Updates on the management of achalasia
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Updates on the management of Achalasia. Joint Hospital Surgical Grand Round 21 July 2012 Lok Hon Ting (NDH). Pathophysiology. Motor disorder of the esophagus characterized by: Incomplete or absent relaxation of LES Aperistalsis of esophageal body

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Updates on the management of achalasia

Updates on the management of Achalasia

Joint Hospital Surgical Grand Round

21 July 2012

Lok Hon Ting (NDH)


Pathophysiology

Pathophysiology

  • Motor disorder of the esophagus characterized by:

    • Incomplete or absent relaxation of LES

    • Aperistalsis of esophageal body

  • Destruction of ganglion cells present in the esophageal wall and LES

    • > Impaired relaxation of LES

  • Cause unknown, proposed etiology:

    • Viral hypothesis (VZV, HSV-1)

      • Jones DB. J Clin Pathol 1983. Robertson CS. Gut 1993

    • Autoimmune hypothesis


Clinical manifestation

Clinical manifestation

  • Epidemiology

    • Prevalence 1 per 100,000

    • No gender predilection

      • Sadowski DC et al. Neurogastroenterol Motil 2010

  • Symptoms:

    • Dysphagia – Both liquids and solids

    • Regurgitation +/- Pulmonary Aspiration

    • Chest pain / Heartburn in ~50% patient

      • Spechler SJ et al. Gut 1995

    • Weight Loss

  • 16-fold increased risk of Ca Esophagus

    • Sandler RS et al. JAMA 1995


Investigation

Investigation

  • OGD

    • tight cardia and food residual in esophgaus

  • Barium Swallow - Sensitivity 95%

    • Ott DJ et al. AJR Am J Roentgenol 1987

  • Esophageal manometry

    • absence of any esophageal peristaltic contractions

    • failure of the LES to relax to less than 8 mm Hg

    • Gideon RM. Gastrointest Endosc Clin N Am 2005


Treatment modalities

Treatment Modalities


Pharmacological treatment

Pharmacological treatment

  • Nitrates, Calcium channel blockers

  • Evidence:

  • Conclusion: Ineffective


Botulinum toxin injection

Botulinum toxin injection

  • Endoscopic injection at 4 quadrants of LES

  • Inhibit release of acetylcholine in muscle synapse

  • First used by Pasricha in 1993


Botulinum toxin injection1

Botulinum toxin injection

  • Promising short term effect

  • Symptoms recurrence beyond 6 months follow up

  • 76% response to 2nd injection, but not to further injection

Farnoosh Farrokhi etal. Orphanet Journal of Rare Diseases 2007


Botulinum toxin injection2

Botulinum toxin injection

  • Side effects 0 – 33%

    • Chest pain, reflux symptoms and rash

      • D Gui. Aliment Pharmacol Ther 2003

  • Subsequent myotomy more difficult

    • Pehlivanov N. Neurogastroenterol Motil 2006

  • Conclusion:

    • Safe and effective in short term symptoms relief

    • For elderly or frail patient only


  • Pneumatic dilatation

    Pneumatic dilatation

    • To disrupt circular muscle fiber of LES without full thickness perforation

    • First used by Sir Thomas Willis since the condition was first recognized

    • Rigiflex Polyethylene balloon

      (30, 35, 40mm diameter)


    Pneumatic dilatation1

    Pneumatic dilatation

    Guilherme M. Campos et al. Annals of Surgery 2009


    Pneumatic dilatation2

    Pneumatic dilatation

    • A pool of 1065 patients in 15 controlled series

    • Mean follow-up 30.8 months (6 – 111 months)

    • Rate of symptom improvement decreases with FU duration

    • Perforation rate: 1.6% (0 – 8%)

    • Subsequent treatment after index dilatation:

      • Repeated dilatation 25%

      • Myotomy 5%


    Heller s myotomy

    Heller’s myotomy

    • First described by Ernest Heller in 1914

      • Cutting the anterior and posterior aspect of LES

      • Current practice: myotomy over anterior aspect only

    • Minimally invasive approach 1990s

      • Thoracoscopic versus laparoscopic

      • Laparoscopic approach: less morbidity and quicker recovery

        • Richter JE. Gastroenterol hepatol 2008

      • > standard approach


    Heller s myotomy1

    Heller’s myotomy

    Bresadola et al. Surg Laparosc Endoscc Percutan Tech 2012


    Heller myotomy

    Heller myotomy

    • A pool of 1708 patients in 19 publications

    • Follow-up duration: 4.78 year (range: 0.5 -11.2 years)

    • Symptom response rate: 79.3% (range: 47 – 97%)

    • GERD:

      • With fundoplication: 15.2% (range: 0 – 44%)

      • Without fundoplication: 37% (range: 11 – 60%)

    • Response rates decreased in patients with longer FU

      • > 7 years: 80%> 10 years: 74% > 20 years 65%

        Csendes. Ann Surg 2006


    Heller s myotomy and anti reflux surgery

    Heller’s myotomy and anti reflux surgery

    • Conclusion:

      • Heller’s myotomy with concomitant Dor’s fundoplication is the procedure of choice


    Pneumatic dilatation versus heller s myotomy

    Pneumatic Dilatation versus Heller’s Myotomy

    A Csendes et al. Guts 1989

    Randomized controlled trial

    Subjects:Pneumatic dilatation (n = 39)

    Open Heller’s myotomy + Dor’s fundoplication (n =42)

    Conclusion:

    The study shows that surgical treatment offers a better final clinical result than pneumatic dilatation with the Mosher bag


    Pneumatic dilatation versus lap heller s myotomy

    Pneumatic Dilatation versus Lap Heller’s Myotomy

    S Kostic et al. World J Surg 2006

    Randomized controlled trial

    Subjects:Graded pneumatic dilatation (n = 26)

    Heller’s myotomy + toupet’s fundoplication (n =25)

    Primary outcome: Treatment failure rate

    2 Perforations after pneumatic dilatation


    Pneumatic dilatation versus lap heller s myotomy1

    Pneumatic Dilatation versus Lap Heller’s Myotomy

    • Lopushinsky SR et al. JAMA 2006

      • Retrospective longitudinal study

      • Subjects:Pneumatic dilatation 1181 (80.8%)

      • Surgical myotomy 280 (19.2%)

      • Primary outcome: use of subsequent intervention

      • Differences in risk were observed only when subsequent pneumatic dilatation was included as an adverse outcome


    Pneumatic dilatation versus lap heller s myotomy2

    Pneumatic Dilatation versus Lap Heller’s Myotomy


    Pneumatic dilatation versus heller s myotomy1

    Pneumatic Dilatation versus Heller’s Myotomy

    • Emerging evidence showing comparable result between pneumatic dilatation and Heller’s Myotomy

      • Improvement of dilatation devices and technique

      • Definition of treatment failure

        • Some of the latest studies accept repeated dilatation as part of the dilatation program, instead of treatment failure

      • Both pneumatic dilatation and Heller’s Myotomy are reasonable choices of treatment if patients accept repeated dilatation


    Per oral endoscopic myotomy

    Per Oral Endoscopic Myotomy

    • Natural orifice transluminal endoscopic surgery -> Novel approach for Achalasia

    • The concept of Submucosal tunneling and procedure was described by Samiyama K in 2007

    • Endoscopic myotomy was first reported by Pasricha et al. in a porcine model

      • Endoscopy 2007


    Per oral endoscopic myotomy1

    Per Oral Endoscopic Myotomy

    • First series of 17 patients with achalasia treated by P.O.E.M., reported by Inoue et al

      • Endoscopy 2010


    Per oral endoscopic myotomy2

    Per Oral Endoscopic Myotomy

    • 17 patients

      • seven women, ten men

      • mean age 41.4 years, range 18–62

    • Long submucosal tunnel created (mean 12.4cm)

    • Mean myotomy length = 8.1cm

    • Dysphagia symptoms score: 10  1.3 (p = 0.0003)

    • LES pressure: 52.4mmHg  19.8mmHg (p = 0.0001)


    Per oral endoscopic myotomy3

    Per Oral Endoscopic Myotomy

    • Experience from various centers


    Conclusion

    Conclusion

    • Laparoscopic cardiomyotomy + partial fundoplication is the standard treatment for achalasia

    • Pneumatic dilatation is reasonable alternative if patient accepts risk of repeated dilatation

    • Botox injection is only recommended for elderly and frail patients


    Conclusion1

    Conclusion

    • POEM is a novel approach showing promising short term results

    • Long term follow up needed

      • rate of symptoms recurrence

      • need for subsequent intervention

      • incidence of GERD

      • complication profile


    Thank you

    Thank you


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