Achalasia: Classic View
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1 Achalasia: Dilate, Botox, Knife or POEM Prateek Sharma, MD Kansas University School of Medicine Achalasia: Classic View 1
2 Diagnosis of Achalasia Endoscopy may be normal in as many as 44% Upper GI series may be normal in 36% The test with the highest sensitivity in the diagnosis of achalasia is esophageal manometry Howard, Gut 1992 Vaezi, Richter Am J Gastro 1999 Ergun, Kahrilas Gastro 1996 Therapeutic Options In Achalasia Smooth muscle relaxants Botulinum toxin Pneumatic dilation Per oral endoscopic myotomy (POEM) Heller myotomy 2
3 Pneumatic Dilation versus Laparoscopic Heller s Myotomy for Idiopathic Achalasia 3
4 Pneumatic Dilation versus Laparoscopic Heller s Myotomy for Idiopathic Achalasia Pneumatic Dilation versus Laparoscopic Heller s Myotomy for Idiopathic Achalasia 4
5 Pneumatic Dilation versus Laparoscopic Heller s Myotomy for Idiopathic Achalasia Complications of Treatment Perforation Pneumatic Dilation (PD) Esophageal perforation 4% 3 perforations with 30 mm; 1 with 35 mm 2 underwent surgery; 2 conservative care Heller Myotomy (HM) Mucosal tear in 13/106 (12%) Repaired during initial surgery GERD Increased acid exposure similar: 15% PD; 23% HM Erosive esophagitis similar: 19% PD; 21% HM Peroral Esophageal Myotomy Originally described in porcine model by Pasricha (Endoscopy 2007) First described in a patient by Inoue at DDW 2009 Per oral endoscopic myotomy (POEM) Initial report of 17 pts (Inoue Endoscopy 2010) 5
6 POEM for Achalasia 100% 97% 89% - Prospective multicenter study - Europe + North America - 70 patients - Mean age: 45 years - Males: 57%; Females: 43% Success rate (%) 82% General anesthesia Time: 105 minutes Length: 13 cm GERD: 37% 0% 3 months (n=70) 6 months (n=61) Follow-up 12 months (n=51) Von Renteln D et al. Gastroenterology 2013;145: Endoscopic Versus Surgical Myotomy for Idiopathic Achalasia: Results of a Prospective Multicenter Study and Comparison With Laparoscopic Surgery Prospective, international multicenter trial of POEM compared to a retrospective cohort of lap Heller myotomy Primary outcome of symptom relief at 3 mos 70 pts underwent POEM from 5 centers Mean operative time 105 minutes ( min) No conversions to open or laparoscopic surgery Treatment t success in 97% with POEM; LESP: 28 to 9mmHg Compared with review of LHM, POEM had significantly lower 3 mos symptom scores (1 vs 1.4) and lower LESP (9 vs 12 mmhg). Reflux esophagitis higher in POEM but NSS (41 vs 28%) Von Renteln Fuchs Brendenoord Rosch DDW
7 Is all achalasia the same? High Resolution Manometry Swallow 0 Pharynx Upper esophageal sphincter Esophageal peristalsis 20 Cm 25 Lower esophageal sphincter seconds LES deglutitive relaxation 35 Stomach 7
8 Manometric Subtypes in Achalasia Type I IRP > 15 mmhg Absent peristalsis Absent contractile activity Type II IRP > 15 mmhg Absent peristalsis >20% swallows with panesophageal pressurization Type III IRP > 15 mm Hg Absent peristalsis 2 or more spastic contractions with or without periods of compartmentalized pressurization mmhg s 5 s 5 s 0 Time (s) Time (s) Time (s) Pandolfino Gastro 2008:135: Treatment depending on Achalasia type 80% 65% - European Achalasia trial patients - Mean age: 46 years Patients (%) 25% 10% 0% Type I Type II Type III Rohof W.O et al. Gastroenterology 2013;144:
9 Treatment depending on Achalasia type 100% 85% 81% 100% 93% 83% Success (%) Dilation 40% Surgery 0% Type I Type II Type III Rohof W.O et al. Gastroenterology 2013;144:
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