Pharmacotherapy for the management of achalasia: Current status, challenges and future directions

Diagnostic and therapeutic strategies for achalasia of the cardia

The diagnosis of achalasia of the cardidia (AC) is primarily based on clinical symptoms, esophagographic findings, esophagodynamic examination, and upper gastrointestinal endoscopic findings. High resolution manometry is considered the gold standard for diagnosis. With the advan-cement of new technologies, the diagnostic methods for AC have become more diverse, and three-dimensional modeling may facilitate early detection of AC. The use of endoscopic functional intracavity imaging probe can enhance diagnostic accuracy. Common treatment options include endoscopic balloon dilation, laparoscopic Heller myotomy, and peroral endoscopic myotomy (POEM). POEM has emerged as the most widely utilized therapeutic approach currently, significantly improving the clinical success rate in treating AC. This article provides a comprehensive review on recent research progress in the diagnosis and treatment of AC.

The Role of Botulinum Toxin A Neuromodulator in the Management of Synkinesis in Facial Palsy

Facial palsy describes the denervation of the facial nerve leading to difficulty in facial animation and expression. Facial synkinesis is the result of complex pathological nerve regeneration following damage to the facial nerve axons. Synkinesis in facial palsy can be managed using facial neuromuscular rehabilitation, botulinum toxin neuromodulators, and surgical treatment options. Botulinum toxin A can be used as an adjunct to other treatment options to manage synkinesis. This article will explore the role of botulinum toxin A in the management of synkinesis in facial palsy including the clinical assessment, injection location (muscles targeted), dosages, treatment interval, and long-term results. It will also include surgical management options.

An overview of the efficacy, safety, and predictors of achalasia treatments

INTRODUCTION

Achalasia is a rare esophageal motility disorder characterized by abnormal esophageal peristalsis and the inability of the lower esophageal sphincter to relax, resulting in poor esophageal emptying. This can be relieved by endoscopic and surgical treatments; each comes with certain advantages and disadvantages.

AREAS COVERED

This review aims to guide the clinician in clinical decision making on the different treatment options for achalasia regarding the efficacy, safety, and important predictors.

EXPERT OPINION

Botulinum toxin injection is only recommended for a selective group of achalasia patients because of the short term effect. Pneumatic dilation improves achalasia symptoms, but this effect diminishes over time and requiring repeated dilations to maintain clinical effect. Heller myotomy combined with fundoplication and peroral endoscopic myotomy are highly effective on the long term but are more invasive than dilations. Gastro-esophageal reflux complaints are more often encountered after peroral endoscopic myotomy. Patient factors such as age, comorbidities, and type of achalasia must be taken into account when choosing a treatment. The preference of the patient is also of great importance and therefore shared decision making has to play a fundamental role in deciding about treatment.

Diagnóstico y manejo actual de la acalasia

Introducción. La acalasia es un trastorno motor del esófago poco común, de etiología no clara, caracterizado por la pérdida de relajación del esfínter esofágico inferior, pérdida del peristaltismo normal, regurgitación y disfagia. Métodos. Se realizó una revisión narrativa de la literatura en revistas científicas y bases de datos en español e inglés, con el fin de presentar información actualizada en lo referente al diagnóstico y tratamiento de esta patología. Resultado. Se presenta la actualización de los criterios de los trastornos motores esofágicos según la clasificación de Chicago (CCv4.0) para el diagnóstico de acalasia y sus subtipos de acuerdo con los nuevos criterios, así como los tratamientos actuales. Conclusión. La acalasia es un trastorno esofágico multimodal, con manifestaciones de predominio gastrointestinal, por lo que su diagnóstico y abordaje terapéutico oportuno es esencial para mejorar la calidad de vida de los pacientes.

Poly(lactic acid)-hyperbranched polyglycerol nanoparticles enhance bioadhesive treatment of esophageal disease and reduce systemic drug exposure

The effective treatment of esophageal disease represents a significant unmet clinical need, as existing treatments often lead to unnecessary systemic drug exposure and suboptimal concentrations at the disease site. Here, surface-modified bioadhesive poly(lactic acid)-hyperbranched polyglycerol nanoparticles (BNPs), with an average 100-200 nm diameter, were developed for local and sustained esophageal drug delivery. BNPs showed significantly higher adhesion and permeation into ex vivo human and rat esophageal tissue than non-adhesive nanoparticles (NNPs) and had longer residence times within the rat esophagus in vivo. Incubation with human esophagus (Het-1A) cells confirmed BNPs' biocompatibility at clinically relevant concentrations. In a rat model of achalasia, nifedipine-loaded BNPs significantly enhanced esophageal drug exposure, increased therapeutic efficacy, and reduced systemic drug exposure compared to NNPs and free drug. The safety of BNPs was demonstrated by an absence of intestinal, hepatic, and splenic toxicity following administration. This study is the first to demonstrate the efficacy of BNPs for esophageal drug delivery and highlight their potential for improving the lives of patients suffering with esophageal conditions.

Achalasia in the Elderly: Diagnostic Approach and a Proposed Treatment Algorithm Based on a Comprehensive Literature Review

Achalasia is not uncommonly diagnosed in elderly patients and its incidence and prevalence are growing in this population. However, a scarcity of studies has assessed the typical pathophysiological and clinical features of the disease as well as the effectiveness and safety of the various therapeutic options in elderly populations. Botulinum toxin injection has been used for achalasia treatment since 1994 and is traditionally considered the preferred treatment for fragile elder patients. However, recently more evidence has become available regarding the safety and effectiveness of pneumatic balloon dilation (BD), laparoscopic Heller myotomy (LHM) and per-oral endoscopic myotomy (POEM) in elderly patients with achalasia. In the current review we present the current literature on this topic with a focus on the clinical presentation of achalasia in the elderly and manometric features thereof, as well as summarize the effectiveness and safety of the various therapeutic options. Furthermore, we propose a practical management algorithm as a means to guide the treatment of future cases. We recommend that a conservative/BTI approach should be adopted in the fragile unfit patient. In the elderly fit patient, the treatment decision should be based on the achalasia type, patient preference and the available expertise, similar to the approach adopted for the non-elderly population.

Peroral endoscopic myotomy is a safe and effective treatment modality for geriatric patients with achalasia

BACKGROUND

Peroral endoscopic myotomy (POEM) is an appealing treatment for older patients, as it is minimally invasive but highly efficacious similar to surgical myotomy. However, there is a lack of systematic studies analyzing POEM outcomes in young (< 65 years) versus geriatric patients (≥ 65 years). Hence, we aimed to compare the safety and efficacy of POEM in young versus geriatric patients.

METHODS

Records of all achalasia patients who underwent POEM at our institution between April 2014 and May 2019 were reviewed. Patients were categorized into two groups: young (< 65 years) and old (≥ 65 years). Demographic and procedural details, timed barium esophagram (TBE), high-resolution manometry (HREM), pH study findings and Eckardt scores were compared between the two groups. Post-POEM Eckhardt score of ≤ 3 was defined as treatment success.

RESULTS

A total of 148 patients met the study criteria (young = 93; old = 55). Younger patients were more likely to have lower TBE height at 1 min but wider TBE width at 5 min. The rest of the pre-operative parameters and Eckardt scores were similar in the two groups. Young patients were more likely to have undergone prior Heller myotomy, while Botox injections were common in the older group. The operative details and outcomes were similar in the two groups. Treatment success rates were similar in both groups (94.9% young vs. 94.7% in old patients, p = 1.00). At 2-month follow-up, both groups showed significant improvements in Eckhardt scores and HREM parameters; however, older patients showed greater improvement in TBE height at 1 and 5 min. The rates of symptomatic GERD and abnormal esophageal pH study findings were similar in the two groups.

CONCLUSION

POEM was safe and highly effective treatment for geriatric patients with achalasia. These findings suggest that POEM might emerge as the preferred approach for myotomy in this patient population.

Endoscopic ultrasound: a powerful tool to modify treatment algorithms in opioid-induced achalasia

BACKGROUND

Opioid use in the U.S. has increased dramatically over the last 15 years, recently being declared a public health emergency. Opioid use is associated with esophageal dysmotility lending to a confusing clinical picture compared to true achalasia. Patients exhibit symptoms and elicit diagnostic results consistent with esophageal motility disorders, in particular type III achalasia. Modified therapeutic strategies and outcomes become challenging. Differentiating true achalasia from opioid-induced achalasia is critical. Conventional surgical interventions, i.e., myotomy, are ineffective in the absence of true achalasia. We assess the utility of esophageal muscle layer mapping with endoscopic ultrasound (EUS) in distinguishing primary from opioid-induced achalasia.

METHODS

From 2016 to 2019, patients with abnormal manometry and suspected achalasia underwent esophagogastroduodenoscopy and EUS mapping of esophageal round muscle layer thickness. Maximum round layer thickness and length of round muscle layer thickness > 1.8 mm were collected and compared between opioid users and non-opioid users using Wilcoxon Rank sum test.

RESULTS

45 patients were included: 12 opioid users, 33 non-opioid users. Mean age 56.8 years (range 24-93), 53.3% male patients. Mean BMI in the opioid-induced achalasia group was 30.2 kg/m², mean BMI in the primary achalasia group 26.8 kg/m² (p = 0.11). In comparing endoscopic maximum round layer thickness between groups, non-opioid patients had a thicker round muscle layer (2.7 mm vs 1.8 mm, p = 0.05). Length of abnormally thickened esophageal muscle (greater than 1.8 mm) also differed between the two groups; patients on opioids had a shorter length of thickening (4.0 cm vs 0.0 cm, p = 0.04). Intervention rate was higher in the non-opioid group (p = 0.79). Of the patients that underwent therapeutic intervention, symptom resolution was higher in the non-opioid group (p = 0.002), while re-intervention post-procedure for persistent symptomatology was elevated in the opioid subset (p = 0.06). Patients in the opioid group were less likely to undergo invasive treatment (Heller). As of 2017 all interventions in the opioid group have been endoscopic.

CONCLUSION

Endoscopic ultrasound is an essential tool that has improved our treatment algorithm for suspected achalasia in patients with chronic opioid usage. Incorporation of EUS findings into treatment approach may prevent unnecessary surgery in opioid users.

Esophagogastric Junction Outflow Obstruction: Current Approach to Diagnosis and Management

PURPOSE OF REVIEW

We summarize the current epidemiology, presentation, diagnostic workup, and treatment of esophagogastric junction outflow obstruction (EGJOO). We also propose a treatment algorithm based upon the literature and our personal clinical experience.

RECENT FINDINGS

EGJOO can be caused by functional obstruction (akin to achalasia), mechanical obstruction, medications, or artifact. High-resolution esophageal manometry is currently the gold standard of diagnosis. Recent research on FLIP (functional lumen imaging probe) and timed barium support use as adjunctive testing. The diagnostic yield of cross-sectional imaging is low. Current diagnostic testing and treatment should be targeted to the suspected underlying etiology and clinical presentation of EGJOO. If functional obstruction is present with significant and persistent dysphagia, and either an abnormal FLIP or timed barium swallow, we consider therapy aimed at LES disruption (similar to achalasia). Pharmacologic therapy has a limited role. More research is needed on diagnostic and treatment modalities.

Updated Systematic Review of Achalasia, with a Focus on POEM Therapy

AIM

To systematically review clinical presentation, diagnosis, and therapy of achalasia, focusing on recent developments in high-resolution esophageal manometry (HREM) for diagnosis and peroral endoscopic myotomy (POEM) for therapy.

METHODS

Systematic review of achalasia using computerized literature search via PubMed and Ovid of articles published since 2005 with keywords ("achalasia") AND ("high resolution" or "HREM" or "peroral endoscopic myotomy" or "POEM"). Two authors independently performed literature searches and incorporated articles into this review by consensus according to prospectively determined criteria.

RESULTS

Achalasia is an uncommon esophageal motility disorder, usually manifested by dysphagia to solids and liquids, and sometimes manifested by chest pain, regurgitation, and weight loss. Symptoms often suggest more common disorders, such as gastroesophageal reflux disease (GERD), thus often delaying diagnosis. Achalasia is a predominantly idiopathic chronic disease. Diagnosis is typically suggested by barium swallow showing esophageal dilation; absent distal esophageal peristalsis; smoothly tapered narrowing ("bird's beak") at esophagogastric junction; and delayed passage of contrast into stomach. Diagnostic findings at high-resolution esophageal manometry (HREM) include: distal esophageal aperistalsis and integrated relaxation pressure (trough LES pressure during 4 s) > 15 mmHg. Achalasia is classified by HREM into: type 1 classic; type 2 compartmentalized high pressure in esophageal body, and type 3 spastic. This classification impacts therapeutic decisions. Esophagogastroduodenoscopy is required before therapy to assess esophagus and esophagogastric junction and to exclude distal esophageal malignancy. POEM is a revolutionizing achalasia therapy. POEM creates a myotomy via interventional endoscopy. Numerous studies demonstrate that POEM produces comparable, if not superior, results compared to standard laparoscopic Heller myotomy (LHM), as determined by LES pressure, dysphagia frequency, Eckardt score, hospital length of stay, therapy durability, and incidence of GERD. Other therapies, including botulinum toxin injection and pneumatic dilation, have moderately less efficacy and much less durability than POEM.

CONCLUSION

This comprehensive review suggests that POEM is equivalent or perhaps superior to LHM for achalasia in terms of cost efficiency, hospital length of stay, and relief of dysphagia, with comparable side effects. The data are, however, not conclusive due to sparse long-term follow-up and lack of randomized comparative clinical trials. POEM therapy is currently limited by a shortage of trained endoscopists.

Bridging therapy for achalasia in a second trimester pregnant patient

We present the case of a 28-year-old female who presented for primary care at 22-week gestation with type II achalasia and worsening solid/liquid dysphagia leading to pregnancy weight loss. Considering that durable therapies such as surgical myotomy and pneumatic dilatation have considerable risk, botulinum A toxin injection was selected as a temporizing bridging therapy. She had an uncomplicated post procedure course and had significant rapid improvement in dysphagia symptoms, which enabled her to progress to normal peripartum weight. This case highlights the need for early recognition of achalasia and an unique niche for use of botulinum toxin A as a temporizing therapy in this risk averse population.

An Overview of Achalasia and Its Subtypes

Achalasia is one of the most studied esophageal motility disorders. However, the pathophysiology and reasons that patients develop achalasia are still unclear. Patients often present with dysphagia to solids and liquids, regurgitation, and varying degrees of weight loss. There is significant latency prior to diagnosis, which can have nutritional implications. The diagnosis is suspected based on clinical history and confirmed by esophageal high-resolution manometry testing. Esophagogastroduodenoscopy is necessary to rule out potential malignancy that can mimic achalasia. Recent data presented in abstract form suggest that patients with type II achalasia may be most likely, and patients with type III achalasia may be least likely, to report weight loss compared to patients with type I achalasia. Although achalasia cannot be permanently cured, palliation of symptoms is possible in over 90% of patients with the treatment modalities currently available (pneumatic dilation, Heller myotomy, or peroral endoscopic myotomy). This article reviews the clinical presentation, diagnosis, and management options in patients with achalasia, as well as potential insights into histopathologic differences and nutritional implications of the subtypes of achalasia.