Surgery for achalasia is an anachronism. John C. Dugal Jr. MD

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1 Surgery for achalasia is an anachronism. John C. Dugal Jr. MD

2 Outline: Overview of achalasia Traditional surgical treatments Heller ±fundoplication Less invasive treatments Nitrates/Ca channel blockers Botulism toxin Pneumatic dilation Defile my opponent Local experience Bottom line

3 Achalasia 1-6/100,000 Failure of the esophagus to empty properly Presents as dysphagia to solids then liquids, 66% regurgitation, 10% chest pain Cause unknown, destruction of Aurbach s plexus

4 Workup EGD Manometry Barium esophagram

5 Manometry Elevated resting pressures in esophageal body Wide mirrorlike, weak tertiary waves Complete absence of peristalsis LES resting pressure normal to elevated, incomplete or absent relaxation

6

7 Barium esophagram: Grade 1 <4cm Grade 2 4-6cm Grade 3 >6cm Grade 4 Sigmoid

8

9 Development Sir Thomas Willis 1672 Ernest Heller 1913 Anterior and posterior JH Zaaijer 1923 Anterior only Shimi 1991 lap Pellegrini 1992 VATS

10 Dor Toupet

11 Drawbacks: Reflux Dysphagia Perforations

12 Reflux Peters 2001 J GI Surg 40-60% failure Richards 2004 Ann Surg 47.6% failure

13 Dysphagia Luketich 2001 ATS 38% failure 3 re-do, 5 dilation, 3 esophagectomy

14 Perforations Rakita 2005 J GI surgery: 6-10% Believed to be highly under-reported

15 Nitrates/Ca channel blockers Wen 2008 Cochrane: transient at best, recommended only in trial setting

16 Botulism toxin injection Andrews 1999 Surg Endoscopy: similar decrease in dysphagia score, not durable 77% reintervention at 324d only 25% conversion to Heller Zaninotto 2004 Ann Surg: RCT similar decrease in dysphagia score, not durable 34% symptom free at 2yrs 2004 Surgical Endoscopy cheaper at 2yrs

17 Dilation

18 Dilation Kadakia 1993 Am J Gastroenterology: 27/ % success 16 one dilation 5 two dilations 6 three dilations

19 Dilation Katz 1998 Dig Dis & Sciences: 72pts mean f/u 6.5yrs 80% single dilation success 85% successful with 2 dilations One 25yr single dilation success

20 Dilation Katsinelos 2005 W J Gastroenterology: 39pt mean f/u 9.5yr 13(1) 17(2) 9(3) dilations 78% 5yr 61% 10yr 58% 15yr

21 Dilation Perforation rate % ASGE 2006

22 Surgery long term Malthaner 1994 Ann Thor Surg: Heller +Belsey mark IV: 95% 1yr 77% 5yr 68% 10yr 67% 20yr

23 Patient Preference: Andrews 1999 Surg Endoscopy: 18/22 chose botulism toxin injection Katsinelos 2005 W J Gastroenterology: 39/39 chose dilation

24 Local experience Stephen R. Freeman MD 1-2 new dysphagia patients/month Avg. 1 dilation per month 1 perforation, 1 failure of dilation Only 3 pts. preferred surgery first line

25

26 Cost O Connor 2002 Dig Dis and Sciences Botox $7011 5yr QALY Dilation $7069 5yr $1348 Lap Heller $21,407 5yr $5,376,750

27 Cost Karanicolas 2007 Surg Endoscopy: Dilation $5315 at 5yrs Lap Heller $10,789 at 5yrs initial LM is a more costly management strategy under all clinically plausible scenarios

28 Summary Dilation has nearly equivalent results, cheaper, preferred by both patients and providers.

29

30 Specializing in: Lord procedures Belsey Mark IV Billroth 1 and 2 Open cholecystectomy Heller myotomy McVay and Bassini hernia repair Vineberg procedure

31 References Willis T. Pharmaceutica Rationalis. Sive Diatribe de Medicamentorum Operationibus in Humano Corpore. London: Hagae Comitis; 1674 Heller E. Extramukose cardioplastik beim chronischen cardiospasmus mit dilation des oesophagus. Mitteilungen aus den Grenzgebieten der Medizin und Chirurgie. 1913:141-9 Peters, JH An antireflux procedure is critical to the long term outcome of esophageal myotomy for achalasia. J Gastrointestinal Surgery 2001;5(1):17-20 Richards, WO Heller myotomy vs Heller myotomy with Dor fundoplication for achalasia. Ann Surgery 2004;240(3): Shuchert, MJ Minimally invasive esophagomyotomy in 200 patients: factors influencing postoperative outcomes. Ann Thor Surg 2008;85: Rakita, S Esophagotomy during laparoscopic Heller myotomy cannot be predicted by preoperative therapies and does not influence long term outcome. J of Gastrointestinal Surgery 2005;9(2)

32 References Wen, ZH Nitrates for achalasia (review). Cochrane collaboration Andrews, CN Laparoscopic Heller s myotomy or botulinum toxin injection for management of esophageal achalasia. Surgical Endoscopy 1999;13:742-6 Zaninotto, G Randomized controlled trial of botulinum toxin vs laparoscopic Heller myotomy for esophageal achalasia. Ann Surgery 2004;239(3): Malthaner, RA Long term results in surgically managed achalasia. Ann Thor Surgery 1994;58: Kadakia, SC Graded pnuematic dilation using rigiflex achalasia dilators in patients with primary esophageal achalasia. Am J Gastroenterology 1993;88(1):34-8 Katz, PO Pneumatic dilation is effective long term treatment for achalasia. Dig Dis and Sciences 1998;43(9):1973-7

33 References Katsinelos, P Long term results of pneumatic dilation for achalasia: A 15years experience. W J Gastroenterology 2005;11(36): O Connor, JB The cost effectiveness of treatment strategies for achalasia. Digestive Diseases and Sciences 2002;47(7): Karanicolas, PJ The cost of laparoscopic myotomy vs pneumatic dilation for esophageal achalasia. Surgical Endoscopy 2007;21: Stephen R. Freeman MD- personal communication 4/30/ UGI dilation guidelines 2006

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