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Griffiths EA, Wong E. Navigating reflux disease after achalasia treatments: Balancing risks and benefits. World J Gastroenterol 2024; 30:2740-2743. [PMID: 38899334 PMCID: PMC11185294 DOI: 10.3748/wjg.v30.i21.2740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 04/29/2024] [Accepted: 05/16/2024] [Indexed: 06/03/2024] Open
Abstract
The peroral endoscopic myotomy (POEM) procedure has revolutionized the management of achalasia in many centres around the world as it offers patients a minimally invasive endoscopic solution to their dysphagia caused by achalasia. Alongside its success in alleviating dysphagia, concerns regarding postoperative gastroesophageal reflux disease have emerged as a pertinent issue which are not fully resolved. In this study, Nabi et al have comprehensively reviewed the topic of the prediction, prevention and management of gastroesophageal reflux after POEM. POEM is a purely endoscopic procedure which is usually performed without any anti-reflux procedure. Certain patients may be better served by a laparoscopic Heller's myotomy and fundoplication and it is important that gastroenterologists and surgeons provide comprehensive risks and benefits of each achalasia treatment option so that patients can decide what treatment is best for them. This article by Nabi et al provides a comprehensive review of the current status of this issue to allow these discussions to occur.
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Affiliation(s)
- Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, West Midlands, United Kingdom
- Department of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, West Midlands, United Kingdom
| | - Enoch Wong
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, West Midlands, United Kingdom
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2
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Sharma P, Stavropoulos SN. Is peroral endoscopic myotomy the new gold standard for achalasia therapy? Dig Endosc 2023; 35:173-183. [PMID: 36385512 DOI: 10.1111/den.14477] [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: 08/02/2022] [Accepted: 11/15/2022] [Indexed: 11/18/2022]
Abstract
Our review focuses on critical analysis of the literature to determine whether peroral endoscopic myotomy (POEM) is poised to replace laparoscopic Heller myotomy (LHM) as the new "gold standard" for achalasia therapy. POEM matches or exceeds the efficacy of LHM. The difference in objective gastroesophageal reflux disease (GERD) between POEM and LHM is modest at best and dissipates with time. Post-POEM GERD can be easily managed medically in most patients without long-term GERD sequelae or the need for surgical fundoplication. Emerging POEM technique modifications can further decrease GERD. Endoscopic antireflux procedures such as transoral incisionless fundoplication (TIF) or POEM + F (POEM + fundoplication) can be used in the rare cases of medication-refractory GERD, but their long-term efficacy remains in question. In this comprehensive review, we summarize the current status of POEM with emphasis on GERD evaluation, prevention, treatment, and comparative data vs. LHM. Based on this analysis, it appears that POEM is indeed the new gold standard in the therapy of achalasia.
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Affiliation(s)
- Prabin Sharma
- Department of Gastroenterology, Hartford Health Care-St. Vincent's Medical Center, Bridgeport, USA
| | - Stavros N Stavropoulos
- Division of Gastroenterology, John D. Archbold Memorial Hospital, Digestive Disease Center, Thomasville, USA
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Gong F, Li Y, Ye S. Effectiveness and complication of achalasia treatment: A systematic review and network meta-analysis of randomized controlled trials. Asian J Surg 2023; 46:24-34. [PMID: 35484068 DOI: 10.1016/j.asjsur.2022.03.116] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 03/16/2022] [Accepted: 03/31/2022] [Indexed: 12/16/2022] Open
Abstract
Achalasia(AC) is an esophageal motility disorder characterized by decreased esophageal motility and impaired relaxation of lower esophageal sphincter(LES). The treatment of achalasia is continuously improved for the development of technology, but each treatment has its own advantages and disadvantages. This article was to compare the efficacy and complication of different treatment on AC. PUBMED/MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials were searched for eligible studies. A random-effects model within a Bayesian framework was applied to compare treatment effects as odds ratio (OR) with their corresponding 95% credible interval (CI), also OR was applied to compare complication with 95% CI. The surface under the cumulative ranking area (SUCRA) was calculated to make the ranking of the treatments for outcomes. Twenty-seven randomized controlled trials (RCTs) were eligible. According to SUCRA ranking, anterior peroral endoscopic myotomy (APOEM) (SUCRA = 84.6%) might have the highest probability to be the best treatment for dysphagia remission in AC patients, followed by POEM (SUCRA = 78.4%). For gastroesophageal reflux disease (GERD) assessment, the corresponding SUCRA values indicated that botulinum toxin(BT) (SUCRA = 18.3%) might have lowest GERD incidence rate and POEM ranked the worst (SUCRA = 69.8%).. APOEM might have the highest probability to be the best therapeutic strategy for dysphagia remission in a short-term of follow-up, but the GERD incidence rate was high. BT injection might have the lowest probability to treat dysphagia, but the risk of GERD was the lowest. In the future, more RCTs with higher qualities are needed to make head-to-head comparison between 2 or more treatments.
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Affiliation(s)
- Fangxiao Gong
- Emergency and Critical Care Center, Intensive Care Unit, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, 310014, China
| | - Yuanyuan Li
- Department of Endocrinology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Sen Ye
- Emergency and Critical Care Center, Intensive Care Unit, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, 310014, China.
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Schlottmann F, Herbella FAM, Patti MG. Achalasia. Dysphagia 2023. [DOI: 10.1016/b978-0-323-99865-9.00006-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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Abstract
BACKGROUND Laparoscopic Heller's cardiomyotomy (LHC) is the preferred treatment of achalasia. It improves dysphagia by dividing muscles of the lower oesophageal sphincter, but this intervention can result in debilitating gastro-oesophageal reflux symptoms in some patients. To prevent these reflux symptoms, most surgeons add a fundoplication to Heller's cardiomyotomy, but there is no consensus regarding this or the type of fundoplication which is best suited for the purpose. OBJECTIVES To assess how the addition of a fundoplication affects postoperative reflux and dysphagia in people undergoing LHC and compare the different types of fundoplications used in combination with LHC to determine which is better at controlling reflux without worsening the dysphagia. SEARCH METHODS We searched three databases (CENTRAL, MEDLINE and Embase) on 31 October 2021 and trial registers to identify all published and unpublished randomised controlled trials (RCTs) in any language, comparing different fundoplications used in combination with LHC to treat achalasia. We also included RCTs where LHC with a fundoplication is compared with LHC without any fundoplication. SELECTION CRITERIA We only included RCTs which recruited adult participants with achalasia undergoing LHC with minimal hiatal dissection. We excluded non-randomised studies or studies involving paediatric participants. We also excluded studies where the procedure was done by open surgery and where circumferential hiatal dissection of the oesophagus was carried out, unless it was necessary to reduce a hiatus hernia or to facilitate a Toupet or Nissen fundoplication. DATA COLLECTION AND ANALYSIS Two review authors independently identified studies to be included, assessed risk of bias using the Cochrane RoB 1 tool, and extracted the data. We calculated the risk ratio (RR) with 95% confidence interval (CI) using both fixed-effect and random-effect models with Review Manager (RevMan) software. MAIN RESULTS We included eight studies in this review, with a total of 571 participants with an average age of 45 years (range 33.5 to 50). LHC without any fundoplication was performed in 65 (11.3%) participants, 298 (52.1%) had Dor fundoplication, 81 (14.1%) had Toupet fundoplication, 72 (12.6%) had Nissen's fundoplication, and 55 (9.6%) participants had angle of His accentuation. Three studies with a total of 143 participants compared LHC + Dor to LHC without fundoplication. We found that the evidence is very uncertain as to whether the addition of a Dor fundoplication made any difference to the outcome of postoperative pathological acid reflux (RR 0.37, 95% CI 0.07 to 1.89; I2 = 56%; 2 studies, 97 participants; very low-certainty evidence) and uncertain for severe postoperative dysphagia (RR 3.00, 95% CI 0.34 to 26.33; I2 = 0%; 3 studies, 142 participants; low-certainty evidence). Three studies with 174 participants compared LHC + Dor to LHC + Toupet. The evidence suggests that there may be little to no difference in the outcomes of postoperative pathological acid reflux (RR 0.75, 95% CI 0.23 to 2.43; I2 = 60%; 3 studies, 105 participants; low-certainty evidence) and severe postoperative dysphagia (RR 0.78, 95% CI 0.19 to 3.15; I2 = 0%; 3 studies, 123 participants; low-certainty evidence) between the two interventions, but the certainty of the evidence is low. One study with 138 participants compared LHC + Dor to LHC + Nissen. Nissen fundoplication caused increased severe postoperative dysphagia (RR 0.19, 95% CI 0.04 to 0.83; 1 study, 138 participants; high-certainty evidence) when compared to Dor fundoplication. This study did not show a difference in postoperative pathological acid reflux (RR 4.72, 95% CI 0.23 to 96.59; 1 study, 138 participants; low-certainty evidence), but the certainty of evidence is low. One study with 110 participants compared LHC + Dor with LCH + angle of His accentuation, and reported that severe postoperative dysphagia was similar between the two interventions (RR 1.56, 95% CI 0.27 to 8.95; 1 study, 110 participants; moderate-certainty evidence), with moderate certainty of evidence. This study did not report on postoperative pathological acid reflux. AUTHORS' CONCLUSIONS When LHC was performed with minimal hiatal dissection, we were very uncertain whether the addition of a Dor fundoplication made a difference in controlling postoperative reflux, and we were uncertain if it increased the risk of severe postoperative dysphagia. There may be little to no difference in the outcomes of postoperative pathological acid reflux or severe dysphagia between Dor and Toupet fundoplications when used in combination with LHC, but the certainty of the evidence is low. Nissen (total) fundoplication used in combination with LHC for achalasia increased the risk of severe postoperative dysphagia. The angle of His accentuation and Dor fundoplication had a similar effect on severe postoperative dysphagia when combined with LHC, but their effect on postoperative pathological acid reflux was not reported.
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Affiliation(s)
- Sumit Midya
- Department of General Surgery, Frimley Park Hospital, Frimley, UK
| | - Debasish Ghosh
- Department of General Surgery, Royal Berkshire Hospital, Reading, UK
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Muacevic A, Adler JR. Comparative Analysis of Heller Myotomy With Dor Versus Toupet Fundoplication for Achalasia Cardia. Cureus 2022; 14:e30243. [PMID: 36381857 PMCID: PMC9652607 DOI: 10.7759/cureus.30243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 01/25/2023] Open
Abstract
Background Heller myotomy (HM) with partial fundoplication is the standard of care for achalasia cardia. However, the choice of partial fundoplication is controversial. In this study, we compared both types of fundoplication concerning subjective and objective parameters. Methodology This prospective comparative study comprised a total of 30 consecutive patients who underwent laparoscopic/robotic HM with either Dor fundoplication (DF) (n = 15) or Toupet fundoplication (TF) (n = 15). Preoperative baseline characteristics, intraoperative details, and postoperative complications were recorded. Patients were followed with Eckardt score, quality of life-related scores, 24-hour pH study, and high-resolution manometry (HRM) at the one-year follow-up. Results There was no significant difference between the two groups regarding preoperative baseline parameters, length of hospital stay, and postoperative complications. The HM+DF group had four (27%) patients with recurrence/failure with none in the HM+TF, but it was not significant (p = 0.79). Symptom scores were similar between the groups at six and 12 months of follow-up. One patient in the HM+DF group and two in the HM+TF group had significant pathological acid reflux (p = 0.483). On HRM, HM+TF showed a trend toward significance in terms of esophagogastric junction (EGJ) relaxation (p = 0.058) with a non-significant difference in median integrated relaxation pressure (p = 0.081). Conclusions The study showed a trend toward lower failure rates and improved EGJ relaxation with similar reflux rates in patients who underwent HM+TF compared to HM+DF. However, long-term follow-up is required to validate our findings with well-defined subjective and objective criteria.
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Arcerito M, Jamal MM, Perez MG, Kaur H, Sundahl A, Moon JT. Esophageal Achalasia: From Laparoscopic to Robotic Heller Myotomy and Dor Fundoplication. JSLS 2022; 26:JSLS.2022.00027. [PMID: 35967962 PMCID: PMC9355798 DOI: 10.4293/jsls.2022.00027] [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] [Indexed: 11/22/2022] Open
Abstract
Objective: Laparoscopic Heller myotomy and Dor fundoplication has become the gold standard in treating esophageal achalasia and robotic surgical platform represents its natural evolution. The objective of our study was to assess durable long-term clinical outcomes in our cohort. Methods and Procedures: Between June 1, 1999 and June 30, 2019, 111 patients underwent minimally invasive treatment for achalasia (96 laparoscopically and 15 robotically). Fifty-two were males. Mean age was 49 years (20 – 96). Esophageal manometry confirmed the diagnosis. Fifty patients underwent pH monitoring study, with pathologic reflux in 18. Preoperative esophageal dilation was performed in 76 patients and 21 patients received botulin injection. Dysphagia was universally present, and mean duration was 96 months (5 – 480). Results: Median operative time was 144 minutes (90 – 200). One patient required conversion to open approach. Four mucosal perforations occurred in the laparoscopic group and were repaired intraoperatively. Seven patients underwent completion esophageal myotomy and added Dor fundoplication. Upper gastrointestinal series was performed before discharge. Median hospital stay was 39 hours (24 – 312). Median follow up was 157 months (6 – 240), and dysphagia was resolved in 94% of patients. Seven patients required postoperative esophageal dilation. Conclusions: Minimally invasive Heller myotomy and Dor fundoplication are feasible. The operation is challenging, but excellent results hinge on the operative techniques and experience. The high dexterity, three-dimensional view, and the ergonomic movements of robotic surgery allow application of all the technical elements, achieving the best durable outcome for the patient. Robotic surgery is the natural evolution of minimally invasive treatment of esophageal achalasia.
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Affiliation(s)
- Massimo Arcerito
- Division of Surgical Oncology and Minimally Invasive Surgery Riverside Medical Clinic Inc. Department of Surgery/Corona Regional Medical Center, Department of Surgery/Riverside Community Hospital, Temescal Valley, California
| | - M Mazen Jamal
- Oceana Gastroenterology Associates, Corona, California
| | - Martin G Perez
- Division of Surgical Oncology and Minimally Invasive Surgery, Riverside Medical Clinic Inc, Department of Surgery / Corona Regional Medical Center, Department of Surgery / Riverside Community Hospital, Riverside, California
| | - Harpreet Kaur
- Hemet Global Medical Center - KPC Health, Hemet, California
| | - Andrew Sundahl
- Department of Surgery / Riverside Community Hospital, Riverside, California
| | - John T Moon
- Department of General Surgery and Minimally Invasive Surgery, University of Maryland Shore Medical Center at Easton, Easton, Maryland
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Andrási L, Ábrahám S, Simonka Z, Paszt A, Erdős M, Rovó L, Rosztóczy A, Ollé G, Lázár G. [Minimally invasive surgery for motility disorders of the oesophagus]. Magy Seb 2022; 75:121-132. [PMID: 35895537 DOI: 10.1556/1046.2022.20006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 04/04/2022] [Indexed: 01/06/2023]
Abstract
Introduction and aims. We present our experience with minimally invasive surgery for pharyngoesophageal (Zenker) diverticulums, epiphrenic diverticulums and achalasia cardiae focusing on the perioperative features and patients’ quality of life. Patients and methods. Between 1 January 2003 and 31 December 2020, patients were selected with a symptom-causing Zenker diverticulum, epiphrenic diverticulum and achalasia cardiae. In 17 cases, transoral stapler diverticulostomy, in 23 cases transcervical diverticulectomy and cricomyotomy were done because of Zenker diverticulum, in 14 cases, laparoscopic transhiatal surgery was performed because of epiphrenic diverticula, while in 63 cases, laparoscopic Heller–Dor operation were carried out because of achalasia cardiae. Perioperative results, the quality of life outcomes of various surgeries were evaluated in mid- and long-term. Results/conclusions. The surgeries were performed with minimal blood loss, zero mortality and low morbidity. According to our result, the two different surgical approaches in the therapy of Zenker’s diverticulum, the laparoscopic Heller–Dor procedure applied in the management of epiphrenic diverticulas and achalasia cardiae are safe and effective operations. In the long term, the symptom control in patients after minimally invasive surgeries is sufficient and only a small percentage of the patients may require additional medication therapy and/or reintervention due to persistent complaints.
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Affiliation(s)
- László Andrási
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - Szabolcs Ábrahám
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - Zsolt Simonka
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - Attila Paszt
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - Márton Erdős
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - László Rovó
- 2 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Fül-Orr-Gégészeti és Fej-Nyaksebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Rovó László)
| | - András Rosztóczy
- 3 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Belgyógyászati Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lengyel Csaba)
| | - Georgina Ollé
- 3 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Belgyógyászati Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lengyel Csaba)
| | - György Lázár
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
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Parsa N, Friedel D, Stavropoulos SN. POEM, GPOEM, and ZPOEM. Dig Dis Sci 2022; 67:1500-1520. [PMID: 35366120 DOI: 10.1007/s10620-022-07398-8] [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] [Accepted: 01/12/2022] [Indexed: 12/09/2022]
Abstract
Our tripartite narrative review discusses Peroral Endoscopic Myotomy (POEM), gastric POEM (GPOEM) and POEM for Zenker's diverticula (ZPOEM). POEM is the prototypical procedure that launched the novel "3rd space endoscopy" field of advanced endoscopy. It revolutionized achalasia therapy by offering a much less invasive version of the prior gold standard, the laparoscopic Heller myotomy (HM). We review in detail indications, outcomes, technique variations and comparative data between POEM and HM particularly with regard to the hotly debated issue of GERD. We then proceed to discuss two less illustrious but nevertheless important offshoots of the iconic POEM procedure: GPOEM for gastroparesis and ZPOEM for the treatment of hypopharyngeal diverticula. For GPOEM, we discuss the rationale of pylorus-directed therapies, briefly touch on GPOEM technique variations and then focus on the importance of proper patient selection and emerging data in this area. On the third and final part of our review, we discuss ZPOEM and expound on technique variations including our "ultra-short tunnel technique". Our review emphasizes that, despite the superiority of endoscopy over surgery for the treatment of hypopharyngeal diverticula, there is no clear evidence yet of the superiority of the newfangled ZPOEM technique compared to the conventional endoscopic myotomy technique practiced for over two decades prior to the advent of ZPOEM.
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Affiliation(s)
- Nasim Parsa
- Division of Gastroenterology and Hepatology, University of Missouri Health System, Columbia, MO, USA
| | - David Friedel
- Division of Gastroenterology, Hepatology and Nutrition, NYU-Winthrop Hospital, 222 Station Plaza N Suite 429, Mineola, NY, 11501, USA
| | - Stavros N Stavropoulos
- Division of Gastroenterology, Hepatology and Nutrition, NYU-Winthrop Hospital, 222 Station Plaza N Suite 429, Mineola, NY, 11501, USA.
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Schlottmann F, Herbella FAM, Patti MG. The Evolution of the Treatment of Esophageal Achalasia: From the Open to the Minimally Invasive Approach. World J Surg 2022; 46:1522-1526. [PMID: 35169899 DOI: 10.1007/s00268-022-06482-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Achalasia is a primary esophageal motility disorder characterized by lack of esophageal peristalsis and partial or absent relaxation of the lower esophageal sphincter in response to swallowing. This study aimed to provide an overview of the evolution of the surgical treatment for esophageal achalasia, from the open to the minimally invasive approach. METHODS Literature review. RESULTS No curative treatment exists for this disorder. At the beginning of the 20th century, surgical esophagoplasties and cardioplasties were mostly done to treat achalasia. The description of the esophageal myotomy by Heller changed the treatment paradigm and rapidly became the treatment of choice. For many years the esophagomyotomy was done with either an open transthoracic or transabdominal approach. With the advancements of minimally invasive surgery, thoracoscopic and laparoscopic operations became available. The ability to add a fundoplication for the prevention of reflux made the laparoscopic Heller myotomy with partial fundoplication the operation of choice. CONCLUSIONS Surgical management of esophageal achalasia has significantly evolved in the last century. Currently, minimally invasive Heller myotomy with partial fundoplication is the standard surgical treatment of achalasia.
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Affiliation(s)
- Francisco Schlottmann
- Division of Esophageal and Gastric Surgery, Department of Surgery, Hospital Alemán of Buenos Aires, Av. Pueyrredon1640, Buenos Aires, Argentina.
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA.
| | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Marco G Patti
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
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Bapaye A, Gandhi A, Bapaye J. Gastroesophageal Reflux after Peroral Endoscopic Myotomy: Myth or Reality? JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0041-1740489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
AbstractPeroral endoscopic myotomy (POEM) is an accepted treatment for achalasia cardia (AC), and results are comparable to those of laparoscopic Heller myotomy (LHM). In recent years, several reports have confirmed higher incidence of gastroesophageal reflux (GER) following POEM. This review evaluates the current evidence regarding post-POEM GER, critically examines the potential contributing factors responsible for GER, limitations of the current available functional testing, and precautions and preventive measures, and provides future directions for research. Factors conclusively contributing to increased post-POEM GER include injury to the sling fibers of the lower esophageal sphincter, length of gastric myotomy > 2 cm, and others. Historically, these same factors have been implicated for development of GER after surgical (laparoscopic) myotomy. Although less invasive, optimal technique of POEM may be important to control post-POEM GER. Most post-POEM GER occurs during the immediate post-POEM period, is mild, and is easily treatable using proton-pump inhibitors. GER incidence plateaus at 2 years and is comparable to that after LHM. Patients should therefore be prescribed proton-pump inhibitors for at least 2 years. Antireflux procedures (ARPs) are infrequently required in these patients as the incidence of refractory GER is low. Novel ARPs have been recently described and are currently under evaluation. Conclusive diagnosis of GER is a clinical challenge. Most patients are asymptomatic, and GER is diagnosed only on abnormal esophageal acid exposure (EAE). Studies have demonstrated that current measures to diagnose GER are inadequate, inaccurate, and cannot differentiate between true GER and abnormal EAE due to food fermentation in the distal esophagus. The Lyon Consensus criteria should be implemented for confirmation of diagnosis of GER. Finally, the review recommends an evidence-based clinical algorithm for evaluation and management of post-POEM GER and provides guidelines for future research in this field.
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Affiliation(s)
- Amol Bapaye
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Ashish Gandhi
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Jay Bapaye
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, United States
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12
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Long-term results of laparoscopic Heller myotomy with Dor-fundoplication in surgical treatment of achalasia: A single-center experience. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.981343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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13
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Andrási L, Paszt A, Simonka Z, Ábrahám S, Erdős M, Rosztóczy A, Ollé G, Lázár G. Surgical Treatment of Esophageal Achalasia in the Era of Minimally Invasive Surgery. JSLS 2021; 25:JSLS.2020.00099. [PMID: 33879995 PMCID: PMC8035823 DOI: 10.4293/jsls.2020.00099] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Introduction: We have analyzed the short- and long-term results of various surgical therapies for achalasia, especially changes in postoperative esophageal function. Patients and Methods: Between January 1, 2008 and December 31, 2017, 54 patients with esophageal achalasia were treated in our institution. Patients scheduled for surgery underwent a comprehensive gastroenterological assessment pre- and post-surgery. Forty-eight of the elective cases involved a laparoscopic cardiomyotomy with Dor’s semifundoplication, while two cases entailed an esophageal resection with an intrathoracic gastric replacement for end-stage achalasia. Torek’s operation was performed on two patients for iatrogenic esophageal perforation, and two others underwent primary suture repair with Heller–Dor surgery as an emergency procedure. The results of the different surgical treatments, as well as changes in the patients’ pre- and post-operative complaints were evaluated. Results: No intra-operative complications were observed, and no mortalities resulted. During the 12 to 24-month follow-up period, recurrent dysphagia was observed mostly in the spastic group (TIII: 33%; diffuse esophageal spasm: 60%), while its occurrence in the TI type did not change significantly (14.5%–20.8%). As a result of the follow-up of more than two years, good symptom control was achieved in 93.7% of the patients, with only four patients (8.3%) developing postoperative reflux. Conclusions: The laparoscopic Heller–Dor procedure provides satisfactory long-term results with low morbidity. In emergency and advanced cases, traditional surgical procedures are still the recommended therapy.
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Affiliation(s)
- László Andrási
- Department of Surgery, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - Attila Paszt
- Department of Surgery, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - Zsolt Simonka
- Department of Surgery, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - Szabolcs Ábrahám
- Department of Surgery, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - Márton Erdős
- Department of Surgery, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - András Rosztóczy
- 1st Department of Internal Medicine, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - Georgina Ollé
- 1st Department of Internal Medicine, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - György Lázár
- Department of Surgery, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
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14
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Delliturri A, Wiesel O, Shaw J, Brichkov I. A Narrative Review of update in per oral endoscopic myotomy (POEM) and endoscopic esophageal surgery. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:909. [PMID: 34164543 PMCID: PMC8184417 DOI: 10.21037/atm-20-5057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The field of endoscopic esophageal surgery is based on the concept of natural orifice transluminal endoscopic surgery (NOTES). Submucosal space surgery or third space surgery with the use of flexible endoscopy allows for decreased morbidity and hospital length of stay with equivalent outcomes for patients. In the case of achalasia, per oral endoscopic myotomy (POEM) allows for management of refractory cases in setting of previous Heller Myotomy or in patients whom laparoscopic or thoracoscopic surgery is contraindicated. Lastly, POEM more directly divides circular muscular layer of esophagus without destroying surrounding structures that exist to prevent reflux. The innovations in endoscopic surgery began in the animal lab with experiments in the porcine model to develop a way to access the peritoneal cavity through an entry point in the gastric mucosa. Over the last 10 years, the biggest treatment innovations in endoscopy have focused on management of achalasia with the use of POEM. POEM became possible as technology was developed that revolutionized the use of flexible technology and the methods of mucosal closure. In addition to benign esophageal disease, endoscopic methods improved in management of esophageal malignancy with endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). The innovations of endoscopic surgery have been developed through the utilization of the submucosal space as a method to ensure adequate closure of the mucosal entry point into the peritoneal cavity. The goal of this review paper is to explore POEM and other techniques in endoscopic esophageal surgery for the management of esophageal diverticulum, submucosal tumors, gastroparesis, and gastrointestinal esophageal reflux disease.
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Affiliation(s)
| | - Ory Wiesel
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Jason Shaw
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Igor Brichkov
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
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15
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Fajardo RA, Petrov RV, Bakhos CT, Abbas AE. Endoscopic and Surgical Treatments for Achalasia: Who to Treat and How? Gastroenterol Clin North Am 2020; 49:481-498. [PMID: 32718566 PMCID: PMC7387747 DOI: 10.1016/j.gtc.2020.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Achalasia is a progressive neurodegenerative disorder characterized by failure of relaxation of the lower esophageal sphincter (LES) and altered motility of the esophagus. The traditional, highly effective, surgical approach to relieve obstruction at the LES includes cardiomyotomy. Fundoplication is added to decrease risk of postoperative reflux. Per oral endoscopic myotomy is a new endoscopic procedure that allows division of the LES via transoral route. It has several advantages including less invasiveness, cosmesis, and tailored approach to the length on the myotomy. However, it is associated with increased rate of post-procedural reflux. Various endoscopic interventions are used to address this problem.
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Affiliation(s)
- Romulo A. Fajardo
- Department of General Surgery, Temple University Hospital, Philadelphia, PA, USA, 3401 N Broad St, C-401, Philadelphia, PA 19140
| | - Roman V. Petrov
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA, 3401 N Broad St, C-501, Philadelphia, PA 19140
| | - Charles T. Bakhos
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA, 3401 N Broad St, C-501, Philadelphia, PA 19140
| | - Abbas E. Abbas
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA, 3401 N Broad St, C-501, Philadelphia, PA 19140
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16
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Nurczyk K, Patti MG. Surgical management of achalasia. Ann Gastroenterol Surg 2020; 4:343-351. [PMID: 32724877 PMCID: PMC7382425 DOI: 10.1002/ags3.12344] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/03/2020] [Accepted: 04/13/2020] [Indexed: 12/17/2022] Open
Abstract
Esophageal achalasia is a primary esophageal motility disorder characterized by lack of peristalsis and by incomplete or absent relaxation of the lower esophageal sphincter in response to swallowing. The cause of the disease is unknown. The goal of treatment is to eliminate the functional outflow obstruction at the level of the gastroesophageal junction, therefore allowing emptying of the esophagus into the stomach. They include the laparoscopic Heller myotomy with partial fundoplication, pneumatic dilatation, and peroral endoscopic myotomy. Esophagectomy is considered as a last resort for patients who have failed prior therapeutic attempts. In this evidence and experience-based review, we will illustrate the technique and results of the surgical treatment of esophageal achalasia and compare it to the other available treatment modalities.
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Affiliation(s)
- Kamil Nurczyk
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNCUSA
- 2nd Department of General and Gastrointestinal Surgery, and Surgical Oncology of the Alimentary TractMedical University of LublinLublinPoland
| | - Marco G. Patti
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Department of MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
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17
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Cisternas D, Monrroy H, Riquelme A, Padilla O, Fuentes-López E, Valle A, Mejia R, Hani A, Ardila-Hani AF, Leguizamo AM, Bilder C, Ditaranto A, Remes-Troche JM, Ruiz de León A, Pérez de la Serna J, Marin I, Serra J. Fair reliability of eckardt scores in achalasia and non-achalasia patients: Psychometric properties of the eckardt spanish version in a multicentric study. Neurogastroenterol Motil 2020; 32:e13827. [PMID: 32100424 DOI: 10.1111/nmo.13827] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 02/05/2020] [Accepted: 02/06/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Eckardt symptom score (ESS) is the most used tool for the evaluation of esophageal symptoms. Recent data suggest that it might have suboptimal reliability and validity. The aims of this study were as follows: (a) Develop and validate an international Spanish ESS version. (b) Perform psychometric ESS evaluation in patients with achalasia and non-achalasia patients. METHODS Eckardt symptom score translation was performed by Delphi process. ESS psychometric evaluation was done in two different samples of patients referred for manometry. First sample: 430 dysphagia non-achalasia patients. Second sample: 161 achalasia patients. Internal consistency was evaluated using Cronbach's α and Guttman coefficient (<0.5 = unacceptable. 0.5-0.7 = fair. >0.7 = acceptable). KEY RESULTS Our data show that in patients without and with achalasia, ESS behaves similarly. Both show a fair reliability with Cronbach's α of 0.57 and 0.65, respectively. Based on our results, we recommend interpretation of the Spanish ESS be done with caution. The psychometric quality of the ESS could not be improved by removal of any items based on the single-factor structure of the scale and no items meeting criteria for elimination. CONCLUSIONS AND INFERENCES Eckardt symptom score Spanish translation was developed. ESS showed a fair reliability for the evaluation of patients with any causes of dysphagia. Our results highlight the need for development and psychometric validation of new dysphagia scoring tools.
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Affiliation(s)
- Daniel Cisternas
- Facultad de Medicina Clínica Alemana, Clínica Alemana de Santiago, Universidad del Desarrollo. Santiago, Chile
| | - Hugo Monrroy
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | | | - Eduardo Fuentes-López
- Department of Health Sciences, Faculty of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Arturo Valle
- Facultad de Medicina Clínica Alemana, Clínica Alemana de Santiago, Universidad del Desarrollo. Santiago, Chile
| | - Ricardo Mejia
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Albis Hani
- San Ignacio Hospital, Pontificia Universidad Javeriana, Bogota, Colombia
| | | | | | - Claudio Bilder
- School of Medicine, Hospital Universitario, Fundación Favaloro, Buenos Aires, Argentina
| | - Andres Ditaranto
- School of Medicine, Hospital Universitario, Fundación Favaloro, Buenos Aires, Argentina
| | | | | | | | - Ingrid Marin
- Motility and Functional Gut Disorders Unit, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University Hospital Germans Trias i Pujol, Universitat Autonoma de Barcelona, Badalona, Spain
| | - Jordi Serra
- Motility and Functional Gut Disorders Unit, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University Hospital Germans Trias i Pujol, Universitat Autonoma de Barcelona, Badalona, Spain
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18
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Inaba CS, Wright AS. Laparoscopic Heller Myotomy and Toupet Fundoplication for Achalasia. J Laparoendosc Adv Surg Tech A 2020; 30:630-634. [PMID: 32392447 DOI: 10.1089/lap.2020.0158] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Achalasia manifests as failure of relaxation of the lower esophageal sphincter resulting in dysphagia. Although there are several medical and endoscopic treatment options, laparoscopic Heller myotomy has excellent short- and long-term outcomes. This article describes in detail our surgical approach to this operation. Key steps include extensive esophageal mobilization, division of the short gastric vessels, mobilization of the anterior vagus nerve, an extended gastric myotomy (3 cm as opposed to the conventional 1-2 cm gastric myotomy), a minimum 6 cm esophageal myotomy through circular and longitudinal muscle layers, and a Toupet partial fundoplication. We routinely use intraoperative endoscopy both to check for inadvertent full-thickness injury and to assess completeness of the myotomy and the geometry of the anti-reflux wrap.
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Affiliation(s)
- Colette S Inaba
- Department of Surgery, Center for Esophageal and Gastric Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Andrew S Wright
- Department of Surgery, Center for Esophageal and Gastric Surgery, University of Washington School of Medicine, Seattle, Washington, USA
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19
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Aiolfi A, Tornese S, Bonitta G, Cavalli M, Rausa E, Micheletto G, Campanelli G, Bona D. Dor versus Toupet fundoplication after Laparoscopic Heller Myotomy: Systematic review and Bayesian meta-analysis of randomized controlled trials. Asian J Surg 2019; 43:20-28. [PMID: 31031056 DOI: 10.1016/j.asjsur.2019.03.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/28/2019] [Indexed: 02/06/2023] Open
Abstract
Laparoscopic Heller Myotomy (LHM) with partial fundoplication has become the treatment of choice for esophageal achalasia. However, the choice of the partial fundoplication is debated. The aim of this study was to compare outcomes for Dor and Toupet fundoplication after LHM. A systematic search of randomized controlled trials comparing Dor and Toupet fundoplication was performed using PubMed, EMBASE and Web of Science. Three studies met the inclusion criteria. Overall, 174 patients were included in the analysis. The postoperative abnormal acid reflux [pooled Risk Ratio 0.98 (95% HPD 0.54-1.80)] and dysphagia [pooled Risk Ratio 1.03 (95% HPD 0.51-2.05)] were similar comparing Dor and Toupet fundoplication. The % total time pH ≤ 4 [estimated pooled mean difference -0.08 (95% HPD -1.04-0.90)] and DeMeester score [estimated pooled mean difference 0.51 (95% HPD -0.90-1.94)] were comparable. Additionally, the operative time [estimated pooled mean difference 0.02 (95% HPD -0.53-0.52)] and iatrogenic esophageal perforation [pooled Risk Ratio 1.05 (95% HPD 0.52-2.10)] were similar in the two groups. Dor and Toupet fundoplication after laparoscopic Heller myotomy seem comparable in term of postoperative abnormal acid exposure and dysphagia. The choice of the partial fundoplication should be left to surgeon experience and tailored on each patient.
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Affiliation(s)
- Alberto Aiolfi
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istituto Clinico Sant'Ambrogio, Milan, Italy.
| | - Stefania Tornese
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istituto Clinico Sant'Ambrogio, Milan, Italy.
| | - Gianluca Bonitta
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istituto Clinico Sant'Ambrogio, Milan, Italy.
| | - Marta Cavalli
- Department of Surgery, University of Insubria, Istituto Clinico Sant'Ambrogio, Milan, Italy.
| | - Emanuele Rausa
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istituto Clinico Sant'Ambrogio, Milan, Italy.
| | - Giancarlo Micheletto
- Department of Pathophysiology and Transplantation, INCO and Department of General Surgery, University of Milan, Istituto Clinico Sant'Ambrogio, Milan, Italy.
| | - Giampiero Campanelli
- Department of Surgery, University of Insubria, Istituto Clinico Sant'Ambrogio, Milan, Italy.
| | - Davide Bona
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istituto Clinico Sant'Ambrogio, Milan, Italy.
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20
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Di Corpo M, Farrell TM, Patti MG. Laparoscopic Heller Myotomy: A Fundoplication Is Necessary to Control Gastroesophageal Reflux. J Laparoendosc Adv Surg Tech A 2019; 29:721-725. [PMID: 31009312 DOI: 10.1089/lap.2019.0155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Achalasia is a rare esophageal motility disorder that causes progressive dysphagia and regurgitation. The aim of treatment for achalasia is to provide symptom relief by reducing esophageal outflow resistance by disrupting the muscles at the level of the esophagogastric junction to allow esophageal emptying by gravity. Methods: A review of the literature concerning laparoscopic treatment of esophageal achalasia. Results: Surgical myotomy with partial fundoplication is very effective in relieving symptoms, and is able to strike a balance between relief of symptoms and control of abnormal reflux. Conclusions: Since reflux of gastric contents into the aperistaltic esophagus can cause esophagitis, peptic strictures, Barrett's esophagus, and even esophageal carcinoma, the addition of a partial fundoplication is very important. The choice of partial fundoplication is based on surgeons' preference and expertise.
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Affiliation(s)
- Marco Di Corpo
- 1 Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Timothy M Farrell
- 1 Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Marco G Patti
- 1 Department of Surgery, University of North Carolina, Chapel Hill, North Carolina.,2 Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
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21
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Siddaiah-Subramanya M, Yunus RM, Khan S, Memon B, Memon MA. Anterior Dor or Posterior Toupet with Heller Myotomy for Achalasia Cardia: A Systematic Review and Meta-Analysis. World J Surg 2019; 43:1563-1570. [DOI: 10.1007/s00268-019-04945-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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22
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Angle of His Accentuation Is a Viable Alternative to Dor Fundoplication as an Adjunct to Laparoscopic Heller Cardiomyotomy: Results of a Randomized Clinical Study. Dig Dis Sci 2018; 63:2395-2404. [PMID: 29796913 DOI: 10.1007/s10620-018-5130-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 05/18/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND There is no consensus regarding the type of anti-reflux procedure to be used as an adjunct to laparoscopic Heller cardiomyotomy (LHCM). The aim of this study was to compare Angle of His accentuation (AOH) with Dor Fundoplication (Dor) as an adjunct to LHCM. METHODS A total of 110 patients with achalasia cardia presenting for LHCM from March 2010 to July 2015 were randomized to Dor and AOH. Symptom severity, achalasia-specific quality of life (ASQOL), new onset heartburn, and patient satisfaction were assessed using standardized scores preoperatively, at 3, 6 months, and then yearly. The primary outcome was relief of esophageal symptoms while secondary outcomes were new onset heartburn and ASQOL. RESULTS Both groups were comparable with respect to the baseline demographic characteristics. There was no conversion to open and no mortality in either group. Median operative time was 128 min in AOH and 144 min in Dor group (p < 0.01). Mean follow-up was 36 months and was available in 98% patients. There was significant improvement in esophageal symptoms in both groups with no statistically significant difference between the two groups (p > 0.05). There was no difference in cumulative symptom scores between the two groups over the period of follow-up. New onset heartburn was seen in 11% in AOH and 9% in Dor group. Mean ASQOL score improved in both groups with no difference between the two groups (p = 0.83). Patient satisfaction was similar in both groups. CONCLUSION AOH is similar to Dor as an adjunct to LHCM in safety and efficacy and can be performed in shorter time. CLINICAL REGISTRATION NUMBER CTRI: REF/2014/06/007146.
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23
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Abstract
In 2008, a new treatment modality for esophageal achalasia was introduced—peroral endoscopic myotomy (POEM). POEM is a procedure performed endoscopically, which allows transection of the muscular fibers of the distal esophagus and of the lower esophageal sphincter. The procedure is therefore similar to a laparoscopic Heller myotomy without a fundoplication. Short-term studies have shown that POEM is very effective in relieving dysphagia and regurgitation, but concerns have been raised about the incidence of post-POEM gastroesophageal reflux. Prospective and randomized trials will be needed to determine the role of this new procedure in the treatment algorithm of esophageal achalasia.
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Affiliation(s)
- Daniel A. Kroch
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ian S. Grimm
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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24
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Laparoscopic graduated cardiomyotomy with anterior fundoplication as treatment for achalasia: experience of 48 cases. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2018. [DOI: 10.1016/j.rgmxen.2017.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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25
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Repici A, Fuccio L, Maselli R, Mazza F, Correale L, Mandolesi D, Bellisario C, Sethi A, Khashab MA, Rösch T, Hassan C. GERD after per-oral endoscopic myotomy as compared with Heller's myotomy with fundoplication: a systematic review with meta-analysis. Gastrointest Endosc 2018; 87:934-943.e18. [PMID: 29102729 DOI: 10.1016/j.gie.2017.10.022] [Citation(s) in RCA: 149] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 10/13/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Per-oral endoscopic myotomy (POEM) represents a less invasive alternative to conventional laparoscopic Heller's myotomy (LHM) for patients with achalasia. It cannot be excluded, however, that the lack of fundoplication after POEM may result in a higher incidence of reflux disease, as compared with LHM. The aim of our study was to conduct a systematic review of prospective studies reporting the incidence of reflux disease developed after POEM and LHM. METHODS A literature search with electronic databases was performed (up to February 2017) to identify full articles on the incidence of gastroesophageal reflux symptoms and endoscopic monitoring and pH monitoring findings after POEM and LHM (with fundoplication). Proportions and rates were pooled by means of random or fixed-effects models, according to the level of heterogeneity between studies. RESULTS After we applied the selection criteria, 17 and 28 studies, including 1542 and 2581 participants who underwent POEM and LHM, respectively, were included. The pooled rate of postprocedural symptoms was 19.0% (95% confidence interval [CI], 15.7%-22.8%) after POEM and 8.8% (95% CI, 5.3%-14.1%) after LHM, respectively. The pooled rate estimate of abnormal acid exposure at pH monitoring was 39.0% (95% CI, 24.5%-55.8%) after POEM and 16.8% (95% CI, 10.2%-26.4%) after LHM, respectively. The rate of esophagitis after POEM was 29.4% (95% CI, 18.5%-43.3%) after POEM and 7.6% (95% CI, 4.1%-13.7%) after LHM. At meta-regression, heterogeneity was explained partly by the POEM approach and study population. CONCLUSION The incidence of reflux disease appears to be significantly more frequent after POEM than after LHM with fundoplication. Monitoring pH and ensuring appropriate treatment after POEM should be considered in order to prevent long-term reflux-related adverse events.
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Affiliation(s)
- Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Rozzano (MI), Italy
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Roberta Maselli
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Rozzano (MI), Italy
| | - Fabrizio Mazza
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Rozzano (MI), Italy
| | | | - Daniele Mandolesi
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Cristina Bellisario
- Department of Cancer Screening, Centre for Epidemiology and Prevention in Oncology, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Thomas Rösch
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
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26
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Abstract
Esophageal achalasia is a primary esophageal motility disorder defined by the lack of esophageal peristalsis, and by a lower esophageal sphincter that fails to relax in response to swallowing. Patients’ symptoms include dysphagia, regurgitation, aspiration, heartburn, and chest pain. Achalasia is a chronic condition without cure, and treatment options are aimed at providing symptomatic relief, improving esophageal emptying, and preventing the development of megaesophagus. Presently, a laparoscopic Heller myotomy with a partial fundoplication is considered the best treatment modality. A properly executed operation is key for the success of a laparoscopic Heller myotomy.
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Affiliation(s)
| | - Marco E. Allaix
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Marco G. Patti
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
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27
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Torres-Villalobos G, Coss-Adame E, Furuzawa-Carballeda J, Romero-Hernández F, Blancas-Breña B, Torres-Landa S, Palacios-Ramírez A, Alejandro-Medrano E, Hernández-Ávila A, Flores-Najera A, Ávila Escobedo LM, Ramírez Angulo C, Rodríguez-Garcés A, Valdovinos MÁ. Dor Vs Toupet Fundoplication After Laparoscopic Heller Myotomy: Long-Term Randomized Controlled Trial Evaluated by High-Resolution Manometry. J Gastrointest Surg 2018; 22:13-22. [PMID: 28924729 DOI: 10.1007/s11605-017-3578-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 09/06/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic Heller myotomy (LHM) with partial fundoplication is an effective treatment for achalasia. However, the type of fundoplication is still a subject of debate. AIM The aim of the study is to identify which partial fundoplication leads to better control of acid exposure, manometric parameters, and symptoms scores. METHODS A randomized controlled trial was performed to compare Dor vs Toupet fundoplication after LHM. The preoperative diagnosis was made by high-resolution manometry (HRM), upper endoscopy, and barium esophagogram. Preoperative and postoperative symptoms were evaluated with Eckardt, GERD-HRQL, and EAT-10 questionnaires. RESULTS Seventy-three patients were randomized, 38 underwent Dor and 35 Toupet. Baseline characteristics were similar between groups. Postoperative HRM showed that the integrated relaxation pressure (IRP) and basal lower esophageal sphincter (LES) pressure were similar at 6 and 24 months. The number of patients with abnormal acid exposure was significantly lower for Dor (6.9%) than that of Toupet (34.0%) at 6 months, but it was not different at 12 or 24 months. No differences were found in postoperative symptom scores at 1, 6, or 24 months. CONCLUSION There were no differences in symptom scores or HRM between fundoplications in the long term. A higher percentage of abnormal 24-h pH test were found for the Toupet group, with no difference in the long term.
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Affiliation(s)
- Gonzalo Torres-Villalobos
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col Belisario Domínguez, Sección XVI, Alcaldía Tlalpan, 14080, Mexico City, Mexico. .,Department of Experimental Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col Belisario Domínguez, Sección XVI, Alcaldía Tlalpan, 14080, Mexico City, Mexico.
| | - Enrique Coss-Adame
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col Belisario Domínguez, Sección XVI, Alcaldía Tlalpan, 14080, Mexico City, Mexico
| | - Janette Furuzawa-Carballeda
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col Belisario Domínguez, Sección XVI, Alcaldía Tlalpan, 14080, Mexico City, Mexico
| | - Fernanda Romero-Hernández
- Department of Experimental Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col Belisario Domínguez, Sección XVI, Alcaldía Tlalpan, 14080, Mexico City, Mexico
| | - Blanca Blancas-Breña
- Department of Experimental Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col Belisario Domínguez, Sección XVI, Alcaldía Tlalpan, 14080, Mexico City, Mexico
| | - Samuel Torres-Landa
- Department of Experimental Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col Belisario Domínguez, Sección XVI, Alcaldía Tlalpan, 14080, Mexico City, Mexico
| | - Axel Palacios-Ramírez
- Department of Experimental Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col Belisario Domínguez, Sección XVI, Alcaldía Tlalpan, 14080, Mexico City, Mexico
| | - Edgar Alejandro-Medrano
- Department of Experimental Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col Belisario Domínguez, Sección XVI, Alcaldía Tlalpan, 14080, Mexico City, Mexico
| | - Axel Hernández-Ávila
- Department of Experimental Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col Belisario Domínguez, Sección XVI, Alcaldía Tlalpan, 14080, Mexico City, Mexico
| | - Athenea Flores-Najera
- Department of Experimental Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col Belisario Domínguez, Sección XVI, Alcaldía Tlalpan, 14080, Mexico City, Mexico
| | - Lourdes Margarita Ávila Escobedo
- Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col Belisario Domínguez, Sección XVI, Alcaldía Tlalpan, 14080, Mexico City, Mexico
| | - Cecilia Ramírez Angulo
- Department of Experimental Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col Belisario Domínguez, Sección XVI, Alcaldía Tlalpan, 14080, Mexico City, Mexico
| | - Angélica Rodríguez-Garcés
- Department of Experimental Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col Belisario Domínguez, Sección XVI, Alcaldía Tlalpan, 14080, Mexico City, Mexico
| | - Miguel Ángel Valdovinos
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15, Col Belisario Domínguez, Sección XVI, Alcaldía Tlalpan, 14080, Mexico City, Mexico
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Schlottmann F, Herbella F, Allaix ME, Patti MG. Modern management of esophageal achalasia: From pathophysiology to treatment. Curr Probl Surg 2018; 55:10-37. [DOI: 10.1067/j.cpsurg.2018.01.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Etchegaray-Dondé A, Rodríguez-Espínola G, Higuera-Hidalgo F, Ortiz-Higareda V, Chapa-Azuela O, Etchegaray-Solana A. Laparoscopic graduated cardiomyotomy with anterior fundoplication as treatment for achalasia: experience of 48 cases. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2017; 83:106-111. [PMID: 28843659 DOI: 10.1016/j.rgmx.2017.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 04/25/2017] [Accepted: 06/01/2017] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- A Etchegaray-Dondé
- Clínica de Cirugía de Tracto Digestivo Superior, Departamento de Cirugía General, Hospital General de México «Dr. Eduardo Liceaga», Ciudad de México, México.
| | - G Rodríguez-Espínola
- Departamento de Cirugía General, Hospital General Dolores Hidalgo «Cuna de la Independencia Nacional», Dolores Hidalgo, Guanajuato, México
| | - F Higuera-Hidalgo
- Clínica de Cirugía de Tracto Digestivo Superior, Departamento de Cirugía General, Hospital General de México «Dr. Eduardo Liceaga», Ciudad de México, México
| | - V Ortiz-Higareda
- Departamento de Gastrocirugía, Hospital de Especialidades «Dr. Bernardo Sepúlveda», UMAE Centro Médico Nacional Siglo XXI, IMSS, Ciudad de México, México
| | - O Chapa-Azuela
- Clínica de Cirugía Hepato Pancreato Biliar, Departamento de Cirugía General, Hospital General de México «Dr. Eduardo Liceaga», Ciudad de México, México
| | - A Etchegaray-Solana
- Facultad de Ciencias de la Salud, Universidad Anáhuac, Ciudad de México, México
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Nieponice A, Nachman F, Badaloni A, Ciotola F, Zubieta C, Ramirez M. The impact of flexible endoscopy in esophageal surgery. J Thorac Dis 2017; 9:S681-S688. [PMID: 28815063 DOI: 10.21037/jtd.2017.05.61] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Achalasia and Treatment of esophageal Adenocarcinoma are commonly associated to surgical resection. Newer technologies in interventional endoscopy gave way to a substantial paradigm shift in the management of these conditions. In the case of achalasia, endoscopic myotomy is rapidly displacing Heller's myotomy as the gold standard in many centers. Early stage neoplasia in Barrett's esophagus (BE) comprising high-grade dysplasia (HGD), intramucosal and, in some cases, submucosal carcinoma is now being treated without the need of esophagectomy. This review presents a summary of the most relevant endoscopic techniques for both achalasia and esophageal cancer. Endoscopic advances in diagnostic and therapeutic arenas allow for minimally invasive therapies and organ preservation in most settings of achalasia and early stage neoplasia of the esophagus provided that the clinical setting and physician's expertise are prepared for this approach.
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Affiliation(s)
- Alejandro Nieponice
- Esophageal Institute, Hospital Universitario Fundacion Favaloro, Buenos Aires, Argentina
| | - Fabio Nachman
- Esophageal Institute, Hospital Universitario Fundacion Favaloro, Buenos Aires, Argentina
| | - Adolfo Badaloni
- Esophageal Institute, Hospital Universitario Fundacion Favaloro, Buenos Aires, Argentina
| | - Franco Ciotola
- Esophageal Institute, Hospital Universitario Fundacion Favaloro, Buenos Aires, Argentina
| | - Cecilia Zubieta
- Esophageal Institute, Hospital Universitario Fundacion Favaloro, Buenos Aires, Argentina
| | - Mauricio Ramirez
- Esophageal Institute, Hospital Universitario Fundacion Favaloro, Buenos Aires, Argentina
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Per oral endoscopic myotomy vs. laparoscopic Heller myotomy, does gastric extension length matter? Surg Endosc 2017; 32:282-288. [DOI: 10.1007/s00464-017-5675-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 06/19/2017] [Indexed: 12/21/2022]
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Abstract
This review examines the etiology and pathogenesis of idiopathic achalasia. This disease is clinically characterized by dysphagia of solids and liquids due to the presence of simultaneous or absent esophageal contractions and impaired or absent relaxation of the lower esophageal sphincter. It includes a review of (a) etiology and pathogenesis of this inflammatory process that damage the ganglion cells of the Auerbach plexus that is limited to the esophagus; (b) genetic abnormalities and polymorphisms associated with this disease that may help explain its heterogeneity expressed by the different motility abnormalities of its phenotypes as well as differences in its clinical progression. These different genetic abnormalities may be responsible for the slow progression of types I or II phenotypes; (c) indirect evidence of viruses present in these patients that may initiate its development; (d) the abnormalities of the muscle layer that may be responsible for the dilation of the body of the esophagus that ultimately causes the sigmoid-like esophagus in the very last phase of this disease. This progression to the end-stage phase tends to occur in about 5% of patients. And, (e) the chronic inflammatory abnormalities in the squamous mucosa that may be the cause of the dysplastic and neoplastic changes that may lead to squamous cell carcinoma whose incidence in this disease is increased. These mucosal abnormalities are usually present in patients with markedly dilated body of the esophagus and severe food stasis.
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Furuzawa-Carballeda J, Torres-Landa S, Valdovinos M&A, Coss-Adame E, Martín del Campo LA, Torres-Villalobos G. New insights into the pathophysiology of achalasia and implications for future treatment. World J Gastroenterol 2016; 22:7892-7907. [PMID: 27672286 PMCID: PMC5028805 DOI: 10.3748/wjg.v22.i35.7892] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 07/06/2016] [Accepted: 08/05/2016] [Indexed: 02/06/2023] Open
Abstract
Idiopathic achalasia is an archetype esophageal motor disorder, causing significant impairment of eating ability and reducing quality of life. The pathophysiological underpinnings of this condition are loss of esophageal peristalsis and insufficient relaxation of the lower esophageal sphincter (LES). The clinical manifestations include dysphagia for both solids and liquids, regurgitation of esophageal contents, retrosternal chest pain, cough, aspiration, weight loss and heartburn. Even though idiopathic achalasia was first described more than 300 years ago, researchers are only now beginning to unravel its complex etiology and molecular pathology. The most recent findings indicate an autoimmune component, as suggested by the presence of circulating anti-myenteric plexus autoantibodies, and a genetic predisposition, as suggested by observed correlations with other well-defined genetic syndromes such as Allgrove syndrome and multiple endocrine neoplasia type 2 B syndrome. Viral agents (herpes, varicella zoster) have also been proposed as causative and promoting factors. Unfortunately, the therapeutic approaches available today do not resolve the causes of the disease, and only target the consequential changes to the involved tissues, such as destruction of the LES, rather than restoring or modifying the underlying pathology. New therapies should aim to stop the disease at early stages, thereby preventing the consequential changes from developing and inhibiting permanent damage. This review focuses on the known characteristics of idiopathic achalasia that will help promote understanding its pathogenesis and improve therapeutic management to positively impact the patient’s quality of life.
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Modayil R, Stavropoulos SN. A Western Perspective on "New NOTES" from POEM to Full-thickness Resection and Beyond. Gastrointest Endosc Clin N Am 2016; 26:413-432. [PMID: 27036906 DOI: 10.1016/j.giec.2015.12.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Most new natural orifice translumenal endoscopic surgery procedures originated in Asia; therefore, most data come from operators and a health care environment different from those in the West. We provide a Western perspective. We discuss East-West differences; review areas in which the United States is leading the way; and discuss the vagaries of coding and reimbursement. In the United States, reimbursement remains problematic. A Current Procedural Terminology code for peroral endoscopic myotomy is inevitable given the rapidly accumulating overwhelmingly positive outcomes data. However, coordinated efforts may help accelerate the process.
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Affiliation(s)
- Rani Modayil
- Winthrop University Hospital, 222 Station Plaza North Suite 429, Mineola, NY 11501, USA
| | - Stavros N Stavropoulos
- Columbia University, 161 Fort Washington Ave., New York, NY 10032, USA; Temple University, 3401 N Broad St., Philadelphia, PA 19140, USA; Program in Advanced GI Endoscopy (P.A.G.E.), Winthrop University Hospital, 222 Station Plaza North Suite 429, Mineola, NY 11501, USA.
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Stavropoulos SN, Modayil R, Friedel D. The State of The Art in Per-Oral Endoscopic Myotomy. Semin Thorac Cardiovasc Surg 2016; 28:137-46. [DOI: 10.1053/j.semtcvs.2015.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2015] [Indexed: 02/07/2023]
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Abstract
UNLABELLED Per oral endoscopic myotomy (POEM) represents the culmination of natural orifice transluminal endoscopic surgery (NOTES) research, and its most successful application to date. Over a thousand POEMs have been performed globally with remarkable results in terms of clinical efficacy and safety. PURPOSE OF REVIEW We examine the most recent literature concerning POEM since the last two comprehensive analyses [Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) White Paper, ASGE Preservation and Incorporation of Valuable endoscopic Innovations (PIVI)], and integrate this literature in the consensus POEM guidelines and perspective. These current works are largely centered on POEM operator learning curve, comparison of POEM and laparoscopic Heller myotomy (LHM) and extended application of POEM. RECENT FINDINGS POEM and LHM are comparable in terms of efficacy (diminished dysphagia and Eckardt score) and complications including GERD. POEM has been successfully performed in a wide variety of patients including children, those with prior achalasia therapy and those with spastic esophageal disorders. SUMMARY POEM has been validated as a treatment for achalasia. Issues remain regarding its longer term efficacy in comparison with LHM. Subsequent comparison trials are needed. VIDEO ABSTRACT http://links.lww.com/COG/A14.
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Abstract
Idiopathic achalasia is a primary esophageal motor disorder characterized by loss of esophageal peristalsis and insufficient lower esophageal sphincter relaxation in response to deglutition. Patients with achalasia commonly complain of dysphagia to solids and liquids, bland regurgitation often unresponsive to an adequate trial of proton pump inhibitor, and chest pain. Weight loss is present in many, but not all patients. Although the precise etiology is unknown, it is often thought to be either autoimmune, viral immune, or neurodegenerative. The diagnosis is based on history of the disease, barium esophagogram, and esophageal motility testing. Endoscopic assessment of the gastroesophageal junction and gastric cardia is necessary to rule out malignancy. Newer diagnostic modalities such as high resolution manometry help in predicting treatment response in achalasia based on esophageal pressure topography patterns identifying three phenotypes of achalasia (I-III) and outcome studies suggest better treatment response with types I and II compared to type III. Although achalasia cannot be permanently cured, excellent outcomes are achieved in over 90 % of patients. Current medical and surgical therapeutic options (pneumatic dilation, endoscopic and surgical myotomy, and pharmacologic agents) aim at reducing the LES pressure and facilitating esophageal emptying by gravity and hydrostatic pressure of retained food and liquids. Either graded pneumatic dilatation or laparoscopic surgical myotomy with a partial fundoplication are recommended as initial therapy guided by patient age, gender, preference, and local institutional expertise. The prognosis in achalasia patients is excellent. Most patients who are appropriately treated have a normal life expectancy but the disease does recur and the patient may need intermittent treatment.
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Affiliation(s)
| | - Hannah P Kim
- Department of Internal Medicine, Nashville, TN, USA
| | | | - Michael F Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA.
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