Surgical Options for Achalasia

Educational Objectives

The goal of this program is to improve the surgical care of patients with achalasia. After hearing and assimilating this program, the clinician will be better able to:

1. Compare peroral endoscopic myotomy with Heller myotomy in the treatment of patients with achalasia.

Summary

Diagnostic workup: endoscopy necessary to exclude mechanical obstruction; esophagography helpful for assessing tortuosity of esophagus, extent of dilation, and presence of diverticula; high resolution manometry establishes diagnosis and defines subtype of achalasia; esophagogastric outflow obstruction — characterized by hypertensive lower esophageal sphincter (LES); in selected patients, managed as with achalasia; type I achalasia — dilation of esophagus common; contractions absent; type II — ordered contractions absent; entire esophagus generates pressure on swallowing; type III — in addition to failure of LES to relax, characterized by spastic contractions

Options in management: medical therapy — eg, calcium channel blockers; limited to patients who cannot tolerate any procedure; botulinum toxin — injected endoscopically into 4 quadrants of LES; rate of improvement 75% at 4 wk; vast majority of patients require further injections (often in <6 mo); recommended in patients unable to tolerate other procedures, with life expectancy <2 yr, or with uncertain diagnosis; pneumatic dilation — sequential dilation to diameter of 30 to 40 mm; risk for perforation ≈3.6% (surgical exploration required in >50%)

Myotomy: peroral endoscopic myotomy (POEM) — introduced in United States in 2011; early publication comparing 64 patients undergoing Heller myotomy with 37 undergoing POEM found comparable results; randomized controlled trials lacking; meta-analysis found that POEM provides greater relief from dysphagia but with higher rates of reflux, esophagitis, and abnormal pH study; Heller myotomy — advantage lower risk for reflux; long-term results good (durability >90% at 5-yr follow-up); length of hospital stay longer than with POEM; because of fundoplication, revision challenging; POEM — relief from dysphagia superior; other advantages absence of incisions and performance as outpatient; disadvantages include difficulty in learning technique and need for unique endoscopic skill set; durability of POEM unknown, but data encouraging

Management of subtypes of achalasia: type II associated with rate of success of 96%; management of type I less successful because myotomy often insufficient to treat dilated esophagus; study of patients with type III achalasia reported rate of success of POEM 92% compared with 70% to 80% with Heller myotomy (POEM affords ability to perform full-length esophageal myotomy)

Algorithm: Heller myotomy recommended in patients with associated hiatal hernia; if other anatomic abnormalities requiring resection (eg, epiphrenic diverticulum) present, laparoscopic procedure favored; Heller recommended if concomitant procedures (eg, bariatric procedure) necessary; POEM favored in patients with type III achalasia, previous abdominal surgery, or previous Heller myotomy

Readings

Kahrilas PJ et al: Clinical Practice Update: the use of per-oral endoscopic myotomy in achalasia: expert review and best practice advice from the AGA Institute. Gastroenterology 2017 Nov;153(5):1205-1211; Schlottmann F 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; Patti MG et al: POEM vs laparoscopic Heller myotomy and fundoplication: which is now the gold standard for treatment of achalasia? J Gastrointest Surg 2017 Feb;21(2):207-214.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Shada was recorded at the 9th Annual Current Topics in General Surgery, presented by University of Wisconsin School of Medicine and Public Health, and held June 8-9, 2018, in Madison, WI. For information on the 10th Annual Current Topics in General Surgery, please visit med.wisc.edu. The Audio Digest Foundation thanks the speakers and the sponsor for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GS651702

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.