SAGES guidelines for the surgical treatment of esophageal achalasia

Abstract

PreambleThe guidelines for the surgical treatment of esophageal achalasia are a series of systematically developed statements to assist surgeon (and patient) decisions about the appropriate use of minimally invasive techniques for the treatment of achalasia in specific clinical circumstances. It addresses the indications, risks, benefits, outcomes, alternatives, and controversies of the procedures used to treat this condition. The statements included in this guideline are the product of a systematic review of published work on the topic, and the recommendations are explicitly linked to the supporting evidence. The strengths and weaknesses of the available evidence are highlighted, and expert opinion is sought where published evidence lacks depth. DisclaimerClinical practice guidelines are intended to indicate the best available approach to medical conditions as established by a systematic review of available data and expert opinion. The approach suggested may not necessarily be the only acceptable approach given the complexity of the healthcare environment. These guidelines are intended to be flexible, because the surgeon must always choose the approach best suited to the individual patient and variables in existence at the moment of decision. These guidelines are applicable to all physicians who are appropriately credentialed and address the clinical situation in question, regardless of specialty.Guidelines are developed under the auspices of SAGES-the guidelines committee-and are approved by the Board of Governors. The recommendations of each guideline undergo multidisciplinary review and are considered valid at the time of production based on the data available. New developments in medical research and practice pertinent to each guideline are reviewed, and guidelines will be periodically updated. Literature review methodA systematic literature search was performed on MED-LINE in October 2010. The search strategy was limited to adult English language articles and is shown in Fig. 1.We identified 214 relevant articles. The abstracts were reviewed by four committee members (DS, WR, TMF, and GPK) and divided into the following categories:(a) Randomized studies, meta-analyses, and systematic reviews and Other Interventional Techniques (b) Prospective studies (c) Retrospective studies (d) Case reports (e) Review articlesRandomized controlled trials, meta-analyses, and systematic reviews were selected for further review along with prospective and retrospective studies that included at least 50 patients. Studies with smaller samples were considered when additional evidence was lacking. The most recent reviews also were included. All case reports, old reviews, and smaller studies were excluded. According to these exclusion criteria, 102 articles were selected for review. Whenever the available evidence from Level I studies was considered to be adequate, lower evidence level studies were not considered.The reviewers graded the level of evidence and manually searched the bibliography of each article for additional articl...

Is Heller Myotomy Better than Balloon Dilation? A Meta-Analysis

“…The combination of myotomy with a partial fundoplication decreases, but does not completely eliminate the risk of GERD. Recently published guidelines from both gastroenterology and surgical societies recommend an antireflux procedure along with myotomy [10,34]. A prospective randomized trial [35] evidenced a pathological GERD rate of 47.6 % in the group with Heller myotomy without antireflux procedure compared to a 9.1% in the group with Heller myotomy followed by anterior fundoplication.…”

“…Endoscopic balloon dilation (EBD) of the LES is the most effective non-surgical endoscopic treatment for achalasia [10]. Pneumatic dilation was the first attempt in the treatment of esophageal achalasia.…”

The impact of flexible endoscopy in esophageal surgery

“…In patients who have undergone a Heller myotomy, a new myotomy on the anterior face is subject to a high risk of mucosal opening with the possible complications that this entails. POEM performed in hour 7 (posterior face), eliminates this risk and adds the possibility of a better myotomy (5). This is probably the clearest and most relevant indication for this method.…”

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

“…Pneumatic dilation (PD) is an effective nonsurgical treatment for achalasia (34). The procedure is performed under sedation and fluoroscopic guidance.…”