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Updates on management of achalasia

Updates on management of achalasia. Hung Sze Wing Dorothy. Achalasia. Achalasia is a primary esophageal motility disorder characterised by absence of esophageal peristalsis, impaired lower esophageal sphincter response Peak incidence 30-60 years old Equally common among men and women

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Updates on management of achalasia

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  1. Updates on management of achalasia Hung Sze Wing Dorothy

  2. Achalasia • Achalasia is a primary esophageal motility disorder characterised by absence of esophageal peristalsis, impaired lower esophageal sphincter response • Peak incidence 30-60 years old • Equally common among men and women • 1 in 100,000 incidence per year ACG Clinical Guideline: Diagnosis and Management of Achalasia Michael F. Vaezi , MD, PhD, MSc, FACG 1 , John E. Pandolfi no , MD, MSCI 2 and Marcelo F. Vela , MD, MSCR 3

  3. Presenting symptoms: • Dysphagia (most common) • Regurgitation • Chest pain • Weight loss

  4. Investigations • OGD • Grossly normal • Tight lower esophageal sphincter (LES) • Dilated sigmoid esophagus with retained food and saliva • Ba swallow: bird’s beak appearance • High resolution manometry (HRM) =gold standard Radiology, St Vincent’s university hospital

  5. Proximal esophagus Normal HRM Distal esophagus Lower pressure Higher pressure The University Hospital, Cincinnati

  6. Chicago classification • Developed by investigators at Northwestern University of Chicago • facilitate the diagnosis of achalasia • classify achalasia • Integrated relaxation pressure (IRP) = mean pressure of LES during the 4 seconds of maximal relaxation in the 10-second window beginning at UES relaxation • Normal IRP ≤ 15 mmHg • Achalasia = ↑ IRP + failed peristalsis or spasm  The Chicago Classification of esophageal motility disorders, v3.0 P.J. Kahrilas et al. Neurogastroenterology and motility. Dec 2014

  7. Chicago classification • Type I (“classic achalasia”): minimal pressure in esophagus • Type II: pan-esophageal pressurization (most common) • Type III: Spasm. At least 20% of swallows reveal rapidly propagating or spastic simultaneous contraction Type II Type I Type III Per oral endoscopic myotomy (POEM) for all spastic esophageal disorders? Endosc Int Open 2015 Jun; 3(3): E202–E204.

  8. Prognosis • Response to pneumatic dilatation or laparoscopic Heller myotomy • Type I intermediate response (~81%) • Type II has best response (~96%) • Type III has the least favorable response (~66%) JAMA. 2015;313(18):1841. Achalasia: a systematic review

  9. Eckardt Score for achalasia severity Score: 0-12 Eckardt AJ, Eckardt VF. Treatment and surveillance strategies in achalasia: an update. Nat Rev Gastroenterol Hepatol. 2011;8(6):311-319.

  10. Treatment options • Pharmacological • Endoscopic • Surgical

  11. Pharmacological options • Calcium channel blockers and nitrates • Least effective • Side effects e.g. dizziness, headache • Symptomatic improvement 53 to 87% Achalasia: a new clinically relevant classification by high-resolution manometry. PandolfinoJE, Kwiatek MA, Nealis T, Bulsiewicz W, Post J, KahrilasPJ. Gastroenterology. 2008 Nov; 135(5):1526-33.

  12. Endoscopic • Botulinum toxin • Durability 6-12months • 1 month response rate >75% • Pneumatic dilatation Annese V, Bassotti G, Coccia G et al. A multicentre randomised study of intrasphincteric botulinum toxin in patients with oesophageal achalasia. GISMAD Achalasia Study Group. Gut 2000;46:597–600

  13. Pneumatic dilatation • Endoscopic, graded dilatation • Good short term results • No GA • Requires repeated dilatation • Risk of perforation ~5% Pneumatic dilation versus laparoscopic Heller’s myotomy for idiopathic achalasia. Boeckxstaens GE et al. N Eng J Med, May 2011

  14. Surgical options • Laparoscopic Heller myotomy New options • Per-oral endoscopic myotomy (POEM)

  15. Heller myotomy • Divide circular and longitudinal muscles • Extended 6-8cm on the esophagus and 1.5-3cm on gastric cardia • + Fundoplication to reduce reflux • Dor/Toupet • 87% success after 2 years Boeckxstaens GE, Annese V, des Varannes SB et al. Pneumatic dilation versus laparoscopic Heller’s myotomy for idiopathic achalasia. N Engl J Med 2011;364:1807–181 Surgical treatment for achalasia – GI motility online – Nature. Jedediah A. Kaufman at al

  16. POEM Submucosal tunneling Tunneling beyond GE junction Circular muscles divided Closure of mucosal entry Per-Oral Endoscopic Myotomy: A Series of 500 Patients. H Inoue et al. Journal of the American College of Surgeons, august 2015.

  17. POEM vs Heller: systemic review and meta-analysis

  18. HK data POEM vs Heller

  19. Retrospective cohort study • 2001 to 2014 • 33 patients POEM • 23 patients laparoscopic Heller myotomy • Similar post-operative dysphagia score at 4 weeks, 3 months, 6 months • GERD symptoms similar (25% Heller, 15.2% POEM p = 0.311)

  20. POEM vs Heller • Similar efficacy • ?more GERD post-op in POEM patients

  21. Longer myotomy = better? • Theoretical advantage of a longer myotomy in POEM = ?better outcome Incision limited superiorly by hiatus

  22. Prognosis • Response to pneumatic dilatation or laparoscopic Heller myotomy • Type I intermediate prognosis(~81%) • Type II has best prognosis (~96%) • Type III has the least favorable response to treatment (~66%) JAMA. 2015;313(18):1841. Achalasia: a systematic review

  23. Endoscopy International Open, Jun 2015 • 75 patients with type III achalasia • 49 underwent POEM • 26 underwent laparoscopic Heller’s myotomy • POEM better response (98.0 % vs 80.8 %; P =0.01) and significantly shorter OT time

  24. Update in American gastroenterological association (AGA) guideline 2017 • If expertise available: • POEM should be considered as primary therapy for type III achalasia • POEM should be considered a treatment option comparable to laparoscopic Heller myotomy for any of the achalasia syndromes

  25. Dilatation vs Heller vs POEM

  26. Conclusion • Treatment options • Botox and oral medications for unfit patients • Pneumatic dilatation • Heller, POEM • Fitness for OT • Patient’s preference • $ • Expertise • Type of achalasia

  27. Thank you

  28. Fit for OT Yes No Type 3 achalasia Types 1 or 2 achalasia Botulinum toxin Fail Expertise available financially accept POEM or Heller Yes No Calcium channel blockers Nitrates Heller POEM

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