update on achalasia – techniques and outcomes william o. richards md, facs professor and chair...

Update on Achalasia – Techniques and Outcomes

• William O. Richards MD, FACS• Professor and Chair• Department of Surgery and the Division of Gastrointestinal/Oncologic Surgery• University of South Alabama College of Medicine• University of South Alabama Medical Center• Mobile, Alabama

Esophageal Motility - Achalasia

Postop LES Pressure > 18mmHg=bad result

6

45

05

1015202530354045

% Patients with Moderate

Dysphagia

LES<18 LES>18

moderate

Postop LES Pressure Change < 18 mmHg = bad result

100

59

0

41

0102030405060708090

100

% Patients with

Dysphagia

None/Mild Moderate

Change LESP >18Change LESP < 18

Transesophageal Endoscopic Myotomy (TEEM)

• Pig study• EMR mid esophagus with

snare• Submucosal tunnel• After reaching the GE

junction the LES was divided using triangular knife and electrocautery

Gazala et al Surg Endosc 26: 2012

Transesophageal Endoscopic Myotomy (TEEM) Results in 3 animals

• Mediastinal sepsis• Esophageal ulcer• Pneumothorax

Gazala et al Surg Endosc 26: 2012

Transesophageal Endoscopic Myotomy (TEEM)

Potential pitfall Action taken

Mucosal Ischemia Slim endoscope10 cm tunnel

pneumothorax Circular muscle dissection, CO2, Dedicated instruments, CXR, Deflation of mediastinum

Vagus nerve injury Orientation of myotomy in 10 o’clock position

Gazala et al Surg Endosc 26: 2012

Transesophageal Endoscopic Myotomy (TEEM) Results with modifications to

procedure

Gazala et al Surg Endosc 26: 2012

Transesophageal Endoscopic Myotomy (TEEM)

• Revised procedure• Effective in opening GE

junction• No mucosal ulcer

Gazala et al Surg Endosc 26: 2012

Transesophageal Endoscopic Myotomy (TEEM) Conclusions

• Technically feasible but not ready for prime time

• Recommend– Strict protocols– Dedicated instruments

• Hook knife• Balloon dissection of tunnel

Gazala et al Surg Endosc 26: 2012

Transesophageal Endoscopic Myotomy (TEEM)

• 7 patients• Operative time 69-124 minutes• Circular layers divided leaving longitudinal

layer intact• Start 5 cm above GEJ and extending 2 cm on

stomach• Mucosotomy site closed with endoscopic clips

Meireles et al presented at SAGES March 2011

Transesophageal Endoscopic Myotomy (TEEM)

• 7 patients• Operative time 69-124 minutes• 1 patient developed pneumoperitoneum• 1 patient with subcutaneous emphysema• Dischared home on POD #2 taking liquid diet• Resolution of dysphagia in all

Meireles et al presented at SAGES March 2011

Transesophageal Endoscopic Myotomy (TEEM) Results in 3 patients

36

43

10

0.43

05

1015

2025

3035

4045

baseline 6 month followup

LES resting pressuremm HgLES residual pressuremm Hg

Meireles et al presented at SAGES March 2011

Transesophageal Endoscopic Myotomy (TEEM) Results in 3 patients

Meireles et al presented at SAGES March 2011

0

5

10

15

20

Pre OP Post OP

GERD HRQL

2 patients developed GERD and were placed on PPI

Transesophageal Endoscopic Myotomy (TEEM) Conclusions

• “TEEM provides benefits of a complete surgical myotomy, while being a totally endoscopic procedure and therefore associated with very quick post-procedural recovery, minimal pain and the possibly of evolving to an outpatient procedure.”

• “Hence TEEM has the potential to become a routine practice in the near future as the treatment of choice.”

Meireles et al presented at SAGES March 2011

Per Oral Endoscopic MyotomyPOEM Procedure

Esophageal Acid exposure

• Symptoms do not correlate with acid exposure

• Reduced LES pressure• Reduced esophageal clearance increases

esophageal acid exposure

No Correlation Between Acid Exposure and Symptoms

Postoperative GSRS GERD Score

% to

tal r

eflu

x

0 820

4

8

12

16

Postoperative GSRS GERD Score

R2=0.05

Mechanisms of GERD

Typical post-Heller Upright RefluxTypical post-Heller Upright Reflux

Mechanisms of GERD

Typical post-Heller Recumbent refluxTypical post-Heller Recumbent reflux

Heller with Dor FundoplicationHeller with Dor Fundoplication

Completed Dor FundoplicationCompleted Dor Fundoplication

Video of Heller + Dor

Incidence of Pathologic GERIncidence of Pathologic GER

0

4

8

12

16

20

Heller Heller + Dor

Patients

Pathologic GER Normal pH study

Heller + Dor procedure was associated with a significant reduction in the risk of pathologic GER (relative risk: 0.11; 95% confidence interval 0.02-0.59; P=0.01)

P=0.005

47.6 %

9.1 %

Distal Esophageal Acid ExposureDistal Esophageal Acid Exposure

Data are shown as median (horizontal line), interquartile range (box), and 5th to 95th percentile (vertical line). Outliers are marked with the asterisk (*).

P=0.001

Postoperative LES pressurePostoperative LES pressuremmHg

Heller Heller + Dor

5.0

10.0

15.0

20.0

25.0

30.0

LE

S p

ress

ure

(m

mH

g)

Data are shown as median (horizontal line), interquartile range (box), and 5th to 95th percentile (vertical line). Outliers are marked with the asterisk (*).

Heller Heller + Dor

0.00

2.00

4.00

6.00

8.00

10.00

Dys

ph

agia

Sco

re

Postoperative Dysphagia ScoresPostoperative Dysphagia Scores

Data are shown as median (horizontal line), interquartile range (box), and 5th to 95th percentile (vertical line). Outliers are marked with the asterisk (*).

ConclusionsConclusionsDor fundoplication significantly reduces postop GERD after Heller myotomyRelief of dysphagia is similar in both techniquesHeller + Dor fundoplication is preferred procedure for treatment of Achalasia