benign esophageal disease.ppt - department of surgery at ... · y2nd most common functional...

Joel A. Ricci MDSUNY Downstate Medical Center

Lutheran Medical Center Department of Surgery

June 26, 2009

www.downstatesurgery.org

HistoryXx year old female with worsening dysphagia and solid food regurgitation for 2 daysOther symptoms included: poor appetite and Other symptoms included: poor appetite and occasional epigastric tendernessDenied weight loss, fever, dysuria or changes in bowel habitsKnown hx of Achalasia (2006): refused Tx at the timePMH NIDDM HTN h li id i GERD?PMHx: NIDDM, HTN, hyperlipidemia, GERD?No Tobacco or EtOH useMeds: Lipitor Glipizide Zolpidem Toprol XL PrilosecMeds: Lipitor, Glipizide, Zolpidem, Toprol XL, Prilosec


Physical ExamVital Signs: T: 97.8°F, BP: 169/81 mmHg, HR: 100 b/mGen: AAO x 3, NADHEENT: PERRL, moist mucous membranes, no icterusCV: RRR, S1S2, no murmurs or gallopsLungs: CTA b/l Abd: Soft, NT/ND, +BSExt: 2+ pulses throughout, no edema

L b k blLabs were unremarkable


ImagingChest x‐ray: Large bullae in Right upper lobe extending into lower neck

Chest CT Scan: Diffusely dilated esophagus with food residues and mildly compressed airway residues and mildly compressed airway


Chest X‐Ray


CT Scan


ProcedureThoracoscopic Heller myotomywith intra‐operative Esophago‐gastroduodenoscopy (EGD)

EGD: Dilated esophagus with spastic LESEGD: Dilated esophagus with spastic LESLeft side decubitus4 VATS incisions Adhesiolysis; Esophagus encircled w/ penrose drainNarrowed tapering of LES visualizedMuscular layer divided w/ scissors 5 cm onto proximal Muscular layer divided w/ scissors 5 cm onto proximal esophagus and 2 cm beyond the GEJEGD confirmed adequate passageGas insufflation confirmed no mucosal perforation


Post‐op CoursePOD #1:

UGI Series: No obstruction or leakageTolerated clear liquids

POD #2: T l t d f ll li idTolerated full liquidsDischarged home

Currently (4 months post 0p):Currently (4 months post‐0p):Adequate relief of dysphagia, no complaints


Upper GI Series


Joel A. Ricci M.D.SUNY Downstate Medical CenterSUNY Downstate Medical Center

Department of SurgeryJune 26, 2009


Esophageal DiseaseMotility DisordersGERD }See previous presentationsBarrett’s Esophagus Esophageal Cancer

}See previous presentations

by yours truly


l dMotility DisordersClassification based on manometry

AchalasiaInadequate LES relaxation

Diffuse Esophageal SpasmUncoordinated contraction

N k E hNutcracker EsophagusHypercontraction

Ineffective Esophageal MotilityIneffective Esophageal MotilityHypocontraction

Spechler et al. Gut 49:145-151, 2001


h lAchalasiaSymptomatology

Progressive dysphagia Liquids to solids

Chest painAspirationR i iRegurgitationWeight loss


A h l iAchalasiaEtiology

Complex motor abnormality of the LES6 in 100,ooo individuals2nd most common functional disorder of the esophagus requiring surgery (GERD = 1st)C i k d diff h iCause is unknown: data suggests different theories

HereditaryDegenerativeDegenerativeAutoimmuneInfectiousInfectious


h lAchalasiaPathophysiology

T‐lymphocyte, eosinophil, and mast cell infiltration in the myenteric (Auerbach) plexus

Myenteric neural fibrosisMyenteric neural fibrosisHypertrophy of the two muscle layers and nerve fibersDegeneration of NO and producing inhibitory neurons

Affects relaxation of LES Basal LES pressure rises


h lAchalasiaManometry

Manometric features:Incomplete LES relaxationrelaxationElevated resting pressure (>45 mmHg)

l fAperistalsis of esophageal bodyElevated lower esophageal pressure


h lAchalasiaWork‐up

Chest X‐rayAbsence of gastric b bblbubbleDilated fluid filled esophagusp gRight side posterior mediastinal shadow


AchalasiaWork‐up

Barium SwallowAir fluid level“ d’ b k”“Bird’s beak”

Fl i i iFluoroscopic imagingFlaccid non‐peristaltic esophagusesophagusAbsence of “stripping” waves


h lAchalasiaWork‐up

EGDNarrowed distal lumen“ k” l d f d“Stuck” solid food particlesRule out “pseudo‐Rule out pseudoachalasia” caused by obstructing tumor in di t l hdistal esophagus


h lAchalasiaTreatment

Pharmacologic TreatmentIsosorbide dinitrate

Reduces LES 66% for 90 minutes

NifedipineReduces LES pressure 30‐40% for > 60 minutes

BotulinumToxin InjectionBotulinumToxin InjectionInhibits acetylcholine release60 – 80% relief50% recurrence within 6 monthsmonthsObliterates plane btwnmucosa & submucosaIncreased rate of perforation during surgeryduring surgery


h lAchalasiaTreatment

Pneumatic DilatationSuccess increases with repeat dilatations60‐80% success rate; 5yr recurrence rate: 50%

West RL, et al. Long term results of pneumatic dilation in achalasia followed for more than 5 years. Am J Gastroenterol. 2002 Jun;97(6):1346-51.


h lAchalasiaManagement Algorithm


h lAchalasiaSurgicalTreatment

Heller MyotomyThoracoscopicLaparoscopic

FundoplicationGERD tiGERD preventionNissenDorDorToupet


h lAchalasiaWhich treatment is better?

Zaninotto et al: Randomized controlled trialBotox (n = 40) vs Myotomy w/ fundoplication (n = 40)Both groups initial improvement of symptoms6 months: 45% recurrence in Botox group ( t f ) 8 % t % B t2 years (symptom free): 87% myotomy; 34% Botox

Csendes et al: Prospective randomized trialPneumatic dilatation (n 20) vs Myotomy (n 18)Pneumatic dilatation (n = 20) vs Myotomy (n = 18)3.5 years (no dysphagia): 100% myotomy

60% pneumatic dilatation60% pneumatic dilatation1. Zaninotto et al. Randomized controlled trial of botulinum toxin versus laparoscopic heller myotomy for

esophageal achalasia. Ann Surg. 2004 Mar;239(3):364-702. Csendes A, et al. Late results of a prospective randomised study comparing forceful dilatation and

oesophagomyotomy in patients with achalasia Gut. 1989 Mar;30(3):299-304


h lAchalasiaHeller Myotomy

Ernest Heller; 1913Both ant & post LES

l fib di t dmuscle fibers disruptedModified version

Single anterior Single, anterior, longitudinal myotomy

Standard operative ptechnique


h lAchalasiaThoracoscopic Esophagomyotomy

Port placement Division of muscle fibers


h lAchalasiaLaparoscopic Heller Myotomy

Patient positioning Port placement


h lAchalasiaLaparoscopic Heller Myotomy

Identification of LES Division of muscle fibers


h lAchalasiaFundoplication

Dor (Anterior fundoplication) Toupet (Posterior fundoplication)


h lAchalasiaExtent of Myotomy

From GEJ: Proximal (5 – 6 cm); Distal (1.5 – 3 cm)

Chen et al: 7 to 16 years post myotomy and fundoplication67% incidence of epiphrenic pseudo‐diverticulumLikely caused by absence of coverage over proximal extent of myotomy

Oelschlager et al: Standard (1.5 cm) vs Extended (3 cm) distal myotomy ( n = 110 pts)

Lower post‐op LES pressures with extended (9 5 mmHg) vsLower post‐op LES pressures with extended (9.5 mmHg) vsstandard (15.8 mmHg)Improved dysphagia24‐hr pH monitoring: no increase in GERD

1. Chen LQ et al. Long-term effects of myotomy and partial fundoplication for esophageal achalasia. Dis Esophagus. 2002;15(2):171-9.

2. Oelschlager BK et al. Improved outcome after extended gastric myotomy for achalasia. Arch Surg. 2003 May;138(5):490-5; discussion 495-7.


h lAchalasiaAddition of Fundoplication

Myotomy:Lowers esophageal outflow resistanceImproves esophageal emptyingIncreases propensity for GERD

Is Fundoplication always needed?


h lAchalasiaAddition of Fundoplication

Richards et al: Randomized trialHeller myotomyw/ Dor vs w/o Dor ( n = 43)Post‐op GERD (by 24‐hr pH monitoring)p y p g

47.5% in pts w/ Heller myotomy alone9.1% in pts w/ added Dor fundoplicationNo difference in LES pressure or dysphagia scores

Rice et al: Retrospective studyHeller with and w/o Dor (n = 149)Decreased incidence of GERD (by 24‐hr pH monitoring) following fundoplicationFundoplication did not decrease esophageal emptying time ( d b b i h h )(assessed by barium esophagography)

1. Richards WO, et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-bline clinical trial. Ann Surg 2004; 240(3):405-415.

2. Rice TW, et al. A physiologic clinical study of achalasia: Should Dor fundoplication be added to Heller myotomy?. J Thorac Cardiovasc Surg 2005; 130(6):1593-1600.


h lAchalasiaWhich Fundoplication?

Complete fundoplication (Nissen) should be avoided due to aperistaltic esophagusP i l D ( i ) T ( i )Partial: Dor (anterior) versus Toupet (posterior)

Minimal differenceArain et al: No difference in relief ofArain et al: No difference in relief of

Dysphagia, Heartburn, Chest painNeed of proton pump inhibitors

Advantage DorTechnically easierP i f l i hPreservation of natural posterior attachments

Arain MA, et al: Preoperative lower esophageal sphincter pressure affects outcome of laparoscopic esophageal myotomy for achalasia. J Gastrointest Surg 2004; 8:328-334.


h lAchalasiaThoracoscopic vs Laparoscopic

Patti et al: Thoracoscopic Heller myotomy versus Laparoscopic Heller w/ Dor fundoplication

6 ( i h )60 pts (30 in each group)Avg hospital stay: 84 hrs (thorac.); 42 hrs (lap)Relieved dysphagia: 87% vs 90%Relieved dysphagia: 87% vs 90%Abnormal reflux (by pH monitoring)

60% thoracoscopic ptsp p10% laparoscopic/fundoplication pts

Patti MG, et al. Comparison of thoracoscopic and laparoscopic heller myotomy for achalasia. Journal of Gastrointestinal Surgery. Volume 2, Number 6 / December, 1998; 561-566


h lAchalasiaOutcomes following Laparoscopic Heller Myotomy

Author Year Patients Follow‐upmonths

Relief of Dysphagia

(%)

Length of Stay

(median)

Perforation(%) Reflux (%)

Portale 2005 248 43 (1–131) 88 5 (3–11) 4.0 7 *

Bonatti 2005 75 64 (10–131) 84 2 (1–6) 4.0 11

Khajanchee 2005 121 9 (6–48) 91 1.7 (na) 6.6 13 *

Arain 2004 78 24 (6 100) 77 na 0 17Arain 2004 78 24 (6–100) 77 na 0 17

Perrone 2004 100 26 (6–72) 96 1.2 (1–4) 3.0% na

Oelschlager 2003 110 26 (1–85) 90 na na 23

Donahue 2002 81 45 (1–70) 84 1 (na) 14.0% 4

Sharp 2002 100 11 (na) 93 1.5 (na) 8.0% 4

Patti 2001 102 25 (na) 89 1.5 (na) 5.0% na

Zaninotto 2001 113 24 (1–83) 91 na na 6

Patti 1999 133 23 (na) 89 2 5.0% 17


llHeller MyotomyEffects on Symptoms


h lAchalasiaOutcome Predictors

Degree of improvement in resting LES

If reduced to < 10 mmHg = long‐lasting li f f d h i ( relief of dysphagia ( 5

years or more)

> 20 mmHg = recurrent dysphagia within 12 to 24 months following 4 gsurgery

Eckardt VF, Gockel I, Bernhard G: Pneumatic dilatation for achalasia: late results of a prospective follow up investigation. Gut 2004; 53:629.


Laparoscopic MyotomyOutcome Predictors

High pre‐operative resting LES pressure increases relief of dysphagiay p g

> 35 mmHg = 21.3 times more likely to have relief more likely to have relief than those with < 35 mmHg

The greater the decrease in LES pressure following surgery, better g y,improvement in dysphagia


Diffuse Esophageal SpasmRapid progression of:

Abnormally high amplitude wavesLonger duration contractionsAperistalsis during more than 20 swallows

N t k hNutcracker esophagus:Variant of diffuse esophageal spasmRapid progression of esophageal pump with high Rapid progression of esophageal pump with high amplitude waves (> 180 mmHg) of the distal esophagus


Diffuse Esophageal SpasmLES may show:

Normal resting pressure w/ relaxation after deglutitionIntermittent episodes of incomplete relaxationIntermittent episodes of incomplete relaxation

Higher risk of epiphrenic diverticulum

Treatment:Medical Tx and lifestyle adjustmentsIf persistent symptoms: surgical intervention

Long esophageal myotomy via thoracoscopic approachMyotomy throughout entire distance of manometricMyotomy throughout entire distance of manometricabnormality (from aortic arch to LES)


Esophageal HypercontractionResting pressure in LES exceeds upper limit of normalEsophageal body peristalsis remains normalSymptoms:Symptoms:

DysphagiaChest painGERD

Occasionally 2ry to GERD and/or type III hiatal herniaAlteration of configuration of the cardiaAlteration of configuration of the cardia

Treatment: Laparoscopic myotomyw/ partial fundoplicationNi f d li i (if GERD/hi l h i )Nissen fundoplication (if 2ry to GERD/hiatal hernia)


Esophageal HypocontractionTypically 2ry to systemic illness

SclerodermaRheumatoid ArthritisRheumatoid ArthritisSLEAlcoholism

Abnormally low amplitude (< 30 mmHg) contractionsDiscoordination leads to ineffective peristalsisNormal LESGERD due to lack of peristalsisH tb d R fl th d h iHeartburn and Reflux more common than dysphagia


Esophageal HypocontractionNeed to rule out:

Mechanical obstructionMalignant disorders

Contrast esophagogramsMManometry24‐hr pH monitoring

Treatment: directed towards GERDSurgical Anti reflux proceduresSurgical Anti‐reflux procedures


ConclusionLap Heller myotomy has become the standard surgical approach for patients w/ achalasia.Surgical myotomy provides superior long‐term symptom Surgical myotomy provides superior long term symptom relief compared to non‐surgical interventions.Extended distal myotomy with partial fundoplication has been found to provide greater dysphagia relief with been found to provide greater dysphagia relief with minimal development of GERD.A high pre‐operative LES pressure portends a better

i f ll i symptomatic outcome following surgery.Persistent or recurrent symptoms following myotomy can be treated effectively with pneumatic dilatationy p


Question 1A 34 y.o man has a progressive hx of dysphagia to solids and liquids. Over the last several weeks he has regurgitated food that is several days old. Barium swallow reveals ynarrowed tapering of distal esophagus and EGD reveals retained food particles. The most appropriate management for this pt is:g p

a) Botulinum toxin injection of the LESb) Calcium channel blocker therapyb) Calcium channel blocker therapyc) Esophageal myotomyd) Esophageal myotomywith fundoplicatione) Pneumatic dilation of the LES


Question 2A 70 y.o man presents with dysphagia and intermittent regurgitation of mucoid material. He has lost 35 lbs. since the onset of symptoms 3 months ago. Barium since the onset of symptoms 3 months ago. Barium swallow reveals a “bird’s beak” appearance. All of the following are pertinent to his work‐up EXCEPT:

a) Esophagoscopyb) 24‐hr pH monitoring) 4 p gc) Esophageal manometryd) Serum albumin

he) Chest x‐ray


Question 3A 52 y.o woman presents c/o several year hx of progressive dysphagia to liquid and solid food. She describes a sensation of food “sticking” and not passing into her stomach. Barium swallow reveals narrow tapering of distal esophagus swallow reveals narrow tapering of distal esophagus. Manometry reveals LES pressure that remains constant thru a swallow test. You diagnose achalasia. Which of the following is TRUE regarding LES in healthy pts?

a) LES is a specific anatomic sphincterb) Gastric distention causes decreased LES tone) LES d d i th i iti ti f llc) LES pressure decreases during the initiation of a swallowd) The LES serves to prevent air from entering the stomach during a

swallowe) The LES can be visualized by upper endoscopy) y pp py


benign esophageal disease.ppt - department of surgery at ... · y2nd most common functional...

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