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Achalasia
1. Endotherapy in achalasia â
Where do we stand
Dr.Vadivel Kumaran.S.,M.D.,D.M(Gastro)
Consultant Medical Gastroenterologist
Kauvery Hospital
Chennai
2. Achalasia
⢠Achalasia is derived from Greek
(Îą = non, ĎιΝιĎΚι = relaxation).
⢠HRM -manometric subtyping predicts response to treatment.
⢠Drug therapy for achalasia is not effective.
⢠The traditional- surgical myotomy and endoscopic methods that
disrupt or weaken the LES.
o [ pneumatic dilation (PD) and botulinum toxin injection (BTI)].
⢠Per oral endoscopic myotomy (POEM), a novel endoscopic therapy
that allows performance of myotomy via an endoscopic approach.
3. Suggested algorithm for the treatment of achalasia.
Richter J E , and Boeckxstaens G E Gut 2011;60:869-876
Copyright Š BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved.
4. Pneumatic
dilation
Surgical myotomy Botulinum toxin
Ease of technique ââ â âââ
Duration of effect ââ âââ â
Safety ââ ââ âââ
Cost ââ â ââ
Easy return to
work
âââ â âââ
Success in
vigorous achalasia
â ââ âââ
Success in
pediatric patients
ââ âââ â
Success in elderly
patients
âââ âââ ââ
5. Pneumatic dilation
⢠17th century - whalebone was employed as a primitive
bougie to achieve disruption of the sphincter [Spiess and
Kahrilas, 1998] .
6. Endoscopy
⢠An antecedent endoscopy excludes intraluminal
malignancy, ensures esophageal clearance.
⢠Gauges the anatomy in terms of esophageal angulation,
hiatus hernia and epiphrenic diverticula.
8. Procedure
⢠No single, accented standard method for balloon dilation.
⢠Start with the 30 mm balloon and progress serially to the
35 mm and 40 mm balloons.
⢠Risk of perforation may be less with the smallest balloon.
⢠Performed under fluoroscopic guidance utilizing a
stiff guidewire with a soft distal tip that is placed using
endoscope.
10. X-ray images showing the Rigiflex balloon (dotted lines) positioned across the
oesophagogastric junction.
Richter J E , and Boeckxstaens G E Gut 2011;60:869-876
Copyright Š BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved.
11. Efficacy of PD
⢠Over 20 retrospective and prospective studies analyzed the
efficacy of P.D. using the Rigiflex balloon dilator
⢠[Walzer and Hirano, 2008].
⢠General consensus - single successful dilation may have an
efficacy duration of several years
⢠Patients typically require serial dilations to remain in remission.
⢠Eckardt et al. 2004 - 5-year response of 40% with a single
dilation.
⢠Parkman et al. 1993 - 3 dilations maintained remission in 90%
of patients over 5 years.
⢠Zerbid et al. 2006 - 97% and 93% efficacy over 5 and 10 years
respectively with serial dilations.
12. Assessment of success
⢠ECKARDT SCORE
⢠Decrease in esophageal LES pressure via manometry, and
a decrease in esophageal diameter on a barium
esophagram [Gockel et al. 2005].
13. Timed barium esophagram
The height of the barium column at 1 min on timed barium esophagram after PD or
Heller myotomy has been found to be a reliable predictor of long-term response
[Andersson et al. 2009)
Ingestion of 50-100 ml of barium with plain
thoracic radiographs taken at 1, 2 and 5 minutes.
14. Predictors of response
⢠Patient â associated factors.
⢠Response rates in younger patients are relatively lower
⢠Exact cut-off age â 40 to 60 yrs.
⢠Eckhardt et al. 2004; Howard et al. 2010.
⢠Technique â associated factors
⢠Use of the 30 mm balloon as opposed to the larger sizes was associated
with PD failure for younger male patients.
⢠Dobrucali et al. 2004; Wong, 2006.
⢠Response - Type I and Type II achalasia > Type III achalasia
⢠Pretap et al. 2011.
⢠Failure to lower the LES pressure significantly (<10 mmHg) is
associated with a poor outcome.
⢠Hulselmans et al. 2010; Ghoshal et al. 2012.
15. PD vs surgical myotomy
⢠Spiess and Kahrilas, 1998; Richter, 2008, Gockel 2005 &
Hulselmans et al. 2010 â few prospective RCTs done.
⢠Both options result in excellent initial relief of dysphagia.
⢠Surgery was shown to be superior at longer follow up.
⢠PD fares poorly in diminishing chest pain.
⢠Better LES pressure reduction was seen with surgery.
⢠Need for repeat intervention was greater with PD.
⢠Older trials had PD performed with outmoded dilation
balloons and surgical techniques were not refined.
17. Results
⢠Mean follow-up duration was 43 months.
⢠At 1 year - No difference between the groups in terms of
dysphagia and overall Eckardt score.
⢠At 2 years - No significant difference in terms of LES
pressure, esophageal emptying as assessed by timed
barium esophagram, or quality of life as assessed by
standard questionnaire.
⢠CONCLUSION
⢠PD remains a time tested effective modality in the
achalasia treatment armamentarium
18. BOTOX
⢠BTI yields good short-term results.
⢠effect wanes within 2 years of the last injection
⢠benefit of injection will be minimal even if repeated.
⢠waning effect may be due to regional fibrosis or antibodies
to the toxin.
⢠BTI is best reserved for infirm older people, patients with
significant comorbid conditions or patients refusing other
forms of treatment.
⢠Richter, 2008; Walzer and Hirano, 2008
20. Intersphincteric Injection
of Botulinum Toxin
Make injections at the squamocolumnar
junction or up to 1 cm proximally, and usually
100 units in total are injected in four to five
equal volume aliquots. An attempt is made to
equally space the injections in a
circumferential manner and at the same level
21. PD vs. botox
⢠Recent cochrane database review.
⢠No significant differencein remission between PD and
botox treatment within 4 weeks of the initial intervention.
⢠Review at 12 months â remission with PD 70% . 25 % for
botox.
⢠conclusion
⢠PD is more eff ective than botox in the long term
forpatients with achalasia.
⢠Leyden JE , Moss AC , MacMathuna P . Endoscopic pneumatic dilationversus
botulinum toxin injection in the management of primary achalasia
.Cochrane Database Syst Rev 2006 : (4) : CD005046
22. Nonvalidated alternative therapies and
investigational therapies with limited data
⢠Non-traditional therapies
⢠Savary dilation (20%), Maloney dilation (10%) and small
caliber balloon dilation similar to that used for esophageal
strictures (4%). [Enesvedt et al. 2011)
⢠Single center studies â advocated use of specially designed
covered SEMS (usually 30 mm) and ethanolamine injection
into the LES - No guidelines.
23. POEM
⢠Natural orifice transluminal endoscopic surgery (NOTES)
in 2004, novel endoscopic technique called was developed.
⢠Inoue - endoscopic LES myotomy for achalasia in 2008,
Yokohoma, Japan.
⢠Over 20 centers are currently performing POEM.
26. Efficacy
⢠Initial data. - Efficacy similar to that of LHM.
⢠International POEM Survey
⢠POEM treatment success is over 90%.
⢠Mean Eckardt score improved from 7.41 before to 1.0 after
POEM.
27. Adverse effects
⢠Aspiration pneumonia
⢠Submucosal hematoma
⢠Local peritonitis
⢠Cutaneous emphysema
⢠Pleural effusion
⢠Segmental atelectasis of
the lungs
⢠Esophageal stricture
⢠Dehiscence at tunnel
entrance
⢠Superficial ulcer at cardia
⢠Junctional flap perforation
⢠Cervical emphysema
⢠Pneumomediastinum
⢠Mild chest pain
⢠Full thickness dissection
into peritoneal cavity
⢠Full thickness dissection
into mediastinum
⢠Cutaneous emphysema
⢠Pneumoperitoneum
⢠Mucosal perforation
28. Potential advantages of
POEM over LHM
⢠Easy extension of the myotomy to any length helpful in DES
& other EMD.
⢠Less risk of injury to the vagus nerve.
⢠Less reflux since attachments of the esophagus such as the
phrenoesophageal membrane are not disrupted.
⢠Less pain than in LHM
Hinweis der Redaktion
Suggested algorithm for the treatment of achalasia. Healthy patients with a low risk of complications after surgery can be offered potentially definitive therapy with either pneumatic dilation or laparoscopic myotomy. Patients younger than 40â years may preferentially be referred to surgery, as they frequently need more repeat dilations than older subjects. Failures are best referred to oesophageal centres of excellence with expertise in pneumatic dilation, repeat myotomy, and oesophagectomy. High-risk patients, especially the elderly, are best treated with botulinum toxin injections, or alternatively pneumatic dilation, if the latter procedure is done at an oesophageal centre of excellence. (Updated from the American College of Gastroenterology Practice Guidelines: Diagnosis and management of achalasia. Am J Gastro 1999;94:3406â12, with permission.)â
polyethylene balloons are more reliable than their latex balloon predecessors in inflating to a fixed diameter
X-ray images showing the Rigiflex balloon (dotted lines) positioned across the oesophagogastric junction. The waist in the balloon is clearly visible before (left panel) but has completely disappeared at the end (right panel) of the pneumodilation procedure.