What is New in Esophageal Motility Disorders

Transcription

1 What is New in Esophageal Motility Disorders Daniel Sadowski Edmonton May 26-28, 2017 Fairmont Chateau Lake Louise, Lake Louise, Alberta

2 Disclosure of Commercial Support Disclosure of Commercial Support: None Potential for conflict(s) of interest: None

3 Case 55 year old male. Referred for 5 year history of dysphagia?achalasia? Dysphagia for liquids and solids Takes 45 minutes to finish a meal Intermittent and not progressive Initial 5 kg weight loss but stable in past year Chronic MSK pain: Oxycodone (10/day) Morphine Sulfate (600 mg/day) Citalopram

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7 Questions arising from case How to tell if this is EGJOO vs. achalasia and does it matter if it is Type I, II or III? How to identify if this is drug effect? What is the best treatment if this is achalasia? What if I do nothing but watch and wait?

8 WEIGHT LOSS IN ACHALASIA IS DETERMINED BY ITS PHENOTYPE Background- Dysphagia a common symptom in achalasia Some patients lose significantly more weight than others Aim to identify clinical characteristics correlated with weight loss in a cohort of patients with achalasia Methods 6 year retrospective review at Vanderbilt Medical centre demographic, clinical, endoscopic, radiology, manometry

9 Results 100 patients had complete evaluation 51% male, mean age 56 yrs. Median wt. loss 28 lbs. (range lbs.) Wt. loss not significantly associated with age, gender, symptom presentation. 63% of Type II achalasia reported weight loss. 73% of Type III denied any weight loss.

10 III II Conclusion - Type II achalasia patients are most likely, and type III achalasia are least likely to have weight loss compared to type I achalasia. Comments Further confirmation that identification of achalasia subtype has clinical significance I

11 PREDICTIVE VALUE OF TIMED BARIUM SWALLOW IN SEPARATING PATIENTS WITH ACHALASIA, ESOPHGAGOGASTRIC JUNCTION OUTFLOW OBSTRUCTION AND NON-ACHALASIA DYSPHAGIA Background TBS commonly used to assess pre-post treatment esophageal emptying in achalasics

12 Aim to determine predictive value of TBS in pts. with achalasia and non-achalasia dysphagia Methods Retrospective review of 380 consecutive pts. medical records who underwent TBS evaluation. Pts. separated into achalasia, EGJOO and non-achalasia groups by HRM. AUC calculations Results 168 pts. with achalasia (44% Type II), 46 with EGJOO and 146 without achalasia AUC for barium height 1/5 minutes good diagnostic accuracy for achalasia (AUC 0.865) EGOO no barium retention at 5 minutes Tablet retention only fair diagnostic accuracy for achalasia (AUC 0.736) Conclusion Barium height > 2cm at 5 minutes good predictor of achalasia diagnosis.

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15 PERORAL ENDOSCOPIC MYOTOMY (POEM) VERSUS PNEUMATIC DILATATION IN THERAPY-NAIVE PATIENTS WITH ACHALASIA: RESULTS OF A RANDOMIZED CONTROLLED TRIAL

16 Background- Case series suggest POEM as an excellent treatment for achalasia Aim to compare the efficacy of POEM versus pneumatic dilatation as initial treatment of therapy-naïve patients with idiopathic achalasia Methods New achalasia pts. randomized to POEM or PD PD mm dilatation protocol Primary Outcome Therapeutic success defined by Eckardt score less than or equal to 3.

17 Results- 133 randomized Baseline characteristics similar Therapeutic success at three months: POEM 63/64 (98.4%) PD 52/66 (79% ) p<0.01 Clinical remission after one year: POEM 59/64 (92.2%) PD 46/66 (70%), p<0.01 Endoscopy at 1 year (off PPI) POEM esophagitis (40.0% grade A/B, 8.3% grade C/D PD (13.1% grade A/B, 0% grade C/D), p=0.02

18 Conclusions- POEM results in a significantly higher one-year therapeutic success rate compared to PD. POEM is a refluxogenic procedure Comments Too early to tell if POEM will become treatment of choice Need RCT POEM vs. LHM Need longer term follow-up Efficacy of POEM for previous treatment failures?

19 LACK OF LONG-TERM ACHALASIA FOLLOW UP IS ASSOCIATED WITH PROGRESSION OF DISEASE Background Follow-up intensity after treatment for achalasia is currently unclear Aim - To evaluate the degree of follow up care on disease progression Methods Retrospective cohort study of achalasia patients diagnosed at Mayo more than 10 years prior 30-day Mayo Dysphagia Questionnaire (MDQ-30) was mailed.

20 Results MDQ-30 was mailed to 157 patients -62 were returned (39.5%) Mean age was 63 years (range: 24-89) with 34 females (54.8%) The median disease duration was 16 years (IQR: 13-22). 37 patients (60%) reported trouble swallowing in the last month. For patients with dysphagia 23/37(62.2%) did not follow up in the clinic compared to patients without dysphagia of whom 18/25 (72%) were followed in clinic OR: 1.6 (95% CI: , p=0.4) Increasing interval between visits increases the risk of more severe esophageal dilation with RR: 1.2 per year (95% CI: ).

21 Comments- Small numbers but a definite signal Esophageal dilatation is to be avoided Regular timed barium swallows should be carried out to identify people at risk