Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... ·...
Transcript of Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... ·...
![Page 1: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/1.jpg)
Management of the Difficult Patient
with Type 3 Achalasia
Steven R. DeMeester
Professor and Clinical Scholar
Department of Surgery
![Page 2: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/2.jpg)
Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of
peristalsis in the esophageal body
• Treatment aimed at relief of outflow obstruction at
LES
• No treatment restores function of LES
• All therapies move obstructed LES toward open
LES (from dysphagia toward GERD)
GERD Outflow
obstruction
Low High Efficacy and Invasiveness
Botox PD (single) Lap HM+Dor
![Page 3: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/3.jpg)
HRM Subtypes of Achalasia
I II
III
![Page 4: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/4.jpg)
HRM and Outcome
Rohof WO, et al. Gastro, 2013
![Page 5: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/5.jpg)
HRM and Outcome
Rohof WO, et al. Gastro, 2013
![Page 6: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/6.jpg)
Type I (n=10) Type II (n=30) Type III (n=9) p value
Operation
- Heller Myotomy with Fundoplication
- POEM
9 (90%)
1 (10%)
23 (77%)
7 (23%)
7 (78%)
2 (22%)
0.49
Resolution of Dysphagia 8 (80%) 28 (93%) 8 (89%) 0.71
Post-operative reflux 2 (20%) 6 (20%) 1 (11%) 0.73
Post-Op Eckardt Score
Eckardt score of Zero (Asymptomatic)
1 (0-1)
40%
0 (0-1)
57%
0 (0-1)
78%
0.43
0.18
Post-Op Timed Barium: @ 1 min
- 100% Clearance
- >75% Clearance
(n=7)
0 (0%)
2 (29%)
(n=27)
15 (55%)
22 (81%)
(n=6)
5 (83%)
6 (100%)
0.18
0.49
Post-Op Timed Barium: @ 5 min
- 100% Clearance
- >75% Clearance
(n=7)
1 (14%)
3 (43%)
(n=27)
17(63%)
24 (89%)
(n=6)
6 (100%)
6 (100%)
0.16
0.77
Greene CL, et al. Surg Endosc, 2014
High resolution manometry sub-classification of Achalasia: Does it really matter?
Christina L. Greene, Erica J. Chang, Daniel S. Oh , Stephanie G. Worrell, Jeffrey A. Hagen,
Steven R. DeMeester
![Page 7: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/7.jpg)
Type III Achalasia Pre-POEM
![Page 8: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/8.jpg)
Achalasia Type III Post-POEM
![Page 9: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/9.jpg)
Major Differences POEM versus
Laparoscopic Myotomy and Dor
• No disruption of phreno-esophageal ligament
• Division of clasp fibers rather than sling fibers at GEJ and in cardia
• Myotomy is longer, extends further up into mediastinum, but preservation of longitudinal fibers may prevent or minimize thoracic diverticulum that often develops after standard myotomy
![Page 10: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/10.jpg)
POEM Versus Lap Heller Myotomy
• 2 papers, both retrospective
• Portland (Bhayani NH, et al. Ann Surg, 2014) • 64 LHM with partial fundoplication
• 37 POEM (prior achalasia treatment okay) – 2007-9: 48 LHM
– 2010: 14 LHM and 5 POEM
– 2011: 2 LHM and 16 POEM
– 2012: 0 LHM and 16 POEM
• Northwestern (Hungness ES, et al. J Gastrointest Surg, 2013)
• August 2010-May 2012 – 55 LHM with partial fundoplication
– 18 POEM (no prior treatment for achalasia both groups)
![Page 11: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/11.jpg)
POEM vs LHM and Partial Fundoplication
Bhayani NH, et al. Ann Surg, 2014
![Page 12: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/12.jpg)
POEM vs LHM and Partial Fundoplication
Bhayani NH, et al. Ann Surg, 2014
![Page 13: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/13.jpg)
POEM vs LHM and Partial Fundoplication
Bhayani NH, et al. Ann Surg, 2014
32% vs 39%
![Page 14: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/14.jpg)
POEM vs LHM and Partial Fundoplication
Hungness ES, et al. J Gastrointest Surg, 2013
![Page 15: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/15.jpg)
Hungness ES, et al. J Gastrointest Surg, 2013
POEM vs LHM and Partial Fundoplication
![Page 16: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/16.jpg)
POEM: A Viable Option?
• 1. Must be safe
• 2. Must produce similar results (or better) than
existing options, preferably with additional
benefits
• 3. Morbidity should be similar or better than
existing options
• 4. Results must be reproducible at multiple
centers
• 5. Patients want it
5 requirements
![Page 17: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/17.jpg)
POEM: Safety • First human procedure in Sept 2008
• Worldwide over 1200 procedures performed
• Single center reports and recent multi-center prospective study
• No reported mortality
• Surprisingly little morbidity for new procedure
• Capnoperitoneum, capnomediastinum, capnothorax
• Injury to mucosa overlying tunnel
• Post-operative tunnel hemorrhage (1/119; 0.8%)
Ren Z, et al. Surg Endosc, 2012
Swanstrom LL, et al. Ann Surg, 2012
![Page 18: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/18.jpg)
POEM: Efficacy Eckardt Symptom Score
0
1
2
3
4
5
6
7
8
9
10
1 2
Series1
Series2
Series3
Series4
Series5
Series6
Series7
1. Swanstrom LL, et al. Ann Surg, 2012; 2. Bhayani NH, et al. Ann Surg, 2014;
3. Costamagna G, et al. Dig Liver Dis, 2012; 4. von Rentein D, et al. Am J Gastro, 2012;
5. Hungness ES, et al. J Gastrointest Surg, 2012; 6 and 7. Li Q, et al. J Am Coll Surg, 2013
Pre-POEM Post-POEM
n=452
![Page 19: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/19.jpg)
POEM: Efficacy
0
5
10
15
20
25
30
35
40
45
50
1 2 3 4 5 6 7
LES Resting Pressure
mmHg
1 2 3 4 5 6 7
1. Swanstrom LL, et al. Ann Surg, 2012; 2. Bhayani NH, et al. Ann Surg, 2014;
3. Costamagna G, et al. Dig Liver Dis, 2012; 4. von Rentein D, et al. Am J Gastro, 2012;
5. Hungness ES, et al. J Gastrointest Surg, 2012; 6 and 7. Li Q, et al. J Am Coll Surg, 2013
n=452
![Page 20: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/20.jpg)
POEM: Efficacy
TBS, 5 minutes
Pre: 48%
Post: 100%
Swanstrom LL, et al. Ann Surg, 2012
![Page 21: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/21.jpg)
POEM: Efficacy
Hungness ES, et al.
J Gastrointest Surg, 2013
![Page 22: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/22.jpg)
POEM: Efficacy
• 70 patients from 5 centers in Europe and Canada
• Mean follow-up 10 months
Multi-institutional prospective study
0
1
2
3
4
5
6
7
8
1 2 3
Eckhardt score
Pre 6 mo 12 mo
Manometry
61/70 patients
at 3 months:
LESP pre=28
post=9 mmHg
Von Renteln D, et al. Gastro, 2013
![Page 23: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/23.jpg)
POEM: Efficacy Multi-institutional prospective study
Von Renteln D, et al. Gastro, 2013
![Page 24: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/24.jpg)
POEM: Efficacy
• Follow-up limited (under 2 years) in
published series thus far
• Improvements in dysphagia and
regurgitation persist up to 18 months [1]
• Treatment failure reported in 11 patients
(11/452; 2.4%), 6 successfully treated with
balloon dilatation
1. Swanstrom LL, et al. Ann Surg, 2012; 2. Bhayani NH, et al. Ann Surg, 2014;
3. Costamagna G, et al. Dig Liver Dis, 2012; 4. von Rentein D, et al. Am J Gastro, 2012;
5. Hungness ES, et al. J Gastrointest Surg, 2012; 6 and 7. Li Q, et al. J Am Coll Surg, 2013
![Page 25: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/25.jpg)
POEM: Morbidity
• Literature summary
• Capnoperitoneum requiring decompression: 5-10% (higher without CO2)
• Mucosal injury during tunnel creation: 10%
• Full-thickness esophageal injury (biliary balloon dissection): 5-10%
• Bleeding in tunnel: 5%
• Leak in closure: rare
Von Renteln D, et al. Gastro, 2013
![Page 26: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/26.jpg)
POEM: Morbidity
• Reflux
• Symptoms: 33% [1], 0 [3], 0 [4], 22% [5], 17%
[6 and 7] Overall: 16.5%
• pH studies: 6/13 positive: 46% [1]
• Esophagitis: 4/14: 28% [1], 0/10 [3], 1/16: 6%
[4], 5/15: 33% [5], 20/234: 8.5% [6 and 7]
Overall: 10.3%
1. Swanstrom LL, et al. Ann Surg, 2012; 2. Bhayani NH, et al. Ann Surg, 2014;
3. Costamagna G, et al. Dig Liver Dis, 2012; 4. von Rentein D, et al. Am J Gastro, 2012;
5. Hungness ES, et al. J Gastrointest Surg, 2012; 6 and 7. Li Q, et al. J Am Coll Surg, 2013
![Page 27: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/27.jpg)
POEM: GERD
Von Renteln D, et al. Gastro, 2013
![Page 28: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/28.jpg)
POEM in Perspective • Treatment failure with Heller myotomy and partial
fundoplication (Kilic A, et al. Surgery, 2009)
• 46 patients, mean follow-up 6.4 years
• 9 patients (20%) with failure
• Mean time to recurrence was 21.3 months
• Reflux is a problem after Heller myotomy even with
partial fundoplication (Multi-center RCT)
6-12 months post-op
Rawlings A,
et al. Surg
Endosc, 2012
![Page 29: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/29.jpg)
POEM in Perspective • Late failures after Heller myotomy are largely due to reflux
7-10 10-20 >20
Years post-op Csendes A, et al. Ann Surg, 2006
![Page 30: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/30.jpg)
• 331 patients treated with achalasia balloon dilatation
• Mean follow-up 6 years
• 34% developed esophagitis
• 8.4% Barrett’s
• 28% in those with hiatal hernia, 2% in those without hiatal hernia
• 4% cancer: 12 squamous and 2 adenocarcinoma
![Page 31: Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis](https://reader031.fdocuments.us/reader031/viewer/2022022513/5aef14bb7f8b9aa9168c0f6b/html5/thumbnails/31.jpg)
Conclusion: POEM is a Viable Option!
• POEM achieves the short-term requirements to stay as a therapy for achalasia
• Safe
• Effectively alleviates symptoms • Short-term results are equal or better than LHM
• Minimal complications • Peri-op complications similar or less than LHM
• GERD not dissimilar to LHM
• Reproducible results at multiple centers
• Results do not seem to depend on HRM subtype
• Many patients prefer it over LHM and seek out a center where it can be performed