in addition to routine endoscopy, appears to be highly important.
Collapse
Affiliation(s)
- Tadashi Ishii
- Department of Surgery, Tohoku University Graduate School of Medicine.,Department of Education and Support for Regional Medicine, Tohoku University Hospital
| | - Tetsuya Akaishi
- Department of Education and Support for Regional Medicine, Tohoku University Hospital
| | - Michiaki Abe
- Department of Education and Support for Regional Medicine, Tohoku University Hospital
| | - Shin Takayama
- Department of Education and Support for Regional Medicine, Tohoku University Hospital
| | - Ken Koseki
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Toru Nakano
- Division of Gastroenterology and Hepatobiliary Pancreatic Surgery, Tohoku Medical and Pharmaceutical University
| |
Collapse
|
154
|
Trindade AJ, McKinley MJ, Alshelleh M, Levi G, Stewart M, Quinn KJ, Thomas RM. Mutational load may predict risk of progression in patients with Barrett's oesophagus and indefinite for dysplasia: a pilot study. BMJ Open Gastroenterol 2019; 6:e000268. [PMID: 30815274 PMCID: PMC6361327 DOI: 10.1136/bmjgast-2018-000268] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 01/03/2019] [Accepted: 01/12/2019] [Indexed: 12/20/2022] Open
Abstract
Background and aims Mutational load (ML) has been shown to help risk-stratify those that may progress from non-dysplastic Barrett’s oesophagus (BE) to dysplastic disease. Management of patients with BE and indefinite for dysplasia (BE-IND) is challenging and risk stratification tools are lacking. The aim of this pilot study is to evaluate the utility of ML for risk stratification in patients with BE-IND. Methods This is a single-centre, retrospective pilot study evaluating ML quantification in patients with BE-IND. Histology at follow-up endoscopy at least 1 year after the baseline endoscopy was used to determine if a patient progressed to low or high dysplasia. The ML levels were then compared among patients who progressed to dysplasia versus those who did not. Results Thirty-five patients who met the inclusion criteria were identified, and seven met the exclusion criteria. Twenty-eight patients were analysed, of whom eight progressed to low-grade dysplasia (6) and high-grade dysplasia (2). Seven of these eight patients had some level of genomic instability detected in their IND biopsy (ML ≥0.5). Ten of the 20 (50%) who did not progress had no ML level. At an ML cut-off above 1.5, the risk of progression to high-grade dysplasia was 33% vs 0% (p=0.005), with a sensitivity of 100% and a specificity of 85%. Conclusion These results indicate that ML may be able to risk-stratify progression to high-grade dysplasia in BE-IND. Larger studies are needed to confirm these findings.
Collapse
Affiliation(s)
- Arvind J Trindade
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Matthew J McKinley
- Division of Gastroenterology, ProHEALTH Care Associates, Lake Success, New York, USA
| | - Mohammad Alshelleh
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Gabriel Levi
- Division of Pathology, ProHEALTH Care Associates, Lake Success, New York, USA
| | - Molly Stewart
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Kathy J Quinn
- Division of Pathology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Rebecca M Thomas
- Division of Pathology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| |
Collapse
|
155
|
Bonifácio P, de Moura DTH, Bernardo WM, de Moura ETH, Farias GFA, Neto ACM, Lordello M, Korkischko N, Sallum R, de Moura EGH. Pneumatic dilation versus laparoscopic Heller's myotomy in the treatment of achalasia: systematic review and meta-analysis based on randomized controlled trials. Dis Esophagus 2019; 32:5149492. [PMID: 30380036 DOI: 10.1093/dote/doy105] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Achalasia is a primary esophageal motor disorder with a variety of causes. It is most common in Central and South America, where Chagas disease is endemic. In addition to the infectious etiology, achalasia can be idiopathic, autoimmune, or drug induced. It is an incurable, progressive condition that destroys the intramural nerve plexus, causing aperistalsis of the esophageal body and impaired relaxation of the lower esophageal sphincter. The literature on the treatment of achalasia comparing pneumatic dilation (PD) and laparoscopic Heller's myotomy (LHM) shows conflicting results. Therefore, a systemic review and meta-analysis are needed. A systematic review and meta-analysis of randomized controlled trials of PD and LHM, based on the preferred reporting items for systematic reviews and meta-analyses recommendations, was presented. The primary outcome was symptom remission based on the Eckardt score. Secondary outcomes were lower esophageal sphincter pressure (LESP), gastroesophageal reflux (GER), and perforation. A total of four studies were included in this analysis. The total number of patients was 404. Posttreatment symptom remission rates did not differ significantly between LHM and PD at 2 years (RD = 0.03, 95% CI [-0.05, 0.12], P = 0.62), or 5 years (RD = 0.13, 95% CI [-0.12, 0.39], P = 0.32). The posttreatment perforation rate was lower for LHM (RD = 0.04, 95% CI [-0.08, -0.01], P = 0.03). There was no significant difference in terms of LESP or GER. For the treatment of esophageal achalasia, LHM and PD were found to be similar in terms of their long-term efficacy, as well as in terms of the posttreatment GER rates. However, the perforation rate appears to be lower when LHM is employed.
Collapse
Affiliation(s)
- P Bonifácio
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - D T H de Moura
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - W M Bernardo
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - E T H de Moura
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - G F A Farias
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - A C M Neto
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - M Lordello
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - N Korkischko
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - R Sallum
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - E G H de Moura
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| |
Collapse
|
156
|
Shah ED, Chang AC, Law R. Valuing innovative endoscopic techniques: per-oral endoscopic myotomy for the management of achalasia. Gastrointest Endosc 2019; 89:264-273.e3. [PMID: 29684386 DOI: 10.1016/j.gie.2018.04.2341] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 04/04/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Unclear reimbursement for new and innovative endoscopic procedures can limit adoption in clinical practice despite effectiveness in clinical trials. The aim of this study was to determine maximum cost-effective reimbursement for per-oral endoscopic myotomy (POEM) in treating achalasia. METHODS We constructed a decision-analytic model assessing POEM versus laparoscopic Heller myotomy with Dor fundoplication (LHM) in managing achalasia from a payer perspective over a 1-year time horizon. Reimbursement data were derived from 2017 Medicare data. Responder rates were based on clinically meaningful improvement in validated Eckardt scores. Validated health utility values were assigned to terminal health states based on data previously derived with a standard gamble technique. Contemporary willingness-to-pay (WTP) levels per quality-adjusted life year (QALY) were used to estimate maximum reimbursement for POEM using threshold analysis. RESULTS Effectiveness of POEM and LHM was similar at 1 year of follow-up (0.91 QALY). Maximum cost-effective reimbursement for POEM was $8033.37 to $8223.14, including all professional and facility fees. This compares favorably with contemporary total reimbursement of 10 to 15 total relative value units for advanced endoscopic procedures. Rates of postprocedural GERD did not affect the preference for POEM compared with LHM, assuming at least 10% cost savings with POEM compared with LHM in cost-minimization analysis, or at least 44% cost savings in cost-effectiveness analysis (WTP = $100,000/QALY). LHM was only preferred over POEM if both procedures were reimbursed similarly, and these findings were primarily driven by lower rates of postprocedural GERD. The rate of conversion to open laparotomy due to perforation or bleeding was infrequent in published clinical practice experience, thus did not significantly affect reimbursement. DISCUSSION POEM is an example of an innovative and potentially disruptive endoscopic technique offering greater cost-effective value and similar outcomes to the established surgical standard at contemporary reimbursement levels.
Collapse
Affiliation(s)
- Eric D Shah
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Andrew C Chang
- Section of Thoracic Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Ryan Law
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan, USA
| |
Collapse
|
157
|
Andolfi C, Fisichella PM. Meta-analysis of clinical outcome after treatment for achalasia based on manometric subtypes. Br J Surg 2019; 106:332-341. [PMID: 30690706 DOI: 10.1002/bjs.11049] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 08/30/2018] [Accepted: 10/11/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND The introduction of high-resolution manometry and the Chicago classification has made it possible to diagnose achalasia and predict treatment response accurately. The aim of this study was to compare the effect of the different treatments available on symptomatic outcomes across all achalasia subtypes. METHODS The study was conducted according to PRISMA and MOOSE guidelines. A literature search of PubMed and MEDLINE databases was undertaken to identify all relevant articles reporting clinical outcomes of patients with achalasia after botulinum toxin injection, pneumatic dilatation, laparoscopic Heller myotomy (LHM) and peroral endoscopic myotomy (POEM) based on manometric subtypes. Patients were grouped according to the Chicago classification and the success rate in treating symptoms was measured as the primary endpoint. RESULTS Twenty studies (1575 patients) were selected, and data on botulinum toxin, pneumatic dilatation, LHM and POEM were extracted. Success rates for LHM in type I, II and III achalasia were 81, 92 and 71 per cent respectively. Those for POEM were 95, 97 and 93 per cent respectively. POEM was more likely to be successful than LHM for both type I (odds ratio (OR) 2·97, 95 per cent c.i. 1·09 to 8·03; P = 0·032) and type III (OR 3·50, 1·39 to 8·77; P = 0·007) achalasia. The likelihood of success of POEM and LHM for type II achalasia was similar. CONCLUSION Pneumatic dilatation had a lower but still acceptable success rate compared with POEM or LHM in patients with type II achalasia. POEM is an excellent treatment modality for type I and type III achalasia, although it did not show any superiority over LHM for type II achalasia.
Collapse
Affiliation(s)
- C Andolfi
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - P M Fisichella
- Department of Surgery, Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
158
|
Mari A, Patel K, Mahamid M, Khoury T, Pesce M. Achalasia: Insights into Diagnostic and Therapeutic Advances for an Ancient Disease. Rambam Maimonides Med J 2019; 10:RMMJ.10361. [PMID: 30720423 PMCID: PMC6363376 DOI: 10.5041/rmmj.10361] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Achalasia is a chronic idiopathic disease characterized by the absence of esophageal body peristalsis and by defective lower esophageal sphincter (LES) relaxation. The incidence rate ranges from 1.07 to up to 2.8 new cases per year per 100,000 population. Presenting symptoms include dysphagia, regurgitation, vomiting, and weight loss. The diagnosis of achalasia has undergone a revolution in the last decade due to the advent of high-resolution manometry (HRM) and the consequent development of the Chicago Classification. Recent progress has allowed achalasia to be more precisely diagnosed and to be categorized into three subtypes, based on the prevalent manometric features of the esophageal peristalsis. Treatment options are pharmacotherapy, endoscopic management (Botox injection or pneumatic dilation), and surgery, e.g. laparoscopic Heller myotomy (LHM). More recently, a new endoscopic technique, per oral endoscopic myotomy (POEM), has developed as a less invasive approach alternative to the traditional LHM. Since the first POEM procedure was performed in 2008, increasing evidence is accumulating regarding its efficacy and safety profiles. Currently, POEM is being introduced as a reasonable therapeutic option, though randomized controlled trails are still lacking. The current review sheds light onto the diagnosis and management of achalasia, with special focus on the recent advances of HRM and POEM.
Collapse
Affiliation(s)
- Amir Mari
- Gastroenterology Institute, Nazareth EMMS Hospital, Nazareth, Israel
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- GI Physiology Unit, University College London Hospital, London, United Kingdom
| | - Kalp Patel
- GI Physiology Unit, University College London Hospital, London, United Kingdom
| | - Mahmud Mahamid
- Gastroenterology Institute, Nazareth EMMS Hospital, Nazareth, Israel
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Tawfik Khoury
- Gastroenterology Institute, Nazareth EMMS Hospital, Nazareth, Israel
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Marcella Pesce
- GI Physiology Unit, University College London Hospital, London, United Kingdom
| |
Collapse
|
159
|
Affiliation(s)
- Hajime Isomoto
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Tottori University Faculty of Medicine, Tottori, Japan
| | - Yuichiro Ikebuchi
- Division of Medicine and Clinical Science, Department of Multidisciplinary Internal Medicine, Tottori University Faculty of Medicine, Tottori, Japan
| |
Collapse
|
160
|
Chatterjee A, Saha S. Achalasia in a child confirmed by high-resolution manometry. ACTA MEDICA INTERNATIONAL 2019. [DOI: 10.4103/ami.ami_14_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
161
|
Neubert ZS, Stickle ET. Bridging therapy for achalasia in a second trimester pregnant patient. J Family Med Prim Care 2019; 8:289-297. [PMID: 30911523 PMCID: PMC6396631 DOI: 10.4103/jfmpc.jfmpc_389_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
We present the case of a 28-year-old female who presented for primary care at 22-week gestation with type II achalasia and worsening solid/liquid dysphagia leading to pregnancy weight loss. Considering that durable therapies such as surgical myotomy and pneumatic dilatation have considerable risk, botulinum A toxin injection was selected as a temporizing bridging therapy. She had an uncomplicated post procedure course and had significant rapid improvement in dysphagia symptoms, which enabled her to progress to normal peripartum weight. This case highlights the need for early recognition of achalasia and an unique niche for use of botulinum toxin A as a temporizing therapy in this risk averse population.
Collapse
Affiliation(s)
- Zachary S Neubert
- Department of Gastroenterology, Naval Medical Center, San Diego, Bob Wilson Drive, San Diego, California, United States
| | - Edward T Stickle
- Department of Gastroenterology, Naval Medical Center, San Diego, Bob Wilson Drive, San Diego, California, United States
| |
Collapse
|
162
|
Tassi V, Lugaresi M, Mattioli B, Fortunato F, Zagari RM, Daddi N, Bassi F, Pilotti V, Mattioli S. Incidence and risk factors for the development of epidermoid carcinoma in oesophageal achalasia†. Eur J Cardiothorac Surg 2018; 55:956-963. [DOI: 10.1093/ejcts/ezy401] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 10/07/2018] [Accepted: 10/23/2018] [Indexed: 12/13/2022] Open
Affiliation(s)
- Valentina Tassi
- PhD Course in Cardio-Nephro-Thoracic Sciences, Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Marialuisa Lugaresi
- Division of Thoracic Surgery, Maria Cecilia Hospital, Cotignola, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Benedetta Mattioli
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Francesca Fortunato
- Department of Statistical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Rocco Maurizio Zagari
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Niccolò Daddi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Francesco Bassi
- Division of Radiology, Policlinico Sant’Orsola-Malpighi, Bologna, Italy
- Division of Radiology, Maria Cecilia Hospital, Cotignola, Italy
| | - Vladimiro Pilotti
- Division of Thoracic Surgery, Maria Cecilia Hospital, Cotignola, Italy
| | - Sandro Mattioli
- PhD Course in Cardio-Nephro-Thoracic Sciences, Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Division of Thoracic Surgery, Maria Cecilia Hospital, Cotignola, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| |
Collapse
|
163
|
Abstract
Peroral endoscopic myotomy surgery is an incisionless, minimally invasive, natural orifice technique used to treat the symptoms of achalasia and other spastic disorders of the esophagus. Recent experience demonstrates that it can be performed safely by experienced esophageal surgeons and there are very good short-term outcomes comparable to laparoscopic myotomy. The rapid worldwide adoption of this technique demonstrates its potential to replace the current therapies available for achalasia. A cautionary note is important in that long-term outcomes are not yet available in terms of dysphagia and GERD symptoms.
Collapse
Affiliation(s)
- Lara W Schaheen
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian, Suite C-800, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Manuel Villa Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian, Suite C-800, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - James D Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian, Suite C-800, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
| |
Collapse
|
164
|
Negative video capsule enteroscopy – what's the next step? GASTROENTEROLOGIA Y HEPATOLOGIA 2018; 41:663-669. [DOI: 10.1016/j.gastrohep.2018.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/31/2018] [Accepted: 06/04/2018] [Indexed: 02/08/2023]
|
165
|
Triantafyllou T, Theodoropoulos C, Georgiou G, Kalles V, Chrysikos D, Filis K, Zografos G, Theodorou D. Long-term outcome of myotomy and fundoplication based on intraoperative real-time high-resolution manometry in achalasia patients. Ann Gastroenterol 2018; 32:46-51. [PMID: 30598591 PMCID: PMC6302195 DOI: 10.20524/aog.2018.0326] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 10/16/2018] [Indexed: 12/29/2022] Open
Abstract
Background Current treatment options for achalasia of the esophagus predominantly consist of endoscopic myotomy or laparoscopic myotomy combined with a partial fundoplication. The intraoperative use of conventional manometry has previously been proposed with various results. The aim of the present study was to introduce the use of high-resolution manometry (HRM) during surgical treatment for achalasia and to assess the long-term outcome of this technique. Methods We enrolled achalasia patients within the time period November 2013 to July 2016 who underwent HRM and evaluation of Eckardt scores (ES) before and after tailored laparoscopic myotomy and fundoplication with intraoperative recording using HRM. Results Twenty patients were classified as having achalasia type I (20%), type II (55%), or type III (25%). During surgery, 9 myotomies were extended and 13 fundoplications were modified according to HRM findings. Mean resting (16.1 vs. 41.9 mmHg) and residual (9 vs. 28.7 mmHg) pressures of the lower esophageal sphincter and ES (0.7 vs. 6.9) were significantly eliminated postoperatively over a mean follow-up time of 17.7 months. Conclusions The use of intraoperative HRM gives us the advantage of simultaneous real-time estimation of intraluminal pressures of the esophagus and the ability to identify the exact points that produce pressure during laparoscopy. Consequently, it may be the key to the tailoring of the Heller-Dor technique and improving the outcomes for achalasia patients.
Collapse
Affiliation(s)
- Tania Triantafyllou
- Department of Surgery, 1 Propaedeutic Surgical Clinic, Hippocration General Hospital of Athens, University of Athens (Tania Triantafyllou, Charalampos Theodoropoulos, Georgia Georgiou, Vasileios Kalles, Konstantinos Filis, Georgios Zografos, Dimitrios Theodorou)
| | - Charalampos Theodoropoulos
- Department of Surgery, 1 Propaedeutic Surgical Clinic, Hippocration General Hospital of Athens, University of Athens (Tania Triantafyllou, Charalampos Theodoropoulos, Georgia Georgiou, Vasileios Kalles, Konstantinos Filis, Georgios Zografos, Dimitrios Theodorou)
| | - Georgia Georgiou
- Department of Surgery, 1 Propaedeutic Surgical Clinic, Hippocration General Hospital of Athens, University of Athens (Tania Triantafyllou, Charalampos Theodoropoulos, Georgia Georgiou, Vasileios Kalles, Konstantinos Filis, Georgios Zografos, Dimitrios Theodorou)
| | - Vasileios Kalles
- Department of Surgery, 1 Propaedeutic Surgical Clinic, Hippocration General Hospital of Athens, University of Athens (Tania Triantafyllou, Charalampos Theodoropoulos, Georgia Georgiou, Vasileios Kalles, Konstantinos Filis, Georgios Zografos, Dimitrios Theodorou)
| | - Demosthenis Chrysikos
- General and Oncologic Hospital of Kifissia "Agii Anargiri" (Demosthenis Chrysikos), Athens, Greece
| | - Konstantinos Filis
- Department of Surgery, 1 Propaedeutic Surgical Clinic, Hippocration General Hospital of Athens, University of Athens (Tania Triantafyllou, Charalampos Theodoropoulos, Georgia Georgiou, Vasileios Kalles, Konstantinos Filis, Georgios Zografos, Dimitrios Theodorou)
| | - Georgios Zografos
- Department of Surgery, 1 Propaedeutic Surgical Clinic, Hippocration General Hospital of Athens, University of Athens (Tania Triantafyllou, Charalampos Theodoropoulos, Georgia Georgiou, Vasileios Kalles, Konstantinos Filis, Georgios Zografos, Dimitrios Theodorou)
| | - Dimitrios Theodorou
- Department of Surgery, 1 Propaedeutic Surgical Clinic, Hippocration General Hospital of Athens, University of Athens (Tania Triantafyllou, Charalampos Theodoropoulos, Georgia Georgiou, Vasileios Kalles, Konstantinos Filis, Georgios Zografos, Dimitrios Theodorou)
| |
Collapse
|
166
|
The Role of Botulinum Toxin Injections for Esophageal Motility Disorders. ACTA ACUST UNITED AC 2018; 16:528-540. [DOI: 10.1007/s11938-018-0212-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
167
|
Bostanci EB, Oter V, Karaman K. The Use of Rigiflex Pneumatic Balloon Dilator during Laparoscopic Heller's Myotomy in Patients with Achalasia: A Novel Technical Method and Its Surgical Outcomes. Am Surg 2018. [DOI: 10.1177/000313481808401138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Pneumatic balloon dilatation (BD) and laparoscopic Heller's myotomy (LHM) are usually preferred treatment options for relieving dysphagia symptoms in achalasia. The aim of the present study was to describe a new technical method for a safe and effective LHM. Endoscopic BD tube (Rigiflex 30-mm pneumatic balloon) is simultaneously insufflated and desufflated in the esophagus during LHM to assess myotomy in 50 consecutive patients. Dysphagia symptoms were determined using Eckardt's score. Three esophageal mucosal perforations occurred during surgery, which was primary repaired. The preoperative Eckardt score improved significantly from 4.54 ± 1.85 to 0.54 ± 0.73 ( P < 0.001) at the first postoperative annual follow-up. The use of endoscopic BD tube during LHM is an easy and valuable method that allows to assess whether the dissection of muscular fibers in the myotomy area is appropriate or not.
Collapse
Affiliation(s)
- Erdal Birol Bostanci
- Department of Gastroenterological Surgery, Turkiye Yuksek Ihtisas Teaching and Research Hospital, University of Health Science, Ankara, Turkey and
| | - Volkan Oter
- Department of Gastroenterological Surgery, School of Medicine, Sakarya University, Sakarya, Turkey
| | - Kerem Karaman
- Department of Gastroenterological Surgery, School of Medicine, Sakarya University, Sakarya, Turkey
| |
Collapse
|
168
|
Ponds FA, Oors JM, Smout AJPM, Bredenoord AJ. Rapid drinking challenge during high-resolution manometry is complementary to timed barium esophagogram for diagnosis and follow-up of achalasia. Neurogastroenterol Motil 2018; 30:e13404. [PMID: 29989262 DOI: 10.1111/nmo.13404] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 05/31/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Esophageal stasis is a hallmark of achalasia. Timed barium esophagogram (TBE) is used to measure stasis but exposes patients to ionizing radiation. It is suggested that esophageal stasis can be objectified on high-resolution manometry (HRM) as well using a rapid drinking challenge test (RDC). We aimed to assess esophageal stasis in achalasia by a RDC during HRM and compare this to TBE. METHODS Thirty healthy subjects (15 male, age 40 [IQR 34-49]) and 90 achalasia patients (53 male, age 47 [36-59], 30 untreated/30 treated symptomatic/30 treated asymptomatic) were prospectively included to undergo HRM with RDC and TBE. RDC was performed by drinking 200 mL of water. Response to RDC was measured by basal and relaxation pressure in the esophagogastric junction (EGJ) and esophageal pressurization during the last 5 seconds. KEY RESULTS EGJ basal and relaxation pressure during RDC were higher in achalasia compared to healthy subjects (overall P < .01). Esophageal body pressurization was significantly higher in untreated (43 [33-35 mm Hg]) and symptomatic treated patients (25 [16-32] mm Hg) compared to healthy subjects (6 [3-7] mm Hg) and asymptomatic treated patients (11 [8-15] mm Hg, overall P < .01). A strong correlation was observed between esophageal pressurization during RDC and barium column height at 5 minutes on TBE (r = .75, P < .01), comparable to the standard predictor of esophageal stasis, IRP (r = .66, P < .01). CONCLUSIONS & INFERENCES The RDC can reliably predict esophageal stasis in achalasia and adequately measure treatment response to a degree comparable to TBE. We propose to add this simple test to each HRM study in achalasia patients.
Collapse
Affiliation(s)
- F A Ponds
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - J M Oors
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - A J P M Smout
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - A J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| |
Collapse
|
169
|
|
170
|
Affiliation(s)
- Amit Patel
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina
- Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Shai Posner
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina
- Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri
| |
Collapse
|
171
|
Kim SS, Guillen-Rodriguez J, Little AG. Optimal surgical intervention for achalasia: laparoscopic or robotic approach. J Robot Surg 2018; 13:397-400. [PMID: 30218251 DOI: 10.1007/s11701-018-0865-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 08/26/2018] [Indexed: 01/15/2023]
Abstract
Laparoscopic esophageal myotomy is the standard surgical intervention for achalasia. Compared to standard laparoscopic techniques, use of the robot has theoretical advantages of improved visualization and dexterity. We evaluated the University of Arizona's experience with the two alternatives to compare outcomes. Patients who underwent either laparoscopic or robot-assisted myotomy were identified from a retrospective database from 1/1/2006 to 12/31/2015. Patient demographics, prior treatment, intra-operative complications, operative time, post-operative length of stay and complications, and long-term results were compared between the two groups. We identified 35 laparoscopic and 37 robot-assisted Heller myotomies performed by multiple surgeons. Patient demographics were similar between the two groups with no statistical difference in age, gender, previous operations, pre-operative Botox or dilation treatment, or pre-op Eckardt score. In univariate analysis, the patients with the robotic procedure received a longer myotomy (5.85 cm vs. 5.56 cm for esophageal and 2.92 cm vs. 2.68 cm for gastric) and had a lower post-operative Eckardt score (0.51 vs. 1.09). A trend toward lower incidence of recurrent achalasia symptoms was found in the robotic group (0 patient vs. 4 patients) compared with those who had laparoscopic surgery (p < 0.05). Multivariate analysis showed that a longer gastric myotomy was associated with a lower recurrence rate (p = 0.0002). Both laparoscopic and robot-assisted Heller myotomy can provide definitive treatment of achalasia with good results and few complications. The mechanical advantage provided by the robotic approach may improve outcomes by providing a more complete myotomy and durable long-term result.
Collapse
Affiliation(s)
- Samuel S Kim
- Division of Cardiothoracic Surgery, University of Arizona, Tucson, AZ, USA.
| | - Jose Guillen-Rodriguez
- Section of Biostatistics and Informatics, University of Arizona Cancer Center, Tucson, AZ, USA
| | - Alex G Little
- Division of Cardiothoracic Surgery, University of Arizona, Tucson, AZ, USA
| |
Collapse
|
172
|
Abstract
Esophageal cancer affects more than 4,50,000 persons worldwide, and its incidence has increased in recent years. It is the eighth most common cancer across the globe. The main histologic types are esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EA), and their associated risk factors are well known. Achalasia, an idiopathic esophageal disorder that conditions aperistalsis and the absence of lower esophageal sphincter relaxation, stands out among them. The prevalence of ESCC in subjects with esophageal achalasia is 26 in every 1,000 cases, whereas the prevalence of EA is 4 in every 1,000. Patients with achalasia have a 50 times higher risk of presenting with ESCC than the general population, and the disease manifests 20-25 years after achalasia symptom onset. Multiple mechanisms are related to the development of ESCC in achalasia, and they include bacterial overgrowth, food stasis, genetic alterations, and chronic inflammation. Regarding the risk of EA in achalasia patients, most cases are associated with Barrett's esophagus, due to uncontrolled chronic acid reflux. Given that achalasia is a well-established factor for ESCC/EA, clinicians must be aware of said associations to enable the development of programs for the prevention and opportune detection of these cancers in patients with achalasia.
Collapse
Affiliation(s)
- Maura Torres-Aguilera
- Department of Pediatric Gastroenteritis, Hospital CMN "La Raza", Mexico City, Mexico
| | - José María Remes Troche
- Digestive Physiology and Motility Laboratory, Medical Biological Research Institute, Universidad Veracruzana, Veracruz, Mexico,
| |
Collapse
|
173
|
Inoue H, Shiwaku H, Iwakiri K, Onimaru M, Kobayashi Y, Minami H, Sato H, Kitano S, Iwakiri R, Omura N, Murakami K, Fukami N, Fujimoto K, Tajiri H. Clinical practice guidelines for peroral endoscopic myotomy. Dig Endosc 2018; 30:563-579. [PMID: 30022514 DOI: 10.1111/den.13239] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 07/17/2018] [Indexed: 12/11/2022]
Abstract
Peroral endoscopic myotomy (POEM) is a novel clinical technique developed in Japan used to treat esophageal achalasia and esophageal motility disorders. This technique has been rapidly accepted and widely disseminated throughout our clinical practice because of its low invasiveness, technical novelty, and high efficacy. Since the advent of POEM, there have been no clinical guidelines that clearly indicated its standard of care, and these guidelines have been anticipated both nationally and internationally by clinicians who engage in POEM practice. In 2017, to meet these needs, the Japan Gastroenterological Endoscopy Society (JGES) launched the guideline committee for POEM. Based on the guideline development process proposed by the Medical Information Network Distribution Service (MINDS), the guideline committee initially created research questions on POEM and conducted a systematic review and meta-analysis on each topic. The clinical research extracted from databases for these clinical questions and the systematic review mainly comprised a few retrospective studies with a small number of participants and short trial periods; hence, the strength of the evidence and recommendations derived from these results was low. Throughout this process, the guideline committee met thrice: once on May 13, 2017, and again on September 17, 2017, to formulate the draft. A consensus meeting was then held on January 14, 2018, in Tokyo to establish the guideline statements and finalize the recommendations using the modified Delphi method. This manuscript presents clinical guidelines regarding current standards of practice and recommendations in terms of the nine chief topics in POEM.
Collapse
Affiliation(s)
- Haruhiro Inoue
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | | | - Manabu Onimaru
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Hitomi Minami
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Hiroki Sato
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Seigo Kitano
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Nobuo Omura
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Norio Fukami
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Hisao Tajiri
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| |
Collapse
|
174
|
Wiggins T, Markar SR, MacKenzie H, Faiz O, Zaninotto G, Hanna GB. The influence of hospital volume upon clinical management and outcomes of esophageal achalasia: an English national population-based cohort study. Dis Esophagus 2018; 31:5050667. [PMID: 29985997 DOI: 10.1093/dote/doy045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Management of achalasia is potentially complex. Previous studies have identified equivalence between pneumatic dilatation and surgical cardiomyotomy in terms of clinical outcomes. However, previous research has not investigated whether a management strategies and outcomes are different in high-volume achalasia centers. This national population-based cohort study aimed to identify the treatment modalities utilized in centers, which regularly manage achalasia and those which manage it infrequently. This study also assessed rates of re-intervention and complications to establish if a volume-outcome relationship exists for the management of achalasia in England. In this study, the Hospitals Episode Statistics database was used to identify all patients treated for achalasia in England from 2002 to 2012. Primary treatment was defined as surgical cardiomyotomy, sequential pneumatic dilatation, or botulinum toxin therapy. Primary outcome measure was reintervention. Centers were divided into regular achalasia centers (≥5.7 cases per annum) and infrequent achalasia centers (<5.7 cases per annum), and were analyzed according to tertiary cancer center status. In total, there were 7,487 patients treated for achalasia. Out of 1,947 cases (26%) were treated in regular achalasia centers, with 5,540 (74%) treated in infrequent centers. In binary logistic regression modeling regular centers treated a similar proportion of patients with primary surgical cardiomyotomy (OR: 1.11 (95% CI 0.98-1.27)) and had similar rates of re-intervention to infrequent achalasia centers (HR: 1.03 (0.94-1.12)). RA-CUSUM analysis demonstrated no relationship between total hospital volume and reintervention rates. Tertiary cancer centers treated more achalasia patients with primary surgical cardiomyotomy (OR: 1.51 (95% CI 1.31-1.73)) but there was no significant difference in reintervention rates (OR: 1.05 (95% CI 0.95-1.16)). In conclusion, this analysis failed to demonstrate a volume-outcome relationship in the management of achalasia in England. This study highlights that achalasia is treated infrequently by the majority of centers.
Collapse
Affiliation(s)
- T Wiggins
- Department Surgery & Cancer, Imperial College London
| | - S R Markar
- Department Surgery & Cancer, Imperial College London
| | - H MacKenzie
- Department Surgery & Cancer, Imperial College London
| | - O Faiz
- Department Surgery & Cancer, Imperial College London.,St Mark's Hospital and Academic Institute, Harrow, United Kingdom
| | - G Zaninotto
- Department Surgery & Cancer, Imperial College London
| | - G B Hanna
- Department Surgery & Cancer, Imperial College London
| |
Collapse
|
175
|
Zaninotto G, Bennett C, Boeckxstaens G, Costantini M, Ferguson MK, Pandolfino JE, Patti MG, Ribeiro U, Richter J, Swanstrom L, Tack J, Triadafilopoulos G, Markar SR, Salvador R, Faccio L, Andreollo NA, Cecconello I, Costamagna G, da Rocha JRM, Hungness ES, Fisichella PM, Fuchs KH, Gockel I, Gurski R, Gyawali CP, Herbella FAM, Holloway RH, Hongo M, Jobe BA, Kahrilas PJ, Katzka DA, Dua KS, Liu D, Moonen A, Nasi A, Pasricha PJ, Penagini R, Perretta S, Sallum RAA, Sarnelli G, Savarino E, Schlottmann F, Sifrim D, Soper N, Tatum RP, Vaezi MF, van Herwaarden-Lindeboom M, Vanuytsel T, Vela MF, Watson DI, Zerbib F, Gittens S, Pontillo C, Vermigli S, Inama D, Low DE. The 2018 ISDE achalasia guidelines. Dis Esophagus 2018; 31:5087687. [PMID: 30169645 DOI: 10.1093/dote/doy071] [Citation(s) in RCA: 155] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.
Collapse
Affiliation(s)
- G Zaninotto
- Department of Surgery and Cancer, Imperial College, London, UK
| | - C Bennett
- Office of Research and Innovation, Royal College of Surgeons in Ireland, Ireland
| | - G Boeckxstaens
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - M Costantini
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - M K Ferguson
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - J E Pandolfino
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - M G Patti
- Department of Medicine and Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - U Ribeiro
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - J Richter
- Department of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - L Swanstrom
- Institute of Image-Guided Surgery, Strasbourg, France; Interventional Endoscopy and Foregut Surgery, Oregon Health Science University, Portland, Oregon, USA
| | - J Tack
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - G Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford Esophageal Multidisciplinary Program in Innovative Research Excellence (SEMPIRE), Stanford University, Stanford, California, USA
| | - S R Markar
- Department of Surgery and Cancer, Imperial College, London, UK
| | - R Salvador
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - L Faccio
- Division of Surgery, Padova University Hospital, Padova, Italy
| | - N A Andreollo
- Faculty of Medical Science, State University of Campinas, Campinas, São Paulo, Brazil
| | - I Cecconello
- Digestive Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - G Costamagna
- Digestive Endoscopy Unit, A. Gemelli Hospital, Catholic University, Rome, Italy
| | - J R M da Rocha
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - E S Hungness
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - P M Fisichella
- Department of Surgery, Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
| | - K H Fuchs
- Department of Surgery, AGAPLESION-Markus-Krankenhaus, Frankfurt, Germany
| | - I Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - R Gurski
- Department of Surgery, School of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - F A M Herbella
- Department of Surgery, School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - R H Holloway
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, The University of Adelaide, Adelaide, Australia
| | - M Hongo
- Department of Medicine, Kurokawa Hospital, Taiwa, Kurokawa, Miyagi, Japan
| | - B A Jobe
- Esophageal and Lung Institute, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania, USA
| | - P J Kahrilas
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - D A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - K S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - D Liu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - A Moonen
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - A Nasi
- Digestive Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - P J Pasricha
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - R Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico; Department of Pathophysiology and Transplantation; Università degli Studi, Milan, Italy
| | - S Perretta
- Institute for Image Guided Surgery IHU-Strasbourg, Strasbourg, France
| | - R A A Sallum
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - G Sarnelli
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - E Savarino
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - F Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - D Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - N Soper
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - R P Tatum
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - M F Vaezi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - M van Herwaarden-Lindeboom
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - T Vanuytsel
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - M F Vela
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - D I Watson
- Department of Surgery, Flinders University, Adelaide, Australia
| | - F Zerbib
- Department of Gastroenterology, University of Bordeaux, Bordeaux, France
| | - S Gittens
- ECD Solutions, Atlanta, Georgia, USA
| | - C Pontillo
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - S Vermigli
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - D Inama
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - D E Low
- Department of Thoracic Surgery Virginia Mason Medical Center, Seattle, Washington, USA
| |
Collapse
|
176
|
Khalaf M, Chowdhary S, Elias PS, Castell D. Distal Esophageal Spasm: A Review. Am J Med 2018; 131:1034-1040. [PMID: 29605413 DOI: 10.1016/j.amjmed.2018.02.031] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 02/23/2018] [Accepted: 02/24/2018] [Indexed: 12/28/2022]
Abstract
Distal esophageal spasm is a rare motility disorder presenting principally with nonobstructive dysphagia and noncardiac chest pain. In symptomatic patients, the manometric diagnosis is made when >10% of the wet swallows have simultaneous and/or premature contractions intermixed with normal peristalsis. We characterize manometry and barium as complementary diagnostic approaches, and given the intermittent nature of the disorder, one should be always aware that it is almost impossible to rule out spasm. Treatment is difficult; we propose an approach beginning with the least invasive intervention.
Collapse
Affiliation(s)
- Mohamed Khalaf
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston.
| | | | - Puja Sukhwani Elias
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston
| | - Donald Castell
- Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston
| |
Collapse
|
177
|
An original Eurasian haplotype, HLA-DRB1*14:54-DQB1*05:03, influences the susceptibility to idiopathic achalasia. PLoS One 2018; 13:e0201676. [PMID: 30092016 PMCID: PMC6084941 DOI: 10.1371/journal.pone.0201676] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 07/19/2018] [Indexed: 01/04/2023] Open
Abstract
Idiopathic achalasia is a relatively infrequent esophageal motor disorder for which major histocompatibility complex (MHC) genes are well-identified risk factors. However, no information about HLA-achalasia susceptibility in Mexicans has previously been reported. We studied a group of 91 patients diagnosed with achalasia and 234 healthy controls with Mexican admixed ancestry. HLA alleles and conserved extended haplotypes were analyzed using high-resolution HLA typing based on Sanger and next-generation sequencing technologies. Admixture estimates were determined using HLA-B and short tandem repeats. Results were analyzed by non-parametric statistical analysis and Bonferroni correction. P-values < 0.05 were considered significant. Patients with achalasia had 56.7% Native American genes, 24.7% European genes, 16.5% African genes and 2.0% Asian genes, which was comparable with the estimates in the controls. Significant increases in the frequencies of alleles DRB1*14:54 and DQB1*05:03 and the extended haplotypes DRB1*14:54-DQB1*05:03 and DRB1*11:01-DQB1*03:01, even after Bonferroni correction (pC<0.05), were found in the achalasia group compared to those in the controls. Concluding, the HLA class II alleles HLA-DRB1*14:54:01 and DQB1*05:03:01 and the extended haplotype are risk factors for achalasia in mixed-ancestry Mexican individuals. These results also suggest that the HLA-DRB1*14:54-DQB1*05:03 haplotype was introduced by admixture with European and/or Asian populations.
Collapse
|
178
|
Whose patient is it? The path to multidisciplinary management of achalasia. J Surg Res 2018; 228:8-13. [DOI: 10.1016/j.jss.2018.02.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/20/2017] [Accepted: 02/22/2018] [Indexed: 02/06/2023]
|
179
|
Poornachand V, Kumarasamy K, Karamath SP, Seenivasan V, Bavanandam S, Dheivamani N. Achalasia Cardia in a Young Infant. Indian J Pediatr 2018; 85:673-675. [PMID: 29340927 DOI: 10.1007/s12098-018-2610-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 01/01/2018] [Indexed: 11/26/2022]
Abstract
Achalasia cardia is an esophageal motility disorder rarely reported in children and more so in young infants. Common clinical presentations include vomiting, dysphagia, regurgitation, recurrent pulmonary aspiration and failure to thrive. Diagnosis is made by barium swallow study and esophageal manometry, which is the gold standard test. Pharmocological management and endotherapy often fails and results in recurrence of symptoms. Laparoscopic Hellers myotomy, with or without anti-reflux procedure is the standard treatment of choice for children. Per-oral endoscopic myotomy is utilized for treatment of achalasia in adults, but its safety, efficacy, and feasibility is not studied in children.
Collapse
Affiliation(s)
- V Poornachand
- Department of Pediatrics, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India.
| | - K Kumarasamy
- Department of Pediatrics, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India
| | - S P Karamath
- Department of Pediatrics, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India
| | - V Seenivasan
- Department of Pediatrics, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India
| | - Sumathi Bavanandam
- Department of Pediatric Gastroenterology, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India
| | - Nirmala Dheivamani
- Department of Pediatric Gastroenterology, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India
| |
Collapse
|
180
|
Ramchandani M, Nageshwar Reddy D, Nabi Z, Chavan R, Bapaye A, Bhatia S, Mehta N, Dhawan P, Chaudhary A, Ghoshal UC, Philip M, Neuhaus H, Deviere J, Inoue H. Management of achalasia cardia: Expert consensus statements. J Gastroenterol Hepatol 2018; 33:1436-1444. [PMID: 29377271 DOI: 10.1111/jgh.14097] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 01/14/2018] [Indexed: 12/14/2022]
Abstract
Achalasia cardia (AC) is a frequently encountered motility disorder of the esophagus resulting from an irreversible degeneration of neurons. Treatment modalities are palliative in nature, and there is no curative treatment available for AC as of now. Significant advancements have been made in the management of AC over last decade. The introduction of high resolution manometry and per-oral endoscopic myotomy (POEM) has strengthened the diagnostic and therapeutic armamentarium of AC. High resolution manometry allows for the characterization of the type of achalasia, which in turn has important therapeutic implications. The endoscopic management of AC has been reinforced with the introduction of POEM that has been found to be highly effective and safe in palliating the symptoms in short-term to mid-term follow-up studies. POEM is less invasive than Heller's myotomy and provides the endoscopist with the opportunity of adjusting the length and orientation of esophageal myotomy according to the type of AC. The management of achalasia needs to be tailored for each patient, and the role of pneumatic balloon dilatation, POEM, or Heller's myotomy needs to be revisited. In this review, we discuss the important aspects of diagnosis as well as management of AC. The statements presented in the manuscript reflect the cumulative efforts of an expert consensus group.
Collapse
Affiliation(s)
- Mohan Ramchandani
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - D Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Radhika Chavan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Amol Bapaye
- Department of Digestive Diseases and Endoscopy, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra, India
| | - Shobna Bhatia
- Department of Gastroenterology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Nilay Mehta
- Department of Gastroenterology, Vedanta Institute of Medical Sciences, Ahmedabad, Gujarat, India
| | - Pankaj Dhawan
- Department of Gastroenterology, Bhatia General Hospital, Mumbai, Maharashtra, India
| | - Adarsh Chaudhary
- Department of Surgical Gastroenterology, Medanta The Medicity, Gurgaon, Haryana, India
| | - Uday C Ghoshal
- Department of Gastroenterology, SGPGI, Lucknow, Uttar Pradesh, India
| | - Mathew Philip
- Gastroenterology, PVS Memorial Hospital, Ernakulam, Kerala, India
| | - Horst Neuhaus
- Department of Internal Medicine, Evangelical Hospital Düsseldorf, Dusseldorf, Nordrhein-Westfalen, Germany
| | - Jacques Deviere
- Department of Gastroenterology, Erasmus Hospital, Bruxelles, Belgium
| | - Haruhiro Inoue
- Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| |
Collapse
|
181
|
Kethman WC, Thorson CM, Sinclair TJ, Berquist WE, Chao SD, Wall JK. Initial experience with peroral endoscopic myotomy for treatment of achalasia in children. J Pediatr Surg 2018; 53:1532-1536. [PMID: 28827050 DOI: 10.1016/j.jpedsurg.2017.07.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 07/18/2017] [Accepted: 07/29/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Achalasia is a primary esophageal motility disorder characterized by aperistalsis of the esophagus and failed relaxation of the lower esophageal sphincter that presents rarely in childhood. The peroral endoscopic myotomy (POEM) procedure is an emerging treatment for achalasia in adults that has recently been introduced into pediatric surgical practice. METHODS This is a prospective case series of all children referred to Stanford University Lucile Packard Children's Hospital with manometry-confirmed achalasia who underwent a POEM procedure from 2014 to 2016. RESULTS We enrolled 10 subjects ranging in age from 7 to 17years (M=13.4). The mean pre- and 1-month post-procedure Eckardt scores were 7 (SD=2.5) and 2.4 (SD=2) (p<0.001), respectively. The median procedure time for the entire cohort was 142min (range 60-259min) with ongoing improvement with increased experience (R2=0.6, p=0.008). There were no major adverse events. CONCLUSION The POEM procedure can be successfully completed in children for the treatment of achalasia with demonstrated short-term post-operative improvement in symptoms. The adoption of advanced endoscopic techniques by pediatric surgeons may enable development of unique intraluminal approaches to congenital anomalies and other childhood diseases. LEVEL OF EVIDENCE Treatment Study - Level IV.
Collapse
Affiliation(s)
- William C Kethman
- Department of Surgery, Stanford University School of Medicine, Stanford, CA.
| | | | - Tiffany J Sinclair
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | | | | | | |
Collapse
|
182
|
Sultana S, Talegaonkar S, Ray B, Singh H, Ahmad FJ, Mittal G, Bhatnagar A. Formulation development and evaluation of nifedipine as pylorospasm inhibitor. Drug Dev Ind Pharm 2018; 44:1171-1184. [DOI: 10.1080/03639045.2018.1438464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | | | - Bhaskar Ray
- Department of Pharmaceutics, Jamia Hamdard, Delhi, India
| | | | - F. J. Ahmad
- Department of Pharmaceutics, Jamia Hamdard, Delhi, India
| | - Gaurav Mittal
- Department of Pharmaceutics, Jamia Hamdard, Delhi, India
| | | |
Collapse
|
183
|
The role of endoscopic ultrasound for the evaluation and treatment of esophageal motility disorders. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2018.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
184
|
Endoscopic dilation for treatment of esophageal motility disorders. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2018.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
185
|
Jain AS, Kahrilas PJ. Endoscopic atlas of motility disorders. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2018.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
186
|
Abstract
Esophageal achalasia is a primary esophageal motility disorder of unknown origin, characterized by lack of peristalsis and by incomplete or absent relaxation of the lower esophageal sphincter in response to swallowing. The goal of treatment is to eliminate the functional obstruction at the level of the gastroesophageal junction. Areas covered: This comprehensive review will evaluate the current literature, illustrating the diagnostic evaluation and providing an evidence-based treatment algorithm for this disease. Expert commentary: Today, we have three very effective therapeutic modalities to treat patients with achalasia - pneumatic dilatation, peroral endoscopic myotomy, and laparoscopic Heller myotomy with fundoplication. Treatment should be tailored to the individual patient, in centers where a multidisciplinary approach is available. Esophageal resection should be considered as a last resort for patients who have failed prior therapeutic attempts.
Collapse
Affiliation(s)
- Francisco Schlottmann
- a Department of Surgery , University of North Carolina , Chapel Hill , North Carolina , USA
| | - Marco G Patti
- b Department of Medicine and Surgery, Center for Esophageal Diseases and Swallowing , University of North Carolina , Chapel Hill , North Carolina , USA
| |
Collapse
|
187
|
Moradi A, Fazlollahi N, Eshraghi A, Gholipour M, Khoshnia M, Javid N, Montazeri SA, Mikaeli J. Is There Any Evidence for a Viral Cause in Achalasia? Middle East J Dig Dis 2018; 10:169-173. [PMID: 30186580 PMCID: PMC6119833 DOI: 10.15171/mejdd.2018.106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 06/18/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND
Achalasia, as an incurable disease is defined by the lack of normal esophageal peristalsis and
loss of lower esophageal sphincter relaxation due to impaired myenteric neural plexus. The exact
cause of myenteric neural cells degeneration in achalasia is still unknown. One hypothesis is that
certain neurotropic viruses and autoimmune factors cause the inflammatory response in myenteric
network, which consequently destroy neural cells. This study was designed to find the evidence of
viral causes of achalasia.
METHODS
In this case-control study, 52 patients with achalasia and 50 controls referred to Shariati Hospital,
were evaluated for the genome of neurotropic viruses, HPV, and adenovirus by polymerase chain
reaction (PCR) and reverse transcription (RT) PCR techniques.
RESULTS
Genome assessment of neurotropic DNA viruses turned out negative in the patients, however,
the genome of HSV-1 (Herpes simplex virus) was found in tissues of six controls. No neurotropic
RNA viruses were observed in the tissue samples and whole blood of both the patients and controls.
Among non-neurotropic viruses, adenovirus genome was positive in tissues of two out of 52
patients and three out of 50 controls. In addition, one out of 52 patients and two out of 50 controls
were positive for HPV infection in tissues.
CONCLUSION
We could not detect any significant relationship between achalasia and HPV, adenovirus, and
neurotropic viruses in the cases. Nevertheless, it does not exclude the hypothesis of either an alternate
viral species or resolved viral infection as the etiology of achalasia.
Collapse
Affiliation(s)
- Abdolvahab Moradi
- Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan, Iran
| | - Narges Fazlollahi
- Autoimmune and Motility Disorders Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amid Eshraghi
- Autoimmune and Motility Disorders Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahin Gholipour
- Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan, Iran
| | - Masoud Khoshnia
- Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan, Iran
| | - Naeme Javid
- Department of Microbiology, Golestan University of Medical Sciences, Gorgan, Iran
| | - Seyed Ali Montazeri
- Liver and Pancreatobiliary Diseases Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Javad Mikaeli
- Autoimmune and Motility Disorders Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
188
|
Life after per-oral endoscopic myotomy: long-term outcomes of quality of life and their association with Eckardt scores. Gastrointest Endosc 2018; 87:1415-1420.e1. [PMID: 29410304 DOI: 10.1016/j.gie.2018.01.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 01/10/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The clinical efficacy of per-oral endoscopic myotomy (POEM) has been commonly established by reduction in the Eckardt score (<3) after the procedure. However, achalasia can lead to significant impairment in the patient's quality of life that may go beyond the 4 classic achalasia symptoms as measured by the Eckardt score. The aims of our study were to evaluate the effect of POEM on short-term and long-term health-related quality of life (HRQOL) and to assess the association between HRQOL and Eckardt scores. METHODS Single-center, prospective, cohort study of consecutive POEMs during a 3-year period. Eckardt and HRQOL scores as measured by the short-form survey questionnaire (SF-36) were obtained at baseline and at various intervals after POEM. Comparison of the mean scores was described by using univariate linear regression. The association between Eckardt scores and HRQOL were calculated by using a linear, mixed-model analysis. RESULTS POEM was performed in 143 consecutive patients (54% male; mean ± standard deviation [SD] age, 56.9 ± 17.9 years). At long-term follow-up (mean 16.4 months, range 12-40), both the HRQOL baseline mental and physical component scores improved significantly from 61.5 ± 2.2 to 71.2 ± 3.6; (P < .021) and from 55.8 ± 2.2 to 63.6 ± 3.3; (P = < .034), respectively. Mixed-model analysis showed a significant association between Eckardt and all HRQOL scores (P < .001). CONCLUSION POEM improved all dimensions of HRQOL as measured by the SF-36 survey at both short-term and long-term follow-up. A strong association was seen between Eckardt scores and all HRQOL domains. Further studies with the use of disease-specific HRQOL instruments are warranted. (Clinical trial registration number: NCT01832779.).
Collapse
|
189
|
Taft TH, Carlson DA, Triggs J, Craft J, Starkey K, Yadlapati R, Gregory D, Pandolfino JE. Evaluating the reliability and construct validity of the Eckardt symptom score as a measure of achalasia severity. Neurogastroenterol Motil 2018; 30:e13287. [PMID: 29315993 PMCID: PMC5992017 DOI: 10.1111/nmo.13287] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/13/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Achalasia is a disease of mechanical esophageal dysfunction characterized by dysphagia, chest pain, regurgitation, and malnutrition. The Eckardt symptom score (ESS) is the gold standard self-report assessment tool. Current guidelines outline a three-step approach to patient reported outcomes measure design. Developed prior to these policies, the ESS has not undergone rigorous testing of its reliability and validity. METHODS Adult achalasia patients retrospectively identified via a patient registry were grouped based on treatment history. Patients were grouped PREPOST (completed ESS, GERDQ, brief esophageal dysphagia questionnaire, NIH PROMIS Global Health, high resolution manometry, timed barium esophagram prior to treatment and after) and POST (completed measures only after treatment). Clinical characteristics, treatment type and date were obtained via medical record. Standardized psychometric analyses for reliability and construct validity were performed. KEY RESULTS 107 patients identified; 83 POST and 24 PREPOST. The ESS has fair internal consistency and split-half reliability with a single factor structure. Dysphagia accounts for half the variance in ESS, while chest pain and weight loss account for 10% each. Pre-post-surgical assessment demonstrates improvements in ESS, except for weight loss. Effect sizes range from 0.24 to 2.53, with greatest change in regurgitation. Validity of the ESS is supported by modest correlations with GERDQ, HRQOL, and physiological data. CONCLUSIONS & INFERENCES The ESS demonstrates fair reliability and validity, with a single factor structure mostly explained by dysphagia. Based on psychometric findings, weight loss and chest pain items may be decreasing ESS reliability and validity. Further assessment of the ESS under FDA guidelines is warranted.
Collapse
Affiliation(s)
- Tiffany H. Taft
- Northwestern University Feinberg School of Medicine Division of Gastroenterology & Hepatology, Chicago IL
| | - Dustin A. Carlson
- Northwestern University Feinberg School of Medicine Division of Gastroenterology & Hepatology, Chicago IL
| | - Joseph Triggs
- Northwestern University Feinberg School of Medicine Division of Gastroenterology & Hepatology, Chicago IL
| | - Jenna Craft
- Northwestern University Feinberg School of Medicine Division of Gastroenterology & Hepatology, Chicago IL
| | - Kristen Starkey
- Northwestern University Feinberg School of Medicine Division of Gastroenterology & Hepatology, Chicago IL
| | - Rena Yadlapati
- University of Colorado Anschutz Medical Campus, Aurora CO
| | | | - John E. Pandolfino
- Northwestern University Feinberg School of Medicine Division of Gastroenterology & Hepatology, Chicago IL
| |
Collapse
|
190
|
Ortiz V, García-Campos M, Sáez-González E, delPozo P, Garrigues V. A concise review of opioid-induced esophageal dysfunction: is this a new clinical entity? Dis Esophagus 2018. [PMID: 29529126 DOI: 10.1093/dote/doy003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Opioids have become the most widely prescribed analgesics in Western countries. Opioid-induced bowel dysfunction is a widely known adverse effect, with constipation the most common manifestation. Most of the opioid-related effects occur in the stomach, small intestine, and colon and have been widely studied. However, the effects related to esophageal motility are less known. Recently published retrospective studies have suggested that long-term use of opioids can cause esophageal motility dysfunction, reflecting symptoms similar to motility disorders, such as achalasia and functional esophagogastric junction outflow obstruction. The most common manometric findings, as reported in the literature, for patients with opioid-induced dysphagia undergoing long-term therapy with these drugs are impaired lower esophageal sphincter relaxation, high amplitude/velocity, and simultaneous esophageal waves, higher integrated relaxation pressure, lower distal latency, and the esophageal contractility can be normal, hypercontractile, or premature. Based on these studies, a new clinical entity known as opioid-induced esophageal dysfunction has been postulated. For these patients, the diagnostic method of choice is high-resolution manometry, although other causes should be ruled out through endoscopy or Computed Tomography (CT). The best therapeutic option for these patients is withdrawal of the opioid; however, this is not always possible, and other options need to be investigated, such as pneumatic dilation and botulinum toxin injection, considering the risks versus the benefits.
Collapse
Affiliation(s)
- V Ortiz
- Digestive Functional Disorders Unit, Gastroenterology Department, Hospital Universitari i Politècnic La Fe.,Medical Research Institute La Fe (IIS La Fe), Valencia, Spain
| | - M García-Campos
- Digestive Functional Disorders Unit, Gastroenterology Department, Hospital Universitari i Politècnic La Fe
| | - E Sáez-González
- Digestive Functional Disorders Unit, Gastroenterology Department, Hospital Universitari i Politècnic La Fe.,Medical Research Institute La Fe (IIS La Fe), Valencia, Spain
| | - P delPozo
- Digestive Functional Disorders Unit, Gastroenterology Department, Hospital Universitari i Politècnic La Fe
| | - V Garrigues
- Digestive Functional Disorders Unit, Gastroenterology Department, Hospital Universitari i Politècnic La Fe.,Department of Medicine, Universitat de Valencia.,Medical Research Institute La Fe (IIS La Fe), Valencia, Spain
| |
Collapse
|
191
|
Newberry C, Vajravelu RK, Pickett-Blakely O, Falk G, Yang YX, Lynch KL. Achalasia Patients Are at Nutritional Risk Regardless of Presenting Weight Category. Dig Dis Sci 2018; 63:1243-1249. [PMID: 29468378 DOI: 10.1007/s10620-018-4985-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 02/14/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Achalasia is an esophageal motor disorder that leads to swallowing dysfunction and weight loss. Nutritional risk in achalasia patients is not well defined. AIMS The aims of this study were to define baseline body mass index (BMI), changes in weight, and nutritional risk over time in a large cohort of achalasia patients. METHODS This was a retrospective cohort study of achalasia patients at a tertiary care center with documented BMI, symptom severity as per Eckardt score, and nutritional risk assessment as per the Malnutrition Universal Screening Tool, which considers BMI, degree of recent weight loss, and acuity of disease. RESULTS Among the 337 patients presenting for achalasia management, 179 had confirmed disease. Upon presentation 69.8% of patients were classified as overweight or obese. Using the Malnutrition Universal Screening Tool, we found 50% of patients to be at moderate or high risk for malnutrition at presentation. Eckardt score (OR 1.15, 95% CI 1.05-1.26), duration of disease (OR for each additional month 1.04, 95% CI 1.01-1.08), and female gender (OR 1.76, 95% CI 1.02-3.03) were independent predictors of increased risk for malnutrition. Nutrition risk score decreased after therapy in 93.3% of patients. CONCLUSIONS Despite a high prevalence of overweight and obese status in achalasia patients, many are at risk of developing nutritional complications secondary to rapid weight loss. This risk frequently resolves post-treatment. Regardless of baseline BMI, we recommend all patients undergo nutritional assessment to identify high-risk patients who may benefit from dietary intervention and expedited therapy.
Collapse
Affiliation(s)
- Carolyn Newberry
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 7th Floor, South Tower, Philadelphia, PA, 19104, USA.
| | - Ravy K Vajravelu
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 7th Floor, South Tower, Philadelphia, PA, 19104, USA
| | - Octavia Pickett-Blakely
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 7th Floor, South Tower, Philadelphia, PA, 19104, USA
| | - Gary Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 7th Floor, South Tower, Philadelphia, PA, 19104, USA
| | - Yu Xiao Yang
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 7th Floor, South Tower, Philadelphia, PA, 19104, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, 423 Guardian Drive, 733 Blockley Hall, Philadelphia, PA, 19104, USA
| | - Kristle L Lynch
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 7th Floor, South Tower, Philadelphia, PA, 19104, USA
| |
Collapse
|
192
|
Improved Assessment of Bolus Clearance in Patients With Achalasia Using High-Resolution Impedance Manometry. Clin Gastroenterol Hepatol 2018; 16:672-680.e1. [PMID: 29155168 PMCID: PMC5911237 DOI: 10.1016/j.cgh.2017.11.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 11/07/2017] [Accepted: 11/07/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Esophageal retention is typically evaluated by timed-barium esophagram in patients treated for achalasia. Esophageal bolus clearance can also be evaluated using high-resolution impedance manometry. We evaluated the associations of conventional and novel high-resolution impedance manometry metrics, esophagram, and patient-reported outcomes (PROs) in achalasia. METHODS We performed a prospective study of 70 patients with achalasia (age, 20-81 y; 30 women) treated by pneumatic dilation or myotomy who underwent follow-up evaluations from April 2013 through December 2015 (median, 12 mo after treatment; range, 3-183 mo). Patients were assessed using timed-barium esophagrams, high-resolution impedance manometry, and PROs, determined from Eckardt scores (the primary outcome) and the brief esophageal dysphagia questionnaire. Barium column height was measured from esophagrams taken 5 minutes after ingestion of barium (200 mL). Impedance-manometry was analyzed for bolus transit (dichotomized) and with a customized MATLAB program (The MathWorks, Inc, Natick, MA) to calculate the esophageal impedance integral (EII) ratio. RESULTS Optimal cut points to identify a good PRO (defined as Eckardt score of ≤3) were esophagram barium column height of 3 cm (identified patients with a good PRO with 63% sensitivity and 75% specificity) and an EII ratio of 0.41 (identified patients with a good PRO with 83% sensitivity and 75% specificity). Complete bolus transit identified patients with a good PRO with 28% sensitivity and 75% specificity. Of the 25 patients who met these cut points for both esophagram barium column height and EII ratio, 23 (92%) had a good PRO. Of the 17 patients who met neither cut point, 14 (82%) had a poor PRO (Eckardt score above 3). CONCLUSIONS In a prospective study of 70 patients with achalasia, we found EII ratio identified patients with good PROs with higher levels of sensitivity (same specificity) than timed-barium esophagram or impedance-manometry bolus transit assessments. The EII ratio should be added to achalasia outcome evaluations that involve high-resolution impedance manometry as an independent measure and to complement timed-barium esophagram.
Collapse
|
193
|
Systematic Review and Meta-Analysis of Perioperative Outcomes of Peroral Endoscopic Myotomy (POEM) and Laparoscopic Heller Myotomy (LHM) for Achalasia. Surg Laparosc Endosc Percutan Tech 2018; 27:123-131. [PMID: 28472017 DOI: 10.1097/sle.0000000000000402] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIMS AND OBJECTIVES Laparoscopic Heller myotomy (LHM) is the preferred surgical method for treating achalasia. However, peroral endoscopic myotomy (POEM) is providing good short-term results. The objective of this systematic review and meta-analysis was to compare the safety and efficacy of LHM and POEM. MATERIALS AND METHODS A search of PubMed, Cochrane database, Medline, Embase, Science Citation Index, and current contents for English-language articles comparing LHM and POEM between 2007 and 2016 was performed. Variables analyzed included prior endoscopic treatment, prior medical treatment, prior Heller myotomy, operative time, overall complications rate, postoperative gastroesophageal reflux disease (GERD), length of hospital stay, postoperative pain score, and long-term GERD. RESULTS Seven trials consisting of 483 (LHM=250, POEM=233) patients were analyzed. Preoperative variables, for example, prior endoscopic treatment [odds ratio (OR), 1.32; 95% confidence interval (CI), 0.23-4.61; P=0.96], prior medical treatment [weighted mean difference (WMD), 1.22; 95% CI, 0.52-2.88; P=0.65], and prior Heller myotomy (WMD, 0.47; 95% CI, 0.13-1.67; P=0.25) were comparable. Operative time was 26.28 minutes, nonsignificantly longer for LHM (WMD, 26.28; 95% CI, -11.20 to 63.70; P=0.17). There was a comparable overall complication rate (OR, 1.25; 95% CI, 0.56-2.77; P=0.59), postoperative GERD rate (OR, 1.27; 95% CI, 0.70-2.30; P=0.44), length of hospital stay (WMD, 0.30; 95% CI, -0.24 to 0.85; P=0.28), postoperative pain score (WMD, -0.26; 95% CI, -1.58 to 1.06; P=0.70), and long-term GERD (WMD, 1.06; 95% CI, 0.27-4.1; P=0.08) for both procedures. There was a significantly higher short-term clinical treatment failure rate for LHM (OR, 9.82; 95% CI, 2.06-46.80; P<0.01). CONCLUSIONS POEM compares favorably to LHM for achalasia treatment in short-term perioperative outcomes. However, there was a significantly higher clinical treatment failure rate for LHM on short-term postoperative follow-up. Presently long-term postoperative follow-up data for POEM beyond 1 year are unavailable and eagerly awaited.
Collapse
|
194
|
A clinical study of peroral endoscopic myotomy reveals that impaired lower esophageal sphincter relaxation in achalasia is not only defined by high-resolution manometry. PLoS One 2018; 13:e0195423. [PMID: 29608597 PMCID: PMC5880396 DOI: 10.1371/journal.pone.0195423] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 02/23/2018] [Indexed: 12/12/2022] Open
Abstract
Background and aim Achalasia is an esophageal motility disorder characterized by impaired lower esophageal sphincter (LES) relaxation. On high-resolution manometry (HRM), impaired LES relaxation is defined by elevated integrated relaxation pressure (IRP). However, a new category of achalasia within the normal IRP range has been suggested. Methods HRM was performed using a Starlet device and an IRP threshold of 26 mmHg. Peroral endoscopic myotomy (POEM) was performed for cases of achalasia diagnosed using established methods. During POEM, the histology of the LES was assessed. Follow-up was performed 2 months post-operatively. Results Forty-one patients with achalasia (18 women, mean age 53 ± 18.6 years) were included. Among them, 27 were placed in the IRP > 26 mmHg subgroup (impaired LES relaxation on HRM) and 14 in the IRP ≤ 26 mmHg subgroup (normal LES relaxation on HRM). In the IRP ≤ 26 mmHg subgroup, patients were older, had longer symptom duration, and had more esophageal dilation. The IRP ≤ 26 mmHg subgroup had the same symptom severity as the higher IRP subgroup and POEM significantly improved symptoms and IRP, although four patients still had severe LES fibrosis. Conclusions The clinical presentation of achalasia has a gap between a HRM-defined impaired LES relaxation, with aging or disease progression considered reasons for a lowered LES pressure. POEM can be a feasible treatment option, even for cases of achalasia with a normal IRP. However, patients with severe LES fibrosis need more attention for the therapeutic indication.
Collapse
|
195
|
Laparoscopic graduated cardiomyotomy with anterior fundoplication as treatment for achalasia: experience of 48 cases. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2018. [DOI: 10.1016/j.rgmxen.2017.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
196
|
Carlson DA, Gyawali CP. Is High-Resolution Manometry Always Needed for the Diagnosis of Achalasia? Clin Gastroenterol Hepatol 2018; 16:480-482. [PMID: 28987504 DOI: 10.1016/j.cgh.2017.06.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 06/05/2017] [Accepted: 06/08/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri.
| |
Collapse
|
197
|
Sato H, Takahashi K, Mizuno KI, Hashimoto S, Yokoyama J, Hasegawa G, Terai S. Esophageal motility disorders: new perspectives from high-resolution manometry and histopathology. J Gastroenterol 2018; 53:484-493. [PMID: 29134329 DOI: 10.1007/s00535-017-1413-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 11/09/2017] [Indexed: 02/04/2023]
Abstract
High-resolution manometry (HRM) and peroral endoscopic myotomy (POEM) have contributed significantly to the field of esophageal motility disorders in recent years. The development of HRM has categorized various esophageal motility disorders with a focus on a diverse range of manometric anomalies. Additionally, the Chicago classification criteria is widely used for manometric diagnosis. Moreover, POEM was introduced as a minimally invasive radical therapy for achalasia and shows promise for other spastic esophageal motility disorders as well. POEM has also enabled a transluminal endoscopic approach for determining the histology of the esophageal muscle layer, which is expected to assist in elucidating the etiology of disorders associated with esophageal motility. The purpose of this review is to update the diagnosis, pathology, and treatment of esophageal motility disorders, with a focus on the recent advances in this field.
Collapse
Affiliation(s)
- Hiroki Sato
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, 757-1, Asahimachidori, Chuo-ku, Niigata, Niigata, 951-8510, Japan.
| | - Kazuya Takahashi
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, 757-1, Asahimachidori, Chuo-ku, Niigata, Niigata, 951-8510, Japan
| | - Ken-Ichi Mizuno
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, 757-1, Asahimachidori, Chuo-ku, Niigata, Niigata, 951-8510, Japan
| | - Satoru Hashimoto
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, 757-1, Asahimachidori, Chuo-ku, Niigata, Niigata, 951-8510, Japan
| | - Junji Yokoyama
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, 757-1, Asahimachidori, Chuo-ku, Niigata, Niigata, 951-8510, Japan
| | - Go Hasegawa
- Division of Cellular and Molecular Pathology, Department of Cellular Function, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, 757-1, Asahimachidori, Chuo-ku, Niigata, Niigata, 951-8510, Japan
| |
Collapse
|
198
|
Chen YI, Inoue H, Ujiki M, Draganov PV, Colavita P, Mion F, Romanelli J, Chiu P, Balassone V, Patel L, Abbas A, Yang D, Dunst C, Pioche M, Roman S, Rivory J, Ponchon T, Desilets D, Maselli R, Onimaru M, Nakamura J, Hata Y, Hajiyeva G, Ismail A, Ngamruengphong S, Bukhari M, Chavez YH, Kumbhari V, Repici A, Khashab MA. An international multicenter study evaluating the clinical efficacy and safety of per-oral endoscopic myotomy in octogenarians. Gastrointest Endosc 2018; 87:956-961. [PMID: 28235595 DOI: 10.1016/j.gie.2017.02.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 02/10/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Per-oral endoscopic myotomy (POEM) for achalasia is particularly appealing in the elderly because it is minimally invasive. However, data in patients aged ≥80 years are scarce. The aim of this study was to assess the clinical outcome of POEM in octogenarians. METHODS This was a multicenter retrospective study at 8 centers. Consecutive octogenarians with achalasia who underwent POEM between 2010 and 2016 were included. Rates of technical success (completion of myotomy), clinical response (Eckardt score ≤3), and adverse events (severity graded as per American Society for Gastrointestinal Endoscopy lexicon) were assessed. RESULTS A total of 76 patients (47.4% female, mean age 84 years) underwent POEM for treatment of achalasia: type I, 17.1%; type II, 35.5%; type III, 17.1%; and unspecified, 30.3%. Overall, 41.1% were treatment naïve, whereas others had previous botulinum toxin injection and/or pneumatic dilation. The mean (± standard deviation [SD]) age-adjusted Charlson comorbidity index score was 6.2 ± 2.4, with the majority of patients having American Society of Anesthesiologists Physical Status Classification System (ASA) scores of II/III. Technical success was 93.4%, with a median follow-up of 256 days. Fourteen adverse events occurred in 11 patients (14.5%). There were 3 inadvertent mucosotomies, 6 cases of symptomatic capnoperitoneum and/or capnomediastinum, 2 esophageal leaks, 1 cardiac arrhythmia, and 2 other). The severities of these adverse events were mild (78.6%), moderate (14.3%), and severe (7.1%). Clinical success was achieved in 90.8% of patients, with a mean (± SD) Eckardt score reduction from 7.0 ± 2.3 to 0.8 ± 0.1 (P < .001), a median follow-up of 256 days, and interquartile range of 66 to 547. CONCLUSION Although the rate of technical success may be somewhat lower and the rate of adverse events slightly higher than previously reported, our data suggest that POEM in octogenarians is safe and effective, supporting its role as a primary modality for achalasia in this patient population.
Collapse
Affiliation(s)
- Yen-I Chen
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan
| | - Michael Ujiki
- Department of Surgery, Section of Minimally Invasive Surgery, NorthShore University Health System, Evanston, Illinois, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Paul Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, The Oregon Clinic, Portland, Oregon, USA
| | - Francois Mion
- Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France
| | - John Romanelli
- Baystate Medical Center, University of Massachusetts School of Medicine, Springfield, Massachusetts, USA
| | - Philip Chiu
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Valerio Balassone
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan
| | - Lava Patel
- Department of Surgery, Section of Minimally Invasive Surgery, NorthShore University Health System, Evanston, Illinois, USA
| | - Ali Abbas
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Dennis Yang
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Christy Dunst
- Division of Gastrointestinal and Minimally Invasive Surgery, The Oregon Clinic, Portland, Oregon, USA
| | - Mathieu Pioche
- Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France
| | - Sabine Roman
- Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France
| | - Jérôme Rivory
- Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France
| | - Thierry Ponchon
- Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France
| | - David Desilets
- Baystate Medical Center, University of Massachusetts School of Medicine, Springfield, Massachusetts, USA
| | - Roberta Maselli
- Digestive Endoscopy Unit, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan
| | - Jun Nakamura
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan
| | - Yoshitaka Hata
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan
| | - Gulara Hajiyeva
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Amr Ismail
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Saowanee Ngamruengphong
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Majidah Bukhari
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Yamile Haito Chavez
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Mouen A Khashab
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| |
Collapse
|
199
|
Abstract
The last decade has seen growing insight into the pathophysiology of achalasia, and current treatments decreasing the resting pressure in the lower esophageal sphincter by endoscopic (botulinum toxin injection, pneumatic dilation, peroral endoscopic myotomy) or surgical means (Heller myotomy). Manometry is considered the gold standard to confirm the diagnosis of achalasia. Pneumatic dilation and laparoscopic Heller myotomy have similar effectiveness and are both more successful in patients with type II achalasia. Laparoscopic myotomy when combined with partial fundoplication is an effective surgical technique and has been considered the operative procedure of choice until recently. Peroral endoscopic myotomy is an emerging therapy with promising results since it offers a minimally invasive and efficacious option especially in type III achalasia. However, it remains to be determined if peroral endoscopic myotomy offers long-term efficacy.
Collapse
|
200
|
Gong EJ, Kim DH. Retention Esophagitis in Patients with Achalasia Requires Cancer Surveillance. Clin Endosc 2018; 51:111-112. [PMID: 29558793 PMCID: PMC5903086 DOI: 10.5946/ce.2018.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 02/26/2018] [Accepted: 02/27/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, Gangneung, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| |
Collapse
|