Achalasia – position of surgery in current management
Authors:
M. Stašek; Č. Neoral; R. Vrba; R. Aujeský; Dušan Klos
Authors‘ workplace:
1. chirurgická klinika Fakultní nemocnice Olomouc a Lékařské fakulty Univerzity Palackého v Olomouci
Published in:
Rozhl. Chir., 2022, roč. 101, č. 4, s. 148-153.
Category:
Review
doi:
https://doi.org/10.33699/PIS.2022.101.4.148–153
Overview
Oesophageal achalasia is a serious cause of dysphagia. Therapeutic options for achalasia include endoscopic and surgical methods. Indications for individual methods overlap to a certain extent and require careful diagnosis.
The review article describes individual methods, focusing particularly on the issues of indications of pneumatic dilatation, peroral endoscopic myotomy (POEM) and laparoscopic or robotic Heller’s myotomy. Special attention is paid to revision procedures after Heller’s myotomy. The main added value of POEM is the treatment of spastic disorders of the oesophagus and re-do myotomy.
Type 2 achalasia can be treated with dilatation, POEM and HM; type 1 achalasia can be treated using the same modalities. For type 3, POEM is the current method of choice. Despite the current emphasis on endoscopic myotomy, surgical therapy, especially laparoscopic or robotically assisted Heller’s myotomy, remains a safe therapeutic option. It is indicated especially in patients who are not suitable for endoscopic therapy or those with advanced achalasia findings.
In the future, identification of the risk of postoperative complications (perforation, reflux) should lead to differentiation of the indication of the laparoscopic (robotic) approach and POEM, or it may lead to a synchronous or metachronous indication of the cuff construction.
Keywords:
achalasia – laparoscopic Heller’s myotomy – peroral endoscopic myotomy – oesophageal reflux disease – oesophageal perforation
Sources
1. Heller E. Extramukose Kardiaplastik beim chronischen Kardiospasmus mit Dilatation des Oesophagus. Mitt Grenzgeb Med Chir. 1914;27:141–149.
2. Fisichella PM, Patti MG. From Heller to POEM (1914−2014): a 100-year history of surgery for achalasia. J Gastrointest Surg. 2014 Oct;18(10):1870−1875. doi:10.1007/ s11605-014-2547-8.
3. Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010 Apr;42(4):265−271. doi:10.1055/s-0029-1244080.
4. Weusten BLAM, Barret M, Bredenoord AJ, et al. Endoscopic management of gastrointestinal motility disorders – part 1: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2020 Jun;52(6):498−515. doi:10.1055/a-1160-5549. Erratum in: Endoscopy. 2020 Jun;52(6):C6.
5. Zaninotto G, Bennett C, Boeckxstaens G, et al. The 2018 ISDE achalasia guidelines. Dis Esophagus 2018 Sep 1;31(9). doi:10.1093/dote/doy071. PMID: 30169645.
6. Oude Nijhuis RAB, Zaninotto G, Roman S, et al. European guidelines on achalasia: United European Gastroenterology and European Society of Neurogastroenterology and Motility recommendations. United European Gastroenterol J. 2020;8(1):13−33. doi:10.1177/2050640620903213.
7. Herbella FAM, Patti MG. Laparoscopic Heller myotomy and fundoplication in patients with end-stage achalasia. World J Surg. 2015;39, 1631–1633. https://doi. org/10.1007/s00268-014-2940-1.
8. Herbella FAM, Del Grande LM, Schlottmann F, et al. Changes in the treatment of primary esophageal motility disorders imposed by the new classification for esophageal motility disorders on high resolution manometry (Chicago Classification 4.0). Adv Ther. 2021 May;38(5):2017−2026. doi:10.1007/ s12325-021-01714-w.
9. Kala Z, Dolina J, Kysela P, et al. Intraoperative manometry of the lower esophageal sphincter pressure during laparoscopic antireflux surgery with a mechanical calibration – early results. Hepatogastroenterology 2006 Sep-Oct;53(71):710−714. PMID: 17086874.
10. Mattioli S, Ruffato A, Lugaresi M, et al. Long-term results of the Heller-Dor operation with intraoperative manometry for the treatment of esophageal achalasia. J Thorac Cardiovasc Surg. 2010 Nov;140(5):962−969. doi:10.1016/j. jtcvs.2010.07.053.
11. Adikibi BT, MacKinlay GA, Munro FD, et al. Intraoperative upper GI endoscopy ensures an adequate laparoscopic Heller’s myotomy. J Laparoendosc Adv Surg Tech A. 2009 Oct;19(5):687−689. doi:10.1089/lap.2008.0156.
12. Di Martino N, Marano L, Torelli F, et al. The calibrated laparoscopic Heller myotomy with fundoplication. Ann Ital Chir. 2013 Sep-Oct;84(5):505−510. PMID: 24141279.
13. Kwiatek MA, Pandolfino JE, Hirano I, et al. Esophagogastric junction distensibility assessed with an endoscopic functional luminal imaging probe (EndoFLIP). Gastrointest Endosc. 2010 Aug;72(2):272−278. doi:10.1016/j. gie.2010.01.069.
14. Rohof WO, Hirsch DP, Kessing BF, et al. Efficacy of treatment for patients with achalasia depends on the distensibility of the esophagogastric junction. Gastroenterology 2012 Aug;143(2):328−335. doi:10.1053/j.gastro.2012.04.048.
15. Gelfond M, Rozen P, Gilat T. Isosorbide dinitrate and nifedipine treatment of achalasia: a clinical, manometric and radionuclide evaluation. Gastroenterology 1982 Nov;83(5):963−969. PMID: 6288509.
16. Boeckxstaens GE, Zaninotto G, Richter JE. Achalasia. Lancet 2014 Jan 4;383(9911):83−93. doi:10.1016/S0140- 6736(13)60651-0.
17. Moonen A, Annese V, Belmans A, et al. Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut 2016 May;65(5):732−739. doi:10.1136/gutjnl-2015-310602.
18. Pasricha PJ, Ravich WJ, Hendrix TR, et al. Intrasphincteric botulinum toxin for the treatment of achalasia. N Engl J Med. 1995; 332:774−778. doi:10.1056/ NEJM199503233321203.
19. Horgan S, Hudda K, Eubanks T, et al. Does botulinum toxin injection make esophagomyotomy a more difficult operation? Surg Endosc. 1999 Jun;13(6):576−579. doi:10.1007/s004649901044.
20. Sumiyama K, Gostout CJ, Rajan E, et al. Transesophageal mediastinoscopy by submucosal endoscopy with mucosal flap safety valve technique. Gastrointest Endosc. 2007 Apr;65(4):679−683. doi:10.1016/j.gie.2006.10.017.
21. Yoshizumi F, Yasuda K, Kawaguchi K, et al. Submucosal tunneling using endoscopic submucosal dissection for peritoneal access and closure in natural orifice transluminal endoscopic surgery: a porcine survival study. Endoscopy 2009 Aug;41(8):707−711. doi:10.1055/s-0029-1214959.
22. Pasricha PJ, Hawari R, Ahmed I, et al. Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy 2007 Sep;39(9):761−764. doi:10.1055/s-2007-966764.
23. Ngamruengphong S, von Rahden BH, Filser J, et al. Intraoperative measurement of esophagogastric junction cross-sectional area by impedance planimetry correlates with clinical outcomes of peroral endoscopic myotomy for achalasia: a multicenter study. Surg Endosc. 2016 Jul;30(7):2886−2894. doi:10.1007/ s00464-015-4574-2.
24. Bechara R, Onimaru M, Ikeda H, et al. Per-oral endoscopic myotomy, 1000 cases later: pearls, pitfalls, and practical considerations. Gastrointest Endosc. 2016 Aug;84(2):330−338. doi:10.1016/j. gie.2016.03.1469.
25. Ponds FA, Fockens P, Lei A, et al. Effect of peroral endoscopic myotomy vs pneumatic dilation on symptom severity and treatment outcomes among treatment-naive patients with achalasia: A randomized clinical trial. JAMA 2019 Jul 9;322(2):134−144. doi:10.1001/ jama.2019.8859.
26. Martinek J, Svecova H, Vackova Z, et al. Per-oral endoscopic myotomy (POEM): mid-term efficacy and safety. Surg Endosc. 2018 Mar;32(3):1293−1302. doi:10.1007/s00464-017-5807-3.
27. Akintoye E, Kumar N, Obaitan I, et al. Peroral endoscopic myotomy: a meta-analysis. Endoscopy 2016 Dec;48(12):1059−1068. doi:10.1055/s-0042-114426.
28. Zhang XC, Li QL, Xu MD, et al. Major perioperative adverse events of peroral endoscopic myotomy: a systematic 5-year analysis. Endoscopy 2016 Nov;48(11):967−978. doi:10.1055/s-0042-110397.
29. Campos GM, Vittinghoff E, Rabl C, et al. Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis. Ann Surg. 2009 Jan;249(1):45−57. doi:10.1097/ SLA.0b013e31818e43ab.
30. Horgan S, Galvani C, Gorodner MV, et al. Robotic-assisted Heller myotomy versus laparoscopic Heller myotomy for the treatment of esophageal achalasia: multicenter study. J Gastrointest Surg. 2005 Nov;9(8):1020−1029; discussion 1029−1030. doi:10.1016/j.gassur. 2005.06.026.
31. Melvin WS, Dundon JM, Talamini M, et al. Computer-enhanced robotic telesurgery minimizes esophageal perforation during Heller myotomy. Surgery 2005 Oct;138(4):553-8; discussion 558−559. doi:10.1016/j.surg.2005.07.025.
32. Chan SM, Wu JC, Teoh AY, et al. Comparison of early outcomes and quality of life after laparoscopic Heller’s cardiomyotomy to peroral endoscopic myotomy for treatment of achalasia. Dig Endosc. 2016 Jan;28(1):27−32. doi:10.1111/den.12507.
33. Kumbhari V, Tieu AH, Onimaru M, et al. Peroral endoscopic myotomy (POEM) vs laparoscopic Heller myotomy (LHM) for the treatment of type III achalasia in 75 patients: a multicenter comparative study. Endosc Int Open. 2015 Jun;3(3):E195−201. doi:10.1055/s-0034-1391668.
34. Zhang Y, Wang H, Chen X, et al. Per-oral endoscopic myotomy versus laparoscopic Heller myotomy for achalasia: A meta-analysis of nonrandomized comparative studies. Medicine (Baltimore) 2016;95(6):e2736. doi:10.1097/ MD.0000000000002736.
35. Schlottmann F, Luckett DJ, Fine J, et al. Laparoscopic Heller myotomy versus peroral endoscopic myotomy (POEM) for achalasia: A systematic review and meta-analysis. Ann Surg. 2018 Mar;267(3):451−460. doi:10.1097/ SLA.0000000000002311.
36. Rawlings A, Soper NJ, Oelschlager B, et al. Laparoscopic Dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomized-controlled trial. Surg Endosc. 2012 Jan;26(1):18−26. doi:10.1007/s00464-011-1822-y.
37. Stavropoulos SN, Desilets DJ, Fuchs KH, et al. Per-oral endoscopic myotomy white paper summary. White Paper Committee. Gastrointest Endosc. 2014 Jul;80(1):1−15. doi:10.1016/j.gie.2014.04.014.
38. Khoraki J, Campos GM, Alwatari Y, et al. Perioperative outcomes of inpatient laparoscopic Heller myotomy and peroral endoscopic myotomy in the United States. Surgery 2021 Nov;10:S0039- 6060(21)00979-X. doi:10.1016/j. surg.2021.10.019.
39. Werner YB, Hakanson B, Martinek J, et al. Endoscopic or surgical myotomy in patients with idiopathic achalasia. N Engl J Med. 2019 Dec 5;381(23):2219−2229. doi: 10.1056/NEJMoa1905380.
40. Inoue H, Ueno A, Shimamura Y, et al. Peroral endoscopic myotomy and fundoplication: a novel NOTES procedure. Endoscopy 2019 Feb;51(2):161−164. doi:10.1055/a-0820-2731.
41. Bapaye A, Dashatwar P, Dharamsi S, et al. Single-session endoscopic fundoplication after peroral endoscopic myotomy (POEM+F) for prevention of post gastroesophageal reflux – 1-year follow-up study. Endoscopy 2021 Nov;53(11):1114−1121. doi:10.1055/a-1332-5911.
42. Gouda BP, Nelson T, Bhoyrul S. Revisional surgery after Heller myotomy for treatment of achalasia: a comparative analysis focusing on operative approach. Indian J Surg. 2012;74(4):309−313. doi:10.1007/ s12262-011-0402-7.
43. Fernandez-Ananin S, Fernández AF, Balagué C, et al. What to do when Heller’s myotomy fails? Pneumatic dilatation, laparoscopic remyotomy or peroral endoscopic myotomy: A systematic review. J Minim Access Surg. 2018;14(3):177−184. doi:10.4103/jmas.JMAS_94_17.
44. Loviscek MF, Wright AS, Hinojosa MW, et al. Recurrent dysphagia after Heller myotomy: is esophagectomy always the answer? J Am Coll Surg. 2013 Apr;216(4):736−743; discussion 743–4. doi:10.1016/j.jamcollsurg.2012.12.008.
45. Fumagalli U, Rosati R, De Pascale S, et al. Repeated surgical or endoscopic myotomy for recurrent dysphagia in patients after previous myotomy for achalasia. J Gastrointest Surg. 2016 Mar;20(3):494−499. doi:10.1007/s11605-015-3031-9.
46. Devaney EJ, Lannettoni MD, Orringer MB, et al. Esophagectomy for achalasia: patient selection and clinical experience. Ann Thorac Surg. 2001 Sep;72(3):854−858. doi:10.1016/s0003- 4975(01)02890-9.
47. Rodgers M, Jobe BA, O’Rourke RW, et al. Case volume as a predictor of inpatient mortality after esophagectomy. Arch Surg. 2007 Sep;142(9):829−839. doi:10.1001/archsurg.142.9.829.
48. Dehn TC, Slater M, Trudgill NJ, et al. Laparoscopic stapled cardioplasty for failed treatment of achalasia. Br J Surg. 2012 Sep;99(9):1242−1245. doi:10.1002/ bjs.8816.
49. Agarwal AK, Javed A. Laparoscopic esophagogastroplasty: a minimally invasive alternative to esophagectomy in the surgical management of megaesophagus with axis deviation. Surg Endosc. 2013 Jun;27(6):2238−2242. doi:10.1007/ s00464-012-2751-0.
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