Achalasia: treatment options revisited

Clinical Effect of Endoscopic Pneumatic Dilation for Achalasia

Although pneumatic dilation is an accepted method for the treatment of achalasia, this therapy has high recurrence and complication rates, and prolonged follow-up studies on the parameters associated with various outcomes are rare. In this prospective 10-year follow-up study, a satisfactory therapeutic effect was achieved without serious complications. We report the therapeutic experience with pneumatic dilation, having aimed to evaluate the long-term clinical safety and efficacy of pneumatic dilation. In total, 35 consecutive patients with idiopathic achalasia who underwent pneumatic dilation were followed up at regular intervals in person or by a phone interview over a 10-year period. The mean duration of the follow-up was 43.03 ± 26.34 months (range 6-120 months). Remission was assessed by the dysphagia classification and symptom scores. Patients' clinical symptom scores were calculated before and at 6 to 36  months, 37 to 60  months, and >60  months after therapy. The influence of the patients' age, gender, and disease duration on the therapeutic effect was analyzed. The success rate of the operation was 97.2% (35/36), without massive hemorrhaging, perforation or other serious complications. Dysphagia after the therapy was significantly eased (P < 0.01). In total, 35 patients have been followed up for 6 to 36  months after therapy, 21 cases for 37 to 60  months, and 5 cases for >60  months, and the patients' symptom scores separately decreased significantly compared with the pretherapy scores (P < 0.01). For these patients, the 6 to 36  months remission rate was 85.7% (30/35), the 37 to 60  months rate was 61.9% (13/21), and the >60  months rate was 40% (2/5). The dilation effect had no relationship to the patient's age, gender, and disease duration (P > 0.05). The patients in 30 cases (85.7%) were successfully treated with a single dilation, in 4 cases (11.4%) with 2 dilations, and in 1 case (2.9%) with 3 dilations. These results suggest that endoscopic pneumatic dilation is an achalasia therapy with a good response; it is a simple and safe procedure with long-term clinical effectiveness. It is a preferred method in the treatment of achalasia.

Surgical treatment of achalasia: transabdominal versus transthoracic cardiomyotomy

BACKGROUND

Achalasia is a primary esophageal motor disorder involving the body of the esophagus and lower esophageal sphincter. The mechanism is destruction of the myenteric plexus after a viral infection. Multiple methods of treatment with variable results induced in achalasia.

MATERIALS AND METHODS

We analyzed 70 patients with achalasia that underwent surgical treatment with transabdominal or transthoracic cardiomyotomy from 1982 to 2008 in Mashhad (Ghaem and Omid) hospital and at least 2 years follow up for evaluated result of surgery.

RESULTS

The mean age was 39.2 ± 9.42 years and the M/F = 0.89. The most common symptom was dysphagia (100%). The interval between beginnings of symptoms to a definitive diagnosis was 10.6 ± 8.3 month. The ratio between the two techniques was 35/35 = 1. In 67.1% of patients, a previous history of pneumatic dilation was reported. Long-term good results after surgery were seen in 77.2% of patients. Recurrence after surgical treatment was seen in 22.8%. A comparison of the two techniques (with or without antireflux surgery), showed a greater failure rate in transabdominal cardiomyotomy without the antireflux protocol (8/15 = 40%), but by the chi- square test, the difference was not statistically significant (P = 0.107). The most common complication after surgery was esophageal leakage (2.85%), and mortality was zero. In recurrence, most patients underwent pneumatic dilation (9/16 = 56.2%), and if surgery was needed, all patients underwent a transthoracic approach with antireflux treatment.

CONCLUSION

Based on the good, long-term results with the surgical treatment of achalasia, surgery is recommended in most patients. A transthoracic or transabdominal approach had good, long-term results, but a transthoracic approach had better results and usually did not need antireflux surgery.

Meta-analysis of randomized and controlled treatment trials for achalasia

Pharmacological therapy, botulinum toxin injection, pneumatic dilatation, and surgical myotomy are the primary therapeutic modalities for achalasia, for which laparoscopic myotomy is recommended as state-of-the-art therapy. However, its efficacy and safety remain unclear compared with other approaches in the treatment of achalasia. We searched electronic databases (MEDLINE, EMBASE, Cochrane Central Registry of Controlled Trials, LILACS-Latin American, Caribbean health science literature, and Science Citation Index Expanded) for randomized controlled trials to evaluate which therapeutic measures are temporary and reversible and which measures are definitive and effective by pooling data including remission rate, relapse rate, complications, and adverse effects. Seventeen studies with 761 patients met our inclusion criteria. There was better remission rate in pneumatic dilation than in botulinum toxin injection for initial intervention [relative risk (RR) 2.20, 95% confidence interval (CI) 1.51-3.20], Pneumatic dilation had lower relapse rate than did botulinum toxin injection (RR 0.12, 95% CI 0.04-0.32). Compared with pneumatic dilation, laparoscopic myotomy further increased remission rate (RR 1.48, 95% CI 1.48-1.87), and reduced clinical relapse rate (RR 0.14, 95% CI 0.04-0.58), and there was no difference in complication rate (RR 1.48, 95% CI 0.37-5.99). Based on limited randomized and controlled trials, laparoscopic myotomy is the preferred method for patients with achalasia. Future trials should investigate whether laparoscopic myotomy combined with different modalities of fundoplication is superior to isolated laparoscopic myotomy.

Esophageal achalasia: comparison of fluoroscopically-guided double vs. endoscopically-guided single balloon dilation

PURPOSE

To compare the long-term clinical effectiveness of fluoroscopically guided double and endoscopically guided single balloon dilations in esophageal achalasia.

MATERIALS AND METHODS

Thirty-two fluoroscopically guided balloon dilations were performed in 21 patients (group A) and 48 endoscopically guided balloon dilations were performed in 37 patients (group B). The double balloon dilation technique (10 + 20-mm, 15 + 20-mm or 20 + 20-mm in diameter), with preceding single balloon dilation (10, 15, or 20-mm in diameter), was used in group A, whereas the single balloon dilation technique (30, 35, or 40-mm in diameter) with gradually increased internal pressure was used in group B. Technical success, clinical success, complications, and primary/secondary patency rates were compared between the two groups.

RESULTS

All procedures were technically successful without esophageal perforation. Clinical success was achieved in 97% (31/32) and 92% (44/48) of balloon dilations in groups A and B, respectively. The symptomatic improvement in dysphagia was significantly higher in group A than in group B. Incidence of complications was the same (18.8%) in both groups. Group A showed significantly longer primary and secondary patency periods than did group B (P < 0.05).

CONCLUSION

Fluoroscopically guided double balloon dilation has greater long-term effectiveness than endoscopically guided single balloon dilation in the treatment of esophageal achalasia.

Laparoscopic esophagomyotomy for achalasia without a complementary antireflux procedure

BACKGROUND

Achalasia is a progressive motility disorder of the esophagus, without a definitive cure. The principal method of palliation is myotomy of the distal esophagus. We analyzed the 5-year experience at our institution with laparoscopic Heller myotomy without an antireflux procedure to determine its results, particularly regarding postoperative gastroesophageal reflux.

MATERIALS AND METHODS

Thirty-three patients, mean age 43 years (range, 29-62 years) with clinical, manometric, x-ray, and endoscopic proof of achalasia were operated on and followed up for 24 months. Prior to being referred to surgery they had all undergone at least one pneumatic balloon dilation. The operative technique was a 7-cm myotomy that included the lower esophageal sphincter but did not exceed 5 mm of the gastric cardia. Follow-up consisted of clinical observation, cineesophagography, and 24-hour pHmetry.

RESULTS

All patients reported satisfactory to excellent results regarding dysphagia and no heartburn two years after the operation. The 24-hour pHmetry and the radiographic investigation showed no evidence of gastroesophageal reflux.

CONCLUSION

It seems that the risk of gastroesophageal reflux is very low when the cardiomyotomy does not exceed the length of 5 mm. Our results are in accordance with other observational studies as well as larger cohort and meta-analysis studies. Prospective randomized studies are needed to clarify the role of an antireflux procedure after laparoscopic Heller myotomy.

Short-term and long-term effect of pneumatic dilation and botulinum toxin injection in treatment of cardiac achalasia

AIM: To evaluate the short-term and long-term effect of the pneumatic dilation and botulinum toxin A (BTXA) injection for the cardiac achalasia.

METHODS: From July 2000 to May 2004, 35 patients with cardiac achalasia received pneumatic dilation and BTXA injection in our hospital. The improvement of the dysphagia was observed 1 and 12 mo after the treatment.

RESULTS: Of the 35 patients, their conditions of dysphagia were significantly improved. The efficacy rates were 100% and 93.9% in the following up (1 and 12 mo, respectively). Two patients were lost to follow up while dysphagia relapsed in three patients during the following up.

CONCLUSION: The pneumatic dilation and BTXA injection for cardiac achalasia is safe, stable and effective in the treatment of cardiac achalasia.

Early results of laparoscopic Heller myotomy do not necessarily predict long-term outcome

BACKGROUND

We sought to evaluate how patients' symptoms evolve after laparoscopic Heller myotomy.

METHODS

Before and after laparoscopic Heller myotomy, 88 patients graded dysphagia and heartburn on a Likert scale (0 = none; 5 = severe). Patients graded outcomes as excellent, good, fair, or poor. Outcomes were compared in the same patients at 1 and 3 years of follow-up.

RESULTS

At early follow-up (10.6 +/- 7.8 months) significant reductions were noted in dysphagia (11% versus 100%), dysphagia scores (0.6 +/- 1.1 versus 4.7 +/- 0.7), heartburn (31% versus 72%), and heartburn scores (1.2 +/- 1.6 versus 2.7 +/- 1.9). By late follow-up (37.6 months +/- 18.0) these values increased (47%, 1.9 +/- 1.7, 48%, 1.8 +/- 1.5, respectively) but remained significantly reduced compared with before operation. Excellent/good outcomes at early and late follow-up were 89% and 85%, respectively (P = not significant).

CONCLUSIONS

Laparoscopic Heller myotomy is highly effective at palliating the symptoms of achalasia. With time, symptoms may recur owing to esophageal dysmotility, mandating continued surveillance.

Treatment with botulinum neurotoxin of gastrointestinal smooth muscles and sphincters spasms

Local injections of botulinum neurotoxin are now considered an efficacious treatment for neurological and non-neurological conditions. One of the most recent achievements in the field is the observation that botulinum neurotoxin provides benefit in diseases of the gastrointestinal tract. Botulinum neurotoxin inhibits contraction of gastrointestinal smooth muscles and sphincters; it has also been shown that the neurotoxin blocks cholinergic nerve endings in the autonomic nervous system, but it does not block nonadrenergic responses mediated by nitric oxide. This aspect has further promoted the interest to use botulinum neurotoxin as a treatment for overactive smooth muscles, such as the anal sphincters to treat anal fissure and outlet-type constipation, or the lower esophageal sphincter to treat esophageal achalasia. Knowledge of the anatomical and functional organization of innervation of the gastrointestinal tract is a prerequisite to understanding many features of botulinum neurotoxin action on the gut and the effects of injections placed into specific sphincters. This review presents current data on the use of botulinum neurotoxin to treat diseases of the gastrointestinal tract and summarizes recent knowledge on the pathogenesis of disorders of the gut due to a dysfunction of the enteric nervous system.

Selection and evaluation of three interventional procedures for achalasia based on long-term follow-up

AIM: To determine the best method out of the three types of interventional procedure for achalasia based on a long-term follow-up.

METHODS: The study cohort was comprised of 133 patients of achalasia. Among them, 60 patients were treated under fluoroscopy with pneumatic dilation (group A), 8 patients with permanent uncovered or antireflux covered metal stent dilation (group B), and 65 patients with temporary partially covered metal stent dilation (group C).

RESULTS: One hundred and thirty dilations were performed on the 60 patients of group A (mean 2.2 times per case). The mean diameter of the strictured cardia was 3.3 ± 2.1 mm before dilation and 10.6 ± 3.8 mm after dilation. The mean dysphagia score was 2.7 ± 1.4 before dilation and 0.9 ± 0.3 after dilation. Complications in group A were chest pain (n = 30), reflux (n = 16), and bleeding (n = 6). Thirty-six patients (60%) in group A exhibited dysphagia relapse during a 12-month follow-up, and 45 patients (90%) out of 50 exhibited dysphagia relapse during a 36-month follow-up. Five uncovered and 3 antireflux covered expandable metal stents were permanently placed in the 8 patients of group B. The mean diameter of the strictured cardia was 3.4 ± 1.9 mm before dilation and 19.5 ± 1.1 mm after dilation. The mean dysphagia score was 2.6 ± 1.3 before dilation and 0.4 ± 0.1 after dilation. Complications in group B were chest pain (n = 6), reflux (n = 5), bleeding (n = 3), and hyperplasia of granulation tissue (n = 3). Four patients (50%) in group B exhibited dysphagia relapse during a 12-month follow-up, and 2 case (66.7%) out of 3 patients exhibited dysphagia relapse during a 36-month follow-up. Sixty-five partially covered expandable metal stents were temporarily placed in the 65 patients of group C and withdrawn after 3-7 d via gastroscopy. The mean diameter of the strictured cardia was 3.3 ± 2.3 mm before dilation and 18.9 ± 3.5 mm after dilation. The mean dysphagia score was 2.4 ± 1.3 before dilation and 0.5 ± 0.2 after dilation. Complications in group C were chest pain (n = 26), reflux (n = 13), and bleeding (n = 8). 6 patients (9.2%) out of 65 exhibited dysphagia relapse during a 12-month follow-up, and 8 patients (14.5%) out of 55 exhibited dysphagia relapse during a 36-month follow-up. All the stents were inserted and withdrawn successfully. The follow-up in groups A-C lasted 12-96 months.

CONCLUSION: Temporary partially covered metal stent dilation is one of the best methods with interventional procedure for achalasia in terms of long-term follow-up.

Gastroesophageal reflux, quality of life, and satisfaction in patients with achalasia treated with open cardiomyotomy and partial fundoplication

BACKGROUND

Cardiomyotomy, often associated with an antireflux technique, is effective in the management of achalasia, although gastroesophageal reflux (GER) may occur after the procedure. Patient-centered measures, ie, health-related quality of life (HRQoL) and satisfaction, should be included in the evaluation of the patients.

METHODS

A study was made of the incidence of GER (symptoms, upper endoscopy and 24-hour pH monitoring), HRQoL (Short Form-36 Health Survey), and satisfaction after open-access cardiomyotomy and 180-degree anterior fundoplication in 28 consecutive patients, with a minimum postoperative follow-up of 12 months.

RESULTS

Mean age was 45 years (range 15 to 80) and 68% were female. In 8 subjects (all with heartburn) GER morbidity was present (4 with esophagitis and 4 with positive pH study), and 6 patients required proton pump inhibitors. Short Form-36 scores after surgery were similar to those found in the general population. Patient satisfaction was high and was more related to the absence of dysphagia than to the presence of GER symptoms.

CONCLUSIONS

Gastroesophageal reflux is relatively frequent after cardiomyotomy and partial fundoplication, although the efficacy of proton pump inhibitor treatment minimizes its clinical significance.

Other noncosmetic uses of BOTOX

Botulinum toxin A has a wide variety of clinical applications, which are related by blockade of acetylcholine and often are related to abnormal muscle contractures. These applications include ocular disorders, disorders of the upper aerodigestive tract, dystonia and hemifacial spasm, cosmetic, gastrointestinal disorders, genitourinary disorders, management of pain, and use in autonomic nervous system disorders. Many of these diseases will be discussed with regard to their treatment with botulinum toxin compared to conventional treatments. Advantages and disadvantages of botulinum toxin use are delineated. General guidelines for adult and pediatric dosing will also be discussed.

Physiology and pathology of the oesophagus in the elderly patient

In the 1960s, the term 'presbyoesophagus' was introduced for what were felt to be the characteristics of the oesophagus in old age. Since then a number of sophisticated studies using modern manometric, radiological, pH-metric or endoscopic equipment have been performed to better study this subject. Although results in some aspects are still contradictory, these studies have provided us with some more detailed information on the physiology of the ageing oesophagus. Beginning with an overview of what is currently known and discussed about age-induced physiological changes in oesophageal function, this review will then focus on specific problems of oesophagus-related diseases in the elderly. The main topics discussed will include presentation, diagnosis and treatment of primary and secondary motility disorders, oesophageal manifestations of neuromuscular and neurological disease, gastro-oesophageal reflux disease and oesophageal cancer in the elderly.

Videoscopic Heller Myotomy as First-Line Therapy for Severe Achalasia

To many nonsurgeons myotomy is considered an excessively invasive treatment for achalasia and has become a salvage procedure when esophageal dilation and botulinum toxin (botox) injections fail. We sought to examine our experience with videoscopic Heller myotomy to determine whether preoperative therapy predicts perioperative complications and long-term outcome. Videoscopic Heller myotomy was undertaken in 111 patients with achalasia between June 1992 and May 2000. Intraoperative endoscopy was used in all patients. Fundoplication was used selectively for patients with large hiatal hernias or as part of repair of esophageal perforation. Patients were asked to grade their dysphagia and reflux symptoms before and after myotomy on a scale of 0 (no symptoms) to 5 (severe symptoms). Patients were also asked to rate their outcome as excellent (no symptoms), good (greatly improved), fair (slightly improved), or poor (not improved) compared with their preoperative status. Patients were stratified on the basis of preoperative intervention (botox, pneumatic dilation, botox and pneumatic dilation, or no botox or dilation) and compared. Previous pneumatic dilation and/or botox injection had been undertaken before operation in 88 (79%) patients whereas 23 (21%) patients had no invasive preoperative therapy. The overall mean preoperative dysphagia score was 4.8 ± 0.8 and mean preoperative reflux score was 3.3 ± 2.1. Groups of patients undergoing preoperative interventions were similar to those patients not undergoing preoperative interventions in terms of preoperative symptoms, dysphagia scores, and reflux scores. Postoperative complications (13%) and perforations (8%) were slightly more common in patients who had undergone preoperative botox or dilation ( P = not significant). Subjectively, operative myotomy was more difficult in patients who had preoperative botox or dilation. Patients had significant improvement in dysphagia, dysphagia score, reflux score, emesis/regurgitation, and chest pain ( P < 0.05) regardless of preoperative intervention. After myotomy patients who had never undergone botox or pneumatic dilation were less likely to have mild dysphagia compared with those with previous botox injections (30% vs 53%; P = 0.09), previous dilations (30% vs 54%; P = 0.09), or both (30% vs 59%; P = 0.04). As well, dysphagia scores were better if no preoperative therapy had been undertaken: botox 0.8 ± 1.3, dilation 1.0 ± 1.4, botex and dilation 1.0 ± 1.3, and no therapy 0.3 ± 0.7 ( P < 0.05). Overall 97 per cent of patients stated that their symptoms were improved although more patients tended to have excellent or good outcomes if no preoperative intervention was undertaken (91%) compared with patients undergoing preoperative botox (86%), dilation (83%), or both (82%) ( P = not significant). We conclude that videoscopic Heller myotomy is safe and efficacious particularly in patients who have not undergone previous endoscopic interventions. The difference in patients’ outcomes based on preoperative therapy may be related to a less difficult operation in patients who forgo endoscopic therapy and elect to undergo early myotomy. Although videoscopic Heller myotomy provides good outcomes as a salvage procedure after failed dilations and/or botox injections for achalasia we advocate it as first-line therapy in reasonable operative candidates.

Other noncosmetic uses of BOTOX

Botulinum toxin A has a wide variety of clinical applications, which are related by blockade of acetylcholine and often are related to abnormal muscle contractures. These applications include ocular disorders, disorders of the upper aerodigestive tract, dystonia and hemifacial spasm, cosmetic, gastrointestinal disorders, genitourinary disorders, management of pain, and use in autonomic nervous system disorders. Many of these diseases will be discussed with regard to their treatment with botulinum toxin compared to conventional treatments. Advantages and disadvantages of botulinum toxin use are delineated. General guidelines for adult and pediatric dosing will also be discussed.

Practical approaches to dysphagia caused by Esophageal motor disorders

Dysphagia is a common symptom with which patients present. This review focuses primarily on the esophageal motor disorders that result in dysphagia. Following a brief description of the normal swallowing mechanisms and the messengers involved, more specific motor abnormalities are discussed. The importance of achalasia, as the only pathophysiologically defined esophageal motor disorder, is discussed in some detail, including recent developments in pathogenesis and treatment options. Other esophageal spastic disorders are described, with relevant manometric tracings included. In recent years, the importance of gastroesophageal reflux as a primary cause of esophageal dysmotility has been recognized, and this is also discussed. In addition, the motility disturbances that develop after surgical fundoplication are reviewed.