Joint Hospital Surgical Ground RoundApril 2014

Hwang Wan Wui WinstonQueen Elizabeth Hospital

Presentation Outline

Chicago Classification Scheme High Resolution Esophageal Pressure Topography

Achalasia Presentation Investigation Treatment

Chicago Classification Scheme High Resolution Esophageal Pressure Topography

Achalasia Presentation Investigation Treatment

The Chicago Classification

Investigators in the Northwestern University in Chicago developed a new classification scheme to facilitate the diagnosis of esophageal motility disorders by interpretation of high resolution esophageal pressure topography (EPT)

Esophageal pressure topography is a combination of high resolution manometry (HRM) and pressure topography

Esophageal Pressure Topography V.S. Conventional Manometry

The Chicago Classification

IRPIntegrated Relaxation Pressure

Each metric developed to characterize a specific feature of deglutitive esophageal function

Esophageal Pressure Topography V.S. Conventional Manometry

EPT allows more sophisticated interpretation of esophageal motility

The Chicago Classification

YES

YES

YES

NO

NO

IRP >= upper limit of normal AND absent

peristalsis

AchalasiaType I: ClassicType II: Pan-esophageal pressurizationType III: Spastic

IRP >= upper limit of normal AND some

instances of intact or weak peristalsis

EGJ Outflow ObstructionAchalasia variantMechanical obstruction

IRP is normal BUT abnormalities in other

metrics

Other Esophageal Motility DisordersDistal esophageal spasmHypercontractile esophagusAbsent peristalsisNutcracker esophagus

Chicago Classification Scheme High Resolution Esophageal Pressure Topography

Achalasia Presentation Investigation Treatment

Achalasia - Presentation

Dysphagia both liquid and solid

Regurgitation

Chest pain

Cough

Aspiration pneumonia

Weight loss

Achalasia - InvestigationsBarium Esophagogram

Classical “bird’s beak” appearance Dilated esophageal body

High Resolution Manometry

Esophagogastroduodenoscopy Rule out pseudoachalasia

Most common cause is malignancy infiltrating the EGJ

Achalasia – Type I (Classic Achalasia)

Mean IRP >= upper limit of normal (IRP =42mmHg)

100% failed peristalsis

Achalasia – Type II

Mean IRP >= upper limit of normal

No normal peristalsis

Panesophageal pressurization with >20% of swallows, which may exceed LES pressure, causing the esophagus to empty

Achalasia – Type III (Spastic Achalasia)

Mean IRP >= upper limit of normal

No normal peristalsis

Fragments of premature (spastic) distal contractions with 20% of swallows

Although this is also associated with rapidly propagated pressurization, the pressurization is attributable to an abnormal lumen obliterating contraction

Achalasia TreatmentPharmacological

Calcium channel blockers and nitrates short lived response side effects: headache, dizziness and

pedal edema

Botulin toxin injection prevents the release of acetylcholine

at terminal nerve endings results last 6-9 months. [1]

Pharmacological therapies are less effective than endoscopic or surgical therapies

[1] Pasricha PJ, Ravich WJ, Hendrix TR, Sostre S, Jones B, Kal- loo AN. Intrasphincteric botulinum toxin for the treatment of achalasia. N Engl J Med 1995; 332: 774-778

Achalasia TreatmentPneumatic Dilation

Aims at disrupting the LES by forceful dilation using air filled balloons

Many use a graded dilation protocol starting with 3.0 cm, then stepping up to 3.5cm and 4.0cm

Achalasia TreatmentPneumatic Dilation

Promising short term results

Long term follow-up showed recurrence

[1] Eckardt VF, Gockel I, Bernhard G. Pneumatic dilation for achalasia: late results of a prospective follow up investigation. Gut 2004; 53: 629-633 [2] Katsinelos P, Kountouras J, Paroutoglou G, Beltsis A, Zavos C, Papaziogas B, Mimidis K (2005) Long-term results of pneu- matic dilation for achalasia: a 15 years’ experience. World J Gastroenterol 11:5701–5705

Achalasia TreatmentLaparoscopic Heller’s Myotomy (LHM)

Myotomy from 1.5-3cm distal to the EGJ dividing the longitudinal and oblique muscle to 6-8cm proximal to the EGJ dividing longitudinal and circular muscle of esophagus

Partial fundoplication is routinely performed as incidence of reflux after Heller’s myotomy is >50%

Achalasia TreatmentLaparoscopic Heller’s Myotomy (LHM)

LHM considered superior to pneumatic dilation and the first choice of treatment for achalasia

Prospective trials have shown promising long term results of LHM

A prospective trial in Italy followed up 6 years after laparoscopic Heller-Dor operation [1] Primary outcome was therapeutic success in terms of

symptoms improvement At 6 years, 81.7% of patients still have significant

improvement in their symptoms

[1] Costantini M, Zaninotto G, Guirroli E, et al. The laparoscopic Heller-Dor operation remains an effective treatment for esophageal achalasia at a minimum 6-year follow-up. Surg Endosc 2005;19:345-51

Achalasia TreatmentLaparoscopic Heller’s Myotomy (LHM)

Multicenter RCT published by European Achalasia Trial group in 2011 [1] Primary outcome was therapeutic success, measured by

Eckardt score After 2 years of follow up, the study concluded LHM was not

superior to pneumatic dilation Limitations:

2 year cohort study with no evidence on intermediate and long-term remission rates

All patients in the PD group received 2 to 3 sessions of redilation

[1] Boeckxstaens GE, Annese V, des Varannes SB, Chaussade S, Costantini M, Cuttitta A, Elizalde JI, Fumagalli U, Gaudric M, Rohof WO, Smout AJ, Tack J, Zwinderman AH, Zaninotto G, Busch OR. Pneumatic dilation versus laparoscopic Heller’ s myotomy for idiopathic achalasia. N Engl J Med 2011; 364: 1807-1816

Achalasia Treatment in Different Subtypes

[1] Pandolfino JE, Kwiatek MA, Nealis T, Bulsiewicz W, Post J, Kahrilas PJ. Achalasia: a new clinically relevant classification by high-resolution manometry. Gastroenterology 2008;135:1526-1533.[2] Salvador R, Costantini M, Zaninotto G, et al. The preoperative manometric pattern predicts the outcome of surgical treatment for esophageal achalasia. J Gastrointest Surg 2010;14:1635–1645[3] Rohof WO, Salvador R, Annese V, et al. Outcomes of treatment for achalasia depend on manometric subtype. Gastroenterology 2013; 144:718–725

Peroral Endoscopic Myotomy (POEM)

Dissection of inner circular muscle layer of the esophagus

Dissection begins around 7cm proximal to EGJ and down to 2cm distal to EGJ

Good short-term results

Long-term results not available yet

Conclusion Pharmacological therapies are not recommended unless patient is

not fit for endoscopic or surgical therapies

Pneumatic dilation is the most effective nonsurgical treatment with promising short term results but high recurrence rate in the long term

Laparoscopic Heller’s myotomy should be advocated for patients fit for surgery

The Chicago Classification Scheme is providing a better classification for esophageal motility disorders. It has great impact on how we approach esophageal motility disorders, predict treatment outcomes and choose treatment options

Winston HwangQueen Elizabeth Hospital

References Goldblum JR, Rice TW, Richter JE. Histopathologic features in

esophagomyotomy specimens from patients with achala- sia. Gastroenterology 1996; 111: 648-654

Richter JE. Achalasia – An Update. J Neurogastroenterol Motil. Jul 2010; 16(3): 232–242

Boeckxstaens GE, etal. Achalasia. Lancet 2014; 383: 83-93

Stefanidis D, et al. SAGES guidelines of the surgical treatment of esophageal achalasia. Surg Endosc 2012; 26: 296-311