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Management of Achalasia Dennis KY Ngo Department of Surgery Prince of Wales Hospital Joint Hospital Surgical Grand Round.

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Presentation on theme: "Management of Achalasia Dennis KY Ngo Department of Surgery Prince of Wales Hospital Joint Hospital Surgical Grand Round."— Presentation transcript:

1 Management of Achalasia Dennis KY Ngo Department of Surgery Prince of Wales Hospital Joint Hospital Surgical Grand Round

2 Background Greek term : failure to relax One of esophageal motility abnormalities Characterized by Incomplete relaxation of the lower esophageal sphincter (LES ) Aperistalsis of the body of esophagus Simultaneous low amplitudes esophageal contraction No apparent esophageal contraction

3 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 Epidemiology Incidence : 0.5 per Prevalence : < 10 per No sex predilection Age ~ Kraichely et al Disease of the Esophagus 2006

4 Case F/45 Good past health Presented with acid regurgitation for 5 years Initially treated as gastroesophageal reflux disease ( GERD ) Refer to us for surgical treatment of GERD Further questioning : dysphagia symptoms with hold up sensation at lower chest level

5 F/45 Good past health Presented with acid regurgitation for 5 years Initially treated as gastroesophageal reflux disease ( GERD ) Refer to us for surgical treatment of GERD Further questioning : dysphagia symptoms with hold up sensation at lower chest level

6 Symptoms Dysphagia Both solid and liquid Regurgitation and heartburn A common presentation Often misdiagnosed as GERD, esp. early achalasia Delayed clearance – generate lactic acid from retained food residue Howard et al Gut 1992 Chest pain Weight loss

7 Investigation

8 Upper Endoscopy (esophagogastroduodenoscopy) First choice of investigation of dysphagia Mechanical obstruction Malignancy, esp around the lower esophageal sphincter ( pseudoachalasia ) Cues for achalasia Esophageal dilatation Presence of food residue inside the esophagus

9 Radiology ( Barium swallow ) Features on Fluoroscopic Barium swallow “ Bird beak ” like OGJ Esophageal dilatation Non-peristaltic esophagus Signs of aspiration pneumonia

10 Manometry Diagnostic for achalasia Diagnostic features : Incomplete relaxation of LES Normally – 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

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12 Aim of management Cannot reverse the underlying the pathogenesis Focused on reducing the LES pressure Facilitate the emptying of esophageal content by gravity Symptomatic control and prevention of end organ damage

13 Treatment Options

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15 Pharmacologic therapy Commonly calcium channel blocker and nitrates Poor results, effects diminish with time Significant side effects of hypotension, headache and peripheral edema NOT Applicable in clinical setting now Lake et al Alimentary Pharmacology & Therapeutics 2006

16 Botulinum toxin injection Potent inhibitor of the release of Acetylcholine Excitatory influence of LES tone Balance the action between excitation and inhibition neurons Injection to LES Four quadrant manner Total 100 U

17 Study Pt. No. Symptomatic Improvement %  LES pressure % No. Tx session immediate 12m Pasricha et al Fishman et al D’Onofrio et al Kolbasnik et al Annese et al Cuilliere et al

18 Endoscopic dilatation Different size of balloon 30mm, 35mm and 40mm Rigiflex balloon dilator

19 Long term follow-up result 2 large scale long term FU results Retrospective study on 66 patients Success rate : 85.7% ( 12 weeks after procedure ) Cumulative success rate : 74% (5 years), 62%(10 years) 21% requiring second dilatation Perforation rate : 4.5 % ( all managed conservatively ) Chan et al Endoscopy 2004 Prospective study on 54 patients 40% (5 years) and 36% (10 years) One patient with perforation, managed conservatively Eckardt et al Gut 2004

20 Predictors of success Older age Decrease 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

21 Botulinum toxin vs Dilatation StudyDesign Pt no. FU Symptomatic remission Perf. Vaezi et al GUT 1999 RCT20 Dilatation12m70% (P<0.05)5% 22 Botox32%- Milaeli et al APT 2001 RCT20 Dilatation12m53% (P<0.05)0% 20 Botox15%-

22 Cardiomyotomy Heller ’ s myotomy 1914 Original description Anterior and posterior myotomy Currently Less length of myotomy Only done anteriorly Open ( transabdominal or transthoracic ) Laparoscopic transabdominal

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24 Result from Laparoscopic cardiomyotomy StudyNo.FU Relief of dysphagia LES pressure Patti Ann Surg m93% 30 to 9 mmHg Tsiaoussis Am J Surg year91% 35 to < 8 mmHg

25 Controversy 1 ? Antireflux surgery is needed for cardiomyotomy Variable incidence of reflux symptoms after cardiomyotomy

26 Richards et al Ann Surg 2004 LES pressure was similar : 13.7mmHg vs 13.9 mmHg

27 Controversy 2 Antireflux surgery is needed in myotomy ? Total or partial

28 Choice of antireflux surgery Total vs partial Retard the esophageal clearance in a aperistaltic esophagus Not enough pressure for food propagation Progressive dilatation of the esophagus, result in dysphagia again Favour partial fundoplication

29 Controvery 3 Partial fundoplication for myotomy ? Posterior Partial ( Toupet )? Anterior Partial ( Dor )

30 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

31 Treatment options remaining : Laparoscopic cardiomyotomy with partial fundoplication Endoscopic balloon dilatation

32 Lap myotomy vs Diltation One randomized controlled trial recently Kostic et al World J Surg patients 25 Laparoscopic myotomy + Toupet fundoplication 26 Dilatation FU for 12 months Results : Symptomatic relief 96% (Surgery) 77% (Dilatation)

33 Conclusion Achalasia 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

34 Thank you


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