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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
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 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
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