prof. amgad fouad gastroenterology center mansoura university
TRANSCRIPT
Prof. Amgad Fouad Prof. Amgad Fouad
Gastroenterology Gastroenterology
centercenter
Mansoura UniversityMansoura University
Achalasia of the esophagus, Achalasia of the esophagus,
different line for therapydifferent line for therapy
Achalasia
–Greek word
–Failure to relax
–Willis (1672)
Zenker & Vonziemssen (1877): Diminished
contractile power of the esophageal
musculature.
Meltzer & Miklicz (1888): Spasmodic contraction
of the cardiac sphincter.
Einhorn (1888): Failure of relaxation of the
cardia on swallowing.
Horst (1929): Established the term achalasia
(failure to relax).
Achalasia:
–The most recognised motor
disorder of the esophagus.
–Cardinal features:
• Poorly relaxing LES
• Prolonged esophageal transit
• Defective esophageal body peristalsis .
• 1-2 / 200.000
• ♂ =♀ .
• Any age.
• Onset 3rd – 5th decade.
• Duration of symptoms at presentation 2
years average.
(Mayberry & Atkinson, 1985)
Presentation
• Dysphagia (almost 100%)
• Regurgitation (60-90%)
• Chest pain (30 – 50%)
• Wt loss (Advanced disease).
• Pulmonary symptoms.
– Bronchopneumonia
– Lung abscess
– Ht burn (rare presentation )
Diagnosis
– Compatible clinical history.
– Radiography.
– Endoscopy.
– Manometry.
Radiographic studies Plain X ray :
Widened mediastinum .
Air fluid level
Absence of gastric air bubble
Evidence of pulmonary complications
Radiographic studies (continue)(continue)
Barium swallow
Screening test
Esophageal body dilated
Lower end esophagus → tapered point.
(birds Beak )
Nitrite test → Diagnostic.
Radiographic staging
Stage I : Slight dilatation of the body not >3.5cm.
Stage II : Moderate dilatation 3.5-6cm.
Stage III : Marked dilatation >6cm.
Stage IV : Marked dilatation elongation and
tortiousity of the esophagus (sigmoid
esophagus).
Endoscopy
Important diagnostic tool
• Rule out several diseases that mimic achalasia.
• Evaluate esophageal mucasa before therapeutic
manipulation.
Typical finding
• Dilated esophgeal body
• Puckered closed LES
• No organic stricture
Mamometry
•Confirms & establishes the diagnosis
•Features:
Essential features Absence of esophgeal body peristalsis (1ry peristaltic waves) ↑ intraesophageal resting pressure. Abnormal LES relaxation.
Supportive Features Hypertensive LES pressure Low amplitude esophageal contractions
(Castell, 1996)
☺Treatment of Achalasia Treatment of Achalasia
Medical TreatmentMedical TreatmentNitrates .
Ca ++ channel blockers
Anticholinergic drugsAll have been shown to reduce the force of
contraction of esophageal body smooth muscles.
May be of value in reducing chest pain & improving dysphagia
(Gelfond et al ., 1982)
Botulinum toxinBotulinum toxin
Neurotoxin produced by clostridium
botulinum.
Only serotype A+B have been approved
for clinical use.
Two preparations of BTX (A) available:Dysport (UK)
Botox (USA)
Efficacy of BTX in achalasia Efficacy of BTX in achalasia
AuthorYearStudy
designNo. of
patientsDoseResponse 1
mo (%)Response 6
mo (%)
Adults
Pasricha 1994OL1080 U9060
Pasricha 1995DBPC3180 U9066
Annese 1996DBPC8100 U10053
Prakash 1999OL4280U8041
Annese 2000MCRT40200 U8836
D'Onofrio 2002OL37100 U8465
Children
Hurwitz 2000OL2380-100U8343
IP 2000OL730U10033
Pneumatic dilatation Pneumatic dilatation
The most effective non-surgical treatment
option.
Forceful dilatation using air or water
pressure can be applied to the lower
esophageal segment and controlled to
secure further stretching to the point of
rupture of the circular ms fibers.
Recommended technique for pneumatic balloon dilatationRecommended technique for pneumatic balloon dilatation
(Voizi et al, 1994)
1Fasting for at least 12 h before procedure .
2Esophageal lavage with a large-bore tube (if needed).
3Sedation and endoscopy in Rt lateral position.
4Guidewire positioned in stomach and balloon passed over the guidewire.
5Initial dilatation with 3-cm diameter balloon; subsequent progression to 3.5-cm and 4-cm balloons may be required at separate sessions.
6Accurate placement of balloon across gastroesophageal junction fluoroscopically.
7Balloon distention to obliterate the waist, which usually requires 7-10 psi (this is the key to a successful dilatation)
8Gastrograffin study followed by barium swallow to exclude esophageal perforation.
9Observation for 4 h for chest pain and fever.
10Discharge with follow-up in 1 mo.
*Before proceeding with pneumatic dilatation, it is important to ensure that a cardiothoracic surgeon is available in case of an esophageal perforation.
Cumulative effectiveness of pneumatic dilatation in Achalasia Cumulative effectiveness of pneumatic dilatation in Achalasia
ReferenceNumber
of Patients
Study DesignDilator
(Size/cm)
Objective Assessments
% Sx Improvement
Follow-up (yr) Mean (Range)
Pe
rfora
tion
(%) %LES
PressureExcellent/
Good
Cox 7Prospective3860.8(0.5-1) 0
Gelfand 24Prospective3.460,68 70,93 0
Barkin 50Prospective3.5901.3(0.1-3.4) 0
Stark 10Prospective3.5740.50
Makela 17Retrospective3, 3.5, 4 50,75,75 0.55.9
Levine 62Retrospective3, 3.5 85,88 0
Kadakia 29Prospective3, 3.5, 4 67 62,79,93 4(0.3-6) 0
Kim 14Prospective3, 3.5 39 750.3
Lee 28Prospective3, 3.5, 4 7
Reference
Number of
Patients
Study DesignDilator
(Size/cm)
Objective Assessments
% Sx Improvement
Follow-up (yr) Mean (Range)
Pe
rfora
tion
(%) %LES
PressureExcellent/Good
Levine 62Retrospective3, 3.5 85,88 0
Kadakia 29Prospective3, 3.5, 4 67 62,79,93 4(0.3-6)0
Kim 14Prospective3, 3.5 39 750.3
Lee 28Prospective3, 3.5, 4 7
Abid 36Retrospective3.5, 4 88,89 2.3(1-4) 6.6
Wehrmann 40Retrospective3, 3.5 42 89 2.52.5
Lambroza 27Retrospective3 67 1.8(0.1-4.8) 0
Bhatnagar 15Prospective3, 3.5 73,93 1.2(0.3-3) 0
Total359size 3125/168=74% 1.6(0.1-6)yr 7/345=2%
Size 3.5184/214=86%
size 490/100=90%
Continue
Surgical management of AchalasiaSurgical management of Achalasia
• Rationale of surgery is to weaken the lower
esophageal sphincteric pressure but in
controlled Faison avoiding subsequent reflux
(Earlam, 1976)
Heller (1913)
First performed extra mucosal
cardiorytomy.
Two 8cm incisions one ant & one post.
Incisions extending 2cm into the dilated
part cranially & into the fundus of the
stomach caudally.
Modified Heller’s myotomy
(Zaaijer, 1985)• Most widely used technique.• Single anterior myotomy.• Transabdominal.
However
Two problems →poor results
1. Incomplete myotomy
2. Reflux esophagitis .
Anti – Reflux Anti – Reflux
Laparoscopic Heller’s Laparoscopic Heller’s
Most preferred by gastrointestinal
laparoscopic surgeon.
Easy access.
Good result
Anti – reflux +
Results of HellerResults of HellerAuthor (Year)ProcedureNo.
%SAT
%Dys
%RegF/U
Mort )%(
Morb )%(
Esoph Perf
Laparotomy
Black et al (1976)Heller/Post1086625194 y0NANA
Csendes et al (1989)Heller/D4295212862 mo02.30
Paricio et al (1990)Heller/Post4892445.4 yr08.30
Pinotti et al (1991)Heller/Post72295NRNR6 mo-15 yr
0NANA
Bonavina et al (1992)Heller/D206944964.5 mo01.90
Thoracotomy
Menzies-Gow et al (1978)
Heller10280768 yr05.60
Jara et al (1979)Heller145INR114885 mo0NANA
Okike et al (1979)Heller/B or A
46885336.5 yr0.2NA1%
Yong-xian (1982)Heller/DF4493INR
INR
3 mo-19 yr
02.30
Ellis et al (1984)Heller10391546.75 yr09.60
Little et al (1988)Heller/B5788694.8 yr1.8NANA
Laparoscopy
Ancona et al (1995)Heller/D1794607 mo000
Rosati et al (1995)Heller/D25964INR12 mo040
Delgado et al (1996)Heller/D12INR16INR3 mo01.68%
Swanstrom and Pennings (1994)
Heller or Heller/T
129281716 mo000
Hunter et al (1997)Heller/D or T40INR10512.5 mo07.50
Thoracoscopy
Pelligrini et al (1993)Heller228812INR2 yr0180
Aim of work
The aim of this work was to evaluate Heller’s
myotomy and preumatic balloon dilatation as two
alternative lines of therapy for patients with
achalasia of the esophagus.
Patients and MethodsPatients and Methods
o Our study is a retrospective non- randomised study
conducted at GEC during the period between October
1979- November 2002.
o The study included 310 cases with achalasia.
o 169 ♂ & 141♀
o According to the line of management the study included
two groups: Group A: 150 patients treated with myotomy +
fundoplication. Group B: 160 patient treated by pneumatic balloon
dilatation.
Preoperative work up
• Thorough history and clinical examination.
• Patients were divided into 4 groups according to
Demeester's grading for dysphagia.
(Cuschieri et al., 2002)
• No dysphasia
• Mild : occasional episodes.
• Moderate: requires fluids to clear.
• Severe : episodes of solid food impaction &
require medical treatment.
Preoperative work up (continue )(continue )
• Radiological examination
• According to Olsen scoring system, patients
were divided into 4 groups
(Olsen et al., 1983)
• Endoscopic evaluation
• Manometric study
Method of management
Group (A):• Modified Heller myotomy 35 patient (56.8%).• Myotomy + Dor fundoplication 45 patient (30%).• Myotomy + Nissen fundoplication 9 patient (6%).• Myotomy + Taupet fundoplication 4patient (2.6%).• Laparoscopic mytomy 3 patients (2%).• Laparoscopic mytomy + Dor fundoplication 4patints
(2.6%).
Group (B):
• Pneumatic balloon dilatation (1.8+ 1 set)• One session in 79 patients (60.5%).• Two sessions in 48 patients (30%).• Three or more sessions in only 15 patients
(9.5%).
Method of management Continue
ResultsResults
Dysphagiaaccording to Demeester’s
grading for dysphagia
Mild75 patients (24%)
Moderate186 patients (60%)
Sever49 patients (16%)
Regurgitation213 patients (69%)
Heart burn65 patients (21%)
Weight loss220 patients (71%)
Respiratory complications43 patients (11%)
Dysphagia grading of the patients on presentation.
Mild 24%
Moderate60%
Sever16%
Mild
Moderate
Sever
0
20
40
60
80
100
0 0 : 0 0
Clinical presentation of patients
Dysphagia100%
Weight loss71%
Regurgitation69%
Heart burn
Respiratorycomplications11%
Radiological characters of achalasia patients before management .
First and second degree.according to Olsen et al 1953 scoring system
283 patients (91%)
Third and fourth degree .according to Olsen et al 1953 scoring system
27 patients (8.8%)
Delayed evacuation .279 patients (90%)
Normal esophagus .9 patients (2.8%)
Endoscopic findings in patients with achalasia before management .
Dilated esophagus .273 patients (88%)
Marked spastic cardia .36 patients (12%)
Esophagitis .25 patients(8%)
Gastritis and or duodenitis .50 patients (16%)
Manometric features for achalasia paients before management
Symptomatic evaluation of patients after cardiomyotomy .
Dysphagiaaccording to Demeester’s
grading for dysphagia
Complete resolution
105 patients (70%)
Improvement 25 patients (16%)
Persistant20 patients (14%)
Heart burn and regurgitation37 patients (25%)
Weight gain89 patients (60%)
Symptomatic evaluation of patients after pneumatic ballon dilatation .
Dysphagiaaccording to
Demeester’s grading for dysphagia
Complete resolution96 patients (60%)
Improvement 30 patients (19%)
Persistant34 patients (21%)
Heart burn and regurgitation24 patients (15%)
0%
10%
20%
30%
40%
50%
60%
70%
Dysphagia improvment after cardiomyotomy and ballon dilatation.
Cardiomyotomy
Ballon dilatation
Cardiomyotomy 70% 16% 14%
Ballon dilatation 60% 19% 21%
Complete resolution
Improvement Persistant
BeforeAfter
ValueAverageValueAverage
LESLESP34.5 ±4 mmHg
11 to 95 mmHg
12.9 + 3mmHg
5 to 19 mmHg
%RELAXATION58.5+10 %20to 99%80+8 %69 to 99 %
BODYAMPLITUDEPROX24.1+3.5 mmHg
11to 72% mmHg
24+ 3 mmHg
10 to 54 mmHg
MID23+2 mmHg11to 80% mmHg
27+4 mmHg
10 to 68 mmHg
DISTAL22.5 1.9± mmHg
9to 80 mmHg
34+2 mmHg
11 to 65 mmHg
DURATIONPROX4.1 ± 2.1 sec
1.5to 10 sec
3+0.5Sec
0.9 to 5.4 sec
MID4.1 ± 1sec1.7 to 10.1 sec
3.2+0.3Sec
1.1 to 6.7 sec
DISTAL3.7 ± 1.8 sec
1.6to 9.8 sec
3.1+1.8Sec
1 to 6 sec
VELOCITYSIMULTANEUS55 ± 13.2 %6 to 100 %
41+13.2 %
9 to 100 %
NON TRANSMITTED
32.9+9% 6 to 100 %
25.1+9 %9 to 100 %
Manometric study before and after cardiomyotomy
Manometric features before and after pneumatic dilatation.
0
10
20
30
40
50
60
70
80
L.E.S.P % Relaxation
L.E.S changes with cardiomyotomy and ballon dilatation.
Values onpresentation
Aftercardiomyotomy
After ballondilatation
SummarySummary and conclusionand conclusion
We agree that life long palliation of dysphagia is not
guaranteed but It is obvious that Heller cardiomyotomy
in our study gives good to excellent results as regard
the improvement of dysphagia. As in the largest series
puplished about the management of achalasia.
Pneumatic ballon dilatation is also a good method of
management of patients with achalasia, but it doesn’t
give the same longterm response as surgical
cardiomyotomy besides that some cases may have
early recurrence or persistant dysphagia after
dilatation .