Complexities of managing achalasia at a tertiary referral center: use of pneumatic dilatation, Heller myotomy, and botulinum toxin injection

An overview of the efficacy, safety, and predictors of achalasia treatments

INTRODUCTION

Achalasia is a rare esophageal motility disorder characterized by abnormal esophageal peristalsis and the inability of the lower esophageal sphincter to relax, resulting in poor esophageal emptying. This can be relieved by endoscopic and surgical treatments; each comes with certain advantages and disadvantages.

AREAS COVERED

This review aims to guide the clinician in clinical decision making on the different treatment options for achalasia regarding the efficacy, safety, and important predictors.

EXPERT OPINION

Botulinum toxin injection is only recommended for a selective group of achalasia patients because of the short term effect. Pneumatic dilation improves achalasia symptoms, but this effect diminishes over time and requiring repeated dilations to maintain clinical effect. Heller myotomy combined with fundoplication and peroral endoscopic myotomy are highly effective on the long term but are more invasive than dilations. Gastro-esophageal reflux complaints are more often encountered after peroral endoscopic myotomy. Patient factors such as age, comorbidities, and type of achalasia must be taken into account when choosing a treatment. The preference of the patient is also of great importance and therefore shared decision making has to play a fundamental role in deciding about treatment.

A Case of Megaesophagus Secondary to a Massive Phytobezoar in a Patient With Achalasia

Bezoar is a rare entity that is composed of indigested foreign material and is most commonly seen in the stomach. Phytobezoars are the most common type of bezoars and are composed of indigestible cellulose and lignin from fruits and vegetables. We present a unique case of esophageal phytobezoar, which was seen in a patient with long-standing achalasia. The patient presented to the gastroenterology clinic complaining of decreased appetite as she had worsening dysphagia, weight loss, vomiting on eating food. An endoscopy revealed a large phytobezoar that was extending along the whole length of the esophagus. There was stenosis at the gastroesophageal (GE) junction. The phytobezoar was dissolved with carbonated soda lavage and the remainder of the phytobezoar was fragmented with water irrigation and rescue net via the endoscope and fragments were retrieved. Botulinum was injected at the GE junction in all four quadrants which resulted in a relaxation of the stenosis. Untreated long-standing esophageal phytobezoars can lead to life-threatening complications like perforation. Endoscopic modalities with carbonated soda lavage is an efficacious mode of treatment. Surgical interventions are recommended in case of endoscopic modality failure.

Achalasia: Diagnosis, Management and Surveillance

Achalasia is a rare chronic esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter and abnormal peristalsis. This abnormal motor function leads to impaired bolus emptying and symptoms of dysphagia, regurgitation, chest pain, or heartburn. After an upper endoscopy to exclude structural causes of symptoms, the gold standard for diagnosis is high-resolution esophageal manometry. However, complementary diagnostic tools include barium esophagram and functional luminal impedance planimetry. Definitive treatments include pneumatic dilation, Heller myotomy with fundoplication, and peroral endoscopic myotomy.

Clinical efficacy and safety of peroral endoscopic myotomy for esophageal achalasia: A multicenter study in Taiwan

BACKGROUND/OBJECTIVE

Peroral endoscopic myotomy (POEM), a novel minimally invasive treatment for esophageal achalasia, is becoming more popular globally because of its efficacy and safety. We aimed to clarify the technical concerns, efficacy, and safety of POEM for treating esophageal achalasia in Taiwan.

METHODS

We conducted a retrospective study on consecutive patients with achalasia who underwent POEM between October 2016 and May 2021 at three medical centers in Taiwan. All patients underwent a comprehensive work-up before POEM, including symptom questionnaires, esophagogastroduodenoscopy, timed barium esophagogram (TBE), and high-resolution impedance manometry (HRIM), and were re-evaluated three months after POEM. We compared procedure variables, adverse events, and clinical responses, including Eckardt score ≤3 and TBE and HRIM findings.

RESULTS

We analyzed 92 patients in total (54 men; mean age 49.5 years [range: 20-87]; type I/II/III/unclassified: 24/51/1/16). The mean POEM procedure duration was 89.5 ± 38.2 min, though it was significantly longer in patients with prior treatment or sigmoid-type achalasia. In total, 91 patients (98.9%) showed immediate technical success, and the overall clinical success rate at three months after POEM was 95.7%. Nearly 60% of patients experienced adverse events during POEM, but most of these were mild and none required further endoscopic or surgical intervention. During a follow-up period of up to five years (median 25 months), only four patients (4.3%) showed symptomatic recurrence, but none required further treatment.

CONCLUSION

POEM is a very effective and safe treatment for Taiwanese patients with achalasia, irrespective of their achalasia subtype or prior treatment failure.

Surgical Outcomes After Esophagectomy in Patients with Achalasia: a NSQIP Matched Analysis With Non-Achalasia Esophagectomy Patients

PURPOSE

The data on surgical outcomes of esophagectomy in patients with achalasia is limited. We sought to evaluate surgical outcomes in achalasia patients after an esophagectomy versus non-achalasia patients to elucidate if the outcomes are affected by the diagnosis.

METHODS

We conducted a retrospective review of the National Surgical Quality Improvement Program database (2010-2018). Patients who underwent an esophagectomy (open or laparoscopic approach) were included. Patients were divided into two groups, achalasia vs non-achalasia patients, and matched using propensity match analysis.

RESULTS

Of the 10,997 esophagectomy patients who met inclusion criteria, 213 (1.9%) patients had a diagnosis of achalasia. A total of 418 patients were included for the final analysis, with 209 patients in each group (achalasia vs non-achalasia). The overall median age was 57 years (IQR 47-65 years), and 48.6% were female. Most underwent an open (93.1%) vs laparoscopic (6.9%) esophagectomy. Overall complication rate was 40%. No difference was identified on overall complications, readmission, reoperation, or mortality between both groups. Postoperative sepsis was significantly higher in the achalasia group, and organ space SSI was higher in the non-achalasia group. Multivariable analysis showed that a diagnosis (achalasia or non-achalasia) was not predictive of reoperation or overall complications.

CONCLUSION

Esophagectomy outcomes are similar in patients with achalasia vs non-achalasia, and the diagnosis of achalasia does not independently increase the risk of reoperation and overall complications. Finally, regardless of diagnosis, the potential for morbidity following esophagectomy, should to be discussed with patients in the preoperative setting.

Surgical Treatment of Esophageal Achalasia in the Era of Minimally Invasive Surgery

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.

Achalasia: what to do in the face of failures of Heller myotomy

Achalasia is a primary motility disorder of the esophagus, and while there are several treatment options, there is no consensus regarding them. When therapeutic intervention for achalasia fails, a careful evaluation of the cause of the persistent or recurrent symptoms using upper endoscopy, esophageal manometry, and contrast radiologic studies is required to understand the cause of therapy failure and guide plans for subsequent treatment. Options for reintervention are the same as for primary intervention and include pneumatic dilation, botulinum toxin injection, peroral endoscopic myotomy, or redo esophageal myotomy. When reintervention fails or if the esophagus is not amenable to intervention and the disease is considered end-stage, esophagectomy is the last option to manage recurrent achalasia.

2019 Seoul Consensus on Esophageal Achalasia Guidelines

Esophageal achalasia is a primary motility disorder characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. Achalasia is a chronic disease that causes progressive irreversible loss of esophageal motor function. The recent development of high-resolution manometry has facilitated the diagnosis of achalasia, and determining the achalasia subtypes based on high-resolution manometry can be important when deciding on treatment methods. Peroral endoscopic myotomy is less invasive than surgery with comparable efficacy. The present guidelines (the "2019 Seoul Consensus on Esophageal Achalasia Guidelines") were developed based on evidence-based medicine; the Asian Neurogastroenterology and Motility Association and Korean Society of Neurogastroenterology and Motility served as the operating and development committees, respectively. The development of the guidelines began in June 2018, and a draft consensus based on the Delphi process was achieved in April 2019. The guidelines consist of 18 recommendations: 2 pertaining to the definition and epidemiology of achalasia, 6 pertaining to diagnoses, and 10 pertaining to treatments. The endoscopic treatment section is based on the latest evidence from meta-analyses. Clinicians (including gastroenterologists, upper gastrointestinal tract surgeons, general physicians, nurses, and other hospital workers) and patients could use these guidelines to make an informed decision on the management of achalasia.

Gastrointestinal Uses of Botulinum Toxin

Botulinum toxin (BT), one of the most powerful inhibitors that prevents the release of acetylcholine from nerve endings, represents an alternative therapeutic approach for "spastic" disorders of the gastrointestinal tract such as achalasia, gastroparesis, sphincter of Oddi dysfunction, chronic anal fissures, and pelvic floor dyssynergia.BT has proven to be safe and this allows it to be a valid alternative in patients at high risk of invasive procedures but long-term efficacy in many disorders has not been observed, primarily due to its relatively short duration of action. Administration of BT has a low rate of adverse reactions and complications. However, not all patients respond to BT therapy, and large randomized controlled trials are lacking for many conditions commonly treated with BT.The local injection of BT in some conditions becomes a useful tool to decide to switch to more invasive therapies. Since 1980, the toxin has rapidly transformed from lethal poison to a safe therapeutic agent, with a significant impact on the quality of life.

ASGE guideline on the management of achalasia

Achalasia is a primary esophageal motor disorder of unknown etiology characterized by degeneration of the myenteric plexus, which results in impaired relaxation of the esophagogastric junction (EGJ), along with the loss of organized peristalsis in the esophageal body. The criterion standard for diagnosing achalasia is high-resolution esophageal manometry showing incomplete relaxation of the EGJ coupled with the absence of organized peristalsis. Three achalasia subtypes have been defined based on high-resolution manometry findings in the esophageal body. Treatment of patients with achalasia has evolved in recent years with the introduction of peroral endoscopic myotomy. Other treatment options include botulinum toxin injection, pneumatic dilation, and Heller myotomy. This American Society for Gastrointestinal Endoscopy Standards of Practice Guideline provides evidence-based recommendations for the treatment of achalasia, based on an updated assessment of the individual and comparative effectiveness, adverse effects, and cost of the 4 aforementioned achalasia therapies.

The 2018 ISDE achalasia guidelines

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.

Management of achalasia cardia: Expert consensus statements

Achalasia cardia (AC) is a frequently encountered motility disorder of the esophagus resulting from an irreversible degeneration of neurons. Treatment modalities are palliative in nature, and there is no curative treatment available for AC as of now. Significant advancements have been made in the management of AC over last decade. The introduction of high resolution manometry and per-oral endoscopic myotomy (POEM) has strengthened the diagnostic and therapeutic armamentarium of AC. High resolution manometry allows for the characterization of the type of achalasia, which in turn has important therapeutic implications. The endoscopic management of AC has been reinforced with the introduction of POEM that has been found to be highly effective and safe in palliating the symptoms in short-term to mid-term follow-up studies. POEM is less invasive than Heller's myotomy and provides the endoscopist with the opportunity of adjusting the length and orientation of esophageal myotomy according to the type of AC. The management of achalasia needs to be tailored for each patient, and the role of pneumatic balloon dilatation, POEM, or Heller's myotomy needs to be revisited. In this review, we discuss the important aspects of diagnosis as well as management of AC. The statements presented in the manuscript reflect the cumulative efforts of an expert consensus group.

Esophageal Resection for End-Stage Achalasia

Achalasia is a rare disease characterized by impaired lower esophageal sphincter relaxation loss and of peristalsis in the esophageal body. Endoscopic balloon dilation and laparoscopic surgical myotomy have been established as initial treatment modalities. Indications and outcomes of esophagectomy in the management of end-stage achalasia are less defined. A literature search was conducted to identify all reports on esophagectomy for end-stage achalasia between 1987 and 2017. MEDLINE, Embase, and Cochrane databases were consulted matching the terms “achalasia,” “end-stage achalasia,” “esophagectomy,” and “esophageal resection.” Seventeen articles met the inclusion criteria and 1422 patients were included in this narrative review. Most of the patients had previous multiple endoscopic and/or surgical treatments. Esophagectomy was performed through a transthoracic (74%) or a transhiatal (26%) approach. A thoracoscopic approach was used in a minority of patients and seemed to be safe and effective. In 95 per cent of patients, the stomach was used as an esophageal substitute. The mean postoperative morbidity rate was 27.1 per cent and the mortality rate 2.1 per cent. Symptom resolution was reported in 75 to 100 per cent of patients over a mean follow-up of 43 months. Only five series including 195 patients assessed the long-term follow-up (>5 years) after reconstruction with gastric or colon conduits, and the results seem similar. Esophagectomy for end-stage achalasia is safe and effective in tertiary referral centers. A thoracoscopic approach is a feasible and safe alternative to thoracotomy and may replace the transhiatal route in the future.

Heller's myotomy and pneumatic dilatation in the treatment of achalasia: a population-based case-control study assessing long-term quality of life

Long-term health-related quality-of-life (HRQL) outcomes have not been widely reported in the treatment of achalasia. The aims of this study were to examine long-term disease-specific and general HRQL in achalasia patients using a population-based case-control method, and to assess HRQL between treatment interventions. Manometrically diagnosed achalasia cases (n = 120) were identified and matched with controls (n = 115) using a population-based approach. Participants completed general (SF-12) and disease-specific (Achalasia Severity Questionnaire [ASQ]) HRQL questionnaires, as appropriate, in a structured interview. Mean composite scores for SF-12 (Mental Component Summary score [MCS-12] and Physical Component Summary score [PCS-12]) and ASQ were compared between cases and controls, or between intervention groups, using an independent t-test. Adjusted mean differences in HRQL scores were evaluated using a linear regression model. Achalasia cases were treated with a Heller's myotomy (n = 43), pneumatic dilatation (n = 44), or both modalities (n = 33). The median time from last treatment to HRQL assessment was 5.7 years (interquartile range 2.4-11.5). Comparing achalasia patients with controls, PCS-12 was significantly worse (40.9 vs. 44.2, P = 0.01), but MCS-12 was similar. However, both PCS-12 (39.9 vs. 44.2, P = 0.03) and MCS-12 (46.7 vs. 53.5, P = 0.004) were significantly impaired in those requiring dual treatment compared with controls. Overall however, there was no difference in adjusted HRQL between patients treated with Heller's myotomy, pneumatic dilatation or both treatment modalities. In summary, despite treatment achalasia patients have significantly worse long-term physical HRQL compared with population controls. No HRQL differences were observed between the treatment modalities to suggest a benefit of one treatment over another.

Achalasia: Outcome in children

BACKGROUND

Oesophageal achalasia is well-recognized but relatively rare in children, occasionally appearing as the "triple A" syndrome (with adrenal insufficiency and alacrima). Treatment modalities, as in adult practice, are not curative, often needing further interventions and spurring the search for better management. The outcome for syndromic variants is unknown. We sought to define the efficacy of treatments for children with achalasia with and without triple A syndrome.

METHODS

We conducted a retrospective analysis of presentation and outcomes for 42 children with achalasia presenting over three decades to a major pediatric referral center. Long term impact of the diagnosis was assessed by questionnaire.

RESULTS

We identified 42 children including six with triple A syndrome. The median overall age at diagnosis was 10.8 years and median follow-up 1593 days. Initial Heller myotomy in 17 required further interventions in 11 (65%), while initial treatment with botulinum toxin (n = 20) was ultimately followed by myotomy in 17 (85%). Ten out of 35 patients who underwent myotomy required a repeat myotomy (29%). Patients with triple A syndrome developed symptoms earlier, but had delayed diagnosis, were more underweight at diagnosis and at last follow up. Questionnaire results suggested a significant long term deleterious impact on the quality of life of children and their families.

CONCLUSION

Many children with achalasia relapse after initial treatment, undergoing multiple, different procedures, despite which symptoms persist and impact on quality of life. Symptoms develop earlier in patients with triple A syndrome, but the diagnosis is delayed and this has substantial nutritional impact.

Intraprocedural fluoroscopy to determine the extent of the cardiomyotomy during per-oral endoscopic myotomy (with video)

BACKGROUND

An adequate myotomy on the gastric side is considered essential to optimize outcomes in patients undergoing per-oral endoscopic myotomy (POEM). An objective method to measure the length of gastric myotomy has not yet been reported.

OBJECTIVE

To evaluate a new method of precisely determining the length of the submucosal tunnel below the esophagogastric junction (EGJ) using intraprocedural fluoroscopy.

DESIGN

Single-center cohort study.

SETTING

Academic tertiary care center.

PATIENTS

Twenty-four consecutive patients who underwent POEM for management of achalasia.

INTERVENTIONS

A radiopaque marker (endoscopic clip placed at the EGJ or fluoroscopically guided placement of a 19-gauge needle on the skin) was used to mark the EGJ. The endoscope was inserted to the most distal aspect of the submucosal tunnel and, using fluoroscopy, the distance between the radiopaque marker and the tip of the endoscope was measured.

MAIN OUTCOME MEASUREMENTS

Technical success, procedural impact, duration of technique, and adverse events.

RESULTS

Technical success was achieved in 100% of patients. The submucosal tunnel was extended in 5 patients (20.8%) with a mean extension of 1.4±.5 cm. The mean increase in procedure time was 4 minutes with the endoscopic clip and 2 minutes with the 19-gauge needle. There were no adverse events associated with this technique.

LIMITATIONS

Need for fluoroscopy. Absence of available criterion standard.

CONCLUSIONS

Intraprocedural fluoroscopy was an efficient and safe method of objectively documenting the extent of gastric myotomy during POEM. This may benefit those investigating the anatomic and physiologic changes that occur during the myotomy and those early in their experience performing POEM.

Assessment of Pneumatic Balloon Dilation in Patients with Symptomatic Relapse after Failed Heller Myotomy: A Single Center Experience

BACKGROUND

Although Heller myotomy is one of the most effective treatments for achalasia, it may be associated with early or late symptom relapse in some patients. Therefore, additional treatment is required to achieve better control of symptoms.

Aim: To evaluate the safety and efficacy of pneumatic balloon dilation (PBD) in patients with symptom relapse after Heller myotomy.

METHODS

Thirty six post-myotomy patients were evaluated from 1993 to 2013. Six patients were excluded from the analysis because of comorbid diseases or epiphrenic diverticula. Thirty patients were treated with PBD. Primary outcome was defined as a decrease in symptom score to 4 or less and a reduction greater than 80% from the baseline in the volume of barium in timed barium esophagogram in 6 weeks. Achalasia symptom score (ASS) was assessed at 1.5, 3, 6, and 12 months after treatment and then every six months in all patients and PBD was repeated in case of symptom relapse (ASS>4).

RESULTS

The mean age of the patients was 45.5±13.9 years (range: 21-73). Primary outcome was observed in 25 patients (83%). The mean ASS of the patients dropped from 7.8 before treatment to 1.3±2.0 at 1.5 months after treatment (p=0.0001). The mean volume and height of barium decreased from 43.1±33.4 and 7.1±4.7 to 6.0±17.1 and 1.1±2.2, respectively (p=0.003, p=0.003). The mean duration of follow-up was 11.8±6.3 years. At the end of the study, 21 patients (70%) reported sustained good response. No major complications such as perforation or gross bleeding were seen.

CONCLUSION

PBD is an effective and safe treatment option for achalasia in patients with symptom relapse after Heller myotomy.

Hospitalization for esophageal achalasia in the United States

AIM: To assess the outcome of different treatments in patients admitted for esophageal achalasia in the United States.

METHODS: This is a retrospective analysis using the Nationwide Inpatient Sample over an 8-year period (2003-2010). Patients admitted with a primary diagnosis of achalasia were divided into 3 groups based on their treatment: (1) Group 1: patients who underwent Heller myotomy during their hospital stay; (2) Group 2: patients who underwent esophagectomy; and (3) Group 3: patients not undergoing surgical treatment. Primary outcome was in-hospital mortality. Secondary outcomes included length of stay (LOS), discharge destination and total hospital charges.

RESULTS: Among 27141 patients admitted with achalasia, nearly half (48.5%) underwent Heller myotomy, 2.5% underwent esophagectomy and 49.0% had endoscopic or other treatment. Patients in group 1 were younger, healthier, and had the lowest mortality when compared with the other two groups. Group 2 had the highest LOS and hospital charges among all groups. Group 3 had the highest mortality (1.2%, P < 0.001) and the lowest home discharge rate (78.8%) when compared to the other groups. The most frequently performed procedures among group 3 were esophageal dilatation (25.9%) and injection (13.3%). Among patients who died in this group the most common associated morbidities included acute respiratory failure, sepsis and aspiration pneumonia.

CONCLUSION: Surgery for achalasia carries exceedingly low mortality in the modern era; however, in complicated patients, even less invasive treatments are burdened by significant mortality and morbidity.

Treatment of gastrointestinal sphincters spasms with botulinum toxin A

Botulinum toxin A inhibits neuromuscular transmission. It has become a drug with many indications. The range of clinical applications has grown to encompass several neurological and non-neurological conditions. One of the most recent achievements in the field is the observation that botulinum toxin A provides benefit in diseases of the gastrointestinal tract. Although toxin blocks cholinergic nerve endings in the autonomic nervous system, it has also been shown that it does not block non-adrenergic non-cholinergic responses mediated by nitric oxide. This has promoted further interest in using botulinum toxin A as a treatment for overactive smooth muscles and sphincters. The introduction of this therapy has made the treatment of several clinical conditions easier, in the outpatient setting, at a lower cost and without permanent complications. This review presents current data on the use of botulinum toxin A in the treatment of pathological conditions of the gastrointestinal tract.

Per-Oral Endoscopic Myotomy: A Series of 500 Patients

BACKGROUND

After the first case of per-oral endoscopic myotomy (POEM) at our institution in 2008, the procedure was quickly accepted as an alternative to surgical myotomy and is now established as an excellent treatment option for achalasia. This study aimed to examine the safety and outcomes of POEM at our institution.

STUDY DESIGN

Per-oral endoscopic myotomy was performed on 500 consecutive achalasia patients at our institution between September 2008 and November 2013. A review of prospectively collected data was conducted, including procedure time, myotomy location and length, adverse events, and patient data with short- (2 months) and long-term (1 and 3 years) follow-up.

RESULTS

Per-oral endoscopic myotomy was successfully completed in all patients, with adverse events observed in 3.2%. Two months post-POEM, significant reductions in symptom scores (Eckardt score 6.0 ± 3.0 vs 1.0 ± 2.0, p < 0.0001) and lower esophageal sphincter (LES) pressures (25.4 ± 17.1 vs 13.4 ± 5.9 mmHg, p < 0.0001) were achieved, and this persisted at 3 years post-POEM. Gastroesophageal reflux was seen in 16.8% of patients at 2 months and 21.3% at 3-year follow-up.

CONCLUSIONS

Per-oral endoscopic myotomy was successfully completed in all cases, even when extended indications (extremes of age, previous interventions, or sigmoid esophagus) were used. Adverse events were rare (3.2%), and there were no mortalities. Significant improvements in Eckardt scores and LES pressures were seen at 2 months, 1 year, and 3 years post-POEM. Based on our large series, POEM is a safe and effective treatment for achalasia; there are relatively few contraindications, and the procedure may be used as either first- or second-line therapy.

Multiple good options are available for achalasia management

BACKGROUND

The aim of achalasia management is relieving functional obstruction at the esophagogastric junction. Pneumatic dilation (PD), Heller myotomy (HM), and Botox (BT) are available for this purpose. Many studies have compared efficacy of one treatment regimen to another however, many patients with achalasia undergo combinations of different procedures.

AIM

: The aim of this study was to follow-up achalasia patients treated at a tertiary referral center over a 10-year period and to compare patient satisfaction and symptoms in patients who were treated with either a single treatment (ST) versus multiple treatments (MT).

METHODS

A cohort of achalasia patients treated at the Medical University of South Carolina between 2002 and 2012 were identified, contacted by telephone, and completed a questionnaire about their treatments and symptoms. Symptomatic response was classified using the Eckardt score, and overall patient satisfaction was determined on a scale from 1 to 10. Data were analyzed using a paired Student t test.

RESULTS

Data were collected from 57 patients and 3 patients were excluded from the study because they had no prior interventions for achalasia. Demographic analysis of the patients revealed a mean age of 62.7 years (range, 24 to 89 y) with 45% males and 55% females. The average elapsed time since the last definitive treatment was 2.82 years. Twenty-eight patients had an ST performed and 26 patients underwent MT. The average number of different interventions in the MT group was 3 procedures/patient. There were no significant differences in overall patient satisfaction (ST, 7.5 vs. MT, 8; P=0.66) and the Eckardt scores between the 2 groups (ST, 3.39 vs. MT, 3.3; P=0.77).

CONCLUSIONS

MT options are available for management of achalasia. Improvement of clinical symptoms and overall patient satisfaction does not differ if the patient underwent an ST modality or a combination of different treatments.

Endoscopic pneumatic dilation versus botulinum toxin injection in the management of primary achalasia

BACKGROUND

Achalasia is an oesophageal motility disorder, of unknown cause, which results in increased lower oesophageal sphincter (LOS) tone and symptoms of difficulty swallowing. Treatments are aimed at reducing the LOS tone. Current endoscopic therapeutic options include pneumatic dilation (PD) or botulinum toxin (BTX) injection.

OBJECTIVES

To undertake a systematic review comparing the efficacy and safety of two endoscopic treatments, PD and intrasphincteric BTX injection, in the treatment of oesophageal achalasia.

SEARCH METHODS

Trials were initially identified by searching MEDLINE (1966 to August 2008), EMBASE (1980 to September 2008), ISI Web of Science (1955 to September 2008), The Cochrane Library Issue 3, 2008.  Searches in all databases were conducted in October 2005 and updated in September 2008 and April 2014. The Cochrane highly sensitive search strategy for identifying randomised trials in MEDLINE, sensitivity maximising version in the Ovid format, was combined with specific search terms to identify randomised controlled trials in MEDLINE. The MEDLINE search strategy was adapted for use in the other databases that were searched.

SELECTION CRITERIA

Randomised controlled trials comparing PD to BTX injection in individuals with primary achalasia.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study quality assessment and data extraction.

MAIN RESULTS

Seven studies involving 178 participants were included. Two studies were excluded from the meta-analysis of remission rates on the basis of clinical heterogeneity of the initial endoscopic protocols. There was no significant difference between PD or BTX treatment in remission within four weeks of the initial intervention; with a risk ratio of remission of 1.11 (95% CI 0.97 to 1.27). There was also no significant difference in the mean oesophageal pressures between the treatment groups; with a weighted mean difference for PD of -0.77 (95% CI -2.44 to 0.91, P = 0.37). Data on remission rates following the initial endoscopic treatment were available for three studies at six months and four studies at 12 months. At six months 46 of 57 PD participants were in remission compared to 29 of 56 in the BTX group, giving a risk ratio of 1.57 (95% CI 1.19 to 2.08, P = 0.0015); whilst at 12 months 55 of 75 PD participants were in remission compared to 27 of 72 BTX participants, with a risk ratio of 1.88 (95% CI 1.35 to 2.61, P = 0.0002). No serious adverse outcomes occurred in participants receiving BTX, whilst PD was complicated by perforation in three cases.

AUTHORS' CONCLUSIONS

The results of this meta-analysis suggest that PD is the more effective endoscopic treatment in the long term (greater than six months) for patients with achalasia.

Long-term results of pneumatic dilatation for relapsing symptoms of achalasia after Heller myotomy

BACKGROUND

The aim of this study was to assess the efficacy and safety of pneumatic dilatation (PD) to treat symptom recurrence after Heller myotomy (HM).

METHODS

Consecutive patients receiving PD for relapsing symptoms following prior HM were included in this retrospective single-center study. Eckardt score ≤3 and/or ∆ Eckardt (difference between Eckardt score before and after dilatation) ≥3 defined the success of initial dilatation. Patients who maintained response longer than 2 months after initial dilatation were defined as short-term responders. Relapsers were offered further on-demand dilatation. Remission was defined as an Eckardt score ≤3 at the study endpoint. Kaplan-Meier survival curves were used to determine relapse rates.

KEY RESULTS

Eighteen patients (11 women, seven men) were included from January 2004 to January 2013. Ten patients had type I achalasia, and seven had type III, according to the Chicago classification. Thirty-nine PDs were performed (1.5 [1-2.25] per patient). All patients had short-term responses. The remission rate at the endpoint, after a median follow-up of 33 months, was 78%, but 44% were treated with on-demand PD during the follow-up interval. The proportions of patients without relapse and subsequent PD were 72% at 12 months, 65% at 24 and 36 months, and 49% at 48 months. No factors predictive of long-term response, particularly the type of achalasia, could be identified in this series. There were no perforations.

CONCLUSIONS & INFERENCES

In treating symptom recurrence following HM, PD was safe and effective over the long term when combined with subsequent PD.

Esophageal motility disorder achalasia

PURPOSE OF REVIEW

Although not a common disease, the last several years have had exciting breakthroughs in better defining the pathophysiology of achalasia, classifying the disease with high-resolution manometry and potentially exciting new treatments.

RECENT FINDINGS

The introduction of high-resolution manometry with detailed assessment of lower esophageal sphincter function and peristalsis has made it possible to classify achalasia into three subtypes. This becomes clinically important as patients with type II achalasia do best with both pneumatic dilation and surgical myotomy, whereas type III achalasia may respond better to surgery. The first multicenter randomized controlled trial published by the European Achalasia Trial group reported similar excellent outcomes over a 2-year follow-up with both pneumatic dilation and laparoscopic myotomy in a study involving nearly 200 achalasia patients. Although longer follow-up is required, this supports the continued use of pneumatic dilation for treating achalasia. Finally, the novel endoscopic technique of peroral endoscopic myotomy is a promising new treatment option for achalasia, but it requires increased experiences and careful evaluation before widespread application.

SUMMARY

These are exciting times in the diagnosis and treatment of achalasia, which will definitely improve patient treatment outcomes. However, we still await breakthroughs in the basic science arena to identify the actual cause of achalasia.

Outcomes of esophagectomy for esophageal achalasia in the United States

BACKGROUND

While the outcomes after Heller myotomy have been extensively reported, little is known about patients with esophageal achalasia who are treated with esophagectomy.

METHODS

This was a retrospective analysis using the Nationwide Inpatient Sample over an 11-year period (2000-2010). Patients admitted with a primary diagnosis of achalasia who underwent esophagectomy (group 1) were compared to patients with esophageal cancer who underwent esophagectomy (group 2) during the same time period. Primary outcome was in-hospital mortality. Secondary outcomes included length of stay, postoperative complications, and total hospital charges. A propensity-matched analysis was conducted comparing the same outcomes between group 1 and well-matched controls in group 2.

RESULTS

Nine hundred sixty-three patients with achalasia and 18,003 patients with esophageal cancer underwent esophagectomy. The propensity matched analysis showed a trend toward a higher mortality in group 2 (7.8 vs. 2.9 %, p = 0.08). Postoperative length of stay and complications were similar in both groups. Total hospital charges were higher for the achalasia group ($115,087 vs. $99, 654.2, p = 0.006).

CONCLUSION

This is the largest study to date examining outcomes after esophagectomy in patients with achalasia. Based on our findings, esophagectomy can be considered a safe option, and surgeons should not be hindered by a perceived notion of prohibitive operative risk in this patient population.

Achalasia

Achalasia is a rare motility disorder of the oesophagus characterised by loss of enteric neurons leading to absence of peristalsis and impaired relaxation of the lower oesophageal sphincter. Although its cause remains largely unknown, ganglionitis resulting from an aberrant immune response triggered by a viral infection has been proposed to underlie the loss of oesophageal neurons, particularly in genetically susceptible individuals. The subsequent stasis of ingested food not only leads to symptoms of dysphagia, regurgitation, chest pain, and weight loss, but also results in an increased risk of oesophageal carcinoma. At present, pneumatic dilatation and Heller myotomy combined with an anti-reflux procedure are the treatments of choice and have comparable success rates. Per-oral endoscopic myotomy has recently been introduced as a new minimally invasive treatment for achalasia, but there have not yet been any randomised clinical trials comparing this option with pneumatic dilatation and Heller myotomy.

ACG clinical guideline: diagnosis and management of achalasia

Achalasia is a primary motor disorder of the esophagus characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. This results in patients' complaints of dysphagia to solids and liquids, regurgitation, and occasional chest pain with or without weight loss. Endoscopic finding of retained saliva with puckered gastroesophageal junction or barium swallow showing dilated esophagus with birds beaking in a symptomatic patient should prompt appropriate diagnostic and therapeutic strategies. In this ACG guideline the authors present an evidence-based approach in patients with achalasia based on a comprehensive review of the pertinent evidence and examination of relevant published data.

Efficacy and safety of pneumatic dilatation for achalasia in the treatment of post-myotomy symptom relapse

OBJECTIVES

There is no consensus on how best to treat symptom recurrence following previous therapy with Heller myotomy. Our aim was to determine the safety and the short and long-term efficacy of pneumatic dilatation to treat symptomatic recurrence in patients previously treated with Heller myotomy for idiopathic achalasia.

METHODS

We identified 27 eligible patients treated with pneumatic dilatation, for symptom recurrence following Heller myotomy as their initial or secondary treatment, from a prospectively acquired database of 450 patients with a diagnosis of achalasia seen between 1995 and 2010. Our treatment protocol involved sequential, graded pneumatic dilatations (30-35-40 mm) over a 2-6 week period until an initial therapeutic response was achieved. The subsequent relapse rate, defined as the need for any subsequent therapy, was determined. Relapsers were offered further pneumatic dilatation "on demand". A cross-sectional analysis was also performed using a validated achalasia severity questionnaire to determine the overall long-term remission rate.

RESULTS

Of 27 eligible patients, 25 (93%) complied with the institutional dilatation protocol. The two drop-outs did so after the initial 30 mm dilatation and were deemed treatment failures. One additional patient did not respond despite protocol compliance. Therefore, 24 of 27 (89%) patients were responders on intention to treat analysis at 12 months, while the per protocol response rate was 24 of 25 (96%). Among the 24 responders 16, 25, and 42% relapsed at 2, 3 and 4  years, respectively. Overall long-term remission, with on demand dilatations as required, was 95% (median follow-up 30 months). There were no perforations in a total of 50 dilatations in 27 patients.

CONCLUSIONS

In treating symptom recurrence, following prior Heller myotomy, pneumatic dilatation is safe and yields an excellent short-term response rate. Although the long-term relapse rate is substantial, subsequent on demand pneumatic dilatation in this population is highly effective with a long-term remission rate of 95%. These data also highlight the need to keep these patients under long-term review.

Long-term outcome following pneumatic dilatation as initial therapy for idiopathic achalasia: an 18-year single-centre experience

BACKGROUND

Relapse after treatment for idiopathic achalasia is common and long-term outcome data are limited.

AIM

To determine the cumulative relapse rate and long-term outcome after pneumatic dilatation (PD) for achalasia in a tertiary referral centre.

METHODS

A retrospective study of 301 patients with achalasia treated with PD as first-line therapy. Short-term outcome was measured at 12 months. Long-term outcome was assessed in those who were in remission at 12 months by cumulative relapse rate and cross-sectional analysis of long-term remission rate regardless of any interval therapy, using a validated achalasia-specific questionnaire.

RESULTS

Eighty-two percent of patients were in remission 12 months following initial PD. Relapse rates thereafter were 18% by 2 years; 41% by 5 years and 60% by 10 years. Whilst 43% patients underwent additional treatments [PD (29%), myotomy (11%) or botulinum toxin (3%)] beyond 12 months, 32% of those who had not received interval therapy had relapsed at cross-sectional analysis. After a mean follow-up of 9.3 years, regardless of nature, timing or frequency of any interval therapy, 71% (79/111) patients were in remission. The perforation rate from PD was 2%. Chest pain had a poor predictive value (24%) for perforation.

CONCLUSIONS

Long-term relapse is common following pneumatic dilatation. While on-demand pneumatic dilatation for relapse yields a good response, one-third of relapsers neither seek medical attention nor receive interval therapy. Close follow-up with timely repeat dilatation is necessary for a good long-term outcome. Given the poor predictive value of chest pain for perforation, routine gastrografin swallow is recommended postdilatation.

Management of achalasia

Achalasia is a rare motility disorder of the esophagus characterized by the absence of peristalsis and defective relaxation of the lower esophageal sphincter. Patients present at all ages with dysphagia and regurgitation as main symptoms. The diagnosis is suggested by barium swallow and endoscopy and confirmed by manometry. Because there is no curative treatment for achalasia, treatment is confined to disruption of the lower esophageal sphincter to improve bolus passage. The most successful therapies are pneumodilation and laparoscopic Heller myotomy, with comparable short-term clinical rates of success. The prognosis of achalasia patients is good, but re-treatment is often necessary.

Endoscopic approaches to treatment of achalasia

Endoscopic therapy for achalasia is directed at disrupting or weakening the lower esophageal sphincter (LES). The two most commonly utilized endoscopic interventions are large balloon pneumatic dilation (PD) and botulinum toxin injection (BTI). These interventions have been extensively scrutinized and compared with each other as well as with surgical disruption (myotomy) of the LES. PD is generally more effective in improving dysphagia in achalasia than BTI, with the latter reserved for infirm older people, and PD may approach treatment results attained with myotomy. However, PD may need to be repeated. Small balloon dilation and endoscopic stent placement for achalasia have only been used in select centers. Per oral endoscopic myotomy is a newer endoscopic modality that will likely change the treatment paradigm for achalasia. It arose from the field of natural orifice transluminal endoscopic surgery and represents a scarless endoscopic approach to Heller myotomy. This is a technique that requires extensive training and preparation and thus there should be rigorous accreditation and monitoring of outcomes to ensure safety and efficacy.

The feasibility, safety and outcomes of laparoscopic re-operation for achalasia

INTRODUCTION

Heller myotomy for achalasia is associated with a recurrence rate of around 10%, thus reoperative surgery is often necessitated. This paper aims to review the available literature on laparoscopic reoperation for achalasia in order to assess its feasibility and effectiveness.

MATERIAL & METHODS

A Medline, Embase, Ovid, Cochrane database and Google(TM) Scholar search was performed with the following Mesh terms: "laparoscopic", "redo", "reoperative", "Heller's", "esophagomyotomy" and "achalasia". Outcomes of interest included patient demographics and details of primary procedure, operative details, intra- and post operative complications and symptom scores.

RESULTS

Seven studies reported outcomes from 54 cases. Conversion occurred in 7% (4/54) of cases. Thirteen percent (7/54) of patients sustained intra-operative gastric or oesophageal perforation; however these were all noted and repaired intra-operatively leading to no subsequent morbidity. No deaths were reported. Pre- and post operative symptom scores were heterogeneous, however did appear to improve after the procedure.

DISCUSSION

This review demonstrates that laparoscopic reoperation for achalasia is feasible and safe with complication rates comparable to the primary laparoscopic operation. It is recommended that laparoscopic reoperative Heller's myotomy should only be performed by surgeons with special interest in oesophagogastric surgery and adequate experience in laparoscopic surgery for achalasia.

Treatment of the patient with achalasia

PURPOSE OF REVIEW

In recent years, several studies on the treatment and follow-up of achalasia have been published. This review aims at highlighting interesting publications from the recent years.

RECENT FINDINGS

Treatment of achalasia aims at relieving functional obstruction at the level of the esophagogastric junction. Several treatment options such as pneumodilation and laparoscopic Heller myotomy (LHM) are available for this purpose. A large prospective randomized trial comparing pneumodilation and LHM demonstrated comparable success rates and quality of life for the two treatment options. Long-term data demonstrate comparable treatment success rates, when redilation in case of recurrent symptoms after pneumodilation is accepted. The most important risk factor for treatment failure is the manometric subtype, with a worse outcome for type I and type III compared with type II achalasia. Recently, peroral endoscopic myotomy (POEM) has been described with high success rates. Comparative studies with longer follow-up are awaited. A prospective study assessing the risk of esophageal carcinoma in patients with achalasia showed a 28-fold increased risk to develop carcinoma.

SUMMARY

Either LHM or pneumodilation have high comparable short-term clinical success rates. Based on the increased risk to develop esophageal carcinoma, a screening program may be indicated. POEM is a new interesting treatment but longer follow-up data are awaited.

End-stage achalasia

Despite symptom improvement offered to achalasia patients by either pneumatic dilation or surgical myotomy, 10% to 15% of those so treated will present progressive deterioration of their esophageal function and up to 5% may eventually require an esophagectomy. The natural evolution of achalasia to its end stage as well as the timing of esophagectomy in these patients form the basis of this review. The optimal reconstruction for the decompensated resected esophagus will also be explored: gastric interposition, colon interposition, and jejunal interposition all have their respective advantages and disadvantages. Their use is examined in the exclusive context of resection for achalasia.

The Kagoshima consensus on esophageal achalasia

Esophageal achalasia is a primary esophageal motility disorder characterized by lack of peristalsis and a lower esophageal sphincter that fails to relax appropriately in response to swallowing. This article summarizes the most salient issues in the diagnosis and management of achalasia as discussed in a symposium that took place in Kagoshima, Japan, in September 2010 under the auspices of the International Society for Diseases of the Esophagus.