Achalasia cardia-Where do we stand

1. Endotherapy in achalasia –
Where do we stand
Dr.Vadivel Kumaran.S.,M.D.,D.M(Gastro)
Consultant Medical Gastroenterologist
Kauvery Hospital
Chennai

2. Achalasia
• Achalasia is derived from Greek
(α = non, χαλασια = relaxation).
• HRM -manometric subtyping predicts response to treatment.
• Drug therapy for achalasia is not effective.
• The traditional- surgical myotomy and endoscopic methods that
disrupt or weaken the LES.
o [ pneumatic dilation (PD) and botulinum toxin injection (BTI)].
• Per oral endoscopic myotomy (POEM), a novel endoscopic therapy
that allows performance of myotomy via an endoscopic approach.

3. Suggested algorithm for the treatment of achalasia.
Richter J E , and Boeckxstaens G E Gut 2011;60:869-876
Copyright © BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved.

4. Pneumatic
dilation
Surgical myotomy Botulinum toxin
Ease of technique ∗∗ ∗ ∗∗∗
Duration of effect ∗∗ ∗∗∗ ∗
Safety ∗∗ ∗∗ ∗∗∗
Cost ∗∗ ∗ ∗∗
Easy return to
work
∗∗∗ ∗ ∗∗∗
Success in
vigorous achalasia
∗ ∗∗ ∗∗∗
Success in
pediatric patients
∗∗ ∗∗∗ ∗
Success in elderly
patients
∗∗∗ ∗∗∗ ∗∗

5. Pneumatic dilation
• 17th century - whalebone was employed as a primitive
bougie to achieve disruption of the sphincter [Spiess and
Kahrilas, 1998] .

6. Endoscopy
• An antecedent endoscopy excludes intraluminal
malignancy, ensures esophageal clearance.
• Gauges the anatomy in terms of esophageal angulation,
hiatus hernia and epiphrenic diverticula.

7. Rigiflex pneumatic dilation
balloons
(Boston Scientific )

8. Procedure
• No single, accented standard method for balloon dilation.
• Start with the 30 mm balloon and progress serially to the
35 mm and 40 mm balloons.
• Risk of perforation may be less with the smallest balloon.
• Performed under fluoroscopic guidance utilizing a
stiff guidewire with a soft distal tip that is placed using
endoscope.

9. Pneumatic Dilatation

10. X-ray images showing the Rigiflex balloon (dotted lines) positioned across the
oesophagogastric junction.
Richter J E , and Boeckxstaens G E Gut 2011;60:869-876
Copyright © BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved.

11. Efficacy of PD
• Over 20 retrospective and prospective studies analyzed the
efficacy of P.D. using the Rigiflex balloon dilator
• [Walzer and Hirano, 2008].
• General consensus - single successful dilation may have an
efficacy duration of several years
• Patients typically require serial dilations to remain in remission.
• Eckardt et al. 2004 - 5-year response of 40% with a single
dilation.
• Parkman et al. 1993 - 3 dilations maintained remission in 90%
of patients over 5 years.
• Zerbid et al. 2006 - 97% and 93% efficacy over 5 and 10 years
respectively with serial dilations.

12. Assessment of success
• ECKARDT SCORE
• Decrease in esophageal LES pressure via manometry, and
a decrease in esophageal diameter on a barium
esophagram [Gockel et al. 2005].

13. Timed barium esophagram
The height of the barium column at 1 min on timed barium esophagram after PD or
Heller myotomy has been found to be a reliable predictor of long-term response
[Andersson et al. 2009)
Ingestion of 50-100 ml of barium with plain
thoracic radiographs taken at 1, 2 and 5 minutes.

14. Predictors of response
• Patient – associated factors.
• Response rates in younger patients are relatively lower
• Exact cut-off age – 40 to 60 yrs.
• Eckhardt et al. 2004; Howard et al. 2010.
• Technique – associated factors
• Use of the 30 mm balloon as opposed to the larger sizes was associated
with PD failure for younger male patients.
• Dobrucali et al. 2004; Wong, 2006.
• Response - Type I and Type II achalasia > Type III achalasia
• Pretap et al. 2011.
• Failure to lower the LES pressure significantly (<10 mmHg) is
associated with a poor outcome.
• Hulselmans et al. 2010; Ghoshal et al. 2012.

15. PD vs surgical myotomy
• Spiess and Kahrilas, 1998; Richter, 2008, Gockel 2005 &
Hulselmans et al. 2010 – few prospective RCTs done.
• Both options result in excellent initial relief of dysphagia.
• Surgery was shown to be superior at longer follow up.
• PD fares poorly in diminishing chest pain.
• Better LES pressure reduction was seen with surgery.
• Need for repeat intervention was greater with PD.
• Older trials had PD performed with outmoded dilation
balloons and surgical techniques were not refined.

16. Sentinel study
Rigorous prospective randomized controlled study design:2011

17. Results
• Mean follow-up duration was 43 months.
• At 1 year - No difference between the groups in terms of
dysphagia and overall Eckardt score.
• At 2 years - No significant difference in terms of LES
pressure, esophageal emptying as assessed by timed
barium esophagram, or quality of life as assessed by
standard questionnaire.
• CONCLUSION
• PD remains a time tested effective modality in the
achalasia treatment armamentarium

18. BOTOX
• BTI yields good short-term results.
• effect wanes within 2 years of the last injection
• benefit of injection will be minimal even if repeated.
• waning effect may be due to regional fibrosis or antibodies
to the toxin.
• BTI is best reserved for infirm older people, patients with
significant comorbid conditions or patients refusing other
forms of treatment.
• Richter, 2008; Walzer and Hirano, 2008

19. BTI needle

20. Intersphincteric Injection
of Botulinum Toxin
Make injections at the squamocolumnar
junction or up to 1 cm proximally, and usually
100 units in total are injected in four to five
equal volume aliquots. An attempt is made to
equally space the injections in a
circumferential manner and at the same level

21. PD vs. botox
• Recent cochrane database review.
• No significant differencein remission between PD and
botox treatment within 4 weeks of the initial intervention.
• Review at 12 months – remission with PD 70% . 25 % for
botox.
• conclusion
• PD is more eff ective than botox in the long term
forpatients with achalasia.
• Leyden JE , Moss AC , MacMathuna P . Endoscopic pneumatic dilationversus
botulinum toxin injection in the management of primary achalasia
.Cochrane Database Syst Rev 2006 : (4) : CD005046

22. Nonvalidated alternative therapies and
investigational therapies with limited data
• Non-traditional therapies
• Savary dilation (20%), Maloney dilation (10%) and small
caliber balloon dilation similar to that used for esophageal
strictures (4%). [Enesvedt et al. 2011)
• Single center studies – advocated use of specially designed
covered SEMS (usually 30 mm) and ethanolamine injection
into the LES - No guidelines.

23. POEM
• Natural orifice transluminal endoscopic surgery (NOTES)
in 2004, novel endoscopic technique called was developed.
• Inoue - endoscopic LES myotomy for achalasia in 2008,
Yokohoma, Japan.
• Over 20 centers are currently performing POEM.

25. Accessories
Triangular tip knife (Olympus)
T-type hybrid knife

26. Efficacy
• Initial data. - Efficacy similar to that of LHM.
• International POEM Survey
• POEM treatment success is over 90%.
• Mean Eckardt score improved from 7.41 before to 1.0 after
POEM.

27. Adverse effects
• Aspiration pneumonia
• Submucosal hematoma
• Local peritonitis
• Cutaneous emphysema
• Pleural effusion
• Segmental atelectasis of
the lungs
• Esophageal stricture
• Dehiscence at tunnel
entrance
• Superficial ulcer at cardia
• Junctional flap perforation
• Cervical emphysema
• Pneumomediastinum
• Mild chest pain
• Full thickness dissection
into peritoneal cavity
• Full thickness dissection
into mediastinum
• Cutaneous emphysema
• Pneumoperitoneum
• Mucosal perforation

28. Potential advantages of
POEM over LHM
• Easy extension of the myotomy to any length helpful in DES
& other EMD.
• Less risk of injury to the vagus nerve.
• Less reflux since attachments of the esophagus such as the
phrenoesophageal membrane are not disrupted.
• Less pain than in LHM