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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. 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

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  1. Updates on the management of Achalasia Joint Hospital Surgical Grand Round 21 July 2012 Lok Hon Ting (NDH)

  2. 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

  3. 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

  4. 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

  5. Treatment Modalities

  6. Pharmacological treatment • Nitrates, Calcium channel blockers • Evidence: • Conclusion: Ineffective

  7. Botulinum toxin injection • Endoscopic injection at 4 quadrants of LES • Inhibit release of acetylcholine in muscle synapse • First used by Pasricha in 1993

  8. 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

  9. 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

  10. 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)

  11. Pneumatic dilatation Guilherme M. Campos et al. Annals of Surgery 2009

  12. 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%

  13. 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

  14. Heller’s myotomy Bresadola et al. Surg Laparosc Endoscc Percutan Tech 2012

  15. 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

  16. Heller’s myotomy and anti reflux surgery • Conclusion: • Heller’s myotomy with concomitant Dor’s fundoplication is the procedure of choice

  17. 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

  18. 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

  19. 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

  20. Pneumatic Dilatation versus Lap Heller’s Myotomy

  21. 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

  22. 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

  23. Per Oral Endoscopic Myotomy • First series of 17 patients with achalasia treated by P.O.E.M., reported by Inoue et al • Endoscopy 2010

  24. 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)

  25. Per Oral Endoscopic Myotomy • Experience from various centers

  26. 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

  27. 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

  28. Thank you

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