Pathophysiology and endoscopic/balloon treatment of esophageal motility disorders

Gastrointestinal motility disorders and acupuncture

During the last decades, numerous studies have been performed to investigate the effects and mechanisms of acupuncture or electroacupuncture (EA) on gastrointestinal motility and patients with functional gastrointestinal diseases. A PubMed search was performed on this topic and all available studies published in English have been reviewed and evaluated. This review is organized based on the gastrointestinal organ (from the esophagus to the colon), components of gastrointestinal motility and the functional diseases related to specific motility disorders. It was found that the effects of acupuncture or EA on gastrointestinal motility were fairly consistent and the major acupuncture points used in these studies were ST36 and PC6. Gastric motility has been mostly studied, whereas much less information is available on the effect of EA on small and large intestinal motility or related disorders. A number of clinical studies have been published, investigating the therapeutic effects of EA on a number of functional gastrointestinal diseases, such as gastroesophageal reflux, functional dyspepsia and irritable bowel syndrome. However, the findings of these clinical studies were inconclusive. In summary, acupuncture or EA is able to alter gastrointestinal motility functions and improve gastrointestinal motility disorders. However, more studies are needed to establish the therapeutic roles of EA in treating functional gastrointestinal diseases.

Laparoscopic repair of a large symptomatic epiphrenic esophageal diverticulum

PURPOSE

The diagnosis of symptomatic epiphrenic esophageal diverticula is uncommon. Even less common are published reports regarding the efficacy of laparoscopic repair of this malady.

METHODS

We report the case of a 59-year-old male patient with Parkinsonism found to have a large, symptomatic epiphrenic diverticulum and discuss the surgical treatment performed. The patient presented with a 6-month history of worsening dysphagia to both solids and liquids, regurgitation of undigested food, and weight loss. Barium esophagram identified the presence of a large distal esophageal diverticulum. Esophagoscopy confirmed the epiphrenic location of the diverticulum and the absence of other pathology. Laparoscopic transhiatal diverticulectomy was performed utilizing a gastrointestinal endoscopic stapler. Intraoperative esophagoscopy was performed to confirm resection of the diverticulum without constriction of the lumen.

RESULTS

The patient resumed intake of liquids on postoperative day 1 after a water-soluble contrast esophagram revealed no extravasation. The patient was discharged on hospital day 3. He reported residual dysphagia to solids postoperatively, which appeared to resolve after pneumatic dilation.

CONCLUSIONS

We conclude that laparoscopic epiphrenic diverticulectomy is technically feasible and safe. The comorbidity of Parkinsonism adds complexity to the diagnosis and treatment of this uncommon disorder.

Achalasia Complicated by Multiple Intramucosal Carcinomas: Report of a Case

A 56-year-old woman underwent a laparoscopic Heller-Dor operation for esophageal achalasia in June 2002. As dysphagia became exacerbated and the oral intake became extremely poor, an esophagectomy was thus considered to be indicated. In September 2005, a transhiatal esophagectomy was performed, and the esophagus was reconstructed using a gastric tube through the posterior mediastinum. The patient developed pneumonia postoperatively, but responded to conservative therapy and was discharged in good health 30 days after surgery. A histopathological analysis demonstrated degeneration and a loss of gangliocytes throughout the esophagus as well as the presence of seven intramucosal cancers. The main cause of dysphagia was due to a marked flexion of the upper esophagus. Even though we identified a precancerous state, we believe that surgery was an appropriate option in this case.

Long-term outcomes of laparoscopic heller cardiomyotomy without an anti-reflux procedure

Certain technical features of laparoscopic Heller cardiomyotomy (LHM) remain controversial, including the extent of the myotomy and the indication for an antireflux procedure. We completed a retrospective chart review of all patients who underwent LHM for achalasia at 1 tertiary care institution to review our institutional experience with LHM without an antireflux procedure. Forty patients underwent a LHM performed by 2 surgeons, 65% of whom had previous medical management (Botox: 12 patients, LES dilatation: 14). The operating time was significantly increased in patients with Botox injections (98.3 vs. 71.1 minutes, P = 0.005). There were 3 intraoperative complications (mucosal injury in 3 patients, 2 had Botox injections). Postoperative evaluation demonstrated a mean dysphagia score of 0.2, a mean heartburn score of 3.2, and a mean LES pressure of 6.32 mm Hg. Thirty-two patients are maintained on acid-suppressing medications with good control of reflux symptoms. LHM without an antireflux procedure achieves excellent clinical outcomes in most patients with achalasia regardless of previous medical management. Previous medical management may present a greater technical challenge and may place patients at increased risk of mucosal injury.

Esophagotomy during laparoscopic Heller myotomy cannot be predicted by preoperative therapies and does not influence long-term outcome

The conventional wisdom is that inadvertent esophagotomy complicates laparoscopic Heller myotomy. This study was undertaken to determine if esophagotomy at myotomy can be predicted by preoperative therapy, and if esophagotomy and/or its repair jeopardizes outcomes. Of 222 laparoscopic Heller myotomies undertaken since 1992, inadvertent esophagotomy occurred in 16 patients (7%); 60 patients who underwent myotomy without esophagotomy were utilized for comparison. Dysphagia and reflux before/after myotomy were scored by patients on a Likert scale (0-5). The median (mean +/- SD) follow-up after myotomy with esophagotomy was 38.8 months (31.6 +/- 21.9 months) versus 46.3 months (51.0 +/- 21.2 months) after myotomy alone. All esophagotomies were immediately recognized and repaired. Patients who experienced esophagotomy were similar to those who did not in application of Botox (56% vs. 77%) or dilation (44% vs. 65%), years of dysphagia (7.3 +/- 5.4 vs. 7.4 +/- 6.0), and mean preoperative dysphagia score (4.9 +/- 0.4 vs. 4.8 +/- 0.4). Esophagotomy led to longer hospitalizations (5.2 days +/- 2.5 days vs. 1.5 days +/- 0.7 days, P < 0.05) but not different postoperative dysphagia scores (1.5 +/- 1.7 vs. 2.1 +/- 1.4), reflux scores (1.4 +/- 1.7 vs. 2.3 +/- 1.3), or good or excellent outcomes (86% vs 84%). Esophagotomy during laparoscopic Heller myotomy is infrequent and cannot be predicted by preoperative therapy or duration or severity of dysphagia. Furthermore, complications after esophagotomy are infrequent and outcomes are indistinguishable from those of patients undergoing uneventful myotomy.

Balloon dilation-assisted laparoscopic heller myotomy and Dor fundoplication

Two methods are currently used in the treatment of achalasia: endoscopic balloon dilation and surgical Heller myotomy. Laparoscopy has come into use in achalasia surgery, and good outcomes have been achieved. This study included 11 patients (mean age, 30.7 years). Balloon dilation-assisted laparoscopic Heller myotomy and Dor fundoplication were performed in all patients. A 36-F orogastric tube was placed under visualization. The balloon of the tube was placed in the esophagogastric junction. After laparoscopic cardiomyotomy, the balloon was removed and Dor fundoplication was performed. The mean operative time was 90 minutes. The patients were discharged on the second and third postoperative days (mean [standard deviation], 3 +/- 0.46). One month after the operation, the patients were tested with barium swallowing, and no complications or recurrences were observed. Laparoscopic distal esophagomyotomy combined with partial fundoplication may be the surgical approach of choice in achalasia because it is safer, provides good to excellent relief of symptoms and excellent cosmetic results, involves a shorter hospital stay, and is easy to execute. Balloon dilation makes myotomy easier because it separates the muscle fibers. Placing and insufflation of the balloon become safer because the entire procedure is executed under visualization; thus, excessive dilation is avoided.

The role of esophagogastroduodenoscopy in the diagnosis and management of upper gastrointestinal disorders

Esophagogastroduodenoscopy has revolutionized the clinical management of upper gastrointestinal diseases. Millions of EGDs are performed annually in the United States for many indications, such as gastrointestinal bleeding, abdominal pain, dysphagia, or surveillance of premalignant lesions. Esophagogastroduodenoscopy is very safe, with a low risk of serious complications such as perforation, cardiopulmonary arrest, or aspiration pneumonia. It is a highly sensitive and specific diagnostic test, especially when combined with endoscopic biopsy. Esophagogastroduodenoscopy is increasingly being used therapeutically to avoid surgery. New endoscopic technology such as endosonography, endoscopic sewing, and the endoscopic videocapsule will undoubtedly extend the frontiers and increase the indications for endoscopy.

Laparoscopic and thoracoscopic esophagomyotomy for children with achalasia

BACKGROUND

Minimally invasive esophagomyotomy, consisting of a laparoscopic or thoracoscopic approach, has become a preferred surgical treatment for adults with achalasia. This multicenter study reports on the clinical status of children who have undergone minimally invasive esophagomyotomy for achalasia.

METHODS

Symptomatology for achalasia was assessed in 22 pediatric patients who underwent minimally invasive esophagomyotomy for achalasia between 1995 and 2000. All patients were evaluated for duration of hospitalization, postoperative resumption of feeds, postoperative complications, and symptomatic relief. Participants were assigned pre-and postoperative symptom severity scores ranging from 0 (no symptoms) to 3 (severe).

RESULTS

The median age of the 10 females and 12 males at time of surgery was 11.3 years +/- 3.4 (standard deviation). Transabdominal laparoscopic esophagomyotomy with fundoplication was performed in 18 patients, and thoracoscopic esophagomyotomy without fundoplication was performed in 4. Two patients required conversion from transabdominal laparoscopic esophagomyotomy to open esophagomyotomy because of intraoperative esophageal perforation. The mean duration of postsurgical follow-up was 17 +/- 16 (standard deviation) months (range, 1-54 months). Mean duration of hospitalization (days +/- standard error or mean) was less for transabdominal laparoscopic esophagomyotomy than for converted open esophagomyotomy (2.7 +/- 0.3 vs. 9.0 +/- 3.0 days; P < 0.05) or for thoracoscopic esophagomyotomy (4.8 +/- 1.7 days; P = not significant). Mean time to resumption of soft feedings (days +/- standard error or mean) occurred sooner after transabdominal laparoscopic esophagomyotomy than after converted open esophagomyotomy (2.0 +/- 0.2 vs. 5.5 +/- 0.5 days; P < 0.001) or after thoracoscopic esophagomyotomy (4.0 +/- 1.3 days; P = not significant). Patients experienced significant pre-to postoperative improvement in mean severity score with regard to dysphagia (2.6 vs. 0.4; P < 0.001) and regurgitation (1.7 vs. 0.2; P < 0.001).

CONCLUSIONS

Minimally invasive esophagomyotomy can provide excellent symptomatic relief from dysphagia and regurgitation for children with achalasia.

A decision analysis of the optimal initial approach to achalasia: laparoscopic Heller myotomy with partial fundoplication, thoracoscopic Heller myotomy, pneumatic dilatation, or botulinum toxin injection

In the absence of randomized controlled trials that directly compare all of the modern methods of managing achalasia, decision analysis may help determine the optimal treatment strategy. Four strategies for the initial management of achalasia were compared using the following decision model: (1) laparoscopic Heller myotomy and partial fundoplication; (2) pneumatic dilatation; (3) botulinum toxin injection; and (4) thoracoscopic Heller myotomy. Probabilities of clinical events and utilities of health states were estimated using review of the medical literature and patient interviews. A recursive decision tree (Markov model) was used to simulate all the important outcomes of each initial treatment option, allowing for complications, relapses over time, and transitions between strategies when appropriate. After 10 years, laparoscopic Heller myotomy with partial fundoplication was associated with the longest quality-adjusted survival (quality-adjusted life years [QALY] = 7.41). The difference between this strategy and either pneumatic dilatation or botulinum toxin injection was small. Thoracoscopic Heller myotomy was associated with the poorest quality-adjusted survival (QALY = 7.15). Pneumatic dilatation was the favored strategy when the effectiveness of laparoscopic surgery at relieving dysphagia was less than 89.7%, the operative mortality risk was greater than 0.7%, or the probability of reflux after pneumatic dilatation was less than 19%. In a decision model, laparoscopic Heller myotomy with partial fundoplication is at least as effective as endoscopic approaches for managing achalasia symptoms. However, the differences are small enough that patient preferences and local expertise should be taken into consideration when tailoring a treatment plan for an individual patient.

Primary esophageal motility disorders

Esophageal motility disorders often manifest with chest pain and dysphagia. Achalasia is a disorder of the lower esophageal sphincter and the smooth musculature of the esophageal body. In achalasia the lower esophageal sphincter typically fails to relax with swallowing, and the esophageal body fails to undergo peristalsis. In contrast to spastic disorders of the esophagus, achalasia can be progressive and cause pronounced morbidity. Pseudoachalasia mimics achalasia in terms of symptoms but can be caused by infectious disorders or malignancy. Treatment for achalasia is nonstandardized and includes medical, endoscopic, and surgical options. Spastic disorders of the esophagus, such as diffuse esophageal spasm and nutcracker esophagus, and nonspecific esophageal motility disorder are benign and nonprogressive, with similar findings on esophageal manometry. Although the exact cause remains unknown, these disorders may represent a manifestation of gastroesophageal reflux disease. Treatment of spastic disorders includes medical and surgical approaches and is aimed at symptomatic relief.

Evaluation of the use of botulinum toxin in children with achalasia

BACKGROUND

Achalasia is rare in children. Recently, injection of botulinum toxin into the lower esophageal sphincter has been studied as an alternative to esophageal pneumatic dilatation or surgical myotomy as treatment for achalasia. In the current study, the effects of botulinum toxin were investigated in the largest known series of children with achalasia.

METHODS

Treatment for achalasia was assessed in 23 pediatric patients who received botulinum toxin from June 1995 through November 1998. Those who continued to receive botulinum toxin and did not subsequently undergo pneumatic dilatation or surgery were considered repeat responders. Results were compared with those of published studies evaluating the use of botulinum toxin in adults with achalasia.

RESULTS

Nineteen patients initially responded to botulinum toxin. Mean duration of effect was 4.2 months +/- 4.0 (SD). At the end of the study period, three were repeat responders, three experienced dysphagia but did not receive pneumatic dilatation or surgery, three underwent pneumatic dilatation, eight underwent surgery, three underwent pneumatic dilatation with subsequent surgery, and three awaited surgery. Meta-analysis shows that, in the current study group, the data point expressing time of follow-up evaluation versus percentage of patients needing one injection session without additional procedures (botulinum toxin injection, pneumatic dilatation, or surgery) falls within the curve for those in studies on adult patients receiving botulinum toxin for achalasia.

CONCLUSIONS

Botulinum toxin effectively initiates the resolution of symptoms associated with achalasia in children. However, one half of patients are expected to need an additional procedure approximately 7 months after one injection session. The authors recommend that botulinum toxin be used only for children with achalasia who are poor candidates for either pneumatic dilatation or surgery.

Characterization of esophageal striated muscle in patients with achalasia

Many studies have been conducted analyzing the manometric properties of patients with achalasia, but the striated portion of the esophagus has never been analyzed and is often overlooked. We retrospectively reviewed 120 manometric tracings (20 achalasia, 100 controls) performed between 1994 and 1997 and excluded tracings from patients with chronic cough and nutcracker esophagus. The data were assessed for age, sex, symptoms, duration of symptoms, lower esophageal sphincter pressure, gastroesophageal gradient, upper esophageal sphincter pressure, smooth muscle contraction amplitude and duration, striated muscle contraction amplitude and duration, length from upper esophageal sphincter to maximal striated muscle contraction, and esophageal length. The maximum striated muscle contraction amplitude was significantly decreased in achalasia patients with a median amplitude of 45 mm Hg (range 12-95) vs 76 mm Hg (range 30-210) in the control group (P = 0.002). Although the wave forms were similar, the maximum striated muscle contraction duration and the distance from the upper esophageal sphincter in achalasia patients was not significantly different from controls. The length of the esophagus was significantly longer in achalasia patients with a median value of 25 cm (range 21-30) vs 21 cm (range 17-26) in the control group (P < 0.001). Patients with achalasia have significantly lower maximum striated muscle contraction amplitudes and longer esophagi, but the duration of the contractions and the configuration of the wave forms are not different.

Anatomy and physiology of the esophagus

Modern diagnosis and treatment of esophageal disease is a result of progress in assessing the anatomy and physiology of the esophagus, as well as refinements in anesthetic and surgical techniques. Esophageal carcinoma spreads rapidly and metastasizes easily. The tendency for early spread and the absence of symptoms result in late diagnosis that reduces treatment options and cure rates. Lifestyle (i.e., use of alcohol and tobacco), nutritional deficiencies, ingestion of nitrosamines, and mutagen-inducing fungi are blamed for cancer of the esophagus. Other pathologic conditions (e.g., achalasia, Barrett's epithelium, gastric reflux, hiatal hernia) are potential contributors to the development of carcinoma. Nurses are in key positions to identify the existence of factors contributing to premalignant or malignant lesions and to educate patients and make the appropriate referrals.