Achalasia
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This document discusses treatment options for achalasia including balloon dilation, pneumatic dilation, and peroral endoscopic myotomy (POEM). It provides details on each procedure such as efficacy, outcomes, advantages, and concerns. Pneumatic dilation and POEM are shown to be effective treatments for achalasia, especially type 1 and 2, with POEM representing a major advance and potential future treatment of choice due to benefits like smaller incisions and shorter recovery time compared to traditional surgery.
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This document discusses Achalasia, a primary motor disorder of the esophagus characterized by failure of the lower esophageal sphincter to relax during swallowing and loss of peristalsis in the esophageal body. It covers the pathophysiology, classification, clinical presentation, diagnostic tests including manometry, and treatment options for Achalasia such as botulinum toxin injection, pneumatic dilation, Heller's myotomy, and POEM. It also discusses other esophageal motility disorders like DES, jackhammer esophagus, hypertensive LES, and IEM and their associated symptoms, diagnostic findings, and treatment approaches.
Achalasia
This document provides information about Achalasia, including its pathophysiology, symptoms, diagnosis, and treatment options. Achalasia is caused by the loss of inhibitory neurons in the esophagus which leads to failure of the lower esophageal sphincter to relax during swallowing. Patients experience symptoms of dysphagia and regurgitation. Diagnosis involves barium swallow, esophageal manometry, and endoscopy. Treatment options include medications, balloon dilation, botulinum toxin injection, and surgical myotomy, with the goal of weakening the lower esophageal sphincter to improve swallowing.
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This document provides an overview of peroral endoscopic myotomy (POEM) for the treatment of achalasia. POEM is a minimally invasive endoscopic procedure that involves cutting the circular muscle layer of the lower esophageal sphincter through a submucosal tunnel. The procedure was first performed in humans in 2008 and involves creating a mucosal entry point, tunneling in the submucosal plane, performing a circular myotomy, and closing the mucosal entry point. POEM has been shown to be as effective as laparoscopic Heller myotomy with benefits of being less invasive with shorter hospital stays and no external scars. Complications are generally minor but include mucosal injuries and
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Achalasia
This document provides information about Achalasia, including its pathophysiology, symptoms, diagnosis, and treatment options. Achalasia is caused by the loss of inhibitory neurons in the esophagus which leads to failure of the lower esophageal sphincter to relax during swallowing. Patients experience symptoms of dysphagia and regurgitation. Diagnosis involves barium swallow, esophageal manometry, and endoscopy. Treatment options include medications, balloon dilation, botulinum toxin injection, and surgical myotomy, with the goal of weakening the lower esophageal sphincter to improve swallowing.
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It is the terminology used for perforation of duodenal ulcer or gastric ulcer or stomal ulcer.
Otherwise all clinical features and management are similar.
Perforation is common in duodenal ulcer
Mortality is more in gastric ulcer perforation and perforation in elderly
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The document discusses endotherapy options for achalasia, including pneumatic dilation (PD), botulinum toxin injection (BTI), and per oral endoscopic myotomy (POEM). It summarizes that PD and surgery were traditionally used but have limitations. BTI provides short-term relief. POEM is a novel promising technique where an endoscopic myotomy is performed via an internal incision, with efficacy similar to surgery but potential advantages like less reflux. Overall PD remains an effective option for achalasia treatment, though repeated sessions are often needed for long-term remission.
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Peroral endoscopic myotomy
This document provides an overview of peroral endoscopic myotomy (POEM) for the treatment of achalasia. POEM is a minimally invasive endoscopic procedure that involves cutting the circular muscle layer of the lower esophageal sphincter through a submucosal tunnel. The procedure was first performed in humans in 2008 and involves creating a mucosal entry point, tunneling in the submucosal plane, performing a circular myotomy, and closing the mucosal entry point. POEM has been shown to be as effective as laparoscopic Heller myotomy with benefits of being less invasive with shorter hospital stays and no external scars. Complications are generally minor but include mucosal injuries and
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This document discusses achalasia, including its etiology, clinical presentation, diagnosis, and management. It provides a historical overview and describes the current understanding of achalasia as aperistalsis of the esophageal body and incomplete relaxation of the lower esophageal sphincter due to degeneration of inhibitory neurons. For diagnosis, it recommends high resolution manometry, barium swallow, and endoscopy. The standard treatment is described as laparoscopic Heller myotomy with partial fundoplication to prevent reflux, with options for medical management, pneumatic dilation, or injection of botulinum toxin as alternatives. Complications and approaches for managing treatment failure are also outlined.
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1. Performing intraoperative cholangiography to identify stones
2. Making an incision in the bile duct and extracting stones using forceps, balloons, or baskets
3. Placing a T-tube for drainage and performing a follow up cholangiogram to ensure clearance
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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