Mechanical stretching and chemical pyloroplasty to prevent delayed gastric emptying after esophageal cancer resection-a meta-analysis and review of the literature

BACKGROUND

Delayed gastric emptying (DGE) occurs in up to 40% of patients after esophageal resection and prolongs recovery and hospital stay. Surgically pyloroplasty does not effectively prevent DGE. Recently published methods include injection of botulinum toxin (botox) in the pylorus and mechanical interventions as preoperative endoscopic dilatation of the pylorus. The aim of this study was to investigate the efficacy of those methods with respect to the newly published Consensus definition of DGE.

METHODS

A systematic literature search using CENTRAL, Medline, and Web of Science was performed to identify studies that described pre- or intraoperative botox injection or mechanical stretching methods of the pylorus in patients undergoing esophageal resection. Frequency of DGE, anastomotic leakage rates, and length of hospital stay were analyzed. Outcome data were pooled as odd's ratio (OR) or mean difference using a random-effects model. Risk of bias was assessed using the Robins-I tool for non-randomized trials.

RESULTS

Out of 391 articles seven retrospective studies described patients that underwent preventive botulinum toxin injection and four studies described preventive mechanical stretching of the pylorus. DGE was not affected by injection of botox (OR 0.87, 95% confidence interval [CI] 0.37-2.03, P = 0.75), whereas mechanical stretching resulted in significant reduction of DGE (OR 0.26, 95% CI 0.14-0.5, P < 0.0001).

CONCLUSION

Mechanical stretching of the pylorus, but not injection of botox reduces DGE after esophageal cancer resection. A newly developed consensus definition should be used before the conduction of a large-scale randomized-controlled trial.

Accuracy of Achalasia Quality of Life and Eckardt scores for assessment of clinical improvement post treatment for achalasia

Achalasia Quality of Life (ASQ) and Eckardt scores are two patient-reported instruments widely used to assess symptom severity in achalasia patients. ASQ is validated and reliable. Although Eckardt is commonly used, it has not been rigorously assessed for validity or reliability. This study aims to evaluate (i) the accuracy of Eckardt and ASQ for assessing improvement post-treatment (predictive validity), (ii) accuracy of Eckardt and ASQ for assessing improvement post-treatment with pneumatic dilatation (PD) versus surgical myotomy (predictive validity), and (iii) convergent validity of Eckardt and ASQ tools. Patients with achalasia treated between 2011 and 2018 were eligible. Both instruments were administered by telephone. Treatment failure was determined by the review of medical records by two clinicians. The predictive ability of ASQ and Eckardt instruments in identifying treatment successes and failures was determined using receiver operating characteristics analysis and summarized as area under the curve (AUC). A total of 106 patients met inclusion criteria with 39 PD, 51 Heller myotomy, and 16 per-oral endoscopic myotomy. A review of medical records and esophageal testing revealed 13 failures (12%). AUC for Eckardt was 0.96 (95% confidence interval [CI] 0.87-0.99] and ASQ 0.97 (95% CI 0.92-0.99). The Eckardt cutoff 4, and ASQ, cutoff 15, were 94% and 87% accurate in identifying treatment successes versus failures, respectively. The correlation coefficient between the two tools was 0.85. In conclusions, (i) ASQ and Eckardt scores are valid and reliable tools to assess symptom severity in achalasia patients, (ii) both instruments accurately classify treatment successes versus failures, and (iii) the choice of tool should be informed by the physicians and patients' values and preferences and repeat physiologic testing may be reserved for treatment failures with either instrument and patients classified, as treatment successes may be spared routine physiologic testing in the long term.

Surgical management of achalasia

Esophageal achalasia is a primary esophageal motility disorder characterized by lack of peristalsis and by incomplete or absent relaxation of the lower esophageal sphincter in response to swallowing. The cause of the disease is unknown. The goal of treatment is to eliminate the functional outflow obstruction at the level of the gastroesophageal junction, therefore allowing emptying of the esophagus into the stomach. They include the laparoscopic Heller myotomy with partial fundoplication, pneumatic dilatation, and peroral endoscopic myotomy. Esophagectomy is considered as a last resort for patients who have failed prior therapeutic attempts. In this evidence and experience-based review, we will illustrate the technique and results of the surgical treatment of esophageal achalasia and compare it to the other available treatment modalities.

The Treatment of Esophageal Achalasia: At the Intersection Between Innovation and Patient's Care

Innovation is of critical importance for the progress of medicine in general, and of surgery in particular. The introduction of minimally invasive surgery 30 years ago determined a revolution in the way we treat surgical diseases today, as most operations are now performed avoiding large incisions, with a consequent decrease in postoperative pain, shorter hospital stay, and a faster return to daily activities. However, for any innovation to become standard of care, the following criteria must be met: (1) Is it feasible? (2) Is it safe? (3) Does it offer clinical advantages to patients and the health care system? The treatment of esophageal achalasia represents an example of an innovation-per oral endoscopic myotomy-that although feasible and safe has become the standard of care without clear proof that it improves patients' outcome and provides an advantage for the health care system. The review of the treatment of esophageal achalasia during the past 30 years will shed light on this controversial dichotomy-innovation versus patient's care.

Systematic Review and Bayesian Network Meta-Analysis Comparing Laparoscopic Heller Myotomy, Pneumatic Dilatation, and Peroral Endoscopic Myotomy for Esophageal Achalasia

Background: Laparoscopic Heller myotomy (LHM), pneumatic dilatation (PD), and peroral endoscopic myotomy (POEM) are common treatments for esophageal achalasia. Literature evidence is restricted to pairwise analysis and PD versus POEM comparison is missing. The aim of this network meta-analysis (NMA) was to comprehensively compare outcomes within these three surgical approaches with those of esophageal achalasia. Materials and Methods: PubMed, EMBASE, and Web of Science databases were consulted. A systematic review and a fully Bayesian study level arm-based random effect NMA were performed. Results: Nineteen studies (14 observational and 5 randomized controlled trial) and 4407 patients were included. Overall, 50.4% underwent LHM, 42.8% PD, and 6.8% POEM. The postoperative dysphagia remission was statistically significantly improved in POEM compared with LHM and PD (risk ratio [RR] = 1.21; 95% credible intervals [CIs] = 1.04-1.47 and RR = 1.40; 95% CIs = 1.14-1.79, respectively). Postoperative gastroesophageal reflux disease (GERD) rate was higher in POEM than in LHM and PD (RR = 1.75; 95% CIs = 1.35-2.03 and RR = 1.36; 95% CIs = 1.18-1.68, respectively). Postoperative Eckardt score was significantly lower in POEM than in LHM and PD (standardized mean difference (smd) = -0.6; 95% CIs = -1.4 to -0.2 and smd = -1.2; 95% CIs = -2.3 to -0.2, respectively). No statistically significant differences were found comparing LHM and PD in any of the analyzed outcomes. Conclusions: In the short-term follow-up, POEM seems to be associated with better dysphagia improvement and higher postoperative GERD than LHM and PD. The choice of the ideal initial management should be left to multidisciplinary team discussion and personalized on each patient basis.

Preoperative endoscopic pyloric balloon dilatation decreases the rate of delayed gastric emptying after Ivor-Lewis esophagectomy

Delayed gastric emptying (DGE) after Ivor-Lewis esophagectomy occurs postoperatively in up to 50% of the patients. This pyloric dysfunction can lead to severe secondary complications postoperatively such as early aspiration, pneumonia or may even have an impact on anastomotic healing and therefore leakage. Early detection of DGE is essential to prevent further complications. The common treatment postoperatively is endoscopic pyloric balloon dilatation (EPBD) after symptoms already occurred. In our work, we analyzed patients who received a preoperative EPBD during the routine restaging endoscopy and compared those patients to a control group to analyze if preoperative EPBD may prevent postoperative DGE and secondary additional complications. We performed a single-center retrospective analysis of 115 patients who received an Ivor-Lewis esophagectomy by the same surgeon between June 2015 and October 2017. Out of these 115 patients, 91 (79.1%) patients received EPBD preoperatively during the staging/restaging endoscopy (PDG, pyloric dilatation group). In 24 (20.9%) patients, preoperative EPBD was not performed due to stenotic esophageal tumors or logistic reasons (NDG, non-pyloric dilatation group). Data of the PDG and NDG group were compared regarding the rate of postoperative DGE as well as DGE and EPBD related complications. In total, 21 (18.3%) patients developed pyloric dysfunction requiring a total of 27 EPBD during follow-up. There were 12 (13.2%) patients in the PDG and 9 (37.5%) patients in the NDG (p = 0.014), respectively. DGE-related complications such as anastomotic leaks (p = 0.466), pulmonary complications (p = 0.466) and longer median hospital stay (p = 0.685) were more frequent in the NDG group; however this difference did not reach statistical significance. The success rate for postoperative EPBD with 20-mm balloons was lower (58.5%) compared to the usage of 30-mm balloons (93.3%). All pre- and postoperative EPBD were performed without any complications. Preoperative EPBD is feasible, safe and can be combined with restating endoscopy. It seems that preoperative EPBD reduces the incidence of DGE and can prevent the need for early postoperative endoscopic interventions. Our recommendation is therefore to perform an EPBD preoperatively when possible to reduce postoperative complications to a minimum. For postoperative EPBD, we recommend the use of the 30-mm balloon due to lower redilatation rates.

[Esophageal achalasia]

Prevalence, clinical manifestations and of modern classifications of achalasia are reviewed in the article. Diagnosis and treatment of this pathology were analyzed by using of 58 references.

Esophageal achalasia: current diagnosis and treatment

Esophageal achalasia is a primary esophageal motility disorder of unknown origin, characterized by lack of peristalsis and by incomplete or absent relaxation of the lower esophageal sphincter in response to swallowing. The goal of treatment is to eliminate the functional obstruction at the level of the gastroesophageal junction. Areas covered: This comprehensive review will evaluate the current literature, illustrating the diagnostic evaluation and providing an evidence-based treatment algorithm for this disease. Expert commentary: Today, we have three very effective therapeutic modalities to treat patients with achalasia - pneumatic dilatation, peroral endoscopic myotomy, and laparoscopic Heller myotomy with fundoplication. Treatment should be tailored to the individual patient, in centers where a multidisciplinary approach is available. Esophageal resection should be considered as a last resort for patients who have failed prior therapeutic attempts.

Per-oral endoscopic myotomy for achalasia

Symptoms in patients with achalasia are produced by outflow obstruction at the level of the lower esophageal sphincter (LES). As a consequence of neural destruction the LES does not undergo normal swallow-induced relaxation. In addition, the esophageal body loses normal peristaltic function and esophageal emptying is on the basis of gravity. All therapies for achalasia are palliative in that normal LES or esophageal body function cannot be restored. The efficacy of any therapy for achalasia is directly related to its ability to reduce the outflow obstruction at the LES. The three main treatment options are pneumatic dilatation, laparoscopic myotomy and partial fundoplication and per-oral endoscopic myotomy or per-oral esophageal myotomy (POEM). Details of the procedures and outcomes will be discussed.

Multidisciplinary Approach to Esophageal Achalasia: A Single Center Experience

BACKGROUND

The treatment of achalasia is palliative. Pneumatic dilatation (PD) or laparoscopic Heller myotomy (LHM) just eliminates the outflow obstruction allowing easier emptying of the esophagus. The aim of this study was to evaluate the results of a multidisciplinary approach to esophageal achalasia.

MATERIALS AND METHODS

A consecutive series of patients with achalasia treated by a multidisciplinary esophageal team consisting of radiologists, gastroenterologists, and surgeons in a quaternary care center between May 2008 and April 2015 were analyzed.

RESULTS

A total of 147 patients with achalasia underwent LHM and partial fundoplication. Sixty-two patients (42%) had been treated preoperatively with PD and/or botulinum toxin (BT). The preoperative Eckardt score (ES) was 6.4 ± 2. At a median follow-up of 22 months, 128 patients (87%) did well and required no further treatment (ES 0.1). The remaining 19 patients (13%) had recurrence of symptoms and required further treatment: 12 were treated with PD and improved (ES 0.7); 4 were treated with PD and BT and improved (ES 1.3); 3 failed PD. These 3 patients had been treated with multiple sessions of PD and BT before the myotomy. Overall, 144 patients (98%) did well with laparoscopic (87%) or laparoscopic and endoscopic treatment (11%).

CONCLUSIONS

The results of this study show that (a) LHM is an effective treatment modality, (b) PD improved symptoms in the majority of patients with recurrent dysphagia after myotomy and (c) multiple preoperative endoscopic treatments seem to affect outcomes of LHM. Patients with achalasia should be treated in a quaternary care center by a multidisciplinary team.

Pediatric achalasia. Single-center study of interventional treatment

Introduction

Esophageal achalasia is a rare entity in children. However, young age is a factor of failure of conservative treatment, emphasizing the role of surgery. In our institution laparoscopic Heller’s cardiomyotomy is the chosen procedure for surgical treatment.

Aim

To assess the outcome of surgery for achalasia treatment in children operated on in a single institution.

Material and methods

A retrospective analysis of consecutive patient records from the years 1997 to 2014 was performed. There were 11 patients. Their mean age was 13 years, ranging from 6 to 17. Duration of symptoms was 2 to 36 months, mean 16. All 11 patients were operated on with a laparoscopic approach. Pneumatic dilatation was used both pre- and postoperatively but in no case was sufficient on its own. Collected data included patient demographics, preoperative symptoms and their duration, diagnostic findings and therapeutic means. Surgical procedures, complications and long-term follow-up were analyzed. The follow-up lasted from 1 to 10 years and finished when the patient reached 18 years of age.

Results

Twelve laparoscopic cardiomyotomies were performed with concomitant fundoplications, 10 Toupet and 2 Dor and one redo procedure. There were no deaths. Two perforations were repaired promptly. The success rate was 82%, though with subsequent dilatations. One failure was due to serious progression of the disease.

Conclusions

In our opinion, laparoscopic Heller’s myotomy is the procedure of choice for treating achalasia in children. Endoscopic balloon dilatation may be used as a complementary treatment, especially as a primary redo procedure.

Treatment of achalasia in the era of high-resolution manometry

Esophageal achalasia is a primary motility disorder characterized by impaired lower esophageal sphincter relaxation and absence of esophageal peristalsis leading to impaired bolus transit, manifested with symptoms such as dysphagia, regurgitation, retrosternal pain, and weight loss. The standard diagnostic tool is esophageal manometry which demonstrates incomplete relaxation of the lower esophageal sphincter and impaired esophageal peristalsis. Recently, a new advanced technique, high-resolution manometry (HRM) with the addition of pressure topography plotting, using multiple sensors to capture the manometric data as a spatial continuum, allows a detailed pressure recording of the esophageal motility. This technique, currently the gold standard for the diagnosis of achalasia, has led to a subclassification of three manometric types that seem to have different responsiveness to treatment. Because its pathogenesis is as yet unknown, achalasia treatment options are not curative. Type II achalasia patients respond better to treatment compared to those with types I and III. Low-risk patients with type I or II achalasia have good outcome with both graded pneumatic dilatations and laparoscopic Heller myotomy, while type III achalasia patients respond better to laparoscopic Heller myotomy. Although, type III achalasia patients responds less in comparison to types I and II to laparoscopic Heller myotomy. Peroral endoscopic myotomy is a promising new technique but long-term follow-up studies for its safety and efficacy must be performed. This article reviews the current therapeutic options, highlighting the impact of HRM to predict the outcome and the new insights for the treatment of achalasia.

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

BACKGROUND

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

METHODS

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

KEY RESULTS

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

CONCLUSIONS & INFERENCES

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

Efficacy of pneumatic dilatation in Saudi achalasia patients

BACKGROUND/AIMS

Pneumatic dilatation (PD) is one of the effective treatments of achalasia. The aim of this study was to evaluate the efficacy of pneumatic dilation and patient satisfaction in Saudi achalasia patients.

PATIENTS AND METHODS

We have retrospectively recruited patients with confirmed achalasia, who underwent at least one dilatation session from January 1990 to January 2010 at a single tertiary center. Symptoms, including weight loss, dysphagia, retrosternal pain, and regurgitation, were assessed with the use of the Eckardt score (which ranges from 0 to 12, with higher scores indicating more pronounced symptoms). All patients were called and asked about their Eckardt score in addition to their satisfaction score post the dilatation procedure. The primary outcome was therapeutic success (Eckardt score≤3) and patient satisfaction at the time of their calls. The secondary outcomes included the need for retreatment and the rate of complications.

RESULTS

A total of 29 patients were included, with a mean age of 40.30 (95% CI: 36.1-44.6) and 55.2% of them were males. The mean of the pre-dilatation Eckardt score was 8.3 (95% CI: 7.2-9.4), which dropped to 2.59 (95% CI: 1.7-3.5) after PD (P<0.01) with a clinical remission of 76.7% after the first dilatation and a total failure in two patients (7%) after the third dilatation. The mean number of dilatations was 1.3 (95% CI: 1.1-1.5) where 50.7% required one dilatation, 19.2% required two dilatations, and 30.1% required three dilatations. The mean of the symptoms-free period was 53.4 months (SD 52.7, range 1-180) with symptoms recurring in 35% of patients within 2 years. The mean of post-PD patient satisfaction was 7.45 (95% CI: 6.2-8.7). Perforation, which was treated conservatively, occurred in one patient (3.5%), whereas bleeding occurred in two patients (7%). Age or gender was not found to be a predictor of Eckardt score improvement on multivariate linear regression analysis.

CONCLUSION

PD is an efficacious procedure in Saudi achalasia patients with a very good overall patient satisfaction with 53.4 months of symptoms-free period after a successful dilatation.