Achalasia: current treatment options

Comparative Effectiveness of Peroral Endoscopic Myotomy (POEM) Versus Traditional Treatment Modalities for Achalasia: A Systematic Review

Achalasia is a rare esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and absence of peristalsis, leading to significant swallowing difficulties and other symptoms. Traditional treatment options, including Heller myotomy (HM) and pneumatic dilation (PD), have been effective but are associated with risks such as perforation and gastroesophageal reflux disease (GERD). Peroral endoscopic myotomy (POEM) has emerged as a minimally invasive alternative, potentially offering several advantages over conventional methods. This systematic review aims to compare the efficacy, safety, and long-term outcomes of POEM versus HM in the treatment of achalasia. We systematically reviewed studies that compared POEM with HM in achalasia patients, focusing on key outcomes such as myotomy length, operative time, treatment success rates, and complication rates. The review included 15 studies comprising four randomized controlled trials, 10 cohort studies, and one case-control study. The results consistently showed that POEM achieved longer myotomy lengths and shorter operative times compared to HM. POEM also demonstrated higher or comparable treatment success rates, with a uniform definition of success based on achieving an Eckardt score of ≤3. However, the complication rates, particularly the incidence of GERD, varied between the two procedures, highlighting the need for careful patient selection and long-term follow-up. POEM offers a promising alternative to HM for the treatment of achalasia, with advantages in terms of reduced invasiveness, shorter operative times, and potentially higher treatment success rates. However, further high-quality research is necessary to fully establish its long-term efficacy and safety compared to conventional treatments.

Achalasia Cardia: A Case Series

ABSTRACT

Achalasia cardia is a rare disorder that impacts the lower esophageal sphincter and esophageal body. Due to its wide range of symptoms, it can be difficult to diagnose. Here we report three cases of Achalasia Cardia during a period of 9 months. The first patient, an 18-year-old male, presented with dysphagia and was evaluated with barium swallow and high-resolution manometry (HRM) revealing Achalasia Cardia. In the second case, a 37-year-old female had a prolonged diagnostic journey due to multiple comorbidities before a barium swallow finally revealed achalasia cardia. The third patient, a 47-year-old female was promptly diagnosed with barium swallow. All the cases were successfully treated with laparoscopic Heller's myotomy with anterior Dor's fundoplication. This case series highlights the potential for delayed diagnosis and the importance of early recognition, tailored diagnostic approaches, and the efficacy of surgical management.

A case report of end-stage achalasia: Conservative option as the new surgical standard

INTRODUCTION AND IMPORTANCE

End-stage achalasia is a rare disease, consisting of a functional impairment of the esophagus which becomes dilated with a sigmoid shape. While esophagectomy was considered for a long time as the principal surgical procedure in end-stage achalasia, recent literature results demonstrate that laparoscopic Heller Dor (LHD) could be an advocated alternative with acceptable functional results.

CASE PRESENTATION

We present the case of an eighty-three-year-old male, an elderly patient, who had been complaining for one year of dysphagia and general status loss. Endoscopy, manometry then a barium X-ray confirmed end-stage achalasia. The patient had LHD with an improvement of symptomatology post-operatively.

CLINICAL DISCUSSION

Achalasia is a rare disease affecting oesophagal motility. The diagnosis is suggested clinically and confirmed by a wide range of tests notably esophagogastroduodenoscopy, barium swallow and manometry. The diagnosis of achalasia is classically made by demonstrating impaired relaxation of the lower oesophagal sphincter and absent peristalsis in the oesophagal manometry. Esophagogastroduodenoscopy is made mainly to eliminate the diagnosis of oesophagal cancer. Barium swallow, however, is done to appreciate the impact of achalasia on the rest of the esophagus.

CONCLUSION

Our case highlights the satisfying results after an LHD which is an alternative to esophagectomy especially in elderlies with high risk.

Achalasia: Current therapeutic options

Achalasia is an esophageal motor disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and absent peristalsis in the smooth muscle esophageal body. As a result, patients typically experience dysphagia, regurgitation, chest pain, and weight loss. Over the past 10-15 years, there has been a resurgence of interest in the evaluation of therapies for achalasia. Unfortunately, little progress in the development of effective pharmacological treatments has been made. Botulinum toxin injection provides some relief of symptoms in many patients but requires periodic reinjection that may provide progressively less benefit over time. There are now three well-established, safe, and effective therapies for the treatment of achalasia: pneumatic dilation (PD), laparoscopic Heller myotomy (LHM), and peroral endoscopic myotomy (POEM) which can lead to marked symptom improvement in most patients. Each treatment has a specific constellation of risks, benefits, and recurrence rate. The first-line treatment used will depend on patient preference, achalasia subtype, and local expertise. The recent impressive advances in both the art and science of achalasia therapy are explored with a comprehensive review of the various treatment modalities and comparative controlled clinical trials. In addition, key technical pearls of the procedural treatments are demonstrated.

[Heller laparoscopic cardiomyotomy with Douro fundoplication - a standard for the treatment of cardiac achalasia in children]

OBJECTIVE

To analyze 20-year experience in surgical treatment of cardiac achalasia.

MATERIAL AND METHODS

A retrospective analysis included 35 children (20 boys and 15 girls) who underwent surgical treatment of cardiac achalasia at the Filatov Children's Clinical Hospital No. 13 for the period 2001-2020.

RESULTS

Heller laparoscopic cardiomyotomy with Douro fundoplication was followed by favorable outcomes in 33 (94.3%) children. We also observed significant decrease of postoperative Eckardt score compared to baseline values.

CONCLUSION

Methods of cardiodilation (balloon dilatation, bougienage) ensure a short-term effect and may be only used in addition to surgical treatment. Heller laparoscopic cardiomyotomy with Douro fundoplication results favorable outcome in more than 92% of patients and can be considered as a standard for the treatment of this disease in children. Oral endoscopic myotomy cannot be considered as an alternative to Heller laparoscopic cardiomyotomy with Douro fundoplication due to high risk of secondary gastroesophageal reflux and its complications. Therefore, additional fundoplication is required that makes treatment of cardiac achalasia more invasive and expensive compared to Heller laparoscopic cardiomyotomy with Douro fundoplication.

Achalasia and acromegaly: co-incidence of these diseases or a new syndrome?

BACKGROUND

Acromegaly is a disorder associated with hypersecretion of growth hormone, most usually caused by a pituitary adenoma. Dysmotility of the gastrointestinal tract has been reported in acromegalic patients. Achalasia is a disorder characterized by aperistalsis of the oesophagus with incomplete lower oesophageal sphincter relaxation and whose aetiology remains unknown. Mutations in some genes have previously been associated with the development of acromegaly or achalasia. The study aims were to analyse mutations in selected genes in a woman having both of these diseases, to identify their aetiological factors, and to suggest explanations for the co-incidence of acromegaly and achalasia.

METHODS AND RESULTS

A female patient with acromegaly, achalasia, and a multinodular thyroid gland with hyperplastic colloid nodules underwent successful treatment of achalasia via laparoscopic Heller myotomy, a thyroidectomy was performed, and the pituitary macroadenoma was surgically excised via transnasal endoscopic extirpation. Germline DNA from the leukocytes was analysed by sequencing methods for a panel of genes. No pathogenic mutation in AAAS, AIP, MEN1, CDKN1B, PRKAR1A, SDHB, GPR101, and GNAS genes was found in germline DNA. The somatic mutation c.601C>T/p.R201C in the GNAS gene was identified in DNA extracted from a tissue sample of the pituitary macroadenoma.

CONCLUSIONS

We here describe the first case report to our knowledge of a patient with both acromegaly and achalasia. Association of acromegaly and soft muscle tissue hypertrophy may contribute to achalasia's development. If one of these diagnoses is determined, the other also should be considered along with increased risk of oesophageal and colorectal malignancy.

Endoscopic ultrasound-measured muscular thickness of the lower esophageal sphincter and long-term prognosis after peroral endoscopic myotomy for achalasia

BACKGROUND

People with achalasia typically have a thick lower esophageal muscularis propria (LEMP), and peroral endoscopic myotomy (POEM) has been effective in treating most patients. LEMP thickness may be associated with the outcomes and prognosis after POEM. However, more evidence is needed regarding the relationship between LEMP thickness and patient prognosis after POEM.

AIM

To assess the association between LEMP thickness, measured using endoscopic ultrasound (EUS), and long-term prognosis, especially relapse, after POEM for achalasia.

METHODS

All medical records, including EUS data, of patients who underwent POEM to treat achalasia at Shengjing Hospital of China Medical University from January 2012 to September 2018 were retrospectively reviewed. LEMP thickness was measured by EUS, and a thickness of ≥ 3 mm was defined as thickened. The severity of patient symptoms was evaluated using the Eckardt score. Relapse was defined as a 3-point rise in the Eckardt score after a period of clinical remission. The relationship between patient characteristics, muscle thickness, and recurrence was analyzed.

RESULTS

Eighty-two patients (32 males and 50 females, aged 17-78 years) and 85 POEM procedures were included. In total, 76.8% (63/82 patients) of patients had a thickened muscularis propria. Older age and longer disease course were associated with muscularis propria thickening (P < 0.05). The mean postoperative follow-up time was 35.4 ± 17.2 mo (range, 8-87.5 mo) in 60 patients. Five patients with Eckardt scores > 3 refused further management after their symptoms were relieved. The relapse rate was 12.73% (7/55 cases). Five patients, four of whom had muscularis propria thickening, had disease recurrence within 12 mo after the procedure. Achalasia relapsed in one patient who had a thickened muscularis propria after 24 mo and in another patient who did not have a thickened muscularis propria after 30 mo. Patients with recurrence were typically younger and had a shorter disease course (P < 0.05). The relapse rate in patients with a non-thickened muscularis propria tended to be higher (18.2%, 2/11 patients) than that in patients with a thickened muscularis propria (11.4%, 5/44 patients), although no significant difference was found. Age (hazard ratio = 0.92; 95% confidence interval: 0.865-0.979; P < 0.05) and being male (hazard ratio = 7.173; 95% confidence interval: 1.277-40.286; P < 0.05) were identified as risk factors for symptomatic recurrence by multivariable analysis using the Cox model.

CONCLUSION

Patients with a thickened muscularis are typically older and have a longer disease course. Younger age and the male sex are associated with increased recurrence. Patients with a thin muscularis propria may be prone to relapse, although further validation is needed.

Long-term Symptom Control After Laparoscopic Heller Myotomy and Dor Fundoplication for Achalasia

BACKGROUND

Achalasia is a primary esophageal motility disorder in which there is incomplete relaxation of the lower esophageal sphincter and absence of peristalsis in the lower two thirds of the esophagus. A favored treatment is laparoscopic modified Heller myotomy with Dor fundoplication (LHMDor) with more than 90% immediate beneficial effect. The short-term outcomes of LHMDor are well documented, but stability and durability of postoperative symptom control over time is less understood.

METHODS

Between 2004 and 2016, 54 patients with achalasia underwent LHMDor (single center). Using validated questionnaires, patients rated their symptoms in five domains: pain, gastroesophageal reflux disease (GERD), dysphagia, regurgitation, and quality of life. Symptom ratings were done preoperatively, 4 weeks postoperatively, 6 months postoperatively, and yearly after the operation.

RESULTS

As expected, patients reported marked improvement in dysphagia, odynophagia, regurgitation, GERD, and quality of life after the operation (P < .001). From then on, the symptom control remained durable with respect to absence of pain, regurgitation, and odynophagia; however, we observed a recurrence of GERD symptoms beginning 3 to 5 years postoperatively (P = .001 and P = .04, respectively), with associated increased antireflux medication use. After initial LHMDor, 5 patients required endoscopic dilatation an average of 1.5 years postoperatively, and no patient required reoperation. Patients reported preserved improved quality of life to 11 years after the operation (P = .001).

CONCLUSIONS

These results demonstrate the durability of LHMDor in the definitive management of achalasia, offering consistent symptomatic relief and significant improvement in quality of life over the decade after surgery, despite some increase in GERD symptoms and antireflux medication use.

Oropharyngeal swallowing functions are impaired in patients with naive-achalasia

BACKGROUND

It is generally accepted that achalasia is limited to the pathology of the esophageal body and lower esophageal sphincter. However, patients with achalasia still have symptoms such as aspiration and weight loss after even a succesfull treatment, suggesting that additional oropharyngeal pathologies may be frequent in patients with achalasia.

OBJECTIVE

The aim of the study was to assess the oropharyngeal/hypopharyngeal swallowing functions of patients with naive-achalasia.

METHODS

We evaluated the oropharyngeal functions with fiberoptic endoscopic evaluation of swallowing (FEES) and high-resolution manometry (HRM) in 36 patients with naive-achalasia(mean age 47.8 ± 14.7; 20F, 20M) diagnosed with and upper gastrointestinal endoscopy, HRM, radiology compared the results with 40 healthy volunteers (mean age 48.25 ± 12.37; 23F, 17M) as controls. The Beck Depression Inventory (BDI) and the MD Anderson Dysphagia Inventory (MDADI) were used for psychological analysis and to assess quality of life.

RESULTS

Mean integrated relaxation pressure (IRP) values were significantly higher (12.7 ± 10.9) for all patients compared to controls (0 ± 4.40). In the presence of pharyngeal residue IRP was 18.6 ± 11.8 mmHg compare to patients without pharyngeal residue which was 7.2 ± 6.4 mmHg (p < 0.05). Resting pressures were 105.7 ± 60.4 mmHg in study group vs 116 ± 55.1 mmHg in the control group (NS). In the study group we determined that residues of semisolid and liquid food were significantly higher in the vallecula, retrocricoid region, pharyngeal wall, and piriform sinuses with FEES. The average MDADI score was 58.1 ± 19.8 and 87.6 ± 10.7 in the study and control groups, respectively (p < 0.05). Depression may be significantly higher in achalasia patients based on the BDI.

CONCLUSION

Relaxation of the upper esophageal sphincter is insufficient especially in patient with residue. This finding is supported by the presence of residue during FEES evaluation. In the assessment of patients with achalasia, in the presence of residue symptoms,oropharyngeal phases of swallowing should be examined with FEES. Furthermore, the effect of exercises to improve the pathological findings should be evaluated.

What to do when Heller's myotomy fails? Pneumatic dilatation, laparoscopic remyotomy or peroral endoscopic myotomy: A systematic review

BACKGROUND

Surgical treatment of achalasia fails in 10%-20% of patients. The most frequent responsible cause is the performance of an incomplete myotomy at primary surgery. The treatment when the failure happens is not well defined. In this study, we review and evaluate the possible treatments to be carried out when surgical myotomy fails. We define its benefits and results, with the purpose of defining a therapeutic algorithm.

MATERIALS AND METHODS

The systematic review was performed following the guidelines established by the Meta-analysis of Observational Studies in Epidemiology statement. We searched several electronic databases (MEDLINE, PubMED, EMBASE and Cochrane) from January 1991 to March 2017, with the keywords 'recurrent achalasia' 'POEM remyotomy', 'esophagomyotomy failure', 'Heller myotomy failure', 'myotomy failure', 'pneumatic balloon dilatation achalasia' and combinations between them, 'redo Heller', 'redo myotomy', 'reoperative Heller'.

RESULTS

A total of 61 observational studies related to the treatment of patients with failure of Heller's myotomy were initially found. Finally, 37 articles were included in our study that provided data on 289 patients. Of these 289 patients, diagnosed of failed Heller's myotomy, 87 were treated with pneumatic dilatation (PD), 166 underwent surgical revision and finally 36 were treated with POEM. No randomised controlled trial was identified.

CONCLUSIONS

The three therapeutic options analysed in this review are effective and safe in the treatment of patients with achalasia with failure of surgical myotomy. The best results can be achieved following an algorithm similar to the one proposed here, where each procedure must be performed by well-experienced team in the selected modality.

Achalasia: Outcome in children

BACKGROUND

Oesophageal achalasia is well-recognized but relatively rare in children, occasionally appearing as the "triple A" syndrome (with adrenal insufficiency and alacrima). Treatment modalities, as in adult practice, are not curative, often needing further interventions and spurring the search for better management. The outcome for syndromic variants is unknown. We sought to define the efficacy of treatments for children with achalasia with and without triple A syndrome.

METHODS

We conducted a retrospective analysis of presentation and outcomes for 42 children with achalasia presenting over three decades to a major pediatric referral center. Long term impact of the diagnosis was assessed by questionnaire.

RESULTS

We identified 42 children including six with triple A syndrome. The median overall age at diagnosis was 10.8 years and median follow-up 1593 days. Initial Heller myotomy in 17 required further interventions in 11 (65%), while initial treatment with botulinum toxin (n = 20) was ultimately followed by myotomy in 17 (85%). Ten out of 35 patients who underwent myotomy required a repeat myotomy (29%). Patients with triple A syndrome developed symptoms earlier, but had delayed diagnosis, were more underweight at diagnosis and at last follow up. Questionnaire results suggested a significant long term deleterious impact on the quality of life of children and their families.

CONCLUSION

Many children with achalasia relapse after initial treatment, undergoing multiple, different procedures, despite which symptoms persist and impact on quality of life. Symptoms develop earlier in patients with triple A syndrome, but the diagnosis is delayed and this has substantial nutritional impact.