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Chong Tai LI, Akil O, Nguyen KQ, Sharma A. End-Stage Achalasia With Megaesophagus Refractory to Two Heller Myotomies. Cureus 2024; 16:e55721. [PMID: 38586803 PMCID: PMC10998642 DOI: 10.7759/cureus.55721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 04/09/2024] Open
Abstract
Achalasia is a motility disorder of the esophagus in which the lower esophageal sphincter fails to relax. Megaesophagus is a rare complication of achalasia characterized by severe dilatation of the esophagus, often indicative of end-stage achalasia. Typical presenting symptoms include dysphagia, nausea, vomiting, weight loss, and chest pain. The majority of patients with achalasia typically have excellent outcomes after surgical intervention with Heller myotomy. We discuss an interesting case of unsuccessful surgical intervention and hypothesize the reason for its failure in our patient.
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Affiliation(s)
| | - Omar Akil
- Internal Medicine, Broward Health Medical Center, Fort Lauderdale, USA
| | - Kimberly Q Nguyen
- Internal Medicine, Broward Health Medical Center, Fort Lauderdale, USA
| | - Aryama Sharma
- Gastroenterology, Broward Health North, Deerfield Beach, USA
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Mittal S, Kumar A, Gunjan D, Netam RK, Anil AK, Suhani S, Joshi M, Bhattacharjee HK, Sharma R, Parshad R. Long-term outcomes of laparoscopic Heller's myotomy with angle of His accentuation in patients of achalasia cardia. Surg Endosc 2024; 38:659-670. [PMID: 38012444 DOI: 10.1007/s00464-023-10571-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/22/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Laparoscopic Heller's myotomy (LHM) is an established treatment for achalasia cardia. Anti-reflux procedures (ARP) are recommended with LHM to reduce the post-operative reflux though the optimal anti-reflux procedure is still debatable. This study reports on the long-term outcomes of LHM with Angle-of-His accentuation (AOH) in patients of achalasia cardia. METHODS One hundred thirty-six patients of achalasia cardia undergoing LHM with AOH between January 2010 to October 2021 with a minimum follow-up of one year were evaluated for symptomatic outcomes using Eckardt score (ES), DeMeester heartburn (DMH) score and achalasia disease specific quality of life (A-DsQoL) questionnaire. Upper gastrointestinal endoscopy, high resolution manometry (HRM) and timed barium esophagogram (TBE) were performed when feasible and rates of esophagitis and improvement in HRM and TBE parameters evaluated. Time dependent rates of success were calculated with respect to improvement in ES and dysphagia-, regurgitation- and heartburn-free survival using Kaplan-Meier analysis. RESULTS At a median follow-up of 65.5 months, the overall success (ES ≤ 3) was 94.1%. There was statistically significant improvement in ES, heartburn score and A-DsQoL score (p < 0.00001, p = 0.002 and p < 0.00001). Significant heartburn (score ≥ 2) was seen in 12.5% subjects with 9.5% patients reporting frequent PPI use (> 3 days per week). LA-B and above esophagitis was seen in 12.7%. HRM and TBE parameters also showed a significant improvement as compared to pre-operative values (IRP: p < 0.0001, column height: p < 0.0001, column width: p = 0.0002). Kaplan-Meier analysis showed dysphagia, regurgitation, and heartburn free survival of 75%, 96.2% and 72.3% respectively at 10 years. CONCLUSIONS LHM with AOH gives a lasting relief of symptoms in patients of achalasia cardia with heartburn rates similar to that reported in studies using Dor's or Toupet's fundoplication with LHM. Hence, LHM with AOH may be a preferred choice in patients of achalasia cardia given the simplicity of the procedure.
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Affiliation(s)
- Sonali Mittal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Aditya Kumar
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Ritesh Kumar Netam
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Abhijith K Anil
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Suhani Suhani
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Mohit Joshi
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Hemanga K Bhattacharjee
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Sharma
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Rajinder Parshad
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 419, 4th Floor, Surgery Block, New Delhi, 110029, India.
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Chauhan V, Nekarakanti PK, Balachandra D, Choudhary D, Sachdeva S, Nag HH. The outcome of 100 patients with achalasia cardia following laparoscopic Heller myotomy with blunt dissection technique. J Minim Access Surg 2023; 19:408-413. [PMID: 37282436 PMCID: PMC10449042 DOI: 10.4103/jmas.jmas_273_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/08/2022] [Indexed: 06/08/2023] Open
Abstract
Background Laparoscopic Heller myotomy (LHM) can be performed by blunt dissection technique (BDT). Only a few studies have assessed long-term outcomes and relief of dysphagia following LHM. The study reviews our long-term experience following LHM by BDT. Methods This retrospective study was analysed from a prospectively maintained database (from 2013 to 2021) of a single unit of the Department of Gastrointestinal Surgery at G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi. The myotomy was performed by BDT in all patients. A fundoplication was added in selected patients. Post-operative Eckardt score >3 was considered treatment failure. Results A total of 100 patients underwent surgery during the study period. Of them, 66 patients underwent LHM, 27 underwent LHM with Dor fundoplication and 7 underwent LHM with Toupet fundoplication. The median length of myotomy was 7 cm. The mean operative time was 77 ± 29.27 min and the mean blood loss of 28.05 ± 16.06 ml. Five patients had intraoperative oesophageal perforation. The median length of hospital stay was 2 days. There was no hospital mortality. The post-operative integrated relaxation pressure (IRP) was significantly lower than the mean pre-operative IRP (9.78 vs. 24.77). Eleven patients developed treatment failure, of which ten patients presented with recurrence of dysphagia. There was no difference in symptom-free survival amongst various types of achalasia cardia (P = 0.816). Conclusion LHM performed by BDT has a 90% success rate. Complication using this technique is rare, and recurrence post-surgery can be managed with endoscopic dilatation.
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Affiliation(s)
- Vivek Chauhan
- Department of Gastrointestinal Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Phani Kumar Nekarakanti
- Department of Gastrointestinal Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Deepak Balachandra
- Department of Gastrointestinal Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Devendra Choudhary
- Department of Gastrointestinal Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Sanjeev Sachdeva
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Hirdaya Hulas Nag
- Department of Gastrointestinal Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
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Rasmussen M, Ward MA, Aladegbami B, Ogola GO, Leeds SG. Probability of additional intervention and long-term follow-up of esophagomyotomy. Surg Endosc 2023; 37:2347-2353. [PMID: 36656408 DOI: 10.1007/s00464-023-09872-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 01/04/2023] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Two common surgical procedures used to treat esophageal motility disorders are laparoscopic Heller myotomy (LHM) with partial fundoplication and per-oral endoscopic myotomy (POEM). The difference in frequency of follow-up interventions following these procedures is unknown. This study was designed to report differences in post-surgical interventions as one of the major long-term follow-up expectations. METHODS An IRB approved registry was used to identify all patients undergoing surgery with LHM or POEM. Following surgery, patients requiring additional interventions with esophageal non-pneumatic dilation, botox injection, or repeat myotomy, as well as persistent proton pump inhibitor (PPI) use were recorded. Multivariable logistic regression analysis was performed to estimate risk factors associated with return for additional post-operative intervention. RESULTS A total of 203 patients were identified, 139 met inclusion criteria (33 LHM and 106 POEM). There was a higher rate of non-pneumatic EGD dilation (33% vs 15%, p = 0.04), repeat myotomy (18% vs 2%, p < 0.01), and higher rate of overall post-operative intervention in LHM than POEM. With POEM, there was a higher rate of post-operative PPI use (63 vs 29%, p < 0.01). There was no difference in time to post-operative intervention for either group, but if intervention were to occur the median time was within the first year. Patients with a change in pre- to post-operative Eckardt score of 4 or greater decreased their chance of having a post-operative intervention. CONCLUSION Our results for both LHM and POEM emphasize the importance of long-term follow-up in patients with an esophageal motility disorder. We have found that patients undergoing LHM are more likely to have a post-operative intervention as well as a higher rate of repeat myotomy than POEM. With both interventions, a greater change in Eckardt score decreased the likelihood of reintervention.
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Affiliation(s)
- Madeline Rasmussen
- Division of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA.,Center for Advanced Surgery, Baylor Scott & White Health, 3417 Gaston Avenue, Suite 965, Dallas, TX, 75246, USA
| | - Marc A Ward
- Division of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA.,Center for Advanced Surgery, Baylor Scott & White Health, 3417 Gaston Avenue, Suite 965, Dallas, TX, 75246, USA
| | - Bola Aladegbami
- Division of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA.,Center for Advanced Surgery, Baylor Scott & White Health, 3417 Gaston Avenue, Suite 965, Dallas, TX, 75246, USA
| | - Gerald O Ogola
- Research Institute, Baylor Scott & White Health, Dallas, TX, USA
| | - Steven G Leeds
- Division of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA. .,Center for Advanced Surgery, Baylor Scott & White Health, 3417 Gaston Avenue, Suite 965, Dallas, TX, 75246, USA.
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Sanaka MR, Garg R, Chadalavada P, Thota PN, Gabbard S, Parikh MP, Khoudari G, Murthy S, Raja S. Peroral Endoscopic Myotomy Is Safe and Highly Effective Treatment for Advanced Achalasia With Sigmoid Esophagus. J Clin Gastroenterol 2021; 55:505-511. [PMID: 32649445 DOI: 10.1097/mcg.0000000000001388] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/02/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS In advanced achalasia patients with sigmoid esophagus, peroral endoscopic myotomy (POEM) might be technically challenging and its outcomes are not well known in western population. Hence, our study aims were to assess and compare the safety and efficacy of POEM in achalasia patients with and without sigmoid esophagus. MATERIALS AND METHODS Medical records of achalasia patients who had POEM at our institution between April 2014 and December 2019 were reviewed. Patients who underwent work-up comprising timed barium esophagram (TBE) and high-resolution esophageal manometry (HREM) before POEM along with 2-month post-POEM esophageal pH study, TBE and HREM were included in the final analysis. Patients were categorized as either sigmoid or no sigmoid esophagus based on the morphology of esophagus on TBE as per Japan Esophageal Society guidelines. Treatment success was defined as reduction of post-POEM Eckardt score to ≤3. RESULTS A total of 168 patients (sigmoid esophagus=20; no sigmoid esophagus=148) were included. Esophageal width on TBE at 1 minute was significantly higher in sigmoid esophagus group compared with no sigmoid esophagus group (4.9 vs. 3.0 cm, P<0.001). Procedural outcomes and complications were similar in both groups. At 2-month follow-up, both groups had significant improvement in Eckardt scores, TBE, and HREM parameters. Treatment success was high and similar in both sigmoid and no sigmoid groups (94.4% vs. 93.2%, P=0.84). The rates of gastroesophageal reflux disease were also similar in both groups. CONCLUSIONS Our study findings suggest that POEM is safe and highly effective treatment for achalasia patients with sigmoid esophagus similar to those without sigmoid esophagus in western population. POEM should be considered as the treatment of choice in advanced achalasia with sigmoid esophagus.
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Affiliation(s)
| | | | | | | | | | | | | | - Sudish Murthy
- Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH
| | - Siva Raja
- Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH
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Ieong K, Brown A, Yang J, Zhang X, Altieri MS, Spaniolas K, Pryor AD. The incidence of reintervention and reoperation following Heller myotomy across multiple indications. Surg Endosc 2021; 36:1619-1626. [PMID: 33733323 DOI: 10.1007/s00464-021-08357-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 02/04/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Achalasia is a debilitating primary esophageal motility disorder. Heller myotomy (HM) is a first-line therapy for the treatment of achalasia patients who have failed other modalities. Other indications for HM include diverticulum, diffuse esophageal spasm, and esophageal strictures. However, long-term outcomes of HM are unclear. This study aims to assess incidence of reintervention, either endoscopically or through minimally invasive or resectional procedures, in patients who underwent HM in New York State. METHODS The Statewide Planning and Research Cooperative System (SPARCS) administrative longitudinal database identified 1817 adult patients who underwent HM between 2000 and 2008 for achalasia, esophageal diverticulum, diffuse esophageal spasm, and esophageal strictures, based on ICD-9 and CPT codes. Through the use of unique identifiers, patients requiring reintervention were tracked up to 2016 (for at least 8 years follow-up). Primary outcome was incidence of subsequent procedures following HM. Secondary outcomes were time to reintervention and risk factors for reintervention. RESULTS Of the 1817 patients who underwent HM, 320 (17.6%) required subsequent intervention. Of the 320 patients, 234 (73.1%) underwent endoscopic reinterventions, 54 (16.9%) underwent minimally invasive procedures, and 32 (10%) underwent resectional procedures as their initial revisional intervention. Of the 234 patients who underwent endoscopic reintervention as their initial revisional procedure, only 40 (16.8%) required subsequent surgical procedures. Over a mean follow-up of 7.0 years, the mean time to a subsequent procedure was 4.3 ± 3.74 years. Reintervention rates after 10 years following HM for achalasia, diverticulum ,and other indication were 24.4%, 12.6%, and 37%, respectively. CONCLUSION The majority of HM reinterventions were managed solely by endoscopic procedures (60.6%). Heller myotomy remains an excellent procedure to prevent surgical reintervention for achalasia and diverticulum.
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Affiliation(s)
- Kelly Ieong
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA.
| | - Andrew Brown
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
| | - Jie Yang
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
| | - Xiaoyue Zhang
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
| | - Maria S Altieri
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
| | - Konstantinos Spaniolas
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
| | - Aurora D Pryor
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
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Doubova M, Gowing S, Robaidi H, Gilbert S, Maziak DE, Shamji FM, Sundaresan RS, Villeneuve PJ, Seely AJE. Long-term Symptom Control After Laparoscopic Heller Myotomy and Dor Fundoplication for Achalasia. Ann Thorac Surg 2020; 111:1717-1723. [PMID: 32891651 DOI: 10.1016/j.athoracsur.2020.06.095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 06/03/2020] [Accepted: 06/23/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Achalasia is a primary esophageal motility disorder in which there is incomplete relaxation of the lower esophageal sphincter and absence of peristalsis in the lower two thirds of the esophagus. A favored treatment is laparoscopic modified Heller myotomy with Dor fundoplication (LHMDor) with more than 90% immediate beneficial effect. The short-term outcomes of LHMDor are well documented, but stability and durability of postoperative symptom control over time is less understood. METHODS Between 2004 and 2016, 54 patients with achalasia underwent LHMDor (single center). Using validated questionnaires, patients rated their symptoms in five domains: pain, gastroesophageal reflux disease (GERD), dysphagia, regurgitation, and quality of life. Symptom ratings were done preoperatively, 4 weeks postoperatively, 6 months postoperatively, and yearly after the operation. RESULTS As expected, patients reported marked improvement in dysphagia, odynophagia, regurgitation, GERD, and quality of life after the operation (P < .001). From then on, the symptom control remained durable with respect to absence of pain, regurgitation, and odynophagia; however, we observed a recurrence of GERD symptoms beginning 3 to 5 years postoperatively (P = .001 and P = .04, respectively), with associated increased antireflux medication use. After initial LHMDor, 5 patients required endoscopic dilatation an average of 1.5 years postoperatively, and no patient required reoperation. Patients reported preserved improved quality of life to 11 years after the operation (P = .001). CONCLUSIONS These results demonstrate the durability of LHMDor in the definitive management of achalasia, offering consistent symptomatic relief and significant improvement in quality of life over the decade after surgery, despite some increase in GERD symptoms and antireflux medication use.
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Affiliation(s)
- Maria Doubova
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Stephen Gowing
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Hassan Robaidi
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sebastien Gilbert
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Donna E Maziak
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Farid M Shamji
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - R Sudhir Sundaresan
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Patrick James Villeneuve
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Andrew J E Seely
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
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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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Outcomes of Laparoscopic Heller Myotomy for Achalasia: 22-Year Experience. J Gastrointest Surg 2020; 24:1411-1416. [PMID: 32300963 DOI: 10.1007/s11605-020-04586-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 03/25/2020] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Laparoscopic Heller Myotomy is the most effective treatment of achalasia. We examined the durability of symptomatic relief, with and without fundoplication. METHODS A single institution database between 1995 and 2017 was reviewed. Achalasia symptom severity was assessed by Eckardt scores (ES) obtained at 3-time points via patient questionnaire. Primary outcome was treatment success defined as ES of < 3. RESULTS Completed surveys were returned by 130 patients (median follow-up of 6.6 years). A partial fundoplication was performed in 86%. At both 1-year and late follow-up, patients reported a significant improvement in ES compared to baseline (p < 0.05). Of those followed for ≥ 10 years (n = 44), 82% reported ES < 3 at 1-year (p < 0.001), and 78% at last follow-up (p < .001). Of patients who reported treatment success 1-year postoperatively (103/130), 85% continued to report symptomatic relief at last follow-up. Five-year cohort analysis did not show deterioration of dysphagia relief over time. The presence or absence of fundoplication had no impact on long-term outcome (p > 0.05). CONCLUSIONS LHM provides immediate and durable symptomatic relief, with very few patients requiring further therapeutic intervention. Fundoplication does not appear to influence the durability of symptom relief. Treatment success at 1-year is predictive of long-lasting symptomatic relief.
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Khashab MA, Vela MF, Thosani N, Agrawal D, Buxbaum JL, Abbas Fehmi SM, Fishman DS, Gurudu SR, Jamil LH, Jue TL, Kannadath BS, Law JK, Lee JK, Naveed M, Qumseya BJ, Sawhney MS, Yang J, Wani S. ASGE guideline on the management of achalasia. Gastrointest Endosc 2020; 91:213-227.e6. [PMID: 31839408 DOI: 10.1016/j.gie.2019.04.231] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 04/22/2019] [Indexed: 12/11/2022]
Abstract
Achalasia is a primary esophageal motor disorder of unknown etiology characterized by degeneration of the myenteric plexus, which results in impaired relaxation of the esophagogastric junction (EGJ), along with the loss of organized peristalsis in the esophageal body. The criterion standard for diagnosing achalasia is high-resolution esophageal manometry showing incomplete relaxation of the EGJ coupled with the absence of organized peristalsis. Three achalasia subtypes have been defined based on high-resolution manometry findings in the esophageal body. Treatment of patients with achalasia has evolved in recent years with the introduction of peroral endoscopic myotomy. Other treatment options include botulinum toxin injection, pneumatic dilation, and Heller myotomy. This American Society for Gastrointestinal Endoscopy Standards of Practice Guideline provides evidence-based recommendations for the treatment of achalasia, based on an updated assessment of the individual and comparative effectiveness, adverse effects, and cost of the 4 aforementioned achalasia therapies.
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Affiliation(s)
- Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Marcelo F Vela
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Nirav Thosani
- Interventional Gastroenterologists of the University of Texas, Department of Internal Medicine, McGovern Medical School, Houston, Texas, USA
| | - Deepak Agrawal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Syed M Abbas Fehmi
- Division of Gastroenterology/Hepatology, University of California, San Diego, San Diego, California, USA
| | - Douglas S Fishman
- Section of Pediatric Gastroenterology, Baylor College of Medicine; Texas Children's Hospital, Houston, Texas, USA
| | | | - Laith H Jamil
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Terry L Jue
- The Permanente Medical Group, Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Bijun Sai Kannadath
- Interventional Gastroenterologists of the University of Texas, Department of Internal Medicine, McGovern Medical School, Houston, Texas, USA
| | - Joanna K Law
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Jeffrey K Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Mariam Naveed
- Division of Gastroenterology and Hepatology, University of Iowa Hospital & Clinics, Iowa City, Iowa, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, Archbold Medical Group, Thomasville, Georgia, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Julie Yang
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Costantini M, Salvador R, Valmasoni M. Comment on the Article: “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 2020. [DOI: 10.1177/000313482008600127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mario Costantini
- Center for Esophageal Disease Clinica Chirurgica 3 Padua University Hospital Padua, Italy
| | - Renato Salvador
- Center for Esophageal Disease Clinica Chirurgica 3 Padua University Hospital Padua, Italy
| | - Michele Valmasoni
- Center for Esophageal Disease Clinica Chirurgica 3 Padua University Hospital Padua, Italy
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Yu YR, Rosenfeld EH, Chiou EH, Chumpitazi BP, Fallon SC, Brandt ML. High-resolution manometric guidance during laparoscopic Heller myotomy: Impact on quality of life and symptom severity for children with achalasia. J Pediatr Surg 2019; 54:1063-1068. [PMID: 30808541 DOI: 10.1016/j.jpedsurg.2019.01.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 01/27/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND High-resolution esophageal manometry (HREM) during laparoscopic Heller myotomy (LHM) with fundoplication for achalasia allows tailoring of myotomy length and wrap tightness. The purpose of this study is to quantify long-term postoperative symptom severity and quality of life using validated questionnaires. METHODS Children ≤18 years with achalasia who previously underwent LHM with intraoperative HREM from 2010 to 2017 were prospectively surveyed. Eckardt Symptom Score (ESS), Achalasia Severity Questionnaire (ASQ), Pediatric Quality of Life Inventory (PedsQL), and Pediatric GERD Symptom and Quality of Life (PGSQ) questionnaires were administered. Scores for historical controls were obtained from prior survey instrument validation studies as comparison. RESULTS Of 30 eligible patients, 12 (40%) completed the surveys. Mean age at time of surgery was 13 ± 3 years. Assessment was performed at least 10 months after surgery with mean time elapsed of 3.6 ± 2 years. Average premyotomy lower esophageal sphincter (LES) pressure, postmyotomy LES pressure, and postfundoplication LES pressure were 30 ± 10 mmHg, 14 ± 6 mmHg, and 18 ± 9, respectively. ESS (2.3/12), ASQ (39/100 ± 16), PGSQ (symptom: 0.6/4 ± 0.4, school: 0.4/4 ± 0.4), and overall PedsQL (82/100 ± 15) were similar to those of healthy historical controls. CONCLUSION Children with achalasia undergoing LHM with intraoperative HREM had sustained long-term symptom improvement and quality of life scores comparable to healthy patients. STUDY AND LEVEL OF EVIDENCE Retrospective, II.
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Affiliation(s)
- Yangyang R Yu
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Eric H Rosenfeld
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Eric H Chiou
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Bruno P Chumpitazi
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Sara C Fallon
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Mary L Brandt
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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Reintervention After Heller Myotomy for Achalasia: Is It Inevitable? Ann Thorac Surg 2019; 107:860-867. [DOI: 10.1016/j.athoracsur.2018.09.059] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 09/10/2018] [Accepted: 09/24/2018] [Indexed: 01/11/2023]
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14
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Evensen H, Kristensen V, Larssen L, Sandstad O, Hauge T, Medhus AW. Outcome of peroral endoscopic myotomy (POEM) in treatment-naive patients. A systematic review. Scand J Gastroenterol 2019; 54:1-7. [PMID: 30650313 DOI: 10.1080/00365521.2018.1549271] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Achalasia is a primary motility disorder of the esophagus characterized by aperistalsis and failure of lower esophageal sphincter (LES) relaxation. Treatment of achalasia aims at reducing LES pressure. The common treatment modalities are laparoscopic Heller myotomy and pneumatic dilatation, but during the last decade, a promising treatment, per oral endoscopic myotomy (POEM), has been introduced. The aim of the present study was to perform a systematic review of the literature to assess the outcome of POEM in treatment-naive patients. MATERIALS AND METHODS A systematic literature search in PubMed, Embase and Cochrane databases was performed using the terms 'Achalasia AND (POEM OR peroral endoscopic myotomy OR per-oral endoscopic myotomy)'. Inclusion criteria were: original article; English language; n ≥ 20 with ≥90% treatment-naive patients; follow-up ≥3 months; and outcome evaluation of POEM including symptom score and objective tests. Exclusion criteria were: reviews and meta-analyses; pediatric data; duplicates; and articles with overlapping data material. RESULTS Of the 1641 articles identified, seven were included. The included studies all reported a short-term clinical success of >90%. Clinical success including post-POEM reflux was mainly estimated by symptom scorings. There were few procedure-related complications. CONCLUSIONS The studies of treatment-naive patients indicate a high rate of clinical success. Nevertheless, a more systematic and standardized evaluation is recommended to improve the reports on outcome of POEM. The follow-up rate should be high and the evaluation protocol should include both symptom scoring and objective testing with predefined treatment goals.
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Affiliation(s)
- Helge Evensen
- a Department of Gastroenterology , Oslo University Hospital.,b Faculty of Medicine , University of Oslo
| | | | - Lene Larssen
- a Department of Gastroenterology , Oslo University Hospital
| | - Olav Sandstad
- a Department of Gastroenterology , Oslo University Hospital
| | - Truls Hauge
- a Department of Gastroenterology , Oslo University Hospital.,b Faculty of Medicine , University of Oslo
| | - Asle W Medhus
- a Department of Gastroenterology , Oslo University Hospital
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15
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Costantini M, Salvador R, Capovilla G, Vallese L, Costantini A, Nicoletti L, Briscolini D, Valmasoni M, Merigliano S. A Thousand and One Laparoscopic Heller Myotomies for Esophageal Achalasia: a 25-Year Experience at a Single Tertiary Center. J Gastrointest Surg 2019; 23:23-35. [PMID: 30238248 DOI: 10.1007/s11605-018-3956-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 08/28/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The aim of this study was to assess the long-term outcome of laparoscopic Heller-Dor (LHD) myotomy to treat achalasia at a single high-volume institution in the past 25 years. METHODS Patients undergoing LHD from 1992 to 2017 were prospectively registered in a dedicated database. Those who had already undergone surgical or endoscopic myotomy were ruled out. Symptoms were collected and scored using a detailed questionnaire; barium swallow, endoscopy, and manometry were performed before and after surgery; and 24-h pH monitoring was done 6 months after LHD. RESULTS One thousand one patients underwent LHD (M:F = 536:465), performed by six staff surgeons. The surgical procedure was completed laparoscopically in all but 8 patients (0.8%). At a median of follow-up of 62 months, the outcome was positive in 896 patients (89.5%), and the probability of being cured from symptoms at 20 years exceeded 80%. Among the patients who had previously received other treatments, there were 25/182 failures (13.7%), while the failures in the primary treatment group were 80/819 (9.8%) (p = 0.19). All 105 patients whose LHD failed subsequently underwent endoscopic pneumatic dilations with an overall success rate of 98.4%. At univariate analysis, the manometric pattern (p < 0.001), the presence of a sigmoid megaesophagus (p = 0.03), and chest pain (p < 0.001) were the factors that predicted a poor outcome. At multivariate analysis, all three factors were independently associated with a poor outcome. Post-operative 24-h pH monitoring was abnormal in 55/615 patients (9.1%). CONCLUSIONS LHD can durably relieve achalasia symptoms in more than 80% of patients. The pre-operative manometric pattern, the presence of a sigmoid esophagus, and chest pain represent the strongest predictors of outcome.
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Affiliation(s)
- Mario Costantini
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università ed Azienda Ospedaliera di Padova, 2, via Giustiniani, 35128, Padua, Italy.
| | - Renato Salvador
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università ed Azienda Ospedaliera di Padova, 2, via Giustiniani, 35128, Padua, Italy
| | - Giovanni Capovilla
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università ed Azienda Ospedaliera di Padova, 2, via Giustiniani, 35128, Padua, Italy
| | - Lorenzo Vallese
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università ed Azienda Ospedaliera di Padova, 2, via Giustiniani, 35128, Padua, Italy
| | | | - Loredana Nicoletti
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università ed Azienda Ospedaliera di Padova, 2, via Giustiniani, 35128, Padua, Italy
| | - Dario Briscolini
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università ed Azienda Ospedaliera di Padova, 2, via Giustiniani, 35128, Padua, Italy
| | - Michele Valmasoni
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università ed Azienda Ospedaliera di Padova, 2, via Giustiniani, 35128, Padua, Italy
| | - Stefano Merigliano
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università ed Azienda Ospedaliera di Padova, 2, via Giustiniani, 35128, Padua, Italy
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16
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Duan T, Tan Y, Zhou J, Lv L, Liu D. A Retrospective Study of Peroral Endoscopic Full-Thickness Myotomy in Patients with Severe Achalasia. J Laparoendosc Adv Surg Tech A 2017; 27:770-776. [PMID: 28557560 DOI: 10.1089/lap.2016.0445] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Selective circular myotomy (CM) is recommended in peroral endoscopic myotomy (POEM) for achalasia, but completeness of myotmoy is the prerequisite for excellent long-term results of conventional surgical myotomy. The aim of our study was to compare the efficacy and safety between peroral endoscopic full-thickness and simple CM for the treatment of severe achalasia. MATERIALS AND METHODS A total of 123 severe achalasia patients who underwent POEM from August 2011 to May 2013 were included. They were divided into circular or full-thickness myotomy (FTM) groups according to the depth of myotomy. Demographics, Eckardt score, procedure-related parameters, perioperative adverse events, pre- and postoperative esophageal diameter, esophageal manometry, and follow-up results were retrospectively collected and compared between the two groups. RESULTS All the 123 patients underwent POEM successfully, and the mean operation time was significantly shorter in FTM group compared with CM group (57.4 ± 8.2 minutes versus 63.2 ± 12.3 minutes, P < .05). There was no significant difference between the two groups in terms of treatment success, pre- and postoperative Eckardt score, esophageal diameter, esophageal manometry, and perioperative adverse events (P > .05). Twenty-four-hour pH monitoring was performed in 19 patients (11 in FTM, 8 in CM). Although no statistical difference was detected in rate of abnormal esophageal acid exposure between groups, this rate was higher in FTM group than CM group (60% versus 40%, P > .05). CONCLUSION Treatment efficacy in short-to-medium term are comparable between circular or FTM. FTM significantly reduce the operative duration, but it may increase potential risk of gastroesophageal reflux disease incidence.
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Affiliation(s)
- Tianying Duan
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University , Changsha, China
| | - Yuyong Tan
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University , Changsha, China
| | - Junfeng Zhou
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University , Changsha, China
| | - Liang Lv
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University , Changsha, China
| | - Deliang Liu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University , Changsha, China
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Asti E, Sironi A, Lovece A, Bonavina G, Fanelli M, Bonitta G, Bonavina L. Health-related quality of life after laparoscopic Heller myotomy and Dor fundoplication for achalasia. Surgery 2017; 161:977-983. [DOI: 10.1016/j.surg.2016.10.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 10/13/2016] [Accepted: 10/20/2016] [Indexed: 01/21/2023]
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18
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Gray RT, Coleman HG, Lau KW, McCaughey C, Coyle PV, Murray LJ, Johnston BT. Heller's myotomy and pneumatic dilatation in the treatment of achalasia: a population-based case-control study assessing long-term quality of life. Dis Esophagus 2017; 30:1-7. [PMID: 26541271 PMCID: PMC6036654 DOI: 10.1111/dote.12445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Long-term health-related quality-of-life (HRQL) outcomes have not been widely reported in the treatment of achalasia. The aims of this study were to examine long-term disease-specific and general HRQL in achalasia patients using a population-based case-control method, and to assess HRQL between treatment interventions. Manometrically diagnosed achalasia cases (n = 120) were identified and matched with controls (n = 115) using a population-based approach. Participants completed general (SF-12) and disease-specific (Achalasia Severity Questionnaire [ASQ]) HRQL questionnaires, as appropriate, in a structured interview. Mean composite scores for SF-12 (Mental Component Summary score [MCS-12] and Physical Component Summary score [PCS-12]) and ASQ were compared between cases and controls, or between intervention groups, using an independent t-test. Adjusted mean differences in HRQL scores were evaluated using a linear regression model. Achalasia cases were treated with a Heller's myotomy (n = 43), pneumatic dilatation (n = 44), or both modalities (n = 33). The median time from last treatment to HRQL assessment was 5.7 years (interquartile range 2.4-11.5). Comparing achalasia patients with controls, PCS-12 was significantly worse (40.9 vs. 44.2, P = 0.01), but MCS-12 was similar. However, both PCS-12 (39.9 vs. 44.2, P = 0.03) and MCS-12 (46.7 vs. 53.5, P = 0.004) were significantly impaired in those requiring dual treatment compared with controls. Overall however, there was no difference in adjusted HRQL between patients treated with Heller's myotomy, pneumatic dilatation or both treatment modalities. In summary, despite treatment achalasia patients have significantly worse long-term physical HRQL compared with population controls. No HRQL differences were observed between the treatment modalities to suggest a benefit of one treatment over another.
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Affiliation(s)
- R T Gray
- Cancer Epidemiology and Health Services Research Group, Centre for Public Health, Queen's University Belfast, Northern Ireland, UK
| | - H G Coleman
- Cancer Epidemiology and Health Services Research Group, Centre for Public Health, Queen's University Belfast, Northern Ireland, UK
| | - K W Lau
- Cancer Epidemiology and Health Services Research Group, Centre for Public Health, Queen's University Belfast, Northern Ireland, UK
| | - C McCaughey
- Regional Virus Laboratory, Kelvin Building, Belfast Health and Social Care Trust, Royal Victoria Hospital, Belfast, Northern Ireland, UK
| | - P V Coyle
- Regional Virus Laboratory, Kelvin Building, Belfast Health and Social Care Trust, Royal Victoria Hospital, Belfast, Northern Ireland, UK
| | - L J Murray
- Cancer Epidemiology and Health Services Research Group, Centre for Public Health, Queen's University Belfast, Northern Ireland, UK
| | - B T Johnston
- Department of Gastroenterology, Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
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19
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Sawas T, Ravi K, Geno DM, Enders F, Pierce K, Wigle D, Katzka DA. The course of achalasia one to four decades after initial treatment. Aliment Pharmacol Ther 2017; 45:553-560. [PMID: 27925255 DOI: 10.1111/apt.13888] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 10/16/2016] [Accepted: 11/15/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Most follow-up studies of achalasia are limited to <5 years. AIM To study the long-term efficacy of pneumatic dilation (PD) and myotomy in achalasia at least 10 years after treatment. METHODS We performed a retrospective cohort study of achalasia patients with >10 years follow-up after initial myotomy or pneumatic dilation. Symptom recurrence which required repeat dilation or surgery was compared between pneumatic dilation and myotomy. RESULTS One hundred and fifty patients (112 myotomy, 38 pneumatic dilation) of similar characteristics were studied. The mean duration of follow-up after initial treatment was 17.5 ± 7.2 years (10-40 years). Symptoms recurrence rate was 60.7% (100% pneumatic dilation patients vs. 47.3% myotomy), hazard ratio 0.24 demonstrating a lower need for repeat dilation or surgery with myotomy than pneumatic dilation (P = 0.008). All pneumatic dilation patients underwent myotomy in 4 ± 4 (0-16 years). Forty of 53 myotomy patients had symptom recurrence prompting further treatment: 16 pneumatic dilation, 11 myotomy and 13 both. The mean time to repeat procedure was 6.9 years (0-40). The myotomy group required fewer dilations and/or surgeries than the pneumatic dilation group (1.6 vs. 3.6, P < 0.001). 13 patients (10.1%) progressed to end-stage achalasia (five myotomy, eight pneumatic dilation) over 40 years. At last follow-up, 57/62 (92%) patients had absent or mild dysphagia, 53/62 (85%) patients had regurgitation less than once per week and 37 (60.7%) had heartburn episodes <1/week similar for pneumatic dilation and myotomy (P = 0.27). CONCLUSION Although the majority of patients treated for achalasia do well after decades of treatment, most patients may need a series of endoscopic and/or surgical procedures to maintain effective symptom control.
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Affiliation(s)
- T Sawas
- Division of Gastroenterology and Hepatology, Department of Surgery and Department of Population Studies and Biostatistics, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - K Ravi
- Division of Gastroenterology and Hepatology, Department of Surgery and Department of Population Studies and Biostatistics, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - D M Geno
- Division of Gastroenterology and Hepatology, Department of Surgery and Department of Population Studies and Biostatistics, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - F Enders
- Division of Gastroenterology and Hepatology, Department of Surgery and Department of Population Studies and Biostatistics, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - K Pierce
- Division of Gastroenterology and Hepatology, Department of Surgery and Department of Population Studies and Biostatistics, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - D Wigle
- Division of Gastroenterology and Hepatology, Department of Surgery and Department of Population Studies and Biostatistics, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - D A Katzka
- Division of Gastroenterology and Hepatology, Department of Surgery and Department of Population Studies and Biostatistics, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Vaezi MF, Felix VN, Penagini R, Mauro A, de Moura EGH, Pu LZCT, Martínek J, Rieder E. Achalasia: from diagnosis to management. Ann N Y Acad Sci 2016; 1381:34-44. [DOI: 10.1111/nyas.13176] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/09/2016] [Accepted: 06/14/2016] [Indexed: 12/16/2022]
Affiliation(s)
- Michael F. Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Center for Swallowing and Esophageal Disorders; Vanderbilt University Medical Center; Nashville Tennessee
| | - Valter N. Felix
- FMUSP and Nucleus of General and Specialized Surgery; Sao Paulo Brazil
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, and Department of Pathophysiology and Transplantation, Università degli Studi; Milan Italy
| | - Aurelio Mauro
- Gastroenterology and Endoscopy Unit; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, and Department of Pathophysiology and Transplantation, Università degli Studi; Milan Italy
| | - Eduardo Guimarães Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Department of Gastrointestinal Surgery; Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo; São Paulo Brazil
| | - Leonardo Zorrón Cheng Tao Pu
- Gastrointestinal Endoscopy Unit, Department of Gastrointestinal Surgery; Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo; São Paulo Brazil
| | - Jan Martínek
- Department of Hepatogastroenterology; IKEM; Prague Czech Republic
| | - Erwin Rieder
- Department of Surgery; Medical University of Vienna; Vienna Austria
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Abstract
Achalasia is a primary esophageal motility disorder with an estimated annual incidence of 1 per 100,000 persons. It is characterized by the absence of esophageal peristalsis and failure of the lower esophageal sphincter (LES) to relax upon swallowing, resulting in progressively severe dysphagia for solids and liquids, regurgitation, aspiration, chest pain and weight loss. Achalasia results from a loss of enteric neurons, most likely due to an autoimmune reaction in patients with a particular immunogenetic background. To date, 3 manometric subtypes have been identified based on high resolution manometry. To what extent these subtypes also indicate differences in underlying pathophysiological mechanisms is however unclear. As achalasia cannot be cured, treatment is confined to disruption of the LES to improve bolus passage and thereby relieving symptoms. The 2 most commonly used treatment modalities available for this purpose include pneumodilation and laparoscopic Heller myotomy. Both treatments have been shown repeatedly to be successful; however, success rates decline in time, most likely due to progression of the disease. A recent European randomized trial provides objective data indicating that both treatments are equally effective. In view of these data and the low incidence of the disease, the choice between these 2 treatments should be based on the expertise and experience available. Recently, excellent short-term success rates have been reported with a new endoscopic technique, that is, peroral endoscopic myotomy. However, longer follow-up data are absolutely needed before accepting this technique as a new treatment option for achalasia in clinical practice.
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Affiliation(s)
- Guy E Boeckxstaens
- Division of Gastroenterology and Hepatology, University Hospital Leuven, Translational Research Centre for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
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22
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Moonen A, Annese V, Belmans A, Bredenoord AJ, Bruley des Varannes S, Costantini M, Dousset B, Elizalde JI, Fumagalli U, Gaudric M, Merla A, Smout AJ, Tack J, Zaninotto G, Busch OR, Boeckxstaens GE. Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut 2016; 65:732-9. [PMID: 26614104 DOI: 10.1136/gutjnl-2015-310602] [Citation(s) in RCA: 229] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 11/01/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Achalasia is a chronic motility disorder of the oesophagus for which laparoscopic Heller myotomy (LHM) and endoscopic pneumodilation (PD) are the most commonly used treatments. However, prospective data comparing their long-term efficacy is lacking. DESIGN 201 newly diagnosed patients with achalasia were randomly assigned to PD (n=96) or LHM (n=105). Before randomisation, symptoms were assessed using the Eckardt score, functional test were performed and quality of life was assessed. The primary outcome was therapeutic success (presence of Eckardt score ≤3) at the yearly follow-up assessment. The secondary outcomes included the need for re-treatment, lower oesophageal sphincter pressure, oesophageal emptying and the rate of complications. RESULTS In the full analysis set, there was no significant difference in success rate between the two treatments with 84% and 82% success after 5 years for LHM and PD, respectively (p=0.92, log-rank test). Similar results were obtained in the per-protocol analysis (5-year success rates: 82% for LHM vs. 91% for PD, p=0.08, log-rank test). After 5 years, no differences in secondary outcome parameter were observed. Redilation was performed in 24 (25%) of PD patients. Five oesophageal perforations occurred during PD (5%) while 12 mucosal tears (11%) occurred during LHM. CONCLUSIONS After at least 5 years of follow-up, PD and LHM have a comparable success rate with no differences in oesophageal function and emptying. However, 25% of PD patients require redilation during follow-up. Based on these data, we conclude that either treatment can be proposed as initial treatment for achalasia. TRIAL REGISTRATION NUMBERS Netherlands trial register (NTR37) and Current Controlled Trials registry (ISRCTN56304564).
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Affiliation(s)
- An Moonen
- Department of Gastroenterology, Catholic University of Leuven, Leuven, Belgium
| | - Vito Annese
- Head of Gastroenterology, Department of Emergency, AOU Careggi, Florence, Italy
| | - Ann Belmans
- Interuniversity Centre for Biostatistics and Statistical Bioinformatics, KU, Leuven, Belgium
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Mario Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Bertrand Dousset
- Department of GI and Endocrine Surgery, Hôpital Cochin, Paris, France
| | - J I Elizalde
- Department of Gastroenterology, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Uberto Fumagalli
- Upper GI Surgery, Humanitas Clinical and Research Hospital, Rozzano, Italy
| | | | - Antonio Merla
- Division of Gastroenterology, IRCCS, "Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Andre J Smout
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jan Tack
- Department of Gastroenterology, Catholic University of Leuven, Leuven, Belgium
| | - Giovanni Zaninotto
- Department of Academic Surgery, St Mary's Hospital, Imperial College, London, UK
| | - Olivier R Busch
- Gastrointestinal Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Guy E Boeckxstaens
- Department of Gastroenterology, Catholic University of Leuven, Leuven, Belgium
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Allaix ME, Patti MG. Toward a Tailored Treatment of Achalasia: An Evidence-Based Approach. J Laparoendosc Adv Surg Tech A 2016; 26:256-63. [PMID: 27002740 DOI: 10.1089/lap.2016.0067] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The treatment options in achalasia patients aim to improve symptoms by reducing the functional obstruction at the level of the gastroesophageal junction. Available treatment modalities are endoscopic botulinum toxin injection (EBTI), pneumatic dilatation (PD), laparoscopic Heller myotomy (LHM), and peroral endoscopic myotomy (POEM). We provide an evidence-based review of current indications, limitations, and future perspectives of these options for the treatment of achalasia. METHODS The PubMed/Medline electronic databases and the Cochrane Library were searched. Quality of evidence was assessed according to the GRADE system. RESULTS Functional outcomes after EBTI are significantly worse than those after PD or LHM. LHM with partial fundoplication is associated with low complication rates and provides excellent long-term results with lower need for additional treatment of recurrent dysphagia than PD. POEM is a new promising treatment option with good short-term outcomes and low morbidity in experienced hands. CONCLUSIONS LHM should be considered the procedure of choice for the treatment of achalasia in patients who are fit for surgery. Large randomized controlled trials with long follow-up are needed to validate the role of POEM.
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Affiliation(s)
| | - Marco Giuseppe Patti
- 2 Department of Surgery and Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine , Chicago, Illinois
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Amani M, Fazlollahi N, Shirani S, Malekzadeh R, Mikaeli J. Assessment of Pneumatic Balloon Dilation in Patients with Symptomatic Relapse after Failed Heller Myotomy: A Single Center Experience. Middle East J Dig Dis 2016; 8:57-62. [PMID: 26933483 PMCID: PMC4773085 DOI: 10.15171/mejdd.2016.08] [Citation(s) in RCA: 14] [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] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND
Although Heller myotomy is one of the most effective treatments for achalasia, it may be associated with early or late symptom relapse in some patients. Therefore, additional treatment is required to achieve better control of symptoms.
Aim: To evaluate the safety and efficacy of pneumatic balloon dilation (PBD) in patients with symptom relapse after Heller myotomy.
METHODS
Thirty six post-myotomy patients were evaluated from 1993 to 2013. Six patients were excluded from the analysis because of comorbid diseases or epiphrenic diverticula. Thirty patients were treated with PBD. Primary outcome was defined as a decrease in symptom score to 4 or less and a reduction greater than 80% from the baseline in the volume of barium in timed barium esophagogram in 6 weeks. Achalasia symptom score (ASS) was assessed at 1.5, 3, 6, and 12 months after treatment and then every six months in all patients and PBD was repeated in case of symptom relapse (ASS>4).
RESULTS
The mean age of the patients was 45.5±13.9 years (range: 21-73). Primary outcome was observed in 25 patients (83%). The mean ASS of the patients dropped from 7.8 before treatment to 1.3±2.0 at 1.5 months after treatment (p=0.0001). The mean volume and height of barium decreased from 43.1±33.4 and 7.1±4.7 to 6.0±17.1 and 1.1±2.2, respectively (p=0.003, p=0.003). The mean duration of follow-up was 11.8±6.3 years. At the end of the study, 21 patients (70%) reported sustained good response. No major complications such as perforation or gross bleeding were seen.
CONCLUSION
PBD is an effective and safe treatment option for achalasia in patients with symptom relapse after Heller myotomy.
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Affiliation(s)
- Mohammad Amani
- Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Narges Fazlollahi
- Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shapour Shirani
- Department of Radiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Malekzadeh
- Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Javad Mikaeli
- Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Bencini L, Moraldi L, Bartolini I, Coratti A. Esophageal surgery in minimally invasive era. World J Gastrointest Surg 2016; 8:52-64. [PMID: 26843913 PMCID: PMC4724588 DOI: 10.4240/wjgs.v8.i1.52] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 09/18/2015] [Accepted: 12/08/2015] [Indexed: 02/06/2023] Open
Abstract
The widespread popularity of new surgical technologies such as laparoscopy, thoracoscopy and robotics has led many surgeons to treat esophageal diseases with these methods. The expected benefits of minimally invasive surgery (MIS) mainly include reductions of postoperative complications, length of hospital stay, and pain and better cosmetic results. All of these benefits could potentially be of great interest when dealing with the esophagus due to the potentially severe complications that can occur after conventional surgery. Moreover, robotic platforms are expected to reduce many of the difficulties encountered during advanced laparoscopic and thoracoscopic procedures such as anastomotic reconstructions, accurate lymphadenectomies, and vascular sutures. Almost all esophageal diseases are approachable in a minimally invasive way, including diverticula, gastro-esophageal reflux disease, achalasia, perforations and cancer. Nevertheless, while the limits of MIS for benign esophageal diseases are mainly technical issues and costs, oncologic outcomes remain the cornerstone of any procedure to cure malignancies, for which the long-term results are critical. Furthermore, many of the minimally invasive esophageal operations should be compared to pharmacologic interventions and advanced pure endoscopic procedures; such a comparison requires a difficult literature analysis and leads to some confounding results of clinical trials. This review aims to examine the evidence for the use of MIS in both malignancies and more common benign disease of the esophagus, with a particular emphasis on future developments and ongoing areas of research.
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A prospective analysis of GERD after POEM on anterior myotomy. Surg Endosc 2015; 30:2496-504. [PMID: 26416381 PMCID: PMC4887532 DOI: 10.1007/s00464-015-4507-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 08/01/2015] [Indexed: 01/21/2023]
Abstract
Background Peroral endoscopic myotomy (POEM) is an emerging, minimally invasive procedure capable of overcoming limitations of achalasia treatments, but gastroesophageal reflux disease (GERD) after POEM is of concern and its risk factors have not been evaluated. This prospective study examined GERD and the association of POEM with reflux esophagitis. Methods Achalasia patients were recruited from a single center. The pre- and postoperative assessments included Eckardt scores, manometry, endoscopy, and pH monitoring. Results Between September 2011 and November 2014, 105 patients underwent POEM; 70 patients were followed up 3 months after POEM. Postoperatively, significant reductions were observed in lower esophageal sphincter (LES) pressure [from 40.0 ± 22.8 to 20.7 ± 14.0 mmHg (P < 0.05)], LES residual pressure [from 22.1 ± 13.3 to 11.4 ± 6.6 mmHg (P < 0.05)], and Eckardt scores [from 5.7 ± 2.5 to 0.7 ± 0.8 (P < 0.05)]. Symptomatic GERD and moderate reflux esophagitis developed in 5 and 11 patients (grade B, n = 8; grade C, n = 3), respectively, and were well controlled with proton pump inhibitors. Univariate logistic regression analysis revealed integrated relaxation pressure was a predictor of ≥grade B reflux esophagitis. No POEM factors were found to be associated with reflux esophagitis. Conclusion POEM is effective and safe in treating achalasia, with no occurrence of clinically significant refractory GERD. Myotomy during POEM, especially of the gastric side, was not associated with ≥grade B (requiring medical intervention) reflux esophagitis. Extended gastric myotomy (2–3 cm) during POEM is recommended to improve outcomes.
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Ates F, Vaezi MF, Fox M, Gyawali CP, Roman S, Smout AJPM, Pandolfino JE. The Pathogenesis and Management of Achalasia: Current Status and Future Directions. Gut Liver 2015; 9:449-63. [PMID: 26087861 PMCID: PMC4477988 DOI: 10.5009/gnl14446] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Achalasia is an esophageal motility disorder that is commonly misdiagnosed initially as gastroesophageal reflux disease. Patients with achalasia often complain of dysphagia with solids and liquids but may focus on regurgitation as the primary symptom, leading to initial misdiagnosis. Diagnostic tests for achalasia include esophageal motility testing, esophagogastroduodenoscopy and barium swallow. These tests play a complimentary role in establishing the diagnosis of suspected achalasia. High-resolution manometry has now identified three subtypes of achalasia, with therapeutic implications. Pneumatic dilation and surgical myotomy are the only definitive treatment options for patients with achalasia who can undergo surgery. Botulinum toxin injection into the lower esophageal sphincter should be reserved for those who cannot undergo definitive therapy. Close follow-up is paramount because many patients will have a recurrence of symptoms and require repeat treatment.
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Affiliation(s)
| | - Michael F. Vaezi
- Correspondence to: Michael F. Vaezi, Division of Gastroenterology and Hepatology, Center for Swallowing and Esophageal Disorders, Vanderbilt University Medical Center, C2104-MCN, Nashville, TN 37232, USA, Tel: +1-615-322-3739, Fax: +1-615-322-8525, E-mail:
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Abstract
High-resolution manometry enables the categorization of patients with oesophageal dysphagia caused by oesophageal motility disorders into diagnostic categories according to the Chicago Classification. This Review provides an overview of the literature concerning treatment options for patients with dysphagia associated with achalasia, hypercontractile disorders and hypocontractility disorders of the oesophagus. In achalasia, pharmacotherapy and botulinum toxin are less effective than pneumatic dilation or surgical Heller myotomy, which had comparable efficacy in the largest controlled trial to date. Peroral endoscopic myotomy is a novel therapeutic modality that is currently being evaluated in controlled trials versus pneumatic dilation or surgical myotomy. A variety of medical treatments have been evaluated in hypermotility disorders, but only botulinum toxin injection yielded favourable results in a single controlled trial. Few studies have addressed the treatment of dysphagia in patients with oesophageal hypomotility. A variety of prokinetic agents have been studied, but there is no evidence of clinically relevant efficacy from controlled trials.
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Affiliation(s)
- Jan Tack
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Giovanni Zaninotto
- Imperial College, Department of Surgery and Cancer, St Mary's Hospital, Praed Street, Paddington, London W2 1NY, UK
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Hoppo T, Thakkar SJ, Schumacher LY, Komatsu Y, Choe S, Shetty A, Bloomer S, Lloyd EJ, Zaidi AH, VanDeusen MA, Landreneau RJ, Kulkarni A, Jobe BA. A utility of peroral endoscopic myotomy (POEM) across the spectrum of esophageal motility disorders. Surg Endosc 2015; 30:233-44. [DOI: 10.1007/s00464-015-4193-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 03/24/2015] [Indexed: 12/21/2022]
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Wang J, Tan N, Xiao Y, Chen J, Chen B, Ma Z, Zhang D, Chen M, Cui Y. Safety and efficacy of the modified peroral endoscopic myotomy with shorter myotomy for achalasia patients: a prospective study. Dis Esophagus 2014; 28:720-7. [PMID: 25214469 DOI: 10.1111/dote.12280] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Peroral endoscopic myotomy (POEM) has been developed as a minimally invasive endoscopic treatment for achalasia for years. However, the optimal length of submucosal tunnel and myotomy of muscle bundles during procedure of POEM has not yet been determined, so we aim to assess safety and efficacy of modified POEM with shorter myotomy of muscle bundles in achalasia patients. Consecutive achalasia patients had been performed modified POEM with shorter myotomy, and assessed by symptoms, high-resolution manometry, and barium swallow examinations before and 3 months after POEM for safety and efficacy evaluation. Modified POEM with shorter submucosal tunnel (mean length 6.8 cm) and endoscopic myotomy of muscle bundles (total mean length 5.4 cm) were completed in 46 consecutive achalasia patients. During the 3-month follow up in all cases, significant improvement of symptoms (a significant drop in the Eckardt score 8.4 ± 3.2 vs. 2.7 ± 1.9; P < 0.001), decreased lower esophageal sphincter pressure (39.4 ± 10.1 vs. 24.4 ± 9.1 mmHg; P < 0.001) and integrated relaxation pressure (38.6 ± 10.4 vs. 25.7 ± 9.6 mmHg; P < 0.01), and a drop in height of esophagus barium-contrast column (5.4 ± 3.1 vs. 2.6 ± 1.8 cm; P < 0.001) were observed. The frequencies of adverse events were lower in those under endotracheal anesthesia and CO2 insufflations compared with intravenous anesthesia and air insufflations. Only three patients were found to have gastroesophageal reflux disease on follow up. Modified POEM with shorter myotomy under endotracheal anesthesia and CO2 insufflations shows its good safety and excellent short-term efficacy in the treatment of achalasia. But further studies are warranted to assess the long-term efficacy.
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Affiliation(s)
- J Wang
- Department of Gastroenterology and Hepatology, and Endoscopy Center, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - N Tan
- Department of Gastroenterology and Hepatology, and Endoscopy Center, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Y Xiao
- Department of Gastroenterology and Hepatology, and Endoscopy Center, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - J Chen
- Department of Gastroenterology and Hepatology, and Endoscopy Center, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - B Chen
- Department of Gastroenterology and Hepatology, and Endoscopy Center, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Z Ma
- Digestive Department, Shantou Central Hospital, Shantou, Guangdong, China
| | - D Zhang
- Digestive Department, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - M Chen
- Department of Gastroenterology and Hepatology, and Endoscopy Center, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Y Cui
- Department of Gastroenterology and Hepatology, and Endoscopy Center, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
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Vela MF. Management strategies for achalasia. Neurogastroenterol Motil 2014; 26:1215-21. [PMID: 25167952 DOI: 10.1111/nmo.12416] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 07/22/2014] [Indexed: 12/19/2022]
Abstract
Treatment options for achalasia include oral pharmacologic therapy, endoscopic injection of botulinum toxin, pneumatic dilation, and myotomy (conventionally by laparoscopy, but more recently by an endoscopic approach). Oral pharmacologic agents have fallen out of use because of insufficient efficacy and frequent side effects. Endoscopic injection of botulinum toxin is safe and has good short-term effectiveness, but as the effect invariably wears off after a few months, this treatment is reserved for patients who are not candidates for more definitive treatments. Pneumatic dilation and surgical myotomy are currently considered the most effective treatments, with similar effectiveness in randomized controlled trials with follow-up of up to 2 years. The risk/benefit ratio and choice of therapy depend on patient characteristics (age, comorbidities, disease stage, prior treatments), patient's preference, and locally available expertise. Treatment of patients who fail or relapse after initial therapy is challenging and the success rate of pneumatic dilation or myotomy in this group is lower compared with previously untreated patients. The recently developed peroral endoscopic approach to myotomy has achieved excellent results in early uncontrolled studies, but high-quality randomized trials are needed to ensure widespread adoption is reasonable. Finally, retrospective data suggest that achalasia subtypes as defined by high-resolution esophageal pressure topography may guide treatment choice, but confirmation in prospective outcome studies is awaited.
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Affiliation(s)
- M F Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ, USA
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32
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Legros L, Ropert A, Brochard C, Bouguen G, Pagenault M, Siproudhis L, Bretagne JF. Long-term results of pneumatic dilatation for relapsing symptoms of achalasia after Heller myotomy. Neurogastroenterol Motil 2014; 26:1248-55. [PMID: 24916630 DOI: 10.1111/nmo.12380] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 05/16/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this study was to assess the efficacy and safety of pneumatic dilatation (PD) to treat symptom recurrence after Heller myotomy (HM). METHODS Consecutive patients receiving PD for relapsing symptoms following prior HM were included in this retrospective single-center study. Eckardt score ≤3 and/or ∆ Eckardt (difference between Eckardt score before and after dilatation) ≥3 defined the success of initial dilatation. Patients who maintained response longer than 2 months after initial dilatation were defined as short-term responders. Relapsers were offered further on-demand dilatation. Remission was defined as an Eckardt score ≤3 at the study endpoint. Kaplan-Meier survival curves were used to determine relapse rates. KEY RESULTS Eighteen patients (11 women, seven men) were included from January 2004 to January 2013. Ten patients had type I achalasia, and seven had type III, according to the Chicago classification. Thirty-nine PDs were performed (1.5 [1-2.25] per patient). All patients had short-term responses. The remission rate at the endpoint, after a median follow-up of 33 months, was 78%, but 44% were treated with on-demand PD during the follow-up interval. The proportions of patients without relapse and subsequent PD were 72% at 12 months, 65% at 24 and 36 months, and 49% at 48 months. No factors predictive of long-term response, particularly the type of achalasia, could be identified in this series. There were no perforations. CONCLUSIONS & INFERENCES In treating symptom recurrence following HM, PD was safe and effective over the long term when combined with subsequent PD.
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Affiliation(s)
- Ludivine Legros
- Service des Maladies de l'Appareil Digestif, Centre Hospitalo-universitaire de Rennes, Rennes, France
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Kaman L, Iqbal J, Kochhar R, Sinha S. Laparoscopic heller myotomy for achalasia cardia-initial experience in a teaching institute. Indian J Surg 2014. [PMID: 24426483 DOI: 10.1007/s12262-012-0708-0.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Laparoscopic Heller cardiomyotomy and Dor fundoplication is the surgical procedure of choice for esophageal achalasia. The aim of our study was to investigate the clinical outcome and safety of laparoscopic Heller-Dor procedure performed by using Hook electrocautery and as a teaching module for advanced laparoscopic surgery. Between January 2005 and December 2010, 25 consecutive patients with achalasia underwent laparoscopic Heller-Dor operation by a single surgeon. All the patients received upper gastrointestinal series (barium swallow), esophagogastroscopy, and esophageal manometry to exclude esophageal carcinoma and to confirm the diagnosis. All the patients were operated by laparoscopic modified Heller myotomy with Dor fundoplication by using hook electrocautery. Among 25 operated patients, 14 were male and 11 were female with a median age of 43 years (range 18-72 years). The mean operative time was 93.3 min (range 50-50 min), the mean operative blood loss was 90 ml (range 40-200 ml), the median time to oral feeding was 2 days (2-4 days), and the median hospital stay was 4 days (4-7 days). There was no conversion to open surgery. Intraoperative mucosal perforation was encountered in three patients and was repaired in all of them by laparoscopic suture. All the patients had an uneventful recovery without postoperative complication and had excellent clinical response (96 %) during follow-up. Laparoscopic Heller-Dor operation using hook electrocautery is safe, inexpensive, and effective treatment for achalasia which is useful for teaching and training surgical residents in advanced laparoscopic surgery.
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Affiliation(s)
- Lileswar Kaman
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Javid Iqbal
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Saroj Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Abstract
Achalasia is a rare motility disorder of the oesophagus characterised by loss of enteric neurons leading to absence of peristalsis and impaired relaxation of the lower oesophageal sphincter. Although its cause remains largely unknown, ganglionitis resulting from an aberrant immune response triggered by a viral infection has been proposed to underlie the loss of oesophageal neurons, particularly in genetically susceptible individuals. The subsequent stasis of ingested food not only leads to symptoms of dysphagia, regurgitation, chest pain, and weight loss, but also results in an increased risk of oesophageal carcinoma. At present, pneumatic dilatation and Heller myotomy combined with an anti-reflux procedure are the treatments of choice and have comparable success rates. Per-oral endoscopic myotomy has recently been introduced as a new minimally invasive treatment for achalasia, but there have not yet been any randomised clinical trials comparing this option with pneumatic dilatation and Heller myotomy.
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Affiliation(s)
- Guy E Boeckxstaens
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), University Hospital Leuven, Catholic University of Leuven, Leuven, Belgium.
| | - Giovanni Zaninotto
- Department of Surgical and Gastroenterological Sciences, University of Padova, UOC General Surgery, Sts Giovanni e Paolo Hospital, Venice, Italy
| | - Joel E Richter
- Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Esophageal and Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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Liu L, Duan SQ, Meng XM, Dang T, Xu MD. Peroral endoscopic myotomy for treatment of achalasia cardia: Our experience with 7 cases. Shijie Huaren Xiaohua Zazhi 2013; 21:2994-2998. [DOI: 10.11569/wcjd.v21.i28.2994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the clinical efficacy of peroral endoscopic myotomy (POEM) in the treatment of achalasia cardia (AC).
METHODS: The clinical data for 7 patients who were diagnosed with AC and received POEM at our center from May 16, 2011 to May 30, 2013 were reviewed. They ranged in age from 20 to 48 years old, with a mean value of 30.4 years. The disease courses lasted for 2 to 15 years. Key procedures of POEM were esophageal mucosal incision, submucosal tunneling by endoscopic submucosal dissection, endoscopic myotomy of the circular muscle and closure of mucosal entry using hemostatic clips.
RESULTS: POEM was successful in all the patients. Mean operation time was 114 min (range, 55-180 min). Mean submucosal tunneling length was 11.7 cm (range, 10-13 cm). Mean length of endoscopic myotomy of the circular muscle was 9.2 cm (range, 8-11 cm). Two cases underwent full-thickness myotomy. Patients were followed for one year. Five cases of dysphagia were cured, and no obvious effect was observed in two cases.
CONCLUSION: POEM has good short-term efficacy in relieving dysphagia. Further observation is needed to evaluate long-term efficacy and complications.
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Chuah SK, Chiu CH, Tai WC, Lee JH, Lu HI, Changchien CS, Tseng PH, Wu KL. Current status in the treatment options for esophageal achalasia. World J Gastroenterol 2013; 19:5421-5429. [PMID: 24023484 PMCID: PMC3761094 DOI: 10.3748/wjg.v19.i33.5421] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 06/17/2013] [Accepted: 07/05/2013] [Indexed: 02/06/2023] Open
Abstract
Recent advances in the treatment of achalasia include the use of high-resolution manometry to predict the outcome of patients and the introduction of peroral endoscopic myotomy (POEM). The first multicenter randomized, controlled, 2-year follow-up study conducted by the European Achalasia Trial group indicated that laparoscopic Heller myotomy (LHM) was not superior to pneumatic dilations (PD). Publications on the long-term success of laparoscopic surgery continue to emerge. In addition, laparoscopic single-site surgery is applicable to advanced laparoscopic operations such as LHM and anterior fundoplication. The optimal treatment option is an ongoing matter of debate. In this review, we provide an update of the current progress in the treatment of esophageal achalasia. Unless new conclusive data prove otherwise, LHM is considered the most durable treatment for achalasia at the expense of increased reflux-associated complications. However, PD is the first choice for non-surgical treatment and is more cost-effective. Repeated PD according to an “on-demand” strategy based on symptom recurrence can achieve long-term remission. Decision making should be based on clinical evidence that identifies a subcategory of patients who would benefit from specific treatment options. POEM has shown promise but its long-term efficacy and safety need to be assessed further.
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Yaghoobi M, Mayrand S, Martel M, Roshan-Afshar I, Bijarchi R, Barkun A. Laparoscopic Heller's myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized, controlled trials. Gastrointest Endosc 2013; 78:468-75. [PMID: 23684149 DOI: 10.1016/j.gie.2013.03.1335] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Accepted: 03/27/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pneumatic dilation (PD) and laparoscopic Heller's myotomy (LHM) are the mainstays of therapy in idiopathic achalasia. Equipoise exists in choosing the first-line therapy. OBJECTIVE To assess comparative efficacies and adverse event rates of these methods. DESIGN Intention-to-treat, fixed-model, Mantel-Haenszel meta-analysis of randomized, controlled trials comparing PD with LHM. SETTING Randomized controlled trial comparing PD versus LHM. PATIENTS Patients with newly diagnosed idiopathic achalasia. INTERVENTION Comprehensive electronic and manual literature search from 1966 to March 2012 independently by two reviewers. MAIN OUTCOME MEASUREMENTS Response rate, rate of different adverse events, and quality of life after each therapy. RESULTS Three of 161 retrieved studies between 2007 and 2011, including 346 patients, were included. At 1 year, the cumulative response rate was significantly higher with LHM (86% vs 76%, odds ratio 1.98 (confidence interval 1.14-3.45); P = .02), with no significant heterogeneity (P = .39; I(2) 0%). Rates of major mucosal tears requiring subsequent intervention with LHM were significantly lower than those of esophageal perforation with PD requiring postprocedural medical or surgical therapy (0.6% and 4.8%, respectively; P = .04). Postprocedural rates of gastroesophageal reflux, lower esophageal sphincter pressures, and quality of life scores did not differ in trials with sufficient data. Data on longer follow-up were not available. LIMITATIONS Lack of data on follow-ups over 1 year and a small number of included studies. CONCLUSION This meta-analysis suggests that LHM may provide greater response rates as compared with graded PD in the treatment of newly diagnosed idiopathic achalasia, with lesser rates of major adverse events, in up to 1 year after treatment, although additional data are needed to confirm the validity of this conclusion in long-term follow-up.
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Affiliation(s)
- Mohammad Yaghoobi
- Division of Gastroenterology, McGill University Health Sciences, Montreal, Quebec, Canada
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Vaezi MF, Pandolfino JE, Vela MF. ACG clinical guideline: diagnosis and management of achalasia. Am J Gastroenterol 2013; 108:1238-49; quiz 1250. [PMID: 23877351 DOI: 10.1038/ajg.2013.196] [Citation(s) in RCA: 331] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Accepted: 05/01/2013] [Indexed: 12/11/2022]
Abstract
Achalasia is a primary motor disorder of the esophagus characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. This results in patients' complaints of dysphagia to solids and liquids, regurgitation, and occasional chest pain with or without weight loss. Endoscopic finding of retained saliva with puckered gastroesophageal junction or barium swallow showing dilated esophagus with birds beaking in a symptomatic patient should prompt appropriate diagnostic and therapeutic strategies. In this ACG guideline the authors present an evidence-based approach in patients with achalasia based on a comprehensive review of the pertinent evidence and examination of relevant published data.
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Affiliation(s)
- Michael F Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN 37232-5280, USA.
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Zaninotto G, Costantini M. Laparoscopic Esophageal Myotomy. SHACKELFORD'S SURGERY OF THE ALIMENTARY TRACT 2013:354-361. [DOI: 10.1016/b978-1-4377-2206-2.00029-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Weber CE, Davis CS, Kramer HJ, Gibbs JT, Robles L, Fisichella PM. Medium and long-term outcomes after pneumatic dilation or laparoscopic Heller myotomy for achalasia: a meta-analysis. Surg Laparosc Endosc Percutan Tech 2012; 22:289-96. [PMID: 22874676 DOI: 10.1097/sle.0b013e31825a2478] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Recent randomized studies comparing outcomes after pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) for the treatment of achalasia are conflicting and limited to short-term follow-up. Our meta-analysis compared the long-term durability of these approaches, with the hypothesis that LHM offers superior long-term remission compared with PD. We identified 36 studies published between 2001 and 2011 with at least 5 years of follow-up. Those studies describing PD included 3211 patients (mean age, 49.8 y). For PD, the mean 5-year remission rate was 61.9% and the mean 10-year remission rate was 47.9%. Overall, 1526 patients (mean age, 46.3 y) were treated with LHM; 83% received a fundoplication. In contrast, the mean 5- and 10-year remission rates after LHM were 76.1% and 79.6%, respectively. Finally, the perforation rate for LHM was twice that of PD (4.8% vs. 2.4%; P<0.05). We conclude that despite a higher frequency of perforation, LHM affords greater long-term durability.
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Affiliation(s)
- Cynthia E Weber
- Department of Surgery, Loyola University Medical Center, Stritch School of Medicine, Maywood, IL 60153, USA
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Kaman L, Iqbal J, Kochhar R, Sinha S. Laparoscopic heller myotomy for achalasia cardia-initial experience in a teaching institute. Indian J Surg 2012; 75:391-4. [PMID: 24426483 DOI: 10.1007/s12262-012-0708-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 07/18/2012] [Indexed: 10/28/2022] Open
Abstract
Laparoscopic Heller cardiomyotomy and Dor fundoplication is the surgical procedure of choice for esophageal achalasia. The aim of our study was to investigate the clinical outcome and safety of laparoscopic Heller-Dor procedure performed by using Hook electrocautery and as a teaching module for advanced laparoscopic surgery. Between January 2005 and December 2010, 25 consecutive patients with achalasia underwent laparoscopic Heller-Dor operation by a single surgeon. All the patients received upper gastrointestinal series (barium swallow), esophagogastroscopy, and esophageal manometry to exclude esophageal carcinoma and to confirm the diagnosis. All the patients were operated by laparoscopic modified Heller myotomy with Dor fundoplication by using hook electrocautery. Among 25 operated patients, 14 were male and 11 were female with a median age of 43 years (range 18-72 years). The mean operative time was 93.3 min (range 50-50 min), the mean operative blood loss was 90 ml (range 40-200 ml), the median time to oral feeding was 2 days (2-4 days), and the median hospital stay was 4 days (4-7 days). There was no conversion to open surgery. Intraoperative mucosal perforation was encountered in three patients and was repaired in all of them by laparoscopic suture. All the patients had an uneventful recovery without postoperative complication and had excellent clinical response (96 %) during follow-up. Laparoscopic Heller-Dor operation using hook electrocautery is safe, inexpensive, and effective treatment for achalasia which is useful for teaching and training surgical residents in advanced laparoscopic surgery.
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Affiliation(s)
- Lileswar Kaman
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Javid Iqbal
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Saroj Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Achalasia: pneumatic dilation or laparoscopic heller myotomy? J Gastrointest Surg 2012; 16:1284-5. [PMID: 22396091 DOI: 10.1007/s11605-012-1864-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Accepted: 02/26/2012] [Indexed: 01/31/2023]
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Martino ND, Brillantino A, Monaco L, Marano L, Schettino M, Porfidia R, Izzo G, Cosenza A. Laparoscopic calibrated total vs partial fundoplication following Heller myotomy for oesophageal achalasia. World J Gastroenterol 2011; 17:3431-40. [PMID: 21876635 PMCID: PMC3160569 DOI: 10.3748/wjg.v17.i29.3431] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Revised: 12/26/2010] [Accepted: 01/02/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the mid-term outcomes of laparoscopic calibrated Nissen-Rossetti fundoplication with Dor fundoplication performed after Heller myotomy for oesophageal achalasia.
METHODS: Fifty-six patients (26 men, 30 women; mean age 42.8 ± 14.7 years) presenting for minimally invasive surgery for oesophageal achalasia, were enrolled. All patients underwent laparoscopic Heller myotomy followed by a 180° anterior partial fundoplication in 30 cases (group 1) and calibrated Nissen-Rossetti fundoplication in 26 (group 2). Intraoperative endoscopy and manometry were used to calibrate the myotomy and fundoplication. A 6-mo follow-up period with symptomatic evaluation and barium swallow was undertaken. One and two years after surgery, the patients underwent symptom questionnaires, endoscopy, oesophageal manometry and 24 h oesophago-gastric pH monitoring.
RESULTS: At the 2-year follow-up, no significant difference in the median symptom score was observed between the 2 groups (P = 0.66; Mann-Whitney U-test). The median percentage time with oesophageal pH < 4 was significantly higher in the Dor group compared to the Nissen-Rossetti group (2; range 0.8-10 vs 0.35; range 0-2) (P < 0.0001; Mann-Whitney U-test).
CONCLUSION: Laparoscopic Dor and calibrated Nissen-Rossetti fundoplication achieved similar results in the resolution of dysphagia. Nissen-Rossetti fundoplication seems to be more effective in suppressing oesophageal acid exposure.
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Selected Commentary to "Pneumatic dilation versus laparoscopic Heller's myotomy for idiopathic achalasia". Eur Surg 2011. [DOI: 10.1007/s10353-011-0030-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Controversy exists with regard to the optimal treatment for achalasia and whether surveillance for early recognition of late complications is indicated. Currently, surgical myotomy and pneumatic dilation are the most effective treatments for patients with idiopathic achalasia, and a multicenter, randomized, international trial has confirmed similar efficacy of these treatments, at least in the short term. Clinical predictors of outcome, patient preferences and local expertise should be considered when making a decision on the most appropriate treatment option. Owing to a lack of long-term benefit, endoscopic botulinum toxin injection and medical therapies are reserved for patients of advanced age and those with clinically significant comorbidites. The value of new endoscopic, radiologic or surgical treatments, such as peroral endoscopic myotomy, esophageal stenting and robotic-assisted myotomy has not been fully established. Finally, long-term follow-up data in patients with achalasia support the notion that surveillance strategies might be beneficial after a disease duration of more than 10-15 years.
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Affiliation(s)
- Alexander J Eckardt
- Department of Gastroenterology, Deutsche Klinik für Diagnostik, Aukammallee 33, 65191 Wiesbaden, Germany
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Boeckxstaens GE, Annese V, des Varannes SB, Chaussade S, Costantini M, Cuttitta A, Elizalde JI, Fumagalli U, Gaudric M, Rohof WO, Smout AJ, Tack J, Zwinderman AH, Zaninotto G, Busch OR. Pneumatic dilation versus laparoscopic Heller's myotomy for idiopathic achalasia. N Engl J Med 2011; 364:1807-16. [PMID: 21561346 DOI: 10.1056/nejmoa1010502] [Citation(s) in RCA: 554] [Impact Index Per Article: 42.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Many experts consider laparoscopic Heller's myotomy (LHM) to be superior to pneumatic dilation for the treatment of achalasia, and LHM is increasingly considered to be the treatment of choice for this disorder. METHODS We randomly assigned patients with newly diagnosed achalasia to pneumatic dilation or LHM with Dor's fundoplication. Symptoms, including weight loss, dysphagia, retrosternal pain, and regurgitation, were assessed with the use of the Eckardt score (which ranges from 0 to 12, with higher scores indicating more pronounced symptoms). The primary outcome was therapeutic success (a drop in the Eckardt score to ≤3) at the yearly follow-up assessment. The secondary outcomes included the need for retreatment, pressure at the lower esophageal sphincter, esophageal emptying on a timed barium esophagogram, quality of life, and the rate of complications. RESULTS A total of 201 patients were randomly assigned to pneumatic dilation (95 patients) or LHM (106). The mean follow-up time was 43 months (95% confidence interval [CI], 40 to 47). In an intention-to-treat analysis, there was no significant difference between the two groups in the primary outcome; the rate of therapeutic success with pneumatic dilation was 90% after 1 year of follow-up and 86% after 2 years, as compared with a rate with LHM of 93% after 1 year and 90% after 2 years (P=0.46). After 2 years of follow-up, there was no significant between-group difference in the pressure at the lower esophageal sphincter (LHM, 10 mm Hg [95% CI, 8.7 to 12]; pneumatic dilation, 12 mm Hg [95% CI, 9.7 to 14]; P=0.27); esophageal emptying, as assessed by the height of barium-contrast column (LHM, 1.9 cm [95% CI, 0 to 6.8]; pneumatic dilation, 3.7 cm [95% CI, 0 to 8.8]; P=0.21); or quality of life. Similar results were obtained in the per-protocol analysis. Perforation of the esophagus occurred in 4% of the patients during pneumatic dilation, whereas mucosal tears occurred in 12% during LHM. Abnormal exposure to esophageal acid was observed in 15% and 23% of the patients in the pneumatic-dilation and LHM groups, respectively (P=0.28). CONCLUSIONS After 2 years of follow-up, LHM, as compared with pneumatic dilation, was not associated with superior rates of therapeutic success. (European Achalasia Trial Netherlands Trial Register number, NTR37, and Current Controlled Trials number, ISRCTN56304564.).
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Lopes LR, Braga NDS, Oliveira GCD, Coelho Neto JDS, Camargo MA, Andreollo NA. Results of the surgical treatment of non-advanced megaesophagus using Heller-Pinotti's surgery: Laparotomy vs. Laparoscopy. Clinics (Sao Paulo) 2011; 66:41-6. [PMID: 21437434 PMCID: PMC3044574 DOI: 10.1590/s1807-59322011000100008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Revised: 09/02/2010] [Accepted: 10/04/2010] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Dysphagia is the important symptom in achalasia, and surgery is the most common treatment. The Heller-Pinotti technique is the method preferred by Brazilian surgeons. For many years, this technique was performed by laparotomy, and now the laparoscopic method has been introduced. The objective was to evaluate the immediate and long-term results of patients submitted to surgery by either laparotomy or laparoscopy. MATERIALS AND METHODS A total of 67 patients submitted to surgery between 1994 and 2001 with at least 5 years of follow-up were evaluated retrospectively and divided into two groups: laparotomy (41 patients) and laparoscopy (26 patients). Chagas was the etiology in 76.12% of cases. Dysphagia was evaluated according to the classification defined by Saeed et al. RESULTS There were no cases of conversion to open surgery. The mean duration of hospitalization was 3.32 days for laparotomy and 2.54 days for laparoscopy (p < 0.05). An improvement in dysphagia occurred with both groups reporting good or excellent results (laparotomy: 73.17% and laparoscopy: 73.08%). Mean duration of follow-up was 8 years. CONCLUSIONS There was no difference between the two groups with respect to relief from dysphagia, thereby confirming the safety and effectiveness of the Heller-Pinotti technique, which can be performed by laparotomy or laparoscopy, depending on the surgeon's experience.
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Affiliation(s)
- Luiz Roberto Lopes
- Department of Surgery, University of Campinas, Campinas, São Paulo, Brazil.
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Wuller C, Bessell JR, Watson DI. Chest pain before and after laparoscopic cardiomyotomy for achalasia. ANZ J Surg 2010; 81:590-4. [DOI: 10.1111/j.1445-2197.2010.05577.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Salvador R, Costantini M, Zaninotto G, Morbin T, Rizzetto C, Zanatta L, Ceolin M, Finotti E, Nicoletti L, Da Dalt G, Cavallin F, Ancona E. The preoperative manometric pattern predicts the outcome of surgical treatment for esophageal achalasia. J Gastrointest Surg 2010; 14:1635-45. [PMID: 20830530 DOI: 10.1007/s11605-010-1318-4] [Citation(s) in RCA: 178] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2010] [Accepted: 08/09/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND A new manometric classification of esophageal achalasia has recently been proposed that also suggests a correlation with the final outcome of treatment. The aim of this study was to investigate this hypothesis in a large group of achalasia patients undergoing laparoscopic Heller-Dor myotomy. METHODS We evaluated 246 consecutive achalasia patients who underwent surgery as their first treatment from 2001 to 2009. Patients with sigmoid-shaped esophagus were excluded. Symptoms were scored and barium swallow X-ray, endoscopy, and esophageal manometry were performed before and again at 6 months after surgery. Patients were divided into three groups: (I) no distal esophageal pressurization (contraction wave amplitude <30 mmHg); (II) rapidly propagating compartmentalized pressurization (panesophageal pressurization >30 mmHg); and (III) rapidly propagating pressurization attributable to spastic contractions. Treatment failure was defined as a postoperative symptom score greater than the 10th percentile of the preoperative score (i.e., >7). RESULTS Type III achalasia coincided with a longer overall lower esophageal sphincter (LES) length, a lower symptom score, and a smaller esophageal diameter. Treatment failure rates differed significantly in the three groups: I = 14.6% (14/96), II = 4.7% (6/127), and III = 30.4% (7/23; p = 0.0007). At univariate analysis, the manometric pattern, a low LES resting pressure, and a high chest pain score were the only factors predicting treatment failure. At multivariate analysis, the manometric pattern and a LES resting pressure <30 mmHg predicted a negative outcome. CONCLUSION This is the first study by a surgical group to assess the outcome of surgery in 3 manometric achalasia subtypes: patients with panesophageal pressurization have the best outcome after laparoscopic Heller-Dor myotomy.
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Affiliation(s)
- Renato Salvador
- Department of Surgical and Gastroenterological Sciences, Clinica Chirurgica I, School of Medicine, University of Padova, Padova, Italy
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