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Wessels EM, Masclee GMC, Bredenoord AJ. An overview of the efficacy, safety, and predictors of achalasia treatments. Expert Rev Gastroenterol Hepatol 2023; 17:1241-1254. [PMID: 37978889 DOI: 10.1080/17474124.2023.2286279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 11/17/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Achalasia is a rare esophageal motility disorder characterized by abnormal esophageal peristalsis and the inability of the lower esophageal sphincter to relax, resulting in poor esophageal emptying. This can be relieved by endoscopic and surgical treatments; each comes with certain advantages and disadvantages. AREAS COVERED This review aims to guide the clinician in clinical decision making on the different treatment options for achalasia regarding the efficacy, safety, and important predictors. EXPERT OPINION Botulinum toxin injection is only recommended for a selective group of achalasia patients because of the short term effect. Pneumatic dilation improves achalasia symptoms, but this effect diminishes over time and requiring repeated dilations to maintain clinical effect. Heller myotomy combined with fundoplication and peroral endoscopic myotomy are highly effective on the long term but are more invasive than dilations. Gastro-esophageal reflux complaints are more often encountered after peroral endoscopic myotomy. Patient factors such as age, comorbidities, and type of achalasia must be taken into account when choosing a treatment. The preference of the patient is also of great importance and therefore shared decision making has to play a fundamental role in deciding about treatment.
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Affiliation(s)
- Elise M Wessels
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, Netherlands
| | - Gwen M C Masclee
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, Netherlands
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El-Magd ESA, Elgeidie A, Elmahdy Y, Abbas A, Elyamany MA, Abulazm IL. Pre-operative endoscopic balloon dilatation and its impact on outcome of laparoscopic Heller cardiomyotomy for patients with achalasia: does the frequency and interval matter? Surg Endosc 2023; 37:7667-7675. [PMID: 37517041 PMCID: PMC10520180 DOI: 10.1007/s00464-023-10314-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 07/15/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Many surgeons believe that pre-operative balloon dilatation makes laparoscopic myotomy more difficult in achalasia patients. Herein, we wanted to see if prior pneumatic balloon dilatation led to worse outcomes after laparoscopic myotomy. We also assessed if the frequency of dilatations and the time interval between the last one and the surgical myotomy could affect these outcomes. METHODS The data of 460 patients was reviewed. They were divided into two groups: the balloon dilation (BD) group (102 patients) and the non-balloon dilatation (non-BD) group (358 patients). RESULTS Although pre-operative parameters and surgical experience were comparable between the two groups, the incidence of mucosal perforation, operative time, and intraoperative blood loss significantly increased in the BD group. The same group also showed a significant delay in oral intake and an increased hospitalization period. At a median follow-up of 4 years, the incidence of post-operative reflux increased in the BD group, while patient satisfaction decreased. Patients with multiple previous dilatations showed a significant increase in operative time, blood loss, perforation incidence, hospitalization period, delayed oral intake, and reflux esophogitis compared to single-dilatation patients. When compared to long-interval cases, patients with short intervals had a higher incidence of mucosal perforation and a longer hospitalization period. CONCLUSION Pre-operative balloon dilatation has a significant negative impact on laparoscopic myotomy short and long term outcomes. It is associated with a significant increase in operative time, blood loss, mucosal injury, hospitalization period, and incidence of reflux symptoms. More poor outcomes are encountered in patients with multiple previous dilatations and who have a short time interval between the last dilatation and the myotomy.
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Affiliation(s)
- El-Sayed Abou El-Magd
- Department of General Surgery, Faculty of Medicine, Gastrointestinal Surgical Center GISC, Mansoura University, Gehan Street, Mansoura, Al Dakahlia Governorate, 35511, Egypt.
| | - Ahmed Elgeidie
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | | | - Amr Abbas
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Ramezani A, Johnson M, Alvani SR, Odor A, Hosseinpoor S. The P3-model of perioperative psychological preparation: Pre-surgical and pre-medical procedural psychological preparation and psychophysiological interventions. Clin Neurol Neurosurg 2022; 222:107468. [DOI: 10.1016/j.clineuro.2022.107468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/20/2022] [Accepted: 10/04/2022] [Indexed: 11/03/2022]
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Efficacy and Safety of Peroral Endoscopic Myotomy for Esophageal Achalasia and Achalasia-Related Diseases in Patients Aged 75 Years and Over. Healthcare (Basel) 2021; 9:healthcare9121668. [PMID: 34946392 PMCID: PMC8700855 DOI: 10.3390/healthcare9121668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/21/2021] [Accepted: 11/27/2021] [Indexed: 11/23/2022] Open
Abstract
Peroral endoscopic myotomy (POEM) has become a popular treatment for esophageal achalasia and other esophageal motility disorders. However, its efficacy and safety in elderly patients are unclear. To clarify that, we reviewed the medical records of patients who underwent POEM in our hospital. A total of 11 patients who underwent POEM for esophageal achalasia (n = 10) and jackhammer esophagus (n = 1) were included. Procedural success, defined as the completion of an esophageal and gastric myotomy, was 100%. Clinical success, defined as an Eckardt score of 3 or less, without the use of additional treatments at 2 months, was 100%. The median Eckardt score significantly decreased after the POEM (baseline vs. 2 months after POEM; 7 (2–8) vs. 0 (0–1), p < 0.01). In the second and third years, the cumulative treatment effect maintenance rate was 88.9%. All patients taking antithrombotic agents had safe operations with the temporary discontinuation of these agents. There were four adverse events (two pneumoperitoneum, one mucosal injury, and one pneumonia), all of which improved with fasting or antibiotics. In conclusion, POEM is an effective and safe treatment for esophageal achalasia and achalasia-related diseases in patients aged 75 years and over.
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Zhong C, Huang S, Xia H, Tan S, Lü M, Peng Y, Tang X. Role of Peroral Endoscopic Myotomy in Geriatric Patients with Achalasia: A Systematic Review and Meta-Analysis. Dig Dis 2021; 40:106-114. [PMID: 33752208 DOI: 10.1159/000516024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 03/18/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is a particularly attractive intervention for achalasia. Presently, POEM has been reported to be effective and safe for achalasia in geriatric patients. Herein, this systematic review was conducted to explore the role of POEM in geriatric patients with achalasia. METHOD PubMed, Embase, and Cochrane Library were searched to identify studies evaluating the clinical outcome of POEM in geriatric patients with achalasia during January 2009 to October 2020. The primary outcomes were technical and clinical success. Secondary outcomes included postoperative Eckardt score, lower esophageal sphincter (LES) pressure, adverse events, and clinical reflux. RESULTS There were 7 studies with a total of 469 geriatric patients, and the pooled technical success of POEM treatment was 98.1% (95% confidence interval [CI], 95.1-99.3%), and the pooled clinical success was 92.5% (95% CI, 89.3-94.8%). After POEM, the Eckardt score significantly decreased by 6.09 points (95% CI, 5.44-6.74, p < 0.00001), and the LES pressure significantly reduced by 13.53 mm Hg (95% CI, 5.14-21.91, p = 0.002). The pooled adverse events rate was 9.0% (95% CI, 4.3-17.9%), and the post-POEM clinical reflux rate was 17.4% (95% CI, 12.9-23.2%). CONCLUSION Our current study demonstrated that POEM was an effective and safe technique for achalasia in geriatric patients.
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Affiliation(s)
- Chunyu Zhong
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shu Huang
- Department of Gastroenterology, the People's Hospital of Lianshui, Huaian, China
| | - Huifang Xia
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shali Tan
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Muhan Lü
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yan Peng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaowei Tang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
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Oude Nijhuis RAB, Prins LI, Mostafavi N, van Etten-Jamaludin FS, Smout AJPM, Bredenoord AJ. Factors Associated With Achalasia Treatment Outcomes: Systematic Review and Meta-Analysis. Clin Gastroenterol Hepatol 2020; 18:1442-1453. [PMID: 31622735 DOI: 10.1016/j.cgh.2019.10.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 09/26/2019] [Accepted: 10/04/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Identification of factors associated with achalasia treatment outcome might help physicians select therapies based on patient characteristics. We performed a systematic review and meta-analysis to identify factors associated with treatment response. METHODS We searched MEDLINE, EMBASE, and the Cochrane Library through February 21, 2019, for randomized controlled trials and cohort, case-control, and cross-sectional studies that reported patient-specific outcomes of treatment (botulinum toxin injection, pneumatic dilation, peroral endoscopic myotomy, or laparoscopic Heller myotomy). We assessed the methodologic quality of the included studies using the quality in prognosis studies tool. We planned qualitative and quantitative analyses. RESULTS We analyzed data from 75 studies (8 randomized controlled trials, 27 prospective cohort studies, and 40 retrospective studies) on a total of 34 different factors associated with outcomes (3 demographic, 17 clinical, and 14 diagnostic factors). Qualitative assessment showed age, manometric subtype, and presence of a sigmoid-shaped esophagus as factors associated with outcomes of treatment for achalasia with a strong level of evidence. The cumulative evidence for the association with chest pain, symptom severity, and lower esophageal sphincter pressure was inconclusive. A meta-analysis confirmed that older age (mean difference, 7.9 y; 95% CI, 1.5-14.3 y) and manometric subtype 3 (odds ratio, 7.1; 95% CI, 4.1-12.4) were associated with clinical response. CONCLUSIONS In a systematic review and meta-analysis, we found age and manometric subtype to be associated with outcomes of treatment for achalasia. This information should be used to guide treatment decisions.
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Affiliation(s)
- Renske A B Oude Nijhuis
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands.
| | - Leah I Prins
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Nahid Mostafavi
- Biostatistical Unit, Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Andreas J P M Smout
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss the efficacy, morbidity and side-effects of innovative management strategies for achalasia that include high-resolution manometry (HRM), pneumatic dilatation, laparoscopic Heller's myotomy (LHM), injection of botulinum toxin into the lower esophageal sphincter and peroral endoscopic myotomy (POEM). RECENT FINDINGS HRM has enabled identification of achalasia subtypes that have important prognostic implications. Pneumatic dilatation is a commonly-used and cost-effective method of treating achalasia but has shown poor longevity of symptom relief compared with other modalities and carries a risk of esophageal perforation. LHM is often the preferred, most effective treatment modality, however new studies may show that outcomes are equivalent or even inferior to POEM. Botulinum toxin injection of the lower esophageal sphincter has a waning and short duration of efficacy and is used primarily for patients unsuitable for more definitive invasive procedures. POEM is considered the most effective treatment for type III achalasia but carries a high risk of iatrogenic gastroesophageal reflux disease that might predispose to the development of Barrett's esophagus. SUMMARY HRM and POEM are two major innovations in the management of achalasia developed over the past decade. There are now three major management options for patients with achalasia, namely pneumatic dilatation, LHM and POEM. Treatment selection should be tailored to the patient's individual esophageal physiology, physical fitness and dominant symptoms.
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Bechara R, Woo M, Hookey L, Chung W, Grimes K, Ikeda H, Onimaru M, Sumi K, Nakamura J, Hata Y, Maruyama S, Gomi K, Shimamura Y, Inoue H. Peroral endoscopic myotomy (POEM) for complex achalasia and the POEM difficulty score. Dig Endosc 2019; 31:148-155. [PMID: 30417948 DOI: 10.1111/den.13294] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/31/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) for achalasia is technically challenging to carry out in patients with type III, multiple prior treatments, prior myotomy, and sigmoid type. Herein, we present a series of consecutive patients with complex achalasia and introduce the POEM difficulty score (PDS). AIM To demonstrate the application and discuss the utility of PDS and present the feasibility, safety, and efficacy of POEM in complex achalasia patients. METHODS Forty consecutive POEM were carried out with 28 meeting the criteria for complex achalasia. Primary outcome was clinical success (Eckardt score ≤3) at a minimum of 3 months follow-up. Secondary outcomes included adverse events, procedural velocity and PDS. RESULTS Twenty-eight complex and 12 non-complex POEM procedures were carried out with 100% and 92% clinical success, respectively, without any major adverse events with a median follow up of 15 months (complex) and 8 months (non-complex). Mean velocities for non-complex, type III, prior myotomy, ≥4 procedures and sigmoid type were as follows: 4.4 ± 1.6, 4.8 ± 1.5, 5.9 ± 2.2, 6.9 ± 2.2 and 8.2 ± 3.2 min/cm, respectively. Median PDS for non-complex, type III, prior myotomy, ≥4 treatments and sigmoid type were 1 (0-3), 2 (0-4), 2.5 (1-6), 3 (2-6) and 3.5 (1-6), respectively. PDS was shown to correlate well with procedural velocity with a correlation coefficient of 0.772 (Spearman's P < 0.001). CONCLUSIONS PDS identifies the factors that contribute to challenging POEM procedures and correlates well with procedural velocity. The order of increasing difficulty of POEM in complex achalasia appears to be type III, prior myotomy, ≥4 treatments and sigmoid type.
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Affiliation(s)
- Robert Bechara
- Division of Gastroenterology, Kingston Health Sciences Center, Queens University, Kingston General Hospital, Ontario, Canada
| | - Matthew Woo
- Division of Gastroenterology, Kingston Health Sciences Center, Queens University, Kingston General Hospital, Ontario, Canada
| | - Lawrence Hookey
- Division of Gastroenterology, Kingston Health Sciences Center, Queens University, Kingston General Hospital, Ontario, Canada
| | - Wiley Chung
- Division of Thoracic Surgery, Kingston Health Sciences Center, Queens University, Kingston General Hospital, Ontario, Canada
| | - Kevin Grimes
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Haruo Ikeda
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Tokyo, Japan
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Tokyo, Japan
| | - Kazuya Sumi
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Tokyo, Japan
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Yoshitaka Hata
- Department of Medicine and Bioregulatory Science, Kyushu University, Fukuoka, Japan
| | - Shota Maruyama
- Department of Surgery, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Kuniyo Gomi
- Division of Gastroenterology, Showa University, Fujigaoka Hospital, Kanagawa, Japan
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Tokyo, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Tokyo, Japan
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Laparoscopic Heller Myotomy Versus Peroral Endoscopic Myotomy (POEM) for Achalasia: A Systematic Review and Meta-analysis. Ann Surg 2019; 267:451-460. [PMID: 28549006 DOI: 10.1097/sla.0000000000002311] [Citation(s) in RCA: 231] [Impact Index Per Article: 46.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To compare the outcome of per oral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM) for the treatment of esophageal achalasia. BACKGROUND Over the last 2 decades, LHM has become the primary form of treatment in many centers. However, since the first description of POEM in 2010, this technique has widely disseminated, despite the absence of long-term results and randomized trials. METHODS A systematic Medline literature search of articles on LHM and POEM for the treatment of achalasia was performed. The main outcomes measured were improvement of dysphagia and posttreatment gastroesophageal reflux disease (GERD). Linear regression was used to model the effect of each procedure on the different outcomes. RESULTS Fifty-three studies reported data on LHM (5834 patients), and 21 articles examined POEM (1958 patients). Mean follow-up was significantly longer for studies of LHM (41.5 vs. 16.2 mo, P < 0.0001). Predicted probabilities for improvement in dysphagia at 12 months were 93.5% for POEM and 91.0% for LHM (P = 0.01), and at 24 months were 92.7% for POEM and 90.0% for LHM (P = 0.01). Patients undergoing POEM were more likely to develop GERD symptoms (OR 1.69, 95% CI 1.33-2.14, P < 0.0001), GERD evidenced by erosive esophagitis (OR 9.31, 95% CI 4.71-18.85, P < 0.0001), and GERD evidenced by pH monitoring (OR 4.30, 95% CI 2.96-6.27, P < 0.0001). On average, length of hospital stay was 1.03 days longer after POEM (P = 0.04). CONCLUSIONS Short-term results show that POEM is more effective than LHM in relieving dysphagia, but it is associated with a very high incidence of pathologic reflux.
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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: 24] [Impact Index Per Article: 4.8] [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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Zaninotto G, Bennett C, Boeckxstaens G, Costantini M, Ferguson MK, Pandolfino JE, Patti MG, Ribeiro U, Richter J, Swanstrom L, Tack J, Triadafilopoulos G, Markar SR, Salvador R, Faccio L, Andreollo NA, Cecconello I, Costamagna G, da Rocha JRM, Hungness ES, Fisichella PM, Fuchs KH, Gockel I, Gurski R, Gyawali CP, Herbella FAM, Holloway RH, Hongo M, Jobe BA, Kahrilas PJ, Katzka DA, Dua KS, Liu D, Moonen A, Nasi A, Pasricha PJ, Penagini R, Perretta S, Sallum RAA, Sarnelli G, Savarino E, Schlottmann F, Sifrim D, Soper N, Tatum RP, Vaezi MF, van Herwaarden-Lindeboom M, Vanuytsel T, Vela MF, Watson DI, Zerbib F, Gittens S, Pontillo C, Vermigli S, Inama D, Low DE. The 2018 ISDE achalasia guidelines. Dis Esophagus 2018; 31:5087687. [PMID: 30169645 DOI: 10.1093/dote/doy071] [Citation(s) in RCA: 155] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.
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Affiliation(s)
- G Zaninotto
- Department of Surgery and Cancer, Imperial College, London, UK
| | - C Bennett
- Office of Research and Innovation, Royal College of Surgeons in Ireland, Ireland
| | - G Boeckxstaens
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - M Costantini
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - M K Ferguson
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - J E Pandolfino
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - M G Patti
- Department of Medicine and Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - U Ribeiro
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - J Richter
- Department of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - L Swanstrom
- Institute of Image-Guided Surgery, Strasbourg, France; Interventional Endoscopy and Foregut Surgery, Oregon Health Science University, Portland, Oregon, USA
| | - J Tack
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - G Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford Esophageal Multidisciplinary Program in Innovative Research Excellence (SEMPIRE), Stanford University, Stanford, California, USA
| | - S R Markar
- Department of Surgery and Cancer, Imperial College, London, UK
| | - R Salvador
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - L Faccio
- Division of Surgery, Padova University Hospital, Padova, Italy
| | - N A Andreollo
- Faculty of Medical Science, State University of Campinas, Campinas, São Paulo, Brazil
| | - I Cecconello
- Digestive Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - G Costamagna
- Digestive Endoscopy Unit, A. Gemelli Hospital, Catholic University, Rome, Italy
| | - J R M da Rocha
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - E S Hungness
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - P M Fisichella
- Department of Surgery, Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
| | - K H Fuchs
- Department of Surgery, AGAPLESION-Markus-Krankenhaus, Frankfurt, Germany
| | - I Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - R Gurski
- Department of Surgery, School of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - F A M Herbella
- Department of Surgery, School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - R H Holloway
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, The University of Adelaide, Adelaide, Australia
| | - M Hongo
- Department of Medicine, Kurokawa Hospital, Taiwa, Kurokawa, Miyagi, Japan
| | - B A Jobe
- Esophageal and Lung Institute, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania, USA
| | - P J Kahrilas
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - D A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - K S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - D Liu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - A Moonen
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - A Nasi
- Digestive Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - P J Pasricha
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - R Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico; Department of Pathophysiology and Transplantation; Università degli Studi, Milan, Italy
| | - S Perretta
- Institute for Image Guided Surgery IHU-Strasbourg, Strasbourg, France
| | - R A A Sallum
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - G Sarnelli
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - E Savarino
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - F Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - D Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - N Soper
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - R P Tatum
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - M F Vaezi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - M van Herwaarden-Lindeboom
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - T Vanuytsel
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - M F Vela
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - D I Watson
- Department of Surgery, Flinders University, Adelaide, Australia
| | - F Zerbib
- Department of Gastroenterology, University of Bordeaux, Bordeaux, France
| | - S Gittens
- ECD Solutions, Atlanta, Georgia, USA
| | - C Pontillo
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - S Vermigli
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - D Inama
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - D E Low
- Department of Thoracic Surgery Virginia Mason Medical Center, Seattle, Washington, USA
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12
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Chen YI, Inoue H, Ujiki M, Draganov PV, Colavita P, Mion F, Romanelli J, Chiu P, Balassone V, Patel L, Abbas A, Yang D, Dunst C, Pioche M, Roman S, Rivory J, Ponchon T, Desilets D, Maselli R, Onimaru M, Nakamura J, Hata Y, Hajiyeva G, Ismail A, Ngamruengphong S, Bukhari M, Chavez YH, Kumbhari V, Repici A, Khashab MA. An international multicenter study evaluating the clinical efficacy and safety of per-oral endoscopic myotomy in octogenarians. Gastrointest Endosc 2018; 87:956-961. [PMID: 28235595 DOI: 10.1016/j.gie.2017.02.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 02/10/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Per-oral endoscopic myotomy (POEM) for achalasia is particularly appealing in the elderly because it is minimally invasive. However, data in patients aged ≥80 years are scarce. The aim of this study was to assess the clinical outcome of POEM in octogenarians. METHODS This was a multicenter retrospective study at 8 centers. Consecutive octogenarians with achalasia who underwent POEM between 2010 and 2016 were included. Rates of technical success (completion of myotomy), clinical response (Eckardt score ≤3), and adverse events (severity graded as per American Society for Gastrointestinal Endoscopy lexicon) were assessed. RESULTS A total of 76 patients (47.4% female, mean age 84 years) underwent POEM for treatment of achalasia: type I, 17.1%; type II, 35.5%; type III, 17.1%; and unspecified, 30.3%. Overall, 41.1% were treatment naïve, whereas others had previous botulinum toxin injection and/or pneumatic dilation. The mean (± standard deviation [SD]) age-adjusted Charlson comorbidity index score was 6.2 ± 2.4, with the majority of patients having American Society of Anesthesiologists Physical Status Classification System (ASA) scores of II/III. Technical success was 93.4%, with a median follow-up of 256 days. Fourteen adverse events occurred in 11 patients (14.5%). There were 3 inadvertent mucosotomies, 6 cases of symptomatic capnoperitoneum and/or capnomediastinum, 2 esophageal leaks, 1 cardiac arrhythmia, and 2 other). The severities of these adverse events were mild (78.6%), moderate (14.3%), and severe (7.1%). Clinical success was achieved in 90.8% of patients, with a mean (± SD) Eckardt score reduction from 7.0 ± 2.3 to 0.8 ± 0.1 (P < .001), a median follow-up of 256 days, and interquartile range of 66 to 547. CONCLUSION Although the rate of technical success may be somewhat lower and the rate of adverse events slightly higher than previously reported, our data suggest that POEM in octogenarians is safe and effective, supporting its role as a primary modality for achalasia in this patient population.
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Affiliation(s)
- Yen-I Chen
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan
| | - Michael Ujiki
- Department of Surgery, Section of Minimally Invasive Surgery, NorthShore University Health System, Evanston, Illinois, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Paul Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, The Oregon Clinic, Portland, Oregon, USA
| | - Francois Mion
- Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France
| | - John Romanelli
- Baystate Medical Center, University of Massachusetts School of Medicine, Springfield, Massachusetts, USA
| | - Philip Chiu
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Valerio Balassone
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan
| | - Lava Patel
- Department of Surgery, Section of Minimally Invasive Surgery, NorthShore University Health System, Evanston, Illinois, USA
| | - Ali Abbas
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Dennis Yang
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Christy Dunst
- Division of Gastrointestinal and Minimally Invasive Surgery, The Oregon Clinic, Portland, Oregon, USA
| | - Mathieu Pioche
- Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France
| | - Sabine Roman
- Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France
| | - Jérôme Rivory
- Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France
| | - Thierry Ponchon
- Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France
| | - David Desilets
- Baystate Medical Center, University of Massachusetts School of Medicine, Springfield, Massachusetts, USA
| | - Roberta Maselli
- Digestive Endoscopy Unit, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan
| | - Jun Nakamura
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan
| | - Yoshitaka Hata
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan
| | - Gulara Hajiyeva
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Amr Ismail
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Saowanee Ngamruengphong
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Majidah Bukhari
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Yamile Haito Chavez
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Mouen A Khashab
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Ngamruengphong S, Inoue H, Chiu PWY, Yip HC, Bapaye A, Ujiki M, Patel L, Desai PN, Hayee B, Haji A, Wong VWY, Perretta S, Dorwat S, Pioche M, Roman S, Rivory J, Mion F, Ponchon T, Garros A, Nakamura J, Hata Y, Balassone V, Onimaru M, Hajiyeva G, Ismail A, Chen YI, Bukhari M, Haito-Chavez Y, Kumbhari V, Maselli R, Repici A, Khashab MA. Long-term outcomes of per-oral endoscopic myotomy in patients with achalasia with a minimum follow-up of 2 years: an international multicenter study. Gastrointest Endosc 2017; 85:927-933.e2. [PMID: 27663714 DOI: 10.1016/j.gie.2016.09.017] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 09/12/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Per-oral endoscopic myotomy (POEM) has shown promising safety and efficacy in short-term studies. However, long-term follow-up data are very limited. The aims of this study were to assess (1) clinical outcome of patients with a minimum post-POEM follow-up of 2 years and (2) factors associated with long-term clinical failure after POEM. METHODS A retrospective chart review was performed that included all consecutive patients with achalasia who underwent POEM with a minimum follow-up of 2 years at 10 tertiary-care centers. Clinical response was defined by a decrease in Eckardt score to 3 or lower. RESULTS A total of 205 patients (45.8% men; mean age, 49 years) were followed for a median of 31 months (interquartile range, 26-38 months). Of these, 81 patients (39.5%) had received previous treatment for achalasia before POEM. Clinical success was achieved in 98% (185/189), 98% (142/144), and 91% (187/205) of patients with follow-up within 6 months, at 12 months, and ≥24 months, respectively. Of 185 patients with clinical response at 6 months, 11 (6%) experienced recurrent symptoms at 2 years. History of previous pneumatic dilation was associated with long-term treatment failure (odds ratio, 3.41; 95% confidence interval, 1.25-9.23). Procedure-related adverse events occurred in 8.2% of patients and only 1 patient required surgical intervention. Abnormal esophageal acid exposure and reflux esophagitis were documented in 37.5% and 18% of patients, respectively. However, these rates are simply a reference number among a very selective group of patients. CONCLUSIONS POEM is safe and provides high initial clinical success and excellent long-term outcomes. Among patients with confirmed clinical response within 6 months, 6% had recurrent symptoms by 2 years.
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Affiliation(s)
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | | | - Hon Chi Yip
- Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Amol Bapaye
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Michael Ujiki
- Department of Surgery, NorthShore University HealthSystem, Chicago, Illinois, USA
| | - Lava Patel
- Department of Surgery, NorthShore University HealthSystem, Chicago, Illinois, USA
| | | | - Bu Hayee
- Department of Gastroenterology, Kings College Hospital NHS Foundation Trust, London, United Kingdom
| | - Amyn Haji
- Department of Gastroenterology, Kings College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Silvana Perretta
- Department of Gastrointestinal and Endocrine Surgery, University of Strasbourg, Strasbourg, France
| | - Shivangi Dorwat
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Mathieu Pioche
- Gastroenterology and Endoscopy Unit, Digestive Disease Department, L Pavillon-Edouard Herriot Hospital, Lyon, France
| | - Sabine Roman
- Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France; INSERM U1032, Lyon, France
| | - Jérôme Rivory
- Gastroenterology and Endoscopy Unit, Digestive Disease Department, L Pavillon-Edouard Herriot Hospital, Lyon, France
| | - François Mion
- Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France; INSERM U1032, Lyon, France
| | - Thierry Ponchon
- Gastroenterology and Endoscopy Unit, Digestive Disease Department, L Pavillon-Edouard Herriot Hospital, Lyon, France
| | - Aurélien Garros
- Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France; INSERM U1032, Lyon, France
| | - Jun Nakamura
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Yoshitaka Hata
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Valerio Balassone
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Gulara Hajiyeva
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Amr Ismail
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Yen-I Chen
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Majidah Bukhari
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Yamile Haito-Chavez
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Roberta Maselli
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Milan, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Milan, Italy
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
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14
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Schlottmann F, Andolfi C, Kavitt RT, Konda VJA, Patti MG. Multidisciplinary Approach to Esophageal Achalasia: A Single Center Experience. J Laparoendosc Adv Surg Tech A 2017; 27:358-362. [PMID: 28099056 DOI: 10.1089/lap.2016.0594] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The treatment of achalasia is palliative. Pneumatic dilatation (PD) or laparoscopic Heller myotomy (LHM) just eliminates the outflow obstruction allowing easier emptying of the esophagus. The aim of this study was to evaluate the results of a multidisciplinary approach to esophageal achalasia. MATERIALS AND METHODS A consecutive series of patients with achalasia treated by a multidisciplinary esophageal team consisting of radiologists, gastroenterologists, and surgeons in a quaternary care center between May 2008 and April 2015 were analyzed. RESULTS A total of 147 patients with achalasia underwent LHM and partial fundoplication. Sixty-two patients (42%) had been treated preoperatively with PD and/or botulinum toxin (BT). The preoperative Eckardt score (ES) was 6.4 ± 2. At a median follow-up of 22 months, 128 patients (87%) did well and required no further treatment (ES 0.1). The remaining 19 patients (13%) had recurrence of symptoms and required further treatment: 12 were treated with PD and improved (ES 0.7); 4 were treated with PD and BT and improved (ES 1.3); 3 failed PD. These 3 patients had been treated with multiple sessions of PD and BT before the myotomy. Overall, 144 patients (98%) did well with laparoscopic (87%) or laparoscopic and endoscopic treatment (11%). CONCLUSIONS The results of this study show that (a) LHM is an effective treatment modality, (b) PD improved symptoms in the majority of patients with recurrent dysphagia after myotomy and (c) multiple preoperative endoscopic treatments seem to affect outcomes of LHM. Patients with achalasia should be treated in a quaternary care center by a multidisciplinary team.
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Affiliation(s)
- Francisco Schlottmann
- 1 Department of Surgery, Center for Esophageal Diseases and Swallowing, University of North Carolina , Chapel Hill, North Carolina
| | - Ciro Andolfi
- 2 Department of Surgery, University of Chicago , Chicago, Illinois
| | - Robert T Kavitt
- 3 Department of Medicine, University of Chicago , Chicago, Illinois
| | - Vani J A Konda
- 3 Department of Medicine, University of Chicago , Chicago, Illinois
| | - Marco G Patti
- 1 Department of Surgery, Center for Esophageal Diseases and Swallowing, University of North Carolina , Chapel Hill, North Carolina
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15
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Moonen A, Boeckxstaens G. Finding the Right Treatment for Achalasia Treatment: Risks, Efficacy, Complications. ACTA ACUST UNITED AC 2016; 14:420-428. [DOI: 10.1007/s11938-016-0105-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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16
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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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18
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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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19
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Esposito D, Maione F, D’Alessandro A, Sarnelli G, De Palma GD. Endoscopic treatment of esophageal achalasia. World J Gastrointest Endosc 2016; 8:30-39. [PMID: 26839644 PMCID: PMC4724029 DOI: 10.4253/wjge.v8.i2.30] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 09/19/2015] [Accepted: 12/15/2015] [Indexed: 02/05/2023] Open
Abstract
Achalasia is a motility disorder of the esophagus characterized by dysphagia, regurgitation of undigested food, chest pain, weight loss and respiratory symptoms. The most common form of achalasia is the idiopathic one. Diagnosis largely relies upon endoscopy, barium swallow study, and high resolution esophageal manometry (HRM). Barium swallow and manometry after treatment are also good predictors of success of treatment as it is the residue symptomatology. Short term improvement in the symptomatology of achalasia can be achieved with medical therapy with calcium channel blockers or endoscopic botulin toxin injection. Even though few patients can be cured with only one treatment and repeat procedure might be needed, long term relief from dysphagia can be obtained in about 90% of cases with either surgical interventions such as laparoscopic Heller myotomy or with endoscopic techniques such pneumatic dilatation or, more recently, with per-oral endoscopic myotomy. Age, sex, and manometric type by HRM are also predictors of responsiveness to treatment. Older patients, females and type II achalasia are better after treatment compared to younger patients, males and type III achalasia. Self-expandable metallic stents are an alternative in patients non responding to conventional therapies.
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20
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Abstract
A laparoscopic Heller myotomy with partial fundoplication is considered today in most centers in the United States and abroad the treatment of choice for patients with esophageal achalasia. Even though the operation has initially a very high success rate, dysphagia eventually recurs in some patients. In these cases, it is important to perform a careful work-up to identify the cause of the failure and to design a tailored treatment plan by either endoscopic means or revisional surgery. The best results are obtained by a team approach, in Centers where radiologists, gastroenterologists, and surgeons have experience in the diagnosis and treatment of this disease.
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21
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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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22
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Yao S, Linghu E. Peroral endoscopic myotomy can improve esophageal motility in patients with achalasia from a large sample self-control research (66 patients). PLoS One 2015; 10:e0125942. [PMID: 25993648 PMCID: PMC4436219 DOI: 10.1371/journal.pone.0125942] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 03/20/2015] [Indexed: 12/13/2022] Open
Abstract
Background Peroral endoscopic myotomy (POEM) as a new approach to achalasia attracts broad attention. The primary objective of this study was to evaluate the results with esophageal motility after POEM through the first large sample clinical research. Patients and Methods We have a self-control research with all patients (205 in total) who underwent POEM from 2010 to 2014 at our Digestive Endoscopic Center, 66 patients of which underwent high resolution manometry (HRM) before and after POEM in our motility laboratory. Follow-ups last for 5.6 months on average. Outcome variables analyzed included upper esophageal sphincter pressure (UESP), upper esophageal sphincter residual pressure (UESRP), lower esophageal sphincter pressure (LESP), lower esophageal sphincter residual pressure (LESRP) and esophageal body peristalsis. We have a statistical analysis to illustrate how POEM impacts on the change of esophageal motility. Results The symptoms related to dysphagia were relieved in 95% of patients in recent term after POEM. While HRM showed a statistically significant reduction of URSRP, LESP and LESRP (P<0.01), however, peristalsis was not consistently affected. There were 11 patients who had undergone other prior endoscopic treatment (endoscopic dilation or botulinum toxin injection) and 55 patients had not. The statistical difference (P>0.05) did not occur for these two groups on LESP and LESRP reduction. Conclusions POEM clearly relieved the symptoms related to dysphagia by lowering the pressure of upper esophageal sphincter (UES) and lower esophageal sphincter (LES),and other endoscopic treatment before POEM did not affect the improvement of LES pressure. These results are concluded from our short-term follow-up study, while the long-term efficacy remains to be further illustrated. Trial Registration Chinese Clinical Trial Register ChiCTR-TRC-12002204)
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Affiliation(s)
- Shuangzhe Yao
- Department of Gastroenterology, Chinese People's Liberation Army General Hospital, No. 28, Fuxing Road, Haidian District, Beijing 100853, China
| | - Enqiang Linghu
- Department of Gastroenterology, Chinese People's Liberation Army General Hospital, No. 28, Fuxing Road, Haidian District, Beijing 100853, China
- * E-mail:
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Lu B, Li M, Hu Y, Xu Y, Zhang S, Cai LJ. Effect of peroral esophageal myotomy for achalasia treatment: A Chinese study. World J Gastroenterol 2015; 21:5622-5629. [PMID: 25987787 PMCID: PMC4427686 DOI: 10.3748/wjg.v21.i18.5622] [Citation(s) in RCA: 15] [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: 11/29/2014] [Revised: 01/15/2015] [Accepted: 02/13/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the safety and feasibility of peroral esophageal myotomy (POEM) in patients with achalasia.
METHODS: From January 2012 to March 2014, 50 patients (28 men, 22 women; mean age: 42.8 years, range: 14-70 years) underwent POEM. Pre- and postoperative symptoms were quantified using the Eckardt scoring system. Barium swallow and esophagogastroscopy were performed before and after POEM, respectively. Esophageal motility was evaluated in all patients, both preoperatively and one month after POEM treatment, using a high-resolution manometry system. Manometry data, Eckardt scores, lower esophageal sphincter pressure and barium swallow results were used to evaluate the effect of the procedure.
RESULTS: POEM was successfully completed for all patients. The mean procedure time was 55.4 ± 17.3 min and the mean total length of myotomy of the circular esophagus was 10.5 ± 2.6 cm. No specific complications occurred, with the exception of two patients that developed asymptomatic pneumomediastinum and subcutaneous emphysema. Clinical improvement in symptoms was achieved in all patients. Approximately 77.5% of patients experienced weight gain 6 mo after POEM, with an average of 4.78 kg (range: 2-15 kg). The lower esophageal sphincter resting pressure, four second integrated relaxation pressure and Eckardt scores were all significantly reduced after POEM (Ps < 0.05). A small segment of proximal esophageal peristalsis appeared postoperatively in two patients, but without normal esophageal peristalsis. The average diameter of the esophageal lumen decreased significantly from 4.39 to 3.09 cm (P < 0.01).
CONCLUSION: POEM can relieve achalasia symptoms, improve gastroesophageal junction relaxation and restore esophageal body motility function, but not normal esophageal peristalsis.
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The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on peroral endoscopic myotomy. Gastrointest Endosc 2015; 81:1087-100.e1. [PMID: 25799295 DOI: 10.1016/j.gie.2014.12.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 12/08/2014] [Indexed: 12/13/2022]
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Ross SW, Oommen B, Wormer BA, Walters AL, Matthews BD, Heniford BT, Augenstein VA. National outcomes of laparoscopic Heller myotomy: operative complications and risk factors for adverse events. Surg Endosc 2015; 29:3097-105. [PMID: 25588362 DOI: 10.1007/s00464-014-4054-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Accepted: 12/16/2014] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Laparoscopic Heller myotomy (LHM) has supplanted an open approach due to decreased operative morbidity. Our goal was to quantify the incidence of peri-operative complications and identify risk factors for adverse outcomes in LHM. METHODS All LHM were queried from 2005 to 2011 from the National Surgical Quality Improvement Program database. Adverse outcomes were identified, and univariate and stepwise logistic regression (MVR) was then performed to quantify association. RESULTS There were 1,237 LHM in the study period. Patient averages were: age 51.9 ± 16.8 years, BMI 27.3 ± 6.6 kg/m(2), Charlson comorbidity index (CCI) 0.2 ± 0.6. 15.3 % had >10 % body mass loss in the preoperative 6 months. During surgery, 10.2 % underwent concomitant EGD, and mean operative time was 141.6 ± 63.4 min. There were 7(0.06 %) wound complications, 22(1.8 %) general complications, and 30(2.4 %) major complications. Average length of stay (LOS) was 2.8 ± 5.5 days. The rate of readmission and reoperation were 3.1 and 2.3 %, respectively, and there were 4(0.03 %) deaths. General and major complications were associated with alcohol use, pack-years of smoking, weight loss, history of stroke, radiation therapy, and longer operative times (p < 0.05); however, these factors did not remain significant on MVR (p > 0.05). Operative time was found to be significantly longer by 35.3 min for inpatients, 43.1 min in functionally dependent patients, 50.0 min in preoperative septic patients, and 17.2 min with concomitant EGD (p < 0.01 for all). LOS was found to be longer by 1.9 days for inpatients, 1.8 days in ASA category ≥3, and 1.2 days per one point increase in CCI (p < 0.001 for all). CONCLUSION LHM is being performed nationally with a low incidence of operative complications and mortality. General and major complications following LHM are associated with patient alcohol use, pack-years of smoking, weight loss, history of stroke, radiation therapy, and longer operative times. Additionally, independent predictors of longer operative time and LOS were identified.
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Affiliation(s)
- Samuel W Ross
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - Bindhu Oommen
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - Blair A Wormer
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - Amanda L Walters
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - Brent D Matthews
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - B T Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA.
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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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Minami H, Isomoto H, Yamaguchi N, Matsushima K, Akazawa Y, Ohnita K, Takeshima F, Inoue H, Nakao K. Peroral endoscopic myotomy for esophageal achalasia: clinical impact of 28 cases. Dig Endosc 2014; 26:43-51. [PMID: 23581563 DOI: 10.1111/den.12086] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Accepted: 02/12/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of the present study was to clarify the efficacy of peroral endoscopic myotomy (POEM) for esophageal achalasia. PATIENTS AND METHODS Twenty-eight esophageal achalasia patients who underwent POEM in our institution between August 2010 and October 2012 were enrolled. Under general anesthesia with tracheal intubation, initial incision was made on the anterior wall of the esophagus after submucosal injection. Submucosal tunnel was created and extended below the lower esophageal sphincter (LES) onto the gastric cardia. Subsequently, myotomy was done using triangle tip knife. After confirmation of smooth passage of scope through the esophagogastric junction, the entry was closed. Esophagogram and manometry study was done before and after the procedure. Also, subjective symptom score and Eckardt score were assessed before and 3 months after POEM. RESULTS POEM was successfully done in all cases without any severe complications such as perforation and mediastinitis.Mean procedure time was 99.1 min (range 61-160) and mean myotomy length was 14.4 cm (range 10-18). Significant improvement was achieved in both esophagogram and endoscopic findings. Mean LES pressure was 71.2 mmHg (35.8-119.0) and 21.0 mmHg (6.7-41.0) before and after the procedure (P < 0.05), respectively. Mean Eckardt score was 6.7 (3-12, median 7) and 0.7 (0-3, median 1) before and 3 months after POEM, respectively (P < 0.05). Symptomatic gastroesophageal reflux disease that was easily controlled by the usual dose of proton pump inhibitor was seen in six cases (21.4%) after the procedure. CONCLUSION POEM could be a curative standard treatment of choice for esophageal achalasia.
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Affiliation(s)
- Hitomi Minami
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
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Teitelbaum EN, Soper NJ, Arafat FO, Santos BF, Kahrilas PJ, Pandolfino JE, Hungness ES. Analysis of a learning curve and predictors of intraoperative difficulty for peroral esophageal myotomy (POEM). J Gastrointest Surg 2014; 18:92-8; discussion 98-9. [PMID: 24002767 DOI: 10.1007/s11605-013-2332-0] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 08/20/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Peroral esophageal myotomy (POEM) is an endoscopic surgical operation for achalasia. Here, we analyze a single-series POEM learning curve and examine which preoperative patient factors are predictive of operative difficulty. METHODS Two surgeons performed all POEM procedures conjointly. Nonlinear regression was used to determine the learning curve for procedure time. Preoperative patient characteristics were correlated with outcomes. RESULTS Thirty-six POEM procedures were performed. Total operative time did not decrease over the course of the series (mean 112 ± 36 min). Time required to complete the procedural steps of submucosal access and myotomy did decrease with experience, both exhibiting a "learning rate" of seven cases. The incidence of inadvertent mucosal perforations and the number of clips required both decreased with experience. Postoperative Eckardt scores at 1-year follow-up decreased over the course of the series. Prior endoscopic treatment, symptom duration, and esophageal width were all independently predictive of longer procedure time. Preoperative symptom duration was also positively associated with inadvertent mucosal perforation and the number of clips required. CONCLUSIONS In this series, overall procedure time did not decrease with experience and may not be an important marker of procedural skill for POEM. Prior endoscopic treatment, longer symptom duration, and esophageal dilatation may result in increased operative difficulty during POEM.
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Affiliation(s)
- Ezra N Teitelbaum
- Department of Surgery, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 650, Chicago, IL, 60611, USA
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Kumar AR, Schnoll-Sussman FH, Katz PO. Botulinum toxin and pneumatic dilation in the treatment of achalasia. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2014. [DOI: 10.1016/j.tgie.2013.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Tabola R, Grabowski K, Lewandowski A, Augoff K, Markocka-Maczka K. Achalasia--balloon dilation or surgery? Med Sci Monit 2013; 19:1089-94. [PMID: 24296693 PMCID: PMC3862145 DOI: 10.12659/msm.884028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Accepted: 04/17/2013] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The optimal therapeutic schedule in patients with achalasia is still under discussion. The aim of this study was to review our institution's experience with myotomy and dilation in patients with achalasia. MATERIAL AND METHODS Clinical data were available for 59 patients who had ever had myotomy (n=38), dilation (n=21), or both procedures (n=8) between 2000 and 2007. Patients were followed prospectively with objective (a barium esophagogram) and subjective (a simple survey that scored dysphagia and overall patient satisfaction with the procedure) diagnostic tools. In the group of patients after pneumatic dilatations, frequency of interventions was higher (1, 2) than in the myotomy group (0, 2) at 2-year follow-up. Patients after myotomy with recurrence of dysphagia were treated with dilations. RESULTS Mean time of dysphagia occurrence was similar in both groups (10 months). The statistically significant differences in treatment outcomes in both groups were in favor of myotomy during 2-year follow-up. CONCLUSIONS The data indicates that both methods of treatment might be useful in dysphagia control, but better results are obtained after myotomy. Repeat interventions are more frequent after endoscopic dilation. One method of treatment does not exclude the other. A short period of symptom relief after myotomy may suggest the myotomy was incomplete.
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Peroral endoscopic myotomy (POEM) is safe and effective in the setting of prior endoscopic intervention. J Gastrointest Surg 2013; 17:1188-92. [PMID: 23609138 DOI: 10.1007/s11605-013-2193-6] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 03/27/2013] [Indexed: 01/31/2023]
Abstract
OBJECTIVE We aimed to determine the safety and feasibility of peroral endoscopic myotomy (POEM) in the setting of prior endoscopic interventions. PATIENTS This study involves 40 consecutive patients undergoing POEM. INTERVENTION POEM was performed for esophageal motility disorders, including achalasia, nutcracker with nonrelaxing lower esophageal sphincter (LES), hypertensive lower esophageal sphincter, and diffuse esophageal spasm. MAIN OUTCOME MEASURES Outcome measures include length of procedure (LOP), intraoperative complications, and dysphagia relief. RESULTS Forty patients, with a mean age of 54 ± 19 years, underwent POEM. The pre-POEM intervention group consisted of 12 patients (nine achalasia, two nutcracker with nonrelaxing LES, and one diffuse esophageal spasm) who also had previous endoscopic treatment, while the pre-POEM non-intervention group consisted of 28 patients (22 achalasia, 3 hypertensive LES, 2 nutcracker with nonrelaxing LES, and 1 diffuse esophageal spasm). Ten patients had botox injections and two patients had large caliber balloon dilations prior to POEM. The median preoperative Eckardt score was 5 in the pre-POEM intervention group vs 6 in the pre-POEM non-intervention group (p value = 0.4). There was no statistical difference in the mean LOP (134 ± 43 vs 131 ± 41, p = 0.8) or the incidence of intraoperative complications (17 vs 3 %, p = 0.2) between the two groups. There was also no difference in the 6-month postoperative median Eckardt scores between the two groups (1 vs 1, p = 0.4). CONCLUSION POEM is safe and effective even following preoperative endoscopic large caliber balloon dilations or botox injection. These interventions do not seem to contribute to increased adverse intraoperative or postoperative clinical outcomes.
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Peroral endoscopic myotomy periprocedural evaluation: Predicting and measuring outcomes. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2013. [DOI: 10.1016/j.tgie.2013.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Abstract
Achalasia is a rare motility disorder of the esophagus characterized by the absence of peristalsis and defective relaxation of the lower esophageal sphincter. Patients present at all ages with dysphagia and regurgitation as main symptoms. The diagnosis is suggested by barium swallow and endoscopy and confirmed by manometry. Because there is no curative treatment for achalasia, treatment is confined to disruption of the lower esophageal sphincter to improve bolus passage. The most successful therapies are pneumodilation and laparoscopic Heller myotomy, with comparable short-term clinical rates of success. The prognosis of achalasia patients is good, but re-treatment is often necessary.
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Stavropoulos SN, Friedel D, Modayil R, Iqbal S, Grendell JH. Endoscopic approaches to treatment of achalasia. Therap Adv Gastroenterol 2013; 6:115-35. [PMID: 23503707 PMCID: PMC3589133 DOI: 10.1177/1756283x12468039] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Endoscopic therapy for achalasia is directed at disrupting or weakening the lower esophageal sphincter (LES). The two most commonly utilized endoscopic interventions are large balloon pneumatic dilation (PD) and botulinum toxin injection (BTI). These interventions have been extensively scrutinized and compared with each other as well as with surgical disruption (myotomy) of the LES. PD is generally more effective in improving dysphagia in achalasia than BTI, with the latter reserved for infirm older people, and PD may approach treatment results attained with myotomy. However, PD may need to be repeated. Small balloon dilation and endoscopic stent placement for achalasia have only been used in select centers. Per oral endoscopic myotomy is a newer endoscopic modality that will likely change the treatment paradigm for achalasia. It arose from the field of natural orifice transluminal endoscopic surgery and represents a scarless endoscopic approach to Heller myotomy. This is a technique that requires extensive training and preparation and thus there should be rigorous accreditation and monitoring of outcomes to ensure safety and efficacy.
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Abstract
PURPOSE OF REVIEW In recent years, several studies on the treatment and follow-up of achalasia have been published. This review aims at highlighting interesting publications from the recent years. RECENT FINDINGS Treatment of achalasia aims at relieving functional obstruction at the level of the esophagogastric junction. Several treatment options such as pneumodilation and laparoscopic Heller myotomy (LHM) are available for this purpose. A large prospective randomized trial comparing pneumodilation and LHM demonstrated comparable success rates and quality of life for the two treatment options. Long-term data demonstrate comparable treatment success rates, when redilation in case of recurrent symptoms after pneumodilation is accepted. The most important risk factor for treatment failure is the manometric subtype, with a worse outcome for type I and type III compared with type II achalasia. Recently, peroral endoscopic myotomy (POEM) has been described with high success rates. Comparative studies with longer follow-up are awaited. A prospective study assessing the risk of esophageal carcinoma in patients with achalasia showed a 28-fold increased risk to develop carcinoma. SUMMARY Either LHM or pneumodilation have high comparable short-term clinical success rates. Based on the increased risk to develop esophageal carcinoma, a screening program may be indicated. POEM is a new interesting treatment but longer follow-up data are awaited.
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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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Abstract
OBJECTIVES Endoscopic balloon dilatation and laparoscopic myotomy are established treatments for achalasia. Recently, a new endoscopic technique for complete myotomy was described. Herein, we report the results of the first prospective trial of peroral endoscopic myotomy (POEM) in Europe. METHODS POEM was performed under general anesthesia in 16 patients (male:female (12:4), mean age 45 years, range 26-76). The primary outcome was symptom relief at 3 months, defined as an Eckhard score ≤3. Secondary outcomes were procedure-related adverse events, lower esophageal sphincter (LES) pressure on manometry, reflux symptoms, and medication use before and after POEM. RESULTS A 3-month follow-up was completed for all patients. Treatment success (Eckhard score ≤3) was achieved in 94% of cases (mean score pre- vs. post-treatment (8.8 vs. 1.4); P<0.001). Mean LES pressure was 27.2 mm Hg pre-treatment and 11.8 mm Hg post-treatment (P<0.001). No patient developed symptoms of gastro-esophageal reflux after treatment, but one patient was found to have an erosive lesion (LA grade A) on follow-up esophagogastroduodenoscopy. No patient required medication with proton pump inhibitors or antacids after POEM. CONCLUSIONS POEM is a promising new treatment for achalasia resulting in short-term symptom relief in >90% of cases. Studies evaluating long-term efficacy and comparing POEM with established treatments have been initiated.
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Swanström LL, Rieder E, Dunst CM. A stepwise approach and early clinical experience in peroral endoscopic myotomy for the treatment of achalasia and esophageal motility disorders. J Am Coll Surg 2011; 213:751-6. [PMID: 21996484 DOI: 10.1016/j.jamcollsurg.2011.09.001] [Citation(s) in RCA: 138] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 09/08/2011] [Accepted: 09/08/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) has recently been described in humans as a treatment for achalasia. This concept has evolved from developments in natural orifice translumenal endoscopic surgery (NOTES) and has the potential to become an important therapeutic option. We describe our approach as well as our initial clinical experience as part of an ongoing study treating achalasia patients with POEM. STUDY DESIGN Five patients (mean age 64 ± 11 years) with esophageal motility disorders were enrolled in an IRB-approved study and underwent POEM. This completely endoscopic procedure involved a midesophageal mucosal incision, a submucosal tunnel onto the gastric cardia, and selective division of the circular and sling fibers at the lower esophageal sphincter. The mucosal entry was closed by conventional hemostatic clips. All patients had postoperative esophagograms before discharge and initial clinical follow-up 2 weeks postoperatively. RESULTS All (5 of 5) patients successfully underwent POEM treatment, and the myotomy had a median length of 7 cm (range 6 to 12 cm). After the procedure, smooth passage of the endoscope through the gastroesophageal junction was observed in all patients. Operative time ranged from 120 to 240 minutes. No leaks were detected in the swallow studies and mean length of stay was 1.2 ± 0.4 days. No clinical complications were observed, and at the initial follow-up, all patients reported dysphagia relief without reflux symptoms. CONCLUSIONS Our initial experience with the POEM procedure demonstrates its operative safety, and early clinical results have shown good results. Although further evaluation and long-term data are mandatory, POEM could become the treatment of choice for symptomatic achalasia.
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Affiliation(s)
- Lee L Swanström
- The Oregon Clinic, Division of GI and Minimally Invasive Surgery, Portland, OR, USA.
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Kashiwagi H, Omura N. Surgical treatment for achalasia: when should it be performed, and for which patients? Gen Thorac Cardiovasc Surg 2011; 59:389-98. [PMID: 21674305 DOI: 10.1007/s11748-010-0765-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 12/13/2010] [Indexed: 01/11/2023]
Abstract
Achalasia is a rare motor disorder of the esophagus, characterized by the absence of peristalsis and impaired swallow-induced relaxation. In the past decade, evidence has been accumulated suggesting that achalasia may be an immune-mediated inflammatory disorder. With the advent of minimally invasive surgery, laparoscopic Heller myotomy (LHM) has slowly shifted the treatment of achalasia toward the greater use of surgical therapy. The goal of both surgical and nonsurgical treatment is to eliminate the outflow obstruction afforded by a nonrelaxing sphincter, relieving dysphagia and maintaining a barrier against gastroesophageal reflux (GER). Endoscopic botulinum toxin injection (EBTI) is safe, easy to perform, inexpensive, and effective in aged patients, and it is especially effective when the lower esophageal pressure is hypertonic. This therapeutic option is reserved for patients too ill to undergo any surgical procedure. Pneumatic dilation (PD) has been shown to be an effective and inexpensive treatment with few adverse effects. The long-term success rate of PD seems to drop progressively over time. Heller myotomy (HM) has shown the best clinical efficacy in achalasia as a first-line treatment. Multiple endoscopic treatments are associated with poorer outcomes after HM. EBTI also makes LHM more difficult and results in a worse surgical outcome. The inferior symptomatic outcomes after thoracoscopic HM may be caused by the difficulty in extending an adequate myotomy onto the stomach from the chest and the inability to create a fundoplication. LHM with Dor's fundoplication (LHM + Dor) is effective and is safer procedure for avoiding GER, dysphagia, mucosal perforation, and a pseudodiverticulum. LHM + Dor is also effective in the presence of sigmoid achalasia, but the clinical result is not as good as nonsigmoid achalasia. A few patients need esophagectomy for surgical failure of HM. However, considering the risk of esophagectomy, LHM + Dor is the first treatment option for patients with achalasia regardless of the degree of esophageal dilatation. This procedure is therefore considered to be an effective and safe treatment for patients of any age or with any condition.
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Affiliation(s)
- Hideyuki Kashiwagi
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-ku, Tokyo 105-8461, Japan.
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Reynoso JF, Tiwari MM, Tsang AW, Oleynikov D. Does illness severity matter? A comparison of laparoscopic esophagomyotomy with fundoplication and esophageal dilation for achalasia. Surg Endosc 2010; 25:1466-71. [PMID: 20976492 DOI: 10.1007/s00464-010-1415-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Accepted: 09/03/2010] [Indexed: 01/25/2023]
Abstract
INTRODUCTION There is scarce evidence regarding optimal treatment options for achalasia in patients with varying illness severity risk. The objective of this study was to evaluate and compare outcomes with laparoscopic esophagomyotomy with fundoplication (LM) and esophageal dilation (ED) for hospitalized patients with different illness severity. METHODS The University HealthSystem Consortium (UHC) is an alliance of more than 100 academic medical centers and nearly 200 affiliate hospitals. UHC's Clinical Data Base/Resource Manager (CDB/RM) allows member hospitals to compare patient-level risk-adjusted outcomes for performance improvement purposes. The CDB/RM was queried for patients with achalasia who underwent LM (n=1,390) or ED (n=492) during a 3-year period between 2006 and 2008. RESULTS Overall esophageal perforation rates were significantly higher for ED (0.4% LM vs. 2.4% ED; p<0.001). Patients undergoing LM with minor/moderate illness severity showed higher morbidity (9.42% LM vs. 5.15% ED; p<0.05). However, LM patients in this illness severity group showed significantly lower 30-day readmission rate (0.38% LM vs. 7.32% ED; p<0.001) and length of stay (2.23±1.78 LM vs. 4.88±4.42 days ED; p<0.001), but comparable cost ($9,539 LM vs. $8990 ED; p>0.05). In the major/extreme illness severity group mortality was comparable (1.37% LM vs. 2.44% ED; p>0.05). Overall morbidity was significantly greater in LM (50.48% LM vs. 19.57% ED; p<0.001). However, the length of stay was significantly increased in the ED group (8.96±7.86 LM vs. 11.72±11.05 days ED; p=0.04). CONCLUSION In hospitalized patients with minor/moderate illness severity, laparoscopic myotomy for achalasia showed comparable or better outcomes than ED. For major/extreme illness severity, dilation showed comparable or better profile for hospitalized achalasia patients. These results highlight the importance and impact of illness severity on outcomes of achalasia patients.
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Affiliation(s)
- Jason F Reynoso
- Department of Surgery, University of Nebraska, University of Nebraska Medical Center, Omaha, NE, USA.
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Nenshi R, Takata J, Stegienko S, Jacob B, Kortan P, Deitel W, Laporte A, Darling G, Urbach DR. The cost of achalasia: quantifying the effect of symptomatic disease on patient cost burden, treatment time, and work productivity. Surg Innov 2010; 17:291-4. [PMID: 20647236 DOI: 10.1177/1553350610376392] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Although the incidence of achalasia is low, the burden of suffering is high because it is a chronic incurable disease that predominantly affects young persons. This article aims to describe the impact of achalasia on health-related quality of life, patient cost burden, time dedicated to treatment, and work productivity. METHODS Consecutive patients enrolled in a clinical trial comparing laparoscopic myotomy with pneumatic dilatation from 4 sites across Canada (whose clinical and manometric diagnosis was confirmed) were studied using standardized patient-reported outcomes instruments, including the Achalasia Severity Questionnaire (ASQ), the Medical Outcomes Study 36-item Short Form Questionnaire (SF-36), and the Gastrointestinal Disease-Specific Quality of Life (GIQLI) questionnaire. The authors also measured health care utilization. RESULTS Questionnaires were completed by 54 patients (median age = 53.5 years; range = 25-78 years; 50.0% male). Patients had been experiencing symptoms for a mean of 4.5 years (standard deviation = 6.1), and 42.6% were on medication for symptom relief. Among them, 74.1% reported that their disease limited their lifestyle. Patients spent an average of CAD$30.70 a month on medication; 37.0% reported that their disease interfered with their work, and patients missed an average of 10.2 days per 6 months. Patients also spent an average of CAD$24.30 on transportation to and from each clinical appointment. CONCLUSION Achalasia substantially limits the lifestyle of patients with the disease. It also implies a financial burden of care for patients and leads to decreased work productivity.
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Garrigues V, Ortiz V, Casanova C, Bujanda L, Moreno-Osset E, Rodríguez-Téllez M, Montserrat A, Brotons A, Fort E, Ponce J. Disease-specific health-related quality of life in patients with esophageal achalasia before and after therapy. Neurogastroenterol Motil 2010; 22:739-45. [PMID: 20482702 DOI: 10.1111/j.1365-2982.2010.01515.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND To evaluate disease-specific health-related quality of life (HRQoL) in patients with symptomatic esophageal achalasia before and after therapy. METHODS Symptoms and disease-specific HRQoL were evaluated before and 3 months after therapy. Therapy selection, either dilatation or myotomy, depended exclusively on the opinion of the physician on charge of the patient. Symptom severity was graded from 0 to 3, using a scoring system. A disease-specific questionnaire for achalasia developed and validated in Spanish language with 18 items and four subscales (AE-18) was used to evaluate HRQoL. Changes after therapy in HRQoL and its association with clinical improvement were analyzed. KEY RESULTS Sixty-five patients were prospectively included in eight hospitals in Spain. Of them, 47 were treated with dilatation, and 18 with laparoscopic Heller myotomy. After therapy, AE-18 global and subscales scores improved significantly. Changes in HRQoL were associated with improvement in symptoms. An important improvement in symptoms (>or=50%) was needed to obtain a minimal clinically important improvement (>or=20%) in HRQoL. CONCLUSIONS & INFERENCES Disease-specific HRQoL improves in patients with symptomatic achalasia after therapy with dilatation or myotomy. The degree of improvement of HRQoL depends on the degree of improvement of esophageal symptoms.
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Affiliation(s)
- V Garrigues
- Servicio de Medicina Digestiva, Hospital Universitari La Fe, Valencia, Spain.
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Rosemurgy AS, Morton CA, Rosas M, Albrink M, Ross SB. A single institution's experience with more than 500 laparoscopic Heller myotomies for achalasia. J Am Coll Surg 2010; 210:637-45, 645-7. [PMID: 20421021 DOI: 10.1016/j.jamcollsurg.2010.01.035] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Accepted: 01/20/2010] [Indexed: 12/21/2022]
Abstract
BACKGROUND Long-term symptom relief and patient satisfaction after Heller myotomy are being reported. Herein, we report the largest experience of laparoscopic Heller myotomy for the treatment of achalasia. STUDY DESIGN Since 1992, 505 patients have been prospectively followed after laparoscopic Heller myotomy. Until 2004, concomitant fundoplication was undertaken for a patulous hiatus, a large hiatal hernia, or to buttress the repair of an esophagotomy, then concomitant fundoplication became routinely applied. More recently, laparo-endoscopic single site (LESS) Heller myotomy has been performed when possible to improve cosmesis. Before and after myotomy, patients scored their symptoms. RESULTS Before myotomy, 60% of patients underwent endoscopic therapy; of these patients, 27% had Botox (Allergan) therapy alone, 52% underwent dilation therapy alone, and 21% had both. Esophagotomy occurred in 7% of patients. Concomitant diverticulectomy was undertaken in 7%, fundoplication was performed in 59%, and LESS Heller myotomy was done in 12%. Median length of stay was 1 day. With mean follow-up at 31 months, the severity of all symptoms improved significantly. After myotomy, 95% experienced symptoms less than once per week, 86% believed their outcome is satisfying or better, and 92% would undergo myotomy again, if necessary. Symptoms after myotomy are similar with or without fundoplication and regardless of the laparoscopic approach used. CONCLUSIONS Laparoscopic Heller myotomy safely and durably relieves symptoms of dysphagia. Confinement is short and satisfaction is very high. Relief of esophageal obstruction is paramount; the approach used or the application of a fundoplication has a lesser impact. Laparoscopic Heller myotomy, preferably with anterior fundoplication using a single site laparoscopic approach, is strongly encouraged for patients with symptomatic achalasia and is efficacious even after failures of dilation and/or Botox therapy.
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Affiliation(s)
- Alexander S Rosemurgy
- Department of Surgery, University of South Florida College of Medicine, Tampa General Hospital, Tampa, FL, USA
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