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