management of achalasia
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Management of Achalasia. Joint Hospital Surgical Grand Round. Dennis KY Ngo Department of Surgery Prince of Wales Hospital. Background. Greek term : failure to relax One of esophageal motility abnormalities Characterized by Incomplete relaxation of the lower esophageal sphincter (LES ) - PowerPoint PPT PresentationTRANSCRIPT
Management of AchalasiaManagement of Achalasia
Dennis KY NgoDepartment of Surgery
Prince of Wales Hospital
Joint Hospital Surgical Grand Round
BackgroundGreek term : failure to relaxOne of esophageal motility abnormalitiesCharacterized by
Incomplete relaxation of the lower esophageal sphincter (LES )Aperistalsis of the body of esophagus
Simultaneous low amplitudes esophageal contractionNo apparent esophageal contraction
Due to degeneration of inhibitory neurones in the wall of esophagus, preferentially nitric oxide producing.
Cause is unknown ? Viral infection (VZV or HSV-1) ? Immune-mediated
Class II HLA antigen – DQw1
EpidemiologyIncidence : 0.5 per 100 000Prevalence : < 10 per 100 000
No sex predilectionAge ~ 20-50
Kraichely et al Disease of the Esophagus 2006
CaseF/45Good past healthPresented with acid regurgitation for 5 yearsInitially treated as gastroesophageal reflux disease ( GERD )Refer to us for surgical treatment of GERDFurther questioning : dysphagia symptoms with hold up sensation at lower chest level
F/45Good past healthPresented with acid regurgitation for 5 yearsInitially treated as gastroesophageal reflux disease ( GERD )Refer to us for surgical treatment of GERDFurther questioning : dysphagia symptoms with hold up sensation at lower chest level
SymptomsDysphagia
Both solid and liquid
Regurgitation and heartburnA common presentationOften misdiagnosed as GERD, esp. early achalasia
Delayed clearance – generate lactic acid from retained food residue
Howard et al Gut 1992
Chest painWeight loss
Investigation
Upper Endoscopy (esophagogastroduodenoscopy)First choice of investigation of dysphagia
Mechanical obstructionMalignancy, esp around the lower esophageal sphincter ( pseudoachalasia )
Cues for achalasiaEsophageal dilatation Presence of food residue inside the esophagus
Radiology ( Barium swallow )
Features on Fluoroscopic Barium swallow
“Bird beak” like OGJEsophageal dilatationNon-peristaltic esophagusSigns of aspiration pneumonia
ManometryDiagnostic for achalasiaDiagnostic features :
Incomplete relaxation of LESNormally – to a level < 8 mmHg above the gastric pressure
Aperistalsis of esophagus
Other characteristic features: Elevated resting LES ( > 26 mmHg )Pressurization of esophagus
resting pressure in the esophagus exceeds the resting pressure in the stomach
Spechler et al Gut 2001
Aim of managementCannot reverse the underlying the pathogenesisFocused on reducing the LES pressure
Facilitate the emptying of esophageal content by gravity
Symptomatic control and prevention of end organ damage
Treatment OptionsTreatment Options
Treatment OptionsTreatment Options
Pharmacologic therapyCommonly calcium channel blocker and nitratesPoor results, effects diminish with timeSignificant side effects of hypotension, headache and peripheral edema
NOT Applicable in clinical setting now
Lake et al Alimentary Pharmacology & Therapeutics 2006
Botulinum toxin injectionPotent inhibitor of the release of Acetylcholine
Excitatory influence of LES tone
Balance the action between excitation and inhibition neuronsInjection to LES
Four quadrant mannerTotal 100 U
StudyPt. No.
Symptomatic Improvement % LES
pressure %
No. Tx session
immediate 12m
Pasricha et al 31 90 44 - 1-2
Fishman et al 60 70 36 - 1
D’Onofrio et al 37 84 84 30 1-2
Kolbasnik et al 30 77 65 - 1-3
Annese et al 38 84 - 31 1-2
Cuilliere et al 55 72 - 30 1
Endoscopic dilatationDifferent size of balloon
30mm, 35mm and 40mm
Rigiflex balloon dilator
Long term follow-up result2 large scale long term FU results
Retrospective study on 66 patientsSuccess rate : 85.7% ( 12 weeks after procedure )Cumulative success rate : 74% (5 years), 62%(10 years)21% requiring second dilatationPerforation rate : 4.5 % ( all managed conservatively )
Chan et al Endoscopy 2004
Prospective study on 54 patients40% (5 years) and 36% (10 years)One patient with perforation, managed conservatively
Eckardt et al Gut 2004
Predictors of successOlder ageDecrease in LES pressure > 50% after dilatation
Perforation risk : < 5%Risk of gastroesophageal reflux symptoms ~ 4-16%, can be managed by medical therapy
Eckardt et al Gut 2004
Ghoshal et al Am J Gastroenterol 2004
Botulinum toxin vs DilatationStudyStudy DesignDesign Pt no.Pt no. FUFU Symptomatic Symptomatic
remissionremission Perf.Perf.
Vaezi et al GUT 1999
RCT 20 Dilatation 12m 70% (P<0.05) 5%
22 Botox 32% -
Milaeli et alAPT 2001
RCT 20 Dilatation 12m 53% (P<0.05) 0%
20 Botox 15% -
CardiomyotomyHeller’s myotomy
1914Original description
Anterior and posterior myotomy
CurrentlyLess length of myotomyOnly done anteriorly
Open ( transabdominal or transthoracic )Laparoscopic transabdoLaparoscopic transabdominalminal
Result from Laparoscopic cardiomyotomy
StudyStudy No.No. FUFU Relief of Relief of dysphagiadysphagia
LES LES pressurepressure
Patti Ann Surg 1999 133 28m 93% 30 to 9
mmHg
Tsiaoussis Am J Surg 2007 68 8 year 91% 35 to < 8
mmHg
Controversy 1? Antireflux surgery is needed for cardiomyotomy
Variable incidence of reflux symptoms after cardiomyotomy
Richards et al Ann Surg 2004
05
101520253035404550
GERD Acid exp
HellerHeller+Dor
LES pressure was similar : 13.7mmHg vs 13.9 mmHg
Controversy 2Antireflux surgery is needed in myotomy
? Total or partial
Choice of antireflux surgeryTotal vs partial
Retard the esophageal clearance in a aperistaltic esophagusNot enough pressure for food propagationProgressive dilatation of the esophagus, result in dysphagia again
Favour partial fundoplication
Controvery 3Partial fundoplication for myotomy
? Posterior Partial ( Toupet )? Anterior Partial ( Dor )
Studies on individual performance for laparoscopic Heller myotomy + Dor or Toupet fundoplication
Both have good dysphagia relief together with reflux control
However, lack of randomized controlled trial for comparison
The choice is based on the surgeon’s belief and expertise
Treatment options remaining : Laparoscopic cardiomyotomy with partial fundoplication
Endoscopic balloon dilatation
Lap myotomy vs DiltationOne randomized controlled trial recently
Kostic et al World J Surg 2007
51 patients25 Laparoscopic myotomy +
Toupet fundoplication26 Dilatation
FU for 12 monthsResults :
Symptomatic relief96% (Surgery) 77% (Dilatation)
ConclusionAchalasia sometimes mixed up with gastroesophageal reflux disease
High index of suspicion is needed
Manometry is gold standard for Diagnosis of Achalasia
Treatment options available Surgery vs endoscopic balloon dilatation
Trend more towards to Surgery in good operative risk in view of excellent and durable symptomatic risk with low complication rate
Thank you