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Patti MG, Schlottmann F, Herbella FAM. Once an achalasia patient always an achalasia patient: evaluation and treatment of recurrent symptoms. Dysphagia 2023. [DOI: 10.1016/b978-0-323-99865-9.00009-9] [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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Ribolsi M, Andrisani G, Di Matteo FM, Cicala M. Achalasia, from diagnosis to treatment. Expert Rev Gastroenterol Hepatol 2023; 17:21-30. [PMID: 36588469 DOI: 10.1080/17474124.2022.2163236] [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] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Achalasia is an uncommon esophageal motility disorder and is characterized by alterations of the motility of the esophageal body in conjunction with altered lower esophageal sphincter (LES) relaxation. The clinical presentation of patients with achalasia may be complex; however, the most frequent symptom is dysphagia. The management of patients with achalasia is often challenging, due to the heterogeneous clinical presentation. AREAS COVERED The diagnosis and management of achalasia has significantly improved in the last years due to the growing availability of high-resolution manometry (HRM) and the implementation in the therapeutic armamentarium of new therapeutic endoscopic procedures. Traditional therapeutic strategies include botulinum toxin injected to the LES and pneumatic balloon dilation. On the other hand, surgical treatments contemplate laparoscopic Heller myotomy and, less frequently, esophagectomy. Furthermore, in the last few years, per oral endoscopic myotomy (POEM) has been proposed as the main endoscopic therapeutic alternative to the laparoscopic Heller myotomy. EXPERT OPINION Diagnosis and treatment of achalasia still represent a challenging area. However, we believe that an accurate up-front evaluation is, nowadays, necessary in addressing patients with achalasia for a more accurate diagnosis as well as for the best treatment options.
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Affiliation(s)
- Mentore Ribolsi
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, Rome, Italy
| | | | | | - Michele Cicala
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, Rome, Italy
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Cubisino A, Schlottmann F, Dreifuss NH, Baz C, Mangano A, Masrur MA, Bianco FM, Giulianotti PC. Robotic redo Heller myotomy: how I do it? Langenbecks Arch Surg 2022; 407:1721-1726. [PMID: 35583834 DOI: 10.1007/s00423-022-02553-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/10/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite the high success rate associated with Heller myotomy in the treatment of primary achalasia, symptom persistence or relapse occurs in approximately 10-20% of patients. Unfortunately, the ideal treatment after failed myotomy is not well established yet. We present a didactical video with a stepwise technique to perform a robotic revisional procedure after failed Heller myotomy. METHODS In this report, each surgical step is thoroughly described and visually represented with useful technical tips that might help in improving surgical results of revisional Heller myotomy. RESULTS In patients with previous surgical myotomy, the robotic platform with its high-definition magnified view and EndoWrist instruments allow for a safe and precise redo surgical myotomy. CONCLUSIONS Despite its improved surgical capabilities, the role of robotic redo Heller myotomy in the treatment algorithm of patients with recurrent symptoms after failed surgical myotomy should be further explored.
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Affiliation(s)
- Antonio Cubisino
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA.
| | - Francisco Schlottmann
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Nicolas H Dreifuss
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Carolina Baz
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Alberto Mangano
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Mario A Masrur
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Francesco M Bianco
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Pier Cristoforo Giulianotti
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
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Esophageal Achalasia: Evaluation and Treatment of Recurrent Symptoms. World J Surg 2022; 46:1561-1566. [PMID: 35166877 DOI: 10.1007/s00268-022-06466-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Esophageal achalasia is a primary esophageal motility disorder of unknown origin. Treatment is palliative and its goal is to decrease the resistance posed by a non-relaxing and often hypertensive lower esophageal sphincter. This goal can be accomplished by different treatment modalities such as pneumatic dilatation, laparoscopic myotomy or peroral endoscopic myotomy. In some patients, however, symptoms tend to recur overtime. METHODS A comprehensive literature search was performed on PubMed focused on the management of recurrent achalasia. RESULTS The available treatment modalities can be used, alone or in combination. The goal of treatment is to resolve/improve symptoms, avoiding an esophagectomy, an operation linked to significant morbidity. CONCLUSIONS The treatment of these patients is often very challenging, and the best results are obtained in centers where a multidisciplinary team-radiologists, gastroenterologists, and surgeons-is present.
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Brindise E, Khashab MA, El Abiad R. Insights into the endoscopic management of esophageal achalasia. Ther Adv Gastrointest Endosc 2021; 14:26317745211014706. [PMID: 34017943 PMCID: PMC8114742 DOI: 10.1177/26317745211014706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/07/2021] [Indexed: 01/21/2023] Open
Abstract
Achalasia is a primary esophageal motility disorder characterized by the loss of inhibitory neurons in the myenteric plexus, resulting in impaired relaxation of the esophagogastric junction. Achalasia is an incurable disease, and the treatment modalities are aimed at disruption of the esophagogastric junction and vary widely from pharmacological to endoscopic to surgical. Traditional endoscopic therapy includes pneumatic dilation, botulinum toxin injection, and peroral endoscopic myotomy. This review aims to provide an overview of the endoscopic management of achalasia, while focusing on the utilization of peroral endoscopic myotomy and other novel approaches.
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Affiliation(s)
- Elizabeth Brindise
- Division of Gastroenterology and Hepatology, The University of Iowa, Iowa City, IA, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Rami El Abiad
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals & Clinics, The University of Iowa, 4612 JCP, Iowa City, IA 52241, USA
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Peroral endoscopic myotomy is a safe and effective treatment modality for geriatric patients with achalasia. Esophagus 2020; 17:484-491. [PMID: 32394115 DOI: 10.1007/s10388-020-00746-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 04/26/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is an appealing treatment for older patients, as it is minimally invasive but highly efficacious similar to surgical myotomy. However, there is a lack of systematic studies analyzing POEM outcomes in young (< 65 years) versus geriatric patients (≥ 65 years). Hence, we aimed to compare the safety and efficacy of POEM in young versus geriatric patients. METHODS Records of all achalasia patients who underwent POEM at our institution between April 2014 and May 2019 were reviewed. Patients were categorized into two groups: young (< 65 years) and old (≥ 65 years). Demographic and procedural details, timed barium esophagram (TBE), high-resolution manometry (HREM), pH study findings and Eckardt scores were compared between the two groups. Post-POEM Eckhardt score of ≤ 3 was defined as treatment success. RESULTS A total of 148 patients met the study criteria (young = 93; old = 55). Younger patients were more likely to have lower TBE height at 1 min but wider TBE width at 5 min. The rest of the pre-operative parameters and Eckardt scores were similar in the two groups. Young patients were more likely to have undergone prior Heller myotomy, while Botox injections were common in the older group. The operative details and outcomes were similar in the two groups. Treatment success rates were similar in both groups (94.9% young vs. 94.7% in old patients, p = 1.00). At 2-month follow-up, both groups showed significant improvements in Eckhardt scores and HREM parameters; however, older patients showed greater improvement in TBE height at 1 and 5 min. The rates of symptomatic GERD and abnormal esophageal pH study findings were similar in the two groups. CONCLUSION POEM was safe and highly effective treatment for geriatric patients with achalasia. These findings suggest that POEM might emerge as the preferred approach for myotomy in this patient population.
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Santes O, Coss-Adame E, Valdovinos MA, Furuzawa-Carballeda J, Rodríguez-Garcés A, Peralta-Figueroa J, Narvaez-Chavez S, Olvera-Prado H, Clemente-Gutiérrez U, Torres-Villalobos G. Does laparoscopic reoperation yield symptomatic improvements similar to those of primary laparoscopic Heller myotomy in achalasia patients? Surg Endosc 2020; 35:4991-5000. [DOI: 10.1007/s00464-020-07978-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/14/2020] [Indexed: 01/06/2023]
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Abstract
Achalasia is an esophageal motility disorder characterized by aberrant peristalsis and insufficient relaxation of the lower esophageal sphincter. Patients most commonly present with dysphagia to solids and liquids, regurgitation, and occasional chest pain with or without weight loss. High-resolution manometry has identified 3 subtypes of achalasia distinguished by pressurization and contraction patterns. Endoscopic findings of retained saliva with puckering of the gastroesophageal junction or esophagram findings of a dilated esophagus with bird beaking are important diagnostic clues. In this American College of Gastroenterology guideline, we used the Grading of Recommendations Assessment, Development and Evaluation process to provide clinical guidance on how best to diagnose and treat patients with achalasia.
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Felix VN, Murayama KM, Bonavina L, Park MI. Achalasia: what to do in the face of failures of Heller myotomy. Ann N Y Acad Sci 2020; 1481:236-246. [PMID: 32713020 DOI: 10.1111/nyas.14440] [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] [Received: 04/03/2020] [Revised: 06/07/2020] [Accepted: 06/25/2020] [Indexed: 12/21/2022]
Abstract
Achalasia is a primary motility disorder of the esophagus, and while there are several treatment options, there is no consensus regarding them. When therapeutic intervention for achalasia fails, a careful evaluation of the cause of the persistent or recurrent symptoms using upper endoscopy, esophageal manometry, and contrast radiologic studies is required to understand the cause of therapy failure and guide plans for subsequent treatment. Options for reintervention are the same as for primary intervention and include pneumatic dilation, botulinum toxin injection, peroral endoscopic myotomy, or redo esophageal myotomy. When reintervention fails or if the esophagus is not amenable to intervention and the disease is considered end-stage, esophagectomy is the last option to manage recurrent achalasia.
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Affiliation(s)
- Valter N Felix
- Nucleus of General and Specialized Surgery - São Paulo and Department of Gastroenterology - Surgical Division - São Paulo University, FMUSP, Sao Paulo, Brazil
| | - Kenric M Murayama
- Department of Surgery, John A. Burns School of Medicine, the University of Hawaii at Manoa, Honolulu, Hawaii
| | - Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, The University of Milan, San Donato Milanese, Italy
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
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Sanaka MR, Khoudari G, Parikh M, Thota PN, Lopez R, Gupta N, Gabbard S, Ray M, Murthy S, Raja S. Peroral endoscopic myotomy is highly effective for achalasia patients with recurrent symptoms after pneumatic dilatation. Surg Endosc 2020; 35:2965-2975. [PMID: 32556695 DOI: 10.1007/s00464-020-07737-8] [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: 03/15/2020] [Accepted: 06/12/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Previous interventions in achalasia such as pneumatic dilation (PD) might lead to difficulties with peroral endoscopic myotomy (POEM) along with sub-optimal outcomes. There are limited data in the literature on outcomes of POEM after PD, especially from the western hemisphere. Hence, we aimed to determine the safety and efficacy of POEM for recurrent symptoms after PD compared to treatment naïve achalasia patients. METHODS Medical records of achalasia patients who underwent POEM at our institution between April 2014 and October 2019 were reviewed. Patients who had POEM for recurrent symptoms after prior PD were matched at 1:2 ratio with treatment naïve achalasia patients using propensity score matching. Patients who had prior Heller myotomy were excluded. Patient demographics, Eckardt scores, timed barium swallow (TBE), high-resolution esophageal manometry (HREM), and pH study findings were compared between the two groups, pre- and 2 months post-POEM. Treatment success was defined as reduction of Eckardt score to ≤ 3. RESULTS A total of 39 patients (prior PD = 13; treatment naïve = 26) were included. Patient demographics, procedural, and peri-procedural outcomes were similar in both groups. Treatment success was similar in both groups, 100.0% in prior PD vs 91.7% in treatment naïve group (p = 0.53). On adjusted analysis, there was no significant difference in the pre-post-POEM improvement in Eckardt scores, TBE, and HREM parameters in the two groups. Gastroesophageal reflux disease rates were also similar in both groups. CONCLUSIONS In achalasia with recurrent symptoms after PD, POEM is a safe and highly effective treatment modality. Prior PD does not seem to influence the outcomes or efficacy of POEM.
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Affiliation(s)
| | - George Khoudari
- Department of Gastroenterology, Cleveland Clinic, Cleveland, OH, USA
| | - Malav Parikh
- Department of Gastroenterology, Cleveland Clinic, Cleveland, OH, USA
| | | | - Rocio Lopez
- Department of Gastroenterology, Cleveland Clinic, Cleveland, OH, USA
| | - Niyati Gupta
- Department of Gastroenterology, Cleveland Clinic, Cleveland, OH, USA
| | - Scott Gabbard
- Department of Gastroenterology, Cleveland Clinic, Cleveland, OH, USA
| | - Monica Ray
- Department of Gastroenterology, Cleveland Clinic, Cleveland, OH, USA
| | - Sudish Murthy
- Department of Cardiovascular and Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Siva Raja
- Department of Cardiovascular and Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
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Oude Nijhuis RAB, Prins LI, Mostafavi N, van Etten-Jamaludin FS, Smout AJPM, Bredenoord AJ. Factors Associated With Achalasia Treatment Outcomes: Systematic Review and Meta-Analysis. Clin Gastroenterol Hepatol 2020; 18:1442-1453. [PMID: 31622735 DOI: 10.1016/j.cgh.2019.10.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 09/26/2019] [Accepted: 10/04/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Identification of factors associated with achalasia treatment outcome might help physicians select therapies based on patient characteristics. We performed a systematic review and meta-analysis to identify factors associated with treatment response. METHODS We searched MEDLINE, EMBASE, and the Cochrane Library through February 21, 2019, for randomized controlled trials and cohort, case-control, and cross-sectional studies that reported patient-specific outcomes of treatment (botulinum toxin injection, pneumatic dilation, peroral endoscopic myotomy, or laparoscopic Heller myotomy). We assessed the methodologic quality of the included studies using the quality in prognosis studies tool. We planned qualitative and quantitative analyses. RESULTS We analyzed data from 75 studies (8 randomized controlled trials, 27 prospective cohort studies, and 40 retrospective studies) on a total of 34 different factors associated with outcomes (3 demographic, 17 clinical, and 14 diagnostic factors). Qualitative assessment showed age, manometric subtype, and presence of a sigmoid-shaped esophagus as factors associated with outcomes of treatment for achalasia with a strong level of evidence. The cumulative evidence for the association with chest pain, symptom severity, and lower esophageal sphincter pressure was inconclusive. A meta-analysis confirmed that older age (mean difference, 7.9 y; 95% CI, 1.5-14.3 y) and manometric subtype 3 (odds ratio, 7.1; 95% CI, 4.1-12.4) were associated with clinical response. CONCLUSIONS In a systematic review and meta-analysis, we found age and manometric subtype to be associated with outcomes of treatment for achalasia. This information should be used to guide treatment decisions.
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Affiliation(s)
- Renske A B Oude Nijhuis
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands.
| | - Leah I Prins
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Nahid Mostafavi
- Biostatistical Unit, Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Andreas J P M Smout
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Cappell MS, Stavropoulos SN, Friedel D. Updated Systematic Review of Achalasia, with a Focus on POEM Therapy. Dig Dis Sci 2020; 65:38-65. [PMID: 31451984 DOI: 10.1007/s10620-019-05784-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 08/07/2019] [Indexed: 02/06/2023]
Abstract
AIM To systematically review clinical presentation, diagnosis, and therapy of achalasia, focusing on recent developments in high-resolution esophageal manometry (HREM) for diagnosis and peroral endoscopic myotomy (POEM) for therapy. METHODS Systematic review of achalasia using computerized literature search via PubMed and Ovid of articles published since 2005 with keywords ("achalasia") AND ("high resolution" or "HREM" or "peroral endoscopic myotomy" or "POEM"). Two authors independently performed literature searches and incorporated articles into this review by consensus according to prospectively determined criteria. RESULTS Achalasia is an uncommon esophageal motility disorder, usually manifested by dysphagia to solids and liquids, and sometimes manifested by chest pain, regurgitation, and weight loss. Symptoms often suggest more common disorders, such as gastroesophageal reflux disease (GERD), thus often delaying diagnosis. Achalasia is a predominantly idiopathic chronic disease. Diagnosis is typically suggested by barium swallow showing esophageal dilation; absent distal esophageal peristalsis; smoothly tapered narrowing ("bird's beak") at esophagogastric junction; and delayed passage of contrast into stomach. Diagnostic findings at high-resolution esophageal manometry (HREM) include: distal esophageal aperistalsis and integrated relaxation pressure (trough LES pressure during 4 s) > 15 mmHg. Achalasia is classified by HREM into: type 1 classic; type 2 compartmentalized high pressure in esophageal body, and type 3 spastic. This classification impacts therapeutic decisions. Esophagogastroduodenoscopy is required before therapy to assess esophagus and esophagogastric junction and to exclude distal esophageal malignancy. POEM is a revolutionizing achalasia therapy. POEM creates a myotomy via interventional endoscopy. Numerous studies demonstrate that POEM produces comparable, if not superior, results compared to standard laparoscopic Heller myotomy (LHM), as determined by LES pressure, dysphagia frequency, Eckardt score, hospital length of stay, therapy durability, and incidence of GERD. Other therapies, including botulinum toxin injection and pneumatic dilation, have moderately less efficacy and much less durability than POEM. CONCLUSION This comprehensive review suggests that POEM is equivalent or perhaps superior to LHM for achalasia in terms of cost efficiency, hospital length of stay, and relief of dysphagia, with comparable side effects. The data are, however, not conclusive due to sparse long-term follow-up and lack of randomized comparative clinical trials. POEM therapy is currently limited by a shortage of trained endoscopists.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology and Hepatology, MOB #602, William Beaumont Hospital, 3535 W. Thirteen Mile Rd, Royal Oak, MI, 48073, USA. .,Oakland University William Beaumont School of Medicine, MOB #602, William Beaumont Hospital, 3535 W. Thirteen Mile Rd, Royal Oak, MI, 48073, USA.
| | | | - David Friedel
- Division of Gastroenterology, New York University Winthrop Medical Center, Mineola, NY, 11501, USA
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Zaninotto G, Bennett C, Boeckxstaens G, Costantini M, Ferguson MK, Pandolfino JE, Patti MG, Ribeiro U, Richter J, Swanstrom L, Tack J, Triadafilopoulos G, Markar SR, Salvador R, Faccio L, Andreollo NA, Cecconello I, Costamagna G, da Rocha JRM, Hungness ES, Fisichella PM, Fuchs KH, Gockel I, Gurski R, Gyawali CP, Herbella FAM, Holloway RH, Hongo M, Jobe BA, Kahrilas PJ, Katzka DA, Dua KS, Liu D, Moonen A, Nasi A, Pasricha PJ, Penagini R, Perretta S, Sallum RAA, Sarnelli G, Savarino E, Schlottmann F, Sifrim D, Soper N, Tatum RP, Vaezi MF, van Herwaarden-Lindeboom M, Vanuytsel T, Vela MF, Watson DI, Zerbib F, Gittens S, Pontillo C, Vermigli S, Inama D, Low DE. The 2018 ISDE achalasia guidelines. Dis Esophagus 2018; 31:5087687. [PMID: 30169645 DOI: 10.1093/dote/doy071] [Citation(s) in RCA: 155] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.
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Affiliation(s)
- G Zaninotto
- Department of Surgery and Cancer, Imperial College, London, UK
| | - C Bennett
- Office of Research and Innovation, Royal College of Surgeons in Ireland, Ireland
| | - G Boeckxstaens
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - M Costantini
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - M K Ferguson
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - J E Pandolfino
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - M G Patti
- Department of Medicine and Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - U Ribeiro
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - J Richter
- Department of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - L Swanstrom
- Institute of Image-Guided Surgery, Strasbourg, France; Interventional Endoscopy and Foregut Surgery, Oregon Health Science University, Portland, Oregon, USA
| | - J Tack
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - G Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford Esophageal Multidisciplinary Program in Innovative Research Excellence (SEMPIRE), Stanford University, Stanford, California, USA
| | - S R Markar
- Department of Surgery and Cancer, Imperial College, London, UK
| | - R Salvador
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - L Faccio
- Division of Surgery, Padova University Hospital, Padova, Italy
| | - N A Andreollo
- Faculty of Medical Science, State University of Campinas, Campinas, São Paulo, Brazil
| | - I Cecconello
- Digestive Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - G Costamagna
- Digestive Endoscopy Unit, A. Gemelli Hospital, Catholic University, Rome, Italy
| | - J R M da Rocha
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - E S Hungness
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - P M Fisichella
- Department of Surgery, Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
| | - K H Fuchs
- Department of Surgery, AGAPLESION-Markus-Krankenhaus, Frankfurt, Germany
| | - I Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - R Gurski
- Department of Surgery, School of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - F A M Herbella
- Department of Surgery, School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - R H Holloway
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, The University of Adelaide, Adelaide, Australia
| | - M Hongo
- Department of Medicine, Kurokawa Hospital, Taiwa, Kurokawa, Miyagi, Japan
| | - B A Jobe
- Esophageal and Lung Institute, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania, USA
| | - P J Kahrilas
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - D A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - K S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - D Liu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - A Moonen
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - A Nasi
- Digestive Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - P J Pasricha
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - R Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico; Department of Pathophysiology and Transplantation; Università degli Studi, Milan, Italy
| | - S Perretta
- Institute for Image Guided Surgery IHU-Strasbourg, Strasbourg, France
| | - R A A Sallum
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - G Sarnelli
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - E Savarino
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - F Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - D Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - N Soper
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - R P Tatum
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - M F Vaezi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - M van Herwaarden-Lindeboom
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - T Vanuytsel
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - M F Vela
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - D I Watson
- Department of Surgery, Flinders University, Adelaide, Australia
| | - F Zerbib
- Department of Gastroenterology, University of Bordeaux, Bordeaux, France
| | - S Gittens
- ECD Solutions, Atlanta, Georgia, USA
| | - C Pontillo
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - S Vermigli
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - D Inama
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - D E Low
- Department of Thoracic Surgery Virginia Mason Medical Center, Seattle, Washington, USA
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14
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S093: pneumatic balloon dilation for palliation of recurrent symptoms of achalasia after esophagomyotomy. Surg Endosc 2018; 32:4017-4021. [PMID: 29905893 DOI: 10.1007/s00464-018-6271-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/07/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Achalasia is a chronic disease affecting the myenteric plexus of the esophagus and lower esophageal sphincter. Treatment is aimed at palliating symptoms to improve quality of life. Treatment options for symptom relapse after esophagomyotomy include botox injection, repeat myotomy, per-oral endoscopic myotomy, or pneumatic balloon dilation (PBD). Data demonstrating the safety and efficacy of PBD for recurrence are scarce. With a lack of published data, guidelines have suggested avoiding PBD for recurrent achalasia because of concern for a high risk of perforation. METHODS A retrospective review of patients who underwent PBD for recurrent symptoms of achalasia after esophagomyotomy between 2007 and 2017 was conducted. PBD was performed at 30 mm and held for 60 s under fluoroscopic guidance. Patients with residual symptoms had subsequent dilations at increasing 5 mm increments to a maximum of 40 mm. Patient demographics, Eckardt scores, presence of hiatal hernia, time from myotomy to recurrence, and diagnostic modalities were reported. The primary outcome was need for further endoscopic or surgical intervention. Complications are reported as secondary outcomes. RESULTS One-hundred eight esophagomyotomies were done during the study period. Fourteen patients underwent PBD for recurrent symptoms. The median time to symptom recurrence after esophagomyotomy was 28 months. The median Eckardt score was 6. Ten of 14 patients had an intervention between the initial surgery and PBD (9 standard dilations and 1 botox injection). A total of 23 PBD were done. Seven patients required dilation at 35 mm and two patients required dilation at 40 mm. Eleven patients required no further intervention at a median follow-up of 27.7 months. There were three treatment failures: one required repeat esophagomyotomy and two had no further treatments. There were no periprocedural complications. CONCLUSION Serial PBD is safe and effective in treatment of recurrent symptoms of achalasia after esophagomyotomy.
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Abstract
Pneumatic dilation is a well-established treatment modality that has withstood the test of time. Prospective and randomized trials have shown that in expert hands, it provides results similar to a laparoscopic Heller myotomy with fundoplication. In addition, it should be considered the primary form of treatment in patients who experience recurrence of symptoms after a surgical myotomy.
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Affiliation(s)
- Sheraz Markar
- Department of Surgery and Cancer, Imperial College London, London, U.K
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16
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Per-oral endoscopic myotomy in patients with or without prior Heller's myotomy: comparing long-term outcomes in a large U.S. single-center cohort (with videos). Gastrointest Endosc 2018; 87:972-985. [PMID: 29122601 DOI: 10.1016/j.gie.2017.10.039] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 10/23/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Heller's myotomy (HM) is one of the most effective treatments for esophageal achalasia. However, failures do exist, and the success rate tends to decrease with time. The efficacy of rescue treatments for patients with failed HM is limited. A few small-scale studies have reported outcomes of per-oral endoscopic myotomy (POEM) in these patients. We conducted this study to systematically assess feasibility, safety, and efficacy of POEM on patients who have had HM. METHODS Patients at least 3 months out from POEM were selected from our prospective database: 318 consecutive POEMs performed from October 2009 to October 2016. The efficacy and safety of POEM were compared between the 46 patients with prior HM and the remaining 272 patients. RESULTS Patients with prior HM had longer disease history, more advanced disease, more type I and less type II achalasia, lower before-POEM Eckardt scores, and lower before-POEM lower esophageal sphincter (LES) pressure (all P < .01). Procedure parameters and follow-up results (clinical success rate, Eckardt score, LES pressure, GERD score, esophagitis, and pH testing) showed no significant difference between the 2 groups. For the 46 HM-POEM patients, no clinically significant perioperative adverse events occurred. Their overall clinical success rate (Eckardt score ≤3 and no other treatment needed) was 95.7% at a median follow-up of 28 months. CONCLUSION POEM as a rescue treatment for patients with achalasia who failed HM is feasible, safe, and highly effective. It should be the treatment of choice in managing these challenging cases at centers with a high level of experience with POEM.
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17
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Abstract
The last decade has seen growing insight into the pathophysiology of achalasia, and current treatments decreasing the resting pressure in the lower esophageal sphincter by endoscopic (botulinum toxin injection, pneumatic dilation, peroral endoscopic myotomy) or surgical means (Heller myotomy). Manometry is considered the gold standard to confirm the diagnosis of achalasia. Pneumatic dilation and laparoscopic Heller myotomy have similar effectiveness and are both more successful in patients with type II achalasia. Laparoscopic myotomy when combined with partial fundoplication is an effective surgical technique and has been considered the operative procedure of choice until recently. Peroral endoscopic myotomy is an emerging therapy with promising results since it offers a minimally invasive and efficacious option especially in type III achalasia. However, it remains to be determined if peroral endoscopic myotomy offers long-term efficacy.
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18
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Tyberg A, Sharaiha RZ, Familiari P, Costamagna G, Casas F, Kumta NA, Barret M, Desai AP, Schnoll-Sussman F, Saxena P, Martínez G, Zamarripa F, Gaidhane M, Bertani H, Draganov PV, Balassone V, Sharata A, Reavis K, Swanstrom L, Invernizzi M, Seewald S, Minami H, Inoue H, Kahaleh M. Peroral endoscopic myotomy as salvation technique post-Heller: International experience. Dig Endosc 2018; 30:52-56. [PMID: 28691186 DOI: 10.1111/den.12918] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 07/04/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Treatment for achalasia has traditionally been Heller myotomy (HM). Despite its excellent efficacy rate, a number of patients remain symptomatic post-procedure. Limited data exist as to the best management for recurrence of symptoms post-HM. We present an international, multicenter experience evaluating the efficacy and safety of post-HM peroral endoscopic myotomy (POEM). METHODS Patients who underwent POEM post-HM from 13 centers from January 2012 to January 2017 were included as part of a prospective registry. Technical success was defined as successful completion of the myotomy. Clinical success was defined as an Eckardt score of ≤3 on 12-month follow up. Adverse events (AE) including anesthesia-related, operative, and postoperative complications were recorded. RESULTS Fifty-one patients were included in the study (mean age 54.2, 47% male). Technical success was achieved in 100% of patients. Clinical success on long-term follow up was achieved in 48 patients (94%), with a mean change in Eckardt score of 6.25. Seven patients (13%) had AE: six experienced periprocedural mucosal defect treated endoscopically and two patients developed mediastinitis treated conservatively. CONCLUSION For patients with persistent symptoms after HM, POEM is a safe salvation technique with good short-term efficacy. As a result of the challenge associated with repeat HM, POEM might become the preferred technique in this patient population. Further studies with longer follow up are needed.
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Affiliation(s)
- Amy Tyberg
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA
| | | | | | - Fernando Casas
- Gastroenterology, Bogota General Hospital, Bogota, Colombia
| | - Nikhil A Kumta
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA
| | | | - Amit P Desai
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA
| | - Felice Schnoll-Sussman
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA
| | | | | | | | - Monica Gaidhane
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA
| | | | | | - Valerio Balassone
- Gastroenterology, Showa University Northern Yokohama Hospital, Tokyo, Japan
| | | | - Kevin Reavis
- Gastroenterology, Portland Clinic, Portland, USA
| | | | | | - Stefan Seewald
- Gastroenterology, Klinik Hirslanden, Zurich, Switzerland
| | - Hitomi Minami
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Haruhiro Inoue
- Gastroenterology, Showa University Northern Yokohama Hospital, Tokyo, Japan
| | - Michel Kahaleh
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA
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19
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Management of recurrent symptoms after per-oral endoscopic myotomy in achalasia. Gastrointest Endosc 2018; 87:95-101. [PMID: 28478028 DOI: 10.1016/j.gie.2017.04.036] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 04/22/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Per-oral endoscopic myotomy (POEM) has been rapidly gaining ground as a treatment for achalasia. Although POEM is a safe and effective treatment, a subset of patients has persistent or recurrent symptoms after POEM. This study aimed to examine the efficacy of different retreatments after failed POEM. METHODS POEM was performed on 441 patients with achalasia at 3 tertiary-care hospitals between 2010 and 2015. A review of prospectively collected data was conducted. All patients with achalasia with significant persistent or recurrent symptoms within 3 years after POEM, defined as an Eckardt symptom score >3, were included. RESULTS Forty-three of 441 patients (9.8%) had persistent or recurrent symptoms after POEM, of which 34 (8%) received 1 or more retreatments. Retreatment with laparoscopic Heller myotomy and retreatment with POEM showed a modest efficacy of 45% and 63%, respectively, whereas pneumatic dilatation showed a poor efficacy of only 0% to 20%, depending on the size of the balloon. Male patients were more likely to have retreatment failure than female patients (P = .038). CONCLUSIONS In patients with achalasia with persistent or recurrent symptoms after failed POEM, retreatment with laparoscopic Heller myotomy or retreatment with POEM has a higher efficacy than retreatment with pneumatic dilatations. Failure of retreatment occurred more often in male patients.
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20
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Shah SWH, Butt AK, Malik K, Alam A, Khan AA. Pneumatic Balloon Dilatation for Achalasia Cardia; Early & late results, a single center study. Pak J Med Sci 2017; 33:1053-1058. [PMID: 29142537 PMCID: PMC5673706 DOI: 10.12669/pjms.335.13685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Objective: Achalasia Cardia is treated by Pneumatic balloon dilatation, Heller’s Myotomy and recently, by Peroral Esophagaeal Myotomy. This study reports the efficacy of pneumatic balloon dilatation as a non-surgical motility in achieving relief of dysphagia, clinical improvement and recurrence. Long-term complications were reported. Methods: Eight hundred ninety two adult achalasia patients of both genders were treated from January 1988 till December 2011, with pneumatic balloon (Rigiflex Microvasive®) dilatation, under fluoroscopy Barium swallow was obtained prior to and five minutes after dilatation to evaluate for efficacy of dilatation as well as for complications. Patients not responding to 30 mm balloon had repeat dilatation with 35 mm balloon after 8 weeks. All patients were enrolled in regular follow up at one, six months and yearly intervals up to a period of five years. Recurrence was defined as an increase in symptom score at 8 weeks greater than 50% of their baseline value. These patients were treated with 35 mm balloon or referred for surgical intervention. Results: Of 892 patients, follow up was obtained in 50% for 5 years, 9.2% for 4-years), 9.3% for 3-years, 10% for 2-years and 21.5% for 1-year of patients. One patient died after repeat dilatation. Eighty-eight patients were excluded from this analysis (20 died due to non-procedure related causes and another 68 were lost during follow up). Statistically significant improvement was noted in reduction in height and width of barium column and symptom score coupled with weight gain during follow up. Forty-eight patients were subjected to repeat dilatation with 35 mm balloon, two of these developed post-procedure perforations with one mortality. Three non-responsive patients required surgical laparoscopic myotomy. No carcinoma of esophagus was reported during follow up. One patient post dilatation, developed esophageal bezoar. A single pneumatic dilatation achieved a remission rate of 93% at four years, 90% at three years, 95% at two years and 92% at one year post dilatation. Conclusion: Achalasia of esophagus can be effectively and safely treated with balloon dilatation to achieve adequate short and long-term symptomatic relief with a low complication rate.
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Affiliation(s)
- S Waqar H Shah
- Dr. S. Waqar H. Shah, MBBS. Department of Gastroenterology-Hepatology, Shaikh Zayed Medical Complex, Lahore, Pakistan
| | - Arshad K Butt
- Dr. K. Malik, FCPS. Department of Gastroenterology-Hepatology, Shaikh Zayed Medical Complex, Lahore, Pakistan
| | - K Malik
- Dr. Arshad K. Butt, FCPS. Department of Gastroenterology-Hepatology, Shaikh Zayed Medical Complex, Lahore, Pakistan
| | - Altaf Alam
- Dr. Altaf Alam, FRCP. Department of Gastroenterology-Hepatology, Shaikh Zayed Medical Complex, Lahore, Pakistan
| | - Anwaar A Khan
- Dr. Anwaar A. Khan, M.D, MACP, FACG, FRCP. Department of Gastroenterology-Hepatology, Shaikh Zayed Medical Complex, Lahore, Pakistan
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21
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Ngamruengphong S, Inoue H, Ujiki MB, Patel LY, Bapaye A, Desai PN, Dorwat S, Nakamura J, Hata Y, Balassone V, Onimaru M, Ponchon T, Pioche M, Roman S, Rivory J, Mion F, Garros A, Draganov PV, Perbtani Y, Abbas A, Pannu D, Yang D, Perretta S, Romanelli J, Desilets D, Hayee B, Haji A, Hajiyeva G, Ismail A, Chen YI, Bukhari M, Haito-Chavez Y, Kumbhari V, Saxena P, Talbot M, Chiu PWY, Yip HC, Wong VWY, Hernaez R, Maselli R, Repici A, Khashab MA. Efficacy and Safety of Peroral Endoscopic Myotomy for Treatment of Achalasia After Failed Heller Myotomy. Clin Gastroenterol Hepatol 2017; 15:1531-1537.e3. [PMID: 28189695 DOI: 10.1016/j.cgh.2017.01.031] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 01/21/2017] [Accepted: 01/23/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In patients with persistent symptoms after Heller myotomy (HM), treatment options include repeat HM, pneumatic dilation, or peroral endoscopic myotomy (POEM). We evaluated the efficacy and safety of POEM in patients with achalasia with prior HM vs without prior HM. METHODS We conducted a retrospective cohort study of 180 patients with achalasia who underwent POEM at 13 tertiary centers worldwide, from December 2009 through September 2015. Patients were divided into 2 groups: those with prior HM (HM group, exposure; n = 90) and those without prior HM (non-HM group; n = 90). Clinical response was defined by a decrease in Eckardt scores to 3 or less. Adverse events were graded according to criteria set by the American Society for Gastrointestinal Endoscopy. Technical success, clinical success, and rates of adverse events were compared between groups. Patients were followed up for a median of 8.5 months. RESULTS POEM was technically successful in 98% of patients in the HM group and in 100% of patients in the non-HM group (P = .49). A significantly lower proportion of patients in the HM group had a clinical response to POEM (81%) than in the non-HM group (94%; P = .01). There were no significant differences in rates of adverse events between the groups (8% in the HM group vs 13% in the non-HM group; P = .23). Symptomatic reflux and reflux esophagitis after POEM were comparable between groups. CONCLUSIONS POEM is safe and effective for patients with achalasia who were not treated successfully by prior HM. Although the rate of clinical success in patients with prior HM is lower than in those without prior HM, the safety profile of POEM is comparable between groups.
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Affiliation(s)
- Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Michael B Ujiki
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois
| | - Lava Y Patel
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois
| | - Amol Bapaye
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | | | - Shivangi Dorwat
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Jun Nakamura
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Yoshitaka Hata
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Valerio Balassone
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Thierry Ponchon
- Gastroenterology and Endoscopy Unit, Digestive Disease Department, L Pavillon-Edouard Herriot Hospital, Lyon, France
| | - Mathieu Pioche
- Gastroenterology and Endoscopy Unit, Digestive Disease Department, L Pavillon-Edouard Herriot Hospital, Lyon, France
| | - Sabine Roman
- Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France; INSERM U1032, Lyon, France
| | - Jérôme Rivory
- Gastroenterology and Endoscopy Unit, Digestive Disease Department, L Pavillon-Edouard Herriot Hospital, Lyon, France
| | - François Mion
- Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France; INSERM U1032, Lyon, France
| | - Aurélien Garros
- Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France; INSERM U1032, Lyon, France
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, Florida
| | - Yaseen Perbtani
- Division of Gastroenterology and Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, Florida
| | - Ali Abbas
- Division of Gastroenterology and Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, Florida
| | - Davinderbir Pannu
- Division of Gastroenterology and Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, Florida
| | - Dennis Yang
- Division of Gastroenterology and Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, Florida
| | - Silvana Perretta
- Department of Gastrointestinal and Endocrine Surgery, University of Strasbourg, Strasbourg, France
| | - John Romanelli
- Department of Surgery, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts
| | - David Desilets
- Division of Gastroenterology, Department of Medicine, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts
| | - Bu Hayee
- Department of Gastroenterology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Amyn Haji
- Department of Gastroenterology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Gulara Hajiyeva
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Amr Ismail
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Majidah Bukhari
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Yamile Haito-Chavez
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Payal Saxena
- Department of Gastroenterology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Michael Talbot
- University of New South Wales, Sydney, New South Wales, Australia
| | | | - Hon-Chi Yip
- Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | | | - Ruben Hernaez
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Roberta Maselli
- Digestive Endoscopy Unit, Humanitas Research Hospital, Milan, Italy Digestive Endoscopy Unit, Humanitas Unversity, Milan, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Research Hospital, Milan, Italy Digestive Endoscopy Unit, Humanitas Unversity, Milan, Italy
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland.
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Saliakellis E, Thapar N, Roebuck D, Cristofori F, Cross K, Kiely E, Curry J, Lindley K, Borrelli O. Long-term outcomes of Heller's myotomy and balloon dilatation in childhood achalasia. Eur J Pediatr 2017; 176:899-907. [PMID: 28536813 DOI: 10.1007/s00431-017-2924-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Revised: 04/24/2017] [Accepted: 05/02/2017] [Indexed: 02/08/2023]
Abstract
UNLABELLED Achalasia is a rare esophageal motility disorder: its optimal treatment in children is still a matter of debate. Records of children treated for achalasia, over an 18-year period, were reviewed.Forty-eight children (median age at diagnosis 10 years; range 3-17 years) were identified. Twenty-eight patients were initially treated with Heller's myotomy (HM) and 20 with balloon dilatation (BD). At last follow-up (median 3 years; range 1-5.5 years), 43.8% (21/48) of children were symptom free. The number of asymptomatic children was significantly higher among those treated initially with HM compared to BD (HM 15/28, 53.6% BD 6/20, 30%, p < 0.05). All children who underwent BD required HM due to symptom recurrence. The median (range) total number of procedures was significantly higher in the BD group (BD 3 (1-7); HM 1 (1-5); p < 0.05) with a shorter time to the second intervention (BD 14 months, 95%CI 4-24; HM 58 months, 95%CI 38-79; p < 0.05). Of 108 procedures, esophageal perforation occurred in two children after HM (two out of 48 HM procedures in total, 4%) and one child after BD (1/60, 1.7%). CONCLUSION Less than half of children with achalasia are symptom free after initial treatment with either BD or HM. HM, however, when performed as first procedure, provided longer symptom-free period and reduced need for subsequent intervention. What is Known: • Balloon dilatation (BD) and Heller's myotomy (HM) are safe and effective treatment options for achalasia. • Controversy, however, exists regarding the most effective initial therapeutic approach. What is New: • HM with or without fundoplication may represent the initial therapeutic approach of choice. • Initial BD may negatively affect the outcome of a subsequent HM.
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Affiliation(s)
- Efstratios Saliakellis
- Neurogastroenterology and Motility Unit, Department of Gastroenterology,, Great Ormond Street Hospital NHS Foundation Trust, London, UK.
| | - Nikhil Thapar
- Neurogastroenterology and Motility Unit, Department of Gastroenterology,, Great Ormond Street Hospital NHS Foundation Trust, London, UK.,Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Derek Roebuck
- Interventional Radiology Division, Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Fernanda Cristofori
- Neurogastroenterology and Motility Unit, Department of Gastroenterology,, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Kate Cross
- Specialist Neonatal and Paediatric Surgery (SNAPS) Department, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Edward Kiely
- Specialist Neonatal and Paediatric Surgery (SNAPS) Department, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Joseph Curry
- Specialist Neonatal and Paediatric Surgery (SNAPS) Department, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Keith Lindley
- Neurogastroenterology and Motility Unit, Department of Gastroenterology,, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Osvaldo Borrelli
- Neurogastroenterology and Motility Unit, Department of Gastroenterology,, Great Ormond Street Hospital NHS Foundation Trust, London, UK
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Saleh CMG, Ponds FAM, Schijven MP, Smout AJPM, Bredenoord AJ. Efficacy of pneumodilation in achalasia after failed Heller myotomy. Neurogastroenterol Motil 2016; 28:1741-1746. [PMID: 27401049 DOI: 10.1111/nmo.12875] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 05/09/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Heller myotomy is an effective treatment for the majority of achalasia patients. However, a small proportion of patients suffer from persistent or recurrent symptoms after surgery and they are usually subsequently treated with pneumodilation (PD). Data on the efficacy of PD as secondary treatment for achalasia are scarce. Therefore, this study aimed to investigate the efficacy of PD as treatment for achalasia patients suffering from persistent or recurrent symptoms after Heller myotomy. METHODS Patients with recurrent or persistent symptoms (Eckardt score >3) after Heller myotomy were selected. Patients were treated with PD, using a graded distension protocol with balloon sizes ranging from 30 to 40 mm. After each dilation symptoms were assessed to evaluate whether a subsequent dilation with a larger balloon size was required. Patients with recurrent or persistent symptoms (Eckardt score >3) after treatment with a 40-mm balloon were identified as failures. KEY RESULTS Twenty-four patients were included in total; 15 patients with achalasia type I, seven with achalasia type II and two with achalasia type III. Median relapse time was 2.5 years after Heller myotomy (IQR: 9 years and 3 months). Three patients were not suitable for PD; one patient was morbidly obese and not fit for any form of sedation and two had a siphon-shaped esophagus leaving 21 patients to treat. Eight patients were successfully treated with a single 30-mm balloon dilation (median follow-up time: 6.5 years; IQR: 7.5 years). Four patients required dilations with 30- and 35-mm balloons (median follow-up time: 11 years; IQR: 3 years). Nine patients failed on the 35-mm balloon dilation and underwent a subsequent dilation with a 40-mm balloon, and all failed on this balloon as well. Thus, PD was successful in 12 of the 21 treatable patients, resulting in a success rate of 57% for treatable patients or 50% for all patients. Baseline Eckardt scores were also higher in those that failed (median: 8; IQR: 2) than those that were treated successfully (median: 5.5; IQR: 2) treated (p = 0.009). Furthermore, baseline barium column height at 5 min was higher in patients with failed (median: 6 cm; IQR: 6 cm) treatment than in patients with successful (median: 2.6 cm; IQR: 4.7 cm) treatment (p = 0.016). Baseline lower esophageal sphincter pressure was not different between patients who were treated successfully (median: 11 mmHg; IQR: 5 mmHg) and those that failed on PD (median: 17.5 mmHg; IQR: 10.8 mmHg) treatment (p > 0.05). Baseline symptom pattern was also not a predictor of successful treatment. No adverse events were recorded during or after PD. CONCLUSIONS & INFERENCES Pneumodilation for recurrent symptoms after previous Heller myotomy is safe and has a modest success rate of 57%, using 30- and 35-mm balloons. Patients with recurrent symptoms after PD with 35-mm balloon are likely to also fail after subsequent dilation with a 40-mm balloon.
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Affiliation(s)
- C M G Saleh
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - F A M Ponds
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - M P Schijven
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - A J P M Smout
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - A J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.
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Sanaka MR, Thota PN, Murthy SC, Raja S. Creation of a second submucosal tunnel enabled successful per-oral endoscopic myotomy (POEM). J Thorac Cardiovasc Surg 2016; 151:e101-2. [PMID: 26948166 DOI: 10.1016/j.jtcvs.2016.01.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 12/15/2015] [Accepted: 01/20/2016] [Indexed: 12/21/2022]
Affiliation(s)
| | | | - Sudish C Murthy
- Department of Thoracic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Siva Raja
- Department of Thoracic Surgery, Cleveland Clinic, Cleveland, Ohio
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Amani M, Fazlollahi N, Shirani S, Malekzadeh R, Mikaeli J. Assessment of Pneumatic Balloon Dilation in Patients with Symptomatic Relapse after Failed Heller Myotomy: A Single Center Experience. Middle East J Dig Dis 2016; 8:57-62. [PMID: 26933483 PMCID: PMC4773085 DOI: 10.15171/mejdd.2016.08] [Citation(s) in RCA: 14] [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] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND
Although Heller myotomy is one of the most effective treatments for achalasia, it may be associated with early or late symptom relapse in some patients. Therefore, additional treatment is required to achieve better control of symptoms.
Aim: To evaluate the safety and efficacy of pneumatic balloon dilation (PBD) in patients with symptom relapse after Heller myotomy.
METHODS
Thirty six post-myotomy patients were evaluated from 1993 to 2013. Six patients were excluded from the analysis because of comorbid diseases or epiphrenic diverticula. Thirty patients were treated with PBD. Primary outcome was defined as a decrease in symptom score to 4 or less and a reduction greater than 80% from the baseline in the volume of barium in timed barium esophagogram in 6 weeks. Achalasia symptom score (ASS) was assessed at 1.5, 3, 6, and 12 months after treatment and then every six months in all patients and PBD was repeated in case of symptom relapse (ASS>4).
RESULTS
The mean age of the patients was 45.5±13.9 years (range: 21-73). Primary outcome was observed in 25 patients (83%). The mean ASS of the patients dropped from 7.8 before treatment to 1.3±2.0 at 1.5 months after treatment (p=0.0001). The mean volume and height of barium decreased from 43.1±33.4 and 7.1±4.7 to 6.0±17.1 and 1.1±2.2, respectively (p=0.003, p=0.003). The mean duration of follow-up was 11.8±6.3 years. At the end of the study, 21 patients (70%) reported sustained good response. No major complications such as perforation or gross bleeding were seen.
CONCLUSION
PBD is an effective and safe treatment option for achalasia in patients with symptom relapse after Heller myotomy.
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Affiliation(s)
- Mohammad Amani
- Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Narges Fazlollahi
- Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shapour Shirani
- Department of Radiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Malekzadeh
- Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Javad Mikaeli
- Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Repeated Surgical or Endoscopic Myotomy for Recurrent Dysphagia in Patients After Previous Myotomy for Achalasia. J Gastrointest Surg 2016; 20:494-9. [PMID: 26589525 DOI: 10.1007/s11605-015-3031-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 11/12/2015] [Indexed: 01/31/2023]
Abstract
AIM Surgical myotomy of the lower esophageal sphincter has a 5-year success rate of approximately 91 %. Peroral endoscopic myotomy can provide similar results for controlling dysphagia. Some patients experience either persistent or recurrent dysphagia after myotomy. We present here a retrospective analysis of our experience with redo myotomy for recurrent dysphagia in patients with achalasia. METHODS From March 1996 to February 2015, 234 myotomies for primary or recurrent achalasia were performed in our center. Fifteen patients (6.4 %) had had a previous myotomy and were undergoing surgical redo myotomy (n = 9) or endoscopic redo myotomy (n = 6) for recurrent symptoms. RESULTS Patients presented at a median of 10.4 months after previous myotomy. Median preoperative Eckardt score was 6. Among the nine patients undergoing surgical myotomy, three esophageal perforations occurred intraoperatively (all repaired immediately). Surgery lasted 111 and 62 min on average (median) in the surgical and peroral endoscopic myotomy (POEM) groups, respectively. No postoperative complications occurred in either group. Median postoperative stay was 3 and 2.5 days in the surgical and POEM groups, respectively. In the surgical group, Eckardt score was <3 for seven out of nine patients after a mean follow-up of 19 months; it was <3 for all six patients in the POEM group after a mean follow-up of 5 months. CONCLUSIONS A redo myotomy should be considered in patients who underwent myotomy for achalasia and presenting with recurrent dysphagia. Preliminary results using POEM indicate that the technique can be safely used in patients who have undergone previous surgical myotomy.
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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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Ates F, Vaezi MF, Fox M, Gyawali CP, Roman S, Smout AJPM, Pandolfino JE. The Pathogenesis and Management of Achalasia: Current Status and Future Directions. Gut Liver 2015; 9:449-63. [PMID: 26087861 PMCID: PMC4477988 DOI: 10.5009/gnl14446] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Achalasia is an esophageal motility disorder that is commonly misdiagnosed initially as gastroesophageal reflux disease. Patients with achalasia often complain of dysphagia with solids and liquids but may focus on regurgitation as the primary symptom, leading to initial misdiagnosis. Diagnostic tests for achalasia include esophageal motility testing, esophagogastroduodenoscopy and barium swallow. These tests play a complimentary role in establishing the diagnosis of suspected achalasia. High-resolution manometry has now identified three subtypes of achalasia, with therapeutic implications. Pneumatic dilation and surgical myotomy are the only definitive treatment options for patients with achalasia who can undergo surgery. Botulinum toxin injection into the lower esophageal sphincter should be reserved for those who cannot undergo definitive therapy. Close follow-up is paramount because many patients will have a recurrence of symptoms and require repeat treatment.
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Affiliation(s)
| | - Michael F. Vaezi
- Correspondence to: Michael F. Vaezi, Division of Gastroenterology and Hepatology, Center for Swallowing and Esophageal Disorders, Vanderbilt University Medical Center, C2104-MCN, Nashville, TN 37232, USA, Tel: +1-615-322-3739, Fax: +1-615-322-8525, E-mail:
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Wood TW, Ross SB, Ryan CE, Bowman TA, Jacobi BL, Konstantinidis MG, Rosemurgy AS. Reoperative Heller Myotomy: More Pain, Less Gain. Am Surg 2015. [DOI: 10.1177/000313481508100631] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Heller myotomy provides durable and effective treatment of achalasia. Due to recurrence or persistence of symptoms, a small subset of patients seeks reoperation. This study was undertaken to determine if reoperative Heller myotomy provides salutary amelioration of symptoms. 609 patients undergoing laparoscopic Heller myotomy between 1992 to 2013 were prospectively followed; 38 underwent reoperative myotomy. Patients graded their symptom frequency and severity before and after myotomy on a Likert scale. Median data are reported. Patients undergoing reoperative myotomy, when compared to those undergoing their first myotomy, experienced a higher conversion rate to an “open” myotomy (8% vs 1%, P < 0.05) and a longer length of stay (3 vs 1 day, P < 0.05). Reoperative myotomy led to improvement in symptoms, but the magnitude of improvement in symptoms (e.g., dysphagia, choking, and coughing) was less than for patients undergoing their first myotomy (all P < 0.05). Patients undergoing reoperative Heller myotomy were less likely to report symptoms occurring once per month or less (83% vs 56%, P < 0.01). Patients undergoing reoperative myotomy note improvement in symptoms, although to a lesser extent than patients undergoing their first myotomy. Patients undergoing reoperative Heller myotomy can expect to experience less improvement of symptoms, denoting the importance of the first myotomy.
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Affiliation(s)
- Thomas W. Wood
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, Tampa, Florida
| | - Sharona B. Ross
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, Tampa, Florida
| | - Carrie E. Ryan
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, Tampa, Florida
| | - Ty A. Bowman
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, Tampa, Florida
| | - Benjamin L. Jacobi
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, Tampa, Florida
| | - Michael G. Konstantinidis
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, Tampa, Florida
| | - Alexander S. Rosemurgy
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, Tampa, Florida
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30
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Vela MF. Management strategies for achalasia. Neurogastroenterol Motil 2014; 26:1215-21. [PMID: 25167952 DOI: 10.1111/nmo.12416] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 07/22/2014] [Indexed: 12/19/2022]
Abstract
Treatment options for achalasia include oral pharmacologic therapy, endoscopic injection of botulinum toxin, pneumatic dilation, and myotomy (conventionally by laparoscopy, but more recently by an endoscopic approach). Oral pharmacologic agents have fallen out of use because of insufficient efficacy and frequent side effects. Endoscopic injection of botulinum toxin is safe and has good short-term effectiveness, but as the effect invariably wears off after a few months, this treatment is reserved for patients who are not candidates for more definitive treatments. Pneumatic dilation and surgical myotomy are currently considered the most effective treatments, with similar effectiveness in randomized controlled trials with follow-up of up to 2 years. The risk/benefit ratio and choice of therapy depend on patient characteristics (age, comorbidities, disease stage, prior treatments), patient's preference, and locally available expertise. Treatment of patients who fail or relapse after initial therapy is challenging and the success rate of pneumatic dilation or myotomy in this group is lower compared with previously untreated patients. The recently developed peroral endoscopic approach to myotomy has achieved excellent results in early uncontrolled studies, but high-quality randomized trials are needed to ensure widespread adoption is reasonable. Finally, retrospective data suggest that achalasia subtypes as defined by high-resolution esophageal pressure topography may guide treatment choice, but confirmation in prospective outcome studies is awaited.
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Affiliation(s)
- M F Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ, USA
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31
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Legros L, Ropert A, Brochard C, Bouguen G, Pagenault M, Siproudhis L, Bretagne JF. Long-term results of pneumatic dilatation for relapsing symptoms of achalasia after Heller myotomy. Neurogastroenterol Motil 2014; 26:1248-55. [PMID: 24916630 DOI: 10.1111/nmo.12380] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 05/16/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this study was to assess the efficacy and safety of pneumatic dilatation (PD) to treat symptom recurrence after Heller myotomy (HM). METHODS Consecutive patients receiving PD for relapsing symptoms following prior HM were included in this retrospective single-center study. Eckardt score ≤3 and/or ∆ Eckardt (difference between Eckardt score before and after dilatation) ≥3 defined the success of initial dilatation. Patients who maintained response longer than 2 months after initial dilatation were defined as short-term responders. Relapsers were offered further on-demand dilatation. Remission was defined as an Eckardt score ≤3 at the study endpoint. Kaplan-Meier survival curves were used to determine relapse rates. KEY RESULTS Eighteen patients (11 women, seven men) were included from January 2004 to January 2013. Ten patients had type I achalasia, and seven had type III, according to the Chicago classification. Thirty-nine PDs were performed (1.5 [1-2.25] per patient). All patients had short-term responses. The remission rate at the endpoint, after a median follow-up of 33 months, was 78%, but 44% were treated with on-demand PD during the follow-up interval. The proportions of patients without relapse and subsequent PD were 72% at 12 months, 65% at 24 and 36 months, and 49% at 48 months. No factors predictive of long-term response, particularly the type of achalasia, could be identified in this series. There were no perforations. CONCLUSIONS & INFERENCES In treating symptom recurrence following HM, PD was safe and effective over the long term when combined with subsequent PD.
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Affiliation(s)
- Ludivine Legros
- Service des Maladies de l'Appareil Digestif, Centre Hospitalo-universitaire de Rennes, Rennes, France
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Vigneswaran Y, Yetasook AK, Zhao JC, Denham W, Linn JG, Ujiki MB. Peroral endoscopic myotomy (POEM): feasible as reoperation following Heller myotomy. J Gastrointest Surg 2014; 18:1071-6. [PMID: 24658904 DOI: 10.1007/s11605-014-2496-2] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 03/04/2014] [Indexed: 01/31/2023]
Abstract
PURPOSE The purpose of this study was to demonstrate the feasibility of performing peroral endoscopic myotomy (POEM) in the management of recurrent achalasia after failed myotomy. METHODS Eight patients presented to our institution between October 2010 and June 2013 with recurrent/persistent symptoms after prior laparoscopic Heller myotomy. Three patients underwent redo laparoscopic Heller myotomy, and five patients consented to redo myotomy with POEM. RESULTS Demographics were similar between the groups with exception of age (POEM 69.5 vs. laparoscopic Heller myotomy (LHM) 34.5, p = 0.003). Preoperative Eckardt scores, motility, and prior interventions were not significantly different. Three patients who underwent POEM and two who underwent laparoscopic Heller myotomy had prior fundoplication. There was one perforation identified after laparoscopic Heller myotomy and one patient with persistent subcutaneous emphysema after POEM. Both POEM and laparoscopic Heller myotomy demonstrated significant improvement in symptoms and Eckardt scores at average follow-up of approximately 5 months (p < 0.05). CONCLUSION POEM is a feasible option for patients after failed myotomy even in the presence of prior fundoplication. The procedure can be performed safely using a similar technique as for primary myotomy with the exception of creating the myotomy laterally along the right side of the esophagus and lesser curvature avoiding the previous anterior myotomy.
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Abstract
OPINION STATEMENT Achalasia, although rare, remains one of the most commonly diagnosed disorders of esophageal motility. It results from an idiopathic loss of ganglion cells responsible for esophageal motility and relaxation of the lower esophageal sphincter (LES). As a result, patients present with worsening dysphagia to both liquids and solids and often suffer from significant regurgitation of retained food in the esophagus. When the diagnosis of achalasia is suspected, patients should undergo evaluation with esophageal motility testing, endoscopic examination, and contrast esophagram. Once the diagnosis of achalasia has been established, options for treatment rely on controlling patient symptoms. Medical options are available, but their effectiveness is inconsistent. Endoscopic options include injection of botulinum toxin, which can achieve good short-term results, and pneumatic balloon dilation (PBD), considered the most effective non-surgical option. Surgical options, including laparoscopic, open, or endoscopic myotomy, and provide long-lasting results. This chapter will review achalasia and the treatment options available.
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Affiliation(s)
- Jeffrey A Blatnik
- Department of Surgery, University Hospitals Case Medical Center, 11100 Euclid, 5047, Cleveland, OH, 44106, USA,
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Pasha SF, Acosta RD, Chandrasekhara V, Chathadi KV, Decker GA, Early DS, Evans JA, Fanelli RD, Fisher DA, Foley KQ, Fonkalsrud L, Hwang JH, Jue TL, Khashab MA, Lightdale JR, Muthusamy VR, Sharaf R, Saltzman JR, Shergill AK, Cash B. The role of endoscopy in the evaluation and management of dysphagia. Gastrointest Endosc 2014; 79:191-201. [PMID: 24332405 DOI: 10.1016/j.gie.2013.07.042] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 07/29/2013] [Indexed: 02/06/2023]
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Abstract
Achalasia is a rare motility disorder of the oesophagus characterised by loss of enteric neurons leading to absence of peristalsis and impaired relaxation of the lower oesophageal sphincter. Although its cause remains largely unknown, ganglionitis resulting from an aberrant immune response triggered by a viral infection has been proposed to underlie the loss of oesophageal neurons, particularly in genetically susceptible individuals. The subsequent stasis of ingested food not only leads to symptoms of dysphagia, regurgitation, chest pain, and weight loss, but also results in an increased risk of oesophageal carcinoma. At present, pneumatic dilatation and Heller myotomy combined with an anti-reflux procedure are the treatments of choice and have comparable success rates. Per-oral endoscopic myotomy has recently been introduced as a new minimally invasive treatment for achalasia, but there have not yet been any randomised clinical trials comparing this option with pneumatic dilatation and Heller myotomy.
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Affiliation(s)
- Guy E Boeckxstaens
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), University Hospital Leuven, Catholic University of Leuven, Leuven, Belgium.
| | - Giovanni Zaninotto
- Department of Surgical and Gastroenterological Sciences, University of Padova, UOC General Surgery, Sts Giovanni e Paolo Hospital, Venice, Italy
| | - Joel E Richter
- Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Esophageal and Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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Onimaru M, Inoue H, Ikeda H, Yoshida A, Santi EG, Sato H, Ito H, Maselli R, Kudo SE. Peroral endoscopic myotomy is a viable option for failed surgical esophagocardiomyotomy instead of redo surgical Heller myotomy: a single center prospective study. J Am Coll Surg 2013; 217:598-605. [PMID: 23891071 DOI: 10.1016/j.jamcollsurg.2013.05.025] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 05/31/2013] [Accepted: 05/31/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Surgical Heller myotomy has high rates of successful long-term results, but failed cases still remain. Moreover, the treatment strategy in patients with surgical myotomy failure is controversial. Recently, peroral endscopic myotomy (POEM) was reported to be efficient and safe in primary treatment of achalasia. In this study, we aimed to evaluate the efficacy and safety of POEM for surgical myotomy failure as a rescue second-line treatment, and we discuss the treatment options adapted in achalasia recurrence. STUDY DESIGN A total of 315 consecutive achalasia patients received POEM from September 2008 to December 2012 in our hospital. Eleven (3.5%) patients who had persistent or recurrent achalasia and had received surgical myotomy as a first-line treatment from other hospitals were included in this study. Patient background, barium swallow studies, esophagogastroduodenoscopy (EGD), manometry, and symptom scores were prospectively evaluated. In principle, all patients in whom surgical myotomy failed received pneumatic balloon dilatation (PBD) as the first line "rescue" treatment, and only if PBD failed were patients considered for rescue POEM. RESULTS The PBD alone was effective in 1 patient, and in the remaining 10 patients, rescue POEM was performed successfully without complications. Three months after rescue POEM, significant reduction in lower esophageal sphincter (LES) resting pressures (22.1 ± 6.6 mmHg vs 10.9 ± 4.5 mmHg, p < 0.01) and Eckardt symptom scores (6.5 ± 1.3 vs 1.1 ± 1.3, p < 0.001) were observed. CONCLUSIONS Short-term results of POEM for failed surgical myotomy were excellent. Long-term results are awaited.
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Affiliation(s)
- Manabu Onimaru
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan.
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Vaezi MF, Pandolfino JE, Vela MF. ACG clinical guideline: diagnosis and management of achalasia. Am J Gastroenterol 2013; 108:1238-49; quiz 1250. [PMID: 23877351 DOI: 10.1038/ajg.2013.196] [Citation(s) in RCA: 331] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Accepted: 05/01/2013] [Indexed: 12/11/2022]
Abstract
Achalasia is a primary motor disorder of the esophagus characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. This results in patients' complaints of dysphagia to solids and liquids, regurgitation, and occasional chest pain with or without weight loss. Endoscopic finding of retained saliva with puckered gastroesophageal junction or barium swallow showing dilated esophagus with birds beaking in a symptomatic patient should prompt appropriate diagnostic and therapeutic strategies. In this ACG guideline the authors present an evidence-based approach in patients with achalasia based on a comprehensive review of the pertinent evidence and examination of relevant published data.
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Affiliation(s)
- Michael F Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN 37232-5280, USA.
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Efficacy and safety of pneumatic dilatation for achalasia in the treatment of post-myotomy symptom relapse. Am J Gastroenterol 2013; 108:1076-81. [PMID: 23458850 DOI: 10.1038/ajg.2013.32] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 01/18/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES There is no consensus on how best to treat symptom recurrence following previous therapy with Heller myotomy. Our aim was to determine the safety and the short and long-term efficacy of pneumatic dilatation to treat symptomatic recurrence in patients previously treated with Heller myotomy for idiopathic achalasia. METHODS We identified 27 eligible patients treated with pneumatic dilatation, for symptom recurrence following Heller myotomy as their initial or secondary treatment, from a prospectively acquired database of 450 patients with a diagnosis of achalasia seen between 1995 and 2010. Our treatment protocol involved sequential, graded pneumatic dilatations (30-35-40 mm) over a 2-6 week period until an initial therapeutic response was achieved. The subsequent relapse rate, defined as the need for any subsequent therapy, was determined. Relapsers were offered further pneumatic dilatation "on demand". A cross-sectional analysis was also performed using a validated achalasia severity questionnaire to determine the overall long-term remission rate. RESULTS Of 27 eligible patients, 25 (93%) complied with the institutional dilatation protocol. The two drop-outs did so after the initial 30 mm dilatation and were deemed treatment failures. One additional patient did not respond despite protocol compliance. Therefore, 24 of 27 (89%) patients were responders on intention to treat analysis at 12 months, while the per protocol response rate was 24 of 25 (96%). Among the 24 responders 16, 25, and 42% relapsed at 2, 3 and 4 years, respectively. Overall long-term remission, with on demand dilatations as required, was 95% (median follow-up 30 months). There were no perforations in a total of 50 dilatations in 27 patients. CONCLUSIONS In treating symptom recurrence, following prior Heller myotomy, pneumatic dilatation is safe and yields an excellent short-term response rate. Although the long-term relapse rate is substantial, subsequent on demand pneumatic dilatation in this population is highly effective with a long-term remission rate of 95%. These data also highlight the need to keep these patients under long-term review.
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Abstract
Achalasia is a rare motility disorder of the esophagus characterized by the absence of peristalsis and defective relaxation of the lower esophageal sphincter. Patients present at all ages with dysphagia and regurgitation as main symptoms. The diagnosis is suggested by barium swallow and endoscopy and confirmed by manometry. Because there is no curative treatment for achalasia, treatment is confined to disruption of the lower esophageal sphincter to improve bolus passage. The most successful therapies are pneumodilation and laparoscopic Heller myotomy, with comparable short-term clinical rates of success. The prognosis of achalasia patients is good, but re-treatment is often necessary.
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Stavropoulos SN, Friedel D, Modayil R, Iqbal S, Grendell JH. Endoscopic approaches to treatment of achalasia. Therap Adv Gastroenterol 2013; 6:115-35. [PMID: 23503707 PMCID: PMC3589133 DOI: 10.1177/1756283x12468039] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Endoscopic therapy for achalasia is directed at disrupting or weakening the lower esophageal sphincter (LES). The two most commonly utilized endoscopic interventions are large balloon pneumatic dilation (PD) and botulinum toxin injection (BTI). These interventions have been extensively scrutinized and compared with each other as well as with surgical disruption (myotomy) of the LES. PD is generally more effective in improving dysphagia in achalasia than BTI, with the latter reserved for infirm older people, and PD may approach treatment results attained with myotomy. However, PD may need to be repeated. Small balloon dilation and endoscopic stent placement for achalasia have only been used in select centers. Per oral endoscopic myotomy is a newer endoscopic modality that will likely change the treatment paradigm for achalasia. It arose from the field of natural orifice transluminal endoscopic surgery and represents a scarless endoscopic approach to Heller myotomy. This is a technique that requires extensive training and preparation and thus there should be rigorous accreditation and monitoring of outcomes to ensure safety and efficacy.
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Esophageal stasis on a timed barium esophagogram predicts recurrent symptoms in patients with long-standing achalasia. Am J Gastroenterol 2013; 108:49-55. [PMID: 23007004 DOI: 10.1038/ajg.2012.318] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES In achalasia, early recognition of the need for retreatment is of crucial importance to reduce morbidity and long-term complications such as esophageal decompensation. In clinical practice, symptoms and parameters of esophageal function including lower esophageal sphincter (LES) pressure and esophageal emptying are used to decide whether additional treatment is required. However, which of these tests performs best remains unclear. METHODS A cohort of 41 patients with long-standing achalasia (median 17 years), underwent esophageal manometry, timed barium esophagogram and symptom evaluation. Patients were followed up for 10 years, and were regarded as a therapeutic failure if Eckardt score was >3 or when retreatment was needed. Predictors of therapeutic failure were evaluated. RESULTS Of the 41 included patients, 7 patients had an elevated LES pressure (>10 mm Hg) and 26 had esophageal stasis >5 cm on timed barium esophagogram. During follow-up, 25 patients had recurrence of symptoms and were considered therapeutic failures. Of the 25 patients, 5 had an elevated LES pressure, whereas 22 had esophageal stasis on barium esophagogram. Hence, the sensitivity to predict the need of retreatment is higher for esophageal stasis (88%) compared with LES pressure (20%). A total of 16 patients (39%) were in long-term remission, of which 12 patients (75%) did not have stasis at their initial visit. CONCLUSIONS In contrast to LES pressure, esophageal stasis is a good predictor of treatment failure in patients with long-standing achalasia. Based on these findings, we propose to use timed barium esophagogram rather than esophageal manometry as test to decide on retreatment.
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Major complications of pneumatic dilation and Heller myotomy for achalasia: single-center experience and systematic review of the literature. Am J Gastroenterol 2012; 107:1817-25. [PMID: 23032978 PMCID: PMC3808165 DOI: 10.1038/ajg.2012.332] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) can be definitive therapies for achalasia; recent data suggest comparable efficacy. However, risk must also be considered. We reviewed the major complication rate of PD and LHM in a high-volume center and reviewed the corresponding literature. METHODS We reviewed 12 years of our institution's achalasia treatment experience. During this interval, a consistent technique of PD was used utilizing Rigiflex dilators. Medical records were reviewed for post-procedure complications. We administered a telephone survey and examined medical records to assess efficacy of treatment. We also performed a systematic review of the literature for comparable clinical data and examined 80 reports encompassing 12,494 LHM and PD procedures. RESULTS At our center, 463 achalasia patients underwent 567 PD or LHM procedures. In all, 78% of the PDs used a 30-mm Rigiflex dilator. In all, 157/184 (85%) patients underwent 1 or 2 PD without any subsequent treatment. There were seven clinically significant perforations; one from PD and six from LHM. There were no resultant deaths from these perforations; two deaths occurred within 30 days of LHM from unrelated causes. Complications and deaths post-PD were significantly fewer than those post-LHM (P=0.02). CONCLUSIONS Esophageal perforation from PD at our high-volume center was less common than often reported and lower than that associated with LHM. We conclude that, in the hands of experienced operators using conservative technique, PD has fewer major complications and deaths than LHM.
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Rohof WO, Hirsch DP, Kessing BF, Boeckxstaens GE. Efficacy of treatment for patients with achalasia depends on the distensibility of the esophagogastric junction. Gastroenterology 2012; 143:328-35. [PMID: 22562023 DOI: 10.1053/j.gastro.2012.04.048] [Citation(s) in RCA: 226] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Revised: 04/02/2012] [Accepted: 04/24/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Many patients with persistent dysphagia and regurgitation after therapy have low or no lower esophageal sphincter (LES) pressure. Distensibility of the esophagogastric junction (EGJ) largely determines esophageal emptying. We investigated whether assessment of the distensibility of the EGJ is a better and more integrated parameter than LES pressure for determining efficacy of treatment for patients with achalasia. METHODS We measured distensibility of the EGJ using an endoscopic functional luminal imaging probe (EndoFLIP) in 15 healthy volunteers (controls; 8 male; age, 40 ± 4.1 years) and 30 patients with achalasia (16 male; age, 51 ± 3.1 years). Patients were also assessed by esophageal manometry and a timed barium esophagogram. Symptom scores were assessed using the Eckardt score, with a score <4 indicating treatment success. The effect of initial and additional treatment on distensibility and symptoms was evaluated in 7 and 5 patients, respectively. RESULTS EGJ distensibility was significantly reduced in untreated patients with achalasia compared with controls (0.7 ± 0.9 vs 6.3 ± 0.7 mm(2)/mm Hg; P < .001). In patients with achalasia, EGJ distensibility correlated with esophageal emptying (r = -0.72; P < .01) and symptoms (r = 0.61; P < .01) and was significantly increased with treatment. EGJ distensibility was significantly higher in patients successfully treated (Eckardt score <3) compared with those with an Eckardt score >3 (1.6 ± 0.3 vs 4.4 ± 0.5 mm(2)/mm Hg; P = .001). Even when LES pressure was low, EGJ distensibility could be reduced, which was associated with impaired emptying and recurrent symptoms. CONCLUSIONS EGJ distensibility is impaired in patients with achalasia and, in contrast to LES pressure, is associated with esophageal emptying and clinical response. Assessment of EGJ distensibility by EndoFLIP is a better parameter than LES pressure for evaluating efficacy of treatment for achalasia.
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Affiliation(s)
- Wout O Rohof
- Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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Abstract
PURPOSE OF REVIEW In recent years, several studies on the treatment and follow-up of achalasia have been published. This review aims at highlighting interesting publications from the recent years. RECENT FINDINGS Treatment of achalasia aims at relieving functional obstruction at the level of the esophagogastric junction. Several treatment options such as pneumodilation and laparoscopic Heller myotomy (LHM) are available for this purpose. A large prospective randomized trial comparing pneumodilation and LHM demonstrated comparable success rates and quality of life for the two treatment options. Long-term data demonstrate comparable treatment success rates, when redilation in case of recurrent symptoms after pneumodilation is accepted. The most important risk factor for treatment failure is the manometric subtype, with a worse outcome for type I and type III compared with type II achalasia. Recently, peroral endoscopic myotomy (POEM) has been described with high success rates. Comparative studies with longer follow-up are awaited. A prospective study assessing the risk of esophageal carcinoma in patients with achalasia showed a 28-fold increased risk to develop carcinoma. SUMMARY Either LHM or pneumodilation have high comparable short-term clinical success rates. Based on the increased risk to develop esophageal carcinoma, a screening program may be indicated. POEM is a new interesting treatment but longer follow-up data are awaited.
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Vanuytsel T, Lerut T, Coosemans W, Vanbeckevoort D, Blondeau K, Boeckxstaens G, Tack J. Conservative management of esophageal perforations during pneumatic dilation for idiopathic esophageal achalasia. Clin Gastroenterol Hepatol 2012; 10:142-9. [PMID: 22064041 DOI: 10.1016/j.cgh.2011.10.032] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2011] [Revised: 09/25/2011] [Accepted: 10/24/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Esophageal perforation is the most serious adverse event of pneumatic dilation (PD) for achalasia; it is usually managed by surgical repair. We investigated risk factors for esophageal perforation after PD and evaluated safety and long-term outcome of nonsurgical management strategies. METHODS We analyzed medical records of patients with achalasia who were treated with PD from 1992-2010 at the University Hospital Gasthuisberg in Leuven, Belgium; all patients with esophageal perforation were contacted to determine long-term outcomes. Achalasia outcomes were assessed by using the Vantrappen criteria. RESULTS Of 830 PD procedures performed on 372 patients with manometry-confirmed achalasia (57 ± 1 years, 51% male), 16 were complicated by transmural esophageal perforation (4.3% of patients, 1.9% of dilations). Age >65 years was the only significant risk factor for complications (odds ratio, 3.5; 95% confidence interval, 1.2-10.2). All patients were treated conservatively with broad-spectrum antibiotics and nothing by mouth. In 6 patients (38%) the clinical course was further complicated by a pleural effusion, which required a drain in 4 patients. One patient (6%) died of mediastinal hemorrhage within 12 hours after PD. Patients with complications were discharged after 19 ± 2.3 days, compared with 4 ± 0.2 days for those without complications (P < .0001). Long-term outcomes (mean follow-up, 84 ± 14 months) were determined for 12 patients (75%); 11 had excellent or good outcomes (69%), and 1 had a moderate outcome (6%). CONCLUSIONS Age >65 years is a significant risk factor for esophageal perforation after PD. Nonsurgical management of transmural esophageal tears is feasible, with favorable short-term and long-term outcomes, but is not devoid of complications.
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Affiliation(s)
- Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
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SAGES guidelines for the surgical treatment of esophageal achalasia. Surg Endosc 2011; 26:296-311. [PMID: 22044977 DOI: 10.1007/s00464-011-2017-2] [Citation(s) in RCA: 110] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 08/24/2011] [Indexed: 12/19/2022]
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Kashiwagi H, Omura N. Surgical treatment for achalasia: when should it be performed, and for which patients? Gen Thorac Cardiovasc Surg 2011; 59:389-98. [PMID: 21674305 DOI: 10.1007/s11748-010-0765-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 12/13/2010] [Indexed: 01/11/2023]
Abstract
Achalasia is a rare motor disorder of the esophagus, characterized by the absence of peristalsis and impaired swallow-induced relaxation. In the past decade, evidence has been accumulated suggesting that achalasia may be an immune-mediated inflammatory disorder. With the advent of minimally invasive surgery, laparoscopic Heller myotomy (LHM) has slowly shifted the treatment of achalasia toward the greater use of surgical therapy. The goal of both surgical and nonsurgical treatment is to eliminate the outflow obstruction afforded by a nonrelaxing sphincter, relieving dysphagia and maintaining a barrier against gastroesophageal reflux (GER). Endoscopic botulinum toxin injection (EBTI) is safe, easy to perform, inexpensive, and effective in aged patients, and it is especially effective when the lower esophageal pressure is hypertonic. This therapeutic option is reserved for patients too ill to undergo any surgical procedure. Pneumatic dilation (PD) has been shown to be an effective and inexpensive treatment with few adverse effects. The long-term success rate of PD seems to drop progressively over time. Heller myotomy (HM) has shown the best clinical efficacy in achalasia as a first-line treatment. Multiple endoscopic treatments are associated with poorer outcomes after HM. EBTI also makes LHM more difficult and results in a worse surgical outcome. The inferior symptomatic outcomes after thoracoscopic HM may be caused by the difficulty in extending an adequate myotomy onto the stomach from the chest and the inability to create a fundoplication. LHM with Dor's fundoplication (LHM + Dor) is effective and is safer procedure for avoiding GER, dysphagia, mucosal perforation, and a pseudodiverticulum. LHM + Dor is also effective in the presence of sigmoid achalasia, but the clinical result is not as good as nonsigmoid achalasia. A few patients need esophagectomy for surgical failure of HM. However, considering the risk of esophagectomy, LHM + Dor is the first treatment option for patients with achalasia regardless of the degree of esophageal dilatation. This procedure is therefore considered to be an effective and safe treatment for patients of any age or with any condition.
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Affiliation(s)
- Hideyuki Kashiwagi
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-ku, Tokyo 105-8461, Japan.
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Abstract
Controversy exists with regard to the optimal treatment for achalasia and whether surveillance for early recognition of late complications is indicated. Currently, surgical myotomy and pneumatic dilation are the most effective treatments for patients with idiopathic achalasia, and a multicenter, randomized, international trial has confirmed similar efficacy of these treatments, at least in the short term. Clinical predictors of outcome, patient preferences and local expertise should be considered when making a decision on the most appropriate treatment option. Owing to a lack of long-term benefit, endoscopic botulinum toxin injection and medical therapies are reserved for patients of advanced age and those with clinically significant comorbidites. The value of new endoscopic, radiologic or surgical treatments, such as peroral endoscopic myotomy, esophageal stenting and robotic-assisted myotomy has not been fully established. Finally, long-term follow-up data in patients with achalasia support the notion that surveillance strategies might be beneficial after a disease duration of more than 10-15 years.
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Affiliation(s)
- Alexander J Eckardt
- Department of Gastroenterology, Deutsche Klinik für Diagnostik, Aukammallee 33, 65191 Wiesbaden, Germany
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Abstract
Achalasia, diffuse esophageal spasm, nutcracker esophagus, and the hypertensive lower esophageal sphincter are considered primary esophageal motility disorder. These disorders are characterized by esophageal dysmotility that is responsible for the symptoms. While there is today a reasonable consensus about the pathophysiology, the diagnosis, and the treatment of achalasia, this has not occurred for the other disorders. A careful evaluation is therefore necessary before an operation is considered.
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Gutschow CA, Töx U, Leers J, Schäfer H, Prenzel KL, Hölscher AH. Botox, dilation, or myotomy? Clinical outcome of interventional and surgical therapies for achalasia. Langenbecks Arch Surg 2010; 395:1093-9. [PMID: 20845045 DOI: 10.1007/s00423-010-0711-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Accepted: 08/29/2010] [Indexed: 02/07/2023]
Abstract
PURPOSE Achalasia is a rare, but well-defined primary esophageal motor disorder. Classic therapeutic approaches include botulinum toxin injection, balloon dilation, and surgical myotomy of the lower esophageal sphincter. This report summarizes our experience with different treatment modalities for achalasia. METHODS Forty-three patients with achalasia treated in our hospital were subdivided according to therapeutic strategy: endoscopic botulinum toxin injection into the lower esophageal sphincter (EBTI; n = 7), endoscopic esophageal balloon dilation (EBD; n = 16), surgical myotomy after failed esophageal balloon dilation (EBD-HM; n = 14), and first-line surgical myotomy (HM; n = 6). Therapeutic efficiency was evaluated comparing standardized symptom scores preoperatively and at follow-up. RESULTS There was no mortality and no significant difference between the groups for age, sex, or morbidity. The mean follow-up was at 9, 35, 38, and 17 months. At follow-up, recurrent or persistent symptoms were found in 71.4%, 6.3%, 35.7%, and 16.7% in EBTI, EBD, EBD-HM, and HM, respectively. Considering EBD-HM patients as failures of esophageal dilation, the total rate of recurrent or persistent symptoms after EBD was 50%. Poor symptomatic outcome was correlated to a low esophageal sphincter pressure during pretherapeutic manometry (p = 0.03) and to sigmoid-shaped esophageal dilatation (p = 0.06). CONCLUSION Surgical myotomy is the most reliable first-line therapy for achalasia, particularly in patients with a high sphincter pressure and moderate esophageal dilatation. Botox injection has a high failure rate and should be reserved for exceptional cases. Endoscopic dilation provides about 50% of patients with long-term symptomatic relief; in most cases, failure can be successfully treated surgically.
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Affiliation(s)
- Christian Alexander Gutschow
- Department of General-, Visceral-, and Cancer Surgery, University of Cologne, Kerpener Strasse 62, 50931, Cologne, Germany.
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