Pneumatic Dilatation and Surgical Myotomy for Achalasia

Lopushinsky, Steven R.; Urbach, David R.

doi:10.1001/jama.296.18.2227

Cited by 102 publications

(75 citation statements)

References 35 publications

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“…LHM appears to provide a more durable relief in symptoms than PBD at least in adult patients. 16 In a recent case series, LHM was found to be safe and effective. However post-operative intervention (including balloon dilatation and redo myotomy) was required in 28% of patients on subsequent follow-up.…”

Section: Discussionmentioning

confidence: 94%

Per Oral Endoscopic Myotomy in Children with Achalasia Cardia

Nabi

Ramchandani

Reddy

et al. 2016

J Neurogastroenterol Motil

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Background/AimsAchalasia cardia (AC) is a motility disorder, characterized by impaired lower esophageal sphincter relaxation and absence of esophageal peristalsis. AC is rare in children with unclear optimum management strategies. Per oral endoscopic myotomy (POEM) is a novel technique for management of achalasia with encouraging results in adult patients. The efficacy and safety of POEM is not known for pediatric AC. The aim of our study was to evaluate the safety and efficacy of POEM in children with achalasia cardia MethodsThe data of all children (< 18 years) who underwent POEM at our center was retrospectively analysed. Symptoms were analysed using a validated score (Eckardt score) at regular predefined intervals. Objective parameters including high-resolution manometry, timed barium swallow and esophagogastroduodenoscopy were assessed before the procedure and at 1-year follow-up. Clinical success was defined as an Eckardt score ≤ 3. ResultsA total of 15 children underwent POEM during the specified period. Ten out of 15 (10/15) completed 1-year follow-up. Median operative time was 100 (38-240) minutes. Mean pre and post procedure LES pressure were 36.64 ± 11.08 mmHg and 15.65 ± 5.73 mmHg, respectively (P = 0.001). Mean Eckardt score before and after the POEM was 7.32 ± 1.42 and 1.74 ± 0.67, respectively (P = 0.001). Mean percentage improvement in barium emptying at 5 minutes was 63.70 ± 4.46%. All children had complete resolution of symptoms at 1 year. Median weight gain of children at 1 year was 0.65 kg (range, 0.0-4.6). Conclusions

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Section: Discussionmentioning

confidence: 94%

Per Oral Endoscopic Myotomy in Children with Achalasia Cardia

Nabi

Ramchandani

Reddy

et al. 2016

J Neurogastroenterol Motil

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“…A recent population based study reported that both Heller myotomy and PD provided good relief of symptom. 38 However, the cumulative risk of subsequent intervention for achalasia at 10 years was 63.5% for patients initially treated with PD compared to 37.5% for patients initially treated with surgical myotomy. 38 Although many studies indicate that surgical myotomy is superior to PD in providing long term relief of symptoms, a few physicians still favor PD because of the relatively higher risk associated with open surgical myotomy.…”

Section: Choice Of Treatmentmentioning

confidence: 96%

“…34 However, graduated dilatation results in a higher and more durable clinical response. 37,38 A report from Cleveland clinic showed that 41% of newly diagnosed achalasia patients were initially treated with PD. 33 The clinical response was 86% in these patients with improved esophageal emptying of 54%.…”

Section: Medical Treatmentmentioning

confidence: 99%

“…14,34 Gastrooesophageal reflux is seen in 4% to 16% of patients.34 Perforation occurs in 1% to 3% of patients many of who would require emergency surgery. 38 The risk of perforation is highest during the initial dilatation as oppose to subsequent dilatation especially in patients with vigorous achalasia.38 Predictors of good outcome of PD include age above 50 years and more than 50% reduction in LES pressure. 22,38 Overall, PD provides a safe and effective way of achieving long-term control of symptoms in patients with achalasia.…”

Section: Medical Treatmentmentioning

confidence: 99%

“…50 Lopushinsky and Urbarch also did not find any difference in the pattern of antireflux medication use between patients who had antireflux procedure as part of a surgical myotomy and those who did not. 38 Therefore, while Heller myotomy and fundoplication may be safe the need for the antireflux procedure is unknown. It is generally accepted that a complete 360°wrap Nissen fundoplication should be avoided because it creates a high pressure zone in the distal esophagus which negates the intent of the operation.…”

Section: Surgical Treatmentmentioning

confidence: 99%

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Achalasia: What is the best treatment?

Ahmed

2008

Ann Afr Med

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Background: Achalasia is an infrequent primary motility disorder of the esophagus. Because of uncertain etiology, treatment is only palliative and is directed at decreasing lower esophageal sphincter pressure, improving esophageal emptying and relieving the symptoms of achalasia. Current treatment options include pharmacological, endoscopic and surgical. We undertook a systematic literature review of the management strategies currently available for achalasia. Method: A Medline, PubMed and Cochrane database search was conducted using reference manager 11. Original articles and reviews published in the English literature on the management of achalasia were reviewed. Emphasis was placed on articles published in the last ten years on randomized controlled trials comparing the various forms of treatment. Results: Esophageal manometry is the standard diagnostic evaluation for achalasia. Accurate diagnosis can also be made based on clinical findings and barium esophagogram. Medical treatment with nitrates or calcium channel blockers has variable results in alleviating the symptoms of achalasia but long-term results are disappointing because of tolerance and side effects. Intrasphincteric injection of botulinum toxin, pneumatic dilatation and surgical myotomy are variably effective at controlling the symptoms of achalasia but each modality has specific strength and weaknesses which make their choice suitable in a particular group of patients. While pneumatic dilatation is superior to botulinum toxin injection surgical myotomy provides the best long-term control of symptoms in patients with achalasia. Conclusion: Laparoscopic myotomy should be the initial treatment for most patients with achalasia. Pneumatic dilatation is the most cost-effective alternative but its long-term efficacy is less than that of surgical myotomy. Endoscopic botulinum toxin injection can be considered when other forms of treatment are contraindicated. Key words: Achalasia, Heller's esophagomyotomy, pneumatic dilatationRésumé Contexte: L'achalasie est une rare anomalie motrice de l'oesophage. En raison de son étiologie incertaine, le traitement est seulement palliatif et vise la réduire la pression sphinctérienne du bas oesophage, l'amélioration de la vidange et le soulagement des symptômes de l'achalasie. Les options thérapeutiques courantes font appel aux moyens pharmacologiques, endoscopiques et chirurgicaux. Nous avons effectué une revue systématique de la littérature relative aux stratégies thérapeutiques actuellement disponibles pour l'achalasie. Méthode: Une recherche sur Medline, Pubmed et Cochrane a été faite a l'aide du logiciel Reference Manager 11. Les articles originaux et les rapports portant sur la prise en charge de l'achalasie et publiés en anglaise ont été passés en revue. L'accent a été mis sur les articles publiés au cours des dix dernières années et sur les essais contrôlés comparant les diverses formes de traitement. Résultats: La manométrie oesophagienne est la méthode de diagnostic standard pour l'achalasie. Le dia...

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Use and Safety of Per-Oral Endoscopic Myotomy for Achalasia in the US

et al. 2022

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IMPORTANCE Several professional practice guidelines recommend per-oral endoscopic myotomy (POEM) as a potential first-line therapy for the management of achalasia, yet payers remain hesitant to reimburse for the procedure owing to unanswered questions regarding safety.OBJECTIVE To evaluate the use, safety, health care utilization, and costs associated with the use of POEM for treatment of achalasia relative to laparoscopic Heller myotomy (LHM) and pneumatic dilation (PD). DESIGN, SETTING, AND PARTICIPANTSThis was a retrospective national cohort study of commercially insured patients, aged 18 to 63 years, who underwent index intervention for achalasia with either LHM, PD, or POEM in the US between July 1, 2010, and December 31, 2017. Patient data were obtained from a national commercial claims database. Included in the study were patients with at least 12 months of enrollment after index treatment and a minimum of 6 months of continuous enrollment before their index procedure. Patients 64 years or older were excluded to avoid underestimation of health care claims from enrollment in Medicare supplemental insurance. Data were analyzed from July 1, 2019, to July 1, 2021. MAIN OUTCOMES AND MEASURESChanges in the proportion of annual procedures performed for achalasia were evaluated over time. The frequency of severe procedure-related adverse events, including perforation, pneumothorax, bleeding, and death, were compared. Negative binomial regression was used to compare the incidence rates of subsequent diagnostic testing, reintervention, and unplanned hospitalization. Generalized linear models were used to compare differences in 1-year health-related expenditures across procedures. RESULTSThis cohort study included a total of 1921 patients (median [IQR] age: LHM group, 48 [37-56] years; 737 men [51%]; PD group, 51 [41-58] years; 168 men [52%]; POEM group, 50 [40-57] years; 80 men [56%]). The use of POEM increased 19-fold over the study period, from 1.1% (95% CI, 0.2%-3.2%) of procedures in 2010 to 18.9% in 2017 (95% CI, 13.6%-25.3%; P = .01). Adverse events were rare and did not differ between procedures. Compared with LHM, POEM was associated with more subsequent diagnostic testing (incidence rate ratio [IRR], 2.2; 95% CI, 1.9-2.6) and reinterventions (IRR, 1.9; 95% CI, 1.1-3.3). When compared with PD, POEM was associated with more subsequent diagnostic testing (IRR, 1.5; 95% CI, 1.3-1.8) but fewer reinterventions (IRR, 0.4; 95% CI, 0.2-0.6). The total 1-year health care costs were similar between POEM and LHM, but significantly lower for PD

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Pneumatic Dilatation and Surgical Myotomy for Achalasia

Cited by 102 publications

References 35 publications

Per Oral Endoscopic Myotomy in Children with Achalasia Cardia

Per Oral Endoscopic Myotomy in Children with Achalasia Cardia

Achalasia: What is the best treatment?

Use and Safety of Per-Oral Endoscopic Myotomy for Achalasia in the US

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