Surgical Treatment of Achalasia            Update  Foregut: Dysmotility from Mouth to Anus         SAGES Annual Meeting   ...
Conflict of Interest / Disclosure • No financial or other relationship with   any product or treatment discussed in   this...
Achalsia - Background         • First described in 1674 - food blockage              inside the esophagus         • Term A...
Achalsia - Epidemiology         • Incidence 0.03-1.0/100,000 per year         • Prevalence < 10/100,000         • Occurs a...
Achalasia - Etiology         • Unknown cause         • Destruction of myoenteric plexus               responsible for esop...
Achalasia - Diagnosis  • Dysphagia, regurgitation, chest pain  • EGD with normal mucosa (may see        some stasis change...
Achalasia - Treatment     Eliminate esophageal outflow restriction            • Safe            • Effective            • D...
Achalasia - Treatment         Pharmacologic           • Smooth muscle relaxation         Mechanical           • Botox     ...
Achalasia - Treatment Outcomes                                          Early     1 Year   Long-term                      ...
Achalasia - Surgery Controversies                         IssueChest or abdomen                         AbdomenExtent of m...
Achalasia - Surgical FailureSurgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012        11
Achalasia - Esophagogastric Myotomy • Adequate anterior      myotomy - 6 cm      proximal and 2-3 cm      distal (sling fi...
Treatment of Achalasia - StentingDiseases of the Esophagus (2010) 23, 361–367DOI: 10.1111/j.1442-2050.2010.01048.x        ...
Treatment of Achalasia - StentingDiseases of the Esophagus (2010) 23, 361–367DOI: 10.1111/j.1442-2050.2010.01048.x        ...
Treatment of Achalasia - Stenting                                         • Provocative concept                           ...
Treatment of Achalasia - POEM                                          Per-Oral                                         En...
Treatment of Achalasia - POEMSurgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012        17
Treatment of Achalasia - POEM                                         Stavropoulos                                        ...
Treatment of Achalasia - POEM                                         Swanstrom - JACS 2011                               ...
Treatment of Achalasia - POEMSurgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012        20
Treatment of Achalasia - POEM                                         Inoue - Endoscopy 2010 (n=17)                       ...
Treatment of Achalasia - POEM                                         • Promising new                                     ...
Two Predictors of Outcome                                Patient Selection                         Operative TechniqueSurg...
Surgical Treatment of Achalasia            Update  Foregut: Dysmotility from Mouth to Anus         SAGES Annual Meeting   ...
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Achalasia Surgery Update 2012

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Recent presentation during SAGES 2012 Annual meeting. Update includes new data related to POEM and stunting as novel new treatments for achalasia.

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Achalasia Surgery Update 2012

  1. 1. Surgical Treatment of Achalasia Update Foregut: Dysmotility from Mouth to Anus SAGES Annual Meeting March 7, 2012 San Diego, CA C. Daniel Smith, MD, FACS 1
  2. 2. Conflict of Interest / Disclosure • No financial or other relationship with any product or treatment discussed in this talkSurgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012 2
  3. 3. Achalsia - Background • First described in 1674 - food blockage inside the esophagus • Term Achalasia coined in 1927 by Arthur Hunt - Greek for lack of relaxationSurgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012 3
  4. 4. Achalsia - Epidemiology • Incidence 0.03-1.0/100,000 per year • Prevalence < 10/100,000 • Occurs at any age • Peak incidence 20-30 years and 60-70 yearsSurgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012 4
  5. 5. Achalasia - Etiology • Unknown cause • Destruction of myoenteric plexus responsible for esophageal peristalsis and normal LES function • Possibly related to inflammatory or autoimmune processSurgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012 5
  6. 6. Achalasia - Diagnosis • Dysphagia, regurgitation, chest pain • EGD with normal mucosa (may see some stasis changes) - “pop” • Classic contrast swallow - birds beak • EMS - absent peristalsis and non- relaxing LESSurgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012 6
  7. 7. Achalasia - Treatment Eliminate esophageal outflow restriction • Safe • Effective • Durable • Limit side effectsSurgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012 7
  8. 8. Achalasia - Treatment Pharmacologic • Smooth muscle relaxation Mechanical • Botox • Pneumatic dilation • Cardioesophageal myotomySurgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012 8
  9. 9. Achalasia - Treatment Outcomes Early 1 Year Long-term Success Success Success Botox 80% 50% <20% Dilation 80% 50% <20% Myotomy 98% 95% 92%Surgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012 9
  10. 10. Achalasia - Surgery Controversies IssueChest or abdomen AbdomenExtent of myotomy 2-3 below GEJ (sling fibers)Wrap or not WrapToupet or Dor ToupetPostop or intraop test Intraop preferrably with EGDSurgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012 10
  11. 11. Achalasia - Surgical FailureSurgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012 11
  12. 12. Achalasia - Esophagogastric Myotomy • Adequate anterior myotomy - 6 cm proximal and 2-3 cm distal (sling fibers) • Intraoperative endoscopic assessment - adequacy and mucosal integrity • Accompanying antireflux procedure - partial wrapSurgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012 12
  13. 13. Treatment of Achalasia - StentingDiseases of the Esophagus (2010) 23, 361–367DOI: 10.1111/j.1442-2050.2010.01048.x • PRCT • 155 patients • Stent in place for 4-5 days • Patients followed at 6 month intervals Surgical Rx Achalasia. Foregut PG CRS. SAGES Annual Meeting. Mar 7, 2012 13
  14. 14. Treatment of Achalasia - StentingDiseases of the Esophagus (2010) 23, 361–367DOI: 10.1111/j.1442-2050.2010.01048.x stent 92% success pneumatic dilation 66% success Surgical Rx Achalasia. Foregut PG CRS. SAGES Annual Meeting. Mar 7, 2012 14
  15. 15. Treatment of Achalasia - Stenting • Provocative concept • China only stent • Results too good to be true? • Difficult to reproduce in US with current stents availableSurgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012 15
  16. 16. Treatment of Achalasia - POEM Per-Oral Endoscopic MyotomySurgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012 16
  17. 17. Treatment of Achalasia - POEMSurgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012 17
  18. 18. Treatment of Achalasia - POEM Stavropoulos n 12 Op time 150 min Myotomy length 5.5 cm LOS 2.2 F/U 9.5 mon Success 11/12Surgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012 18
  19. 19. Treatment of Achalasia - POEM Swanstrom - JACS 2011 n 18 Op time 156 min Myotomy length 9 cm LOS 1.1 F/U 6 months Success all improvedSurgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012 19
  20. 20. Treatment of Achalasia - POEMSurgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012 20
  21. 21. Treatment of Achalasia - POEM Inoue - Endoscopy 2010 (n=17) Inoue - DDW n 100 Op time 113 min Myotomy length 14 cm LOS 5.9 F/U short-term Success “good”Surgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012 21
  22. 22. Treatment of Achalasia - POEM • Promising new technique • Gaining traction at select centers • ? advantages over existing surgical myotomy • ? controlling GERDSurgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012 22
  23. 23. Two Predictors of Outcome Patient Selection Operative TechniqueSurgical Rx Achalasia. Foregut PG CRS.SAGES Annual Meeting. Mar 7, 2012 23
  24. 24. Surgical Treatment of Achalasia Update Foregut: Dysmotility from Mouth to Anus SAGES Annual Meeting March 7, 2012 San Diego, CA C. Daniel Smith, MD, FACS 24

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