J Gastrointest Surg DOI 10.1007/s11605-014-2556-7
EVIDENCE-BASED CURRENT SURGICAL PRACTICE
Controversies in Management of Achalasia Marco G. Patti & Piero M. Fisichella
Received: 15 May 2014 / Accepted: 26 May 2014 # 2014 The Society for Surgery of the Alimentary Tract
Abstract Background Esophageal achalasia is a primary motility disorder of unknown etiology. It is characterized by lack of esophageal peristalsis and failure of the lower esophageal sphincter to relax appropriately in response to swallowing. The goal of treatment is to improve esophageal emptying and patient’s symptoms by decreasing the functional obstruction at the level of the gastroesophageal junction. This can be accomplished by either endoscopic modalities (intra-sphincteric injection of botulinum toxin, pneumatic dilatation, per oral endoscopic myotomy) or by a laparoscopic Heller myotomy. Results Review of the current literature suggests that a laparoscopic Heller myotomy should be considered today the primary form of treatment for achalasia and recommends a treatment algorithm for this disease. Keywords Esophageal achalasia . Dysphagia . Botulinum toxin . Pneumatic dilatation . Per oral endoscopic myotomy . POEM . Laparoscopic Heller myotomy . Dor fundoplication . Toupet fundoplication
dilatation, (3) per oral endoscopic myotomy (POEM), and (4) laparoscopic Heller myotomy (LHM). This manuscript reviews the current data in order to establish the best treatment algorithm for this disease.
Endoscopic Botulinum Toxin Introduction Esophageal achalasia is a primary motility disorder of unknown etiology. It is characterized by lack of esophageal peristalsis and failure of the lower esophageal sphincter (LES) to relax properly in response to swallowing. The LES is hypertensive in about 50 % of patients only.1 The goal of treatment is to improve esophageal emptying and patient’s symptoms by decreasing the functional obstruction at the level of the gastroesophageal junction (GEJ). This goal can be accomplished by either endoscopic therapy or by surgery. Treatment modalities include the following: (1) endoscopic injection of botulinum toxin, (2) pneumatic M. G. Patti (*) Department of Surgery, Center for Esophageal Diseases, Pritzker School of Medicine, University of Chicago, 5841 S. Maryland Ave, MC 5095, Room G-207, Chicago, IL 60637, USA e-mail: [email protected] P. M. Fisichella Department of Surgery, Boston VAMC, Harvard Medical School, Boston, MA, USA
Endoscopic injection of botulinum toxin blocks the release of acetylcholine at the level of the GEJ. Even though it decreases LES pressure, it does not affect LES relaxation. It is a safe procedure which achieves initial relief or improvement of symptoms in 80 to 85 % of patients. Unfortunately, its effect progressively declines over time, and clinical benefits are short lasting even after repeated injections.2–4 In addition, transmural inflammation and fibrosis with loss of the normal anatomic planes frequently occur at the level of the GEJ and often make a myotomy more challenging and the outcome of the operation less predictable.5,6 For these reasons, endoscopic botulinum injection should be reserved for those patients who are poor candidates for more effective treatment modalities such as pneumatic dilatation and LHM.
Pneumatic Dilatation In 2011, Boeckxstaens and colleagues reported the results of a European multicenter and randomized trial comparing 201
J Gastrointest Surg
untreated achalasia patients with pneumatic dilatation (93 patients) with LHM and Dor fundoplication (106 patients).7 This trial was conducted between 2003 and 2008 in 14 centers in Italy, France, Spain, Belgium, and the Netherlands. Therapeutic success was the primary outcome, and it was defined as a drop in the Eckardt score to
EVIDENCE-BASED CURRENT SURGICAL PRACTICE
Controversies in Management of Achalasia Marco G. Patti & Piero M. Fisichella
Received: 15 May 2014 / Accepted: 26 May 2014 # 2014 The Society for Surgery of the Alimentary Tract
Abstract Background Esophageal achalasia is a primary motility disorder of unknown etiology. It is characterized by lack of esophageal peristalsis and failure of the lower esophageal sphincter to relax appropriately in response to swallowing. The goal of treatment is to improve esophageal emptying and patient’s symptoms by decreasing the functional obstruction at the level of the gastroesophageal junction. This can be accomplished by either endoscopic modalities (intra-sphincteric injection of botulinum toxin, pneumatic dilatation, per oral endoscopic myotomy) or by a laparoscopic Heller myotomy. Results Review of the current literature suggests that a laparoscopic Heller myotomy should be considered today the primary form of treatment for achalasia and recommends a treatment algorithm for this disease. Keywords Esophageal achalasia . Dysphagia . Botulinum toxin . Pneumatic dilatation . Per oral endoscopic myotomy . POEM . Laparoscopic Heller myotomy . Dor fundoplication . Toupet fundoplication
dilatation, (3) per oral endoscopic myotomy (POEM), and (4) laparoscopic Heller myotomy (LHM). This manuscript reviews the current data in order to establish the best treatment algorithm for this disease.
Endoscopic Botulinum Toxin Introduction Esophageal achalasia is a primary motility disorder of unknown etiology. It is characterized by lack of esophageal peristalsis and failure of the lower esophageal sphincter (LES) to relax properly in response to swallowing. The LES is hypertensive in about 50 % of patients only.1 The goal of treatment is to improve esophageal emptying and patient’s symptoms by decreasing the functional obstruction at the level of the gastroesophageal junction (GEJ). This goal can be accomplished by either endoscopic therapy or by surgery. Treatment modalities include the following: (1) endoscopic injection of botulinum toxin, (2) pneumatic M. G. Patti (*) Department of Surgery, Center for Esophageal Diseases, Pritzker School of Medicine, University of Chicago, 5841 S. Maryland Ave, MC 5095, Room G-207, Chicago, IL 60637, USA e-mail: [email protected] P. M. Fisichella Department of Surgery, Boston VAMC, Harvard Medical School, Boston, MA, USA
Endoscopic injection of botulinum toxin blocks the release of acetylcholine at the level of the GEJ. Even though it decreases LES pressure, it does not affect LES relaxation. It is a safe procedure which achieves initial relief or improvement of symptoms in 80 to 85 % of patients. Unfortunately, its effect progressively declines over time, and clinical benefits are short lasting even after repeated injections.2–4 In addition, transmural inflammation and fibrosis with loss of the normal anatomic planes frequently occur at the level of the GEJ and often make a myotomy more challenging and the outcome of the operation less predictable.5,6 For these reasons, endoscopic botulinum injection should be reserved for those patients who are poor candidates for more effective treatment modalities such as pneumatic dilatation and LHM.
Pneumatic Dilatation In 2011, Boeckxstaens and colleagues reported the results of a European multicenter and randomized trial comparing 201
J Gastrointest Surg
untreated achalasia patients with pneumatic dilatation (93 patients) with LHM and Dor fundoplication (106 patients).7 This trial was conducted between 2003 and 2008 in 14 centers in Italy, France, Spain, Belgium, and the Netherlands. Therapeutic success was the primary outcome, and it was defined as a drop in the Eckardt score to
