the new era of esophageal motility disorders
DESCRIPTION
The New Era of Esophageal Motility Disorders. Joint Hospital Surgical Ground Round April 2014 Hwang Wan Wui Winston Queen Elizabeth Hospital. Presentation Outline. Chicago Classification Scheme High Resolution Esophageal Pressure Topography Achalasia Presentation Investigation Treatment. - PowerPoint PPT PresentationTRANSCRIPT
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Joint Hospital Surgical Ground RoundApril 2014
Hwang Wan Wui WinstonQueen Elizabeth Hospital
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Presentation Outline
Chicago Classification Scheme High Resolution Esophageal Pressure Topography
Achalasia Presentation Investigation Treatment
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Chicago Classification Scheme High Resolution Esophageal Pressure Topography
Achalasia Presentation Investigation Treatment
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The Chicago Classification
Investigators in the Northwestern University in Chicago developed a new classification scheme to facilitate the diagnosis of esophageal motility disorders by interpretation of high resolution esophageal pressure topography (EPT)
Esophageal pressure topography is a combination of high resolution manometry (HRM) and pressure topography
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Esophageal Pressure Topography V.S. Conventional Manometry
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The Chicago Classification
IRPIntegrated Relaxation Pressure
Each metric developed to characterize a specific feature of deglutitive esophageal function
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Esophageal Pressure Topography V.S. Conventional Manometry
EPT allows more sophisticated interpretation of esophageal motility
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The Chicago Classification
YES
YES
YES
NO
NO
IRP >= upper limit of normal AND absent
peristalsis
AchalasiaType I: ClassicType II: Pan-esophageal pressurizationType III: Spastic
IRP >= upper limit of normal AND some
instances of intact or weak peristalsis
EGJ Outflow ObstructionAchalasia variantMechanical obstruction
IRP is normal BUT abnormalities in other
metrics
Other Esophageal Motility DisordersDistal esophageal spasmHypercontractile esophagusAbsent peristalsisNutcracker esophagus
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Chicago Classification Scheme High Resolution Esophageal Pressure Topography
Achalasia Presentation Investigation Treatment
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Achalasia - Presentation
Dysphagia both liquid and solid
Regurgitation
Chest pain
Cough
Aspiration pneumonia
Weight loss
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Achalasia - InvestigationsBarium Esophagogram
Classical “bird’s beak” appearance Dilated esophageal body
High Resolution Manometry
Esophagogastroduodenoscopy Rule out pseudoachalasia
Most common cause is malignancy infiltrating the EGJ
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Achalasia – Type I (Classic Achalasia)
Mean IRP >= upper limit of normal (IRP =42mmHg)
100% failed peristalsis
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Achalasia – Type II
Mean IRP >= upper limit of normal
No normal peristalsis
Panesophageal pressurization with >20% of swallows, which may exceed LES pressure, causing the esophagus to empty
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Achalasia – Type III (Spastic Achalasia)
Mean IRP >= upper limit of normal
No normal peristalsis
Fragments of premature (spastic) distal contractions with 20% of swallows
Although this is also associated with rapidly propagated pressurization, the pressurization is attributable to an abnormal lumen obliterating contraction
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Achalasia TreatmentPharmacological
Calcium channel blockers and nitrates short lived response side effects: headache, dizziness and
pedal edema
Botulin toxin injection prevents the release of acetylcholine
at terminal nerve endings results last 6-9 months. [1]
Pharmacological therapies are less effective than endoscopic or surgical therapies
[1] Pasricha PJ, Ravich WJ, Hendrix TR, Sostre S, Jones B, Kal- loo AN. Intrasphincteric botulinum toxin for the treatment of achalasia. N Engl J Med 1995; 332: 774-778
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Achalasia TreatmentPneumatic Dilation
Aims at disrupting the LES by forceful dilation using air filled balloons
Many use a graded dilation protocol starting with 3.0 cm, then stepping up to 3.5cm and 4.0cm
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Achalasia TreatmentPneumatic Dilation
Promising short term results
Long term follow-up showed recurrence
[1] Eckardt VF, Gockel I, Bernhard G. Pneumatic dilation for achalasia: late results of a prospective follow up investigation. Gut 2004; 53: 629-633 [2] Katsinelos P, Kountouras J, Paroutoglou G, Beltsis A, Zavos C, Papaziogas B, Mimidis K (2005) Long-term results of pneu- matic dilation for achalasia: a 15 years’ experience. World J Gastroenterol 11:5701–5705
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Achalasia TreatmentLaparoscopic Heller’s Myotomy (LHM)
Myotomy from 1.5-3cm distal to the EGJ dividing the longitudinal and oblique muscle to 6-8cm proximal to the EGJ dividing longitudinal and circular muscle of esophagus
Partial fundoplication is routinely performed as incidence of reflux after Heller’s myotomy is >50%
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Achalasia TreatmentLaparoscopic Heller’s Myotomy (LHM)
LHM considered superior to pneumatic dilation and the first choice of treatment for achalasia
Prospective trials have shown promising long term results of LHM
A prospective trial in Italy followed up 6 years after laparoscopic Heller-Dor operation [1] Primary outcome was therapeutic success in terms of
symptoms improvement At 6 years, 81.7% of patients still have significant
improvement in their symptoms
[1] Costantini M, Zaninotto G, Guirroli E, et al. The laparoscopic Heller-Dor operation remains an effective treatment for esophageal achalasia at a minimum 6-year follow-up. Surg Endosc 2005;19:345-51
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Achalasia TreatmentLaparoscopic Heller’s Myotomy (LHM)
Multicenter RCT published by European Achalasia Trial group in 2011 [1] Primary outcome was therapeutic success, measured by
Eckardt score After 2 years of follow up, the study concluded LHM was not
superior to pneumatic dilation Limitations:
2 year cohort study with no evidence on intermediate and long-term remission rates
All patients in the PD group received 2 to 3 sessions of redilation
[1] Boeckxstaens GE, Annese V, des Varannes SB, Chaussade S, Costantini M, Cuttitta A, Elizalde JI, Fumagalli U, Gaudric M, Rohof WO, Smout AJ, Tack J, Zwinderman AH, Zaninotto G, Busch OR. Pneumatic dilation versus laparoscopic Heller’ s myotomy for idiopathic achalasia. N Engl J Med 2011; 364: 1807-1816
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Achalasia Treatment in Different Subtypes
[1] Pandolfino JE, Kwiatek MA, Nealis T, Bulsiewicz W, Post J, Kahrilas PJ. Achalasia: a new clinically relevant classification by high-resolution manometry. Gastroenterology 2008;135:1526-1533.[2] Salvador R, Costantini M, Zaninotto G, et al. The preoperative manometric pattern predicts the outcome of surgical treatment for esophageal achalasia. J Gastrointest Surg 2010;14:1635–1645[3] Rohof WO, Salvador R, Annese V, et al. Outcomes of treatment for achalasia depend on manometric subtype. Gastroenterology 2013; 144:718–725
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Peroral Endoscopic Myotomy (POEM)
Dissection of inner circular muscle layer of the esophagus
Dissection begins around 7cm proximal to EGJ and down to 2cm distal to EGJ
Good short-term results
Long-term results not available yet
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Conclusion Pharmacological therapies are not recommended unless patient is
not fit for endoscopic or surgical therapies
Pneumatic dilation is the most effective nonsurgical treatment with promising short term results but high recurrence rate in the long term
Laparoscopic Heller’s myotomy should be advocated for patients fit for surgery
The Chicago Classification Scheme is providing a better classification for esophageal motility disorders. It has great impact on how we approach esophageal motility disorders, predict treatment outcomes and choose treatment options
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Winston HwangQueen Elizabeth Hospital
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References Goldblum JR, Rice TW, Richter JE. Histopathologic features in
esophagomyotomy specimens from patients with achala- sia. Gastroenterology 1996; 111: 648-654
Richter JE. Achalasia – An Update. J Neurogastroenterol Motil. Jul 2010; 16(3): 232–242
Boeckxstaens GE, etal. Achalasia. Lancet 2014; 383: 83-93
Stefanidis D, et al. SAGES guidelines of the surgical treatment of esophageal achalasia. Surg Endosc 2012; 26: 296-311