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Chong Tai LI, Akil O, Nguyen KQ, Sharma A. End-Stage Achalasia With Megaesophagus Refractory to Two Heller Myotomies. Cureus 2024; 16:e55721. [PMID: 38586803 PMCID: PMC10998642 DOI: 10.7759/cureus.55721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 04/09/2024] Open
Abstract
Achalasia is a motility disorder of the esophagus in which the lower esophageal sphincter fails to relax. Megaesophagus is a rare complication of achalasia characterized by severe dilatation of the esophagus, often indicative of end-stage achalasia. Typical presenting symptoms include dysphagia, nausea, vomiting, weight loss, and chest pain. The majority of patients with achalasia typically have excellent outcomes after surgical intervention with Heller myotomy. We discuss an interesting case of unsuccessful surgical intervention and hypothesize the reason for its failure in our patient.
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Affiliation(s)
| | - Omar Akil
- Internal Medicine, Broward Health Medical Center, Fort Lauderdale, USA
| | - Kimberly Q Nguyen
- Internal Medicine, Broward Health Medical Center, Fort Lauderdale, USA
| | - Aryama Sharma
- Gastroenterology, Broward Health North, Deerfield Beach, USA
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2
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North A, Tewari N. Peroral endoscopic myotomy compared to laparoscopic Heller myotomy and pneumatic dilation in the treatment of achalasia: a systematic review. Dis Esophagus 2024; 37:doad055. [PMID: 37539633 PMCID: PMC10762503 DOI: 10.1093/dote/doad055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/28/2023] [Accepted: 07/20/2023] [Indexed: 08/05/2023]
Abstract
Peroral endoscopic myotomy (POEM) is an intervention for the treatment of achalasia which has gained popularity over the last decade. It's efficacy and invasiveness are comparable to laparoscopic Heller myotomy (LHM). The purpose of this systematic review is to compare POEM to existing therapies. The systematic review was performed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. MEDLINE, EMBASE, Web of Science and Cochrane Libraries were searched using keywords: esophageal achalasia, POEM, LHM, pneumatic dilation (PD), and related terms. The studied outcomes were Eckardt score, clinical success, hospital stay, cost-utility analysis, complications, and post-treatment gastro-esophageal reflux disease. Articles were reviewed by one researcher and uncertainty was resolved by a second researcher. The search strategy retrieved 1948 citations. After removing duplicates and applying the exclusion criteria, 91 studies were selected for full-text review of which a total of 31 studies were considered eligible for further analysis, including two studies which were found through manual searching. POEM has improved efficacy compared to PD with similar cost-effectiveness. POEM results showed comparable patient outcomes when compared with laparoscopic myotomy. Overall, POEM is a feasible first-line treatment for achalasia.
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Affiliation(s)
- Adam North
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Nilanjana Tewari
- General Surgery Department, University Hospitals of Derby and Burton, Derby, UK
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3
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Szydlo Shein G, Elazary R, Marom G, Fishman Y, Abu Gazala M, Brodie R, Jacob H, Benson AA, Rivkind A, Pikarsky AJ, Mintz Y. Post-POEM Contrast-Enhanced Swallow Study: Is It Always Necessary? J Gastrointest Surg 2023; 27:878-886. [PMID: 36720757 DOI: 10.1007/s11605-023-05605-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/09/2023] [Indexed: 02/02/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is rapidly becoming the procedure of choice for treating esophageal achalasia. In most centers, contrast-enhanced swallow studies (CESS) are routinely performed postoperatively to confirm mucosal integrity. The aim of this study was to determine the necessity of performing these studies routinely after POEM. METHODS A retrospective review of a prospectively maintained database of patients who underwent POEM between December 2012 and November 2020 was performed. All patients underwent a CESS on the first postoperative day. Medical records including vital signs, complete blood count, and POD-1 CESS were evaluated. RESULTS One hundred thirty-four consecutive patients were included in the study. Sixty-nine (51.49%) CESS showed abnormal findings; while most findings did not change the postoperative course, five (7.2%) demonstrated tunnel leaks, which did alter the overall management. Screening patients for fever, tachycardia, or leukocytosis on POD-1 had a 100% sensitivity and a 62% specificity for finding a clinically significant complication on CESS. CONCLUSIONS The study findings suggest that performing routine contrast-enhanced swallow studies on all patients is not necessary following POEM, as leaks can be screened for by clinical or laboratory abnormalities. Herein, we propose an algorithm based on objective measurable findings for the selection of patients who should undergo CESS.
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Affiliation(s)
- Gabriel Szydlo Shein
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Ram Elazary
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gad Marom
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yuri Fishman
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Mahmud Abu Gazala
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ronit Brodie
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Harold Jacob
- Department of Gastroenterology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Ariel A Benson
- Department of Gastroenterology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Avraham Rivkind
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Alon J Pikarsky
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yoav Mintz
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
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Blonski W, Slone S, Richter JE. Update on the Diagnosis and Treatment of Achalasia. Dysphagia 2023; 38:596-608. [PMID: 35585208 DOI: 10.1007/s00455-022-10435-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 03/04/2022] [Indexed: 12/23/2022]
Abstract
Achalasia is a rare disease of the esophagus with impaired relaxation of the lower esophageal sphincter and aperistalsis. The etiology is unknown but speculations include a viral or autoimmune etiology. All specialists dealing with swallowing and esophageal diseases should recognize the classic symptoms of dysphagia for solids/liquids, regurgitation, and choking, especially at night. High-resolution manometry is critical for the diagnosis with endoscopy and barium esophagram having a supportive role. The disease cannot be cured but most can return to near normal swallowing and a regular diet with appropriate therapy. Treatment includes smooth muscle relaxants, botulinum toxin injections to the lower sphincter, pneumatic dilation, Heller myotomy, and peroral endoscopic myotomy. One treatment does not fit all and a tailored approach through a multidiscipline team will give the best long-term outcomes.
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Affiliation(s)
- Wojciech Blonski
- Division of Gastroenterology, James A. Haley VA Hospital, Tampa, FL, USA
- Division of Gastroenterology and Nutrition, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL, 33612, USA
| | - Samuel Slone
- Division of Gastroenterology and Nutrition, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL, 33612, USA
| | - Joel E Richter
- Division of Gastroenterology and Nutrition, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL, 33612, USA.
- Joy McCann Culverhouse Center for Esophageal Diseases, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
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Li MY, Wang QH, Chen RP, Su XF, Wang DY. Pathogenesis, clinical manifestations, diagnosis, and treatment progress of achalasia of cardia. World J Clin Cases 2023; 11:1741-1752. [PMID: 36970002 PMCID: PMC10037292 DOI: 10.12998/wjcc.v11.i8.1741] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/06/2023] [Accepted: 02/21/2023] [Indexed: 03/07/2023] Open
Abstract
Achalasia cardia, type of esophageal dynamic disorder, is a relatively rare primary motor esophageal disease characterized by the functional loss of plexus ganglion cells in the distal esophagus and lower esophageal sphincter. Loss of function of the distal and lower esophageal sphincter ganglion cells is the main cause of achalasia cardia, and is more likely to occur in the elderly. Histological changes in the esophageal mucosa are considered pathogenic; however, studies have found that inflammation and genetic changes at the molecular level may also cause achalasia cardia, resulting in dysphagia, reflux, aspiration, retrosternal pain, and weight loss. Currently, the treatment options for achalasia focus on reducing the resting pressure of the lower esophageal sphincter, helping to empty the esophagus and relieve symptoms. Treatment measures include botulinum toxin injection, inflatable dilation, stent insertion, and surgical myotomy (open or laparoscopic). Surgical procedures are often subject to controversy owing to concerns about safety and effectiveness, particularly in older patients. Herein, we review clinical epidemiological and experimental data to determine the prevalence, pathogenesis, clinical presentation, diagnostic criteria, and treatment options for achalasia to support its clinical management.
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Affiliation(s)
- Ming-Yue Li
- School of Nursing, Binzhou Medical University, Yantai 264003, Shandong Province, China
| | - Qing-Hua Wang
- School of Nursing, Binzhou Medical University, Yantai 264003, Shandong Province, China
| | - Run-Peng Chen
- School of Nursing, Binzhou Medical University, Yantai 264003, Shandong Province, China
| | - Xiao-Fang Su
- School of Nursing, Binzhou Medical University, Yantai 264003, Shandong Province, China
| | - Dong-Yang Wang
- School of Nursing, Binzhou Medical University, Yantai 264003, Shandong Province, China
- Faculty of Nursing, Mahidol University, Nakhon Pathom 73170, Thailand
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Slim N, Williamson JM. Achalasia: investigation and management. Br J Hosp Med (Lond) 2023; 84:1-9. [PMID: 36708337 DOI: 10.12968/hmed.2022.0437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Achalasia, characterised by the absence of peristalsis and failure of relaxation of the lower oesophageal sphincter, is an uncommon degenerative condition that results in dysphagia. If left untreated it can lead to aspiration, oesophageal perforation, oesophagitis and malnutrition. It has a range of immune, allergic, viral and genetic aetiological causes. Successful diagnosis relies on the use of oesophagogastroduodenoscopy, barium swallow and oesophageal manometry to characterise the severity of the disease and to rule out underlying malignancy. Although no treatment can reverse the degenerative process, therapeutic strategies including lifestyle modification, medication, endoscopic and operative intervention can help to reduce symptoms. This article reviews the latest methods used to investigate and manage achalasia.
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Affiliation(s)
- Naim Slim
- Department of General Surgery, The Great Western Hospital, Swindon, UK
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Rezapanah A, Zandbaf T, Dalili A, Esparham A, Ahmadyar S, Zadeh SM. Post-Surgical Quality of Life After Laparoscopic Heller Myotomy with Fundoplication for the Treatment of Achalasia. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03640-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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Xu J, Cheng LK, Avci R, Du P. Reconstruction of the Gastro-esophageal Junction Based on Ultramill Imaging for Biomechanical Analysis. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:1594-1597. [PMID: 36086610 DOI: 10.1109/embc48229.2022.9871765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The gastro-esophageal junction (GEJ) regulates the entry of food into the stomach and prevents reflux of acidic gastric contents into the lower esophagus. This is achieved through multiple mechanisms and the maintenance of a localized high-pressure zone. Diseases of the GEJ typically involve impairments to its muscular functions and often are accompanied by symptoms of reflux, heartburn, and dysphagia. This study aimed to develop a finite element-based model from a unique human cadaver GEJ data reconstructed from an ultramill imaging setup. A pipeline was developed to generate a mesh from an input stack of images. The anatomy of the model was compared to an existing Visible Human finite element GEJ model. Biomechanical simulations were also performed on both models using loading steps of differing levels of calcium to model different levels of contraction. It was found that the ultramill GEJ model is shorter than the Visible Human model (31 vs 48.3 mm), as well as producing lower pressure (1.35 vs 4.36 kPa). The model will be used to investigate detailed pressure development in the GEJ during swallowing under realistic loading conditions. Clinical Relevance - The modeling of the GEJ would allow further insights into pressure influencing factors and aid in the development and testing of treatments.
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Tang YF, Jin P, Tao YR, Xie H, Wang X, Yu D, Tang S, Sheng JQ. Comparison of fully coated anti-reflux metal stenting and per-oral endoscopic myotomy in patients with achalasia: a propensity score-matched retrospective study. BMC Gastroenterol 2022; 22:253. [PMID: 35585499 PMCID: PMC9118839 DOI: 10.1186/s12876-022-02282-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 04/11/2022] [Indexed: 11/21/2022] Open
Abstract
Background Achalasia is a rare primary esophageal motility disorder disease. It is reported that the long-term effect of fully coated anti-reflux metal stent (FCARMS) implantation is satisfactory. Operated by a skilled and experienced endoscopist, the effect of per-oral endoscopic myotomy (POEM) treatment is equivalent to that of surgical myotomy. So far, there is still few evidence to prove FCARMS implantation or POEM which is better for achalasia. The choice of treatment for achalasia is still controversial. The aim of this study is to find a more suitable therapy for achalasia by comparing the efficacy of FCARMS implantation and POEM. Methods A propensity score (PS) matching (1:2) was used in this retrospective cohort study. Data collected from consecutive patients of Achalasia, receiving FCARMS implantation or POEM therapy at the department of gastroenterology, the Seventh Medical Center of the Chinese People’s Liberation Army General Hospital from May 2007 to May 2018. According to their previous treatment, they are divided into two groups, FCARMS group and POEM group. Clinical efficacy and complications were compared between the two groups. Results A total of 166 cases were collected, including 113 cases of FCARMS and 53 cases of POEM. By PS matching, 150 patients were enrolled (100 cases of FCARMS and 50 cases of POEM). By comparison, the FCARMS group has shorter operation time, shorter fasting time and lower hospitalization costs than the POEM group (p < 0.05). Common complications in the FCARMS group are nausea, vomiting, and stent shift. Repetitions of gastroscopy in the FCARMS group was more often, which were 3.8 ± 2.4 (vs 2.1 ± 1.8 of POEM) (p = 0.00 < 0.05) The 6-month remission rates of the FCARMS combination POEM group were 89% and 94%, respectively (p = 0.39), and the 2-year remission rates were 61% and 90%, respectively (p = 0.00). Conclusions Stent placement is a cost-effective and safe treatment option for achalasia. The short-term effect (less than 6 months) of FCARMS is similar to that of POEM, the long-term effect (more than 2 years), POEM is better than FCARMS. HRMIIis most suitable for POEM treatment. It indicate that Patients can choose treatment methods according to their own conditions.
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Affiliation(s)
- Yu-Fen Tang
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Nanmencang 5#, Dongcheng District, Beijing, 100700, China.,Senior Department of Gastroenterology, The First Medical Center of PLA General Hospital, Beijing, China
| | - Peng Jin
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Nanmencang 5#, Dongcheng District, Beijing, 100700, China.,Senior Department of Gastroenterology, The First Medical Center of PLA General Hospital, Beijing, China
| | - Yu-Rong Tao
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Nanmencang 5#, Dongcheng District, Beijing, 100700, China.,Senior Department of Gastroenterology, The First Medical Center of PLA General Hospital, Beijing, China
| | - Hui Xie
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Nanmencang 5#, Dongcheng District, Beijing, 100700, China
| | - Xin Wang
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Nanmencang 5#, Dongcheng District, Beijing, 100700, China
| | - Dongliang Yu
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Nanmencang 5#, Dongcheng District, Beijing, 100700, China
| | - Shan Tang
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Nanmencang 5#, Dongcheng District, Beijing, 100700, China
| | - Jian-Qiu Sheng
- Department of Gastroenterology, The Seventh Medical Center of PLA General Hospital, Nanmencang 5#, Dongcheng District, Beijing, 100700, China. .,Senior Department of Gastroenterology, The First Medical Center of PLA General Hospital, Beijing, China.
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Engwall-Gill AJ, Soleimani T, Engwall SS. Heller myotomy perforation: robotic visualization decreases perforation rate and revisional surgery is a perforation risk. J Robot Surg 2021; 16:867-873. [PMID: 34570344 DOI: 10.1007/s11701-021-01307-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 06/26/2021] [Indexed: 10/20/2022]
Abstract
Minimally invasive surgery (MIS) has improved surgical access to the foregut. While the benefits of MIS versus open surgery are well accepted, the relative benefits of laparoscopic versus robotic approaches continue to be debated. Procedure-specific comparisons are difficult to obtain for Heller myotomy, due to the relative rarity of the procedure in most practices. A retrospective review of prospectively collected perioperative data of a single surgical practice from 2001 to 2019 was conducted for the rate of perforation during Heller myotomy laparoscopically compared to robotically. From 2001 through February 2012, a laparoscopic approach was employed and from October 2008 to 2019, a robotic approach was employed. All perforations were recorded, as well as secondary outcomes of perforation location (gastric or esophageal), postoperative imaging for evidence of leak, length of stay, and complications. Chi-square and simple t test were employed for data analysis. During the 11 years of laparoscopic Heller myotomy, 14 cases resulted in 7 instances of perforation (50%). During the 11 years of robotic Heller myotomy, 45 cases resulted in 11 instances of perforation (24%) (p value = 0.06). All perforations in both groups were tiny, recognized, and repaired immediately. The length of stay (LOS) was longer in the laparoscopic perforation group (3.4 days) compared to the laparoscopic non-perforation group (1.2 days) (p value = 0.06). LOS for robotic was not significantly longer in the perforation group (2.8 days) compared to the robotic non-perforation group (1.5 days) (p value = 0.18). First time Heller myotomies showed a higher rate of perforation with laparoscopic (50%) vs robotic (14%) (p value = 0.009) approach. In subgroup analysis of revisional procedures, all ten were performed robotically (p value < 0.001) with a 60% perforation rate (p value = 0.001) and one associated, radiographically confirmed leak. Primary laparoscopic Heller myotomy related to more than four times the frequency of perforation than did primary robotic myotomy. We propose that the robotic platform provided the surgeon with superior ability to avoid perforation. Interestingly, the robotic group in this study dealt with more complex redo cases. In fact, reoperation in the area of the hiatus was a separate risk factor for perforation during robotic Heller myotomy. We recommend further prospective trials be done to better evaluate the benefits of robotic platform in regard to revisional foregut surgery.
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Affiliation(s)
- Abigail J Engwall-Gill
- Department of Surgery, Sparrow Hospital, Michigan State University, 1215 East Michigan Ave, Lansing, MI, 48912, USA.
| | - Tahereh Soleimani
- Department of Surgery, Sparrow Hospital, Michigan State University, 1215 East Michigan Ave, Lansing, MI, 48912, USA
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AlHajjaj GM, AlTaweel FY, AlQunais RA, Alshammasi ZH, Alshomimi SJ. Iatrogenic Esophageal Perforation After Laparoscopic Heller's Myotomy Treated Successfully with Endoscopic Stent: Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e931677. [PMID: 34035207 PMCID: PMC8165495 DOI: 10.12659/ajcr.931677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patient: Male, 37-year-old Final Diagnosis: Achalasia Symptoms: Dysphagia Medication:— Clinical Procedure: Laparoscopic surgery Specialty: Surgery
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Affiliation(s)
- Ghadeer M AlHajjaj
- Department of Surgery, College of Medicine, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University, Khobar, Saudi Arabia
| | - Fatimah Yasser AlTaweel
- Department of Surgery, College of Medicine, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University, Khobar, Saudi Arabia
| | - Roaya Ahmed AlQunais
- Department of Surgery, College of Medicine, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University, Khobar, Saudi Arabia
| | - Zahra H Alshammasi
- Department of Surgery, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Saeed J Alshomimi
- Department of Surgery, College of Medicine, King Fahad Hospital of the University, Imam Abdulrahman bin Faisal University, Khobar, Saudi Arabia
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Loosen SH, Kandler J, Luedde T, Kostev K, Roderburg C. Achalasia is associated with a higher incidence of depression in outpatients in Germany. PLoS One 2021; 16:e0250503. [PMID: 33930060 PMCID: PMC8087033 DOI: 10.1371/journal.pone.0250503] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 04/07/2021] [Indexed: 01/02/2023] Open
Abstract
Background and aim Achalasia represents a chronic motility disorder of the esophagus featuring an impaired lower esophageal sphincter relaxation and loss of esophageal peristalsis. By causing dysphagia, regurgitation, aspiration and chest pain, achalasia might tremendously affect life quality of patients. However, the impact of achalasia on the development of mood disorders including depression has largely remained unclear. The aim of this study was to evaluate the incidence of depression in achalasia patients. Methods We analyzed a large primary care cohort database in Germany capturing data from 7.49 million patients. Results A total of n = 1,057 patients with achalasia diagnosed between January 2005 and December 2018 were matched to a cohort of n = 3,171 patients without achalasia controlling for age, sex, physician, index year, and the Charlson comorbidity index. Interestingly, while the frequency of depression prior to the diagnosis of achalasia was comparable in both groups, new diagnoses of depression were significantly higher within one year after the diagnosis of achalasia compared to the control group, suggesting a direct and previously unrecognized association between achalasia and depression. Conclusion Our data suggest that the clinical management of patients with achalasia should include a careful and structured work-up for mood disorders in order to improve long-term quality of life in these patients.
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Affiliation(s)
- Sven H. Loosen
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Jennis Kandler
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Tom Luedde
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | | | - Christoph Roderburg
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- * E-mail:
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Xie J, Vatsan MS, Gangemi A. Laparoscopic versus robotic-assisted Heller myotomy for the treatment of achalasia: A systematic review with meta-analysis. Int J Med Robot 2021; 17:e2253. [PMID: 33844413 DOI: 10.1002/rcs.2253] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/03/2021] [Accepted: 03/12/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Robotic-assisted laparoscopic Heller myotomy has been proposed as an alternative minimally invasive approach to traditional laparoscopy for the treatment of achalasia. This systematic review aims to compare the safety and post-operative outcomes of the two procedures. METHODS Systematic literature search was performed in MEDLINE through Ovid, Scopus and Cochrane to identify clinical trials and retrospective analyses. Outcome measures used for meta-analysis included operative time, estimated blood loss, length of stay, 30-day readmission, intraoperative oesophageal perforation, conversion, mortality, morbidity, symptom relief beyond 1 year, re-intervention for recurrent symptoms and gastroesophageal reflux during follow-up rates. RESULTS Seven studies were selected with a total of 3214 patients. The only factor to be statistically different is intraoperative oesophageal perforation rate, which is lower in robotic-assisted Heller myotomy compared to laparoscopic (odds ratio = 0.1139; 95% confidence interval [0.0334, 0.3887]; p = 0.0005). CONCLUSIONS The results suggest a robotic approach is associated with improved patient safety.
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Affiliation(s)
- Julia Xie
- Division of General, Minimally Invasive & Robotic Surgery, University of Illinois Hospital & Health Sciences System, Chicago, Illinois, USA
| | - Maansi S Vatsan
- Division of General, Minimally Invasive & Robotic Surgery, University of Illinois Hospital & Health Sciences System, Chicago, Illinois, USA
| | - Antonio Gangemi
- Division of General, Minimally Invasive & Robotic Surgery, University of Illinois Hospital & Health Sciences System, Chicago, Illinois, USA
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Kahaleh M, Tyberg A, Suresh S, Lambroza A, Gaidhane M, Zamarripa F, Martínez GM, Carames JC, Moura ET, Farias GF, Porfilio MG, Nieto J, Rey M, Rodriguez Casas F, Mondragón Hernández OV, Vargas-Rubio R, Canadas R, Hani A, Munoz G, Castillo B, Lukashok HP, Robles-Medranda C, de Moura EG. How does per-oral endoscopic myotomy compare to Heller myotomy? The Latin American perspective. Endosc Int Open 2020; 8:E1392-E1397. [PMID: 33015342 PMCID: PMC7508649 DOI: 10.1055/a-1223-1521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 06/12/2020] [Indexed: 12/12/2022] Open
Abstract
Background and study aims Both Heller myotomy (HM) and per-oral endoscopic myotomy (POEM) are efficacious therapies for achalasia. The efficacy and safety of POEM vs HM in Latin America and specifically in patients with Chagas disease is unknown. Patients and methods Consecutive patients undergoing either HM or POEM for achalasia were included from nine Latin American centers in a prospective registry over 5 years. Technical success was defined as undergoing a successful myotomy. Clinical success was defined as achieving an Eckardt score < 3. Data on demographics, procedure info, Eckardt score, and adverse events (AEs) were collected. Student's t test, Chi squared, and logistic regression analyses were conducted. Results One hundred thirty-three patients were included (59 male; 44 %; mean age 47). POEM was performed in 69 patients, HM in 64 patients. A total of 35 patients had Chagas disease, 17 of 69 in the POEM group, 18 of 64 in the HM group. Both groups had significant reduction in Eckardt scores ( P < 0.00001), but successful initial therapy was significantly higher in the POEM group compared to the HM group ( P = 0.01304). AEs were similar in both group (17 % vs 14 %) and consisted of pneumothorax (n = 3 vs 2), bleeding requiring transfusion (n = 3 vs 2), and mediastinitis (n = 3 vs 1). Hospital stay was longer in the HM group than in the POEM group ( P < 0.00001). In the Chagas subgroup, post-procedure Eckardt score in the POEM group was significantly reduced by 5.71 points ( P < 0.00001) versus 1.56 points in the HM group ( P = 0.042793). Conclusion Both HM and POEM are efficacious for achalasia, but POEM was associated with higher initial therapy success and shorter hospital stay in Latin America. In Chagas patients with achalasia, POEM was significantly more effective than HM.
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Affiliation(s)
- Michel Kahaleh
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
| | - Amy Tyberg
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
| | - Supriya Suresh
- Weill Cornell Medical School, New York, New York, United States
| | - Arnon Lambroza
- Weill Cornell Medical School, New York, New York, United States
| | - Monica Gaidhane
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
| | | | | | | | | | | | | | - Jose Nieto
- Borland-Groover, Jacksonville, Florida, United States
| | - Mario Rey
- La Policia Hospital, Bogota, Colombia
| | | | | | | | - Raul Canadas
- San Ignacio University Hospital, Bogota, Colombia
| | - Albis Hani
- San Ignacio University Hospital, Bogota, Colombia
| | - Guillermo Munoz
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
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15
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Olson MT, Triantafyllou T, Singhal S. A Decade of Investigation: Peroral Endoscopic Myotomy Versus Laparoscopic Heller Myotomy for Achalasia. J Laparoendosc Adv Surg Tech A 2019; 29:1093-1104. [PMID: 31313957 DOI: 10.1089/lap.2019.0242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Although laparoscopic Heller myotomy (LHM) with partial fundoplication has long been considered the gold standard for treatment of patients with achalasia, peroral endoscopic myotomy (POEM) has emerged in the last decade as a viable alternative. Methods: A collective review of literature concerning investigations that have reported patient outcomes and treatment success of LHM and POEM for all achalasia subtypes. Results: While POEM has shown excellent short-term safety and efficacy in the relief of symptoms, the long-term symptomatic outcomes after the intervention are yet to be concluded. Further evaluation of patients' interpretations and answers on subjective questionnaires is warranted before determining treatment success for POEM. Use of more reliable and disease-specific health-related quality-of-life questionnaires are better justified when comparing a new endoscopic procedure to an established gold standard. The need for objective parameters to measure reflux, longer follow-up studies, and randomized trials comparing POEM to LHM is particularly important when assessing the outcome of this new technique. High incidence of post-POEM pathologic reflux and indication for daily proton pump inhibitor use is of concern, and the lack of more long-term, objective evidence leaves the clinical value of the procedure in a state of uncertainty. Conclusions: The LHM combined with partial fundoplication is still considered to be the gold standard treatment modality for achalasia, but as the POEM procedure rapidly becomes common practice, this treatment may be performed in the majority of achalasia cases. Given the number of flaws overlooked in seminal investigations, careful consideration should be given to the patients being selected for this therapy.
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Affiliation(s)
- Michael T Olson
- University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Tania Triantafyllou
- Hippocration General Hospital of Athens, University of Athens, Athens, Greece
| | - Saurabh Singhal
- Department of GI Surgery and Liver Transplantation, Indraprastha Apollo Hospital, New Delhi, India
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16
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Reintervention After Heller Myotomy for Achalasia: Is It Inevitable? Ann Thorac Surg 2019; 107:860-867. [DOI: 10.1016/j.athoracsur.2018.09.059] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 09/10/2018] [Accepted: 09/24/2018] [Indexed: 01/11/2023]
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17
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Chuah SK, Lim CS, Liang CM, Lu HI, Wu KL, Changchien CS, Tai WC. Bridging the Gap between Advancements in the Evolution of Diagnosis and Treatment towards Better Outcomes in Achalasia. BIOMED RESEARCH INTERNATIONAL 2019; 2019:8549187. [PMID: 30881999 PMCID: PMC6381566 DOI: 10.1155/2019/8549187] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 01/02/2019] [Accepted: 01/20/2019] [Indexed: 02/05/2023]
Abstract
Over the past few decades, there was an encouraging breakthrough in bridging the gap between advancements in the evolution of diagnosis and treatment towards a better outcome in achalasia. The purpose of this review is to provide updated knowledge on how the current evidence has bridged the gap between advancements in the evolution of diagnosis and treatment of esophageal achalasia. The advent of high-resolution manometry and standardization based on the Chicago classification has increased early recognition of the disease. These 3 clinical subtypes of achalasia can predict the outcomes of patients, and the introduction of POEM has revolutionized the choice of treatment. Previous evidence has shown that laparoscopic Heller myotomy (LHM) and anterior fundoplication were considered the most durable treatments for achalasia. Based on the current evidence, POEM has been evolving as a promising strategy and is effective against all 3 types of achalasia, but the efficacy of POEM is based on short- and medium-term outcome studies from a limited number of centers. Types I and II achalasia respond well to POEM, LHM, and PD, while most studies have shown that type III achalasia responds better to POEM than to LHM and PD. In general, among the 3 subtypes of achalasia, type II achalasia has the most favorable outcomes after medical or surgical therapies. The long-term efficacy of POEM is still unknown. The novel ENDOFLIP measures the changes in intraoperative esophagogastric junction dispensability, which enables a quantitative assessment of luminal patency and sphincter distension; however, this technology is in its infancy with little data to date supporting its intraoperative use. In the future, identifying immunomodulatory drugs and the advent of stem cell therapeutic treatments, including theoretically transplanting neuronal stem cells, may achieve a functional cure. In summary, it is important to identify the clinical subtype of achalasia to initiate target therapy for these patients.
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Affiliation(s)
- Seng-Kee Chuah
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
| | - Chee-Sang Lim
- Department of Hepatology, Hospital Selayang, Lebuh Raya Selayang-Kepong, Batu Caves, Selangor, Malaysia
| | - Chih-Ming Liang
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
| | - Hung-I Lu
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 833 Kaohsiung, Taiwan
| | - Keng-Liang Wu
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
| | - Chi-Sin Changchien
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
| | - Wei-Chen Tai
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
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18
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Marin I, Caballero N, Guarner-Argente C, Serra J. Rapid drink challenge test for the clinical evaluation of patients with Achalasia. Neurogastroenterol Motil 2018; 30:e13438. [PMID: 30101425 DOI: 10.1111/nmo.13438] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 06/29/2018] [Accepted: 07/02/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with achalasia develop a well-defined obstructive pattern of pressure in response to a rapid drink challenge test (RDC). Our aim was to determine if successful treatment of achalasia can revert the obstructive pattern of pressure in response to the RDC, and if this simple test could be useful in the follow-up of patients with achalasia. METHODS In 26 healthy controls and 103 patients with achalasia, pressure responses to a RDC were prospectively analysed using high resolution esophageal manometry in two consecutive protocols: (a) Development study: one RDC was performed in 20 healthy controls, 63 patients with nontreated achalasia, and 21 patients with previously treated achalasia; (b) Validation study: two RDC were performed before, and 8-12 weeks after treatment, in 19 patients with nontreated, newly diagnosed achalasia. KEY RESULTS In the development study no healthy control, 19% of patients with previously treated achalasia and 96% of patients with nontreated achalasia developed an obstructive pressure pattern during the RDC (P < 0.001). In the validation study, 100% of patients had an obstructive pressure pattern before treatment, that reverted to a nonobstructive pattern in 89% of patients after treatment (P < 0.001). The obstructive pressure pattern during the RDC correlated with clinical symptoms (Eckardt score > 3; P < 0.001), and with the height of the water column retained after the RDC, as assessed by impedance (P = 0.015). CONCLUSIONS & INFERENCES The RDC may objectively assess treatment outcome in patients with achalasia, and can be recommended in the evaluation of achalasia.
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Affiliation(s)
- Ingrid Marin
- Department of Medicine, Motility and Functional Gut Disorders Unit, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University Hospital Germans Trias i Pujol, Autonomous University of Barcelona, Badalona, Spain
| | - Noemi Caballero
- Department of Medicine, Motility and Functional Gut Disorders Unit, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University Hospital Germans Trias i Pujol, Autonomous University of Barcelona, Badalona, Spain
| | - Carlos Guarner-Argente
- Gastroenterology Department, Hospital de Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - Jordi Serra
- Department of Medicine, Motility and Functional Gut Disorders Unit, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University Hospital Germans Trias i Pujol, Autonomous University of Barcelona, Badalona, Spain
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Chilukuri P, Odufalu F, Hachem C. Dysphagia. MISSOURI MEDICINE 2018; 115:206-210. [PMID: 30228723 PMCID: PMC6140149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
A complaint of dysphagia suggests difficulty in swallowing and is characterized based on the symptoms and location of pathology. Oropharyngeal dysphagia is typically due to difficulty initiating a swallow and is generally due to structural, anatomic or neuromuscular abnormalities. Esophageal dysphagia arises after the swallow and causes include intrinsic structural pathology, extrinsic compression, or disruption in normal motility. Etiologies, methods of evaluation, and management options of dysphagia are reviewed here.
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Affiliation(s)
- Prianka Chilukuri
- Prianka Chilukuri, MD, is Fellow in the Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St. Louis, Mo
| | - Florence Odufalu
- Florence-Damilola Odufalu, MD, is Fellow in the Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St. Louis, Mo
| | - Christine Hachem
- Christine Hachem, MD, is an Associate Professor of Internal Medicine in the Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St. Louis, Mo
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