Management of the Difficult Patient with Type 3 Achalasia. Steven R. DeMeester Professor and Clinical Scholar Department of Surgery

Transcription

1 Management of the Difficult Patient with Type 3 Achalasia Steven R. DeMeester Professor and Clinical Scholar Department of Surgery

2 Achalasia Treatment Concepts Disease leads to non-relaxing LES and loss of peristalsis in the esophageal body Treatment aimed at relief of outflow obstruction at LES No treatment restores function of LES All therapies move obstructed LES toward open LES (from dysphagia toward GERD) Outflow obstruction GERD Low Botox PD (single) Lap HM+Dor Efficacy and Invasiveness High

3 HRM Subtypes of Achalasia I II III

4 HRM and Outcome Rohof WO, et al. Gastro, 2013

5 HRM and Outcome Rohof WO, et al. Gastro, 2013

6 High resolution manometry sub-classification of Achalasia: Does it really matter? Christina L. Greene, Erica J. Chang, Daniel S. Oh, Stephanie G. Worrell, Jeffrey A. Hagen, Steven R. DeMeester Operation - Heller Myotomy with Fundoplication - POEM Type I (n=10) Type II (n=30) Type III (n=9) p value 9 (90%) 1 (10%) 23 (77%) 7 (23%) 7 (78%) 2 (22%) 0.49 Resolution of Dysphagia 8 (80%) 28 (93%) 8 (89%) 0.71 Post-operative reflux 2 (20%) 6 (20%) 1 (11%) 0.73 Post-Op Eckardt Score Eckardt score of Zero (Asymptomatic) 1 (0-1) 40% 0 (0-1) 57% 0 (0-1) 78% Post-Op Timed 1 min - 100% Clearance - >75% Clearance (n=7) 0 (0%) 2 (29%) (n=27) 15 (55%) 22 (81%) (n=6) 5 (83%) 6 (100%) Post-Op Timed 5 min - 100% Clearance - >75% Clearance (n=7) 1 (14%) 3 (43%) (n=27) 17(63%) 24 (89%) (n=6) 6 (100%) 6 (100%) Greene CL, et al. Surg Endosc, 2014

7 Type III Achalasia Pre-POEM

8 Achalasia Type III Post-POEM

9 Major Differences POEM versus Laparoscopic Myotomy and Dor No disruption of phreno-esophageal ligament Division of clasp fibers rather than sling fibers at GEJ and in cardia Myotomy is longer, extends further up into mediastinum, but preservation of longitudinal fibers may prevent or minimize thoracic diverticulum that often develops after standard myotomy

10 POEM Versus Lap Heller Myotomy 2 papers, both retrospective Portland (Bhayani NH, et al. Ann Surg, 2014) 64 LHM with partial fundoplication 37 POEM (prior achalasia treatment okay) : 48 LHM 2010: 14 LHM and 5 POEM 2011: 2 LHM and 16 POEM 2012: 0 LHM and 16 POEM Northwestern (Hungness ES, et al. J Gastrointest Surg, 2013) August 2010-May LHM with partial fundoplication 18 POEM (no prior treatment for achalasia both groups)

11 POEM vs LHM and Partial Fundoplication Bhayani NH, et al. Ann Surg, 2014

12 POEM vs LHM and Partial Fundoplication Bhayani NH, et al. Ann Surg, 2014

13 POEM vs LHM and Partial Fundoplication 32% vs 39% Bhayani NH, et al. Ann Surg, 2014

14 POEM vs LHM and Partial Fundoplication Hungness ES, et al. J Gastrointest Surg, 2013

15 POEM vs LHM and Partial Fundoplication Hungness ES, et al. J Gastrointest Surg, 2013

16 POEM: A Viable Option? 1. Must be safe 2. Must produce similar results (or better) than existing options, preferably with additional benefits 3. Morbidity should be similar or better than existing options 4. Results must be reproducible at multiple centers 5. Patients want it 5 requirements

17 POEM: Safety First human procedure in Sept 2008 Worldwide over 1200 procedures performed Single center reports and recent multi-center prospective study No reported mortality Surprisingly little morbidity for new procedure Capnoperitoneum, capnomediastinum, capnothorax Injury to mucosa overlying tunnel Post-operative tunnel hemorrhage (1/119; 0.8%) Ren Z, et al. Surg Endosc, 2012 Swanstrom LL, et al. Ann Surg, 2012

18 POEM: Efficacy Eckardt Symptom Score n= Series1 Series2 Series3 Series4 Series5 Series6 Series Pre-POEM Post-POEM Swanstrom LL, et al. Ann Surg, 2012; 2. Bhayani NH, et al. Ann Surg, 2014; 3. Costamagna G, et al. Dig Liver Dis, 2012; 4. von Rentein D, et al. Am J Gastro, 2012; 5. Hungness ES, et al. J Gastrointest Surg, 2012; 6 and 7. Li Q, et al. J Am Coll Surg, 2013

19 50 POEM: Efficacy LES Resting Pressure n= mmhg Swanstrom LL, et al. Ann Surg, 2012; 2. Bhayani NH, et al. Ann Surg, 2014; 3. Costamagna G, et al. Dig Liver Dis, 2012; 4. von Rentein D, et al. Am J Gastro, 2012; 5. Hungness ES, et al. J Gastrointest Surg, 2012; 6 and 7. Li Q, et al. J Am Coll Surg, 2013

20 POEM: Efficacy TBS, 5 minutes Pre: 48% Post: 100% Swanstrom LL, et al. Ann Surg, 2012

21 POEM: Efficacy Hungness ES, et al. J Gastrointest Surg, 2013

22 POEM: Efficacy Multi-institutional prospective study 70 patients from 5 centers in Europe and Canada Mean follow-up 10 months Eckhardt score Pre 1 6 mo mo Manometry 61/70 patients at 3 months: LESP pre=28 post=9 mmhg Von Renteln D, et al. Gastro, 2013

23 POEM: Efficacy Multi-institutional prospective study Von Renteln D, et al. Gastro, 2013

24 POEM: Efficacy Follow-up limited (under 2 years) in published series thus far Improvements in dysphagia and regurgitation persist up to 18 months [1] Treatment failure reported in 11 patients (11/452; 2.4%), 6 successfully treated with balloon dilatation 1. Swanstrom LL, et al. Ann Surg, 2012; 2. Bhayani NH, et al. Ann Surg, 2014; 3. Costamagna G, et al. Dig Liver Dis, 2012; 4. von Rentein D, et al. Am J Gastro, 2012; 5. Hungness ES, et al. J Gastrointest Surg, 2012; 6 and 7. Li Q, et al. J Am Coll Surg, 2013

25 POEM: Morbidity Von Renteln D, et al. Gastro, 2013 Literature summary Capnoperitoneum requiring decompression: 5-10% (higher without CO2) Mucosal injury during tunnel creation: 10% Full-thickness esophageal injury (biliary balloon dissection): 5-10% Bleeding in tunnel: 5% Leak in closure: rare

26 Reflux POEM: Morbidity Symptoms: 33% [1], 0 [3], 0 [4], 22% [5], 17% [6 and 7] Overall: 16.5% ph studies: 6/13 positive: 46% [1] Esophagitis: 4/14: 28% [1], 0/10 [3], 1/16: 6% [4], 5/15: 33% [5], 20/234: 8.5% [6 and 7] Overall: 10.3% 1. Swanstrom LL, et al. Ann Surg, 2012; 2. Bhayani NH, et al. Ann Surg, 2014; 3. Costamagna G, et al. Dig Liver Dis, 2012; 4. von Rentein D, et al. Am J Gastro, 2012; 5. Hungness ES, et al. J Gastrointest Surg, 2012; 6 and 7. Li Q, et al. J Am Coll Surg, 2013

27 POEM: GERD Von Renteln D, et al. Gastro, 2013

28 POEM in Perspective Treatment failure with Heller myotomy and partial fundoplication (Kilic A, et al. Surgery, 2009) 46 patients, mean follow-up 6.4 years 9 patients (20%) with failure Mean time to recurrence was 21.3 months Reflux is a problem after Heller myotomy even with partial fundoplication (Multi-center RCT) Rawlings A, et al. Surg Endosc, months post-op

29 POEM in Perspective Late failures after Heller myotomy are largely due to reflux >20 Years post-op Csendes A, et al. Ann Surg, 2006

30 331 patients treated with achalasia balloon dilatation Mean follow-up 6 years 34% developed esophagitis 8.4% Barrett s 28% in those with hiatal hernia, 2% in those without hiatal hernia 4% cancer: 12 squamous and 2 adenocarcinoma

31 Conclusion: POEM is a Viable Option! POEM achieves the short-term requirements to stay as a therapy for achalasia Safe Effectively alleviates symptoms Short-term results are equal or better than LHM Minimal complications Peri-op complications similar or less than LHM GERD not dissimilar to LHM Reproducible results at multiple centers Results do not seem to depend on HRM subtype Many patients prefer it over LHM and seek out a center where it can be performed