Achalasia surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Pneumatic Dilation

Pneumatic dilation is the most effective non surgical treatment option, however, patients should be a surgical candidate in case an esophageal perforation occurs and immediate surgery is required. Pneumatic dilation is contraindicated in patients who are not surgical candidates such as patients with poor cardiopulmonary status or any other comorbid illness. Nonradiopaque polyethylene balloons (Rigiflex dilators) are the most commonly used dilators for pneumatic dilation.[1]

Procedure[2]

  • Patients are kept on a liquid diet for several days and nil per oral for 12 hours before endoscopy. It is performed as an outpatient procedure.
  • Endoscopy is done under conscious sedation.
  • Rigiflex balloon is passed over the guide-wire, smallest balloon (3 cm) is used first for the initial dilation.
  • Balloon placement is done most commonly using flouroscopy (endoscopic placement can be used too).
  • LES is flattened using 8-15 psi of air, for 15-60 seconds.
  • Post procedure follow up is done for 2-6 hours, and patient is observed for any fever or chest pain.
  • In case of chest pain, Gastrograffin esophagram is done to look for esophageal perforation.
  • In graded dilation protocol, subsequent dilations are done with larger balloons at 2-4 weeks interval after the initial dilation. Serial pneumatic dilation (PD) has been reported to be more successful than single PD. Symptomatic improvement at 6 months occurred in 90% of patients after serial PD compared to 62% patients after single PD.[3]

Complications

  • Esophageal perforation is the most serious complication present in 0-16% patients after pneumatic dilation (2% in experienced hands).[4] 50% of these need surgical treatment. Small perforations can be managed with conservative treatment using antibiotics, parenteral nutrition and stent placement.
    • Patients at high risk for perforation:
    • Elderly patients
    • Patients undergoing PD for the first time
    • Patients in whom 35 mm dilator is used first instead of 30 mm dilator
  • Gastroesophageal reflux disease (GERD) occurs in 15-35% patients, managed with proton pump inhibitors (PPI).
  • Pneumatic dilation causes some scarring which may increase the difficulty of Heller myotomy, if this surgery is needed later.
  • Other minor complications include chest pain, aspiration pneumonia, esophageal hematoma, mucosal tear without perforation, fever and bleeding.

Prognosis

Relapse occurs in one third patients in 4-6 years. Long term remission can be achieved by doing repeated balloon dilation, procedure is performed whenever patient needs it based on the symptoms.[5] Patients older than 40 years of age, female patients and patients with type II achalasia have the best prognosis. Timed barium esophagram is an important tool to predict effectiveness of procedure objectively.[6][7]

Surgery

There are few surgical procedures for the treatment of achalasia such as laproscopic myotomy, per oral endoscopic myotomy (POEM) and oesphagectomy. Myotomy was performed by Ernest Heller for the first time in 1913 by laprotomy approach. Minimally invasive approaches for esophageal myotomy include thoracoscopic and laproscopic approaches. It has been shown that symptomatic improvement is significantly better with laproscopic approach.[8] The myotomy is a lengthwise cut along the esophagus, starting above the LES and extending down onto the stomach a little way. The esophagus is made of several layers, and the myotomy only cuts through the outside muscle layers which are squeezing it shut, leaving the inner muscosal layer intact. A partial fundoplication or "wrap" is added in order to prevent excessive reflux, which can cause serious damage to the esophagus over time. In a Dor (anterior) fundoplication, part of the stomach is laid over the esophagus and stitched in place so whenever the stomach contracts, it also closes off the esophagus instead of squeezing stomach acids into it. After surgery, patients should keep to a soft diet for several weeks to a month, avoiding foods that can aggravate reflux.


  • Bougienage
  • A mechanical dilation of the LES with a firm rubber hose. This tends to be much more effective for patients with strictures than for achalasia.
  • Balloon Dilation
  • Also depends on ripping the LES.
  • There is a fine line between achieving a good result and causing esophageal perforation (seen in 2-6%).
  • Additionally, there are no guidelines concerning inflation time, number of inflations / session, inflation pressure, and how many sessions a patient should have before moving to another therapeutic modality.
  • Approximately 60 –85 % of patients have good initial results. Unfortunately, 50 % of patients will require further therapy within the next 5 years.
    • There is also data that suggests that repeated attempts are less likely to be successful and are associated with an increased risk of perforation.
  • It appears that better results are associated with age > 45 years, patients with symptoms greater than 5 years, and in those with a mildly dilated esophagus.
  • The other major side effect is the development of reflux esophagitis in ~ 2%.
  • Surgical myotomy was first performed by Heller in 1913. The operation consisted of two myotomies on opposite sides of the esophagus performed through a laparotomy.
  • The modified Heller approach (via left thoracotomy) has a success rate of 70–90%, and a mortality rate of 0.3% (similar to the 0.2% for pneumatic dilation).
  • Reflux occurs in ~ 10%, and can be complicated by ulceration, stricture and the development of Barrett’s.
  • There is little good data comparing surgery vs. pneumatic dilation, however surgery may have a higher rate of long-term benefit (95% vs. 65% at ~5 years).
  • Surgery is a good option for younger patients (<40 years old) as balloon dilation is only 50% successful with the 1st treatment, and < 70% effective overall in this age group.
    • It is also recommended for patients in whom dilation is especially risky (those with a tortuous distal esophagus, esophageal diverticula or who have had previous surgery of the gastroenterology (GE) junction), and those who have failed BoTox.
  • The surgery can also be preformed laparoscopically or thoracoscopically, and early data suggests equivalent short term results when compared with the open procedure.

ACG Clinical Guideline: Diagnosis and Management of Achalasia[1]

Recommendations for the Management of Achalasia

"1. Either graded pneumatic dilation (PD) or laparoscopic surgical myotomy with a partial fundoplication are recommended as initial therapy for the treatment of achalasia in those fit and willing to undergo surgery (strong recommendation, moderate-quality evidence)."
"2. PD and surgical myotomy should be performed in high-volume centers of excellence (strong recommendation, low-quality evidence)."
"3. The choice of initial therapy should be guided by patients’ age, gender, preference, and local institutional expertise (weak recommendation, low-quality evidence)."
"4. Botulinum toxin therapy is recommended in patients who are not good candidates for more defi nitive therapy with PD or surgical myotomy (strong recommendation, moderate quality evidence)."
"5. Pharmacologic therapy for achalasia is recommended for patients who are unwilling or cannot undergo definitive treatment with either PD or surgical myotomy and have failed botulinum toxin therapy (strong recommendation, low-quality evidence)."

References

  1. 1.0 1.1 Vaezi MF, Pandolfino JE, Vela MF (2013). "ACG clinical guideline: diagnosis and management of achalasia". Am J Gastroenterol. 108 (8): 1238–49, quiz 1250. doi:10.1038/ajg.2013.196. PMID 23877351.
  2. Boeckxstaens GE, Zaninotto G, Richter JE (2014). "Achalasia". Lancet. 383 (9911): 83–93. doi:10.1016/S0140-6736(13)60651-0. PMID 23871090.
  3. Vela MF, Richter JE, Khandwala F, Blackstone EH, Wachsberger D, Baker ME; et al. (2006). "The long-term efficacy of pneumatic dilatation and Heller myotomy for the treatment of achalasia". Clin Gastroenterol Hepatol. 4 (5): 580–7. PMID 16630776.
  4. Katzka DA, Castell DO (2011). "Review article: an analysis of the efficacy, perforation rates and methods used in pneumatic dilation for achalasia". Aliment Pharmacol Ther. 34 (8): 832–9. doi:10.1111/j.1365-2036.2011.04816.x. PMID 21848630.
  5. Zerbib F, Thétiot V, Richy F, Benajah DA, Message L, Lamouliatte H (2006). "Repeated pneumatic dilations as long-term maintenance therapy for esophageal achalasia". Am J Gastroenterol. 101 (4): 692–7. doi:10.1111/j.1572-0241.2006.00385.x. PMID 16635216.
  6. Rohof WO, Salvador R, Annese V, Bruley des Varannes S, Chaussade S, Costantini M; et al. (2013). "Outcomes of treatment for achalasia depend on manometric subtype". Gastroenterology. 144 (4): 718–25, quiz e13-4. doi:10.1053/j.gastro.2012.12.027. PMID 23277105.
  7. Vaezi MF, Baker ME, Achkar E, Richter JE (2002). "Timed barium oesophagram: better predictor of long term success after pneumatic dilation in achalasia than symptom assessment". Gut. 50 (6): 765–70. PMC 1773230. PMID 12010876.
  8. Campos GM, Vittinghoff E, Rabl C, Takata M, Gadenstätter M, Lin F; et al. (2009). "Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis". Ann Surg. 249 (1): 45–57. doi:10.1097/SLA.0b013e31818e43ab. PMID 19106675.