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Achalasia
- 1. ACHALASIA CARDIA- TREATMENT OPTIONS : BALLOON, KNIFE OR POEM DR SABU KG PARIYARAM MEDICAL COLLEGE
- 4. Pathogenesis
- 7. Barium
- 9. Endoscopy
- 12. High resololution manometry Type I Type 3Type 2
- 14. Endo FLIP
- 15. Endo FLIP
- 17. • Transient effect on LES – results suboptimal • Sublingual nitrate – best result • Advantage – low cost & less complications • Drawback – tachyphylaxis • Overall poor efficacy • Bridge to definitive therapy or on demand for chestpain
- 19. • When to inject? • Where to inject? • How much to inject? • Frequency of injection
- 20. • Clinical response at 1month – 75%-93%, at 1 yr – 25%-60% • Side effects – transient – heartburn, chestpain, epigastric pain
- 22. Technique • No clear consensus on optimal method • Diameter of balloon -30,35,40mm • Fluoroscopic/endoscopic guidance • Pressure – 7-15psi • Rate of balloon inflation • Duration of balloon inflation • No of balloon inflation per session
- 23. Efficacy in large trials
- 24. Predictors of relapse • Male sex • Age <40 • Dilated esophagus • Poor esophageal emptying on TBE • Type 3 achalasia
- 25. Pneumatic dilation Vs LHM
- 29. European achalasia trial Moonen A, Annese V, Belmans A, et al, Gut 2016 LHM PD
- 31. POEM • Recent addition to endoscopic armamentarium • Minimally invasive technique • Inoue etal 2010 – endoscopic alternative to Heller’s
- 32. Prerequisites • 24hr fasting, esophagus to be clean • Broad spectrum antibiotics • Supine position under GA • Co2 insufflation – 1.2l/min
- 33. 1.Mucosal entry
- 35. 3.Endoscopic myotomy of circular muscle
- 36. 4.Closure of mucosal entry
- 37. Post-op care • NPO for 24hrs • Dye study on Day2 • OGD on Day2 • Soft diet on Day2 • IV antibiotics for 3 days. Discharge on Day3 • Functional evaluation at 3months
- 38. Outcome
- 39. LHM vs POEM – Meta-analysis POEMLHM
- 40. GERD symptoms post LHM & POEM
- 41. Advantages of POEM over Heller’s • Less blood loss • Shorter operating time • Less post-op pain and analgesic use • Shorter hospital stay • Cost Tailor myotomy according to the need of patient
- 44. 3 concerns • Post procedure reflux • Durability of response • Learning curve
- 45. Can HRM predict treatment outcome?
- 46. TYPE 2 Vs TYPE 1
- 47. TYPE 3 VS TYPE 1
- 50. summary • Rare primary esophageal motility disorder • Paradigm shift in diagnosis and management • Medical management is ineffective • PD is as effective as LHM in type 1&2 achalasia • POEM represents a major advance in treatment of achalasia • POEM may become the treatment of choice for achalasia in future
Editor's Notes
- Pseudoachalasia 2-4%. normal EGD should not dissuade a clinician from making the diagnosis because up to 40% of patients with achalasia will have normal endoscopy
- Multicenter trial across eurpe 200 patients – 100 in each group. 14 centres, 5 countries
- Scholttman etal – 53 studies(5800 patients) on LHM Vs 21 articles of POEM(1900 patients) – ANNALS OF SURGERY 2017
- GERD symptoms – 11% LHM vs 47% POEM
- Endoscopy int 2015
- 9 studies, 290 patients