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Maydeo A. Achalasia Cardia: Balloon, Tunnel, or Knife? JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0041-1740490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractAchalasia cardia is a rare esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter during swallowing and aperistalsis of the esophageal smooth muscles. The treatment approaches to achalasia include nonsurgical treatment with medications (nitrates, calcium channel blockers), endoscopic treatment (balloon pneumatic dilation [PD], botulinum toxin injection [BTI], peroral endoscopic myotomy [POEM]), and surgery (laparoscopic Heller's myotomy [LHM]). The subtype of achalasia (the Chicago Classification) governs the ideal treatment. For the commonly encountered achalasia subtype I and II, PD, LHM, and POEM all have similar efficacy. However, for type III achalasia, POEM seems to be the best line of treatment. Among high-risk elderly patients or those with comorbidities, BTI is preferred. The choice of treatment should be minimally invasive therapy with good short-term and sustained long-term effects with negligible adverse events. POEM seems to be evolving as a first-line therapy among the available therapies. Here, we review the treatment options among achalasia cardia patients with special attention to post-POEM gastroesophageal reflux disease and its management.
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Affiliation(s)
- Amit Maydeo
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, Maharashtra, India
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Toshimori A, Inoue H, Fujiyoshi MRA, Fujiyoshi Y, Nishikawa Y, Tanabe M, Shimamura Y, Ohwada K, Ono M, Ikeda H, Onimaru M. Novel modified side-by-side balloon dilatation method for esophagogastric junction strictures: Single-/double-barrel techniques. Dig Endosc 2022; 34:641-647. [PMID: 34837409 DOI: 10.1111/den.14205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 02/08/2023]
Abstract
Endoscopic balloon dilatation is an established treatment for benign gastrointestinal strictures. In order to dilatate safely, it is necessary to dilatate gradually and preferably under direct endoscopic visualization. However, it is currently difficult to achieve dilatation widths of 20-30 mm with commercial products and of over 30-mm with endoscopic visualization. Therefore, a safe and innovative application technique is needed for patients who need these 20-mm or greater dilatation widths. We have developed two methods that enable more than 20-mm dilatation under direct visualization. (i) Single-barrel method: an endoscopic balloon dilatation catheter was fixed with grasping forceps at the tip of the endoscope and carried into the stomach. The balloon catheter was released from the endoscope to create a retroflexed view. The endoscope and balloon were positioned adjacent to each other at the gastric cardia. The balloon was inflated gradually and the esophagogastric junction was dilatated under direct visualization. (ii) Double-barrel method: the same procedure was repeated with two balloons. Theoretically, we achieved a dilatation of >30-mm in diameter. These modified methods may be helpful for esophagogastric junction strictures, such as esophageal achalasia (serving as an initial endoscopic balloon dilatation prior to using a 30-mm achalasia balloon), or for functional strictures after Nissen fundoplication. In conclusion, our simple, modified method enables safe and gradual dilatation under direct endoscopic visualization. Additionally, combination of the sizes of one or two balloons can achieve various widths of dilatation.
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Affiliation(s)
- Akiko Toshimori
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Haruhiro Inoue
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | | | - Yusuke Fujiyoshi
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yohei Nishikawa
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Mayo Tanabe
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yuto Shimamura
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Kaori Ohwada
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Masashi Ono
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Haruo Ikeda
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Manabu Onimaru
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
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Modayil RJ, Zhang X, Rothberg B, Kollarus M, Galibov I, Peller H, Taylor S, Brathwaite CE, Halwan B, Grendell JH, Stavropoulos SN. Peroral endoscopic myotomy: 10-year outcomes from a large, single-center U.S. series with high follow-up completion and comprehensive analysis of long-term efficacy, safety, objective GERD, and endoscopic functional luminal assessment. Gastrointest Endosc 2021; 94:930-942. [PMID: 33989646 DOI: 10.1016/j.gie.2021.05.014] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/03/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) is becoming the treatment of choice for achalasia. Data beyond 3 years are emerging but are limited. We herein report our 10-year experience, focusing on long-term efficacy and safety including the prevalence, management, and sequelae of postoperative reflux. METHODS This was a single-center prospective cohort study. RESULTS Six hundred ten consecutive patients received POEM from October 2009 to October 2019, 160 for type 1 achalasia (26.2%), 307 for type II (50.3%), 93 for type III (15.6%), 25 for untyped achalasia (4.1%), and 23 for nonachalasia disorders (3.8%). Two hundred ninety-two patients (47.9%) had prior treatment(s). There was no aborted POEM. Median operation time was 54 minutes. Accidental mucosotomies occurred in 64 patients (10.5%) and clinically significant adverse events in 21 patients (3.4%). No adverse events led to death, surgery, interventional radiology interventions/drains, or altered functional status. At a median follow-up of 30 months, 29 failures occurred, defined as postoperative Eckardt score >3 or need for additional treatment. The Kaplan-Meier clinical success estimates at years 1, 2, 3, 4, 5, 6, and 7 were 98%, 96%, 96%, 94%, 92%, 91%, and 91%, respectively. These are highly accurate estimates because only 13 patients (2%) were missing follow-up assessments. One hundred twenty-five patients (20.5%) had reflux symptoms more than once per week. At a median of 4 months, the pH study was completed in 406 patients (66.6%) and was positive in 232 (57.1%), and endoscopy was completed in 438 patients (71.8%) and showed reflux esophagitis in 218 (49.8%), mostly mild. CONCLUSIONS POEM is exceptionally safe and highly effective on long-term follow-up, with >90% clinical success at ≥5 years.
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Affiliation(s)
- Rani J Modayil
- Division of Gastroenterology, Hepatology & Nutrition, NYU-Winthrop Hospital, Mineola, New York, USA
| | - Xiaocen Zhang
- Department of Medicine, Mt Sinai St Luke's-West Hospital Center, New York, New York, USA
| | - Brooke Rothberg
- Division of Gastroenterology, Hepatology & Nutrition, NYU-Winthrop Hospital, Mineola, New York, USA
| | - Maria Kollarus
- Division of Gastroenterology, Hepatology & Nutrition, NYU-Winthrop Hospital, Mineola, New York, USA
| | - Iosif Galibov
- Division of Gastroenterology, Hepatology & Nutrition, NYU-Winthrop Hospital, Mineola, New York, USA
| | - Hallie Peller
- Division of Gastroenterology, Hepatology & Nutrition, NYU-Winthrop Hospital, Mineola, New York, USA
| | - Sharon Taylor
- Division of Gastroenterology, Hepatology & Nutrition, NYU-Winthrop Hospital, Mineola, New York, USA
| | - Collin E Brathwaite
- Division of Gastroenterology, Hepatology & Nutrition, NYU-Winthrop Hospital, Mineola, New York, USA
| | - Bhawna Halwan
- Division of Gastroenterology, Hepatology & Nutrition, NYU-Winthrop Hospital, Mineola, New York, USA
| | - James H Grendell
- Division of Gastroenterology, Hepatology & Nutrition, NYU-Winthrop Hospital, Mineola, New York, USA
| | - Stavros N Stavropoulos
- Division of Gastroenterology, Hepatology & Nutrition, NYU-Winthrop Hospital, Mineola, New York, USA
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Ofosu A, Mohan BP, Ichkhanian Y, Masadeh M, Febin J, Barakat M, Ramai D, Chandan S, Haiyeva G, Khan SR, Aghaie Meybodi M, Facciorusso A, Repici A, Wani S, Thosani N, Khashab MA. Peroral endoscopic myotomy (POEM) vs pneumatic dilation (PD) in treatment of achalasia: A meta-analysis of studies with ≥ 12-month follow-up. Endosc Int Open 2021; 9:E1097-E1107. [PMID: 34222636 PMCID: PMC8216779 DOI: 10.1055/a-1483-9406] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 11/23/2020] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Peroral endoscopic myotomy (POEM) is increasingly being used as the preferred treatment option for achalasia. The aim of this systematic review and meta-analysis was to compare the efficacy and safety of POEM versus pneumatic balloon dilation (PD). Methods We performed a comprehensive review of studies that reported clinical outcomes of POEM and PD for the treatment of achalasia. Measured outcomes included clinical success (improvement of symptoms based on a validated scale including an Eckardt score ≤ 3), adverse events, and post-treatment gastroesophageal reflux disease (GERD). Results Sixty-six studies (6268 patients) were included in the final analysis, of which 29 studies (2919 patients) reported on POEM and 33 studies (3050 patients) reported on PD and 4 studies (299 patients) compared POEM versus PD. Clinical success with POEM was superior to PD at 12, 24, and 36 months (92.9 %, vs 76.9 % P = 0.001; 90.6 % vs 74.8 %, P = 0.004; 88.4 % vs 72.2 %, P = 0.006, respectively). POEM was superior to PD in type I, II and III achalasia (92.7 % vs 61 %, P = 0.01; 92.3 % vs 80.3 %, P = 0.01; 92.3 %v 41.9 %, P = 0.01 respectively) Pooled OR of clinical success at 12 and 24 months were significantly higher with POEM (8.97; P = 0.001 & 5.64; P = 0.006). Pooled OR of GERD was significantly higher with POEM (by symptoms: 2.95, P = 0.02 and by endoscopic findings: 6.98, P = 0.001). Rates of esophageal perforation (0.3 % vs 0.6 %, P = 0.8) and significant bleeding (0.4 % vs 0.7 %, P = 0.56) were comparable between POEM and PD groups. Conclusions POEM is more efficacious than PD in the treatment of patients with achalasia during short-term and long-term follow-up, albeit with higher risk of abnormal esophageal acid exposure.
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Affiliation(s)
- Andrew Ofosu
- Gastroenterology and Hepatology, Stanford University, Stanford, California, United States
| | - Babu P. Mohan
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, Utah, United States
| | - Yervant Ichkhanian
- Internal Medicine, Henry Ford University Medical Center, Detroit, Michigan, United States
| | - Maen Masadeh
- Kaiser Permanente Northern California, California, United States
| | - John Febin
- Gastroenterology and Hepatology, Stanford University, Stanford, California, United States
| | - Mohamed Barakat
- Gastroenterology and Hepatology, Stanford University, Stanford, California, United States
| | - Daryl Ramai
- Gastroenterology and Hepatology, Stanford University, Stanford, California, United States
| | - Saurabh Chandan
- Gastroenterology and Hepatology, University of Nebraska, United States
| | - Gulara Haiyeva
- Beneficts Hospital Inc., Great Falls, Montana, United States
| | - Shahab R. Khan
- Gastroenterology, Rush University Medical Center, Chicago, Illinois, United States
| | - Mohamad Aghaie Meybodi
- Gastroenterology and Hepatology, John Hopkins University Hospital, Baltimore, Maryland, United States
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Alessandro Repici
- Humanitas Research Hospital, Humanitas University, Rozzano, Milan, Italy
| | - Sachin Wani
- Gastroenterology, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Nirav Thosani
- Gastroenterology, Hepatology and Nutrition, University of Texas Health Science Center at Houston, Houston, Texas, United States
| | - Mouen A. Khashab
- Gastroenterology and Hepatology, John Hopkins University Hospital, Baltimore, Maryland, United States
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Huang S, Ren Y, Peng W, Gao Q, Peng Y, Gong W, Tang X. Peroral endoscopic shorter versus longer myotomy for the treatment of achalasia: a comparative retrospective study. Esophagus 2020; 17:477-483. [PMID: 32361976 DOI: 10.1007/s10388-020-00739-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 04/14/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Peroral esophageal myotomy (POEM) is a novel endoscopic treatment for achalasia. It has gained popularity worldwide among surgeons and endoscopists, but no studies have compared peroral endoscopic short with long myotomy for achalasia. We aimed to compare the clinical efficacy and safety between peroral endoscopic shorter and longer myotomy. METHODS The retrospective study enrolled 129 achalasia patients who underwent POEM from July 2011 to September 2017. Based on the myotomy length (ML), patients were divided into shorter myotomy (SM) group (ML ≤ 7 cm, n = 36) and longer myotomy (LM) group (ML > 7 cm, n = 74). Procedure-related parameters, symptom scores, adverse events and manometric data were compared between two groups. RESULTS The mean ML was 6.0 ± 0.6 cm in SM group, and 11.5 ± 3.1 cm in LM group (p < 0.001). The mean operation time was significantly less in SM group than LM group (46.6 ± 18.5 min vs 62.1 ± 25.2 min, p = 0.001). During a mean follow-up period of 28.7 months, treatment success (Eckardt score ≤ 3) was achieved in 94.4% (34/36) of patients in SM group and 91.9% (68/74) in LM group (p = 0.926). There was no statistical difference in the incidence of intraoperative complications (8.4% vs 8.2%, p = 0.823) and reflux rate (8.3% vs. 14.9%, p = 0.510) between two groups. CONCLUSIONS Peroral endoscopic shorter myotomy is comparable with longer myotomy for treating achalasia with regard to clinical efficacy and has the advantage of shorter procedure time.
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Affiliation(s)
- Silin Huang
- Departmemt of Gastroenterology, Shenzhen Hospital, Southern Medical University, No.1333 Xinhu Road, Baoan District, Shenzhen, 518000, China
| | - Yutang Ren
- Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Wei Peng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China
| | - Qiaoping Gao
- Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yan Peng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China
| | - Wei Gong
- Departmemt of Gastroenterology, Shenzhen Hospital, Southern Medical University, No.1333 Xinhu Road, Baoan District, Shenzhen, 518000, China.
| | - Xiaowei Tang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China.
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Peroral endoscopic myotomy is a safe and effective treatment modality for geriatric patients with achalasia. Esophagus 2020; 17:484-491. [PMID: 32394115 DOI: 10.1007/s10388-020-00746-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 04/26/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is an appealing treatment for older patients, as it is minimally invasive but highly efficacious similar to surgical myotomy. However, there is a lack of systematic studies analyzing POEM outcomes in young (< 65 years) versus geriatric patients (≥ 65 years). Hence, we aimed to compare the safety and efficacy of POEM in young versus geriatric patients. METHODS Records of all achalasia patients who underwent POEM at our institution between April 2014 and May 2019 were reviewed. Patients were categorized into two groups: young (< 65 years) and old (≥ 65 years). Demographic and procedural details, timed barium esophagram (TBE), high-resolution manometry (HREM), pH study findings and Eckardt scores were compared between the two groups. Post-POEM Eckhardt score of ≤ 3 was defined as treatment success. RESULTS A total of 148 patients met the study criteria (young = 93; old = 55). Younger patients were more likely to have lower TBE height at 1 min but wider TBE width at 5 min. The rest of the pre-operative parameters and Eckardt scores were similar in the two groups. Young patients were more likely to have undergone prior Heller myotomy, while Botox injections were common in the older group. The operative details and outcomes were similar in the two groups. Treatment success rates were similar in both groups (94.9% young vs. 94.7% in old patients, p = 1.00). At 2-month follow-up, both groups showed significant improvements in Eckhardt scores and HREM parameters; however, older patients showed greater improvement in TBE height at 1 and 5 min. The rates of symptomatic GERD and abnormal esophageal pH study findings were similar in the two groups. CONCLUSION POEM was safe and highly effective treatment for geriatric patients with achalasia. These findings suggest that POEM might emerge as the preferred approach for myotomy in this patient population.
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Ross SB, Luberice K, Kurian TJ, Paul H, Rosemurgy AS. Defining the Learning Curve of Laparoendoscopic Single-site Heller Myotomy. Am Surg 2020. [DOI: 10.1177/000313481307900829] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Initial outcomes suggest laparoendoscopic single-site (LESS) Heller myotomy with anterior fundoplication provides safe, efficacious, and cosmetically superior outcomes relative to conventional laparoscopy. This study was undertaken to define the learning curve of LESS Heller myotomy with anterior fundoplication. One hundred patients underwent LESS Heller myotomy with anterior fundoplication. Symptom frequency and severity were scored using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Symptom resolution, additional trocars, and complications were compared among patient quartiles. Median data are presented. Preoperative frequency/severity scores were: dysphagia = 10/8 and regurgitation = 8/7. Additional trocars were placed in 12 patients (10%), of whom all were in the first two quartiles. Esophagotomy/gastrotomy occurred in three patients. Postoperative complications occurred in 9 per cent. No conversions to “open” operations occurred. Length of stay was 1 day. Postoperative frequency/severity scores were: dysphagia = 2/0 and regurgitation = 0/0; scores were less than before myotomy ( P < 0.001). There were no apparent scars, except where additional trocars were placed. LESS Heller myotomy with anterior fundoplication well palliates symptoms of achalasia with no apparent scar. Placement of additional trocars only occurred early in the experience. For surgeons proficient with the conventional laparoscopic approach, the learning curve of LESS Heller myotomy with anterior fundoplication is short and safe, because proficiency is quickly attained.
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Affiliation(s)
- Sharona B. Ross
- From HPB & Foregut Advanced Laparoscopic & Robotic Surgery, Florida Hospital Tampa, Tampa, Florida
| | - Kenneth Luberice
- From HPB & Foregut Advanced Laparoscopic & Robotic Surgery, Florida Hospital Tampa, Tampa, Florida
| | - Tony J. Kurian
- From HPB & Foregut Advanced Laparoscopic & Robotic Surgery, Florida Hospital Tampa, Tampa, Florida
| | - Harold Paul
- From HPB & Foregut Advanced Laparoscopic & Robotic Surgery, Florida Hospital Tampa, Tampa, Florida
| | - Alexander S. Rosemurgy
- From HPB & Foregut Advanced Laparoscopic & Robotic Surgery, Florida Hospital Tampa, Tampa, Florida
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Ramchandani M, Pal P. Management of achalasia in 2020: Per-oral endoscopic myotomy, Heller’s or dilatation? INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii200012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Mohan Ramchandani
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Partha Pal
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
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Khashab MA, Vela MF, Thosani N, Agrawal D, Buxbaum JL, Abbas Fehmi SM, Fishman DS, Gurudu SR, Jamil LH, Jue TL, Kannadath BS, Law JK, Lee JK, Naveed M, Qumseya BJ, Sawhney MS, Yang J, Wani S. ASGE guideline on the management of achalasia. Gastrointest Endosc 2020; 91:213-227.e6. [PMID: 31839408 DOI: 10.1016/j.gie.2019.04.231] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 04/22/2019] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Marcelo F Vela
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Nirav Thosani
- Interventional Gastroenterologists of the University of Texas, Department of Internal Medicine, McGovern Medical School, Houston, Texas, USA
| | - Deepak Agrawal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Syed M Abbas Fehmi
- Division of Gastroenterology/Hepatology, University of California, San Diego, San Diego, California, USA
| | - Douglas S Fishman
- Section of Pediatric Gastroenterology, Baylor College of Medicine; Texas Children's Hospital, Houston, Texas, USA
| | | | - Laith H Jamil
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Terry L Jue
- The Permanente Medical Group, Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Bijun Sai Kannadath
- Interventional Gastroenterologists of the University of Texas, Department of Internal Medicine, McGovern Medical School, Houston, Texas, USA
| | - Joanna K Law
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Jeffrey K Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Mariam Naveed
- Division of Gastroenterology and Hepatology, University of Iowa Hospital & Clinics, Iowa City, Iowa, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, Archbold Medical Group, Thomasville, Georgia, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Julie Yang
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Durability of pneumatic dilation monotherapy in treatment-naive achalasia patients. BMC Gastroenterol 2019; 19:181. [PMID: 31711439 PMCID: PMC6849288 DOI: 10.1186/s12876-019-1104-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 10/29/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Pneumatic dilation (PD) is often billed as a "short term" treatment for achalasia but anecdotally can last years. This study sought to explore how long a single pneumatic dilation may induce symptom remission in a treatment-naïve achalasia patient. METHODS A single center, retrospective chart review of patients with an ICD-9 or - 10 code of achalasia between 2005 and 2017 was performed. Treatment naïve patients with manometric diagnosis of primary achalasia were included. Outcomes (success or failure); single vs multiple PD; age; and estimated duration of effect were evaluated. Each patient underwent a single PD unless re-intervention was required for relapse. RESULTS 83 patients (52% female, median 51.6 ± 3.6 years) were included. 43% underwent 2 PD and 13% underwent 3 PD. There was no significant relation between age, gender, and number of PDs. After 1 PD, 87.5% of patients reported > 1 year of symptom remission. 80.5% of relapsed patients reported success after a 2nd dilation. 1 PD was more likely to result in success than multiple PDs (p < 0.001). The measured median duration of remission after 1 PD was 4.23 years, and for 2 PDs, 3.71 years. The median estimated remission time after 1 PD was 8.5 years (CI 7.3-9.7, p = 0.03). CONCLUSIONS PD is a safe, durable treatment for achalasia. A single PD is likely to last years. A second PD, if required, also has a high likelihood of success.
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Tsuboi K, Omura N, Yano F, Hoshino M, Yamamoto SR, Akimoto S, Masuda T, Kashiwagi H, Yanaga K. Effect of preoperative balloon dilation on treatment outcomes of laparoscopic Heller–Dor surgery for achalasia: a propensity score matched study. Surg Today 2018; 48:1068-1075. [DOI: 10.1007/s00595-018-1695-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 07/01/2018] [Indexed: 12/17/2022]
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12
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Abstract
Esophageal achalasia is a primary esophageal motility disorder of unknown origin, characterized by lack of peristalsis and by incomplete or absent relaxation of the lower esophageal sphincter in response to swallowing. The goal of treatment is to eliminate the functional obstruction at the level of the gastroesophageal junction. Areas covered: This comprehensive review will evaluate the current literature, illustrating the diagnostic evaluation and providing an evidence-based treatment algorithm for this disease. Expert commentary: Today, we have three very effective therapeutic modalities to treat patients with achalasia - pneumatic dilatation, peroral endoscopic myotomy, and laparoscopic Heller myotomy with fundoplication. Treatment should be tailored to the individual patient, in centers where a multidisciplinary approach is available. Esophageal resection should be considered as a last resort for patients who have failed prior therapeutic attempts.
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Affiliation(s)
- Francisco Schlottmann
- a Department of Surgery , University of North Carolina , Chapel Hill , North Carolina , USA
| | - Marco G Patti
- b Department of Medicine and Surgery, Center for Esophageal Diseases and Swallowing , University of North Carolina , Chapel Hill , North Carolina , USA
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Felix VN. Results of pneumatic dilation in treating achalasia: predictive factors. Ann N Y Acad Sci 2018; 1434:124-131. [PMID: 29766515 DOI: 10.1111/nyas.13844] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/07/2018] [Accepted: 04/11/2018] [Indexed: 12/14/2022]
Abstract
Forced pneumatic dilatation (PD) of the cardia is one of the most consecrated therapeutic measures for esophageal achalasia. The procedure only achieved better standardization with the appearance of the Rigiflex balloon. Results and predictive factors of success and failure of PD are reviewed, right after the description of the main technical aspects of the procedure. The success rates, providing control of dysphagia for about 1 year from the procedure using the Rigiflex balloon, are quite satisfactory, with success in more than 75% of patients. It is generally observed that good responses sustained for more than 5 years appear in at least 40% of cases. However, approximately half of the patients submitted to PD require additional dilation and a subgroup of them will undergo surgical treatment to attain adequate control of dysphagia. PD is a method with a low rate of acute complications, with esophageal perforation, the most severe of them, not affecting more than 5% of the cases. The best results could be potentially obtained when predictive factors of success were considered before choosing PD as a therapeutic option, but prospective studies in this field are missing until now.
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14
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Müller M, Keck C, Eckardt AJ, Werling S, Wehrmann T, König J, Gockel I. Outcomes of pneumatic dilation in achalasia: Extended follow-up of more than 25 years with a focus on manometric subtypes. J Gastroenterol Hepatol 2018; 33:1067-1074. [PMID: 29140553 DOI: 10.1111/jgh.14044] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 11/02/2017] [Accepted: 11/04/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Pneumatic dilation (PD) is the most popular nonsurgical treatment for achalasia. This study investigated predicting factors, including manometric subtypes for symptom recurrence in the long term, in patients with achalasia treated with a single PD. METHODS Between 1983 and 2013, a total of 107 patients were treated initially with a single PD and included in this longitudinal cohort study. Outcomes were correlated with demographics, symptoms (Eckardt score), and esophagographic and manometric features. Manometric tracings were retrospectively classified according to the three subtypes of the Chicago classification. RESULTS Ninety-one (85%) patients were successfully treated after the first PD. The median follow-up was 13.8 years (interquartile range 7-20). During follow-up, 54% of the patients experienced a clinical relapse. The overall cumulative success rates at 2, 5, 10, 15, 20, and 25 years were 64%, 53%, 49%, 42%, 36%, and 36%, respectively. Age < 40 years, lower esophageal sphincter pressure > 15 mmHg, a cardia width < 5 mm, and an esophageal barium column height > 1 cm 4 to 12 weeks post-dilation significantly correlated with symptom recurrence, whereas achalasia subtypes did not significantly correlate with the treatment results. CONCLUSION Pneumatic dilation in achalasia is an effective therapy in the short term, but its effect wanes in the very long term. Young age at presentation, a high lower esophageal sphincter pressure, a narrow cardia, and an esophageal barium column of > 1 cm after PD are predictive factors for the need of repeated treatment.
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Affiliation(s)
- Michaela Müller
- Department of Gastroenterology, German Diagnostic Clinic Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Christina Keck
- Department of Gastroenterology, German Diagnostic Clinic Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Alexander J Eckardt
- Department of Gastroenterology, German Diagnostic Clinic Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Sarah Werling
- Department of Gastroenterology, Karlsruhe Hospital, Karlsruhe, Germany
| | - Till Wehrmann
- Department of Gastroenterology, German Diagnostic Clinic Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Jochem König
- Departments of Biostatistics and Epidemiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Medical Center of Leipzig, Leipzig, Germany
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Rosemurgy A, Downs D, Luberice K, Rodriguez C, Swaid F, Patel K, Toomey P, Ross S. Laparoscopic Heller Myotomy with Anterior Fundoplication Improves Frequency and Severity of Symptoms of Achalasia, Regardless of Preoperative Severity Determined by Esophagography. Am Surg 2018. [DOI: 10.1177/000313481808400220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study was undertaken to determine whether postoperative outcomes after laparoscopic Heller myotomy with anterior fundoplication could be predicted by preoperative findings on esophagography. Preoperative barium esophagograms of 135 patients undergoing laparoscopic Heller myotomy with anterior fundoplication were reviewed. The number of esophageal curves, esophageal width, and angulation of the gastroesophageal junction (GEJ) were determined; correlations between these determined parameters and symptoms were assessed using linear regression analysis. The number of esophageal curves correlated with the preoperative frequency of dysphagia, vomiting, chest pain, regurgitation, and heartburn. The width of the esophagus negatively correlated with the preoperative frequency of regurgitation. The angulation of the GEJ did not correlate with preoperative symptoms. Laparoscopic Heller myotomy with anterior fundoplication significantly reduced the frequency and severity of all symptoms, regardless of the number of esophageal curves, esophageal width, or angulation of the GEJ. Laparoscopic Heller myotomy with anterior fundoplication provides dramatic palliation for achalasia. More esophageal curves on preoperative esophagography correlate well with the frequency of a broad range of preoperative symptoms, including the frequency of dysphagia and regurgitation. Patients experience dramatically improved frequency and severity of symptoms after laparoscopic Heller myotomy with anterior fundoplication for achalasia regardless of the number of esophageal curves, esophageal width, or the angulation of the GEJ. Findings on barium esophagogram, in evaluating achalasia, should not deter the application of laparosocopic Heller myotomy with anterior fundoplication.
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Schlottmann F, Herbella F, Allaix ME, Patti MG. Modern management of esophageal achalasia: From pathophysiology to treatment. Curr Probl Surg 2018; 55:10-37. [DOI: 10.1067/j.cpsurg.2018.01.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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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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Tang X, Ren Y, Gao Q, Huang S, Zhou J, Zhang X, Yang J, Wei Z, Chen Z, Jiang B, Gong W. Peroral endoscopic myotomy is safe and effective in achalasia patients aged older than 60 years compared with younger patients. Geriatr Gerontol Int 2017; 17:2407-2413. [PMID: 28707343 DOI: 10.1111/ggi.13083] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 01/26/2017] [Accepted: 03/30/2017] [Indexed: 02/05/2023]
Abstract
AIM Peroral endoscopic myotomy (POEM) has been proven to be effective for treating achalasia, but there are limited data on POEM in elderly patients. We therefore aimed to assess the role of POEM for achalasia in patients aged ≥60 years. METHODS All consecutive patients that underwent POEM between December 2011 and November 2015 at a single center were retrospectively reviewed. Patients aged ≥60 years were assigned to group A, whereas patients aged <60 years were assigned to group B. Demographic data, clinical data and treatment outcomes were compared between the two groups. RESULTS During the study period, 113 patients (18 in group A, and 95 in group B) were enrolled. The mean age of patients in group A was 63 ± 3.9 years (range 60-74 years; 55.6% women), and that for patients in group B was 37.7 ± 11.6 years (range 18-59 years; 42.2% women). The procedural time in group A was similar to group B (66.3 ± 33.3 vs 59.8 ± 24.2 min, P = 0.332). There were also no significant differences in the incidence of intraoperative complications (P = 1.000) and gastroesophageal reflux rate (P = 0.906) between the two groups. During the mean follow-up period of 25.2 months, treatment success (Eckardt score ≤3) was achieved in 92.9% of patients in group A, and 89.9% in group B (P = 1.000). CONCLUSIONS As well as in younger patients, POEM can be safely carried out in elderly patients, providing significant symptom relief. POEM might be recommended as the first therapeutic approach to elderly achalasia patients. Geriatr Gerontol Int 2017; 17: 2407-2413.
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Affiliation(s)
- Xiaowei Tang
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Department of Gastroenterology, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, China
| | - Yutang Ren
- Department of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China
| | - Qiaoping Gao
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Silin Huang
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jieqiong Zhou
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaofeng Zhang
- Department of Gastroenterology, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, China
| | - Jianfeng Yang
- Department of Gastroenterology, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, China
| | - Zhengjie Wei
- Department of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China
| | - Zhenyu Chen
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Bo Jiang
- Department of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China
| | - Wei Gong
- Department of Gastroenterology, Shenzhen Hospital of Southern Medical University, Shenzhen, China
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Tang X, Gong W, Deng Z, Zhou J, Ren Y, Zhang Q, Chen Z, Jiang B. Comparison of conventional versus Hybrid knife peroral endoscopic myotomy methods for esophageal achalasia: a case-control study. Scand J Gastroenterol 2016. [PMID: 26212517 DOI: 10.3109/00365521.2015.1059878] [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] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Peroral endoscopic myotomy (POEM) has been developed to treat achalasia as a novel less invasive modality. We aimed to compare the efficacy and safety of conventional knife versus Hybrid knife (HK) during POEM procedure. MATERIALS AND METHODS Between June 2012 and July 2014, 31 patients underwent POEM using HK in our department (HK group), and 36 patients underwent POEM using conventional method (injection needle and triangular tip [TT] knife, TT group). Procedure-related parameters, symptom relief, adverse events were compared between two groups. RESULTS There were no significant differences in the age, sex and other baseline characteristics between the two groups. The mean procedural time was significantly shorter in HK group than TT group (53.0 ± 17.2 vs. 67.6 ± 28.4 min, p = 0.015). The mean frequency of devices exchange was 4.7 ± 1.7 in HK group and 10.9 ± 1.8 in TT group (p = 0.000). No serious adverse events occurred postoperatively in both groups. At one-year follow-up, a total of 94% treatment success was achieved in all patients (93.5% in HK group and 94.4% in TT group, p = 0.877). CONCLUSION HK in POEM can shorten the procedural time, and achieve similar treatment success compared to conventional TT knife.
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Affiliation(s)
- Xiaowei Tang
- a 1 Department of Gastroenterology, Nanfang Hospital, Southern Medical University , Guangzhou, China.,b 2 Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University , Beijing, China
| | - Wei Gong
- a 1 Department of Gastroenterology, Nanfang Hospital, Southern Medical University , Guangzhou, China
| | - Zhiliang Deng
- a 1 Department of Gastroenterology, Nanfang Hospital, Southern Medical University , Guangzhou, China
| | - Jieqiong Zhou
- a 1 Department of Gastroenterology, Nanfang Hospital, Southern Medical University , Guangzhou, China.,b 2 Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University , Beijing, China
| | - Yutang Ren
- b 2 Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University , Beijing, China
| | - Qiang Zhang
- a 1 Department of Gastroenterology, Nanfang Hospital, Southern Medical University , Guangzhou, China
| | - Zhenyu Chen
- a 1 Department of Gastroenterology, Nanfang Hospital, Southern Medical University , Guangzhou, China
| | - Bo Jiang
- a 1 Department of Gastroenterology, Nanfang Hospital, Southern Medical University , Guangzhou, China.,b 2 Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University , Beijing, China
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Uppal DS, Wang AY. Update on the endoscopic treatments for achalasia. World J Gastroenterol 2016; 22:8670-8683. [PMID: 27818585 PMCID: PMC5075544 DOI: 10.3748/wjg.v22.i39.8670] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 08/20/2016] [Accepted: 09/14/2016] [Indexed: 02/06/2023] Open
Abstract
Achalasia is the most common primary motility disorder of the esophagus and presents as dysphagia to solids and liquids. It is characterized by impaired deglutitive relaxation of the lower esophageal sphincter. High-resolution manometry allows for definitive diagnosis and classification of achalasia, with type II being the most responsive to therapy. Since no cure for achalasia exists, early diagnosis and treatment of the disease is critical to prevent end-stage disease. The central tenant of diagnosis is to first rule out mechanical obstruction due to stricture or malignancy, which is often accomplished by endoscopic and fluoroscopic examination. Therapeutic options include pneumatic dilation (PD), surgical myotomy, and endoscopic injection of botulinum toxin injection. Heller myotomy and PD are more efficacious than pharmacologic therapies and should be considered first-line treatment options. Per oral endoscopic myotomy (POEM) is a minimally-invasive endoscopic therapy that might be as effective as surgical myotomy when performed by a trained and experienced endoscopist, although long-term data are lacking. Overall, therapy should be individualized to each patient's clinical situation and based upon his or her risk tolerance, operative candidacy, and life expectancy. In instances of therapeutic failure or symptom recurrence re-treatment is possible and can include PD or POEM of the wall opposite the site of prior myotomy. Patients undergoing therapy for achalasia require counseling, as the goal of therapy is to improve swallowing and prevent late manifestations of the disease rather than to restore normal swallowing, which is unfortunately impossible.
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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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Docimo S, Mathew A, Shope AJ, Winder JS, Haluck RS, Pauli EM. Reduced postoperative pain scores and narcotic use favor per-oral endoscopic myotomy over laparoscopic Heller myotomy. Surg Endosc 2016; 31:795-800. [PMID: 27338580 DOI: 10.1007/s00464-016-5034-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 06/11/2016] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Per-oral endoscopic myotomy (POEM) is a less invasive therapy for achalasia with a shorter hospitalization but with similar short- and long-term outcomes as a laparoscopic Heller myotomy (LHM). Previous literature comparing POEM to LHM has focused primarily on postoperative outcome parameters such as complications, dysphagia scores and gastro-esophageal reflux severity. This study specifically compares postoperative pain following POEM to pain following LHM, the current gold-standard operation. METHODS A retrospective review of all patients undergoing POEM or LHM for achalasia was performed from 2006 to 2015. Data collection included demographics, comorbidities, length of stay (LOS) and pain scores (arrival to the recovery room, 1 h postoperative, average first 24 h and upon discharge). Statistical analysis was performed using Student's t test and Chi-square test. RESULTS Forty-four POEM patients and 122 LHM patients were identified. The average age (52.2 ± 20.75 vs 50.9 ± 17.89 years, p = 0.306) and BMI (28.1 ± 7.62 vs 27.6 ± 7.07 kg/m2, p = 0.824) did not differ between the POEM and LHM groups, respectively; however, the American Society of Anesthesiology scores were higher in the POEM patients (2.43 ± 0.62 vs 2.11 ± 0.71, p = 0.011). There were no differences in rates of smoking, diabetes, cardiac disease or pulmonary disease. The average pain scores upon arrival to the recovery room and 1 h postoperatively were lower in the POEM group (2.3 ± 3.014 vs 3.61 ± 3 0.418, p = 0.025 and 2.2 ± 2.579 vs 3.46 ± 3.063, p = 0.034, respectively). There was no difference in the average pain score over the first 24 h (2.7 ± 2.067 vs 3.29 ± 1.980, p = 0.472) or at the time of discharge (1.6 ± 2.420 vs 2.09 ± 2.157, p = 0.0657) between the POEM and LHM groups. After standardizing opioid administration against 10 mg of oral morphine, the POEM group used significantly less narcotics that the LHM group (35.8 vs 101.8 mg, p < 0.001) while hospitalized. The average LOS for the POEM group was 31.2 h and 55.79 for the LHM group (p < 0.0001). At discharge, fewer POEM patients required a prescription for a narcotic analgesic (6.81 vs 92.4 %, p < 0.0001). CONCLUSION POEM demonstrated significantly less postoperative pain upon arrival to the recovery room and 1 h postoperatively. To achieve similar pain scores during the first 24 h and at discharge, LHM patients required more narcotic analgesic administration. Despite a significantly shorter LOS, fewer POEM patients require a prescription for narcotic analgesics compared to LHM. POEM is a less painful procedure for achalasia than LHM, permitting earlier hospital discharge with little need for home narcotic use.
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Affiliation(s)
- Salvatore Docimo
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Hershey Medical Center, 500 University Drive, H149, Hershey, PA, 17036, USA.
| | - Abraham Mathew
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Alexander J Shope
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Hershey Medical Center, 500 University Drive, H149, Hershey, PA, 17036, USA
| | - Joshua S Winder
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Hershey Medical Center, 500 University Drive, H149, Hershey, PA, 17036, USA
| | - Randy S Haluck
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Hershey Medical Center, 500 University Drive, H149, Hershey, PA, 17036, USA
| | - Eric M Pauli
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Hershey Medical Center, 500 University Drive, H149, Hershey, PA, 17036, USA
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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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Allaix ME, Patti MG. Toward a Tailored Treatment of Achalasia: An Evidence-Based Approach. J Laparoendosc Adv Surg Tech A 2016; 26:256-63. [PMID: 27002740 DOI: 10.1089/lap.2016.0067] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The treatment options in achalasia patients aim to improve symptoms by reducing the functional obstruction at the level of the gastroesophageal junction. Available treatment modalities are endoscopic botulinum toxin injection (EBTI), pneumatic dilatation (PD), laparoscopic Heller myotomy (LHM), and peroral endoscopic myotomy (POEM). We provide an evidence-based review of current indications, limitations, and future perspectives of these options for the treatment of achalasia. METHODS The PubMed/Medline electronic databases and the Cochrane Library were searched. Quality of evidence was assessed according to the GRADE system. RESULTS Functional outcomes after EBTI are significantly worse than those after PD or LHM. LHM with partial fundoplication is associated with low complication rates and provides excellent long-term results with lower need for additional treatment of recurrent dysphagia than PD. POEM is a new promising treatment option with good short-term outcomes and low morbidity in experienced hands. CONCLUSIONS LHM should be considered the procedure of choice for the treatment of achalasia in patients who are fit for surgery. Large randomized controlled trials with long follow-up are needed to validate the role of POEM.
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Affiliation(s)
| | - Marco Giuseppe Patti
- 2 Department of Surgery and Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine , Chicago, Illinois
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Tang X, Ren Y, Wei Z, Zhou J, Deng Z, Chen Z, Jiang B, Gong W. Factors predicting the technical difficulty of peroral endoscopic myotomy for achalasia. Surg Endosc 2015; 30:3774-82. [PMID: 26659228 DOI: 10.1007/s00464-015-4673-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 11/07/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) has been described as a novel treatment for esophageal achalasia. Owing to its technical difficulty, POEM is not widely performed. This study was aimed to prospectively assess the factor predicting technical difficulty of POEM in a single center with large volume cases. METHODS A total of 105 cases of achalasia treated by POEM from April 2011 to September 2014 were analyzed. Difficult cases of POEM were defined as procedure time ≥90 min and occurrence of adverse events, including mucosal perforation, pneumothorax, and major bleeding. Univariate and multivariate logistic regression analyses were performed to assess the predictive factors of difficult POEM. RESULTS POEM was successfully completed in all the patients, and no one was converted to laparoscopy. The number of cases with procedure time ≥90 min was 17. Mucosal perforations occurred in six (5.7 %) patients during submucosal tunnel creation, major bleeding occurred in seven (6.7 %) patients, and pneumothorax occurred in six (5.7 %) patients immediately after procedure. All the complications were managed conservatively. No other intraoperative and immediate postoperative complications, including infections and pneumoperitoneum, occurred. Multivariate analysis showed that early period (odds ratio [OR] 4.173, 95 % confidence interval [95 % CI] 1.36-6.829, P = 0.023) and triangular tip knife ([OR] 6.712, [95 % CI] 1.479-30.460, P = 0.014) were independent factors associated with technical difficulty regarding longer procedure time (procedure time ≥90 min). CONCLUSION POEM is safe for the treatment of esophageal achalasia. Triangular tip knife and early period were independent risk factors for longer procedural time.
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Affiliation(s)
- Xiaowei Tang
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, No.1838, Guangzhou North Ave, Guangzhou, 510515, China.,Department of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China
| | - Yutang Ren
- Department of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China
| | - Zhengjie Wei
- Department of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China
| | - Jieqiong Zhou
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, No.1838, Guangzhou North Ave, Guangzhou, 510515, China.,Department of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China
| | - Zhiliang Deng
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, No.1838, Guangzhou North Ave, Guangzhou, 510515, China
| | - Zhenyu Chen
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, No.1838, Guangzhou North Ave, Guangzhou, 510515, China
| | - Bo Jiang
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, No.1838, Guangzhou North Ave, Guangzhou, 510515, China.,Department of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China
| | - Wei Gong
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, No.1838, Guangzhou North Ave, Guangzhou, 510515, China.
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Tsuboi K, Omura N, Yano F, Hoshino M, Yamamoto SR, Akimoto S, Masuda T, Kashiwagi H, Yanaga K. Data analyses and perspectives on laparoscopic surgery for esophageal achalasia. World J Gastroenterol 2015; 21:10830-10839. [PMID: 26478674 PMCID: PMC4600584 DOI: 10.3748/wjg.v21.i38.10830] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 05/29/2015] [Accepted: 08/31/2015] [Indexed: 02/06/2023] Open
Abstract
In general, the treatment methods for esophageal achalasia are largely classified into four groups, including drug therapy using nitrite or a calcium channel blocker, botulinum toxin injection, endoscopic therapy such as endoscopic balloon dilation, and surgery. Various studies have suggested that the most effective treatment of esophageal achalasia is surgical therapy. The basic concept of this surgical therapy has not changed since Heller proposed esophageal myotomy for the purpose of resolution of lower esophageal obstruction for the first time in 1913, but the most common approach has changed from open-chest surgery to laparoscopic surgery. Currently, the laparoscopic surgery has been the procedure of choice for the treatment of esophageal achalasia. During the process of the transition from open-chest surgery to laparotomy, to thoracoscopic surgery, and to laparoscopic surgery, the necessity of combining antireflux surgery has been recognized. There is some debate as to which type of antireflux surgery should be selected. The Toupet fundoplication may be the most effective in prevention of postoperative antireflux, but many medical institutions have selected the Dor fundoplication which covers the mucosal surface exposed by myotomy. Recently, a new endoscopic approach, peroral endoscopic myotomy (POEM), has received attention. Future studies should examine the long-term outcomes and whether POEM becomes the gold standard for the treatment of esophageal achalasia.
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Molena D, Mungo B, Stem M, Lidor AO. Hospitalization for esophageal achalasia in the United States. World J Gastrointest Endosc 2015; 7:1096-1102. [PMID: 26421106 PMCID: PMC4580951 DOI: 10.4253/wjge.v7.i13.1096] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 05/02/2015] [Accepted: 09/08/2015] [Indexed: 02/05/2023] Open
Abstract
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.
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Endoscopic dilatation, heller myotomy, and peroral endoscopic myotomy: treatment modalities for achalasia. Surg Clin North Am 2015; 95:567-78. [PMID: 25965130 DOI: 10.1016/j.suc.2015.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
At present, LHM with partial fundoplication is considered the gold standard for the treatment of patients with esophageal achalasia. Endoscopic procedures such as EBTI and PD should be considered as primary treatment modalities only in frail patients. POEM is a new approach with promising short-term results.
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Abstract
Idiopathic achalasia is a primary esophageal motor disorder characterized by loss of esophageal peristalsis and insufficient lower esophageal sphincter relaxation in response to deglutition. Patients with achalasia commonly complain of dysphagia to solids and liquids, bland regurgitation often unresponsive to an adequate trial of proton pump inhibitor, and chest pain. Weight loss is present in many, but not all patients. Although the precise etiology is unknown, it is often thought to be either autoimmune, viral immune, or neurodegenerative. The diagnosis is based on history of the disease, barium esophagogram, and esophageal motility testing. Endoscopic assessment of the gastroesophageal junction and gastric cardia is necessary to rule out malignancy. Newer diagnostic modalities such as high resolution manometry help in predicting treatment response in achalasia based on esophageal pressure topography patterns identifying three phenotypes of achalasia (I-III) and outcome studies suggest better treatment response with types I and II compared to type III. Although achalasia cannot be permanently cured, excellent outcomes are achieved in over 90 % of patients. Current medical and surgical therapeutic options (pneumatic dilation, endoscopic and surgical myotomy, and pharmacologic agents) aim at reducing the LES pressure and facilitating esophageal emptying by gravity and hydrostatic pressure of retained food and liquids. Either graded pneumatic dilatation or laparoscopic surgical myotomy with a partial fundoplication are recommended as initial therapy guided by patient age, gender, preference, and local institutional expertise. The prognosis in achalasia patients is excellent. Most patients who are appropriately treated have a normal life expectancy but the disease does recur and the patient may need intermittent treatment.
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Affiliation(s)
| | - Hannah P Kim
- Department of Internal Medicine, Nashville, TN, USA
| | | | - Michael F Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA.
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High-resolution manometry is comparable to timed barium esophagogram for assessing response to pneumatic dilation in patients with achalasia. Indian J Gastroenterol 2015; 34:144-51. [PMID: 25911464 DOI: 10.1007/s12664-015-0551-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 03/30/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Reduction in height of barium column in timed barium esophagogram (TBE) and lower esophageal sphincter (LES) pressure on manometry has been used to assess efficacy of pneumatic dilation (PD) in patients with achalasia; data comparing these two methods to assess efficacy of PD are scanty. METHODS Sixty-two patients with achalasia undergoing PD were evaluated clinically (Eckardt's score), high-resolution manometry (HRM), and TBE (films at 1 and 5 min) before and 4 weeks after PD using 30 and 35 mm Rigiflex balloon (Microvasive, Milliford, MA, USA) in female and male patients, respectively. Response was defined clinically as Eckardt's score <3, by manometry as LES pressure <22.5 mmHg, and by TBE as adequate esophageal emptying (reduction in height of barium column by more than 50 % of pretreatment value in 5-min radiograph). RESULTS Forty-three out of sixty-two (69 %) patients [age 34 ± 12 years, 36 (58 %) male] responded, and 19 (31 %) did not respond to the first session of PD as assessed by post-PD Eckardt's score. Thirty-eight out of 43 (88 %) responders had adequate esophageal emptying of barium in TBE, while 31/43 (72 %) had LES pressure below 22.5 mmHg on HRM (p = ns). Eight out of 19 (42 %) nonresponders showed failure in esophageal emptying (defined by lack of reduction in height of barium column by 50 %) in TBE, and 11/19 (58 %) had LES pressure >22.5 mmHg (p = ns). Kaplan-Meier analysis showed that response on TBE and HRM at 1 month predicted clinical response well during 6 months follow up. CONCLUSION TBE and esophageal HRM were comparable in assessing efficacy of PD in treatment of achalasia.
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Qian L, Wang B, Li K, Yu L, Ding J, Zhang H, Ding X, Shi R. Long-term efficacy of pneumatic dilation and esophageal stenting for the treatment of achalasia. Digestion 2014; 88:209-16. [PMID: 24217292 DOI: 10.1159/000355207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 08/21/2013] [Indexed: 02/04/2023]
Abstract
AIMS To compare the efficacy and safety of pneumatic dilation with stenting for the treatment of achalasia. METHODS Achalasia patients treated with pneumatic dilation or stenting were included in this analysis. Clinical symptoms were assessed by the Eckardt score. An esophagram and esophageal manometry were performed at the pretreatment and posttreatment follow-up visits. Data such as patient demographics and complications were collected. A drop in the Eckardt score to ≤3 was defined as treatment success. RESULTS There were 151 patients treated with pneumatic dilation (n = 76) or stenting (n = 75). The 1-, 12- and 24-month therapeutic success rates were 100, 92 and 79%, respectively, in the dilation group and 100, 93 and 87%, respectively, in the stenting group. The decrease of Eckardt score in the stenting group was significantly notable (p < 0.05) compared to that of the dilation group at the long-term follow-up visits. The maximum esophageal diameter was comparable at baseline and became statistically significant [25 mm (22-30) vs. 22 mm (19-27), p = 0.004] at posttreatment month 24. The recurrence rate was 21% in the dilation group and 13% in the stenting group. The complications of either treatment were usually mild, transient and statistically insignificant. CONCLUSION Esophageal stenting had a comparable short-term but better long-term efficacy in comparison with pneumatic dilation.
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Affiliation(s)
- Lijuan Qian
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
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For patients with primary achalasia the clinical success of pneumatic balloon dilatation can be predicted from the residual fraction of radionuclide during esophageal transit scintigraphy. Dig Dis Sci 2014; 59:375-82. [PMID: 24166664 DOI: 10.1007/s10620-013-2906-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 10/03/2013] [Indexed: 01/21/2023]
Abstract
BACKGROUND Esophageal transit scintigraphy (ETS) and esophagography have long been used to evaluate patients with achalasia. The objectives of our study were to evaluate the efficacy of endoscopic pneumatic dilatation (EPD) as treatment for Koreans with achalasia and to determine which findings from ETS and esophagography predict successful treatment of achalasia. METHODS Patients with achalasia who were treated by EPD between April 2002 and January 2012 were recruited. We defined the success of EPD as 6 months or more of clinical remission without symptoms or a decrease in the Eckardt scores by at least two points and a total Eckardt score not exceeding 3. We reviewed the percentage of maximum scintigraphic activity retained in the esophagus at 30 s (R 30) and the post-PD rate of reduction of R 30 ((Pre R 30 - Post R 30)/Pre R 30 × 100) by ETS. Possible predictive factors determined by ETS and esophagography were analyzed. RESULTS Our study included 53 eligible patients. The median symptom score (Eckardt score) was 5 (4-8). R 30 and T 1/2 were, respectively, 61.8 % and 38.5 min before EPD and 20 % and 4.19 min after EPD. Successful EPD was achieved for 40 of 53 (75.47 %) patients. Age (≥40, p = 0.027) and post-PD rate of reduction of R 30 (>20 %, p = 0.003) were best prognostic indicators of clinical success. There were no perforations related to EPD. CONCLUSION Older age and a post-PD rate of reduction of R 30 were strongly associated with better outcomes. Examination with ETS before and after EPD can be used to objectively assess a patient's short-term response to EPD.
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Pasha SF, Acosta RD, Chandrasekhara V, Chathadi KV, Decker GA, Early DS, Evans JA, Fanelli RD, Fisher DA, Foley KQ, Fonkalsrud L, Hwang JH, Jue TL, Khashab MA, Lightdale JR, Muthusamy VR, Sharaf R, Saltzman JR, Shergill AK, Cash B. The role of endoscopy in the evaluation and management of dysphagia. Gastrointest Endosc 2014; 79:191-201. [PMID: 24332405 DOI: 10.1016/j.gie.2013.07.042] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 07/29/2013] [Indexed: 02/06/2023]
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Aljebreen AM, Samarkandi S, Al-Harbi T, Al-Radhi H, Almadi MA. Efficacy of pneumatic dilatation in Saudi achalasia patients. Saudi J Gastroenterol 2014; 20:43-7. [PMID: 24496157 PMCID: PMC3952419 DOI: 10.4103/1319-3767.126317] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND/AIMS Pneumatic dilatation (PD) is one of the effective treatments of achalasia. The aim of this study was to evaluate the efficacy of pneumatic dilation and patient satisfaction in Saudi achalasia patients. PATIENTS AND METHODS We have retrospectively recruited patients with confirmed achalasia, who underwent at least one dilatation session from January 1990 to January 2010 at a single tertiary center. Symptoms, including weight loss, dysphagia, retrosternal pain, and regurgitation, were assessed with the use of the Eckardt score (which ranges from 0 to 12, with higher scores indicating more pronounced symptoms). All patients were called and asked about their Eckardt score in addition to their satisfaction score post the dilatation procedure. The primary outcome was therapeutic success (Eckardt score≤3) and patient satisfaction at the time of their calls. The secondary outcomes included the need for retreatment and the rate of complications. RESULTS A total of 29 patients were included, with a mean age of 40.30 (95% CI: 36.1-44.6) and 55.2% of them were males. The mean of the pre-dilatation Eckardt score was 8.3 (95% CI: 7.2-9.4), which dropped to 2.59 (95% CI: 1.7-3.5) after PD (P<0.01) with a clinical remission of 76.7% after the first dilatation and a total failure in two patients (7%) after the third dilatation. The mean number of dilatations was 1.3 (95% CI: 1.1-1.5) where 50.7% required one dilatation, 19.2% required two dilatations, and 30.1% required three dilatations. The mean of the symptoms-free period was 53.4 months (SD 52.7, range 1-180) with symptoms recurring in 35% of patients within 2 years. The mean of post-PD patient satisfaction was 7.45 (95% CI: 6.2-8.7). Perforation, which was treated conservatively, occurred in one patient (3.5%), whereas bleeding occurred in two patients (7%). Age or gender was not found to be a predictor of Eckardt score improvement on multivariate linear regression analysis. CONCLUSION PD is an efficacious procedure in Saudi achalasia patients with a very good overall patient satisfaction with 53.4 months of symptoms-free period after a successful dilatation.
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Affiliation(s)
- Abdulrahman M. Aljebreen
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia,Address for correspondence: Dr. Abdulrahman M Aljebreen, Division of Gastroenterology, Internal Medicine Department, King Khalid University Hospital, Po Box 2925, Riyadh - 11461, Saudi Arabia. E-mail:
| | - Sara Samarkandi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Tahani Al-Harbi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Haifa Al-Radhi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Majid A Almadi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia,Gastroenterology, McGill University Health Center, Montreal General Hospital, McGill University, Montreal, Canada
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Kumar AR, Schnoll-Sussman FH, Katz PO. Botulinum toxin and pneumatic dilation in the treatment of achalasia. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2014. [DOI: 10.1016/j.tgie.2013.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Borges AA, Lemme EMDO, Abrahao LJ, Madureira D, Andrade MS, Soldan M, Helman L. Pneumatic dilation versus laparoscopic Heller myotomy for the treatment of achalasia: variables related to a good response. Dis Esophagus 2014; 27:18-23. [PMID: 23551592 DOI: 10.1111/dote.12064] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Achalasia is a motor disorder characterized by esophageal aperistalsis and failure of lower esophageal sphincter relaxation. The cardinal symptoms are dysphagia, food regurgitation and weight loss. The most effective treatments are pneumatic dilation (PD) of the cardia and Heller esophageal myotomy with partial fundoplication. There is still controversy regarding which treatments should be initially done. The aims of this study were to evaluate clinical response and the variables related to good results in both treatments. Ninety-two patients with achalasia diagnosed by esophageal manometry were randomized to receive either PD or laparoscopic Heller myotomy with partial fundoplication. After the procedure, patients were followed up clinically and submitted to esophageal manometry and pH monitoring. Three months after treatment, 73% of the patients from PD group and 84% of the surgery group had good results (P = 0.19). After 2 years of follow-up, 54% of the PD group and 60% of the surgery group (P = not significant) were symptom free. Variables related to a good response to PD were a 50% drop in lower esophageal sphincter pressure (LESP) or a LESP <10 mmHg after treatment. Patients over 40 years old with LESP ≤32 mmHg before treatment and a drop in LESP >50% after treatment significantly achieved better responses after surgical treatment when compared with PD. The reflux rate was significantly higher in the PD group (27.7%) compared with the surgery group (4.7%), P = 0.003. We concluded that surgical treatment and PD for achalasia are equally effective even after 2 years of follow-up. The choice of treatment for achalasia should be based on the following parameters: treatment availability, rate of good results, complication rates, variables related to good responses and also the patient's wish.
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Affiliation(s)
- A A Borges
- Esophagus Unit, Gastroenterology Division, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Elhanafi S, Othman M, Sunny J, Said S, Cooper CJ, Alkhateeb H, Quansah R, McCallum R. Esophageal perforation post pneumatic dilatation for achalasia managed by esophageal stenting. AMERICAN JOURNAL OF CASE REPORTS 2013; 14:532-5. [PMID: 24349606 PMCID: PMC3862140 DOI: 10.12659/ajcr.889637] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 12/09/2013] [Accepted: 09/02/2013] [Indexed: 01/14/2023]
Abstract
Patient: Female, 82 Final Diagnosis: Achalasia Symptoms: Nocturnal regurgtation • weight loss Medication: — Clinical Procedure: Esophageal stenting Specialty: Gastroenterology • Hepatology Objective: Unusual or unexpected effect of treatment
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Affiliation(s)
- Sherif Elhanafi
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, U.S.A
| | - Mohamed Othman
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, U.S.A
| | - Joseph Sunny
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, U.S.A
| | - Sarmad Said
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, U.S.A
| | - Chad J Cooper
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, U.S.A
| | - Haider Alkhateeb
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, U.S.A
| | - Raphael Quansah
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, U.S.A
| | - Richard McCallum
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, U.S.A
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Efficacy and safety of pneumatic dilatation for achalasia in the treatment of post-myotomy symptom relapse. Am J Gastroenterol 2013; 108:1076-81. [PMID: 23458850 DOI: 10.1038/ajg.2013.32] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 01/18/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES There is no consensus on how best to treat symptom recurrence following previous therapy with Heller myotomy. Our aim was to determine the safety and the short and long-term efficacy of pneumatic dilatation to treat symptomatic recurrence in patients previously treated with Heller myotomy for idiopathic achalasia. METHODS We identified 27 eligible patients treated with pneumatic dilatation, for symptom recurrence following Heller myotomy as their initial or secondary treatment, from a prospectively acquired database of 450 patients with a diagnosis of achalasia seen between 1995 and 2010. Our treatment protocol involved sequential, graded pneumatic dilatations (30-35-40 mm) over a 2-6 week period until an initial therapeutic response was achieved. The subsequent relapse rate, defined as the need for any subsequent therapy, was determined. Relapsers were offered further pneumatic dilatation "on demand". A cross-sectional analysis was also performed using a validated achalasia severity questionnaire to determine the overall long-term remission rate. RESULTS Of 27 eligible patients, 25 (93%) complied with the institutional dilatation protocol. The two drop-outs did so after the initial 30 mm dilatation and were deemed treatment failures. One additional patient did not respond despite protocol compliance. Therefore, 24 of 27 (89%) patients were responders on intention to treat analysis at 12 months, while the per protocol response rate was 24 of 25 (96%). Among the 24 responders 16, 25, and 42% relapsed at 2, 3 and 4 years, respectively. Overall long-term remission, with on demand dilatations as required, was 95% (median follow-up 30 months). There were no perforations in a total of 50 dilatations in 27 patients. CONCLUSIONS In treating symptom recurrence, following prior Heller myotomy, pneumatic dilatation is safe and yields an excellent short-term response rate. Although the long-term relapse rate is substantial, subsequent on demand pneumatic dilatation in this population is highly effective with a long-term remission rate of 95%. These data also highlight the need to keep these patients under long-term review.
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Elliott TR, Wu PI, Fuentealba S, Szczesniak M, de Carle DJ, Cook IJ. Long-term outcome following pneumatic dilatation as initial therapy for idiopathic achalasia: an 18-year single-centre experience. Aliment Pharmacol Ther 2013; 37:1210-9. [PMID: 23659347 DOI: 10.1111/apt.12331] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Revised: 02/11/2013] [Accepted: 04/22/2013] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- T R Elliott
- Department of Gastroenterology and Hepatology, St George Hospital, University of New South Wales, Sydney, NSW, Australia
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Lee BH, Shim KY, Hong SJ, Bok GH, Cho JH, Lee TH, Cho JY. Peroral endoscopic myotomy for treatment of achalasia: initial results of a korean study. Clin Endosc 2013; 46:161-7. [PMID: 23614126 PMCID: PMC3630310 DOI: 10.5946/ce.2013.46.2.161] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Revised: 10/04/2012] [Accepted: 10/11/2012] [Indexed: 12/16/2022] Open
Abstract
Background/Aims Achalasia is a rare esophageal motility disorder. Recently, a novel endoscopic technique, peroral endoscopic myotomy (POEM), was introduced as an alternative treatment for achalasia. We report the results and short term outcomes of POEM for patients with achalasia. Methods POEM was performed in 13 patients with achalasia. The procedure consisted of creating a submucosal tunnel followed by endoscopic myotomy of circular muscle bundles. The mucosal entry was closed by conventional hemostatic clips. A validated clinical symptom score (Eckardt score) and high resolution manometry were used to evaluate the outcomes. Results Both the clinical score of achalasia, as well as the resting lower esophageal sphincter (LES) pressure, were significantly reduced after POEM. Mean posttreatment Eckardt score was 0.4±0.7, compared to 6.4±1.9 prior to the treatment (p=0.001). The mean pretreatment and posttreatment LES pressure was 30.3 and 15.3 mm Hg, respectively (p=0.007). Following POEM, symptomatic relief from dysphagia without reflux symptoms was observed in all patients (13/13). No serious complications related to POEM were encountered. Conclusions Based upon our initial experience, the authors believe that POEM is a feasible, safe, and effective treatment and may possibly substitute established treatments of refractory achalasia.
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Affiliation(s)
- Byung Hoo Lee
- Institute for Digestive Research, Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
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Major complications of pneumatic dilation and Heller myotomy for achalasia: single-center experience and systematic review of the literature. Am J Gastroenterol 2012; 107:1817-25. [PMID: 23032978 PMCID: PMC3808165 DOI: 10.1038/ajg.2012.332] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) can be definitive therapies for achalasia; recent data suggest comparable efficacy. However, risk must also be considered. We reviewed the major complication rate of PD and LHM in a high-volume center and reviewed the corresponding literature. METHODS We reviewed 12 years of our institution's achalasia treatment experience. During this interval, a consistent technique of PD was used utilizing Rigiflex dilators. Medical records were reviewed for post-procedure complications. We administered a telephone survey and examined medical records to assess efficacy of treatment. We also performed a systematic review of the literature for comparable clinical data and examined 80 reports encompassing 12,494 LHM and PD procedures. RESULTS At our center, 463 achalasia patients underwent 567 PD or LHM procedures. In all, 78% of the PDs used a 30-mm Rigiflex dilator. In all, 157/184 (85%) patients underwent 1 or 2 PD without any subsequent treatment. There were seven clinically significant perforations; one from PD and six from LHM. There were no resultant deaths from these perforations; two deaths occurred within 30 days of LHM from unrelated causes. Complications and deaths post-PD were significantly fewer than those post-LHM (P=0.02). CONCLUSIONS Esophageal perforation from PD at our high-volume center was less common than often reported and lower than that associated with LHM. We conclude that, in the hands of experienced operators using conservative technique, PD has fewer major complications and deaths than LHM.
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Pneumatic balloon dilation in pediatric achalasia: efficacy and factors predicting outcome at a single tertiary pediatric gastroenterology center. Gastrointest Endosc 2012; 76:927-32. [PMID: 22921148 DOI: 10.1016/j.gie.2012.06.035] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2012] [Accepted: 06/23/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND The use of pneumatic dilation (PD) is well established in adults with achalasia; however, it is less commonly used in children. OBJECTIVE To evaluate the efficacy of PD in pediatric achalasia and to define predictive factors for its treatment failure. DESIGN Single-center, prospective cohort study. SETTING Academic tertiary referral center. PATIENTS Twenty-four patients with achalasia were enrolled from January 2004 to November 2009 and were followed for a median of 6 years. INTERVENTION PD was performed with the patients under general anesthesia. MAIN OUTCOME MEASUREMENTS Efficacy and safety of PD. Follow-up was performed by using the Eckardt score, barium swallow contrast studies, and esophageal manometry at baseline; 1, 3, and 6 months after dilation; and every year thereafter. A Cox regression model was used to identify independent predictors of failure after the first PD. RESULTS The PD success rate was 67%. In 8 patients, the first PD failed, but the parents of one patient refused a second PD and requested surgery. Of the 7 patients who underwent repeated treatment, the second PD failed in 3 (43%). Overall, only 3 of the 24 patients underwent surgery (overall success rate after a maximum of 3 PDs was 87%). Multivariate analysis showed that only older age was independently associated with a higher probability of the procedure success (hazard ratio [HR] 0.66; 95% CI, 0.45-0.97). LIMITATIONS Small sample size, single-center study. CONCLUSIONS PD is a safe and effective technique in the management of pediatric achalasia. Young age is an independent negative predictive factor for successful clinical outcome.
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Molena D, Yang SC. Surgical management of end-stage achalasia. Semin Thorac Cardiovasc Surg 2012; 24:19-26. [PMID: 22643658 DOI: 10.1053/j.semtcvs.2012.01.015] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2012] [Indexed: 02/07/2023]
Abstract
Esophageal achalasia is a chronic and progressive motility disorder that leads to massive esophageal dilation when left untreated. Treatment for achalasia is palliative and aimed to relieve the outflow obstruction at the level of the lower esophageal sphincter, yet protecting the esophageal mucosa from refluxing gastric acids. The best way to accomplish this goal is through an esophageal myotomy and partial fundoplication, with a success rate >90%. Progression of disease, treatment failure, and complications from gastroesophageal reflux disease cause progressive deterioration of the esophageal function to an end stage in about 5% of patients. The only chance to improve symptoms in this small group of patients is through an esophageal resection. This article will review the indications for esophagectomy in end-stage achalasia, present the different types of surgical approach and possibilities for reconstruction of the alimentary tract, and summarize the short-term and long-term postoperative results.
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Affiliation(s)
- Daniela Molena
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA
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Weber CE, Davis CS, Kramer HJ, Gibbs JT, Robles L, Fisichella PM. Medium and long-term outcomes after pneumatic dilation or laparoscopic Heller myotomy for achalasia: a meta-analysis. Surg Laparosc Endosc Percutan Tech 2012; 22:289-96. [PMID: 22874676 DOI: 10.1097/sle.0b013e31825a2478] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Recent randomized studies comparing outcomes after pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) for the treatment of achalasia are conflicting and limited to short-term follow-up. Our meta-analysis compared the long-term durability of these approaches, with the hypothesis that LHM offers superior long-term remission compared with PD. We identified 36 studies published between 2001 and 2011 with at least 5 years of follow-up. Those studies describing PD included 3211 patients (mean age, 49.8 y). For PD, the mean 5-year remission rate was 61.9% and the mean 10-year remission rate was 47.9%. Overall, 1526 patients (mean age, 46.3 y) were treated with LHM; 83% received a fundoplication. In contrast, the mean 5- and 10-year remission rates after LHM were 76.1% and 79.6%, respectively. Finally, the perforation rate for LHM was twice that of PD (4.8% vs. 2.4%; P<0.05). We conclude that despite a higher frequency of perforation, LHM affords greater long-term durability.
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Affiliation(s)
- Cynthia E Weber
- Department of Surgery, Loyola University Medical Center, Stritch School of Medicine, Maywood, IL 60153, USA
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Gockel I, Sgourakis G, Drescher DG, Lang H. Impact of minimally invasive surgery in the spectrum of current achalasia treatment options. Scand J Surg 2012; 100:72-7. [PMID: 21737381 DOI: 10.1177/145749691110000202] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Minimally invasive Heller myotomy has evolved the "gold standard" procedure for achalasia in the spectrum of current treatment options. The laparoscopic technique has proved superior to the thoracoscopic approach due to improved visualization of the esophagogastric junction. Operative controversies most recently include the length of the myotomy, especially of its fun-dic part, with respect to the balance between postoperative persistent dysphagia and development of gastroesophageal reflux, as well as the type of the added antireflux procedure. Peri-operative mortality should approach 0%, and favorable long-term results can be achieved in > 90%.
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Affiliation(s)
- I Gockel
- Department of General and Abdominal Surgery, Johannes Gutenberg University Hospital, Mainz, Germany.
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Vanuytsel T, Lerut T, Coosemans W, Vanbeckevoort D, Blondeau K, Boeckxstaens G, Tack J. Conservative management of esophageal perforations during pneumatic dilation for idiopathic esophageal achalasia. Clin Gastroenterol Hepatol 2012; 10:142-9. [PMID: 22064041 DOI: 10.1016/j.cgh.2011.10.032] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2011] [Revised: 09/25/2011] [Accepted: 10/24/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Esophageal perforation is the most serious adverse event of pneumatic dilation (PD) for achalasia; it is usually managed by surgical repair. We investigated risk factors for esophageal perforation after PD and evaluated safety and long-term outcome of nonsurgical management strategies. METHODS We analyzed medical records of patients with achalasia who were treated with PD from 1992-2010 at the University Hospital Gasthuisberg in Leuven, Belgium; all patients with esophageal perforation were contacted to determine long-term outcomes. Achalasia outcomes were assessed by using the Vantrappen criteria. RESULTS Of 830 PD procedures performed on 372 patients with manometry-confirmed achalasia (57 ± 1 years, 51% male), 16 were complicated by transmural esophageal perforation (4.3% of patients, 1.9% of dilations). Age >65 years was the only significant risk factor for complications (odds ratio, 3.5; 95% confidence interval, 1.2-10.2). All patients were treated conservatively with broad-spectrum antibiotics and nothing by mouth. In 6 patients (38%) the clinical course was further complicated by a pleural effusion, which required a drain in 4 patients. One patient (6%) died of mediastinal hemorrhage within 12 hours after PD. Patients with complications were discharged after 19 ± 2.3 days, compared with 4 ± 0.2 days for those without complications (P < .0001). Long-term outcomes (mean follow-up, 84 ± 14 months) were determined for 12 patients (75%); 11 had excellent or good outcomes (69%), and 1 had a moderate outcome (6%). CONCLUSIONS Age >65 years is a significant risk factor for esophageal perforation after PD. Nonsurgical management of transmural esophageal tears is feasible, with favorable short-term and long-term outcomes, but is not devoid of complications.
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Affiliation(s)
- Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
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Ghoshal UC, Rangan M, Misra A. Pneumatic dilation for achalasia cardia: reduction in lower esophageal sphincter pressure in assessing response and factors associated with recurrence during long-term follow up. Dig Endosc 2012; 24:7-15. [PMID: 22211406 DOI: 10.1111/j.1443-1661.2011.01159.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Data on utility of post-pneumatic dilation (PD) lower esophageal sphincter (LES) pressure measurement in evaluating short and long-term efficacy of dilation, which tears the non-relaxing LES in achalasia, are scanty. METHODS Post-PD LES pressure was measured in 72/98 patients with achalasia. The best cut-off pressure classifying responders and non-responders was determined by receiver operating characteristic (ROC) curve. Factors associated with non-response and recurrence were evaluated. RESULTS Of 98 patients (41.1 ± 13.3 years, 58 male), 75 improved, three had perforation requiring surgery, and 20 did not respond to the first PD session. Of 18/20 patients undergoing a second PD, 11 improved and six non-responders needed myotomy. 37/58 (71%) male and 17/40 (42.5%) female patients had a first PD with a 35-mm balloon (P = 0.03). Age and gender of patients did not influence outcome. LES pressure was lower in responders or in those having recurrence than in non-responders (17 mmHg [6.4-75], 11 mmHg [4.6-31]vs 25 mmHg [13-55]). On the ROC curve, 22.5 mmHg was the best cut-off value differentiating responders and non-responders (area under curve [AUC] 0.73). Of the 86 patients responding to PD, 20 had recurrence. Patients who responded to one session of PD or had LES pressure <10 mmHg after the procedure recurred less often, although there was no relationship with age and gender. CONCLUSION Post-PD LES pressure measurement is useful to assess treatment response. Patients responding to the first session and those with post-PD LES pressure <10 mmHg tended to recur less. Age and gender did not influence outcome, which might be related to preferential use of a 35-mm balloon, particularly for male patients, during the first session.
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Affiliation(s)
- Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
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Fisichella PM, Carter SR, Robles LY. Presentation, diagnosis, and treatment of oesophageal motility disorders. Dig Liver Dis 2012; 44:1-7. [PMID: 21697019 DOI: 10.1016/j.dld.2011.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Revised: 04/22/2011] [Accepted: 05/03/2011] [Indexed: 12/11/2022]
Abstract
Whilst the current treatment of achalasia is well understood, the management of other oesophageal disorders is still debated, as these are rare and the literature on their clinical presentation and management is scarce. The following review describes the clinical presentation of oesophageal motility disorders, gives an overview of their diagnosis in light of the new advances in oesophageal motility testing, and provides an evidence-based approach to their management with different forms of treatment (medical, endoscopic, and minimally invasive).
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Affiliation(s)
- Piero Marco Fisichella
- Swallowing Center, Department of Surgery, Loyola University Medical Center, Maywood, IL, United States.
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Katzka DA, Castell DO. Review article: an analysis of the efficacy, perforation rates and methods used in pneumatic dilation for achalasia. Aliment Pharmacol Ther 2011; 34:832-9. [PMID: 21848630 DOI: 10.1111/j.1365-2036.2011.04816.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pneumatic dilation has re-emerged as a first line treatment for achalasia, but conclusions are limited by the relatively small numbers of patients studied and the lack of long term follow-up. AIM To summarise and analyse 29 available studies evaluating pneumatic dilation for achalasia with focus on efficacy, rate or perforation and dilation technique. METHODS A literature search for all studies, in which pneumatic dilation was performed for treatment of achalasia, was conducted. Studies, in which clear endpoints of efficacy of single dilation sessions over a period of years, were chosen. RESULTS The response for a single dilation session was 66% at 1 year and 59, 53, 50 and 25% at 2, 3, 5 and 10 years respectively. Use of a Rigiflex dilator and multiple dilations during the initial treatment improved efficacy. Overall perforation rate was only 2% (24/1358) of which only 1% required surgery. Use of multiple dilations led to increased perforation risk. The method of dilation used with regard to balloon size, pressure used, dilation times and single or multiple dilations varied in almost every study. CONCLUSIONS Pneumatic dilation is safer than commonly thought and efficacious, although multiple dilations will be needed over a lifetime in most patients. Standardisation of the technique should be attempted.
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Affiliation(s)
- D A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.
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