Finding the Right Treatment for Achalasia Treatment: Risks, Efficacy, Complications

Management of achalasia in 2019

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.

Mechanical dilation, botulinum toxin A injection, and surgical myotomy with fundoplication for treatment of lower esophageal sphincter achalasia-like syndrome in dogs

Background

Megaesophagus (ME) carries a poor long‐term prognosis in dogs. In people, lower esophageal sphincter (LES) achalasia is a rare cause of ME that may respond to targeted intervention. Dogs with lower esophageal sphincter achalasia‐like syndrome (LES‐AS) have been described recently, warranting investigation of analogous targeted treatment.

Hypothesis/Objectives

Evaluate response of dogs with LES‐AS to LES mechanical dilation and botulinum toxin A (BTA) injections, with or without surgical myotomy and fundoplication. We hypothesized that clinical and videofluoroscopic swallow study (VFSS) features of LES‐AS would improve after treatment targeting functional LES obstruction.

Animals

Fourteen client‐owned dogs with LES‐AS diagnosed by VFSS.

Methods

Retrospective study. Dogs diagnosed with LES‐AS underwent treatment between April 2015 and December 2017. Outcome measures included client perception of clinical severity, body weight (BW), body condition score (BCS), regurgitation frequency, and VFSS parameters (ME, esophageal motility, gastric filling). Dogs with positive responses were considered candidates for LES myotomy with fundoplication.

Results

By a median IQR of 21 (IQR, 14‐25) days after mechanical dilation and BTA, clients reported clinical improvement in 100% of dogs, BW increased 20.4% (IQR, 12.7%‐25%), pre‐ and post‐treatment BCS was 3 (IQR, 3‐4) and 5 (IQR, 4‐5), respectively, and frequency of regurgitation decreased by 80% (IQR, 50%‐85%). Duration of effect was 40 (IQR, 17‐53) days. Despite clinical improvement, ME and abnormal esophageal motility persisted in 14 dogs. Six dogs subsequently underwent myotomy and fundoplication and maintained improvement observed after mechanical dilation and BTA.

Conclusions and Clinical Importance

Dogs with LES‐AS experienced significant, temporary, clinical improvement after mechanical dilation and BTA. Preliminary results suggest myotomy with fundoplication provide lasting clinical benefit despite persistence of ME.

Pneumatic dilation versus laparoscopic Heller's myotomy in the treatment of achalasia: systematic review and meta-analysis based on randomized controlled trials

Achalasia is a primary esophageal motor disorder with a variety of causes. It is most common in Central and South America, where Chagas disease is endemic. In addition to the infectious etiology, achalasia can be idiopathic, autoimmune, or drug induced. It is an incurable, progressive condition that destroys the intramural nerve plexus, causing aperistalsis of the esophageal body and impaired relaxation of the lower esophageal sphincter. The literature on the treatment of achalasia comparing pneumatic dilation (PD) and laparoscopic Heller's myotomy (LHM) shows conflicting results. Therefore, a systemic review and meta-analysis are needed. A systematic review and meta-analysis of randomized controlled trials of PD and LHM, based on the preferred reporting items for systematic reviews and meta-analyses recommendations, was presented. The primary outcome was symptom remission based on the Eckardt score. Secondary outcomes were lower esophageal sphincter pressure (LESP), gastroesophageal reflux (GER), and perforation. A total of four studies were included in this analysis. The total number of patients was 404. Posttreatment symptom remission rates did not differ significantly between LHM and PD at 2 years (RD = 0.03, 95% CI [-0.05, 0.12], P = 0.62), or 5 years (RD = 0.13, 95% CI [-0.12, 0.39], P = 0.32). The posttreatment perforation rate was lower for LHM (RD = 0.04, 95% CI [-0.08, -0.01], P = 0.03). There was no significant difference in terms of LESP or GER. For the treatment of esophageal achalasia, LHM and PD were found to be similar in terms of their long-term efficacy, as well as in terms of the posttreatment GER rates. However, the perforation rate appears to be lower when LHM is employed.

INPP4B overexpression and c-KIT downregulation in human achalasia

BACKGROUND

Achalasia is a rare motility disorder characterized by myenteric neuron and interstitial cells of Cajal (ICC) abnormalities leading to deranged/absent peristalsis and lack of relaxation of the lower esophageal sphincter. The mechanisms contributing to neuronal and ICC changes in achalasia are only partially understood. Our goal was to identify novel molecular features occurring in patients with primary achalasia.

METHODS

Esophageal full-thickness biopsies from 42 (22 females; age range: 16-82 years) clinically, radiologically, and manometrically characterized patients with primary achalasia were examined and compared to those obtained from 10 subjects (controls) undergoing surgery for uncomplicated esophageal cancer (or upper stomach disorders). Tissue RNA extracted from biopsies of cases and controls was used for library preparation and sequencing. Data analysis was performed with the "edgeR" option of R-Bioconductor. Data were validated by real-time RT-PCR, western blotting and immunohistochemistry.

KEY RESULTS

Quantitative transcriptome evaluation and cluster analysis revealed 111 differentially expressed genes, with a P ≤ 10^-3 . Nine genes with a P ≤ 10^-4 were further validated. CYR61, CTGF, c-KIT, DUSP5, EGR1 were downregulated, whereas AKAP6 and INPP4B were upregulated in patients vs controls. Compared to controls, immunohistochemical analysis revealed a clear increase in INPP4B, whereas c-KIT immunolabeling resulted downregulated. As INPP4B regulates Akt pathway, we used western blot to show that phospho-Akt was significantly reduced in achalasia patients vs controls.

CONCLUSIONS & INFERENCES

The identification of altered gene expression, including INPP4B, a regulator of the Akt pathway, highlights novel signaling pathways involved in the neuronal and ICC changes underlying primary achalasia.

Absence of Complications after Endoscopic Mucosal Biopsy

BACKGROUND

There is no clarity with regard to the occurrence of serious complications from EGD-driven mucosal biopsy. This is important for considering both clinically indicated procedures and mucosal sampling for research.

METHODS

We sought to quantify rates of serious complications from esophagogastroduodenoscopy (EGD) with biopsy. We studied 13,233 patients undergoing outpatient EGD with biopsy over 5 years in 2 North Dakota community hospitals, based on the reasoning that serious complications would cause hospitalization within 30 days. We reviewed the records of all patients with a diagnostic or procedure code or admission within 30 days after the outpatient EGD with biopsy.

RESULTS

Of the 13,233 patients who underwent outpatient EGD with biopsy, 411 were admitted within 30 days, most of them because of their underlying diagnosis. Two patients were admitted due to complications that resulted because of additional simultaneous procedures. No patient was admitted because of complications that could be ascribed to conscious sedation, upper GI endoscopic access, or mucosal biopsy.

CONCLUSIONS

These data confirm that EGD biopsy is safe within community settings and suggest that the risk/benefit ratio for performing EGD biopsy for research is likely to be favorable if the research has scientific merit. Serious complications or perforation following EGD biopsy did not occur in 13,233 patients in community hospitals in North Dakota.

Open peroral endoscopic myotomy (O-POEM) for the treatment of achalasia

With the development of endoscopic interventions and inspired by the success of peroral endoscopic myotomy (POEM) for the treatment of achalasia, we investigated an old method of direct peroral endoscopic myotomy without a submucosal tunnel for the treatment of achalasia, which we call open peroral endoscopic myotomy (O-POEM). In this study, Clinical success was achieved in the patient after O-POEM. A reduction of LES pressure, Eckardt score, and a timed barium esophagogram were observed during follow-up. There were no severe complications and no recurrences during two months of follow-up. Therefore, open peroral endoscopic myotomy is a feasible and effective endoscopic treatment modality for achalasia. However, long-term outcomes of O-POEM requires further follow-up.

Laparoscopic esophageal myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized controlled trials

BACKGROUND

Achalasia is a primary esophageal motility disorder of unknown etiology associated with abnormalities in peristalsis and lower esophageal sphincter relaxation. The disease is incurable; however, definitive treatment procedures like pneumatic dilation (PD)/balloon dilation and laparoscopic esophageal myotomy (LEM) are performed to relieve dysphagia and related symptoms. Currently, there is paucity of data comparing the outcomes of these procedures. The aim of this meta-analysis is to compare the short- and long-term success rates of PD and LEM.

METHODS

A thorough systematic search of PubMed, Scopus, clinicaltrials.gov, and Cochrane library was conducted for randomized controlled trials (RCTs) comparing the outcomes of PD versus LEM in the treatment of achalasia. The Mantel-Haenszel method and random effect model were used to analyze the data. RCTs with outcome data at 3-month, 1-year, and 5-year intervals were analyzed.

RESULTS

A total of 437,378 and 254 patients at 3-month, 1-year, and 5-year intervals were analyzed for outcome data. At 3 months and 1 year, PD was not as effective as LEM (odds ratio [OR]: 0.50; confidence interval [CI] 0.31-0.82; P = 0.009 and OR: 0.47; CI 0.22-0.99; P = 0.21) but at 5 years, one procedure was non-inferior to the other (OR: 0.62; 0.33-1.19; P = 0.34).

CONCLUSION

PD was as effective as LEM in relieving symptoms of achalasia in the long-term.

Achalasia

Achalasia is a rare neurogenic motility disorder of the esophagus, occurring in approximately 0.11 cases per 100,000 children. The combination of problems (aperistalsis, hypertensive lower esophageal sphincter (LES), and lack of receptive LES relaxation) results in patients having symptoms of progressive dysphagia, weight loss, and regurgitation. Treatment modalities have evolved over the past few decades from balloon dilation and botulinum toxin injection to laparoscopic Heller myotomy and endoscopic myotomy. Most data on achalasia management is extrapolated to children from adult experience. This article describes understanding of the pathogenesis and discusses newer therapeutic techniques as well as controversies in management.