34th Annual Toronto Thoracic Surgery Refresher Course

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1 34th Annual Toronto Thoracic Surgery Refresher Course TREATMENT OPTIONS FOR ACHALASIA Dr. Carmine Simone Director, Intensive Care Unit Head, Division of Critical Care Departments of Medicine and Surgery Thoracic Surgeon Department of Surgery

2 OVERVIEW

3 QUESTIONS 1. Achalasia is best imaged by a. CXR b. CT scan c. Barium swallow d. Endoscopy

4 QUESTIONS 2. Achalasia is best treated with a. Medication b. Botox injection to LES c. Balloon dilation of LES d. Surgical myotomy

5 QUESTIONS 3. Surgical myotomy is best done with a. Antireflux procedure b. No antireflux procedure c. Gastroplasty d. Botulinum injection

Achalasia = does not relax Unkown cause Increasing incidence in Ontario 4/million 1988 8/million 1999 Loss of peristalsis in distal esophagus

6 Achalasia = does not relax Unkown cause Increasing incidence in Ontario 4/million /million 1999 Loss of peristalsis in distal esophagus (predominantly smooth muscle) and a failure of LES relaxation Symptoms and signs of achalasia are due primarily to the defect in LES relaxation ACHALASIA

Diseases associated with achalasia-like motility disorders

Amyloidosis Sarcoidosis Neurofibromatosis Eosinophilic

Juvenile Sjögren's syndrome with achalasia and gastric

7 Diseases associated with achalasia-like motility disorders Malignancy, especially gastric carcinoma Chagas' disease Amyloidosis Sarcoidosis Neurofibromatosis Eosinophilic gastroenteritis Multiple endocrine neoplasia, type 2B Juvenile Sjögren's syndrome with achalasia and gastric hypersecretion Chronic idiopathic intestinal pseudo-obstruction Anderson-Fabry's disease

8 SIGNS AND SYMPTOMS

9 CXR INVESTIGATIONS

10 INVESTIGATIONS CT scan Barium swallow Endoscopy

11 INVESTIGATIONS Manometry CCK OP Test

12 No treatment restores function in body of esophagus Therapies are aimed at decreasing LES pressure Nitrates Calcium channel blockers Taken 30 minutes prior to meal MEDICAL THERAPY

13 DILATION OF LES Bougienage Pneumatic balloon dilation Rigiflex balloon Diameter 2.4 to 5.0 cm 105 to >1000 mmhg Rapid versus gradual 2 seconds to 5 minutes 1 5 inflations / session

dilations are progressively less likely to have sustained effect Surgery for

14 DILATION OF LES - OUTCOME Good to excellent shortterm results in 60 85% with single session 50% will require further therapy within 5 years Subsequent dilations are progressively less likely to have sustained effect Surgery for those who have had > 2 dilations Complications perforations 2 6 %, mortality 0.2%

15 Has been used clinically since 1994 Mostly for cosmetic use, blepharospasm, torticollis Excellent short-term results (1 week 6 months) Long-term safety now in question BOTULINUM TOXIN INJECTION

SURGICAL MYOTOMY Myotomy technique first described in 1913 by Ernst Heller Open abdominal approach, laparoscopic, open thoracic and tharacoscopic approaches Most common

16 SURGICAL MYOTOMY Myotomy technique first described in 1913 by Ernst Heller Open abdominal approach, laparoscopic, open thoracic and tharacoscopic approaches Most common is laparoscopic (since 1998) - 72% in US) Good to excellent relief of symptoms in 70 to 90% 0.3% mortality, reflux esophagitis, ulceration, stricture or Barrett s in 11%

17 SURGICAL MYOTOMY Long-term remission rates 70 85% at 10 years 65% at 20 years Difference with or without fundoplication?

18 SURGICAL MYOTOMY

19 SURGICAL MYOTOMY Contraindications to surgery: Inability to undergo general anesthesia Inability to obtain consent Previous hiatal or esophageal surgery (relative) Megaesophagus or dilation > 8 cm (controversial)

20 SURGICAL MYOTOMY - CONTROVERSIES Length of myotomy 0.5 cm on stomach 27% with post-op dysphagia cm on stomach 11% post-op dysphagia 3 cm on stomach - <5% post-op dysphagia Antireflux procedure Few exceptions, no dysphagia risk No antireflux procedure shorter OR times and ease at which GER can be treated Fundoplication technique 360 degree wrap avoided Dor (45%) or Toupet (35%) with Toupet having less post-op GER Sigmoid-shaped or megaesophagus Try myotomy first!

, 2006) Myotomy with fundoplication, follow up 30 years 3 squamous cell cancer 9 Barrett

21 SURGICAL MYOTOMY vs DILATION Excellent result after 5 years follow up (n= 79) (Csendes et al., 1989) 95% with surgery 65% with dilation Follow up study (n= 67) (Csendes et al., 2006) Myotomy with fundoplication, follow up 30 years 3 squamous cell cancer 9 Barrett s esophagus Clinical results good to excellent 73% 22 failed mainly due to reflux esophagitis

22 EMERGING TECHNOLOGIES Robotic Myotomy Endoscopic submucosal myotomy

23 ACHALASIA MANAGEMENT

24 BOTTOM LINE Consider achalasia as a cause for dysphagia Endoscopic dilation and surgery are good options, while medical therapy is not With surgical myotomy, laparoscopic approach with antireflux procedure with 3 cm myotomy on to stomach most common

25 QUESTIONS 1. Achalasia is best imaged by a. CXR b. CT scan c. Barium swallow d. Endoscopy

26 QUESTIONS 2. Achalasia is best treated with a. Medication b. Botox injection to LES c. Balloon dilation of LES d. Surgical myotomy

27 QUESTIONS 3. Surgical myotomy is best done with a. Antireflux procedure b. No antireflux procedure c. Gastroplasty d. Botulinum injection

28 34th Annual Toronto Thoracic Surgery Refresher Course THANK YOU Dr. Carmine Simone Director, Intensive Care Unit Head, Division of Critical Care Departments of Medicine and Surgery Thoracic Surgeon Department of Surgery

Treating Achalasia. When to consider surgery and New options for therapy

Treating Achalasia. When to consider surgery and New options for therapy Treating Achalasia When to consider surgery and New options for therapy James B. Wooldridge,Jr., MD Ochsner Medical Center Senior Staff Surgeon General, Laparoscopic, and Bariatric Surgery Disclosures