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Denzer U, Müller M, Kreuser N, Thieme R, Hoffmeister A, Feisthammel J, Niebisch S, Gockel I. [Therapy of esophageal motility disorders]. Laryngorhinootologie 2023; 102:824-838. [PMID: 37263277 DOI: 10.1055/a-1949-3583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2020 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.
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Affiliation(s)
- Ulrike Denzer
- Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Germany
| | - Michaela Müller
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - Nicole Kreuser
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - René Thieme
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Juergen Feisthammel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Stefan Niebisch
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
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2
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Kahrilas PJ, Carlson DA, Pandolfino JE. Advances in the Diagnosis and Management of Achalasia and Achalasia-Like Syndromes: Insights From HRM and FLIP. GASTRO HEP ADVANCES 2023; 2:701-710. [PMID: 37503535 PMCID: PMC10373628 DOI: 10.1016/j.gastha.2023.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
High-resolution manometry, Chicago Classification v4.0, the functional lumen imaging probe, Panometry, and peroral endoscopic myotomy (POEM) are all now integral parts of the landscape for managing achalasia or, more precisely, achalasia-like syndromes. This narrative review examines the impact of these innovations on the management of achalasia-like syndromes. High-resolution manometry was the disruptive technology that prompted the paradigm shift to thinking of motility disorders as patterns of obstructive physiology involving the esophagogastric junction and/or the distal esophagus rather than as siloed entities. An early observation was that the cardinal feature of achalasia-impaired lower esophageal sphincter relaxation-can occur in several subtypes: without peristalsis, with pan-esophageal pressurization, with premature (spastic) distal esophageal contractions, or even with preserved peristalsis (esophagogastric junction outlet obstruction). Furthermore, there being no biomarker for achalasia, no manometric pattern is perfectly sensitive or specific for 'achalasia' and there is also no 'gold standard' for the diagnosis. Consequently, complimentary physiological testing with a timed barium esophagram or functional lumen imaging probe are employed both to improve the detection of patients likely to respond to treatments for 'achalasia' and to characterize other syndromes also likely to benefit from achalasia therapies. These findings have become particularly relevant with the development of a minimally invasive technique for performing a tailored esophageal myotomy, POEM. Now and in the future, optimal achalasia management is to render treatment in a phenotype-specific manner, that is, POEM calibrated in a patient-specific manner for obstructive physiology including the distal esophagus and more conservative strategies such as a short POEM or pneumatic dilation for obstructive physiology limited to the lower esophageal sphincter.
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Affiliation(s)
- Peter J Kahrilas
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Dustin A Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - John E Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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3
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Denzer UW, Müller M, Kreuser N, Thieme R, Hoffmeister A, Feisthammel J, Niebisch S, Gockel I. [Therapy of esophageal motility disorders]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:183-197. [PMID: 35835360 DOI: 10.1055/a-1833-9299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2020 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.
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Affiliation(s)
- Ulrike W Denzer
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - Michaela Müller
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - Nicole Kreuser
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - René Thieme
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Juergen Feisthammel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Stefan Niebisch
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
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4
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Slim N, Williamson JM. Achalasia: investigation and management. Br J Hosp Med (Lond) 2023; 84:1-9. [PMID: 36708337 DOI: 10.12968/hmed.2022.0437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Achalasia, characterised by the absence of peristalsis and failure of relaxation of the lower oesophageal sphincter, is an uncommon degenerative condition that results in dysphagia. If left untreated it can lead to aspiration, oesophageal perforation, oesophagitis and malnutrition. It has a range of immune, allergic, viral and genetic aetiological causes. Successful diagnosis relies on the use of oesophagogastroduodenoscopy, barium swallow and oesophageal manometry to characterise the severity of the disease and to rule out underlying malignancy. Although no treatment can reverse the degenerative process, therapeutic strategies including lifestyle modification, medication, endoscopic and operative intervention can help to reduce symptoms. This article reviews the latest methods used to investigate and manage achalasia.
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Affiliation(s)
- Naim Slim
- Department of General Surgery, The Great Western Hospital, Swindon, UK
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Rolland S, Paterson W, Bechara R. Achalasia: Current therapeutic options. Neurogastroenterol Motil 2023; 35:e14459. [PMID: 36153803 DOI: 10.1111/nmo.14459] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 07/13/2022] [Accepted: 08/01/2022] [Indexed: 12/31/2022]
Abstract
Achalasia is an esophageal motor disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and absent peristalsis in the smooth muscle esophageal body. As a result, patients typically experience dysphagia, regurgitation, chest pain, and weight loss. Over the past 10-15 years, there has been a resurgence of interest in the evaluation of therapies for achalasia. Unfortunately, little progress in the development of effective pharmacological treatments has been made. Botulinum toxin injection provides some relief of symptoms in many patients but requires periodic reinjection that may provide progressively less benefit over time. There are now three well-established, safe, and effective therapies for the treatment of achalasia: pneumatic dilation (PD), laparoscopic Heller myotomy (LHM), and peroral endoscopic myotomy (POEM) which can lead to marked symptom improvement in most patients. Each treatment has a specific constellation of risks, benefits, and recurrence rate. The first-line treatment used will depend on patient preference, achalasia subtype, and local expertise. The recent impressive advances in both the art and science of achalasia therapy are explored with a comprehensive review of the various treatment modalities and comparative controlled clinical trials. In addition, key technical pearls of the procedural treatments are demonstrated.
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Affiliation(s)
- Sebastien Rolland
- Division of Gastroenterology, Hôpital Maisonneuve-Rosemont and Université de Montreal, Montreal, Quebec, Canada
| | - William Paterson
- Division of Gastroenterology and GI Diseases Research Unit, Queen's University, Kingston, Ontario, Canada
| | - Robert Bechara
- Division of Gastroenterology and GI Diseases Research Unit, Queen's University, Kingston, Ontario, Canada
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Patti MG, Schlottmann F, Herbella FAM. Once an achalasia patient always an achalasia patient: evaluation and treatment of recurrent symptoms. Dysphagia 2023. [DOI: 10.1016/b978-0-323-99865-9.00009-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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7
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Young AM, El Moheb M, Viktorsson SA, Martin LW. Esophagectomy for recurrent dysphagia in esophageal motility disorders. Dysphagia 2023. [DOI: 10.1016/b978-0-323-99865-9.00004-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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Mandavdhare HS, Samanta J, Jafra A, Singh H, Gupta P, Dutta U. OUTCOME OF PER ORAL ENDOSCOPIC MYOTOMY (POEM) IN SIGMOID ACHALASIA AT A MEDIAN FOLLOW UP OF 17 MONTHS. ARQUIVOS DE GASTROENTEROLOGIA 2022; 59:478-482. [PMID: 36515342 DOI: 10.1590/s0004-2803.202204000-85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/01/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Advanced achalasia cardia (AC) represents the end stage in the natural history of AC. Role of per oral endoscopic myotomy (POEM) in this technically difficult subset is emerging. METHODS Retrospective review of the patients who had undergone POEM for advanced AC with sigmoid esophagus. We assessed the technical success, clinical success and adverse event rate. Pre and post POEM Eckardt score (ES), integrated relaxation pressure-4sec (IRP-4), lower oesophageal sphincter pressure (LESP) and height and width of barium column at 5 minutes were noted. RESULTS Of the 85 patients who underwent POEM for AC, 10 patients had advanced AC with sigmoid esophagus of which eight were sigmoid and two were advanced sigmoid. The clinical and technical success was 100% with significant reduction of ES, IRP-4, LESP and height and width of barium column at 5 minutes. One patient had a minor adverse event in the form of mucosal injury that was closed with hemoclips. At a median follow up of 17 months there was no recurrence. CONCLUSION Our study demonstrates POEM to be a safe and effective modality of treatment in this technically difficult subset of AC with sigmoid morphology.
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Affiliation(s)
- Harshal S Mandavdhare
- Post Graduate Institute of Medical Education and Research, Department of Gastroenterology, Chandigarh, India
| | - Jayanta Samanta
- Post Graduate Institute of Medical Education and Research, Department of Gastroenterology, Chandigarh, India
| | - Anudeep Jafra
- Post Graduate Institute of Medical Education and Research, Department of Anesthesiology, Chandigarh, India
| | - Harjeet Singh
- Post Graduate Institute of Medical Education and Research, Department of Surgery, Chandigarh, India
| | - Pankaj Gupta
- Post Graduate Institute of Medical Education and Research, Department of Radiodiagnosis, Chandigarh, India
| | - Usha Dutta
- Post Graduate Institute of Medical Education and Research, Department of Gastroenterology, Chandigarh, India
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Abstract
Esophagectomy for achalasia is reserved for patients with end-stage disease for whom prior treatment has failed. Esophagectomy can be performed safely through a variety of techniques. Conduit options include stomach, colon, and small intestine. There are many potential complications following esophagectomy. Outcomes of esophagectomy for achalasia are good when performed in experienced surgical centers.
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Affiliation(s)
- John Waters
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Linda W Martin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Daniela Molena
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.
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Tustumi F. Evaluating the Non-conventional Achalasia Treatment Modalities. Front Med (Lausanne) 2022; 9:941464. [PMID: 35814742 PMCID: PMC9263126 DOI: 10.3389/fmed.2022.941464] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionAchalasia is a primary esophageal dysmotility disorder. Despite the high volume of studies addressing the conventional treatments for achalasia, few are debated regarding the non-conventional treatments, such as cardiectomy, cardioplasty, endoluminal substances injection (ethanolamine oleate, polidocanol, botulinum toxin), stents, and certain drugs (beta-agonists, anticholinergic, nitrates, calcium channel blockers, and phosphodiesterase inhibitors).MethodsA critical review was performed.ResultsEndoscopic, surgical, and pharmacological treatments were included. A qualitative synthesis was presented.ConclusionNon-conventional therapeutic options for treating achalasia encompass medical, endoscopic, and surgical procedures. Clinicians and patients need to know all the tools for the management of achalasia. However, several currently available studies of non-conventional treatments lack high-quality evidence, and future randomized trials are still needed.
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Affiliation(s)
- Francisco Tustumi
- Department of Gastroenterology, Universidade de São Paulo, São Paulo, Brazil
- Department of Surgery, Hospital Israelita Albert Einstein, São Paulo, Brazil
- *Correspondence: Francisco Tustumi
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Mandavdhare HS, M PK, Shukla J, Kumar A, Sharma V. Role of Peroral Endoscopic Myotomy in Advanced Achalasia Cardia With Sigmoid and/or Megaesophagus: A Systematic Review and Metanalysis. J Neurogastroenterol Motil 2022; 28:15-27. [PMID: 34980686 PMCID: PMC8748859 DOI: 10.5056/jnm21122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/01/2021] [Accepted: 10/04/2021] [Indexed: 11/20/2022] Open
Abstract
Background/Aims Sigmoid esophagus and/or megaesophagus are considered as an advanced stage in the natural history of achalasia cardia. The role of peroral endoscopic myotomy (POEM) in these subset of patients is emerging. We performed a systematic review and metanalysis to study the efficacy of POEM in advanced achalasia cardia with sigmoid and megaesophagus. Methods A literature search in PubMed and Embase was done from inception till August 3, 2021 to look for studies reporting exclusively on the role of POEM in advanced achalasia cardia with sigmoid and/or megaesophagus. The random effect method with inverse variance approach was used for the computation of pooled prevalence. For 2 groups’ analysis of continuous outcome standardized mean difference was used as the summary measure. Results Eleven studies with 428 patients were included for analysis. The pooled technical and clinical success was 98.27% (95% CI, 96.19-99.22; I2 = 0%) and 89.38% (95% CI, 84.49-92.86; I2 = 26%) and on subgroup analysis into sigmoid and megaesophagus it was (98.06% [95% CI, 95.41-99.19; I2 = 0%], 98.47% [95% CI, 92.72-99.69; I2 = 0%] and 87.92% [95% CI, 80.68-92.70; I2 = 37%], 88.36% [95% CI, 62.62-97.17; I2 = 77%]) respectively. The clinical success at < 1 year and 1-3 year follow-up was 89.37% (95% CI, 82.82-93.61; I2 = 0%) and 88.66% (95% CI, 81.65-91.22; I2 = 46%) respectively. There was a significant reduction in the post-POEM scores with standardized mean difference for Eckardt score (4.81), for integrated relaxation pressure at 4 seconds (1.93), and for lower esophageal sphincter pressure (2.06). Conclusions POEM is an effective modality of treatment even in the subset of patients of advanced achalasia cardia with sigmoid and megaesophagus.
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Affiliation(s)
- Harshal S Mandavdhare
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Praveen Kumar M
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jayendra Shukla
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Antriksh Kumar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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12
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Milito P, Siboni S, Lovece A, Andreatta E, Asti E, Bonavina L. Revisional Therapy for Recurrent Symptoms After Heller Myotomy for Achalasia. J Gastrointest Surg 2022; 26:64-69. [PMID: 34341888 PMCID: PMC8760227 DOI: 10.1007/s11605-021-05098-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 07/17/2021] [Indexed: 01/31/2023]
Abstract
PURPOSE Symptom recurrence after initial surgical management of esophageal achalasia occurs in 10-25% of patients. The aim of this study was to analyze safety and efficacy of revisional therapy after failed Heller myotomy (HM). METHODS A retrospective review of a prospective database was performed searching for patients with recurrent symptoms after primary surgical therapy for achalasia. Patients with previously failed HM were considered for the final analysis. The Foregut questionnaire, and the Atkinson and Eckardt scales were used to assess severity of symptoms. Objective investigations routinely included upper gastrointestinal endoscopy and barium swallow study. Redo treatments consisted of endoscopic pneumatic dilation (PD), laparoscopic HM, hybrid Ivor Lewis esophagectomy, or stapled cardioplasty. A yearly clinical and endoscopic follow-up was scheduled in all patients. RESULTS Over a 20-year period, 26 patients with a median age of 66 years (IQR 19.5) underwent revisional therapy after failed HM for achalasia at a tertiary-care university hospital. The median time after index procedure was 10 years (IQR 21). Revisional therapy consisted of endoscopic pneumatic dilation (n=13), laparoscopic HM and fundoplication (n=10), esophagectomy (n=2), and stapled cardioplasty and fundoplication (n=1). Nine (34.6%) of these patients required further endoscopic or surgical treatments. There was no mortality, and the overall complication rate was 7.7%. At a median follow-up of 42 months (range 10-149), a significant decrease of dysphagia, regurgitation, chest pain, respiratory symptoms, and median Eckardt score (p<0.05) was noted. CONCLUSION In specialized and multidisciplinary centers, revisional therapy for achalasia is feasible, safe, and effective.
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Affiliation(s)
- Pamela Milito
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy
| | - Stefano Siboni
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy
| | - Andrea Lovece
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy
| | - Erika Andreatta
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy
| | - Emanuele Asti
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy ,Division of General and Foregut Surgery, IRCCS Policlinico San Donato, Piazza Malan 1, 20097 San Donato Milanese (Milano), Italy
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13
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Pomenti S, Blackett JW, Jodorkovsky D. Achalasia: Diagnosis, Management and Surveillance. Gastroenterol Clin North Am 2021; 50:721-736. [PMID: 34717867 DOI: 10.1016/j.gtc.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Achalasia is a rare chronic esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter and abnormal peristalsis. This abnormal motor function leads to impaired bolus emptying and symptoms of dysphagia, regurgitation, chest pain, or heartburn. After an upper endoscopy to exclude structural causes of symptoms, the gold standard for diagnosis is high-resolution esophageal manometry. However, complementary diagnostic tools include barium esophagram and functional luminal impedance planimetry. Definitive treatments include pneumatic dilation, Heller myotomy with fundoplication, and peroral endoscopic myotomy.
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Affiliation(s)
- Sydney Pomenti
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, 630 West 168th Street, Suite 3-401, New York, NY 10032, USA
| | - John William Blackett
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, 630 West 168th Street, Suite 3-401, New York, NY 10032, USA
| | - Daniela Jodorkovsky
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, 630 West 168th Street, Suite 3-401, New York, NY 10032, USA.
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14
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Orlandini MF, Serafim MCA, Datrino LN, Tavares G, Tristão LS, Dos Santos CL, Bernardo WM, Tustumi F. Myotomy in sigmoid megaesophagus: is it applicable? A systematic review and meta-analysis. Dis Esophagus 2021; 34:6342447. [PMID: 34355243 DOI: 10.1093/dote/doab053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/02/2021] [Accepted: 07/18/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Achalasia may evolve to sigmoid megaesophagus in 10-15% of patients and is usually treated with esophagectomy, which has high morbi-mortality. Many surgeons debate the applicability of the Heller myotomy for treating sigmoid megaesophagus. This study intents to analyze the effectiveness of myotomy for treating patients with sigmoid megaesophagus. METHODS A systematic review and meta-analysis was conducted in PubMed, Cochrane, Lilacs and Embase alongside manual search of references. The inclusion criteria were clinical trials, cohort, case-series; patients with sigmoid megaesophagus and esophageal diameter ≥ 6 cm; and patients undergoing primary myotomy. The exclusion criteria were reviews, case reports, cross-sectional studies, editorials, letters, congress abstracts, full-text unavailability; previous surgical treatment for achalasia; and pediatric or animal model studies. No restrictions on language and date of publication, and no filters were applied. Subgroups analyses were performed to assess the laparoscopic myotomy perioperative outcomes. Besides, subgroup analyses were performed to assess the long-term outcomes of the studies with a follow-up time > 24 months. To verify heterogeneity, the I2 test was used. The random effects were applied, and the fixed model was evaluated as sensitivity analysis. To assess risk of bias and certainty of evidence, the tools ROBINS-I and GRADE were used, respectively. Registration number: CRD42020199667. RESULTS Sixteen articles were selected, encompassing 350 patients. The mean age ranged from 36 to 61 years old, and the mean follow-up ranged from 16 to 109 months. Complications rate was 0.08 (CI: 0.040-0.153; P = 0.01). Need for retreatment rate was 0.128 (CI: 0.031-0.409; P = 0.01). The probability of good or excellent outcomes after myotomy was 0.762 (CI: 0.703-0.812; P < 0.01). Postoperative mortality rate was 0.008 (CI: 0.004-0.015; P < 0.01). CONCLUSION Surgical myotomy is an option for avoiding esophagectomy in achalasia, with a low morbi-mortality rate and good results. It is effective for most patients and only a minority will demand retreatment.
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Affiliation(s)
| | | | | | - Guilherme Tavares
- Department of Evidence-Based Medicine, Centro Universitário Lusíada, Santos, Brazil
| | | | | | - Wanderley Marques Bernardo
- Department of Evidence-Based Medicine, Centro Universitário Lusíada, Santos, Brazil.,Department of Evidence-Based Medicine, Universidade de São Paulo, São Paulo, Brazil
| | - Francisco Tustumi
- Department of Evidence-Based Medicine, Centro Universitário Lusíada, Santos, Brazil.,Department of Evidence-Based Medicine, Universidade de São Paulo, São Paulo, Brazil.,Department of Surgery, Hospital Israelita Albert Einstein, São Paulo, Brazil
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15
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Torres-Landa S, Crafts TD, Jones AE, Dewey EN, Wood SG. Surgical Outcomes After Esophagectomy in Patients with Achalasia: a NSQIP Matched Analysis With Non-Achalasia Esophagectomy Patients. J Gastrointest Surg 2021; 25:2455-2462. [PMID: 34131865 DOI: 10.1007/s11605-021-05056-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/24/2021] [Indexed: 01/31/2023]
Abstract
PURPOSE The data on surgical outcomes of esophagectomy in patients with achalasia is limited. We sought to evaluate surgical outcomes in achalasia patients after an esophagectomy versus non-achalasia patients to elucidate if the outcomes are affected by the diagnosis. METHODS We conducted a retrospective review of the National Surgical Quality Improvement Program database (2010-2018). Patients who underwent an esophagectomy (open or laparoscopic approach) were included. Patients were divided into two groups, achalasia vs non-achalasia patients, and matched using propensity match analysis. RESULTS Of the 10,997 esophagectomy patients who met inclusion criteria, 213 (1.9%) patients had a diagnosis of achalasia. A total of 418 patients were included for the final analysis, with 209 patients in each group (achalasia vs non-achalasia). The overall median age was 57 years (IQR 47-65 years), and 48.6% were female. Most underwent an open (93.1%) vs laparoscopic (6.9%) esophagectomy. Overall complication rate was 40%. No difference was identified on overall complications, readmission, reoperation, or mortality between both groups. Postoperative sepsis was significantly higher in the achalasia group, and organ space SSI was higher in the non-achalasia group. Multivariable analysis showed that a diagnosis (achalasia or non-achalasia) was not predictive of reoperation or overall complications. CONCLUSION Esophagectomy outcomes are similar in patients with achalasia vs non-achalasia, and the diagnosis of achalasia does not independently increase the risk of reoperation and overall complications. Finally, regardless of diagnosis, the potential for morbidity following esophagectomy, should to be discussed with patients in the preoperative setting.
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Affiliation(s)
- Samuel Torres-Landa
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Trevor D Crafts
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Amy E Jones
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Elizabeth N Dewey
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Stephanie G Wood
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA.
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16
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Oude Nijhuis RAB, Zaninotto G, Roman S, Boeckxstaens GE, Fockens P, Langendam MW, Plumb AA, Smout A, Targarona EM, Trukhmanov AS, Weusten B, Bredenoord AJ. European guidelines on achalasia: United European Gastroenterology and European Society of Neurogastroenterology and Motility recommendations. United European Gastroenterol J 2021; 8:13-33. [PMID: 32213062 PMCID: PMC7005998 DOI: 10.1177/2050640620903213] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Achalasia is a primary motor disorder of the oesophagus characterised by absence of peristalsis and insufficient lower oesophageal sphincter relaxation. With new advances and developments in achalasia management, there is an increasing demand for comprehensive evidence-based guidelines to assist clinicians in achalasia patient care. METHODS Guidelines were established by a working group of representatives from United European Gastroenterology, European Society of Neurogastroenterology and Motility, European Society of Gastrointestinal and Abdominal Radiology and the European Association of Endoscopic Surgery in accordance with the Appraisal of Guidelines for Research and Evaluation II instrument. A systematic review of the literature was performed, and the certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Recommendations were voted upon using a nominal group technique. RESULTS These guidelines focus on the definition of achalasia, treatment aims, diagnostic tests, medical, endoscopic and surgical therapy, management of treatment failure, follow-up and oesophageal cancer risk. CONCLUSION These multidisciplinary guidelines provide a comprehensive evidence-based framework with recommendations on the diagnosis, treatment and follow-up of adult achalasia patients.
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Affiliation(s)
- R A B Oude Nijhuis
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - G Zaninotto
- Department of Surgery and Cancer, Imperial College, London, UK
| | - S Roman
- Digestive Physiology, Hôpital Edouard Herriot, Lyon, France
| | - G E Boeckxstaens
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Centre for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - P Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - M W Langendam
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - A A Plumb
- Centre for Medical Imaging, University College London, London, UK
| | - Ajpm Smout
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - E M Targarona
- Department of General and Digestive Surgery, Hospital De La Santa Creu I Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - A S Trukhmanov
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Blam Weusten
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
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17
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Bona D, Lombardo F, Matsushima K, Cavalli M, Panizzo V, Mendogni P, Bonitta G, Campanelli G, Aiolfi A. Diaphragmatic herniation after esophagogastric surgery: systematic review and meta-analysis. Langenbecks Arch Surg 2021; 406:1819-1829. [PMID: 34129106 PMCID: PMC8481172 DOI: 10.1007/s00423-021-02214-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/23/2021] [Indexed: 11/30/2022]
Abstract
Introduction The anatomy of the esophageal hiatus is altered during esophagogastric surgery with an increased risk of postoperative hiatus hernia (HH). The purpose of this article was to examine the current evidence on the surgical management and outcomes associated with HH after esophagogastric surgery for cancer. Materials and methods Systematic review and meta-analysis. Web of Science, PubMed, and EMBASE data sets were consulted. Results Twenty-seven studies were included for a total of 404 patients requiring surgical treatment for HH after esophagogastric surgery. The age of the patients ranged from 35 to 85 years, and the majority were males (82.3%). Abdominal pain, nausea/vomiting, and dyspnea were the commonly reported symptoms. An emergency repair was required in 51.5%, while a minimally invasive repair was performed in 48.5%. Simple suture cruroplasty and mesh reinforced repair were performed in 65% and 35% of patients, respectively. The duration between the index procedure and HH repair ranged from 3 to 144 months, with the majority (67%) occurring within 24 months. The estimated pooled prevalence rates of pulmonary complications, anastomotic leak, overall morbidity, and mortality were 14.1% (95% CI = 8.0–22.0%), 1.4% (95% CI = 0.8–2.2%), 35% (95% CI = 20.0–54.0%), and 5.0% (95% CI = 3.0–8.0%), respectively. The postoperative follow-up ranged from 1 to 110 months (mean = 24) and the pooled prevalence of HH recurrence was 16% (95% CI = 13.0–21.6%). Conclusions Current evidence reporting data for HH after esophagogastric surgery is narrow. The overall postoperative pulmonary complications, overall morbidity, and mortality are 14%, 35%, and 5%, respectively. Additional studies are required to define indications and treatment algorithm and evaluate the best technique for crural repair at the index operation in an attempt to minimize the risk of HH.
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Affiliation(s)
- Davide Bona
- Division of General Surgery, Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy
| | - Francesca Lombardo
- Division of General Surgery, Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA
| | - Marta Cavalli
- Department of Surgery, University of Insubria, Milan, Italy
| | - Valerio Panizzo
- Division of General Surgery, Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy
| | - Paolo Mendogni
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Via Francesco Sforza, 35, Milan, Italy
| | - Gianluca Bonitta
- Division of General Surgery, Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy
| | | | - Alberto Aiolfi
- Division of General Surgery, Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy.
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18
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Aiolfi A, Cavalli M, Del Ferraro S, Manfredini L, Lombardo F, Bonitta G, Bruni PG, Panizzo V, Campanelli G, Bona D. Total extraperitoneal (TEP) versus laparoscopic transabdominal preperitoneal (TAPP) hernioplasty: systematic review and trial sequential analysis of randomized controlled trials. Hernia 2021; 25:1147-1157. [PMID: 33851270 PMCID: PMC8514389 DOI: 10.1007/s10029-021-02407-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 03/29/2021] [Indexed: 01/09/2023]
Abstract
Purpose To examine the updated evidence on safety, effectiveness, and outcomes of the totally extraperitoneal (TEP) versus the laparoscopic transabdominal preperitoneal (TAPP) repair and to explore the timely tendency variations favoring one treatment over another. Methods Systematic review and trial sequential analysis (TSA) of randomized controlled trials (RCTs). MEDLINE, Scopus, Web of Science, Cochrane Central Library, and ClinicalTrials.gov were consulted. Risk Ratio (RR), weighted mean difference (WMD), and 95% confidence intervals (CI) were used as pooled effect size measures. Results Fifteen RCTs were included (1359 patients). Of these, 702 (51.6%) underwent TAPP and 657 (48.4%) TEP repair. The age of the patients ranged from 18 to 92 years and 87.9% were males. The estimated pooled RR for hernia recurrence (RR = 0.83; 95% CI 0.35–1.96) and chronic pain (RR = 1.51; 95% CI 0.54–4.22) were similar for TEP vs. TAPP. The TSA shows a cumulative z-curve without crossing the monitoring boundaries line (Z = 1.96), thus supporting true negative results while the information size was calculated as adequate for both outcomes. No significant differences were found in term of early postoperative pain, operative time, wound-related complications, hospital length of stay, return to work/daily activities, and costs. Conclusions TEP and TAPP repair seems comparable in terms of postoperative hernia recurrence and chronic pain. The cumulative evidence and information size are sufficient to provide a conclusive evidence on recurrence and chronic pain. Similar trials or meta-analyses seem unlikely to show diverse results and should be discouraged. Supplementary Information The online version contains supplementary material available at 10.1007/s10029-021-02407-7.
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Affiliation(s)
- Alberto Aiolfi
- Division of General Surgery, Department of Biomedical Science for Health, Istitituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy.
| | - Marta Cavalli
- Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Milan, Italy
| | - Simona Del Ferraro
- Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Milan, Italy
| | - Livia Manfredini
- Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Milan, Italy
| | - Francesca Lombardo
- Division of General Surgery, Department of Biomedical Science for Health, Istitituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Gianluca Bonitta
- Division of General Surgery, Department of Biomedical Science for Health, Istitituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Piero Giovanni Bruni
- Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Milan, Italy
| | - Valerio Panizzo
- Division of General Surgery, Department of Biomedical Science for Health, Istitituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Giampiero Campanelli
- Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Milan, Italy
| | - Davide Bona
- Division of General Surgery, Department of Biomedical Science for Health, Istitituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
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19
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Laparoscopic hand-sewn cardioplasty: an alternative procedure for end-stage achalasia. Langenbecks Arch Surg 2021; 406:1675-1682. [PMID: 33760978 PMCID: PMC8370937 DOI: 10.1007/s00423-021-02117-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/03/2021] [Indexed: 10/28/2022]
Abstract
BACKGROUND Primary achalasia is a rare oesophageal motor disorder characterized by the absence of swallow-induced relaxation of the lower oesophageal sphincter and diminished or absent oesophageal body peristalsis. Around 5% of these patients will develop end-stage achalasia, where oesophagectomy may be advocated. We present the laparoscopic hand-sewn cardioplasty as an alternative 'oesophagus-preserving' procedure in patients with end-stage achalasia. METHODS We present a retrospective review of four patients who underwent laparoscopic hand-sewn cardioplasty. Data collected included pre-operative demographic information and investigations; and post-operative outcomes. Patients were scored pre- and post-operatively using Reflux Symptom Index, Eating Assessment Tool-10 and Voice Handicap Index-10 questionnaires. RESULTS Four patients underwent laparoscopic hand-sewn cardioplasty during the study period. In one patient, it was performed as a rescue procedure during attempted myotomy following multiple perforations of friable mucosa. In the other three patients, laparoscopic hand-sewn cardioplasty was performed for end-stage achalasia. None of the patients had post-operative complications and all patients were discharged on the second post-operative day. All patients experienced improvement in swallowing symptoms (EAT-10; p = 0.03) but developed post-operative gastroesophageal reflux. CONCLUSION To our knowledge, this is the first published case series of laparoscopic hand-sewn cardioplasty for end-stage achalasia. It appears to be a safe and effective procedure for the treatment of end-stage achalasia, offering an alternative minimally invasive procedure to oesophagectomy. Laparoscopic hand-sewn cardioplasty can also be used as a 'rescue' procedure during myotomy in patients who have poor-quality mucosa which perforates intra-operatively or is at high risk of perforation/leaking post-operatively.
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20
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Pesce M, Sweis R. Advances and caveats in modern achalasia management. Ther Adv Chronic Dis 2021; 12:2040622321993437. [PMID: 33786159 PMCID: PMC7958157 DOI: 10.1177/2040622321993437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 01/15/2021] [Indexed: 12/18/2022] Open
Abstract
Achalasia is a rare esophageal motility disorder characterized by the incomplete
relaxation of the lower esophageal sphincter (LES) and impaired peristaltic
activity. The advent of high-resolution manometry (HRM) and the rapidly evolving
role of therapeutic endoscopy have revolutionized the approach to the diagnosis
and management of achalasia patients in the last decade. With advances in HRM
technology and methodology, fluoroscopy and EndoFlip, achalasia can be
differentiated into therapeutically meaningful phenotypes with a high degree of
accuracy. Further, the newest treatment option, per-oral endoscopic myotomy
(POEM), has become a staple therapy following the last 10 years of experience,
and recent randomized trials appear to show no difference between POEM, graded
pneumatic dilatation and surgical Heller myotomy in terms of short- and
long-term efficacy or complication rate. On the other hand, how treatment
outcomes are measured as well as the risk of reflux following therapy remain
areas of contention. This review aims to summarize the recent advancements in
achalasia testing and therapy, describes the recent randomized clinical trials
as well as their potential setbacks, and touches on the future of personalizing
achalasia treatment.
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Affiliation(s)
- Marcella Pesce
- Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Naples, Italy
| | - Rami Sweis
- University College London Hospital, GI Services, 235 Euston Rd, London, NW1 2BU, UK
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21
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Qiu S, Chai N, Zhai Y, Wang X, Wang Y, Linghu E. Advanced achalasia: good candidate for peroral endoscopic myotomy. Dis Esophagus 2021; 34:5923116. [PMID: 33693695 DOI: 10.1093/dote/doaa097] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 08/03/2020] [Accepted: 08/11/2020] [Indexed: 12/11/2022]
Abstract
Peroral endoscopic myotomy (POEM) has been increasingly accepted as the first-line treatment of achalasia. However, laparoscopic Heller myotomy or esophagectomy still remains as the mainstay treatment for advanced achalasia featured with megaesophagus and/or sigmoid-shaped esophagus. Although the efficacy of POEM for advanced achalasia with sigmoid-shaped esophagus has been described, little is known about the role of POEM for patients with megaesophagus. The aim of our study is to evaluate the efficacy and safety of POEM for advanced achalasia with megaesophagus. Patients who received initial examinations and underwent POEM in our hospital from June 2013 to December 2018 were identified and data were retrospectively analyzed. The advanced achalasia was defined as megaesophagus with a diameter of ≥6 cm. The primary outcome was clinical success. The secondary outcomes were technical success and adverse events. A total of 112 patients (50 females, 44.6%) were included with a mean age of 44.8 years. The median symptom duration was 6.5 years (IQR:3.0-13.0 years). Modified POEM techniques were used in 27.7% (31/112) of patients. Technical success rate was 99.1% (112/113) per procedure. Clinical success was seen in 93.1% patients with median Eckardt score decreasing from 8.0 to 1.0 (P < 0.001) during a median 31.0 months of follow-up. The mean LES pressure decreased from 29.5 mmHg to 14.2 mmHg after POEM (P < 0.05). Procedure-related adverse events occurred in 8.9% patients. Reflux disease was observed postoperatively in 26.7% of patients. POEM is also indicated for patients with advanced achalasia with a favorable safety and efficacy.
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Affiliation(s)
- Shaotian Qiu
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Ningli Chai
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Yaqi Zhai
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Xiangyao Wang
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Yan Wang
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
| | - Enqiang Linghu
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
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22
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Liu D, Liu YY, Chen JX, Song L, Zhou YY, Ullah S, Zhao LX, Hai B, Zheng QF, Li DY, He DZ, Liu BR. Influence of esophageal morphology on the clinical efficacy of peroral endoscopic myotomy in treating advanced achalasia cardia. Exp Ther Med 2021; 21:196. [PMID: 33488805 PMCID: PMC7812585 DOI: 10.3892/etm.2021.9629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 11/26/2020] [Indexed: 12/13/2022] Open
Abstract
Peroral endoscopic myotomy (POEM) is the first-line treatment of achalasia cardia (AC). However, the efficacy of POEM in treating patients with advanced AC remains to be determined. The aim of the present study was to evaluate the feasibility and clinical outcome of POEM in treating patients with advanced AC involving different esophageal morphologies. The study was a single-center, retrospective analysis of patients suffering from advanced AC. The primary endpoint was the Eckardt score at the follow-up examination. Secondary endpoints were procedural-related details, including the operation time and length of myotomy, adverse events (AEs) and hospital stay, as well as post-procedural gastroesophageal reflux disease. The technical success rate was 100%. All 50 patients enrolled underwent successful endoscopic myotomy (conventional POEM, n=20; modified POEM, n=30). AEs were observed in 10 patients. During a 6- to 50-month follow-up period, 41 patients achieved clinical success as evidenced by a decrease in the Eckardt score. Only 3 of 6 patients with a sigmoid-shaped megaesophagus obtained symptomatic relief. Symptomatic reflux occurred in 13 of 46 patients who completed their follow-up. In conclusion, POEM is safe, feasible and effective in treating advanced AC. Patients with a sigmoid-shaped megaesophagus are less likely to report palliation of symptoms.
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Affiliation(s)
- Dan Liu
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Yue-Yuan Liu
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Jia-Xin Chen
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Lei Song
- Department of Gastroenterology, The Hospital of Hei Long Jiang Province, Harbin, Heilongjiang 150036, P.R. China
| | - Yang-Yang Zhou
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Saif Ullah
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Li-Xia Zhao
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China.,Department of Digestive Endoscopy Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Bin Hai
- Department of Digestive Endoscopy Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Qing-Fen Zheng
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Dong-Ying Li
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - De-Zhi He
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Bing-Rong Liu
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China.,State Key Laboratory of Esophageal Cancer Prevention and Treatment, Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
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23
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Ortiz López D, Acosta Mérida MA, Callejón Cara MDM, Marchena Gómez J. Severe respiratory failure secondary to megaesophagus due to terminal achalasia. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 113:463-464. [PMID: 33393337 DOI: 10.17235/reed.2020.7672/2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We present the case of a 56-year-old male diagnosed with achalasia ten years previously without follow-up. He presented with fever, dysphonia and dyspnea associated with a constitutional syndrome of one month of evolution. Laboratory tests showed leucocytosis of 15,870/ul. The chest radiography confirmed mediastinal widening and a chest computed tomography (CT) showed full esophageal dilation up to 10 cm compressing the trachea and right main bronchus, with tapering at the esophagogastric junction.
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Affiliation(s)
- David Ortiz López
- Cirugía General y del Aparato Digestivo, Hospital Universitario de Gran Canaria Doctor Negrín, España
| | | | | | - Joaquín Marchena Gómez
- Cirugía General y del Aparato Digestivo, Hospital Universitario de Gran Canaria Doctor Negrín
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24
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Crafts TD, Lyo V, Rajdev P, Wood SG. Treatment of achalasia in the bariatric surgery population: a systematic review and single-institution experience. Surg Endosc 2020; 35:5203-5216. [PMID: 33048227 DOI: 10.1007/s00464-020-08015-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 09/16/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although the link between achalasia and morbid obesity is unclear, the reported prevalence is 0.5-1% in this population. For bariatric surgery patients, optimal type and timing of achalasia intervention is uncertain. METHODS Patient charts from a single academic institution were retrospectively reviewed. Between 2012 and 2019, 245 patients were diagnosed with achalasia, 13 of whom underwent bariatric surgery and were included. Patients were divided into two groups depending on the timing of their achalasia diagnosis and bariatric surgery. Groups were compared in terms of type and timing of intervention as well as treatment response. RESULTS Group 1 included 4 patients diagnosed with achalasia before bariatric surgery. Three had laparoscopic Heller myotomy (LHM) and 1 had a per oral endoscopic myotomy (POEM). These patients had laparoscopic gastric bypass (LGB) within 5 years of achalasia diagnosis. Postoperatively, 1 had severe reflux with regurgitation necessitating radiofrequency energy application to the lower esophageal sphincter. All had relief from dysphagia. Group 2 included 9 patients diagnosed with achalasia after bariatric surgery. Achalasia subtypes were evenly distributed. Initial operations were: 5 LGB, 2 laparoscopic sleeve gastrectomy (LSG), 1 duodenal switch (DS), 1 lap band. One LSG patient was converted to LGB concurrently with LHM. On average, achalasia was diagnosed 8.3 years after bariatric surgery. Achalasia interventions included: 1 pneumatic dilation, 1 Botox injection, 1 POEM, 6 LHM. While LHM was the most common procedure, 4 of 6 patients experienced recurrent dysphagia, one of whom required esophagectomy. CONCLUSIONS Achalasia is a challenging problem in the bariatric surgery population. Recurrent symptoms are common. Patients treated for achalasia after bariatric surgery tended to have worse symptom resolution than those diagnosed prior to bariatric surgery. Additional prospective studies are needed to elucidate whether interventions for achalasia should be performed concurrently or in a particular sequence for optimal results.
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Affiliation(s)
- Trevor D Crafts
- Department of Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: L223A, Portland, OR, 97239, USA
| | - Victoria Lyo
- Department of Surgery, University of California Davis, 2335 Stockton Blvd., #6113, Sacramento, CA, 95817, USA
| | - Priya Rajdev
- Department of General Surgery, University of Arizona College of Medicine, Phoenix, AZ, 85004, USA
| | - Stephanie G Wood
- Department of Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: L223A, Portland, OR, 97239, USA.
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25
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Abstract
Achalasia is an esophageal motility disorder characterized by aberrant peristalsis and insufficient relaxation of the lower esophageal sphincter. Patients most commonly present with dysphagia to solids and liquids, regurgitation, and occasional chest pain with or without weight loss. High-resolution manometry has identified 3 subtypes of achalasia distinguished by pressurization and contraction patterns. Endoscopic findings of retained saliva with puckering of the gastroesophageal junction or esophagram findings of a dilated esophagus with bird beaking are important diagnostic clues. In this American College of Gastroenterology guideline, we used the Grading of Recommendations Assessment, Development and Evaluation process to provide clinical guidance on how best to diagnose and treat patients with achalasia.
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The Malnutrition Universal Screening Tool can predict malnutrition in patients with esophageal achalasia. Eur J Gastroenterol Hepatol 2020; 32:1135-1140. [PMID: 32541242 DOI: 10.1097/meg.0000000000001798] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND At present, little research has been done to clarify why some achalasia patients do not lose weight or are even obese and to investigate their nutritional status. The aim of this study was to identify predictive factors of malnutrition in these patients and to assess their response to treatment. METHODS We conducted a retrospective cohort study on consecutive patients referred to a tertiary-care center for laparoscopic or endoscopic treatment of achalasia. Demographics, anthropometric variables, presenting symptoms, and results of the objective investigation were recorded on a prospectively collected database. The severity of symptoms and the nutritional risk were assessed by the Eckardt score and the Malnutrition Universal Screening Tool (MUST), respectively, before and after treatment. RESULTS Between 2013 and 2019, 171 patients met the study inclusion criteria. There were 87 (50.9%) male and the median age was 53.0 (39-66) years. The median Eckardt score was 6 (interquartile range 3). Based on the MUST score, 121 (70.8%) patients were classified at moderate/high risk of malnutrition. Of these, 93 (76.9%) were overweight or obese. Compared to low-risk group, predictive factors of moderate/high risk of malnutrition were higher Eckardt score [odds ratio (OR) 1.63; 95% CI, 1.35-1.99], more severe dysphagia (OR 2.68, 95% CI, 1.66-4.30), and greater absolute weight loss (OR 2.37; 95% CI, 1.77-3.17). The latter was the only independent predictive factor of malnutrition (OR 2.54; 95% CI, 1.69-3.82). After treatment, the measured MUST score was 0 in 96% of patients. CONCLUSIONS Over 70% of achalasia patients were at moderate/high risk of malnutrition. These individuals may benefit from a perioperative multidisciplinary approach including dietary intervention to stabilize weight and improve their nutritional status.
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Paula DMP, Barbosa JP, Barbosa E, Barbosa J. Surgery Outcomes and Quality of Life in Achalasia's Treatment. J Laparoendosc Adv Surg Tech A 2020; 30:1308-1313. [PMID: 32716691 DOI: 10.1089/lap.2020.0186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Objectives: Evaluate the quality of life (QoL) in patients diagnosed with achalasia who performed Heller's myotomy. Methods: Between January 1, 2000 and March 27, 2019, 99 patients were submitted to esophagomyotomy at the São João Hospital in Oporto, Portugal. The exclusion criteria were other diagnoses, age <18 years at the date of surgery, and death. Seventy-five patients were contacted. Pre- and postoperative evaluations were performed using the achalasia disease-specific QoL questionnaire and by the Eckardt score. QoL was assessed by the Medical Outcomes Study SF-36. Results: Forty-nine patients (65%) answered the questionnaires. The median difference in the achalasia-DSQoL questionnaire between the pre- and postoperative period was -9.0 (interquartile range [IQR]: 5-12), whereas in the Eckardt score was -5.0 (IQR: 3.25-7). Lower postoperative scores correlated with higher scores on the SF-36's mental and physical summary measures (Spearman's rho [ρ] = -0.651 and ρ = -0.577 for the achalasia-DSQoL questionnaire and ρ = -0.552 and ρ = -0.515 for the Eckardt score, P < .001). Physical and mental summary measures were correlated with each other (ρ = 0.788, P < .001). Conclusions: Heller's myotomy allows a decrease in symptoms and an increase in QoL. Patients with severe symptoms before surgery had higher postoperative scores and patients with fewer symptoms had lower postoperative scores.
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Affiliation(s)
| | - José Pedro Barbosa
- Department of Community Medicine, Information and Decision in Heathcare, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Elisabete Barbosa
- Faculty of Medicine, University of Porto, Porto, Portugal.,Department of General Surgery, Hospital of São João, Porto, Portugal
| | - José Barbosa
- Faculty of Medicine, University of Porto, Porto, Portugal.,Department of General Surgery, Hospital of São João, Porto, Portugal
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Felix VN, Murayama KM, Bonavina L, Park MI. Achalasia: what to do in the face of failures of Heller myotomy. Ann N Y Acad Sci 2020; 1481:236-246. [PMID: 32713020 DOI: 10.1111/nyas.14440] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/07/2020] [Accepted: 06/25/2020] [Indexed: 12/21/2022]
Abstract
Achalasia is a primary motility disorder of the esophagus, and while there are several treatment options, there is no consensus regarding them. When therapeutic intervention for achalasia fails, a careful evaluation of the cause of the persistent or recurrent symptoms using upper endoscopy, esophageal manometry, and contrast radiologic studies is required to understand the cause of therapy failure and guide plans for subsequent treatment. Options for reintervention are the same as for primary intervention and include pneumatic dilation, botulinum toxin injection, peroral endoscopic myotomy, or redo esophageal myotomy. When reintervention fails or if the esophagus is not amenable to intervention and the disease is considered end-stage, esophagectomy is the last option to manage recurrent achalasia.
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Affiliation(s)
- Valter N Felix
- Nucleus of General and Specialized Surgery - São Paulo and Department of Gastroenterology - Surgical Division - São Paulo University, FMUSP, Sao Paulo, Brazil
| | - Kenric M Murayama
- Department of Surgery, John A. Burns School of Medicine, the University of Hawaii at Manoa, Honolulu, Hawaii
| | - Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, The University of Milan, San Donato Milanese, Italy
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
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Nurczyk K, Patti MG. Surgical management of achalasia. Ann Gastroenterol Surg 2020; 4:343-351. [PMID: 32724877 PMCID: PMC7382425 DOI: 10.1002/ags3.12344] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/03/2020] [Accepted: 04/13/2020] [Indexed: 12/17/2022] Open
Abstract
Esophageal achalasia is a primary esophageal motility disorder characterized by lack of peristalsis and by incomplete or absent relaxation of the lower esophageal sphincter in response to swallowing. The cause of the disease is unknown. The goal of treatment is to eliminate the functional outflow obstruction at the level of the gastroesophageal junction, therefore allowing emptying of the esophagus into the stomach. They include the laparoscopic Heller myotomy with partial fundoplication, pneumatic dilatation, and peroral endoscopic myotomy. Esophagectomy is considered as a last resort for patients who have failed prior therapeutic attempts. In this evidence and experience-based review, we will illustrate the technique and results of the surgical treatment of esophageal achalasia and compare it to the other available treatment modalities.
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Affiliation(s)
- Kamil Nurczyk
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNCUSA
- 2nd Department of General and Gastrointestinal Surgery, and Surgical Oncology of the Alimentary TractMedical University of LublinLublinPoland
| | - Marco G. Patti
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Department of MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
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Smith KE, Saad AR, Hanna JP, Tran T, Jacobs J, Richter JE, Velanovich V. Revisional Surgery in Patients with Recurrent Dysphagia after Heller Myotomy. J Gastrointest Surg 2020; 24:991-999. [PMID: 31147973 DOI: 10.1007/s11605-019-04264-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/06/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recurrent/persistent symptoms of achalasia occur in 10-20% of individuals after Heller myotomy. The causes and treatment outcomes are ambiguous. Our aim is to assess the causes and outcomes of a multidisciplinary approach to this patient population. METHODS All patients undergoing revisional operations after a Heller myotomy were reviewed retrospectively. DATA COLLECTED demographics, date of initial Heller myotomy, preoperative evaluation, etiology of recurrent symptoms, date of revisional operation, and surgical outcomes. RESULTS A total of 34 patients underwent 37 revisional operations. Operations were tailored based on preoperative multidisciplinary evaluation. Causes of symptoms: periesophageal/perihiatal fibrosis 11 (27%), obstructing fundoplication 11 (27%), incomplete myotomy 8 (20%), progression of disease 9 (22%), and epiphrenic diverticulum 1 (2%). Operations performed: reversal/no creation of fundoplication with or without re-do myotomy 22 (59%), revision/creation of fundoplication with or without myotomy 6 (16%), and esophagectomy 9 (24%). Ten patients in the 37 operations (27%) developed postoperative complications. Of 33 patients for 36 operations with follow-up, 25 patient-operations (69%) resulted in resolution or improved dysphagia. Although there was variation in symptomatic improvement by cause and operation type, none reached statistical significance. CONCLUSION There are several causes of dysphagia after Heller myotomy and a thoughtful evaluation is required. Complication rates are higher than first-time operations. Symptomatic improvement occurs in the majority of cases, but a significant minority will have persistent dysphagia. Although an individualized approach to dysphagia after Heller myotomy may improve symptoms and passage of food, the perception of dysphagia may persist in patients.
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Affiliation(s)
- Kaylee E Smith
- Division of General Surgery, Department of Surgery, University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA
| | - Adham R Saad
- Division of General Surgery, Department of Surgery, University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA.,The Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, FL, USA
| | - John P Hanna
- Division of Surgical Research, Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Thanh Tran
- Division of Surgical Research, Department of Surgery, University of South Florida, Tampa, FL, USA
| | - John Jacobs
- The Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, FL, USA.,Division of Gastroenterology, Department of Medicine, University of South Florida, Tampa, FL, USA
| | - Joel E Richter
- The Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, FL, USA.,Division of Gastroenterology, Department of Medicine, University of South Florida, Tampa, FL, USA
| | - Vic Velanovich
- Division of General Surgery, Department of Surgery, University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA. .,The Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Tampa, FL, USA.
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Jung HK, Hong SJ, Lee OY, Pandolfino J, Park H, Miwa H, Ghoshal UC, Mahadeva S, Oshima T, Chen M, Chua ASB, Cho YK, Lee TH, Min YW, Park CH, Kwon JG, Park MI, Jung K, Park JK, Jung KW, Lim HC, Jung DH, Kim DH, Lim CH, Moon HS, Park JH, Choi SC, Suzuki H, Patcharatrakul T, Wu JCY, Lee KJ, Tanaka S, Siah KTH, Park KS, Kim SE. 2019 Seoul Consensus on Esophageal Achalasia Guidelines. J Neurogastroenterol Motil 2020; 26:180-203. [PMID: 32235027 PMCID: PMC7176504 DOI: 10.5056/jnm20014] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/08/2020] [Indexed: 12/13/2022] Open
Abstract
Esophageal achalasia is a primary motility disorder characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. Achalasia is a chronic disease that causes progressive irreversible loss of esophageal motor function. The recent development of high-resolution manometry has facilitated the diagnosis of achalasia, and determining the achalasia subtypes based on high-resolution manometry can be important when deciding on treatment methods. Peroral endoscopic myotomy is less invasive than surgery with comparable efficacy. The present guidelines (the "2019 Seoul Consensus on Esophageal Achalasia Guidelines") were developed based on evidence-based medicine; the Asian Neurogastroenterology and Motility Association and Korean Society of Neurogastroenterology and Motility served as the operating and development committees, respectively. The development of the guidelines began in June 2018, and a draft consensus based on the Delphi process was achieved in April 2019. The guidelines consist of 18 recommendations: 2 pertaining to the definition and epidemiology of achalasia, 6 pertaining to diagnoses, and 10 pertaining to treatments. The endoscopic treatment section is based on the latest evidence from meta-analyses. Clinicians (including gastroenterologists, upper gastrointestinal tract surgeons, general physicians, nurses, and other hospital workers) and patients could use these guidelines to make an informed decision on the management of achalasia.
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Affiliation(s)
- Hye-Kyung Jung
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Su Jin Hong
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Oh Young Lee
- Department of Internal Medicine, Hanyang University Hospital, Hanyang University College of Medicine, Seoul, Korea
| | - John Pandolfino
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Hyojin Park
- Division of Gastroenterology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hiroto Miwa
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Mukogawa-cho, Nishinomiya, Hyogo, Japan
| | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sanjiv Mahadeva
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Tadayuki Oshima
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Mukogawa-cho, Nishinomiya, Hyogo, Japan
| | - Minhu Chen
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | | | - Yu Kyung Cho
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Tae Hee Lee
- Department of Internal Medicine, College of Medicine, Soonchunhyang University Hospital, Seoul, Korea
| | - Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Joong Goo Kwon
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Kyoungwon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Jong Kyu Park
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Gangwon-do, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun Chul Lim
- Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Da Hyun Jung
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Hyun Lim
- Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hee Seok Moon
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jung Ho Park
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Suck Chei Choi
- Department of Internal Medicine and Digestive Disease Research Institute, Wonkwang University School of Medicine, Iksan, Korea
| | - Hidekazu Suzuki
- Department of Gastroenterology and Hepatology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Tanisa Patcharatrakul
- Department of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Justin C Y Wu
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong, China
| | - Kwang Jae Lee
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Gyeonggi-do, Korea
| | - Shinwa Tanaka
- Department of Gastroenterology, Kobe University Hospital, Hyogo, Japan
| | - Kewin T H Siah
- Division of Gastroenterology and Hepatology, National University Health System, Singapore City, Singapore
| | - Kyung Sik Park
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Sung Eun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
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Weche M, Saad AR, Richter JE, Jacobs JJ, Velanovich V. Revisional Procedures for Recurrent Symptoms After Heller Myotomy and Per-Oral Endoscopic Myotomy. J Laparoendosc Adv Surg Tech A 2020; 30:110-116. [DOI: 10.1089/lap.2019.0277] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- McWayne Weche
- Division of General Surgery, the University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Adham R. Saad
- Division of General Surgery, the University of South Florida Morsani College of Medicine, Tampa, Florida
- The Joy McCann Culverhouse Center for Swallowing Disorders, the University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Joel E. Richter
- The Joy McCann Culverhouse Center for Swallowing Disorders, the University of South Florida Morsani College of Medicine, Tampa, Florida
- Division of Gastroenterology, the University of South Florida Morsani College of Medicine, Tampa, Florida
| | - John J. Jacobs
- The Joy McCann Culverhouse Center for Swallowing Disorders, the University of South Florida Morsani College of Medicine, Tampa, Florida
- Division of Gastroenterology, the University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Vic Velanovich
- Division of General Surgery, the University of South Florida Morsani College of Medicine, Tampa, Florida
- The Joy McCann Culverhouse Center for Swallowing Disorders, the University of South Florida Morsani College of Medicine, Tampa, Florida
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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.
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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
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