[New trends and concepts in diagnosis and treatment of achalasia]

Laparoscopic graduated cardiomyotomy with anterior fundoplication as treatment for achalasia: experience of 48 cases

INTRODUCTION AND AIMS

At the Upper Gastrointestinal Tract Clinic of the Hospital General de Mexico, achalasia treatment has been standarized through strictly graduated cardiomyotomy. This procedure guarantees a complete myotomy for the satisfactory resolution of dysphagia, a characteristic symptom of achalasia. To ensure the inclusion of the entire lower esophageal sphincter, an 8cm Penrose drain is placed at the surgical site 6cm above the gastroesophageal junction and 2cm in a caudal direction, for accurate laparoscopic measuring. The aim of our study was to evaluate the results of this technique.

MATERIALS AND METHODS

A descriptive, retrospective, longitudinal, and observational study was conducted on a cohort of patients diagnosed with achalasia at the Upper Gastrointestinal Tract Clinic of the Hospital General de México "Dr. Eduardo Liceaga".

RESULTS

The study included 48 patients, 40 of whom had no prior surgical treatment and 8 that presented with recurrence. Forty-seven patients (97.9%) underwent a laparoscopic procedure and conversion to open surgery was required in 2 of them (4.25% conversion rate). Postoperative progression was satisfactory in all cases, with mean oral diet commencement at 52h and mean hospital stay of 5.7 days. No recurrence was registered during the mean follow-up period of 35.75 months and there were no deaths.

CONCLUSIONS

Laparoscopic graduated (strictly measured) cardiomyotomy with anterior fundoplication is a reproducible, efficacious, and safe option for the surgical treatment of achalasia.

Clinical Outcomes and Safety of Partial Full-Thickness Myotomy versus Circular Muscle Myotomy in Peroral Endoscopic Myotomy for Achalasia Patients

Background. Here we aimed to evaluate and compare the efficacy and safety between partial full-thickness myotomy and circular muscle myotomy during POEM procedure in achalasia patients. Methods. Clinical data of achalasia of cardia (AC) patients who underwent POEM in our center during January 2014 to January 2015 was collected (34 cases). 19 patients who received partial full-thickness myotomy were assigned to group A and 14 patients who received circular muscle myotomy were assigned to group B. The procedure-related parameters between the two groups were compared. Symptom relief rate and postprocedure manometry outcomes were compared to evaluate the efficacy. Procedure-related adverse events and complications were compared to evaluate the safety. Results. (1) Mean operation times were significantly shorter in group A than group B (62.42 ± 23.17 vs 87.86 ± 26.44 min, p < 0.01). (2) Symptom relief rate and postprocedure manometry outcomes had no statistical differences when compared between the two groups (all p > 0.05). (3) Comparison of procedure-related adverse events and complications had no statistical differences (all p > 0.05). Conclusion. Partial full-thickness myotomy had no significant differences in efficacy or safety with circular myotomy, but partial full-thickness myotomy significantly reduced the procedure time.

Per-Oral Endoscopic Myotomy Versus Laparoscopic Heller Myotomy for Achalasia: A Meta-Analysis of Nonrandomized Comparative Studies

We aimed to assess the short-term outcomes of per-oral endoscopic myotomy (POEM) compared with laparoscopic Heller myotomy (LHM) for achalasia through a meta-analysis of nonrandomized comparative studies.We searched PubMed, Embase, Medline, Cochrane Library, and Google Scholar for studies that compared POEM and LHM for achalasia and were published between January 1, 2008 and December 31, 2014. The Methodological Index for Nonrandomized Studies (MINORS) was used to evaluate the quality of the studies. Random- and fixed-effects meta-analytical models were used, and between-study heterogeneity was assessed.Four nonrandomized comparative studies that included 317 patients (125 in the POEM group and 192 in the LHM group) met our research criteria and were assessed. There were no differences between the POEM and LHM groups in terms of sex, preoperative Eckhart score, length of myotomy, operation time, length of hospital stay, and complications. The patients in the POEM group were older than those in the LHM group (MD =2.81, 95% CI 0.27-5.35; P = 0.03) with high between-study homogeneity (χ = 1.96, df = 2, I = 0%; P = 0.38). The patients in the POEM group had a lower Eckardt score after surgery compared with those in the LHM group (MD = -0.30, 95% CI -0.42 to -0.18; P < 0.001) with high between-study homogeneity (χ = 0.00, df = 1, I = 0%; P = 1.00).The efficacy and safety of POEM appear to be comparable to those of LHM. Multicenter and randomized trials with larger sample size are needed to further compare the efficacy and safety of POEM and LHM for the treatment of achalasia.

Function of high-resolution manometry in the analysis of peroral endoscopic myotomy for achalasia

BACKGROUND

Peroral endoscopic myotomy (POEM) was introduced as a new effective therapeutic option for esophageal achalasia.

METHOD

A total of 112 achalasia patients categorized into three subtypes by HRM who underwent POEM were enrolled in our study. Eckardt score and HRM were performed preoperation, 6 months, and 1 year after POEM to evaluate the effectiveness, safety, and feasibility of POEM and to investigate the treatment response to POEM for the three subtypes of achalasia, classified by high-resolution manometry (HRM).

RESULTS

POEM was successfully performed in all patients. Compared with pre-POEM scores, the Eckardt scores were significantly reduced from 7.3 ± 1.4 to 1.0 ± 0.8 6 months after POEM and to 1.2 ± 0.6 1 year after POEM (p < 0.05). The LESP before treatment was 41.8 ± 15.3 mmHg, compared with a LESP of 18.4 ± 7.1 mmHg 6 months after POEM and 20.7 ± 7.5 mmHg 1 year after POEM (p < 0.05). In addition, POEM decreased the 4-s IRP from 33.4 ± 9.0 to 14.6 ± 3.8 mmHg 6 months after POEM and to 16.4 ± 3.9 mmHg 1 year after POEM (p < 0.05). The 4-s IRP was reduced to <15 mmHg in 64 of 112 patients. Type II had the best response to POEM, while type III exhibited the worst response.

CONCLUSIONS

POEM appears to be an effective and less invasive treatment for achalasia. HRM can be useful in the classification of achalasia, while these subclassifications help to predict the responsiveness to POEM.

Management of primary achalasia: The role of endoscopy

Achalasia is an oesophageal motor disorder which leads to the functional obstruction of the lower oesophageal sphincter (LES) and is currently incurable. The main objective of all existing therapies is to achieve a reduction in the obstruction of the distal oesophagus in order to improve oesophageal transit, relieve the symptomatology, and prevent long-term complications. The most common treatments used are pneumatic dilation (PD) and laparoscopic Heller myotomy, which involves partial fundoplication with comparable short-term success rates. The most economic non-surgical therapy is PD, with botulinum toxin injections reserved for patients with a higher surgical risk for whom the former treatment option is unsuitable. A new technology is peroral endoscopic myotomy, postulated as a possible non-invasive alternative to surgical myotomy. Other endoluminal treatments subject to research more recently include injecting ethanolamine into the LES and using a temporary self-expanding metallic stent. At present, there is not enough evidence permitting a routine recommendation of any of these three novel methods. Patients must undergo follow-up after treatment to guarantee that their symptoms are under control and to prevent complications. Most experts are in favour of some form of endoscopic follow-up, however no established guidelines exist in this respect. The prognosis for patients with achalasia is good, although a recurrence after treatment using any method requires new treatment.