BCM Gastroenterology Grand Rounds - Discussion
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Final Diagnosis: End stage esophagus secondary to Achalasia.

Achalasia is a Greek word that means “does not relax” The first case was reported 300 years ago by Thomas Willis, the patients cardiospasm responded to dilation with a whalebone. (Visual 1)

This is a primary esophageal motor disorder of unknown etiology characterized manometrically by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. (Visual 2)

The annual incidence is approximately 1 case per 100,000. Usually diagnosed in patients who are between 25-60 years., men and women affected equally. Symptoms are (Visual 3)

Patients with achalasia are at increased risk for esophageal squamous cell carcinoma. A population based study in Sweden found the risk being high in the first year after diagnosis of achalasia, over the long term the risk increases 16 fold compared with normal control population. Risk is not high enough to warrant regular surveillance, as some series did not note increase in risk with early treatment of achalasia.

Radiologically: A barium swallow is the primary screening test  with a diagnostic accuracy of 95%, showing a dilated esophagus with a bird beak narrowing by contracted lower esophageal sphincter. CXR shows a widened mediastinum with air fluid level and and absence of normal gastric air bubble.  (Visual 4)

Manometry: 1) elevated resting LES pressure, above 45 mm Hg. 2) Incomplete LES relaxation. 3) Aperistalsis in the body of the esophagus. (Visual 5)

MANAGEMENT:

The goal of the treatment is improved esophageal emptying and relief of patient symptoms, as there is no cure for this disorder. No treatment can restore the the muscular activity to the denervated achalasiac esophagus; aim is to reduce the pressure gradient across the LES, thus facilitating esophageal emptying by gravity.

The options are:

1) Pneumatic dilation:PD

2) Heller Myotomy:HM

3) Botox injection and

4) Medical therapy

Algorithm: (Visual 6)

 

Pneumatic Dilation is the most effective non surgical treatment, using a Rigiflex balloon, which comes in three sizes, 3, 3.5 and 4 cm.   (Visual 9)  The clinical response improved in a graded fashion with increasing size of the balloon diameter (Vaezi and Richter in Journal of Clinical Gastroenterology 1998) a good to excellent relief of symptoms occurred in 50-93% of patients. 

Eckhardt et al published (GUT 2004) a prospective study of 54 pts treated with PD between 1981 and 1991; these pts were followed for a median of 13.8 yrs. Complete follow up until 2002 was obtained. A single PD resulted in a five year remission rate of 40 % and a 10 year remission rate of 36%. Repeated dilations only mildly improved the clinical response. Patients who were older than 40 yrs had a significantly better outcome than younger patients. The most significant predictive factor for a favorable long term outcome was a post dilation lowered esophageal sphincter pressure of less than 10 mm Hg. Patients who remain in remission for five yrs are likely to benefit from the long lasting treatment effect of PD.

 

Botulinum Toxin injection inhibits the calcium dependent release of acetylcholine from nerve terminals , thereby countering the effect of the selective loss of inhibitory neurotransmitters . It is initially effective in relieving symptoms in about 85% of pts. How ever symptoms recur in more than 50% of these pts within 6 months possibly because of regeneration of the affected receptors. Older patients >60 yrs. or with vigorous achalasia are more likely to have a sustained response.

 

Heller myotomy  is  a definitive treatment, with a good outcome in younger patients. Long term results of surgery tend to worsen with time. It may take up to 15 yrs for recurrent symptoms of dysphagia and the development of symptomatic GERD to become clinically evident. Therefore the number of patients with good results will diminish with long follow-up evaluation;  Di Simmone et al showed that post op reflux esophagitis appeared during a mean period of 76.5 months after operation. After an initial excellent result, there was a progressive recurrence of symptoms until 15 yrs after the operation, at which point the number of patients free of dysphagia and reflux were 71.9% and 69.2% respectively. The predominant cause of failure was incomplete myotomy, followed by severe reflux and incorrect diagnosis at the time of initial evaluation.

Because of the risk of GERD, the combination of loose Nissen fundoplication with myotomy is currently under debate. In a study published in Surgical endoscopy in Jan 2005, from Italy, a total of 71 consecutive patients who underwent laparoscopic Heller –Dor operation were followed for a minimum of 6 yr. They were evaluated, with time Barium swallow(TBS), EGD,  Manometry and pH monitoring.  The median symptom score decreased from 22 preop to 4 at the last follow up at 6 yrs; 81.7 % were satisfied with the treatment; 13 pts suffered symptom recurrence and were treated with PD. Most of the symptomatic failures occurred in the early period after the operation. This is the first long term follow up study of myotomy combined with fundoplication.

 

PD after a failed HM:

 Zinnotto et al (Ann of Surg 2002) reported 56% success rate in nine patients treated with PD after a failed HM, with no perforations supporting the notion that prior myotomy does not increase the risk of perforation.

 

How about a HM after a failed PD?

Gockel et al published their experience in Annals of Surgery in March 2004. 19 pts who never reached a clinical remission after PD underwent myotomy. Their clinical course was compared with that of patients who had reached a clinical remission after a single (n=34) or multiple (n=14) PDs. The 10 yr remission rate was 77% in pts undergoing myotomy, 72% in pts successfully treated with a single PD and 45% in pts undergoing several dilations. Myotomy was therefore shown to be an effective treatment modality in patients with achalasia who have failed to respond to PD.

 

Redo laparoscopic surgery is safe and feasible as  reported by Mayo’s surgical group (Gorecki et al), study published in Surgical Endoscopy 2002. Eight patients underwent redo procedures between 1994 and 1998. The reason for failure was incomplete myotomy in five, incorrect diagnosis in two, and new onset of reflux symptoms in one. The redo lap surgery resulted in symptom improvement (83%) in all, but one, with the quality of life score improving from poor to good. Surgeon experience and recognition of the cause for failure of the original operation are most important in predicting the outcome. This however, is reported to carry a high morbidity and mortality of 32% and 5.4% respectively, therefore efforts should be made to exhaust less invasive approaches before subjecting the patient to a more extensive procedure. (Visual 10)

Esophagectomy and colon interposition is the next approach taken for failed myotomy or PD. Patients with mega esophagus and esophageal diameter > 8 cm or those with low LES pressure and persistent symptoms typically do not do well with either PD or HM and may require an esophagectomy with a gastric pull up or colon interposition. A recent article published in Annals of Thoracic surgery 2003 , 9 patients underwent limited distal esophagectomy with short colon interposition through a left thoracoabdominal approach as an alternative to nearly total esophagectomy with a right thoracotomy or trans hiatal approach. This procedure was safe and involved less dissection of the intrathoracic esophagus and easy mobilization of the wrapped EG junction. Another study from Cleveland Clinic, in a 10-year period, 32 patients underwent esophagectomy with gastric reconstruction for achalasia; 30 (94%) underwent elective surgery, 2 emergent surgery. No postoperative deaths occurred. Of 30 patients, 26 (87%) felt better after esophagectomy. Esophagectomy with gastric reconstruction relieved preoperative dysphagia and regurgitation in the majority of patients. Dietary function and weight maintenance were excellent, attesting to the durability of the procedure in patients with end-stage achalasia.

In a recent article published in Am. J. of Gastro in 2004 by Marcelo and Richter discussed the complexities of managing achalasia at a tertiary referral center. 232 pts were evaluated, out of these,184 were untreated, 48 had prior esophageal surgery. PD was used in111pts. With improvement in symptoms in 86%, and Barium emptying improve in 54%. 19 (17%) required subsequent Heller myotomy. Perforation rate was 3/111(2.7%). 16% required PPI for  GERD. HM was used in 72 pts (81% laparoscopic). 1/3 rd had their procedure combined with an anti reflux procedure, usually a post partial(Toupet) or more infrequently an anterior partial(Belsey or dor). It should be noted that the rate of PPI use was similar either with or without fundoplication(44%vs59%). Symptom and barium emptying improved in 89% and 44% respectively. PPI required in 53%. Botox was used in 39 older patients (mean age 71); symptom improvement lasted for a mean 6.2 months, with frequent need for repeated injection (mean:1.7, range: 1-7). About 43% required additional treatment with a different modality. Esophagectomy was done in three patients. (Visual 7) .  (Visual 8). Patients with prior surgery (n=48): PD 9(n=10) achieved symptom and barium emptying improvement in 67% and 11%, comparable to redo HM (n= 21) with 57% symptom improvement and 38% improved emptying. Redo HM was performed thru the abdomen with either a lap or open approach. Esophagectomy was required in eight (17%) despite all the modalities available, their disease was either too far advanced at the time they sought treatment or they failed all the other treatments. Esophagectomy was performed via the trans hiatal route, gastric reconstruction, cervical anastomosis, and pyloromyotomy. Botox was reserved for elderly high risk or as a part of multimodality treatment approach

In summary the treatment of achalasia can be complex. The best balance of success lies in being able to utilize all the available therapies, including Botox for palliation, the more definitive treatment (PD or HM), and esophagectomy for those with end stage disease. In this study prior Botox treatment did not affect the outcome of PD, similarly prior PDs have no effect on the success of HM. The treatment of achalasia patients after failing an initial myotomy is less successful; PD in this group can be performed safely, but repeat HM has the better chance of improving both symptoms and esophageal emptying.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



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