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Chuah KH, Ramasami N, Mahendran HA, Shanmuganathan G, Koleth GG, Voon K, Gew LT, Jahit MS, Lau PC, Muthukaruppan R, Said RHM, Mahadeva S, Ho SH, Lim SY, Tee SC, Siow SL, Ooi WK, Lee YY. Malaysian joint societies' consensus recommendations on diagnosis and management of disorders of esophagogastric junction outflow. J Gastroenterol Hepatol 2024; 39:431-445. [PMID: 38087846 DOI: 10.1111/jgh.16403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 09/13/2023] [Accepted: 10/18/2023] [Indexed: 03/05/2024]
Abstract
Disorders of esophagogastric junction (EGJ) outflow, including achalasia and EGJ outflow obstruction, are motility disorders characterized by inadequate relaxation of lower esophageal sphincter with or without impaired esophageal peristalsis. Current guidelines are technical and less practical in the Asia-Pacific region, and there are still massive challenges in timely diagnosis and managing these disorders effectively. Therefore, a Malaysian joint societies' task force has developed a consensus on disorders of EGJ outflow based on the latest evidence, while taking into consideration the practical relevance of local and regional context and resources. Twenty-one statements were established after a series of meetings and extensive review of literatures. The Delphi method was used in the consensus voting process. This consensus focuses on the definition, diagnostic investigations, the aims of treatment outcome, non-surgical or surgical treatment options, management of treatment failure or relapse, and the management of complications. This consensus advocates the use of high-resolution esophageal manometry for diagnosis of disorders of EGJ outflow. Myotomy, via either endoscopy or laparoscopy, is the preferred treatment option, while pneumatic dilatation can serve as a secondary option. Evaluation and management of complications including post-procedural reflux and cancer surveillance are recommended.
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Affiliation(s)
- Kee Huat Chuah
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Naveen Ramasami
- Gastroenterology and Hepatology Unit, Department of Medicine, Sultanah Bahiyah Hospital, Alor Setar, Kedah, Malaysia
| | | | | | - Glenn George Koleth
- Gastroenterology and Hepatology Unit, Department of Medicine, Sultan Ismail Hospital, Johor Bahru, Johor, Malaysia
| | - Kelvin Voon
- Department of General Surgery, Penang General Hospital, George Town, Penang, Malaysia
| | - Lai Teck Gew
- Gastroenterology and Hepatology Unit, Department of Medicine, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia
| | | | - Peng Choong Lau
- Pantai Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
- Department of Surgery, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Raman Muthukaruppan
- Gastroenterology and Hepatology Unit, Department of Medicine, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Rosaida Hj Md Said
- Gastroenterology and Hepatology Unit, Department of Medicine, Serdang Hospital, Serdang, Selangor, Malaysia
| | - Sanjiv Mahadeva
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Shiaw-Hooi Ho
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Shyang Yee Lim
- Department of General Surgery, Penang General Hospital, George Town, Penang, Malaysia
| | - Sze Chee Tee
- Department of Surgery, National Cancer Institute, Putrajaya, Malaysia
| | - Sze Li Siow
- Department of General Surgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Wei Keat Ooi
- Department of Surgery, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia
- GI Function and Motility Unit, Universiti Sains Malaysia Hospital, Kota Bharu, Kelantan, Malaysia
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Endoscopic Balloon Dilation Versus Laparoscopic Heller Myotomy: Comparing Two Treatment Methods for Achalasia. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03521-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
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Zambetti BR, Murphy WG, Craner D, Wong DL, Pettigrew BD, Webb DL, Voeller GR, Stoikes NFN. Laparoscopic Heller Myotomy With EGD and Balloon Dilation: A Durable Solution for Achalasia. Am Surg 2022:31348221101473. [PMID: 35544037 DOI: 10.1177/00031348221101473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Laparoscopic Heller myotomy (LHM) and esophageal balloon dilation (BD) are the two mainstays of achalasia treatment-this study examines the outcomes when they are performed simultaneously without fundoplication. METHODS All patients undergoing LHM&BD were reviewed for demographic and procedural data, and to see if additional procedures for achalasia had been performed. Patients were surveyed using the Eckardt score and the GERD quality-of-life score (GERD-HRQL) to assess the durability of repair. RESULTS From 2013-2020, 66 patients underwent LHM&BD. There were no esophageal perforations and a median LOS of 1 day. Seven patients have required additional operations or procedures at median 4-years follow up. 31 patients (47%) responded to the survey. The average Eckardt score was 2.9 (goal<4) with mean GERD-HRQL of 14.4 (goal<25). CONCLUSIONS LHM&BD allows for a safe, durable repair of achalasia. Reflux symptoms are manageable with PPI without fundoplication and the re-intervention rate similar to published values.
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Affiliation(s)
- Benjamin R Zambetti
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - William G Murphy
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Domenic Craner
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Denise L Wong
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Benjamin D Pettigrew
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - David L Webb
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Guy R Voeller
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
| | - Nathaniel F N Stoikes
- Department of Surgery, 12326University of Tennessee Health Science Center, Memphis, TN, USA
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Andrási L, Paszt A, Simonka Z, Ábrahám S, Erdős M, Rosztóczy A, Ollé G, Lázár G. Surgical Treatment of Esophageal Achalasia in the Era of Minimally Invasive Surgery. JSLS 2021; 25:JSLS.2020.00099. [PMID: 33879995 PMCID: PMC8035823 DOI: 10.4293/jsls.2020.00099] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Introduction: We have analyzed the short- and long-term results of various surgical therapies for achalasia, especially changes in postoperative esophageal function. Patients and Methods: Between January 1, 2008 and December 31, 2017, 54 patients with esophageal achalasia were treated in our institution. Patients scheduled for surgery underwent a comprehensive gastroenterological assessment pre- and post-surgery. Forty-eight of the elective cases involved a laparoscopic cardiomyotomy with Dor’s semifundoplication, while two cases entailed an esophageal resection with an intrathoracic gastric replacement for end-stage achalasia. Torek’s operation was performed on two patients for iatrogenic esophageal perforation, and two others underwent primary suture repair with Heller–Dor surgery as an emergency procedure. The results of the different surgical treatments, as well as changes in the patients’ pre- and post-operative complaints were evaluated. Results: No intra-operative complications were observed, and no mortalities resulted. During the 12 to 24-month follow-up period, recurrent dysphagia was observed mostly in the spastic group (TIII: 33%; diffuse esophageal spasm: 60%), while its occurrence in the TI type did not change significantly (14.5%–20.8%). As a result of the follow-up of more than two years, good symptom control was achieved in 93.7% of the patients, with only four patients (8.3%) developing postoperative reflux. Conclusions: The laparoscopic Heller–Dor procedure provides satisfactory long-term results with low morbidity. In emergency and advanced cases, traditional surgical procedures are still the recommended therapy.
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Affiliation(s)
- László Andrási
- Department of Surgery, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - Attila Paszt
- Department of Surgery, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - Zsolt Simonka
- Department of Surgery, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - Szabolcs Ábrahám
- Department of Surgery, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - Márton Erdős
- Department of Surgery, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - András Rosztóczy
- 1st Department of Internal Medicine, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - Georgina Ollé
- 1st Department of Internal Medicine, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
| | - György Lázár
- Department of Surgery, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary
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Oude Nijhuis RAB, Zaninotto G, Roman S, Boeckxstaens GE, Fockens P, Langendam MW, Plumb AA, Smout A, Targarona EM, Trukhmanov AS, Weusten B, Bredenoord AJ. European guidelines on achalasia: United European Gastroenterology and European Society of Neurogastroenterology and Motility recommendations. United European Gastroenterol J 2021; 8:13-33. [PMID: 32213062 PMCID: PMC7005998 DOI: 10.1177/2050640620903213] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Achalasia is a primary motor disorder of the oesophagus characterised by absence of peristalsis and insufficient lower oesophageal sphincter relaxation. With new advances and developments in achalasia management, there is an increasing demand for comprehensive evidence-based guidelines to assist clinicians in achalasia patient care. METHODS Guidelines were established by a working group of representatives from United European Gastroenterology, European Society of Neurogastroenterology and Motility, European Society of Gastrointestinal and Abdominal Radiology and the European Association of Endoscopic Surgery in accordance with the Appraisal of Guidelines for Research and Evaluation II instrument. A systematic review of the literature was performed, and the certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Recommendations were voted upon using a nominal group technique. RESULTS These guidelines focus on the definition of achalasia, treatment aims, diagnostic tests, medical, endoscopic and surgical therapy, management of treatment failure, follow-up and oesophageal cancer risk. CONCLUSION These multidisciplinary guidelines provide a comprehensive evidence-based framework with recommendations on the diagnosis, treatment and follow-up of adult achalasia patients.
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Affiliation(s)
- R A B Oude Nijhuis
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - G Zaninotto
- Department of Surgery and Cancer, Imperial College, London, UK
| | - S Roman
- Digestive Physiology, Hôpital Edouard Herriot, Lyon, France
| | - G E Boeckxstaens
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Centre for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - P Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - M W Langendam
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - A A Plumb
- Centre for Medical Imaging, University College London, London, UK
| | - Ajpm Smout
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - E M Targarona
- Department of General and Digestive Surgery, Hospital De La Santa Creu I Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - A S Trukhmanov
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Blam Weusten
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
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Rieder E, Fernandez-Becker NQ, Sarosiek J, Guillaume A, Azagury DE, Clarke JO. Achalasia: physiology and diagnosis. Ann N Y Acad Sci 2020; 1482:85-94. [PMID: 33140485 DOI: 10.1111/nyas.14510] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/17/2020] [Accepted: 09/22/2020] [Indexed: 12/18/2022]
Abstract
Achalasia is a rare motility disorder with incomplete relaxation of the lower esophageal sphincter and ineffective contractions of the esophageal body. It has been hypothesized that achalasia does not result from only one pathway but rather involves a combination of infectious, autoimmune, and familial etiological components. On the basis of other observations, a novel hypothesis suggests that a muscular form of eosinophilic esophagitis is involved in the pathophysiology of achalasia in some patients. This appears to progressively diminish the myenteric plexus at stage III, gradually destroy it at stage II, and finally eliminate it at stage I, the most advanced and final stage of achalasia. Although high-resolution manometry has identified these three different types of achalasia, another subset of patients with a normal-appearing sphincter relaxation has been proposed. Provocative maneuvers, such as the rapid drinking challenge, have recently been demonstrated to improve diagnosis in certain borderline patients, but have to be studied in more detail. However, whether the different types of achalasia will have a long-term impact on tailored therapies is still a matter of debate. Additionally, novel aspects of the standard timed barium swallow appear to be an important adjunct of diagnosis, as it has been shown to have a diagnostic as well as a predictive value.
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Affiliation(s)
- Erwin Rieder
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Jerzy Sarosiek
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, El Paso, Texas
| | - Alexandra Guillaume
- Gastrointestinal Motility Center, Renaissance School of Medicine, Stony Brook University Hospital, Stony Brook, New York
| | - Dan E Azagury
- Minimally Invasive & Bariatric Surgery, Stanford University School of Medicine, Palo Alto, California
| | - John O Clarke
- Department of Medicine, Stanford University, Redwood City, California
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Jawaid S, Draganov PV, Yang D. Esophageal POEM: the new standard of care. Transl Gastroenterol Hepatol 2020; 5:47. [PMID: 33073042 DOI: 10.21037/tgh.2019.12.17] [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: 10/10/2019] [Accepted: 12/19/2019] [Indexed: 01/06/2023] Open
Abstract
Since its introduction into clinical practice nearly a decade ago, per-oral endoscopic myotomy (POEM) has now become an accepted minimally invasive approach for the treatment of achalasia with excellent short- and mid-term clinical outcomes in both treatment naïve and those who have failed prior therapy. POEM is comparable to laparoscopic Heller myotomy (LHM) in terms of efficacy and safety, with less procedural pain and faster recovery time. Recent data also reveals that POEM may be more effective and durable than pneumatic dilation (PD) for the treatment of achalasia, with similar safety profile. Preliminary data on POEM for spastic esophageal disorders (SED) is promising yet scarce. Post-POEM gastroesophageal reflux disease (GERD) is common but asymptomatic in most patients, further highlighting the need for ongoing research in this field and the importance of long-term surveillance of these patients.
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Affiliation(s)
- Salmaan Jawaid
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida Health, Gainesville, FL, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida Health, Gainesville, FL, USA
| | - Dennis Yang
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida Health, Gainesville, FL, USA
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Objectively Confirmed Gastroesophageal Reflux Disease Following Per Oral Endoscopic Myotomy Higher in Obese Patients (BMI>30). Surg Laparosc Endosc Percutan Tech 2020; 31:146-149. [PMID: 32890250 DOI: 10.1097/sle.0000000000000856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/28/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Per oral endoscopic myotomy (POEM) is a promising minimally invasive therapy in the treatment of achalasia and other esophageal motility disorders. A concern surrounding POEM is the development of gastroesophageal reflux disease (GERD) postoperatively. This study was designed to report outcomes and identify risk factors for the development of postoperative GERD. METHODS Patients who underwent POEM between January 1, 2015 and December 12, 2019 were prospectively followed in an Institutional Review Board approved database. All patients were invited for a full comprehensive workup 6 months post-POEM including symptom scores, pH testing, manometry and esophagogastroduodenoscopy. In a retrospective review of this database, those who developed postoperative GERD were compared with those who did not. RESULTS There were 82 patients that met study criteria (median age 59). Indications for POEM include 35 type I achalasia, 16 type II achalasia, 21 type III achalasia and other spastic esophageal motility disorders, and 10 esophagogastric junction outflow obstruction. Mean Eckardt scores post-POEM were 2.67 compared with 6.79 pre-POEM (P<0.05). Mean integrated relaxation pressure improvement decreased from 27 to 13.1 (P<0.05). The presence of postoperative GERD was defined as an abnormal DeMeester score (>14.7) with pH testing off-medications or the presence of Grade C/D esophagitis on endoscopy. Thirty-five percent (29/82) of patients developed postoperative GERD following POEM. Negative predictive factors for the development of postoperative GERD include myotomy length and normal body mass index (BMI). Obesity (BMI>30) was a positive predictive risk factor in the development of GERD (P=0.029). CONCLUSIONS POEM provides symptomatic relief and reduced Eckardt scores in patient with achalasia and other esophageal motility disorders. Patients who undergo POEM are at risk for developing gastroesophageal reflux disease especially in obese patients.
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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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Comparative efficacy of first-line therapeutic interventions for achalasia: a systematic review and network meta-analysis. Surg Endosc 2020; 35:4305-4314. [PMID: 32856150 PMCID: PMC8011535 DOI: 10.1007/s00464-020-07920-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 08/17/2020] [Indexed: 12/12/2022]
Abstract
Background Several interventions with variable efficacy are available as first-line therapy for patients with achalasia. We assessed the comparative efficacy of different strategies for management of achalasia, through a network meta-analysis combining direct and indirect treatment comparisons. Methods We identified six randomized controlled trials in adults with achalasia that compared the efficacy of pneumatic dilation (PD; n = 260), laparoscopic Heller myotomy (LHM; n = 309), and peroral endoscopic myotomy (POEM; n = 176). Primary efficacy outcome was 1-year treatment success (patient-reported improvement in symptoms based on validated scores); secondary efficacy outcomes were 2-year treatment success and physiologic improvement; safety outcomes were risk of gastroesophageal reflux disease (GERD), severe erosive esophagitis, and procedure-related serious adverse events. We performed pairwise and network meta-analysis for all treatments, and used GRADE criteria to appraise quality of evidence. Results Low-quality evidence, based primarily on direct evidence, supports the use of POEM (RR [risk ratio], 1.29; 95% confidence intervals [CI], 0.99–1.69), and LHM (RR, 1.18 [0.96–1.44]) over PD for treatment success at 1 year; no significant difference was observed between LHM and POEM (RR 1.09 [0.86–1.39]). The incidence of severe esophagitis after POEM, LHM, and PD was 5.3%, 3.7%, and 1.5%, respectively. Procedure-related serious adverse event rate after POEM, LHM, and PD was 1.4%, 6.7%, and 4.2%, respectively. Conclusions POEM and LHM have comparable efficacy, and may increase treatment success as compared to PD with low confidence in estimates. POEM may have lower rate of serious adverse events compared to LHM and PD, but higher rate of GERD. Electronic supplementary material The online version of this article (10.1007/s00464-020-07920-x) contains supplementary material, which is available to authorized users.
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In network meta-analysis, most of the information comes from indirect evidence: empirical study. J Clin Epidemiol 2020; 124:42-49. [DOI: 10.1016/j.jclinepi.2020.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/23/2020] [Accepted: 04/09/2020] [Indexed: 11/24/2022]
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Siow SL, Mahendran HA, Najmi WD, Lim SY, Hashimah AR, Voon K, Teoh KH, Boo HS, Chuah JS, Nurazim S, Faqihuddin MH. Laparoscopic Heller myotomy and anterior Dor fundoplication for achalasia cardia in Malaysia: Clinical outcomes and satisfaction from four tertiary centers. Asian J Surg 2020; 44:158-163. [PMID: 32423838 DOI: 10.1016/j.asjsur.2020.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND To evaluate the clinical outcomes and satisfaction of patients following laparoscopic Heller myotomy for achalasia cardia in four tertiary centers. METHODS Fifty-five patients with achalasia cardia who underwent laparoscopic Heller myotomy between 2010 and 2019 were enrolled. The adverse events and clinical outcomes were analyzed. Overall patient satisfaction was also reviewed. RESULTS The mean operative time was 144.1 ± 38.33 min with no conversions to open surgery in this series. Intraoperative adverse events occurred in 7 (12.7%) patients including oesophageal mucosal perforation (n = 4), superficial liver injury (n = 1), minor bleeding from gastro-oesophageal fat pad (n = 1) & aspiration during induction requiring bronchoscopy (n = 1). Mean time to normal diet intake was 3.2 ± 2.20 days. Mean postoperative stay was 4.9 ± 4.30 days and majority of patients (n = 46; 83.6%) returned to normal daily activities within 2 weeks after surgery. The mean follow-up duration was 18.8 ± 13.56 months. Overall, clinical success (Eckardt ≤ 3) was achieved in all 55 (100%) patients, with significant improvements observed in all elements of the Eckardt score. Thirty-seven (67.3%) patients had complete resolution of dysphagia while the remaining 18 (32.7%) patients had some occasional dysphagia that was tolerable and did not require re-intervention. Nevertheless, all patients reported either very satisfied or satisfied and would recommend the procedure to another person. CONCLUSIONS Laparoscopic Heller myotomy and anterior Dor is both safe and effective as a definitive treatment for treating achalasia cardia. It does have a low rate of oesophageal perforation but overall has a high degree of patient satisfaction with minimal complications.
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Affiliation(s)
- Sze Li Siow
- Department of General Surgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia; Committee of Malaysian Upper Gastrointestinal Surgical Society, Malaysia.
| | - Hans Alexander Mahendran
- Department of General Surgery, Sultanah Aminah Hospital, Johor Bahru, Johor, Malaysia; Committee of Malaysian Upper Gastrointestinal Surgical Society, Malaysia
| | - Wan Daud Najmi
- Department of General Surgery, Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia; Committee of Malaysian Upper Gastrointestinal Surgical Society, Malaysia
| | - Shyang Yee Lim
- Department of General Surgery, Penang General Hospital, Pulau Pinang, Malaysia; Committee of Malaysian Upper Gastrointestinal Surgical Society, Malaysia
| | - Abdul Rahman Hashimah
- Department of General Surgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia; Committee of Malaysian Upper Gastrointestinal Surgical Society, Malaysia
| | - Kelvin Voon
- Department of General Surgery, Penang General Hospital, Pulau Pinang, Malaysia
| | - Keat How Teoh
- Department of General Surgery, Penang General Hospital, Pulau Pinang, Malaysia
| | - Han Sin Boo
- Department of General Surgery, Penang General Hospital, Pulau Pinang, Malaysia
| | - Jun Sen Chuah
- Department of General Surgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Sidi Nurazim
- Department of General Surgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia
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Zotti OR, Herbella FAM, Armijo PR, Oleynikov D, Aquino JL, Leandro-Merhi VA, Velanovich V, Salvador R, Costantini M, Low D, Wirsching A, Boshier PR, Kristem L, Gurski RR, Patti MG. Achalasia Treatment in Patients over 80 Years of Age: A Multicenter Survey. J Laparoendosc Adv Surg Tech A 2020; 30:358-362. [PMID: 31990609 DOI: 10.1089/lap.2019.0749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background and Aims: Laparoscopic Heller's myotomy (LHM), per oral endoscopic myotomy, and pneumatic dilatation are well-established methods to treat achalasia. The ideal treatment algorithm in elderly patients is, however, still elusive. This multicenter study aims to evaluate outcomes and changes in routine therapeutic options in patients >80 years of age. Methods: Worldwide high-volume centers for the treatment of achalasia were surveyed. Therapeutic options and outcomes in patients >80 years of age were reviewed. Results: Eighty-five (54% men, mean age 84 ± 4 years) patients were studied. Primary treatment was endoscopic in 43 (51%) patients, surgical in 39 (46%) patients (30 LHM, 9 cardioplasty + gastrectomy), and medical in 3 (4%) patients. Four centers tailored treatment based on age (14% of the patients). Secondary treatment was necessary in 34 (40%) patients: 30 of them with endoscopic treatment as primary treatment. LHM was performed in 20 patients and endoscopic treatment in 14 patients. A total of 11 (13%) patients had complications after LHM. Seven had LHM or cardioplasty + gastrectomy as primary treatment. Four had LHM as secondary treatment. The mean time of hospitalization was 4 ± 2 days for those who did not have complications, and 7 ± 6 days for those who had complications. Conclusions: Most specialized centers do not tailor treatment based on advanced age. Treatment of the oldest-old patients should be based solely on their physiologic and mental health, not their age. Endoscopic treatment has a high rate of recurrence and gastrectomy a high rate of complications in his population. LHM seems to be a safe option with good outcomes in this population.
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Affiliation(s)
- Orlando R Zotti
- Department of Surgery, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | | | | | - José L Aquino
- Department of Surgery, Catholic University of Campinas, Campinas, Brazil
| | | | - Vic Velanovich
- Department of Surgery, University of South Florida, Tampa, Florida
| | | | | | - Donald Low
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Andrea Wirsching
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Piers R Boshier
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Leonardo Kristem
- Department of Surgery, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Richard R Gurski
- Department of Surgery, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Marco G Patti
- Department of Medicine and Surgery, University of North Carolina, Chapel Hill, North Carolina
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de Heer J, Desai M, Boeckxstaens G, Zaninotto G, Fuchs KH, Sharma P, Schachschal G, Mann O, Rösch T, Werner Y. Pneumatic balloon dilatation versus laparoscopic Heller myotomy for achalasia: a failed attempt at meta-analysis. Surg Endosc 2020; 35:602-611. [PMID: 32180002 DOI: 10.1007/s00464-020-07421-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 02/10/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The advent of peroral endoscopic myotomy (POEM) shed some light on the role of the current standards in the treatment of idiopathic achalasia, namely endoscopic pneumatic dilatation (PD) and laparoscopic Heller myotomy (LHM). We analyzed the quality of the current evidence comparing LHM and PD. METHODS A systematic literature search was performed in Pubmed/Medline, Web of Science, Google Scholar and Cochrane for meta-analyses/systematic reviews comparing PD and LHM or open surgery, limited to English language full-text articles. After a detailed review of these meta-analyses, all studies included were analyzed further in depth with respect to treatment protocol, assessment of success, complications and sequelae such as gastroesophageal reflux (GER), as well as follow-up details. RESULTS Six randomized controlled trials (RCT), 5 with LHM and 1 with open surgery, were found, published in 10 papers. In contrast to a rather homogeneous LHM technique, PD regimens as well as the clinical dysphagia scores were different in every RCT; most RCTs also showed methodological limitations. There were nine meta-analyses which included a variable number of these RCTs or other cohort studies. Meta-analyses between 2009 and 2013 favored surgery, while the 4 most recent ones reached divergent conclusions. The main difference might have been whether repeated dilatation was regarded as part of the PD protocol or as failure. CONCLUSIONS The variability in PD techniques and in definition of clinical success utilized in the achalasia RCTs on PD versus LHM render the conclusions of meta-analyses unreliable. Further randomized studies should be based on uniform criteria; in the meantime, publication of even more meta-analyses should be avoided.
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Affiliation(s)
- Jocelyn de Heer
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Madhav Desai
- Department of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas, MO, USA
| | - Guy Boeckxstaens
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | | | - Karl-Hermann Fuchs
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Prateek Sharma
- Department of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas, MO, USA
| | - Guido Schachschal
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Oliver Mann
- Department of General and Abdominal Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Yuki Werner
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Podboy AJ, Hwang JH, Rivas H, Azagury D, Hawn M, Lau J, Kamal A, Friedland S, Triadafilopoulos G, Zikos T, Clarke JO. Long-term outcomes of per-oral endoscopic myotomy compared to laparoscopic Heller myotomy for achalasia: a single-center experience. Surg Endosc 2020; 35:792-801. [DOI: 10.1007/s00464-020-07450-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 02/11/2020] [Indexed: 02/07/2023]
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Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss the efficacy, morbidity and side-effects of innovative management strategies for achalasia that include high-resolution manometry (HRM), pneumatic dilatation, laparoscopic Heller's myotomy (LHM), injection of botulinum toxin into the lower esophageal sphincter and peroral endoscopic myotomy (POEM). RECENT FINDINGS HRM has enabled identification of achalasia subtypes that have important prognostic implications. Pneumatic dilatation is a commonly-used and cost-effective method of treating achalasia but has shown poor longevity of symptom relief compared with other modalities and carries a risk of esophageal perforation. LHM is often the preferred, most effective treatment modality, however new studies may show that outcomes are equivalent or even inferior to POEM. Botulinum toxin injection of the lower esophageal sphincter has a waning and short duration of efficacy and is used primarily for patients unsuitable for more definitive invasive procedures. POEM is considered the most effective treatment for type III achalasia but carries a high risk of iatrogenic gastroesophageal reflux disease that might predispose to the development of Barrett's esophagus. SUMMARY HRM and POEM are two major innovations in the management of achalasia developed over the past decade. There are now three major management options for patients with achalasia, namely pneumatic dilatation, LHM and POEM. Treatment selection should be tailored to the patient's individual esophageal physiology, physical fitness and dominant symptoms.
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Yu YR, Rosenfeld EH, Chiou EH, Chumpitazi BP, Fallon SC, Brandt ML. High-resolution manometric guidance during laparoscopic Heller myotomy: Impact on quality of life and symptom severity for children with achalasia. J Pediatr Surg 2019; 54:1063-1068. [PMID: 30808541 DOI: 10.1016/j.jpedsurg.2019.01.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 01/27/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND High-resolution esophageal manometry (HREM) during laparoscopic Heller myotomy (LHM) with fundoplication for achalasia allows tailoring of myotomy length and wrap tightness. The purpose of this study is to quantify long-term postoperative symptom severity and quality of life using validated questionnaires. METHODS Children ≤18 years with achalasia who previously underwent LHM with intraoperative HREM from 2010 to 2017 were prospectively surveyed. Eckardt Symptom Score (ESS), Achalasia Severity Questionnaire (ASQ), Pediatric Quality of Life Inventory (PedsQL), and Pediatric GERD Symptom and Quality of Life (PGSQ) questionnaires were administered. Scores for historical controls were obtained from prior survey instrument validation studies as comparison. RESULTS Of 30 eligible patients, 12 (40%) completed the surveys. Mean age at time of surgery was 13 ± 3 years. Assessment was performed at least 10 months after surgery with mean time elapsed of 3.6 ± 2 years. Average premyotomy lower esophageal sphincter (LES) pressure, postmyotomy LES pressure, and postfundoplication LES pressure were 30 ± 10 mmHg, 14 ± 6 mmHg, and 18 ± 9, respectively. ESS (2.3/12), ASQ (39/100 ± 16), PGSQ (symptom: 0.6/4 ± 0.4, school: 0.4/4 ± 0.4), and overall PedsQL (82/100 ± 15) were similar to those of healthy historical controls. CONCLUSION Children with achalasia undergoing LHM with intraoperative HREM had sustained long-term symptom improvement and quality of life scores comparable to healthy patients. STUDY AND LEVEL OF EVIDENCE Retrospective, II.
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Affiliation(s)
- Yangyang R Yu
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Eric H Rosenfeld
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Eric H Chiou
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Bruno P Chumpitazi
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Sara C Fallon
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Mary L Brandt
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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Bonifácio P, de Moura DTH, Bernardo WM, de Moura ETH, Farias GFA, Neto ACM, Lordello M, Korkischko N, Sallum R, de Moura EGH. Pneumatic dilation versus laparoscopic Heller's myotomy in the treatment of achalasia: systematic review and meta-analysis based on randomized controlled trials. Dis Esophagus 2019; 32:5149492. [PMID: 30380036 DOI: 10.1093/dote/doy105] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Achalasia is a primary esophageal motor disorder with a variety of causes. It is most common in Central and South America, where Chagas disease is endemic. In addition to the infectious etiology, achalasia can be idiopathic, autoimmune, or drug induced. It is an incurable, progressive condition that destroys the intramural nerve plexus, causing aperistalsis of the esophageal body and impaired relaxation of the lower esophageal sphincter. The literature on the treatment of achalasia comparing pneumatic dilation (PD) and laparoscopic Heller's myotomy (LHM) shows conflicting results. Therefore, a systemic review and meta-analysis are needed. A systematic review and meta-analysis of randomized controlled trials of PD and LHM, based on the preferred reporting items for systematic reviews and meta-analyses recommendations, was presented. The primary outcome was symptom remission based on the Eckardt score. Secondary outcomes were lower esophageal sphincter pressure (LESP), gastroesophageal reflux (GER), and perforation. A total of four studies were included in this analysis. The total number of patients was 404. Posttreatment symptom remission rates did not differ significantly between LHM and PD at 2 years (RD = 0.03, 95% CI [-0.05, 0.12], P = 0.62), or 5 years (RD = 0.13, 95% CI [-0.12, 0.39], P = 0.32). The posttreatment perforation rate was lower for LHM (RD = 0.04, 95% CI [-0.08, -0.01], P = 0.03). There was no significant difference in terms of LESP or GER. For the treatment of esophageal achalasia, LHM and PD were found to be similar in terms of their long-term efficacy, as well as in terms of the posttreatment GER rates. However, the perforation rate appears to be lower when LHM is employed.
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Affiliation(s)
- P Bonifácio
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - D T H de Moura
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - W M Bernardo
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - E T H de Moura
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - G F A Farias
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - A C M Neto
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - M Lordello
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - N Korkischko
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - R Sallum
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - E G H de Moura
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
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Hung YC, Westfal ML, Chang DC, Kelleher CM. Heller myotomy is the optimal index procedure for esophageal achalasia in adolescents and young adults. Surg Endosc 2018; 33:3355-3360. [PMID: 30552502 DOI: 10.1007/s00464-018-06625-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 12/11/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND There is limited and conflicting data on the optimal intervention for the treatment of achalasia in adolescents and young adults (AYA), Heller myotomy (HM), esophageal dilation (ED) or botulinum toxin injection (botox). The goal of this study is to determine the most appropriate index intervention for achalasia in the AYA population. METHODS We completed a longitudinal, population-based analysis of the California (2005-2010) and New York (1999-2014) statewide databases. We included patients 9-25 years old with achalasia who underwent HM, ED or botox. Comparisons were made based on the patients' index procedure. Rates of 30-day complications, long-term complications, and re-intervention up to 14 years were calculated. Cox regression was performed to determine the risk of re-intervention, adjusting for patient demographics. RESULTS A total of 442 AYAs were analyzed, representing the largest cohort of young patients with this disease studied to date. Median follow-up was 5.2 years (IQR 1.8-8.0). The overall rate of re-intervention was 29.3%. Rates of re-intervention for ED and botox were equivalent and higher than HM (65.0% for ED, 47.4% for botox and 16.4% for HM, p < 0.001). Ultimately, 46.9% of ED and botox patients underwent HM. The overall short-term complication rate was 4.3% and long-term, 1.9%. There was no difference in the short-term and long-term complication rates between intervention groups (p > 0.05). On adjusted analysis, ED and botox were associated with increased risks of re-intervention when compared to HM (HR 5.9, HR 4.8, respectively, p < 0.01). Black patients were found to have a risk of re-intervention twice that of white patients (HR 2.0, p = 0.05). CONCLUSIONS HM has a similar risk of complications but a significantly lower risk of re-intervention when compared to ED and botox. Based on our findings, we recommend HM as the optimal index procedure for AYAs with achalasia.
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Affiliation(s)
- Ya-Ching Hung
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Maggie L Westfal
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
- Department of Pediatric Surgery, MassGeneral Hospital for Children, Boston, MA, USA
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Cassandra M Kelleher
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA.
- Department of Pediatric Surgery, MassGeneral Hospital for Children, Boston, MA, USA.
- Pediatric Surgery, Massachusetts General Hospital, 55 Fruit St. WRN-11, Boston, MA, 02114, USA.
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20
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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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Whose patient is it? The path to multidisciplinary management of achalasia. J Surg Res 2018; 228:8-13. [DOI: 10.1016/j.jss.2018.02.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/20/2017] [Accepted: 02/22/2018] [Indexed: 02/06/2023]
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22
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Repici A, Fuccio L, Maselli R, Mazza F, Correale L, Mandolesi D, Bellisario C, Sethi A, Khashab MA, Rösch T, Hassan C. GERD after per-oral endoscopic myotomy as compared with Heller's myotomy with fundoplication: a systematic review with meta-analysis. Gastrointest Endosc 2018; 87:934-943.e18. [PMID: 29102729 DOI: 10.1016/j.gie.2017.10.022] [Citation(s) in RCA: 149] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 10/13/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Per-oral endoscopic myotomy (POEM) represents a less invasive alternative to conventional laparoscopic Heller's myotomy (LHM) for patients with achalasia. It cannot be excluded, however, that the lack of fundoplication after POEM may result in a higher incidence of reflux disease, as compared with LHM. The aim of our study was to conduct a systematic review of prospective studies reporting the incidence of reflux disease developed after POEM and LHM. METHODS A literature search with electronic databases was performed (up to February 2017) to identify full articles on the incidence of gastroesophageal reflux symptoms and endoscopic monitoring and pH monitoring findings after POEM and LHM (with fundoplication). Proportions and rates were pooled by means of random or fixed-effects models, according to the level of heterogeneity between studies. RESULTS After we applied the selection criteria, 17 and 28 studies, including 1542 and 2581 participants who underwent POEM and LHM, respectively, were included. The pooled rate of postprocedural symptoms was 19.0% (95% confidence interval [CI], 15.7%-22.8%) after POEM and 8.8% (95% CI, 5.3%-14.1%) after LHM, respectively. The pooled rate estimate of abnormal acid exposure at pH monitoring was 39.0% (95% CI, 24.5%-55.8%) after POEM and 16.8% (95% CI, 10.2%-26.4%) after LHM, respectively. The rate of esophagitis after POEM was 29.4% (95% CI, 18.5%-43.3%) after POEM and 7.6% (95% CI, 4.1%-13.7%) after LHM. At meta-regression, heterogeneity was explained partly by the POEM approach and study population. CONCLUSION The incidence of reflux disease appears to be significantly more frequent after POEM than after LHM with fundoplication. Monitoring pH and ensuring appropriate treatment after POEM should be considered in order to prevent long-term reflux-related adverse events.
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Affiliation(s)
- Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Rozzano (MI), Italy
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Roberta Maselli
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Rozzano (MI), Italy
| | - Fabrizio Mazza
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Rozzano (MI), Italy
| | | | - Daniele Mandolesi
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Cristina Bellisario
- Department of Cancer Screening, Centre for Epidemiology and Prevention in Oncology, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Thomas Rösch
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
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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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Rahden BHAV, Filser J, Al-Nasser M, Germer CT. [Surgical treatment of achalasia - endoscopic or laparoscopic? : Proposal for a tailored approach]. Chirurg 2018; 88:204-210. [PMID: 28120018 DOI: 10.1007/s00104-016-0365-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Primary idiopathic achalasia is the most common form of the rare esophageal motility disorders. A curative therapy which restores the normal motility does not exist; however, the therapeutic principle of cardiomyotomy according to Ernst Heller leads to excellent symptom control in the majority of cases. The established standard approach is Heller myotomy through the laparoscopic route (LHM), combined with Dor anterior fundoplication for reflux prophylaxis/therapy. At least four meta-analyses of randomized controlled trials (RCTs) have demonstrated superiority of LHM over pneumatic dilation (PD); therefore, LHM should be used as first line therapy (without prior PD) in all operable patients. Peroral endoscopic myotomy (POEM) is a new alternative approach, which enables Heller myotomy to be performed though the endoscopic submucosal route. The POEM procedure has a low complication rate and also leads to good control of dysphagia but reflux rates can possibly be slightly higher (20-30%). Long-term results of POEM are still scarce and the results of the prospective randomized multicenter trial POEM vs. LHM are not yet available; however, POEM seems to be the preferred treatment option for certain indications. Within the framework of the tailored approach for achalasia management of POEM vs. LHM established in Würzburg, we recommend long-segment POEM for patients with type III achalasia (spasmodic) and other hypercontractile motility disorders and potentially type II achalasia (panesophageal compression) with chest pain as the lead symptom, whereas LHM can also be selected for type I. For sigmoid achalasia, especially with siphon-like transformation of the esophagogastric junction, simultaneous hiatal hernia and epiphrenic diverticula, LHM is still the preferred approach. The choice of the procedure for revisional surgery in case of recurrent dysphagia depends on the suspected mechanism (morphological vs. functional/neuromotor).
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Affiliation(s)
- B H A von Rahden
- Klinik für Allgemein-, Viszeral, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin (ZOM), Universitätsklinikum Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Deutschland.
| | - J Filser
- Klinik für Allgemein-, Viszeral, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin (ZOM), Universitätsklinikum Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Deutschland
| | - M Al-Nasser
- Klinik für Allgemein-, Viszeral, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin (ZOM), Universitätsklinikum Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Deutschland
| | - C-T Germer
- Klinik für Allgemein-, Viszeral, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin (ZOM), Universitätsklinikum Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Deutschland
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25
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Submucosal surgery: novel interventions in the third space. Lancet Gastroenterol Hepatol 2018; 3:134-140. [PMID: 29353638 DOI: 10.1016/s2468-1253(17)30286-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 08/09/2017] [Accepted: 08/11/2017] [Indexed: 02/07/2023]
Abstract
Traditional surgeries involve accessing body cavities, such as the abdomen and thorax, via incisions that divide skin and muscle. These operations result in postoperative pain and convalescence, and a risk of complications such as wound infection and hernia. The development of flexible endoscopy allowed diseases as varied as gastrointestinal bleeding and colon adenomas to be treated without incisions, but this technique is restricted by its endoluminal nature. A novel category of surgical endoscopic procedures has recently been developed that uses flexible endoscopic techniques to enter and access the submucosa of the gastrointestinal tract. Through this approach, the advantages of incisionless endoscopy can be applied to areas of the body that previously could only be reached with surgery. This Review introduces this new class of interventions by describing two examples of such submucosal surgeries for the treatment of benign gastrointestinal disease: per-oral endoscopic myotomy and per-oral pyloromyotomy. The approach to pre-procedure patient evaluation, operative technique, and the published outcomes are discussed, as well as potential future applications of similar techniques and procedures in this so-called third space.
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Tsuboi K, Omura N, Yano F, Hoshino M, Yamamoto SR, Akimoto S, Masuda T, Kashiwagi H, Yanaga K. Impact of preoperative balloon dilatation on outcomes of laparoscopic surgery in young patients with esophageal achalasia. Esophagus 2018; 15:39-46. [PMID: 29892807 DOI: 10.1007/s10388-017-0593-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 09/13/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND Balloon dilatation is reportedly less effective for young patients with esophageal achalasia than for older patients. However, there is no consensus on the impact of prior balloon dilatation on outcomes of surgical treatment. This study investigated the significance of preoperative balloon dilatation on surgical outcomes in young patients with esophageal achalasia. METHODS Of patients aged less than 40 years who had undergone a laparoscopic Heller-Dor operation for esophageal achalasia, 201 with a postoperative follow-up period of at least 1 year were included. They were divided into two groups with and without a history of balloon dilatation, and compared preoperative pathological conditions and surgical outcomes. RESULTS This study included 100 men and 101 women with a median age of 31 years, of whom 158 patients without a history of pneumatic dilatation (79%, non-PD group) and 43 with a history of pneumatic dilatation (21%, PD group) The preoperative symptom scores for dysphagia and regurgitation were significantly higher in the non-PD group. Although no differences were observed in surgical outcomes or postoperative course, the esophageal clearance rates calculated on preoperative and postoperative timed barium esophagograms were lower in terms of both height and width of the barium column in the PD group than in the non-PD group. Subjectively, both groups expressed equally high satisfaction. CONCLUSIONS In patients aged less than 40 years with esophageal achalasia, although preoperative balloon dilatation did not affect subjective levels of satisfaction with surgery, postoperative improvement in esophageal clearance in the lower esophagus was inhibited.
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Affiliation(s)
- Kazuto Tsuboi
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Nobuo Omura
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Fumiaki Yano
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Masato Hoshino
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Se-Ryung Yamamoto
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Shunsuke Akimoto
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Takahiro Masuda
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hideyuki Kashiwagi
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Katsuhiko Yanaga
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
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Baniya R, Upadhaya S, Khan J, Subedi SK, Shaik Mohammed T, Ganatra BK, Bachuwa G. Laparoscopic esophageal myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized controlled trials. Clin Exp Gastroenterol 2017; 10:241-248. [PMID: 29026325 PMCID: PMC5627730 DOI: 10.2147/ceg.s130449] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Achalasia is a primary esophageal motility disorder of unknown etiology associated with abnormalities in peristalsis and lower esophageal sphincter relaxation. The disease is incurable; however, definitive treatment procedures like pneumatic dilation (PD)/balloon dilation and laparoscopic esophageal myotomy (LEM) are performed to relieve dysphagia and related symptoms. Currently, there is paucity of data comparing the outcomes of these procedures. The aim of this meta-analysis is to compare the short- and long-term success rates of PD and LEM. METHODS A thorough systematic search of PubMed, Scopus, clinicaltrials.gov, and Cochrane library was conducted for randomized controlled trials (RCTs) comparing the outcomes of PD versus LEM in the treatment of achalasia. The Mantel-Haenszel method and random effect model were used to analyze the data. RCTs with outcome data at 3-month, 1-year, and 5-year intervals were analyzed. RESULTS A total of 437,378 and 254 patients at 3-month, 1-year, and 5-year intervals were analyzed for outcome data. At 3 months and 1 year, PD was not as effective as LEM (odds ratio [OR]: 0.50; confidence interval [CI] 0.31-0.82; P = 0.009 and OR: 0.47; CI 0.22-0.99; P = 0.21) but at 5 years, one procedure was non-inferior to the other (OR: 0.62; 0.33-1.19; P = 0.34). CONCLUSION PD was as effective as LEM in relieving symptoms of achalasia in the long-term.
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Affiliation(s)
- Ramkaji Baniya
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI, USA
| | - Sunil Upadhaya
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI, USA
| | - Jahangir Khan
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI, USA
| | - Suresh Kumar Subedi
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI, USA
| | - Tabrez Shaik Mohammed
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI, USA
| | - Balvant K Ganatra
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI, USA
| | - Ghassan Bachuwa
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI, USA
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Molina JC, Misariu AM, Nicolau I, Spicer J, Mulder D, Ferri LE, Mueller CL. Same day discharge for benign laparoscopic hiatal surgery: a feasibility analysis. Surg Endosc 2017; 32:937-944. [PMID: 28779258 DOI: 10.1007/s00464-017-5769-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/14/2017] [Indexed: 01/29/2023]
Abstract
BACKGROUND Advances in minimally invasive surgery and the development of enhanced recovery pathways have favored the spread of day-surgery programs. Despite laparoscopic approaches being accepted as the standard of care for benign hiatal diseases, safety and feasibility of same day discharges for laparoscopic hiatal surgeries other than fundoplication has yet to be established. OBJECTIVE This study aimed to assess the feasibility of same day discharge for primary and revisional laparoscopic hiatal surgeries including paraesophageal hernia repairs (PEHR), fundoplication for reflux, and Heller myotomy (±diverticulectomy). METHODS A retrospective cohort study including all patients undergoing elective laparoscopic hiatal procedures in the division of Thoracic surgery between 2011 and 2016 at McGill University Health Centre was performed. Planned day-surgery (DAYCASE) was compared to planned inpatient (INPATIENT) cohorts with respect to operative and postoperative outcomes, length of stay, readmission, and emergency room visits. RESULTS A total of 261 patients were identified, 161 female (62%); median age 62 (20). The case distribution was: PEHR (123; 47.1%), Heller myotomy (94;36%, 7 diverticulectomy), and fundoplication (44; 16.9%). Twenty patients had revisional procedures (7.7%). Same day discharge was planned in 98 cases (38%) and was successful in 80 (81.6%). Proportion of DAYCASE increased form 12% prior to 2013 to 67% in 2016. INPATIENTs were older (median 66 vs. 60 years), and had a higher proportion of PEHR (55 vs. 34%), p < 0.05. Both cohorts were comparable in gender proportion, ASA classification, and length of surgery. Complications, readmission, and emergency visits did not differ between the two cohorts. On multivariate analysis, female gender (OR 37, 95% CI 1.46-936, p = 0.028), surgery beginning after noon (OR 5.4, 95% CI 1.1-26.9, p = 0.038), intraoperative complications (OR 20.4 95% CI 1.5-286, p = 0.025), and postoperative complications (OR 52.1, 95% CI 4.5-602, p = 0.002) were independently associated with unplanned admission. CONCLUSIONS Day-case surgery for complex laparoscopic hiatal procedures is feasible and can be achieved in a significant number of patients without compromising safety.
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Affiliation(s)
- Juan Carlos Molina
- Division of Thoracic and Upper GI Surgery, Montreal General Hospital, McGill University Health Center, 1650 Cedar Avenue, L8-512, Montreal, QC, H3G 1A4, Canada.
| | - Ana María Misariu
- Division of Thoracic and Upper GI Surgery, Montreal General Hospital, McGill University Health Center, 1650 Cedar Avenue, L8-512, Montreal, QC, H3G 1A4, Canada
| | - Ioana Nicolau
- Division of Thoracic and Upper GI Surgery, Montreal General Hospital, McGill University Health Center, 1650 Cedar Avenue, L8-512, Montreal, QC, H3G 1A4, Canada
| | - Jonathan Spicer
- Division of Thoracic and Upper GI Surgery, Montreal General Hospital, McGill University Health Center, 1650 Cedar Avenue, L8-512, Montreal, QC, H3G 1A4, Canada
| | - David Mulder
- Division of Thoracic and Upper GI Surgery, Montreal General Hospital, McGill University Health Center, 1650 Cedar Avenue, L8-512, Montreal, QC, H3G 1A4, Canada
| | - Lorenzo E Ferri
- Division of Thoracic and Upper GI Surgery, Montreal General Hospital, McGill University Health Center, 1650 Cedar Avenue, L8-512, Montreal, QC, H3G 1A4, Canada
| | - Carmen L Mueller
- Division of Thoracic and Upper GI Surgery, Montreal General Hospital, McGill University Health Center, 1650 Cedar Avenue, L8-512, Montreal, QC, H3G 1A4, Canada
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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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Clinical outcomes five years after POEM for treatment of primary esophageal motility disorders. Surg Endosc 2017; 32:421-427. [PMID: 28664434 DOI: 10.1007/s00464-017-5699-2] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 06/22/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is a novel operation for the treatment of achalasia and other esophageal motility disorders. While POEM has shown excellent short-term safety and efficacy, the long-term symptomatic outcomes after the procedure are unknown. METHODS Patients from a single center that underwent POEM for treatment of esophageal motility orders and were greater than 5 years removed from their operation were studied. Patients were contacted to assess current symptoms and encouraged to undergo repeat endoscopy for objective follow-up. RESULTS Thirty-six patients underwent POEM from October, 2010 to February, 2012 and current symptom scores were obtained from 29 patients at median 65-month follow-up. In the 23 patients with achalasia, Eckardt scores were significantly improved from preoperative baseline (mean current 1.7 vs. preoperative 6.4, p < 0.001). Nineteen patients (83%) with achalasia had a symptomatic success (Eckardt ≤3) and none required retreatment for symptoms. Eckardt scores were dramatically improved at 6 months and maintained at 2 years; however, there was a small but significant worsening of symptoms between 2 and 5-years. Of the five patients with EGJ outflow obstruction, all had current Eckardt scores ≤3 but two needed reintervention for persistent or recurrent symptoms, one with a laparoscopic Heller myotomy and another with an endoscopic cricomyotomy and proximal esophageal myotomy extension. At 6-month follow-up, repeat manometry showed decreased EGJ relaxation pressures and esophagram demonstrated improved emptying. 24-h pH monitoring showed abnormal distal esophageal acid exposure in 38% of patients. Fifteen patients underwent endoscopy at 5-years, revealing erosive esophagitis in two (13%), new hiatal hernia in two, and new non-dysplastic Barrett's esophagus in one. The patient with Barrett's underwent a subsequent laparoscopic hiatal hernia repair and Toupet fundoplication. CONCLUSIONS POEM resulted in a successful palliation of symptoms in the majority of patients after 5 years, though these results emphasize the importance of long-term follow-up in all patients.
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Rieder E, Asari R, Paireder M, Lenglinger J, Schoppmann SF. Endoscopic stent suture fixation for prevention of esophageal stent migration during prolonged dilatation for achalasia treatment. Dis Esophagus 2017; 30:1-6. [PMID: 28375470 DOI: 10.1093/dote/dow002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Indexed: 02/07/2023]
Abstract
The aim of this study is to compare endoscopic stent suture fixation with endoscopic clip attachment or the use of partially covered stents (PCS) regarding their capability to prevent stent migration during prolonged dilatation in achalasia. Large-diameter self-expanding metal stents (30 mm × 80 mm) were placed across the gastroesophageal junction in 11 patients with achalasia. Stent removal was scheduled after 4 to 7 days. To prevent stent dislocation, endoscopic clip attachment, endoscopic stent suture fixation, or PCS were used. The Eckardt score was evaluated before and 6 months after prolonged dilatation. After endoscopic stent suture fixation, no (0/4) sutured stent migrated. When endoscopic clips were used, 80% (4/5) clipped stents migrated (p = 0.02). Of two PCS (n = 2), one migrated and one became embedded leading to difficult stent removal. Technical adverse events were not seen in endoscopic stent suture fixation but were significantly correlated with the use of clips or PCS (r = 0.828, p = 0.02). Overall, 72% of patients were in remission regarding their achalasia symptoms 6 months after prolonged dilatation. Endoscopic suture fixation of esophageal stents but not clip attachment appears to be the best method of preventing early migration of esophageal stents placed at difficult locations such as at the naive gastroesophageal junction.
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Cheng JW, Li Y, Xing WQ, Lv HW, Wang HR. Laparoscopic Heller myotomy is not superior to pneumatic dilation in the management of primary achalasia: Conclusions of a systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2017; 96:e5525. [PMID: 28207499 PMCID: PMC5319488 DOI: 10.1097/md.0000000000005525] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Achalasia is an esophageal motility disorder, of unknown cause, which results in increased lower esophageal sphincter tone and symptoms of difficulty swallowing. Current major therapeutic options include laparoscopic Heller myotomy (LHM) and pneumatic dilation (PD). We undertake a systematic review comparing the efficacy and safety of these 2 treatments in the treatment of esophageal achalasia. METHODS PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched for randomized controlled trial investigating LHM versus PD in the treatment of primary achalasia. The primary outcome was symptom remission rates. The Mantel-Haenszel method with fixed-effect or random-effects model was used to calculate relative risks and 95% confidence intervals (CIs). RESULTS Five studies involving 498 participants were included. The cumulative remission rate was significantly higher with LHM at 3 months and 1 year (short-term), with a risk ratio of 1.16 (95% CI 1.01-1.35, P = 0.04) and 1.14 (95% CI 1.02-1.27, P = 0.02), respectively. There were no significant differences between LHM and PD in 2-year and 5-year remission rate (long-term), with a risk ratio of 1.05 (95% CI 0.91-1.22, P = 0.49) and 1.17 (95% CI 0.84-1.64, P = 0.34), respectively. Rates of major mucosal tears requiring subsequent intervention with LHM were significantly lower than those of esophageal perforation with PD requiring postprocedural medical or surgical therapy, with a risk ratio of 0.25 (95% CI 0.08-0.81, P = 0.02). Postprocedural rates of gastroesophageal reflux, lower esophageal sphincter pressures, and quality of life scores did not differ in trials with sufficient data. CONCLUSIONS There were no significant differences between LHM and PD in 2-year and 5-year remission rate. This study indicates that either treatment can be proposed as initial treatment for achalasia.
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Schlottmann F, Andolfi C, Kavitt RT, Konda VJA, Patti MG. Multidisciplinary Approach to Esophageal Achalasia: A Single Center Experience. J Laparoendosc Adv Surg Tech A 2017; 27:358-362. [PMID: 28099056 DOI: 10.1089/lap.2016.0594] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The treatment of achalasia is palliative. Pneumatic dilatation (PD) or laparoscopic Heller myotomy (LHM) just eliminates the outflow obstruction allowing easier emptying of the esophagus. The aim of this study was to evaluate the results of a multidisciplinary approach to esophageal achalasia. MATERIALS AND METHODS A consecutive series of patients with achalasia treated by a multidisciplinary esophageal team consisting of radiologists, gastroenterologists, and surgeons in a quaternary care center between May 2008 and April 2015 were analyzed. RESULTS A total of 147 patients with achalasia underwent LHM and partial fundoplication. Sixty-two patients (42%) had been treated preoperatively with PD and/or botulinum toxin (BT). The preoperative Eckardt score (ES) was 6.4 ± 2. At a median follow-up of 22 months, 128 patients (87%) did well and required no further treatment (ES 0.1). The remaining 19 patients (13%) had recurrence of symptoms and required further treatment: 12 were treated with PD and improved (ES 0.7); 4 were treated with PD and BT and improved (ES 1.3); 3 failed PD. These 3 patients had been treated with multiple sessions of PD and BT before the myotomy. Overall, 144 patients (98%) did well with laparoscopic (87%) or laparoscopic and endoscopic treatment (11%). CONCLUSIONS The results of this study show that (a) LHM is an effective treatment modality, (b) PD improved symptoms in the majority of patients with recurrent dysphagia after myotomy and (c) multiple preoperative endoscopic treatments seem to affect outcomes of LHM. Patients with achalasia should be treated in a quaternary care center by a multidisciplinary team.
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Affiliation(s)
- Francisco Schlottmann
- 1 Department of Surgery, Center for Esophageal Diseases and Swallowing, University of North Carolina , Chapel Hill, North Carolina
| | - Ciro Andolfi
- 2 Department of Surgery, University of Chicago , Chicago, Illinois
| | - Robert T Kavitt
- 3 Department of Medicine, University of Chicago , Chicago, Illinois
| | - Vani J A Konda
- 3 Department of Medicine, University of Chicago , Chicago, Illinois
| | - Marco G Patti
- 1 Department of Surgery, Center for Esophageal Diseases and Swallowing, University of North Carolina , Chapel Hill, North Carolina
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Herbella FA, Moura EG, Patti MG. Achalasia 2016: Treatment Alternatives. J Laparoendosc Adv Surg Tech A 2017; 27:6-11. [DOI: 10.1089/lap.2016.0468] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Fernando A.M. Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil
| | - Eduardo G.H. Moura
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | - Marco G. Patti
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
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Pediatric achalasia. Single-center study of interventional treatment. GASTROENTEROLOGY REVIEW 2016; 12:98-104. [PMID: 28702097 PMCID: PMC5497128 DOI: 10.5114/pg.2016.64845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 01/12/2016] [Indexed: 01/29/2023]
Abstract
Introduction Esophageal achalasia is a rare entity in children. However, young age is a factor of failure of conservative treatment, emphasizing the role of surgery. In our institution laparoscopic Heller’s cardiomyotomy is the chosen procedure for surgical treatment. Aim To assess the outcome of surgery for achalasia treatment in children operated on in a single institution. Material and methods A retrospective analysis of consecutive patient records from the years 1997 to 2014 was performed. There were 11 patients. Their mean age was 13 years, ranging from 6 to 17. Duration of symptoms was 2 to 36 months, mean 16. All 11 patients were operated on with a laparoscopic approach. Pneumatic dilatation was used both pre- and postoperatively but in no case was sufficient on its own. Collected data included patient demographics, preoperative symptoms and their duration, diagnostic findings and therapeutic means. Surgical procedures, complications and long-term follow-up were analyzed. The follow-up lasted from 1 to 10 years and finished when the patient reached 18 years of age. Results Twelve laparoscopic cardiomyotomies were performed with concomitant fundoplications, 10 Toupet and 2 Dor and one redo procedure. There were no deaths. Two perforations were repaired promptly. The success rate was 82%, though with subsequent dilatations. One failure was due to serious progression of the disease. Conclusions In our opinion, laparoscopic Heller’s myotomy is the procedure of choice for treating achalasia in children. Endoscopic balloon dilatation may be used as a complementary treatment, especially as a primary redo procedure.
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Moonen A, Boeckxstaens G. Finding the Right Treatment for Achalasia Treatment: Risks, Efficacy, Complications. ACTA ACUST UNITED AC 2016; 14:420-428. [DOI: 10.1007/s11938-016-0105-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Crespin OM, Liu LWC, Parmar A, Jackson TD, Hamid J, Shlomovitz E, Okrainec A. Safety and efficacy of POEM for treatment of achalasia: a systematic review of the literature. Surg Endosc 2016; 31:2187-2201. [PMID: 27633440 DOI: 10.1007/s00464-016-5217-y] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 08/23/2016] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Peroral endoscopic myotomy (POEM) is a novel intervention for the treatment of achalasia, which combines the advantages of endoscopic access and myotomy. The purpose of this study was to perform a systematic review of the literature to evaluate the efficacy and safety of POEM. METHODS The systematic review was conducted following the PRISMA guidelines. Evidence-Based Medicine Reviews, Cochrane Central Register of Controlled Trials, Ovid MEDLINE (R) including in-process and non-indexed citations were searched for POEM studies using the keywords: esophageal achalasia, POEM, endoscopy, natural orifice surgery, laparoscopic Heller myotomy (LHM), and related terms. Eckardt score, lower esophageal sphincter (LES) pressure, and reported complications were the main outcomes. Two authors reviewed the search result independently. A third reviewer resolved all disagreements. Data abstraction was pilot-tested and approved by all authors. Data were examined for clinical, methodological, and statistical heterogeneity with the aim of determining whether evidence synthesis using meta- analysis was possible. RESULTS The search strategy retrieved 2894 citations. After removing duplicates and applying the exclusion criteria, 54 studies were selected for full-text review of which a total of 19 studies were considered eligible for further analysis. There were 10 retrospective and 9 prospective studies, including 1299 POEM procedures. No randomized control trial (RCT) was identified. Overall, the pre- and post-POEM Eckardt scores and LES pressure were significantly different. The most frequently reported complications were mucosal perforation, subcutaneous emphysema, pneumoperitoneum, pneumothorax, pneumomediastinum, pleural effusion, and pneumonia. The median follow-up was 13 months (range 3-24). CONCLUSION POEM is a safe and effective alternative for the treatment of achalasia. However, only short-term follow-up data compared with LHM are available. RCTs and long-term follow-up studies are needed to establish the efficacy and safety of POEM in the management of patients with achalasia.
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Affiliation(s)
- Oscar M Crespin
- Division of General Surgery, University Health Network, Toronto, ON, Canada. .,Department of Surgery, University of Toronto, Toronto, ON, Canada.
| | - Louis W C Liu
- Division of Gastroenterology, University Health Network, Toronto, ON, Canada
| | - Ambica Parmar
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Timothy D Jackson
- Division of General Surgery, University Health Network, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jemila Hamid
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Eran Shlomovitz
- Division of General Surgery, University Health Network, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of Interventional Radiology, University Health Network, Toronto, ON, Canada
| | - Allan Okrainec
- Division of General Surgery, University Health Network, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
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Souma Y, Nakajima K, Taniguchi E, Takahashi T, Kurokawa Y, Yamasaki M, Miyazaki Y, Makino T, Hamada T, Yasuda J, Yumiba T, Ohashi S, Takiguchi S, Mori M, Doki Y. Mucosal perforation during laparoscopic surgery for achalasia: impact of preoperative pneumatic balloon dilation. Surg Endosc 2016; 31:1427-1435. [PMID: 27501729 DOI: 10.1007/s00464-016-5133-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 07/15/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Controversy remains whether preoperative pneumatic balloon dilation (PBD) influences the surgical outcome of laparoscopic esophagocardiomyotomy in patients with esophageal achalasia. The aim of this study was to evaluate whether preoperative PBD represents a risk factor for surgical complications and affects the symptomatic and/or functional outcomes of laparoscopic Heller myotomy with Dor fundoplication (LHD). METHODS A retrospective chart review was conducted on a prospectively compiled surgical database of 103 consecutive patients with esophageal achalasia who underwent LHD from November 1994 to September 2014. The following data were compared between the patients with preoperative PBD (PBD group; n = 26) and without PBD (non-PBD group; n = 77): (1) patients' demographics: age, gender, body mass index, duration of symptoms, maximum transverse diameter of esophagus; (2) operative findings: operating time, blood loss, intraoperative complications; (3) postoperative course: complications, clinical symptoms, postoperative treatment; and (4) esophageal functional tests: preoperative and postoperative manometric data and postoperative profile of 24-h esophageal pH monitoring. RESULTS (1) No significant differences were observed in the patients' demographics. (2) Operative findings were similar between the two groups; however, the incidence of mucosal perforation was significantly higher in the PBD group (n = 8; 30.7 %) compared to the non-PBD group (n = 6; 7.7 %) (p = 0.005). (3) Postoperative complications were not encountered in either group. The differences were not significant for postoperative clinical symptoms, the incidence of gastroesophageal reflux disease, or necessity of postoperative treatments. (4) Lower esophageal sphincter pressure was effectively reduced in both groups, and no differences were observed in manometric data or 24-h pH monitoring profiles between the two groups. Multivariate logistic regression analysis showed that preoperative PBD and the maximum transverse diameter of esophagus were significantly associated with intraoperative mucosal perforation. CONCLUSIONS Although postoperative outcomes were not affected, additional caution is recommended in identifying intraoperative mucosal perforation in patients with preoperative PBD when performing LHD.
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Affiliation(s)
- Yoshihito Souma
- Department of Surgery, Osaka Central Hospital, 3-3-30, Umeda, Kita-ku, Osaka, 530-0001, Japan
| | - Kiyokazu Nakajima
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan. .,Division of Next Generation Endoscopic Intervention, Global Center for Medical Engineering and Informatics, Osaka University, 2-2, E-2, Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | | | - Tsuyoshi Takahashi
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yukinori Kurokawa
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Makoto Yamasaki
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasuhiro Miyazaki
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tomoki Makino
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tetsuhiro Hamada
- Department of Surgery, Osaka Central Hospital, 3-3-30, Umeda, Kita-ku, Osaka, 530-0001, Japan
| | - Jun Yasuda
- Department of Surgery, Osaka Central Hospital, 3-3-30, Umeda, Kita-ku, Osaka, 530-0001, Japan
| | - Takeyoshi Yumiba
- Department of Surgery, Osaka Central Hospital, 3-3-30, Umeda, Kita-ku, Osaka, 530-0001, Japan
| | - Shuichi Ohashi
- Department of Surgery, Osaka Central Hospital, 3-3-30, Umeda, Kita-ku, Osaka, 530-0001, Japan
| | - Shuji Takiguchi
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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Abstract
Achalasia is a primary esophageal motility disorder with an estimated annual incidence of 1 per 100,000 persons. It is characterized by the absence of esophageal peristalsis and failure of the lower esophageal sphincter (LES) to relax upon swallowing, resulting in progressively severe dysphagia for solids and liquids, regurgitation, aspiration, chest pain and weight loss. Achalasia results from a loss of enteric neurons, most likely due to an autoimmune reaction in patients with a particular immunogenetic background. To date, 3 manometric subtypes have been identified based on high resolution manometry. To what extent these subtypes also indicate differences in underlying pathophysiological mechanisms is however unclear. As achalasia cannot be cured, treatment is confined to disruption of the LES to improve bolus passage and thereby relieving symptoms. The 2 most commonly used treatment modalities available for this purpose include pneumodilation and laparoscopic Heller myotomy. Both treatments have been shown repeatedly to be successful; however, success rates decline in time, most likely due to progression of the disease. A recent European randomized trial provides objective data indicating that both treatments are equally effective. In view of these data and the low incidence of the disease, the choice between these 2 treatments should be based on the expertise and experience available. Recently, excellent short-term success rates have been reported with a new endoscopic technique, that is, peroral endoscopic myotomy. However, longer follow-up data are absolutely needed before accepting this technique as a new treatment option for achalasia in clinical practice.
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Affiliation(s)
- Guy E Boeckxstaens
- Division of Gastroenterology and Hepatology, University Hospital Leuven, Translational Research Centre for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
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41
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Moonen A, Annese V, Belmans A, Bredenoord AJ, Bruley des Varannes S, Costantini M, Dousset B, Elizalde JI, Fumagalli U, Gaudric M, Merla A, Smout AJ, Tack J, Zaninotto G, Busch OR, Boeckxstaens GE. Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut 2016; 65:732-9. [PMID: 26614104 DOI: 10.1136/gutjnl-2015-310602] [Citation(s) in RCA: 229] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 11/01/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Achalasia is a chronic motility disorder of the oesophagus for which laparoscopic Heller myotomy (LHM) and endoscopic pneumodilation (PD) are the most commonly used treatments. However, prospective data comparing their long-term efficacy is lacking. DESIGN 201 newly diagnosed patients with achalasia were randomly assigned to PD (n=96) or LHM (n=105). Before randomisation, symptoms were assessed using the Eckardt score, functional test were performed and quality of life was assessed. The primary outcome was therapeutic success (presence of Eckardt score ≤3) at the yearly follow-up assessment. The secondary outcomes included the need for re-treatment, lower oesophageal sphincter pressure, oesophageal emptying and the rate of complications. RESULTS In the full analysis set, there was no significant difference in success rate between the two treatments with 84% and 82% success after 5 years for LHM and PD, respectively (p=0.92, log-rank test). Similar results were obtained in the per-protocol analysis (5-year success rates: 82% for LHM vs. 91% for PD, p=0.08, log-rank test). After 5 years, no differences in secondary outcome parameter were observed. Redilation was performed in 24 (25%) of PD patients. Five oesophageal perforations occurred during PD (5%) while 12 mucosal tears (11%) occurred during LHM. CONCLUSIONS After at least 5 years of follow-up, PD and LHM have a comparable success rate with no differences in oesophageal function and emptying. However, 25% of PD patients require redilation during follow-up. Based on these data, we conclude that either treatment can be proposed as initial treatment for achalasia. TRIAL REGISTRATION NUMBERS Netherlands trial register (NTR37) and Current Controlled Trials registry (ISRCTN56304564).
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Affiliation(s)
- An Moonen
- Department of Gastroenterology, Catholic University of Leuven, Leuven, Belgium
| | - Vito Annese
- Head of Gastroenterology, Department of Emergency, AOU Careggi, Florence, Italy
| | - Ann Belmans
- Interuniversity Centre for Biostatistics and Statistical Bioinformatics, KU, Leuven, Belgium
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Mario Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Bertrand Dousset
- Department of GI and Endocrine Surgery, Hôpital Cochin, Paris, France
| | - J I Elizalde
- Department of Gastroenterology, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Uberto Fumagalli
- Upper GI Surgery, Humanitas Clinical and Research Hospital, Rozzano, Italy
| | | | - Antonio Merla
- Division of Gastroenterology, IRCCS, "Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Andre J Smout
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jan Tack
- Department of Gastroenterology, Catholic University of Leuven, Leuven, Belgium
| | - Giovanni Zaninotto
- Department of Academic Surgery, St Mary's Hospital, Imperial College, London, UK
| | - Olivier R Busch
- Gastrointestinal Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Guy E Boeckxstaens
- Department of Gastroenterology, Catholic University of Leuven, Leuven, Belgium
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42
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Familiari P, Greco S, Volkanovska A, Gigante G, Cali A, Boškoski I, Costamagna G. Achalasia: current treatment options. Expert Rev Gastroenterol Hepatol 2016; 9:1101-14. [PMID: 26186641 DOI: 10.1586/17474124.2015.1052407] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Achalasia is a rare esophageal motility disorder, characterized by impaired swallow-induced, lower esophageal sphincter (LES) relaxation and defective esophageal peristalsis. Unfortunately, there are no etiological therapies for achalasia. Patients present with dysphagia, chest pain and regurgitation of undigested food, often leading to weight loss. The currently available treatments have the common aim of relieving symptoms by decreasing the pressure of the LES. This can be achieved with some medications, by inhibiting the cholinergic innervation (botulinum toxin), by stretching (endoscopic dilation) or cutting (surgery) the LES. Recently, other therapeutic options, including per-oral endoscopic myotomy have been developed and are gaining international consensus. The authors report on the benefits and weaknesses of the different therapies and provide an updated approach to the management of achalasia.
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Affiliation(s)
- Pietro Familiari
- Digestive Endoscopy Unit - Gemelli University Hospital Università Cattolica del Sacro Cuore, Rome, Italy
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43
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Ou YH, Nie XM, Li LF, Wei ZJ, Jiang B. High-resolution manometric subtypes as a predictive factor for the treatment of achalasia: A meta-analysis and systematic review. J Dig Dis 2016; 17:222-35. [PMID: 26860986 DOI: 10.1111/1751-2980.12327] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 01/28/2016] [Accepted: 02/05/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To assess manometric subtypes as predictive factors for the treatment efficacies of pneumatic balloon dilatation (PBD) and laparoscopic Heller myotomy (LHM) in patients with achalasia. METHODS A systematic search of the Pubmed, Embase and Cochrane Library database was conducted to identify relevant publications on high-resolution manometric subtypes and different therapies for achalasia with predefined inclusion and exclusion criteria. Data on the success rates after PBD or LHM for different manometric subtypes were extracted. The pooled odds ratio (OR) and 95% confidence interval (CI) for different manometric subtypes were estimated using STATA 13.0. RESULTS In all, nine studies met the inclusion criteria. A total of 298 patients having achalasia receiving PBD and 429 undergoing LHM were included in the meta-analysis. The pooled OR between the subtypes of achalasia after PBD or LHM showed that the best and worse treatment outcomes were found in patients with type II and III achalasia, respectively (type I vs type II after PBD: OR 0.16, 95% CI 0.08-0.36, P = 0.000; type I vs type III after PBD: OR 3.64, 95% CI 1.55-8.53, P = 0.003; type II vs type III after PBD: OR 27.18, 95% CI 9.08-81.35, P = 0.000; type I vs type II after LHM: OR 0.26, 95% CI 0.12-0.56, P = 0.001; type I vs type III after LHM: OR 1.89, 95% CI 0.80-4.50, P = 0.148; type II vs type III after LHM: OR 6.86, 95% CI 2.72-17.28, P = 0.000). CONCLUSION Type II achalasia shows the best prognosis after PBD and LHM, while type III achalasia has the worst prognosis.
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Affiliation(s)
- Ying Hua Ou
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University
| | - Xi Ming Nie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University
| | - Li Fu Li
- Department of Gastroenterology, Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong Province
| | - Zheng Jie Wei
- Department of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China
| | - Bo Jiang
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University
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Hong D, Pescarus R, Khan R, Ambrosini L, Anvari M, Cadeddu M. Early clinical experience with the POEM procedure for achalasia. Can J Surg 2016; 58:389-93. [PMID: 26574830 DOI: 10.1503/cjs.017214] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Per oral endoscopic myotomy (POEM) is a viable alternative to standard Heller myotomy for surgical treatment of achalasia. Outcomes from the United States, Europe and Asia have been reported. We sought to report data after the initiation of POEM in a Canadian centre. METHODS We enrolled patients with achalasia in a research ethics board-approved pilot study. Surgeons learned the POEM procedure in a systematic manner that included visiting experts in POEM, practice in an animal laboratory and mentoring from POEM experts. Preoperative evaluation included manometry, 24-hour pH, barium swallow, endoscopy and Eckhardt Symptom Score. All patients underwent gastrograffin swallow on postoperative day 1. Patients were re-evaluated using the Eckhardt score on postoperative day 14. RESULTS Ten patients underwent POEM. Seven patients had previous endoscopic treatments: 6 had balloon dilatation and 1 had botulinum toxin injection. Mean preoperative Eckhardt score was 8.1 ± 2.4. Mean preoperative lower esophageal sphincter resting and residual pressure was 32.3 ± 9.2 and 20.8 ± 5.3, respectively. Mean duration of surgery was 141.3 ± 43.7 minutes. Mean length of hospital stay was 1 day. No major perioperative complications occurred. On postoperative day 14, the mean Eckhardt score was 1 ± 1.2. CONCLUSION Our approach to POEM introduction was systematic and deliberate. The procedure is safe, feasible and has good perioperative outcomes. Our early results are consistent with current literature.
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Affiliation(s)
- Dennis Hong
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
| | - Radu Pescarus
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
| | - Rana Khan
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
| | - Luciano Ambrosini
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
| | - Mehran Anvari
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
| | - Margherita Cadeddu
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
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Zhang Y, Wang H, Chen X, Liu L, Wang H, Liu B, Guo J, Jia H. Per-Oral Endoscopic Myotomy Versus Laparoscopic Heller Myotomy for Achalasia: A Meta-Analysis of Nonrandomized Comparative Studies. Medicine (Baltimore) 2016; 95:e2736. [PMID: 26871816 PMCID: PMC4753912 DOI: 10.1097/md.0000000000002736] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
We aimed to assess the short-term outcomes of per-oral endoscopic myotomy (POEM) compared with laparoscopic Heller myotomy (LHM) for achalasia through a meta-analysis of nonrandomized comparative studies.We searched PubMed, Embase, Medline, Cochrane Library, and Google Scholar for studies that compared POEM and LHM for achalasia and were published between January 1, 2008 and December 31, 2014. The Methodological Index for Nonrandomized Studies (MINORS) was used to evaluate the quality of the studies. Random- and fixed-effects meta-analytical models were used, and between-study heterogeneity was assessed.Four nonrandomized comparative studies that included 317 patients (125 in the POEM group and 192 in the LHM group) met our research criteria and were assessed. There were no differences between the POEM and LHM groups in terms of sex, preoperative Eckhart score, length of myotomy, operation time, length of hospital stay, and complications. The patients in the POEM group were older than those in the LHM group (MD =2.81, 95% CI 0.27-5.35; P = 0.03) with high between-study homogeneity (χ = 1.96, df = 2, I = 0%; P = 0.38). The patients in the POEM group had a lower Eckardt score after surgery compared with those in the LHM group (MD = -0.30, 95% CI -0.42 to -0.18; P < 0.001) with high between-study homogeneity (χ = 0.00, df = 1, I = 0%; P = 1.00).The efficacy and safety of POEM appear to be comparable to those of LHM. Multicenter and randomized trials with larger sample size are needed to further compare the efficacy and safety of POEM and LHM for the treatment of achalasia.
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Affiliation(s)
- Yuan Zhang
- From the Center of Evidence-Based Medicine (YZ, HJ); Department of Gastroenterology, Second Hospital of Shandong University, Jinan, China (HW, LL, HW, BL, JG); and Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (XC)
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Naumann DN, Zaman S, Daskalakis M, Nijjar R, Richardson M, Super P, Singhal R. Day surgery for achalasia cardia: Time for consensus? Ann R Coll Surg Engl 2016; 98:150-4. [PMID: 26829668 PMCID: PMC5210494 DOI: 10.1308/rcsann.2016.0063] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2015] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Laparoscopic Heller's myotomy (LHM) is the most effective therapy for achalasia of the oesophagus. Most case series of LHM report a length of hospital stay (LOS) >1 day. We present 14 years of experience of LHM to examine the safety and feasibility of LHM as a day case procedure. METHODS We retrospectively examined patients undergoing elective LHM for achalasia at our institution between 2000 and 2014. Demographics, episode statistics, prior investigations and interventions were collated. Outcomes, including LOS, complications and re-interventions, were compared for the periods before and after a consensus decision at our institution in 2008 to perform LHM as a day case procedure. RESULTS Sixty patients with a mean age of 41 ± 13 years were included, of whom 58% were male. The median LOS for all patients was 1 day (interquartile range [IQR] 0-2.25). Overall, LHM was performed as a day case in 27 (45%) cases, at 2/26 (7.7%) in the first period versus 25/34 (73.5%) in the second (p<0.01). There were no significant differences in age, gender or previous interventions between day surgery and non-day surgery groups. One patient required subsequent unplanned surgery, while six (10%) needed endoscopic treatment of recurrent symptoms within 12 months. CONCLUSIONS LHM can be performed safely as a day case procedure. Complication rates are low, with only a small proportion of patients requiring endoscopic treatment for symptom recurrence within 1 year.
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Affiliation(s)
- D N Naumann
- Heart of England NHS Foundation Trust , Birmingham , UK
| | - S Zaman
- Heart of England NHS Foundation Trust , Birmingham , UK
| | - M Daskalakis
- Heart of England NHS Foundation Trust , Birmingham , UK
| | - R Nijjar
- Heart of England NHS Foundation Trust , Birmingham , UK
| | - M Richardson
- Heart of England NHS Foundation Trust , Birmingham , UK
| | - P Super
- Heart of England NHS Foundation Trust , Birmingham , UK
| | - R Singhal
- Heart of England NHS Foundation Trust , Birmingham , UK
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47
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Abstract
Esophageal epiphrenic diverticulum (EED) is a pseudodiverticulum of pulsion type located in the distal 10 cm of the esophagus and frequently associated to achalasia. The symptoms and the pathophysiology of achalasia and EED may overlap, leading to the speculation that achalasia may be responsible for the symptoms. Similarly to patients with achalasia without EED, a careful preoperative evaluation is essential in patients with EED. Endoscopy and an esophagram are mandatory in the workup of these patients, while esophageal manometry confirms the associated motility disorder. Treatment is indicated in all patients fit for an operation except those who are asymptomatic with a small EED and no prior history of aspiration. Laparoscopic Heller's myotomy and partial fundoplication is the most adequate therapy. Diverticulectomy must be added to the procedure in large diverticula. Experience with endoscopic therapy is very limited.
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Affiliation(s)
- Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003l, Brazil,
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48
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von Rahden BHA, Filser J, Seyfried F, Veldhoen S, Reimer S, Germer CT. [Diagnostics and therapy of achalasia]. Chirurg 2015; 85:1055-63. [PMID: 25421249 DOI: 10.1007/s00104-014-2803-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The low incidence (1:100,000) makes primary idiopathic achalasia a problem of special importance. Patients often have a long medical history of suffering before the diagnosis is established and adequate therapy provided. Surgeons who perform antireflux surgery must be certain of detecting achalasia patients within their collective of gastroesophageal reflux disease (GERD) patients to avoid contraindicated fundoplication. The current gold standard for establishing the diagnosis of achalasia is manometry. Especially in early stages, symptom evaluation, endoscopy and barium swallow lack adequate sensitivity. High-resolution manometry (HRM) is increasingly used and allows characterization of different achalasia types (i.e. type I classical achalasia, type II panesophageal pressurization and type III spasmodic achalasia) and differentiation from other motility disorders (e.g. distal esophageal spasm, jackhammer esophagus and nutcracker esophagus). For patients over 45 years of age additional endoscopic ultrasound and computed tomography are recommended to exclude pseudoachalasia. A curative treatment restoring normal esophageal function does not exist; however, there are good options for symptom control. Therapy aims are abolishment of dysphagia, improvement of esophageal clearance, prevention of reflux and abolishment of chest pain. The current standard treatment is cardiomyotomy, which was first described 100 years ago by the German surgeon Ernst Heller and has been shown to be clearly superior when compared to endoscopic treatment (e.g. botox injection and balloon dilatation). Heller's myotomy procedure is preferentially performed via the laparoscopic route and combined with partial fundoplication. Currently, an alternative to performing Heller's myotomy via the endoscopic route is under intensive investigation in several centers worldwide. The peroral endoscopic myotomy (POEM) procedure has shown very promising initial results and warrants further clinical evaluation.
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Affiliation(s)
- B H A von Rahden
- Klinik für Allgemein-, Visceral-, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin (ZOM), Universitätsklinikum Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Deutschland,
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Jones EL, Meara MP, Pittman MR, Hazey JW, Perry KA. Prior treatment does not influence the performance or early outcome of per-oral endoscopic myotomy for achalasia. Surg Endosc 2015; 30:1282-6. [PMID: 26123336 DOI: 10.1007/s00464-015-4339-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 06/13/2015] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Per-oral endoscopic myotomy (POEM) is an emerging treatment for achalasia. Pneumatic dilation, botulinum toxin injection, and previous myotomy increase the difficulty of subsequent Heller myotomy, but their impact on POEM remains unknown. The purpose of this study was to compare patients who had undergone prior treatment for their achalasia to those undergoing POEM as an initial therapy. METHODS AND PROCEDURES All patients undergoing POEM were entered into a prospective database from August 2012 to October 2014. Data collected included demographics, dysphagia and symptom survey scores, operative time, clips required for mucosotomy closure, perioperative complications and length of hospital stay. RESULTS Forty-five patients underwent POEM during the study period. Fifteen (30%) had undergone previous treatment (seven Botox injection, five pneumatic dilation and three Heller myotomy). Primary POEM patients were younger than those who had had prior treatment (mean age 46 ± 17 vs. 64 ± 12 years, p < 0.001), but gender, body mass index and ASA class were not significantly different. There were no conversions to Heller myotomy or perioperative complications in either group. Operative time for primary POEM was 103 ± 27 versus 102 ± 29 min following prior treatment (p = 0.84). Mucosotomy closure required a median 7 (4-16) and 8 (5-16) clips, respectively (p = 0.08). Length of stay was 1 day in each group. Median dysphagia scores decreased from 4 (0-5) to 1 (0-4) following primary POEM and 4 (0-5) to 0 (0-4) in the prior treatment group (p = 0.45) during a median follow-up of 10 months (5-17 months). All patients in each group expressed satisfaction with their procedure and would undergo the procedure again given the benefit of hindsight. CONCLUSION Per-oral endoscopic myotomy is a safe and effective treatment for achalasia which improves dysphagia and disease-specific quality of life. Previous endoscopic or laparoscopic treatment of achalasia does not affect the performance or early outcome of POEM.
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Affiliation(s)
- Edward L Jones
- Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA.
| | - Michael P Meara
- Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA
| | - Matthew R Pittman
- Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA
| | - Jeffrey W Hazey
- Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA
| | - Kyle A Perry
- Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA
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Jones EL, Meara MP, Schwartz JS, Hazey JW, Perry KA. Gastroesophageal reflux symptoms do not correlate with objective pH testing after peroral endoscopic myotomy. Surg Endosc 2015; 30:947-52. [PMID: 26123332 DOI: 10.1007/s00464-015-4321-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 06/09/2015] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Peroral endoscopic myotomy (POEM) is an emerging treatment for esophageal achalasia. Postoperative reflux has been found in a significant number of patients, but it is unknown whether subjective reports of reflux correlate with objective pH testing. The purpose of this study was to compare the objective rate of reflux with standardized reflux symptom scales after POEM. Our hypothesis was that subjective symptoms would not correlate with objective measurement of reflux. METHODS AND PROCEDURES Data on all patients undergoing POEM were collected prospectively between August 2012 and June 2014 and included demographics, objective testing (48-h pH probe, manometry, endoscopy), as well as gastroesophageal reflux disease health-related quality of life (GERD-HRQL), GERD symptom scale (GERSS), and antacid use. RESULTS Forty-three patients underwent POEM during the study period. The mean age was 53.5 ± 17.4 years with a BMI of 29.6 ± 8.4 kg/m(2), and 27 (63%) were male. Forty-two patients (98%) completed at least 6 months of follow-up, and 26 (60%) underwent repeat pH measurement. Dysphagia scores improved from 4 (0-5) at baseline to 0 (0-3) (p < 0.001). On follow-up pH testing, 11 (42%) were normal and 15 (58%) had elevated DeMeester scores. Postoperative GERSS or GERD-HRQL scores did not correlate with DeMeester scores on Spearman's rank-order tests (r = 0.02, p = 0.93 and r = 0.04, p = 0.50, respectively). Postoperative PPI use was not significantly associated with normal or abnormal pH testing: 5 of 7 (71%) patients who were taking PPIs postoperatively had abnormal DeMeester scores compared to 9 of 18 (50%) of patients who were not taking PPIs (p = 0.332). CONCLUSIONS Peroral endoscopic myotomy provides excellent dysphagia relief for patients with achalasia, but is associated with a high rate of reflux on pH testing postoperatively. Subjective symptoms are not a reliable indicator of postoperative reflux. Routine pH testing should be considered in all patients following POEM.
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Affiliation(s)
- Edward L Jones
- Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA.
| | - Michael P Meara
- Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA
| | - Jennifer S Schwartz
- Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA
| | - Jeffrey W Hazey
- Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA
| | - Kyle A Perry
- Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA
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