Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis

Management of the Difficult Patient

with Type 3 Achalasia

Steven R. DeMeester

Professor and Clinical Scholar

Department of Surgery

Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of

peristalsis in the esophageal body

• Treatment aimed at relief of outflow obstruction at

LES

• No treatment restores function of LES

• All therapies move obstructed LES toward open

LES (from dysphagia toward GERD)

GERD Outflow

obstruction

Low High Efficacy and Invasiveness

Botox PD (single) Lap HM+Dor

HRM Subtypes of Achalasia

I II

III

HRM and Outcome

Rohof WO, et al. Gastro, 2013

HRM and Outcome

Rohof WO, et al. Gastro, 2013

Type I (n=10) Type II (n=30) Type III (n=9) p value

Operation

- Heller Myotomy with Fundoplication

- POEM

9 (90%)

1 (10%)

23 (77%)

7 (23%)

7 (78%)

2 (22%)

0.49

Resolution of Dysphagia 8 (80%) 28 (93%) 8 (89%) 0.71

Post-operative reflux 2 (20%) 6 (20%) 1 (11%) 0.73

Post-Op Eckardt Score

Eckardt score of Zero (Asymptomatic)

1 (0-1)

40%

0 (0-1)

57%

0 (0-1)

78%

0.43

0.18

Post-Op Timed Barium: @ 1 min

- 100% Clearance

- >75% Clearance

(n=7)

0 (0%)

2 (29%)

(n=27)

15 (55%)

22 (81%)

(n=6)

5 (83%)

6 (100%)

0.18

0.49

Post-Op Timed Barium: @ 5 min

- 100% Clearance

- >75% Clearance

(n=7)

1 (14%)

3 (43%)

(n=27)

17(63%)

24 (89%)

(n=6)

6 (100%)

6 (100%)

0.16

0.77

Greene CL, et al. Surg Endosc, 2014

High resolution manometry sub-classification of Achalasia: Does it really matter?

Christina L. Greene, Erica J. Chang, Daniel S. Oh , Stephanie G. Worrell, Jeffrey A. Hagen,

Steven R. DeMeester

Type III Achalasia Pre-POEM

Achalasia Type III Post-POEM

Major Differences POEM versus

Laparoscopic Myotomy and Dor

• No disruption of phreno-esophageal ligament

• Division of clasp fibers rather than sling fibers at GEJ and in cardia

• Myotomy is longer, extends further up into mediastinum, but preservation of longitudinal fibers may prevent or minimize thoracic diverticulum that often develops after standard myotomy

POEM Versus Lap Heller Myotomy

• 2 papers, both retrospective

• Portland (Bhayani NH, et al. Ann Surg, 2014) • 64 LHM with partial fundoplication

• 37 POEM (prior achalasia treatment okay) – 2007-9: 48 LHM

– 2010: 14 LHM and 5 POEM



• Northwestern (Hungness ES, et al. J Gastrointest Surg, 2013)

• August 2010-May 2012 – 55 LHM with partial fundoplication

– 18 POEM (no prior treatment for achalasia both groups)

POEM vs LHM and Partial Fundoplication

Bhayani NH, et al. Ann Surg, 2014





32% vs 39%


Hungness ES, et al. J Gastrointest Surg, 2013

Hungness ES, et al. J Gastrointest Surg, 2013


POEM: A Viable Option?

• 1. Must be safe

• 2. Must produce similar results (or better) than

existing options, preferably with additional

benefits

• 3. Morbidity should be similar or better than

existing options

• 4. Results must be reproducible at multiple

centers

• 5. Patients want it

5 requirements

POEM: Safety • First human procedure in Sept 2008

• Worldwide over 1200 procedures performed

• Single center reports and recent multi-center prospective study

• No reported mortality

• Surprisingly little morbidity for new procedure

• Capnoperitoneum, capnomediastinum, capnothorax

• Injury to mucosa overlying tunnel

• Post-operative tunnel hemorrhage (1/119; 0.8%)

Ren Z, et al. Surg Endosc, 2012

Swanstrom LL, et al. Ann Surg, 2012

POEM: Efficacy Eckardt Symptom Score

0

1

2

3

4

5

6

7

8

9

10

1 2

Series1

Series2

Series3

Series4

Series5

Series6

Series7

1. Swanstrom LL, et al. Ann Surg, 2012; 2. Bhayani NH, et al. Ann Surg, 2014;

3. Costamagna G, et al. Dig Liver Dis, 2012; 4. von Rentein D, et al. Am J Gastro, 2012;

5. Hungness ES, et al. J Gastrointest Surg, 2012; 6 and 7. Li Q, et al. J Am Coll Surg, 2013

Pre-POEM Post-POEM

n=452

POEM: Efficacy

0

5

10

15

20

25

30

35

40

45

50

1 2 3 4 5 6 7

LES Resting Pressure

mmHg

1 2 3 4 5 6 7




n=452

POEM: Efficacy

TBS, 5 minutes

Pre: 48%

Post: 100%

Swanstrom LL, et al. Ann Surg, 2012

POEM: Efficacy

Hungness ES, et al.

J Gastrointest Surg, 2013

POEM: Efficacy

• 70 patients from 5 centers in Europe and Canada

• Mean follow-up 10 months

Multi-institutional prospective study

0

1

2

3

4

5

6

7

8

1 2 3

Eckhardt score

Pre 6 mo 12 mo

Manometry

61/70 patients

at 3 months:

LESP pre=28

post=9 mmHg

Von Renteln D, et al. Gastro, 2013

POEM: Efficacy Multi-institutional prospective study


POEM: Efficacy

• Follow-up limited (under 2 years) in

published series thus far

• Improvements in dysphagia and

regurgitation persist up to 18 months [1]

• Treatment failure reported in 11 patients

(11/452; 2.4%), 6 successfully treated with

balloon dilatation




POEM: Morbidity

• Literature summary

• Capnoperitoneum requiring decompression: 5-10% (higher without CO2)

• Mucosal injury during tunnel creation: 10%

• Full-thickness esophageal injury (biliary balloon dissection): 5-10%

• Bleeding in tunnel: 5%

• Leak in closure: rare


POEM: Morbidity

• Reflux

• Symptoms: 33% [1], 0 [3], 0 [4], 22% [5], 17%

[6 and 7] Overall: 16.5%

• pH studies: 6/13 positive: 46% [1]

• Esophagitis: 4/14: 28% [1], 0/10 [3], 1/16: 6%

[4], 5/15: 33% [5], 20/234: 8.5% [6 and 7]

Overall: 10.3%




POEM: GERD


POEM in Perspective • Treatment failure with Heller myotomy and partial

fundoplication (Kilic A, et al. Surgery, 2009)

• 46 patients, mean follow-up 6.4 years

• 9 patients (20%) with failure

• Mean time to recurrence was 21.3 months

• Reflux is a problem after Heller myotomy even with

partial fundoplication (Multi-center RCT)

6-12 months post-op

Rawlings A,

et al. Surg

Endosc, 2012

POEM in Perspective • Late failures after Heller myotomy are largely due to reflux

7-10 10-20 >20

Years post-op Csendes A, et al. Ann Surg, 2006

• 331 patients treated with achalasia balloon dilatation

• Mean follow-up 6 years

• 34% developed esophagitis

• 8.4% Barrett’s

• 28% in those with hiatal hernia, 2% in those without hiatal hernia

• 4% cancer: 12 squamous and 2 adenocarcinoma

Conclusion: POEM is a Viable Option!

• POEM achieves the short-term requirements to stay as a therapy for achalasia

• Safe

• Effectively alleviates symptoms • Short-term results are equal or better than LHM

• Minimal complications • Peri-op complications similar or less than LHM

• GERD not dissimilar to LHM

• Reproducible results at multiple centers

• Results do not seem to depend on HRM subtype

• Many patients prefer it over LHM and seek out a center where it can be performed

Documents

Management of the Difficult Patient with Type 3 Achalasia Course Presentations/DeMeester... · Achalasia Treatment Concepts • Disease leads to non-relaxing LES and loss of peristalsis