Management of Achalasia · Management of Achalasia The 18thAnnual Congress of the Lebanese Society...

Management of Achalasia

The 18thAnnual Congress ofthe Lebanese Society ofGASTROENTEROLOGY

November 2019Rami Sweis

University College London Hospital

Achalasia I Achalasia II Achalasia III

Lumen-obliteratingSpastic contractions

High Resolution Manometry Achalasia subtypes

• Other conditions with similar clinical picture with destruction of the myenteric plexus :• Local or distant cancer (pseudoachalasia) - infiltrating tumors or by circulating Abies

Tracey J P, Traube M. 1994.Hejazi R A, et al. Am J Med Sci 2009

• Chagas’ disease - Trypanosoma cruzi infectionHerbella F A et al. Dis Esophagus 2008

Achalasia subtype response to therapy

Boeckxstaens G, Zaninotto G. Achalasia and esophago-gastric junction outflow obstruction: focus on the subtypes. Neurogastroenterol Motil 2012;24 Suppl 1:27-31

Treatment options

– Pharmacotherapy (Nitrates/Ca-channel blockers)

– Botulinum Toxin

– Pneumatic Dilatation

– Heller’s Myotomy +/- partial wrap

– Per Oral Endoscopic myotomy (POEM)

• All current treatment options limited to reducing pressure gradient across LOS, thus facilitating passive oesophageal emptying by gravity.

End-stage achalasiaWant to Avoid!

• 2-5% patients develop end stage achalasia– Massive dilation (> 6cm) + retention food – Pneumatic dilation - less effective

Duranceau A et al. Dis Esophagus 2012

• Heller myotomy - symptomatic improvement reported in 72-92% with megaesophagus

Mineo TC et al Eur J Cardiothorac Surg 2004Sweet MP et al. J Gastrointest Surg 2008

• Esophagectomy– severe symptoms & very poor clearance after other treatments– if severe squamous dysplasia

Glatz SM, Richardson JD. J Gastointest Surg 2007

#Studies #Patients Estimated pooled prevalence 95% CI Heterogeneity Index

Pneumonia 7 1185 10% 4-18% 82%

Leakage 7 344 7% 4-10% 0%

Mortality 8 1307 2% 1-3% 0%

Aiolfi et al American Surgery 2018

Medical therapy• Data from randomized controlled studies is lacking • Cohort studies suggest improves dysphagia in some cases

– Do not reduce disease progression– Nifedipine or ISDN - Side effects (headache, orthostatic hypotension, edema)

Gelfond M, et al. Gastroenterol 1982

• Viagra (sildenafil – 5’-phosphodiesterase inhibitors)– Blocks enzyme that degrade NO & ↑ its local concentration in smooth muscle– Reduces LES pressure and can attenuate distal esophageal contractions. – Lack of long-term data + cost = restricted off-label use

Bortolotti et al Gastorenterology 2000

• There is no convincing evidence that medical treatment with nitrates, calcium blockers or phosphodiesterase inhibitors are effective for symptomatic relief in adults with achalasia. – Agree: 84-88%

• Gelfond M, et al Gastroenterology 1982; 83: 963–9.• Wen Z H, et al Syst Rev 2004: Cd002299.• Bassotti G, et al. Aliment Pharmacol Ther 1999; 13: 1391–6.• Storr M, Allescher H D. et al Dis Esophagus 1999; 12: 241–57.• Annese V, Bassotti G. World J Gastroenterol 2006; 12: 5763–6.• Roman S, Kahrilas P J. Gastro Clin North Am 2013; 42: 27–43.• Triadafilopoulos G, et al. Digest Dis Sci 1991; 36: 260–7.• Bortolotti M, Labo G. 1981; 80: 39–44.

• Nasrallah S M, Tommaso C L, et al. South Med J 1985; 78: 312–5.• Traube M, et al, Am J Gastroenterol 1989; 84: 1259–62.• Maradey-Romero C, et al Curr Treat Options Gastro 2014; 12: 441–55.• Bortolotti M, et al Gastroenterology 2000; 118: 253–7.• Simren M, et al. Gut 2003; 52: 784–90.• Eherer A J, et al Gut 2002; 50: 758–64.• Fox M, Sweis R, et al. Neurogastroenterol Motil 2007; 19: 798–803.

Botulinum Toxin 100IU into 4 quadrants of the LOS

Blocks release of acetylcholine → reduces LES pressure in achalasiaPasricha PJ. et al N. Engl. J. Med 1995

Advantages• Easy/Safe/Day case• 66% improvement in dysphagia

for at least 6 monthsPasricha PJ et al Gastroenterology 1996

Disadvantages• Occasional transient chest pain• Temporary due to axonal regeneration

(80% relapse by 2yrs)• Meta-analysis - symptomatic response

after one injection: – 78%, 70%, 53%, 41% at 1, 3, 6, 12 mths

Campos et al Ann. Surg 2009

• Expensive• No physiological improvement• Does not halt progression• No evidence that increasing dosage of

Botulinum toxin is more efficaciousZaninotto et al_Dis of Esoph_2018

Botulinum toxinReserved for:

• Repeated Botox have been associated with inferior response rates compared to subsequent Heller myotomy.

Smith CD et al. Ann Surg 2006

• Botox primarily only in elderly/multiple comorbidities unfit for other treatments

Triadafilopoulos G et al Dis of the Esophagus 2012Zaninotto et al_Dis of Esoph_2018

Pneumatic Dilatation

Advantages• Outpatient/Day case• Potentially halts progression • Long term remission in majority • Repeated on demand dilatation

(Zerbib et al AJG 2006)

Disadvantages• 2-4% perforation risk

– Primarily 1st dilatation– Associated with keeping balloon in place

(Richter_Exp Rev Gastro Hep 2008)(Boeckxstaens Lancet 2014)

– 50% Tx conservatively/risk thoracotomy

• >1/3 will have relapse over 4-6yrs(Hulselmans et al CGH 2010)(Vela et al CGH 2006)(Zerbib et al AJG 2006)

• 15-35% Heartburn – treated with PPI(Richter. Exp Rev Gastro Hep 2008)

Dilatation protocol

• Studies describe various protocols

• Graded dilatations 2-4 weeks apart is logical:

• 1144 patients across 24 studies– Average follow-up 1.6 years - symptom relief in a graded fashion:

• 30, 35, 40mm balloon diameters → symptomatic relief in 74%, 86%, 90%– Rate of perforation lower with the serial balloon dilation approach– Overall rate of perforation 1.9%.– Most perforations occur during the first dilation

• Primary risk factor – difficulty keeping the balloon in positionBoeckxstaens PJK GE, et al. NEJM 2011Richter. Exp Rev Gastro Hep 2008Boeckxstaens Lancet 2014

Heller Myotomy(Earnest Heller 1914)

Advantages (presumed)• Most effective & definitive

therapy– (Until recently!)

• Can halt disease progression

Disadvantages• Requires hospitalization & GA• Peri/Operative complications

– Death 0.1%– Perforation 3-15% (repaired immediately)

• Expensive• Post-treatment reflux (up to 60% w/out wrap)

– Floppy anti-reflux procedure now common butmay also lead to dysphagia

– Wrap can deteriorate over time• Still risk of reflux up to 21% - 42%

Khajanchee et al Arch Surg 2005Rawlings et al Surg Endosc 2012

• 15-21% success rate if following another form of therapy

Heller Myotomy

Portale et al J Gastrointest Surg 2005.Schuchert et al Ann Thorac Surg 2008.Richer Expert Rev Gastroenterol Hepatol 2008Campos et al Ann Surg 2009Salvador et al J Gastrointest Surg 2014

• Laparoscopic Heller myotomy should include a myotomy 6 cm into the esophagus and 2 to 3 cm into the stomach as measured from the GEJ, for effective symptom control in achalasia patients.– Agree: 94.2%

• Partial fundoplication should be added to laparoscopic myotomy in patients with achalasia to reduce the risk of subsequent gastro-esophageal reflux.– Agree: 94.2%

Long term outcome of Graded Pneumatic dilatation vs. Heller’s Myotomy

Success defined as dysphagia/regurgitation < 3 times/week or freedom from alternative treatment

Single dilatation

Graded (1-3) pneumaticdilatations (n=106)

Heller Myotomy(n=73)

6 months 62% 90% 89%

6 years 28% 44% 57%

• LHM better in patients <40years• No difference at 5 years F/U: 24% of dilatation patients required further dilatation• Reflux symptoms were 65% without fundoplication vs. 39% with fundoplication

Vela et al CGH 2006• Other studies corroborate - 5 year success rates for both Dilatation and Myotomy

decline over time to 65-85%Hulselmans et al CGH 2010Zerbib et al AJG 2006

The European Achalasia Trial:2 year results (mean 43 months)

2003-2008; 14 hospitalsn=201 naiive achalasics randomised to PD vs LHM

All patients without previous treatment

Pneumatic Dilatation(n=85)

Heller Myotomy + Dor fundoplication(n=107)

P=

Successful Treatment(drop in Eckardt score to ≤3)

86% 90% 0.46

LOS pressure 12 mmHg 10 mmHg 0.27

Timed Barium swallow 3.7 cm 1.9 cm 0.21

Abnormal pH 15% 23% 0.28

Boeckxstaens PJK GE, et al. NEJM 2011; 364(19):19

5 year results All patients without previous treatment

Pneumatic Dilatation(n=57)

Heller Myotomy + Dor fundoplication(n=71)

P=

Successful Treatment(drop in Eckardt score to ≤3)

85%(perforations and refusals considered failures)

84% 0.52

LOS pressure 10.8 mmHg 7.4 mmHg 0.19

Timed Barium swallow 1.6 cm 0.5 cm 0.7

Abnormal pH 15% 23% 0.28

Treatment failuresLHM - 22 out of 105 patients had a treatment failure (21%)

8 within the first year, 4 between the first and the second year, 6 after > 5 years. PD - 8 out of 96 patients had treatment failure (8%)

24 of the 96 (25%) patients of the PD group required re-dilatation

GUT 2016

5 years

2cm incision ≈13cm above LOS

Submucosal tunnel to expose circular musclesTunnel continued up to 2-3cm distal to OGJ

Myotomy begins ≈3 cm distal to initial mucosal incision

Circular muscles cut to 2-3cm below OGJ

Mucosa clipped closed

POEM

Published POEM ResultsStudy Country N Outcome measure Efficacy Follow up

(months)

Inoue, 2010 Japan 17 Dysphagia score (0-10)10->1.3

5

Von Renteln, 2012 Germany 16 Eckardt score ≤ 3 8.8->1.4 3Hungness, 2013 USA 18 Eckardt score ≤ 3 8.8->1.5 6

Costamagna, 2012 Italy 11 Eckardt score ≤ 3 8.8->1.6 3Kurian, 2013 USA 40 NA 6

Veerlaan, 2013 Netherlands 10 Eckardt 8->1 3Chiu, 2013 China 16 Dysphagia score 2->0 3.7-7.7

Minami, 2014 Japan 28 Eckardt score ≤ 3 6.7->0.7 3-28Meireles, 2013 USA 7 NA 1-6

Rieder, 2013 USA 4 NA NALee, 2013 Korea 13 Eckardt score ≤ 3 6.4->0.4 6.9Li, 2013 China 238 Eckardt score ≤ 3 7.6->1.2 12

Ujiki, 2013 USA 18 Eckardt 6.4->0.7 9.7Von Renteln, 2013 International study 70 NA 97%, 89% and 82% 3, 6 & 12

Khashab, 2014 USA 9 Eckardt 1 post-POEM NATeitelbaum, 2014 USA 36 Eckardt 7->1.5 12

Zhou, 2012 China 205 Dysphagia relief 97% 8.5Swanstrom, 2012 USA 18 Eckardt score ≤ 3 94 and 100% 1 & 6

Inoue, 2014 Japan 500 Eckardt score ≤ 391% (n=286) 12-2488.5% (n=61) 36

Stavropulos, 2014 USA 100 Eckardt score ≤ 3 98% 13

Barbieri et al UEG 2015 (N=551)Meta-analysis of 551 patientsPooled rate of clinical success – 93% (CIs: 90–95%)Mean of Eckardt scores reduced from 7 to 1 (p< 0.001)

POEM Durability

• Inoue et al. J of ACS 2015• Hungness et al. Annals of Surgery 2016

Hungness 2016 (Chicago)

• Teitelbaum et al. Clinical outcomes five years after POEM for treatment of primary esophagealmotility disorders. Surg Endosc 2018

• Wenrer et al. Gut 2015• Chen et al. Gastrointest Endosc 2015

• Ryan et al. Treatment of Idiopathic Achalasia with Per-Oral Esophageal Myotomy. PMC 2018

Intraoperative risk and Postoperative Adverse Events in POEM vs. LHM

• Zhongshan Hospital, China (n=1680) POEM between August 2010 and July 2015

• Major AE = Total of 55 patients (3.3%) • Delayed mucosal barrier failure (n=13, 0.8%)• Delayed bleeding (n=3, 0.2%)• Hydrothorax (n=8, 0.5%) • Pneumothorax (n=25, 1.5%)• Miscellaneous (n=6, 0.4%)• ICU admission (n=4, 0.2%)• No surgical conversion, 30-day mortality 0

• Related risk factors for AEs• Institution experience of <1 year (odds ratio [OR] 3.85,

95%CI 1.49–9.95)• Air insufflation (OR 3.41, 95%CI 1.37–8.50) – n=223• Mucosal edema (OR 2.01, 95%CI 1.14–3.53)

• After introducing CO2 insufflation, the mAE rate declined to 1.9% (95 %CI 1.2%–2.7 %) and plateaued after 3.5 years at <1%.

Endoscopy 2016

Bar graph explored relation between mAErate and the learning phases. • Phase 1 (year 1) 19.1%• Phase 2 (2.5 years) plateau 3.1% • Phase 3 (0.8%)

Adverse eventsAuthors Patients (n) Post-POEM oesophagitis

Adverse events (n)Additional treatments(Including nonclinically significant & asymptomatic events)

Inoue, 2010 17 1 1 pneumoperitoneum Veress needle

von Renteln, 2012 16 16 minor cutaneous emphysema Veress needle8 capnoperitoneum treated with Veress needle Endoscopic clips1 small perforation at GEJ, treated with endoscopic clips

Hungness, 2013 18 5 7 capnoperitoneum Veress needle1 contained perforation at the EGJ

Costamagna, 2012 11 02 small perforations at junctional flap

Endoscopic clipsAsymptomatic pneumomediastinum in all patients2 transient cervical emphysema

Kurian, 2013 40 NA

19 esophageal perforation Clips7 pneumoperitoneum Aspirated1 pneuothorox Decompressed1 post-operative haematemesis

Verlaan, 2013 10 6 No complications reported None

Chiu, 2012 16 3 1 aspiration pneumonia Hospital admission and monitoring2 transient cervical emphysema

Minami, 2013 28 11 1 perforation at GEJ Endoscopic clips2 postoperative bleedingsMeireless, 2013 7 NA 0 0Lee, 2013 13 NA 0 0

Li, 2013 238 20

2 pneumoperitoneum Drained with needle1 subcuntaneous emphysema + pneumothorax Pneumothorax drain15 Plerual effusion Thoracic drain1 tunnel infection, 1 epileptic seizure, 1 tunnel bleed

Ujiki, 2013 18 NA 3 pneumoperitneum Veress needle

Von Renteln, 2013 70 NA

3 clip dislocation at mucosal closure Reclipped1 perforation at mucosal entry site, 3 mucosal injuries Endoscopic clips1 bleeding requiring intervention Endoscopic Tx1 cap detached in submucosal tunnel Endoscopic removal

Khasab, 2014 9 NA 0 0

Swanstrom, 2011 18 2 small perforations in gastric cardia Endoscopic clips3 capnoperitoneum Veress needle

Zhou, 2013 205

1 small perforation at GEJ Endoscopic clips3 capnoperitoneum, one treated with Veress needle Veress needle4 pneumothorax, one treated with thoracic tube Thoracic tube4 mediastinal emphysema, 2 subcutaneous emphysema

Adverse eventsAuthors Patients (n) Post-POEM oesophagitis

Adverse events (n)Additional treatments(Including nonclinically significant & asymptomatic events)

Inoue, 2010 17 1 1 pneumoperitoneum Veress needle

von Renteln, 2012 16 16 minor cutaneous emphysema Veress needle8 capnoperitoneum treated with Veress needle Endoscopic clips1 small perforation at GEJ, treated with endoscopic clips

Hungness, 2013 18 5 7 capnoperitoneum Veress needle1 contained perforation at the EGJ

Costamagna, 2012 11 02 small perforations at junctional flap

Endoscopic clipsAsymptomatic pneumomediastinum in all patients2 transient cervical emphysema

Kurian, 2013 40 NA

19 esophageal perforation Clips7 pneumoperitoneum Aspirated1 pneumothorox Decompressed1 post-operative haematemesis

Verlaan, 2013 10 6 No complications reported None

Chiu, 2012 16 3 1 aspiration pneumonia Hospital admission and monitoring2 transient cervical emphysema

Minami, 2013 28 11 1 perforation at GEJ Endoscopic clips2 postoperative bleedingsMeireless, 2013 7 NA No complications reported 0Lee, 2013 13 NA No complications reported 0

Li, 2013 238 20

2 pneumoperitoneum Drained with needle1 subcuntaneous emphysema + pneumothorax Pneumothorax drain15 Plerual effusion Thoracic drain1 tunnel infection, 1 epileptic seizure, 1 tunnel bleed

Ujiki, 2013 18 NA 3 pneumoperitneum Veress needle

Von Renteln, 2013 70 NA

3 clip dislocation at mucosal closure Reclipped1 perforation at mucosal entry site, 3 mucosal injuries Endoscopic clips1 bleeding requiring intervention Endoscopic Tx1 cap detached in submucosal tunnel Endoscopic removal

Khasab, 2014 9 NA No complications reported 0

Swanstrom, 2011 18 2 small perforations in gastric cardia Endoscopic clips3 capnoperitoneum Veress needle

Zhou, 2013 205

1 small perforation at GEJ Endoscopic clips3 capnoperitoneum, one treated with Veress needle Veress needle4 pneumothorax, one treated with thoracic tube Thoracic tube4 mediastinal emphysema, 2 subcutaneous emphysema

Adverse events

• Reported incidence of AEs has ranged between 0 and 72.2%• Variability partly related to lack of consensus about AE definition

• Subcutaneous emphysema, asymptomatic capnoperitoneum/capnothorax, and mediastinal emphysema should not be considered as AEs.

• Study of CT immediately after POEM - 54% incidence of pneumomediastinum and pneumoperitoneum but only one case related to esophageal perforation. – No correlation between CO2-related CT findings & severe AEs

Yang et al Acta Radiol 2015

Tang X , et al . Surg Endosc 2015 ; 30 : 3774 – 82 .Sharata AM , et al J Gastrointest Surg 2015 ; 19 : 161 – 70 .Khashab MA , et al . Gastrointest Endosc 2015 ; 81 : 1170 – 7.Wang X , et al Neth J Med 2015 ; 73 : 76 – 81 .Familiari P , et al Ann Surg 2016 ; 263 : 82 – 7 .Yang D , et al. Endosc Int Open 2015 ; 3 : E289 – 95 .Chai N , et al Surg Endosc 2016 ; 31 : 368 – 73 .El Khoury R et al . Surg Endosc 2016 ; 30 : 2969 – 74.

Khashab MA , et al. Gastrointest Endosc 2016 ; 83 : 117 – 25.Inoue H , et al J Am Coll Surg 2015 ; 221 : 256 – 64 .Ling TS , et al . J Dig Dis 2014 ; 15 : 352 – 8 .Shiwaku H , et al Surg Endosc 2016 ; 30 : 4817 – 26 Von Renteln D , et al Gastroenterology 2013 ; 145 : 309 – 311.e1-3.Li QL , et al J Am Coll Surg 2013 ; 217 : 442 – 51 .Ren Z , et al Surg Endosc 2012 ; 26 : 3267 – 72 .Cai MY , et al. Surg Endosc 2014 ; 28 : 1158 – 65 .Ramchandani M , et al. Dig Endosc 2016 ; 28 : 19 – 26 .

• Of 1,826 patients -137 experienced a total of 156 AEs – overall prevalence of 7.5%. – Mild (6.4%), moderate (1.7%), and severe (0.5%)– Most common AE - inadvertent mucosotomy (2.8%).

• AEs related to insufflation occurred in 30 patients (22 capnoperitoneum, 5 capnothorax, 1 pneumothorax, and 2 capnomediastinum)– Symptomatic capnoperitoneum was successfully decompressed

intra-procedurally and procedure completed as planned in all.

AJG 2017

Surg Laparosc Endosc Percutan Tech; 2017

Complications

POEM vs LHM Comparative studies Bhayani et al Annals of Surgery 2014

Ujiki et al Surgery 2013

Bhayani et al Annals of Surgery 2014 (n=101)Ujiki et al Surgery 2013 (n=39)Hungness et al J Gastroint srug 2013 (n=73)

Pooled analysis of comparative studies – similar between the groups:• Total adverse events – Similar

– pooled ORs = 1.2; 95% CI = 0.5 to 2.86; P= 0.69• Perforation rate - Similar

– ORs = 0.81; 95% CI = 0.28 to 2.3; P = 0.69)• Operative time – Similar

– weighted mean difference = −15.13 minutes; 95% CI = −50.09 to 19.83; P = 0.4

• Length of stay in hospital – Non-sig trend toward reduced stay in POEM group

– weighted mean difference = − 0.95 days; 95% CI = − 1.92 to 0.01; P = 0.05

(6 months follow up)

Chan et al Dig Endos 2016

Forest plots showing proportion of patients with improvement of dysphagia after Laparoscopic Heller Myotomy (LHM) and Peroral Endoscopic Myotomy (POEM).

• 53 studies on LHM (5834 patients)

• 21 studies on POEM (1958 patients)

• Averaged across all the studies and timelines, improvement of dysphagia

– 93.2% for POEM – 87.7% for LHM

• At 12 months– 93.4% for POEM – 90.2% for LHM (P =0.004)

• At 24 months– 93.5% for POEM – 90.4% for LHM (P =0.004)

Heller’s POEM

2018

POEM vs LHM with partial wrap in Type III achalasia

• Adverse event profile: POEM 6% vs. LHM 27% (p<0.01)• Significantly more ‘moderate’ complications reported

in the LHM cohort. • Ileus due to transabdominal approach (3/6)• wound infection 1/6• longer procedure times for LHM

Kumbhari et al Endosc Int Open 2015

Target POEM starting point

Length of myotomy can be predetermined

Reflux post POEM?

Reflux post POEM vs LHM

Von Renteln D, et al. Gastro, 2013 (N=70)

Inoue et al J of Am Coll Surg 2015 (N=500)

POEM vs LHM with partial wrap

• Post-POEM esophagitis metanalysis :• 13% (16 studies; N=551 patients)

Barbieri et al UEG 2015 • 19% (22studies; N=1122 patients)

Patel et al Dis of Oesoph 2015

Post POEM• 12 studies (N=1056 patients)• F/U 9.3 months (range 2-30 months). • 449 (29.4%) esophagitis of any severity

• 92.0% (54.3%, 244/449) = LA Grade A • 4.47% (95% CI, 3.27%-6.07%) Grade C/D

Post LHM• 5 studies (N=752 patients)• F/U 26.6 months (range 12-49 months)• 46 (7.6%) esophagitis of any severity

• 48.5% (39.4%, 13/43) = LA Grade A • 1% (95% CI, 0.4%-.3.0%) Grade C/D

GASTROINTESTINAL ENDOSCOPY 2018

• High-grade oesophagitis (LA grades C or D), Barrett’s oesophagus or peptic stricture = confirmatory evidence for GERD.

• LA grade A - non-specific - found in 5%–7.5% of asymptomatic controls.• When accurately defined, LA grade B oesophagitis provides adequate evidence for

GERD, but problems with interobserver variability– expert panel to conclude that additional pH-metry evidence is requisite prior to

pursuing ARS in Grade B oesophagitis

• Labenze et al Prospective Follow-Up Data from the ProGERD Study Suggest that GERD Is Not a Categorial Disease. Am J Gastro 2006.

• Roman S, et al. Ambulatory reflux monitoring for diagnosis of gastro-esophageal reflux disease: update of the Porto consensus and recommendations from an international consensus group. Neurogastroenterol Motil 2017;29:1–15.

• Akdamar K, Ertan A, Agrawal NM, et al. Upper gastrointestinal endoscopy in normal asymptomatic volunteers. Gastrointest Endosc 1986;32:78–80.

• Takashima T, Iwakiri R, Sakata Y, et al. Endoscopic reflux esophagitis and Helicobacter pylori infection in young healthy Japanese volunteers. Digestion 2012;86:55–8.

• Zagari RM, Fuccio L, Wallander MA, et al. Gastro-oesophageal reflux symptoms, oesophagitis and Barrett’s oesophagus in the general population: the Loiano- Monghidoro study. Gut 2008;57:1354–9.

• Jobe BA, et al. Preoperative diagnostic workup before antireflux surgery: an evidence and experience-based consensus of the Esophageal Diagnostic Advisory Panel. J Am Coll Surg2013;217:586–97.

GUT 2018

Werner Y. Endoscopic versus surgical myotomy in patients with primary idiopathicachalasia [abstract LB08]. United European gastroenterology journal. 2018;6:1590.

Achalasia treatment options

Achalasia

Botox

Pneumatic dilatation

POEMDrugs

Heller’s myotomy + partial

wrap

Patient choice + local expertise

Balance of Treatment for Achalasia

GORD

Dysphagia

Outflowresistance

SphincterDisruption

Thank you

Perforation/Tear

• 5 of the 96 patient (5%) = 2.1% per procedure– 4 perforation during 1st dilatation series – 1 perforation during re-treatment for recurrent

symptoms (35 mm balloon)• 3 managed conservatively (restriction of oral food

and antibiotic therapy) • 2 patients managed surgically

– All recovered without complications.

Post-procedure reflux at 4 years

Pneumatic dilatation Heller’s Myotomy• 13 of the 105 patients (12%).

– In all tear corrected during the surgery & 1 required conversion to open surgery.

– Outcome was not influenced

• OGD performed in 39 LHM & 37 PD patients• PD - 14% oesophagitis (4 grade A and one grade C) • LHM - 18% had oesophagitis (3 grade A and 4 grade B)

• 24 h pH measurement performed in 33 LHM & 33 PD patients• PD – Total reflux 2.3±3.9% • LHM - Total reflux 5.6±10.1%

P=0.76

P=0.7Moonen et al. Gut 2016

• Heller without anti-reflux procedure 20-100% GORD(fully dissect oesophageal hiatus, take down phreno-oesophageal membrane and angle of His)

Falkenback D, et al. Dis Esophagus. 2003Richards et al Ann Surg 2004Awaiz et al Surg Laparosc Endosc Percutan Tech 2017

• POEM without anti-reflux procedure DOES NOT result in unmitigated reflux of gastric contents – preservation of the anatomic relationships at the hiatus (eg. Phreno-

esophageal ligament, angle of His) +/- maintenance of the oesophageal longitudinal muscle fibres offer some degree of protection

Hungeness et al Annals of surgery 2016

0

4

8

12

16

20

Heller Heller + DorPathologic GER Normal pH Study

56%

10%

Patie

nts

*P = 0.005 vs. Heller plus Dor

*

Myotomy with or without wrap (n=43)randomized, double-blind clinical trial

F/U 6 months

Type of Wrap

• 360◦ wrap can lead to increased rate of postoperative dysphagia – Topart P, et al. Ann Thorac Surg 1992; 54: 1046–52– Hunter J G, et al. Ann Surg 1997; 225: 655–65– Malthaner R A, et al. Ann Thorac Surg 1994; 58: 1343–7– Khajanchee Y S, et al. Arch Surg 2005; 140: 827–33

• RCT comparing anterior (Dor) vs 360◦ (Nissen)– dysphagia significantly higher in 360◦ Nissen but without a significant

difference in reflux control. – Rebecchi F, et al. Ann Surg 2008; 248: 1023–30.

• No consensus regarding choice between anterior Dor (180◦) and posterior Toupet (270◦) (partial) fundoplications.

– Lyass S, ert al. Surg Endosc 2003; 17: 554–8.– Rawlings A, et al. Surg Endosc 2012; 26: 18–26.– Kurian A A, et al. JAMA Surg 2013; 148: 85–90.

Effect of endoscopic treatmentsbefore laparoscopic myotomy

• LHM success reduced by up to 20%– more technically difficult if following other therapies– 3.7% - 16.8% Schuchert et al 2008– 10.1% - 19.5% Smith et al 2006

• 10-20% long term failure after Heller myotomyRedo Heller Myotomy or Pneumodilatationsuccess rates ≈ 50% increased dysphagia, regurgitation and heartburn

after surgeryFinley et al 2010

POEM after failed Heller Myotomy

• Ngamruengphong et al CGH 2017• 180 POEM from 13 different hospitals

• 90 with prior HM and 90 without prior HM• F/U median 8.5 months• Eckardt <3 in 81% in prior HM and 94% without prior HM (P = .01)• No diff in rates of adverse events between groups (8% vs 13%; P = 0.23)

• Awaiz et al; Metanalysis of POEM vs LHM. Surg LaparoscEndosc Percut Tech 2017– POEM beneficial in previous laparotomy/adhesions or failed LHM

• Avoids entry into ‘hostile peritoneum’ or previously scarred anterior myotomy area - as POEM’s submucosal tunnel is usually lateral

• Post LHM should have POEM directed toward posterior aspect of esophageal wall to avoid fibrosis

• Of the 18 failures, 8 were among the first 10 cases treatedMay have biased the estimate of long-term treatment success rate

Gut 2016

N = 79

Annals of Surgery 2016

• January 2012 and March 2015• N = 115 POEM at a single, high-volume center EXCLUDING first 15 cases• Average 2.4 years post POEM (range 12–52 months)

• Overall success rate 92%• 94% of patients with Type I/II achalasia • 90% Type 3 achalasia/spastic esophageal motility disorders

CaseMs NH

• 36 year old woman• Dysphagia and chest pain

• May 2013• Ba swallow - delay in emptying• Endoscopy – Not dilated, Some

resistance at OGJ• Manometry - Type II achalasia

Ms NHMarch 2013

5ml water

Free drinking

1cc Bread

CaseMs NH

• Laparoscopic Heller’s Myotomy & fundoplication (May 2014) prandial/postprandial spontaneous pain and dysphagia occasional nocturnal pain

• Botox injected into OGJ (Dec 2013 & Oct/July/Dec 2014) Improved symptoms markedly for 3 months every time But symptoms would recur with chest pain/dysphagia

• Repeat manometry

Case NH - HRM due to ongoing symptoms

High Resolution Manometry

Prox oes

Stomach

Stomach

UOS

Liquid Boli reasonably

cleared

Absent peristalsis but no oesophageal body

pressurisation and normotensive LOS

LOS

Low Impedance - Liquid High Impedance - Air / Gas

Intermittent mid-oesophageal pressure on swallowing

HRM-post initial Achalasia treatment (July 2014)

• LOS pressure normal• Integrated Relaxation Pressure normal• Absent peristalsis

Water swallows

Viscous swallows

Original Manometry

DL<4.5s DL<4.5s

Decision for POEM March 2015

1st case at UCLH

F/U 13 months• Symptoms almost entirely resolved• Eckardt score dropped from 7 1• Able to eat almost anything• Mild reflux symptoms – well controlled with PPI• No further pain but niggling discomfort in

proximal oesophagus at 5 months OGD– single retained clip – knocked off

• Familiari P, et al Dig Endosc. 2016;28:33–41• Chan et al Dig Endosc. 2015;28:27–32 • Kumbhari V, et al. Endosc Int Open. 2015;03:E195–E201.• Bhayani et al Ann Surg. 2014;259:1098–1103• Ujiki MB et al Surgery. 2013;154:893–897


Forest plot for postoperative GERD symptoms

﹜• GERD found equally in both post LHM and POEM

&• Treated successfully with

PPI in both

• Comparable risk of short-term GERD symptoms for both LHM and POEM

• N=500 underwent surgical myotomy• Median 6.4 years following surgery 241 (48%)

responded to symptom questionnaire– 170 (70.5% ) - Heartburn– 89 (36.9% ) - Regurgitation– 159 (66.0% ) taking medication to treat reflux

• antacids, 114 (47.3%)• H2 blockers, 38 (15.8%)• PPIs 96 (39.8%)

The Journal of Thoracic and Cardiovascular Surgery, 2014

Forest plots showing proportion of patients with gastroesophageal reflux disease (GERD) symptoms after Laparoscopic Heller Myotomy (LHM) and Peroral Endoscopic Myotomy (POEM).

• GERD symptoms: LHM -17.5% vs. 18.5% POEM– Odds of GERD

symptoms among POEM was 1.69 times the odds of GERD symptoms among LHM (OR 1.69, 95% CI 1.33–2.14, P < 0.0001)

• Oesophagitis seen in 11.5% LHM vs. 22.4% POEM

Forest plots showing proportion of patients with gastroesophageal reflux disease (GERD) evidenced by esophagogastroduodenoscopy(EGD) after Laparoscopic Heller Myotomy (LHM) and Peroral Endoscopic Myotomy (POEM).

Medications Unadjusted AdjustedHistamine-2 receptor blockers 1.16 (0.77-1.74) 1.19 (0.79-1.80)Proton pump inhibitors 1.03 (0.71-1.50) 1.02 (0.70-1.49)Prokinetic agents 0.98 (0.64-1.49) 0.92 (0.60-1.41)

Relative Risk of Use of Antireflux and Prokinetic Medications After Treatment for Achalasia

Lopushinsky, S.R., et al, JAMA. 2006;296:2227-2233

Hazard Ratio (95% CI)

• Compared with persons treated initially with surgical myotomy (n=280), those treated with pneumatic dilatation (n=1181) were not statistically different with respect to:

Khajanchee et al Arch Surg 2005 – 9 months (n=121)

32% persistent reflux symptoms following surgery.

33% of those who had pH studies were positive

Opiates vs. Type III AchalasiaType 3 achalasia on opiate Type 3 achalasia not on opiate

• Manometric findings of type 3 achalasia mimic those induced by opiates• patients with type 3 achalasia-like trace on opiates seem to have increased contractile vigor

and a shorter distal latency compared with those not on opiatesRavi et al Dis of Oesoph 2016

Conclusion

• Diagnosis depends on several modalities of testing• Decision for therapy is largely dependent on patient

choice and local expertise– SEQUENTIAL dilatation (30 then 35mm…then possibly 40mm)– Heller’s Myotomy with partial wrap– POEM (learning curve)– Avoid Botox unless elderly/comorbidities

• Treatment should be in high volume centers• Pre- and post-therapy assessment (Eckardt/TBS/HRM)

- Don’t wait

THE TREATMENT OF ACHALASIA IN PATIENTS WITH OESOPHAGEAL VARICES : AN INTERNATIONAL CASE SERIES

C Magee, R Holloway, P Gyawali, S Roman, M Pioche, E Savarino, F Quader, A Bredenoord, R Sweis

UEG 2017

13 patients from 6 international centres• Mean age 61 +/- 9 years• Median pre-therapy Eckardt score = 7 (Range = 5-10)• Type I (n=3), Type II (n=6), Type III (n=2), OGJOO (n=2)• Grade III varices (n=2), Grade II (n=3), Grade I (n=3)• Liver disease: Alcohol (n=7), NASH (n=3), Cryptogenic (n=2), Hepatitis C (n=1)

– Child Pugh A 75%Child Pugh B 25%

Results• All patients had symptomatic improvement

• Median Eckardt score post treatment = 1 (Range 0-3) p<0.0001 vs pre-treatment

• Matched group of 20 sequential patients without varices had similar outcomes p=NS

• No recorded bleeding or perforations• Both patients with TIPPS had transient

hepatic decompensation

• Multicentre retrospective Trial (Hamburg, Portland, Rome)• N= 80 POEM procedures between 2010 and 1014

• F/U 29 months (range 24–41)• At 3-6 months - good clinical response observed in 74/80 cases• At mean 20 months – Good Clinical response observed in 62/80

• Accounting for 21.5% failure rate overall• Multivariate analysis - age and endoscopic reflux signs were independent predictors of

treatment success.

Gut 2016

A prospective randomized multi-center study comparing endoscopic pneumodilation and per oral endoscopic

myotomy (POEM) as treatment of idiopathic achalasia

• Central site– University Hospital Leuven

• Guy E.E. Boeckxstaens

• UK sites– University College London Hospital

• Rami Sweis, Matt Banks– Nottingham University Hospitals

• Krish Ragunath– Queen Alexandra Hospital, Portsmouth

• Pradeep Bhandari– Guys and St Thomas’ Hospital

• Abrie Botha, Jason Dunn, John Meenan

Conclusion• Outcomes

– Short and long term (up to 2-3 year) at least as good as Dilatation and Heller’s myotomy with wrap (Cohort/comparative studies only)

• Reflux (Depends on what you are measuring!)– Not dissimilar to Heller’s with wrap– All patients should have PPI– Consider warning patients with BMI>35 of increased reflux risk

• Learning curve– POEM should be provided only in high volume centres with experienced

(named) endoscopist/s dedicated to POEM

• Provides another therapeutic option– No evidence of superiority to other therapies– Might be better for Type III achalasia who require long myotomy

• 31 patients (28%) reported symptomatic GERD at a mean follow-up of 24 months

• 27 (40%) of the 68 patients who underwent testing had objective evidence of GERD.

• The only significant predictors for the development of objective evidence of reflux after POEM were – presence of a hiatal hernia on preoperative endoscopy or HRM

• 5 of 6 such patients had objective evidence of reflux, compared with 22 of 62 without hiatal hernia; P . 0.022

– BMI >35 kg/m2 (63% with BMI >35 vs 37% with BMI <35). • Objective GERD rate for all patients was 40%

– (33% for patients without hiatal hernia and BMI <35).

Predictors of treatment failures overall(Dilatation or Heller’s)

• Pre-existing daily chest pain (HR 2.8; 95% CI, 1.1 to 7.1; P = 0.03)

• Height of the barium-contrast column >10 cm (HR 1.3; 95% CI, 1.1 to 1.5; P = 0.01)

• Width of esophagus of <4 cm before treatment (HR 3.5; 95% CI, 1.3 to 9.9; P = 0.02)

– unclear why

Timed Barium Swallow Utility

• Vaezi et al: <50% reduction in 5min Barium column height post therapy in naïve patients predicts need for retreatment >1 year following dilatation

Vaezi MF. Gut 2002

• Rohof et al: >5cm column height (not change) predicts symptom recurrence/need for retreatment over 10 years

Rohof WO. AJG 2012

• Measurement of height of residual Ba column at 5 min -Current gold standard

Boeckxstaens et al. NEJM 2011Moonen et al. Gut 2016

• The POEM learning curve has been evaluated by several centers including ours– Teitelbaum EN, Soper NJ, Arafat FO, et al. Analysis of a learning curve and predictors of

intraoperative difficulty for peroral esophageal myotomy (POEM). J Gastrointest Surg. 2014;18:92–99.

– Kurian AA, Dunst CM, Sharata A, et al. Peroral endoscopic esophageal myotomy: defining the learning curve. Gastrointest Endosc. 2013;77:719–725.

– Patel KS, Calixte R, Modayil RJ, et al. The light at the end of the tunnel: a single-operator learning curve analysis for per oral endoscopic myotomy. Gastrointest Endosc. 2015;81:1181–1187.

• Kurian et al reported learning curve observed during first 40 by Oregon group – Using an analysis of length of procedure and rate of inadvertent mucosotomies –

proposed the learning curve ‘‘plateau’’ was reached ~20 cases• Patel et al - Largest series looking at a single-gastroenterologist learning curve

– found efficiency to be achieved after 40 cases and mastery after 60 cases (similar to previous reports of learning curves for ESD)

– In a prior publication by Teitelbaum et al,8 analyzing the• Teitelbaum et al reported learning curve for 2 surgeons who jointly performed the

initial 36 cases at our institution– Component analysis revealed an 7 cases for submucosal access and performing the

myotomy - the time required for creation of the submucosal tunnel (the longest component) started to ‘‘funnel’’ toward the mean after 15 cases.

• Chicago group propose that the learning curve for POEM by minimally invasive surgeons with significant achalasia and endoscopy experience is approximately 15 cases – so applied that cut-off

• 1 in 100,000, – if you live in a city with 1 million inhabitants, there

is 10 people with achalasia

• And if learning curve is 15 – POEM should only be performed in units with a large catchment area and

Long-Term Outcomes of Heller Myotomy• N=149, Mean follow up 8.2 years:

>90% at 5 years 75% at 15 yrs11% oesophagitis

Ortiz, et al Ann Surg 2008

• Treatment failures: 7% at 2 yrs 10% at 5 yrs 18% at 10 yrs

Zaninotto, et al Ann Surg 2008

• Excellent/good results in:80% at 10 yrs 65% at 20 yrsErosive esophagitis, peptic ulcers & other GORD sequelae

• 15% at 10 years• 24% at 20 years • 47% in >20 years

Csendes et al Ann Surg 2006

Early Achalasia

Megaoesophagus

N=149, Mean follow up 8.2 years:>90% at 5 years 75% at 15 yrs11% oesophagitis

Ortiz, et al Ann Surg 2008

• The symptom score for dysphagia, chest pain, and regurgitation was calculated by adding the severity of each symptom (0, none; 2, mild; 4, moderate; 6, severe) to the frequency (0, never; 1, occasionally; 2, once a month; 3, every week; 4, twice a week; 5, daily); the highest score obtainable was 33.

• postoperative symptom score higher than the 10th percentile of the preoperative score

• Zaninotto G, Costantini M, Portale G, et al. Etiology, diagnosis, and treatment of failures after laparoscopic Heller myotomy for achalasia. Ann Surg. 2002;235:186 –192.

Outcome measurement following achalasia therapy

Score 0 1 2 3

Dysphagia No Occasionally Daily At each meal

Regurgitation No Occasionally Daily At each meal

Chest pain No Occasionally Daily At each meal

Weight loss 0 kg 0-5kg 5-10 kg > 10 kg

Eckardt VF, Aignherr C, Bernhard G. Predictors of outcome in patients with achalasia treated by pneumatic dilation. Gastroenterology. 1992

Eckardt ≤ 3 in keeping with improvement

Eckardt Score

Subjective


Length of Stay in Hospital

Endoflip distensibility in POEM• Teitelbaum et al,30 using the functional lumen imaging• probe (FLIP), measured the EGJ distensibility at 2 timepoints:• (a) at baseline after induction of anesthesia and (b)• following completion of either POEM (n=12) and LHM• (n=19). They reported that patients with postoperative• distensibility index of <6mm2/Hg did not suffer from• GERD (GERDQ score >7), whereas 36% of patients with• postoperative distensibility index of >9mm2/mmHg had• GERD symptoms requiring further subsequent treatment. In• conclusion, postoperative distensibility index was the most• important factor predicting the future occurrence of GERD.

Perforation/Tear





Post-procedure reflux at 4 years

Pneumatic dilatation Heller’s Myotomy• 13 of the 105 patients (12%).

– In all tear corrected during the surgery & 1 required conversion to open surgery.


• OGD performed in 39 LHM & 37 PD patients• PD - 14% oesophagitis (4 grade A and one grade C) • LHM - 18% had oesophagitis (3 grade A and 4 grade B)


P=0.76

P=0.7Moonen et al. Gut 2016

Reflux post POEM• 103 post POEM patients - All Eckardt <3

– GERD evaluation after mean follow-up of 7.6 +/- 3.6 months– >50% had AET >5% with mean DeMeester Score of 39.7– Complete clinical remission with standard PPI therapy.

Familiari P, et al Dig Endosc 2016

• 282 post POEM patients – Eckardt <3 in 94%– GERD evaluation after mean follow-up of 12 (IQR 10-24) months– 58% had DeMeester score of ≥ 14.7

• Multivariable analysis - female sex was only independent association (OR 1.69)• No intra-procedural variables associated with GER.

– Endoscopy performed in 233 patients - 23% had reflux esophagitis - :• LA grade A - 27 [11.6%]• LA grade B 14 [6.0%]• LA grade C 9 [3.9%]• LA grade D 4 [1.7 %]

– 60% had asymptomatic GER (DM>14.7 but not requiring PPI)Kumbhari et al Endoscopy 2017

POEM (Per-oral Endoscopic Myotomy)

• Innovative endoscopic method for dissection of the LOS using a needle-knife to cut the muscular fibers from the lumenal side

• Ortega - first described an endoscopic approach to myotomyOrtega et al. Gastro Endosc 1980

• Pasricha - described the feasibility of endoscopic submucosal esophagealmyotomy in a survival Porcine animal model

Parishca et al Endoscopy 2007

• Inoue - first POEM in humansInoue et al Endoscopy 2010

• Youngest patient to date - 3 years and the eldest 93 years oldMaselli et al Endoscopy 2012Stavropoulos et al Therap Adv Gastroenterol. 2013

• Indications now include hypertensive and spastic pathologyKo et al Korean J Gastroenterol. 2014Tamhankar et al J. Gastrointest. Surg. 2003 Minami et al Endoscopy. 2014





Pneumatic dilatation Heller’s Myotomy

• 13 of the 105 patients (12%).– In all tear corrected during the surgery

& 1 required conversion to open surgery.


Moonen et al. Gut 2016

GUT 2016

Post-procedure reflux at 4 years• OGD performed in 39 LHM & 37 PD patients

• PD - 14% oesophagitis (4 grade A and one grade C) • LHM - 18% had oesophagitis (3 grade A and 4 grade B)


P=0.76

P=0.7

GUT 2016

• The cumulative risk of any subsequent intervention for achalasia after 1, 5, and 10 years, respectively, was 36.8%, 56.2%, and 63.5% for persons treated initially

• with pneumatic dilatation and was 16.4%, 30.3%, and 37.5% for persons treated initially with surgical myotomy

Lopushinsky, S.R., et al, JAMA. 2006;296:2227-2233

0

4

8

12

16

20

Heller Heller + Dor

Pathologic GER Normal pH Study

56%

Ric

hard

s WO

et a

l. An

n Su

rg20

04; 2

40: 4

05-4

15

Myotomy with or without wrap (n=43)prospective, randomized, double-blind clinical trial

F/U 6 months

Patie

nts

*

*P = 0.005 vs. Heller plus Dor

10%


• Based on 3 comparative studies - significantly higher clinical treatment failure rate for LHM than POEM (OR, 9.82; 95% CI, 2.06-46.80; P<0.01)

• Criteria for treatment failure varied and had not been agreed upon by various authors• Teitelbaum et al described failure rate as Endoflip distensibility index of EGJ of

<2.9mm2/mm Hg • Kumbhari et al reported following treatment of Type III (2 post LHM patients required

repeat surgery)• Chan et al described 3/23 post LHM had further dysphagia but only one had re-intervention

and thus constituted a failure

Forest plot for clinical response to treatment

Chan et al Dig Endosc. 2015Kumbhari et al Endosc Int Open. 2015Teitelbaum et al Surg Endosc. 2015

• Reflux-associated ‘complications’– 1 case of a severe reflux-associated stricture requiring dilatation, – 2 patients with minor transient Eckardt score elevations curable by proton pump inhibitor

(PPI) treatment.

• Endoscopic signs of reflux oesophagitis (primarily LA grade A/B) were seen in 37.5% (37/72) buy 12-18 months

– Grade A 20.8% – Grade B 12.5%– Grade C 2.8% – Undefined 1.4%

• Conclusions– High initial success rate of POEM is followed by a midterm recurrence rate of 18%. – 1 in 5 patients had suffered a recurrence of symptoms or required further intervention

Of the 18 failures, 8 were among the first 10 cases treated– May have biased the estimate of long-term treatment success rate

Werner et al continued…

Botulinum toxin 0% (0/2) 86% (6/7) 22% (2/9) 39% (7/18)

Pneumatic dilation 38% (3/8) 73% (19/26) 0% (0/11) 53% (24/45)

Heller Myotomy 67% (4/6) 100% (13/13) 0% (0/1) 85% (17/20)

All (any) interventions 44% (7/16) 83% (38/46) 9% (2/21) 56% (47/83)

Response Rates of Achalasia Treatments 83 Patients categorized by HRM subtype

Number of interventions 1.6 ± 1.5 1.2 ±0.4* 2.4 ± 1.0† 1.8 ± 0.7

Successful last intervention 56% 96%* 29%*† 71%

Last intervention type B-0,P-10,M-6 B-6,P-25,M-15 B-8,P-8,M-5 B-14,P-43,M-26

Subsequent Interventions

*P<0.05 vs Type I, †p<0.05 vs Type III

Pandolfino JE et al, Gastroenterology 2008Nov;135(5):1526-33

AchalasiaIntervention

Type IClassic

Type IIcompression

Type IIISpasm

AllTypes

achalasia subtype - important predictor of clinical outcome

Years postHeller

1 yr(n=136)

5 yr(n=65)

10 yr(n=38)

≥ 15 yr(n=25) P

PathologicalpH studies

11 (8.1%) 12 (18.5%) 9 (23.7%) 6 (24%) 0.006

Ortiz, A., et al., Ann Surg 2008;247:258-364

Heller Myotomy + Posterior Partial Fundoplication

Bhayani et al. Annals of Surgery 2014 (N=101)

Post-POEM 20-46%(objective data - erosive esophagitis &/or abnormal pH study)

Stavropoulos et al. White Paper. Gastroint Endosc 2014

Post LHM rates of reflux based on pH studies 20% - 42%Boeckxstaens et al NEJM 2011 – 2 years (n=107)

LHM 23% positive pH studiesRawlings et al Surg Endosc 2012 – 12 months (n=43 followed up)

42% Dor vs. 21% Toupet (p=NS) positive pH study Moonen et al. Gut 2016 – 5 years (n=71)

LHM 23% positive pH studies

POEM vs LHM with partial wrap

Well–designed multi-centred randomized studies reported >30% rates of objective GORD after Heller myotomy + wrap

Management of Achalasia · Management of Achalasia The 18thAnnual Congress of the Lebanese Society...

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