Pneumatic Dilation versus Laparoscopic Heller's Myotomy for Idiopathic Achalasia

Boeckxstaens, Guy E.; Annese, Vito; Varannes, Stanislas Bruley des; Chaussade, Stanislas; Costantini, Mario; Cuttitta, Antonello; Elizalde, JI; Fumagalli, Uberto; Gaudric, M; Rohof, Wout O.; Smout, A. J. P. M.; Tack, Jan; Zwinderman, Aeilko H.; Zaninotto, Giovanni; Busch, Olivier R.

doi:10.1056/nejmoa1010502

Cited by 752 publications

(595 citation statements)

References 30 publications

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“…Because of the propensity of this procedure to cause reflux, LHM is usually combined with a partial fundoplication. An extensive literature has compared LHM with pneumatic dilation 51 , culminating in a multi center European randomized controlled trial comparing the two for the treatment of achalasia, which concluded that both approaches were ~90% effective with no statistically significant difference in therapeutic success between them 56,57 . However, that trial (and all preceding trials) did not consider achalasia subtypes in their design or in their assessment of treatment efficacy.…”

Section: Lhm and Pneumatic Dilationmentioning

confidence: 99%

Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

Kahrilas

Bredenoord

Fox

et al. 2017

Nat Rev Gastroenterol Hepatol

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High-resolution manometry (HRM), along with the analysis algorithms characterized in the Chicago Classification (CC) first proposed in 2008, have led to a major restructuring of the classification of oesophageal motility disorders. The inherently quantitative output of HRM devices fuelled enthusiastic expectation among motility experts that these advances would add a level of precision to the diagnosis of oesophageal motility disorders that was not previously possible. Nowhere was this advance more evident than in our concept of achalasia, now differentiated into subtypes as a direct result of HRM. Coincident with the assimilation of HRM into clinical practice was the development of a major therapeutic intervention for the management of oesophageal motility disorders, per-oral endoscopic myotomy (POEM). Not only does the POEM procedure provide a therapeutic option for myotomy with reduced morbidity relative to laparoscopic or open myotomy, but it also enables a calibrated intervention that is customized to patient-specific physiology. Together, these develop ments fostered an increasing emphasis on targeting therapy to specific aspects of oesophageal dysfunction, as measured by physiological testing, rather than discrete diagnoses. Again, nowhere is this evolution more evident than in our strategies for managing achalasia. This Consensus Statement examines the effect of HRM on our current understanding of oesophageal motility disorders with a focus on how this technology has affected the diagnosis, epidemiology and management of achalasia and achalasia-like syndromes. on behalf of the International Working Group for Disorders of Gastrointestinal Motility and FunctionAbstract | High-resolution manometry (HRM) and new analysis algorithms, summarized in the Chicago Classification, have led to a restructured classification of oesophageal motility disorders. This advance has led to increased detection of clinically relevant disorders, in particular achalasia. It has become apparent that the cardinal feature of achalasia -impaired lower oesophageal sphincter (LES) relaxation -can occur in several disease phenotypes: without peristalsis (type I), with pan-oesophageal pressurization (type II), with premature (spastic) distal oesophageal contractions (type III), or with preserved peristalsis (outlet obstruction). Furthermore, no manometric pattern is perfectly sensitive or specific for achalasia caused by a myenteric plexopathy, and there is no biomarker for this pathology. Consequently, physiological testing reveals other syndromes not meeting achalasia criteria that also benefit from therapies formerly reserved for achalasia. These findings have become particularly relevant with the development of a minimally invasive technique for performing a long oesophageal myotomy, the per-oral endoscopic myotomy (POEM). Optimal management is to render treatment in a phenotype-specific manner; that is, POEM calibrated to patient-specific physiology for spastic achalasia and the spastic disorders, and more conservative strategies...

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Section: Lhm and Pneumatic Dilationmentioning

confidence: 99%

Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

Kahrilas

Bredenoord

Fox

et al. 2017

Nat Rev Gastroenterol Hepatol

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“…Therapeutic success was defined as a reduction in the Eckardt symptom score below 4. The report proves similar and excellent outcomes over a 2-year follow-up with both PD and LHM in a study involving 201 achalasia patients (86% vs 90%).Although longer follow up is required, the authors concluded that LHM does not achieve superior rates of therapeutic success compared with PD as primary treatment for achalasia, at least after a mean follow up of 43 months, and, therefore, either one can be recommended as an initial therapy (15).…”

Section: Heller Myotomymentioning

confidence: 53%

“…Heartburn and nocturnal cough can initially lead to a diagnosis of gastroesophageal reflux disease (GERD). Chest pain is the most refractory and difficult to treat symptom, as opposed to dysphagia and regurgitation which usually respond to treatment (15). The Eckardt score grades the 4 most frequent symptoms (dysphagia, chest pain, regurgitation,weight loss) based on their frequence of occurence (each meal, daily,weekly or never).…”

Section: Achalasiamentioning

confidence: 99%

“…Before HRM era, a symptom score of 0-1 corresponded to clinical stage 0, a score of 2-3 to stage I, a score of 4-6 to stage II, and a score >6 to stage III. Stages 0 and I indicated remission of the diseass, while stages II and III represented failure of treatment (15,16). The role of Eckhardt score in the evaluation of treatment efficacy significantly decreased during the last years, being replaced by more objective HR manometric parameters (14,15).…”

Section: Achalasiamentioning

confidence: 99%

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High Resolution Manometry - A Mandatory Examination in the Pre and Postoperative Assessment of Patients with Achalasia

Dimitriu¹,

Gheorghe²

2018

chr

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RezumatManometria esofagiană cu rezoluţie înaltă este actual investigaţia gold-standard în diagnosticul acalaziei şi a bolilor esofagiene funcţionale. Această examinare este întotdeauna precedată de endoscopia digestivă superioară, care are scopul de a face diagnosticul diferenţial al acalaziei cu pseudoacalazia (formaţiuni tumorale de fornix gastric/esofag distal). La momentul actual, nu există tratament curativ pentru acalazie. Însă, cele 3 subtipuri de acalazie (conform clasificării Chicago) au răspuns diferit în ceea ce priveşte eficacitatea în tratamentului ales. Astfel, comparativ cu tipurile I şi III, tipul II de acalazie are cel mai bun răspuns la intervenţiile terapeutice invazive (dilatare pneumatică sau cardiomiotomie Heller). În schimb, în tipul III cardiomiotomia Heller este de ales ca prima abordare terapeutică. Miotomia endoscopică perorală (POEM) este o tehnică relativ recentă, care necesită însă studii pe termen lung în ceea ce priveşte siguranţa şi eficacitatea. Articolul prezent îşi propune să prezinte variantele actuale de tratament ale acalaziei, comparându-le pe baza eficacităţii şi siguranţei pe termen scurt şi lung, subliniind de asemenea rolul manometriei cu rezoluţie înaltă în diagnosticul, alegerea metodei terapeutice şi prognosticul acestor pacienţi. Review ArticleAbstract High resolution manometry (HRM) is currently the gold standard for the diagnosis of achalasia and other functional esophageal disorders. All patients accusing dysphagia should be endoscopically evaluated prior to manometric investigations in order to rule out pseudoachalasia. The Chicago HRM classification has led to a subclassification of three manometric types of achalasia that seem to have different results to treatment. None of the actual achalasia treatment options are curative. Type II achalasia patients respond best to all treatment options compared to those with types I and III. Pneumatic dilation (PD) or Heller miotomy (LHM) can be both chosen as initial therapy in type I and II as they have good outcome , while type III achalasia patients respond better to LHM as a first therapeutic option. Peroral endoscopic myotomy (POEM) is a promising new technique but long-term follow-up studies for its safety and efficacy must be performed. This article reviews the current therapeutic options in achalasia and other functional esophageal disorders, based on the differences in safety and efficacy between approaches, highlighting the impact of HRM to predict the outcome but also the role of the techinque in guiding antireflux surgery.

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“…In achalasia, perforation rates up to 4% were described for pneumatic dilation. These rates may be reduced by starting with a 30 mm balloon, progressing only if symptoms do not improve and never using a balloon larger than 35 mm [41]. Perforation rates in benign gastric outlet obstruction are high as 7.4%, risk factors are dilation in the setting of active ulceration and balloon size greater than 15 mm [42].…”

Section: Dilationmentioning

confidence: 99%

Emergencies after endoscopic procedures

Rolanda

Caetano

Dinis-Ribeiro

2013

Best Practice & Research Clinical Gastroenterology

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Keywords:GI endoscopy adverse events GI emergencies Bleeding Haemorrhage Perforation Infection Embolization Diagnosis and management of severe complications a b s t r a c t Endoscopy adverse events (AEs), or complications, are a rising concern on the quality of endoscopic care, given the technical advances and the crescent complexity of therapeutic procedures, over the entire gastrointestinal and bilio-pancreatic tract. In a small percentage, not established, there can be real emergency conditions, as perforation, severe bleeding, embolization or infection. Distinct variables interfere in its occurrence, although, the awareness of the operator for their potential, early recognition, and local organized facilities for immediate handling, makes all the difference in the subsequent outcome. This review outlines general AEs' frequencies, important predisposing factors and putative prophylactic measures for specific procedures (from conventional endoscopy to endoscopic cholangio-pancreatography and ultrasonography), with comprehensive approaches to the management of emergent bleeding and perforation.

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Pneumatic Dilation versus Laparoscopic Heller's Myotomy for Idiopathic Achalasia

Abstract: After 2 years of follow-up, LHM, as compared with pneumatic dilation, was not associated with superior rates of therapeutic success. (European Achalasia Trial Netherlands Trial Register number, NTR37, and Current Controlled Trials number, ISRCTN56304564.).

Cited by 752 publications

References 30 publications

Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

High Resolution Manometry - A Mandatory Examination in the Pre and Postoperative Assessment of Patients with Achalasia

Emergencies after endoscopic procedures

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