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El Abiad R, Khashab MA. Role of biodegradable stents in octogenarians with achalasia. Endosc Int Open 2021; 9:E767-E769. [PMID: 34080587 PMCID: PMC8159592 DOI: 10.1055/a-1393-5665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Rami El Abiad
- Division of Gastroenterology and Hepatology, University of Iowa, Iowa City, Iowa, United States
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
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2
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Abstract
Idiopathic achalasia is an esophageal motor disorder characterized by the loss of the lower esophageal sphincter ganglion, resulting in impaired lower esophageal relaxation and absence of esophageal peristalsis. Patients commonly present with progressive dysphagia accompanied by reflux, heartburn, retrosternal pain, and severe weight loss. Diagnosis is primarily based on the patient's chief complaints, barium esophagography, and the most recent high-resolution manometry. Endoscopic assessment and endoscopic ultrasonography also have significant value with regard to the exclusion of esophageal anatomical lesions, neoplastic diseases, and pseudoachalasia. However, as most patients with achalasia demonstrate a gradual onset, early diagnosis is difficult. Currently, treatment of idiopathic achalasia, including pneumatic dilation, stent placement, and surgical myotomy, is aimed at reducing lower esophageal sphincter pressure and relieving the symptoms of dysphagia. Peroral endoscopic myotomy has gradually become the mainstream treatment because it causes less trauma and has a rapid recovery rate. This article reviews the main methods of diagnosis and treatment of achalasia, with an emphasis on the potential of peroral endoscopic myotomy and the advancements of immunotherapy for achalasia.
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3
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Galliamov EA, Erin SA, Agapov MA, Gorbacheva IV, Yurkyliev NA, Gololobov GY, Gadlevskiy GS, Kosyakov AN, Chicherina MA, Burmistrov AI, Sarukhanyan IG. ACHALASIA: DIAGNOSTIC FEATURES AND EFFECTIVE TREATMENT METHODS. REVIEW. SURGICAL PRACTICE 2020. [DOI: 10.38181/2223-2427-2020-3-36-43] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Еsophageal achalasia is a neuromuscular disease of esophagus characterized by a distortion of the relaxation of the lower esophageal sphincter (LES) and manifested by marked clinical symptoms. To date, methods for diagnosing pathology and various surgical methods for its correction have been developed and actively used. In this review, the authors summarized all available data on principles of modern classification based on the identification of characteristic diagnostic criteria of the disease. The modern treatment methods are described in detail, the effectiveness of the presented methods is evaluated.
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Affiliation(s)
- E. A. Galliamov
- Federal State Autonomous Educational Institution of Higher Education I. M. Sechenov First Moscow State Medical University (Sechenov University)
| | - S. A. Erin
- City Clinical Hospital named after S. I. Spasokukotsky
| | - M. A. Agapov
- Federal State Budget Educational Institution of Higher Education M.V. Lomonosov Moscow State University (Lomonosov MSU)
| | - I. V. Gorbacheva
- Federal State Autonomous Educational Institution of Higher Education I. M. Sechenov First Moscow State Medical University (Sechenov University)
| | | | - G. Yu. Gololobov
- Federal State Autonomous Educational Institution of Higher Education I. M. Sechenov First Moscow State Medical University (Sechenov University)
| | - G. S. Gadlevskiy
- Federal State Autonomous Educational Institution of Higher Education I. M. Sechenov First Moscow State Medical University (Sechenov University)
| | | | - M. A. Chicherina
- Federal State Autonomous Educational Institution of Higher Education I. M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A. I. Burmistrov
- Federal State Budget Educational Institution of Higher Education A.I. Yevdokimov Moscow State University of Medicine and Dentistry (MSUMD)
| | - I. G. Sarukhanyan
- Federal State Autonomous Educational Institution of Higher Education I. M. Sechenov First Moscow State Medical University (Sechenov University)
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4
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Zaninotto G, Bennett C, Boeckxstaens G, Costantini M, Ferguson MK, Pandolfino JE, Patti MG, Ribeiro U, Richter J, Swanstrom L, Tack J, Triadafilopoulos G, Markar SR, Salvador R, Faccio L, Andreollo NA, Cecconello I, Costamagna G, da Rocha JRM, Hungness ES, Fisichella PM, Fuchs KH, Gockel I, Gurski R, Gyawali CP, Herbella FAM, Holloway RH, Hongo M, Jobe BA, Kahrilas PJ, Katzka DA, Dua KS, Liu D, Moonen A, Nasi A, Pasricha PJ, Penagini R, Perretta S, Sallum RAA, Sarnelli G, Savarino E, Schlottmann F, Sifrim D, Soper N, Tatum RP, Vaezi MF, van Herwaarden-Lindeboom M, Vanuytsel T, Vela MF, Watson DI, Zerbib F, Gittens S, Pontillo C, Vermigli S, Inama D, Low DE. The 2018 ISDE achalasia guidelines. Dis Esophagus 2018; 31:5087687. [PMID: 30169645 DOI: 10.1093/dote/doy071] [Citation(s) in RCA: 155] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.
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Affiliation(s)
- G Zaninotto
- Department of Surgery and Cancer, Imperial College, London, UK
| | - C Bennett
- Office of Research and Innovation, Royal College of Surgeons in Ireland, Ireland
| | - G Boeckxstaens
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - M Costantini
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - M K Ferguson
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - J E Pandolfino
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - M G Patti
- Department of Medicine and Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - U Ribeiro
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - J Richter
- Department of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - L Swanstrom
- Institute of Image-Guided Surgery, Strasbourg, France; Interventional Endoscopy and Foregut Surgery, Oregon Health Science University, Portland, Oregon, USA
| | - J Tack
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - G Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford Esophageal Multidisciplinary Program in Innovative Research Excellence (SEMPIRE), Stanford University, Stanford, California, USA
| | - S R Markar
- Department of Surgery and Cancer, Imperial College, London, UK
| | - R Salvador
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - L Faccio
- Division of Surgery, Padova University Hospital, Padova, Italy
| | - N A Andreollo
- Faculty of Medical Science, State University of Campinas, Campinas, São Paulo, Brazil
| | - I Cecconello
- Digestive Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - G Costamagna
- Digestive Endoscopy Unit, A. Gemelli Hospital, Catholic University, Rome, Italy
| | - J R M da Rocha
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - E S Hungness
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - P M Fisichella
- Department of Surgery, Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
| | - K H Fuchs
- Department of Surgery, AGAPLESION-Markus-Krankenhaus, Frankfurt, Germany
| | - I Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - R Gurski
- Department of Surgery, School of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - F A M Herbella
- Department of Surgery, School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - R H Holloway
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, The University of Adelaide, Adelaide, Australia
| | - M Hongo
- Department of Medicine, Kurokawa Hospital, Taiwa, Kurokawa, Miyagi, Japan
| | - B A Jobe
- Esophageal and Lung Institute, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania, USA
| | - P J Kahrilas
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - D A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - K S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - D Liu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - A Moonen
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - A Nasi
- Digestive Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - P J Pasricha
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - R Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico; Department of Pathophysiology and Transplantation; Università degli Studi, Milan, Italy
| | - S Perretta
- Institute for Image Guided Surgery IHU-Strasbourg, Strasbourg, France
| | - R A A Sallum
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - G Sarnelli
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - E Savarino
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - F Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - D Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - N Soper
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - R P Tatum
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - M F Vaezi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - M van Herwaarden-Lindeboom
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - T Vanuytsel
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - M F Vela
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - D I Watson
- Department of Surgery, Flinders University, Adelaide, Australia
| | - F Zerbib
- Department of Gastroenterology, University of Bordeaux, Bordeaux, France
| | - S Gittens
- ECD Solutions, Atlanta, Georgia, USA
| | - C Pontillo
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - S Vermigli
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - D Inama
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - D E Low
- Department of Thoracic Surgery Virginia Mason Medical Center, Seattle, Washington, USA
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Gugig R, Muñoz Jurado G, Huang C, Oleas R, Robles-Medranda C. Self-expandable metal stent placement in a child for treatment of achalasia after failed Heller myotomy. Endosc Int Open 2018; 6:E64-E66. [PMID: 29344561 PMCID: PMC5770269 DOI: 10.1055/s-0043-118745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 07/24/2017] [Indexed: 11/29/2022] Open
Abstract
Background and study aims Childhood achalasia treatment remains inconclusive. What is next after myotomy failure? Repeated pneumatic-dilation put patients at greater risk of perforation with possible symptom recurrence. We report on a 12-year-old patient with a 1-year history of achalasia whom underwent Heller myotomy with fundoplication and recurred with symptoms 1 week after surgery. Pneumatic dilatation was considered but not done because of the risk of esophageal perforation. The decision was made to place a fully covered self-expanding metallic stent (FC-SEMS) for 3 months, which resolved the stenosis as confirmed by esophagram. The patient has remained asymptomatic since the procedure was performed 2 years ago. FC-SEMS is an alternative for treatment of refractory achalasia in children who do not respond to conventional treatment.
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Affiliation(s)
- Roberto Gugig
- University of California San Francisco and Valley Children’s Healthcare, San Francisco, California, United States
| | - Guillermo Muñoz Jurado
- Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital OMNI, Guayaquil, Ecuador
| | - Clifton Huang
- University of California San Francisco and Valley Children’s Healthcare, San Francisco, California, United States
| | - Roberto Oleas
- Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital OMNI, Guayaquil, Ecuador
| | - Carlos Robles-Medranda
- Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital OMNI, Guayaquil, Ecuador,Corresponding author Carlos Robles-Medranda IECED, Omni HospitalAv. Abel R Castillo y Av. Juan Tanca Marengo s/n, Ciudad del Sol, Office Mezanine 3090505, Guayaquil, GuayasEcuador+59342109180
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6
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Baniya R, Upadhaya S, Khan J, Subedi SK, Shaik Mohammed T, Ganatra BK, Bachuwa G. Laparoscopic esophageal myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized controlled trials. Clin Exp Gastroenterol 2017; 10:241-248. [PMID: 29026325 PMCID: PMC5627730 DOI: 10.2147/ceg.s130449] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Achalasia is a primary esophageal motility disorder of unknown etiology associated with abnormalities in peristalsis and lower esophageal sphincter relaxation. The disease is incurable; however, definitive treatment procedures like pneumatic dilation (PD)/balloon dilation and laparoscopic esophageal myotomy (LEM) are performed to relieve dysphagia and related symptoms. Currently, there is paucity of data comparing the outcomes of these procedures. The aim of this meta-analysis is to compare the short- and long-term success rates of PD and LEM. METHODS A thorough systematic search of PubMed, Scopus, clinicaltrials.gov, and Cochrane library was conducted for randomized controlled trials (RCTs) comparing the outcomes of PD versus LEM in the treatment of achalasia. The Mantel-Haenszel method and random effect model were used to analyze the data. RCTs with outcome data at 3-month, 1-year, and 5-year intervals were analyzed. RESULTS A total of 437,378 and 254 patients at 3-month, 1-year, and 5-year intervals were analyzed for outcome data. At 3 months and 1 year, PD was not as effective as LEM (odds ratio [OR]: 0.50; confidence interval [CI] 0.31-0.82; P = 0.009 and OR: 0.47; CI 0.22-0.99; P = 0.21) but at 5 years, one procedure was non-inferior to the other (OR: 0.62; 0.33-1.19; P = 0.34). CONCLUSION PD was as effective as LEM in relieving symptoms of achalasia in the long-term.
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Affiliation(s)
- Ramkaji Baniya
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI, USA
| | - Sunil Upadhaya
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI, USA
| | - Jahangir Khan
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI, USA
| | - Suresh Kumar Subedi
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI, USA
| | - Tabrez Shaik Mohammed
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI, USA
| | - Balvant K Ganatra
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI, USA
| | - Ghassan Bachuwa
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI, USA
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8
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Rieder E, Asari R, Paireder M, Lenglinger J, Schoppmann SF. Endoscopic stent suture fixation for prevention of esophageal stent migration during prolonged dilatation for achalasia treatment. Dis Esophagus 2017; 30:1-6. [PMID: 28375470 DOI: 10.1093/dote/dow002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Indexed: 02/07/2023]
Abstract
The aim of this study is to compare endoscopic stent suture fixation with endoscopic clip attachment or the use of partially covered stents (PCS) regarding their capability to prevent stent migration during prolonged dilatation in achalasia. Large-diameter self-expanding metal stents (30 mm × 80 mm) were placed across the gastroesophageal junction in 11 patients with achalasia. Stent removal was scheduled after 4 to 7 days. To prevent stent dislocation, endoscopic clip attachment, endoscopic stent suture fixation, or PCS were used. The Eckardt score was evaluated before and 6 months after prolonged dilatation. After endoscopic stent suture fixation, no (0/4) sutured stent migrated. When endoscopic clips were used, 80% (4/5) clipped stents migrated (p = 0.02). Of two PCS (n = 2), one migrated and one became embedded leading to difficult stent removal. Technical adverse events were not seen in endoscopic stent suture fixation but were significantly correlated with the use of clips or PCS (r = 0.828, p = 0.02). Overall, 72% of patients were in remission regarding their achalasia symptoms 6 months after prolonged dilatation. Endoscopic suture fixation of esophageal stents but not clip attachment appears to be the best method of preventing early migration of esophageal stents placed at difficult locations such as at the naive gastroesophageal junction.
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9
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History of the Use of Esophageal Stent in Management of Dysphagia and Its Improvement Over the Years. Dysphagia 2017; 32:39-49. [PMID: 28101666 DOI: 10.1007/s00455-017-9781-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 01/01/2017] [Indexed: 01/07/2023]
Abstract
The art and science of using stents to treat dysphagia and seal fistula, leaks and perforations has been evolving. Lessons learnt from the deficiencies of previous models led to several improvements making stent deployment easier, and with some designs, it was also possible to remove the stents if needed. With these improvements, besides malignant dysphagia, newer indications for using stents emerged. Unfortunately, despite several decades of evolution, as yet, there is no perfect stent that "fits all." This article is an overview of how this evolution process happened and where we are currently with using stents to manage patients with dysphagia and with other esophageal disorders.
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10
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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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11
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Irani S, Kozarek RA. Techniques and principles of endoscopic treatment of benign gastrointestinal strictures. Curr Opin Gastroenterol 2015; 31:339-50. [PMID: 26247823 DOI: 10.1097/mog.0000000000000200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW The fundamental goal of treating any stenosis is luminal enlargement to ameliorate the underlying obstructive symptoms. Symptoms depend on the etiology and the site of the stricture and may include dysphagia, nausea and vomiting, abdominal pain, obstipation, or frank bowel obstruction. This article compares the various current technologies available for the treatment of gastrointestinal stenoses with regard to ease and site of application, patient tolerance, safety and efficacy data, and cost-benefit ratio. RECENT FINDINGS Recent studies indicate that gastrointestinal dilation and stenting have evolved to a point at which in many if not most situations they can be the first line therapy and potentially the final therapy needed to treat the underlying condition. SUMMARY Following techniques and principles in the management of gastrointestinal strictures would allow for the well tolerated and effective treatment of most patients with the tools currently available today.
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Affiliation(s)
- Shayan Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
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12
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Zhao H, Wan XJ, Yang CQ. Comparison of endoscopic balloon dilation with metal stent placement in the treatment of achalasia. J Dig Dis 2015; 16:311-8. [PMID: 25765898 DOI: 10.1111/1751-2980.12241] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To compare the outcomes of endoscopic balloon dilation and metal stent placement in patients with achalasia. METHODS The patients with newly diagnosed achalasia between July 2001 and December 2011 were retrospectively studied. A total of 88 patients underwent either balloon dilation (n = 41) or metal stent placement (n = 47), their global symptom score and esophageal kinetics index were determined before, one week after and one month after the treatment. All the patients were followed up in the Outpatient Clinics or with a telephone interview every 6 months. RESULTS There were significant improvements in the global symptom scores and esophageal kinetics indices in all patients. No major complications were encountered in either group. There were no significant differences with regard to overall treatment failure or long-term outcome. CONCLUSION Balloon dilation and removable stents can effectively relieve clinical manifestations in patients with achalasia.
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Affiliation(s)
- Hang Zhao
- Department of Gastroenterology, First People's Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Xin Jian Wan
- Department of Gastroenterology, First People's Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Chang Qing Yang
- Department of Gastroenterology, Tongji Hospital, Tongji University, Shanghai, China
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13
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Endoscopic botulinum toxin injection: Benefit and limitation. GASTROINTESTINAL INTERVENTION 2014. [DOI: 10.1016/j.gii.2014.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Srinivasan N, Kozarek RA. The future of esophageal endoprosthetics including the use of biodegradable materials. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2014. [DOI: 10.1016/j.tgie.2014.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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15
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Hatle H, Erwied BM, Lode I, Sandvik ÅR, Hatlebakk JG, Øvrebø K, Hoff DAL. [A pregnant woman with vomiting and breathing difficulties]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2014; 134:426-9. [PMID: 24569744 DOI: 10.4045/tidsskr.13.0442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Müller M, Eckardt AJ, Wehrmann T. Endoscopic approach to achalasia. World J Gastrointest Endosc 2013; 5:379-390. [PMID: 23951393 PMCID: PMC3742703 DOI: 10.4253/wjge.v5.i8.379] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 05/10/2013] [Indexed: 02/05/2023] Open
Abstract
Achalasia is a primary esophageal motor disorder. The etiology is still unknown and therefore all treatment options are strictly palliative with the intention to weaken the lower esophageal sphincter (LES). Current established endoscopic therapeutic options include pneumatic dilation (PD) or botulinum toxin injection. Both treatment approaches have an excellent symptomatic short term effect, and lead to a reduction of LES pressure. However, the long term success of botulinum toxin (BT) injection is poor with symptom recurrence in more than 50% of the patients after 12 mo and in nearly 100% of the patients after 24 mo, which commonly requires repeat injections. In contrast, after a single PD 40%-60% of the patients remain asymptomatic for ≥ 10 years. Repeated on demand PD might become necessary and long term remission can be achieved with this approach in up to 90% of these patients. The main positive predictors for a symptomatic response to PD are an age > 40 years, a LES-pressure reduction to < 15 mmHg and/or an improved radiological esophageal clearance post-PD. However PD has a significant risk for esophageal perforation, which occurs in about 2%-3% of cases. In randomized, controlled studies BT injection was inferior to PD and surgical cardiomyotomy, whereas the efficacy of PD, in patients > 40 years, was nearly equivalent to surgery. A new promising technique might be peroral endoscopic myotomy, although long term results are needed and practicability as well as safety issues must be considered. Treatment with a temporary self expanding stent has been reported with favorable outcomes, but the data are all from one study group and must be confirmed by others before definite recommendations can be made. In addition to its use as a therapeutic tool, endoscopy also plays an important role in the diagnosis and surveillance of patients with achalasia.
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Cai XB, Dai YM, Wan XJ, Zeng Y, Liu F, Wang D, Zhou H. Comparison between botulinum injection and removable covered self-expanding metal stents for the treatment of achalasia. Dig Dis Sci 2013; 58:1960-6. [PMID: 23397470 DOI: 10.1007/s10620-013-2564-6] [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: 11/05/2012] [Accepted: 01/03/2013] [Indexed: 12/09/2022]
Abstract
BACKGROUND Intrasphincteric injection of botulinum toxin (BTX) and removable self-expanding metal stents (SEMS) have both been used for the treatment of achalasia. AIM To compare the effectiveness and long-term outcome of SEMS placement and BTX injection in patients with achalasia. METHODS A total of 110 patients with newly diagnosed achalasia were enrolled in the study between July 2003 and December 2009. The patients received either BTX injection (n = 51) or SEMS placement (n = 59). Clinical symptoms, objective parameters, and long-term clinical outcomes were evaluated after 7 and 30 days and then every 6 months until withdrawal from the study. The mean duration of follow-up was 28 months (range 10-36 months). RESULTS Improvements in global symptom and dysphagia scores and in basal lower esophageal sphincter pressure were significantly more marked in the SEMS group than in the BTX group (all P < 0.05). After 12 months, the remission rate in the SEMS group (81.28 %) was statistically significantly higher than that in the BTX group (64.58; P < 0.05). At 36 months, the remission rates in the two groups were 49.1 and. 4.2 %, respectively (P < 0.01). The symptom-free interval was 831 ± 46 days in the SEMS group and 522 ± 42 days in the BTX group (P < 0.01). No side effects were reported with BTX treatment. In the SEMS group there were 13 episodes of chest pain, nine cases of regurgitation, and four stent migrations. No serious complications occurred. CONCLUSION Removable SEMS was associated with better long-term outcomes than BTX injection in patients with achalasia.
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Affiliation(s)
- Xiao Bo Cai
- Department of Gastroenterology, First People's Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200080, China
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Zeng Y, Dai YM, Wan XJ. Clinical remission following endoscopic placement of retrievable, fully covered metal stents in patients with esophageal achalasia. Dis Esophagus 2013; 27:103-8. [PMID: 23796127 DOI: 10.1111/dote.12083] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Metal stents may represent an alternative therapy in the treatment of achalasia. We therefore evaluated the effectiveness of retrievable, fully covered metal stents in patients with achalasia. Fifty-nine patients with achalasia were treated with retrievable, fully covered metal stents. Symptoms using a global symptom score (0-10), lower esophageal sphincter (LES) resting pressure, LES relaxation, and simultaneous contraction of the esophagus were analyzed before and 1 week and 1 month after intervention. Complications and treatment outcomes were followed up at 6, 12, 18, and 24 months postoperatively. Stent placement was successful, and clinical symptoms resolved (P < 0.01) in all patients. Regurgitation, dysphagia and chest pain improved significantly (all P < 0.01). Therapy improved LES resting pressure (51.4 ± 9.7 mmHg pretherapy vs. 20.9 ± 8.1 mmHg post-therapy), LES relaxation (58.1 ± 17.1% pretherapy vs. 84.5 ± 18.9% post-therapy), and simultaneous contraction of the esophagus (36.1 ± 8.6% pretherapy vs. 69.4 ± 23.1% post-therapy) 1 month after stent placement (all P < 0.01). The cumulative clinical remission rates 6, 12, 18, 24, 30, and 36 months after stent removal were 90.9%, 81.8%, 76.4%, 69.1%, 65.5%, and 49.1%, respectively. All patients tolerated stent placement. Twelve patients (25.5%) complained of substernal pain and five (10.6%) had substernal burning. Stents migrated in four patients (8.5%). Insertion of retrievable, fully covered metal stents is an effective and safe treatment in patients with achalasia.
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Affiliation(s)
- Y Zeng
- Department of Gastroenterology, Shanghai First People's Hospital, School of Medicine, Shanghai Jiaog Tong University, Shanghai, China
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Stavropoulos SN, Friedel D, Modayil R, Iqbal S, Grendell JH. Endoscopic approaches to treatment of achalasia. Therap Adv Gastroenterol 2013; 6:115-35. [PMID: 23503707 PMCID: PMC3589133 DOI: 10.1177/1756283x12468039] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Endoscopic therapy for achalasia is directed at disrupting or weakening the lower esophageal sphincter (LES). The two most commonly utilized endoscopic interventions are large balloon pneumatic dilation (PD) and botulinum toxin injection (BTI). These interventions have been extensively scrutinized and compared with each other as well as with surgical disruption (myotomy) of the LES. PD is generally more effective in improving dysphagia in achalasia than BTI, with the latter reserved for infirm older people, and PD may approach treatment results attained with myotomy. However, PD may need to be repeated. Small balloon dilation and endoscopic stent placement for achalasia have only been used in select centers. Per oral endoscopic myotomy is a newer endoscopic modality that will likely change the treatment paradigm for achalasia. It arose from the field of natural orifice transluminal endoscopic surgery and represents a scarless endoscopic approach to Heller myotomy. This is a technique that requires extensive training and preparation and thus there should be rigorous accreditation and monitoring of outcomes to ensure safety and efficacy.
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Abstract
Endoscopic therapy for achalasia is centered on disrupting or weakening the lower esophageal sphincter. The three traditional treatment options for achalasia are surgical myotomy, pneumatic dilation, and botulinum toxin injection. Pneumatic dilation yields results that are generally better than botulinum toxin injection and may approach a clinical response comparable with surgery. Per oral endoscopic myotomy is a newer endoscopic modality that will likely change the treatment paradigm for achalasia.
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Affiliation(s)
- Stavros N Stavropoulos
- Division of Gastroenterology, Hepatology and Nutrition, Winthrop University Hospital, Mineola, NY 11501, 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, Müller M, Schumacher J. Achalasia--a disease of unknown cause that is often diagnosed too late. DEUTSCHES ARZTEBLATT INTERNATIONAL 2012; 109:209-14. [PMID: 22532812 DOI: 10.3238/arztebl.2012.0209] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 01/17/2012] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Many physicians are inadequately familiar with the clinical features of achalasia. Often, it is not diagnosed until years after the symptoms arise. This is unfortunate, because a delay in diagnosis worsens the prognosis. METHODS Selective review of the literature. RESULTS Achalasia has a lifetime prevalence of 1:10 000. It is a neurodegenerative disorder in which the neurons of the myenteric plexus are lost, leading to dysfunction of the lower esophageal sphincter and to a derangement of esophageal peristalsis. In the final stage of achalasia, esophageal motility is irreversibly impaired, and complications ensue because of the retention of food that is no longer transported into the stomach. Aspiration causes pulmonary disturbances in up to half of all patients with achalasia. There may also be inflammation of the esophageal mucosa (retention esophagitis); this, in turn, is a risk factor for esophageal cancer, which arises in 4% to 6% of patients. The cause of achalasia is not fully known, but autoimmune processes appear to be involved in patients with a genetic susceptibility to the disease. CONCLUSION Achalasia should be diagnosed as early as possible, so that complications can be prevented. In addition, guidelines should be established for cancer prevention in achalasia patients. Currently ongoing studies of the molecular causes of achalasia will probably help us understand its pathophysiology.
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Affiliation(s)
- Ines Gockel
- Department of General and Abdominal Surgery, University Medical Center of the Johannes Gutenberg University Mainz
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Abstract
Partially covered self-expandable esophageal stents have been associated with unacceptable complications when used for benign esophageal disorders. With the introduction of removable or potentially removable fully covered stents and biodegradable stents, interest in using expandable stents for benign indications has been revived. Although expandable stents can offer a minimally invasive alternative to surgery, they can be associated with serious complications; hence, this approach should be considered in carefully selected patients, preferably on a protocol basis.
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Affiliation(s)
- Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
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Abstract
Controversy exists with regard to the optimal treatment for achalasia and whether surveillance for early recognition of late complications is indicated. Currently, surgical myotomy and pneumatic dilation are the most effective treatments for patients with idiopathic achalasia, and a multicenter, randomized, international trial has confirmed similar efficacy of these treatments, at least in the short term. Clinical predictors of outcome, patient preferences and local expertise should be considered when making a decision on the most appropriate treatment option. Owing to a lack of long-term benefit, endoscopic botulinum toxin injection and medical therapies are reserved for patients of advanced age and those with clinically significant comorbidites. The value of new endoscopic, radiologic or surgical treatments, such as peroral endoscopic myotomy, esophageal stenting and robotic-assisted myotomy has not been fully established. Finally, long-term follow-up data in patients with achalasia support the notion that surveillance strategies might be beneficial after a disease duration of more than 10-15 years.
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Affiliation(s)
- Alexander J Eckardt
- Department of Gastroenterology, Deutsche Klinik für Diagnostik, Aukammallee 33, 65191 Wiesbaden, Germany
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