Randomized Controlled Trial of Botulinum Toxin Versus Laparoscopic Heller Myotomy for Esophageal Achalasia

Zaninotto, Giovanni; Annese, Vito; Costantini, Mario; Genio, A. Del; Costantino, Michela; Epifani, Magdalena; Gatto, G.; D'Onofrio, V.; Benini, Luigi; Contini, Sandro; Molena, Daniela; Battaglia, Giorgio; Tardio, B; Andriulli, Angelo; Ancona, Ermanno

doi:10.1097/01.sla.0000114217.52941.c5

Cited by 235 publications

(123 citation statements)

References 22 publications

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“…A randomized controlled trial published in 2017 comparing POEM with pneumatic dilation found the POEM procedure to be more efficacious in terms of therapeutic success, but also more likely to result in post-procedure reflux oesophagitis 61 . The preceding discussion makes no mention of medical treatments for achalasia, specifically botulinum toxin [62][63][64][65] , calcium-channel blockers 66 , nitrates 66 and phosphodiesterase type 5 inhibitors 67 primarily because, although these agents provide some symptomatic benefit, they are not durable therapies and they do not halt the disease progression toward oesophageal decompensation characterized by dilatation and food retention. For example, in the case of botulinum toxin injected into the LES, about two-thirds of patients with achalasia report an improvement in dysphagia, but most relapse within a year and repeat treatments have diminished effectiveness, making it a poor firstline therapy [62][63][64][65] .…”

Section: Poemmentioning

confidence: 99%

Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

Kahrilas

Bredenoord

Fox

et al. 2017

Nat Rev Gastroenterol Hepatol

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High-resolution manometry (HRM), along with the analysis algorithms characterized in the Chicago Classification (CC) first proposed in 2008, have led to a major restructuring of the classification of oesophageal motility disorders. The inherently quantitative output of HRM devices fuelled enthusiastic expectation among motility experts that these advances would add a level of precision to the diagnosis of oesophageal motility disorders that was not previously possible. Nowhere was this advance more evident than in our concept of achalasia, now differentiated into subtypes as a direct result of HRM. Coincident with the assimilation of HRM into clinical practice was the development of a major therapeutic intervention for the management of oesophageal motility disorders, per-oral endoscopic myotomy (POEM). Not only does the POEM procedure provide a therapeutic option for myotomy with reduced morbidity relative to laparoscopic or open myotomy, but it also enables a calibrated intervention that is customized to patient-specific physiology. Together, these develop ments fostered an increasing emphasis on targeting therapy to specific aspects of oesophageal dysfunction, as measured by physiological testing, rather than discrete diagnoses. Again, nowhere is this evolution more evident than in our strategies for managing achalasia. This Consensus Statement examines the effect of HRM on our current understanding of oesophageal motility disorders with a focus on how this technology has affected the diagnosis, epidemiology and management of achalasia and achalasia-like syndromes. on behalf of the International Working Group for Disorders of Gastrointestinal Motility and FunctionAbstract | High-resolution manometry (HRM) and new analysis algorithms, summarized in the Chicago Classification, have led to a restructured classification of oesophageal motility disorders. This advance has led to increased detection of clinically relevant disorders, in particular achalasia. It has become apparent that the cardinal feature of achalasia -impaired lower oesophageal sphincter (LES) relaxation -can occur in several disease phenotypes: without peristalsis (type I), with pan-oesophageal pressurization (type II), with premature (spastic) distal oesophageal contractions (type III), or with preserved peristalsis (outlet obstruction). Furthermore, no manometric pattern is perfectly sensitive or specific for achalasia caused by a myenteric plexopathy, and there is no biomarker for this pathology. Consequently, physiological testing reveals other syndromes not meeting achalasia criteria that also benefit from therapies formerly reserved for achalasia. These findings have become particularly relevant with the development of a minimally invasive technique for performing a long oesophageal myotomy, the per-oral endoscopic myotomy (POEM). Optimal management is to render treatment in a phenotype-specific manner; that is, POEM calibrated to patient-specific physiology for spastic achalasia and the spastic disorders, and more conservative strategies...

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Section: Poemmentioning

confidence: 99%

Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

Kahrilas

Bredenoord

Fox

et al. 2017

Nat Rev Gastroenterol Hepatol

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“…31 The clinical effects of a single injection are short lived with relapse in more than 50% within 6 months. 28 However, repeated injections may confer clinical benefit in 70% to 90%. 32 In one report, 21% of newly diagnosed achalasia patients were treated with BTox as the initial modality of treatment with an average duration of effect of 6 months.…”

Section: Medical Treatmentmentioning

confidence: 99%

“…34 Usually, 80 to 100 units of BTox-A are injected in each quadrant of the LES in 0.5 to 1ml aliquots. 28 This improves the symptoms of achalasia, decrease LES pressure, increase lower esophageal aperture and improve esophageal emptying. 31 The clinical effects of a single injection are short lived with relapse in more than 50% within 6 months.…”

Section: Medical Treatmentmentioning

confidence: 99%

“…The toxins specifically bind the presynaptic membrane and enter the cystol of the nerve terminal where they cleave different proteins involved in neuroexocytosis. 28,29 Botulinum toxin-A which is used for the treatment of achalasia cleaves the SNAP-25 molecule of the presynaptic membrane, thus blocking acetylcholine (ACH) release. 29,30 In the early nineties, Pasrich and colleagues evaluated the usefulness of intrasphincteric injection of BTox in achalasia patients.…”

Section: Medical Treatmentmentioning

confidence: 99%

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Achalasia: What is the best treatment?

Ahmed

2008

Ann Afr Med

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Background: Achalasia is an infrequent primary motility disorder of the esophagus. Because of uncertain etiology, treatment is only palliative and is directed at decreasing lower esophageal sphincter pressure, improving esophageal emptying and relieving the symptoms of achalasia. Current treatment options include pharmacological, endoscopic and surgical. We undertook a systematic literature review of the management strategies currently available for achalasia. Method: A Medline, PubMed and Cochrane database search was conducted using reference manager 11. Original articles and reviews published in the English literature on the management of achalasia were reviewed. Emphasis was placed on articles published in the last ten years on randomized controlled trials comparing the various forms of treatment. Results: Esophageal manometry is the standard diagnostic evaluation for achalasia. Accurate diagnosis can also be made based on clinical findings and barium esophagogram. Medical treatment with nitrates or calcium channel blockers has variable results in alleviating the symptoms of achalasia but long-term results are disappointing because of tolerance and side effects. Intrasphincteric injection of botulinum toxin, pneumatic dilatation and surgical myotomy are variably effective at controlling the symptoms of achalasia but each modality has specific strength and weaknesses which make their choice suitable in a particular group of patients. While pneumatic dilatation is superior to botulinum toxin injection surgical myotomy provides the best long-term control of symptoms in patients with achalasia. Conclusion: Laparoscopic myotomy should be the initial treatment for most patients with achalasia. Pneumatic dilatation is the most cost-effective alternative but its long-term efficacy is less than that of surgical myotomy. Endoscopic botulinum toxin injection can be considered when other forms of treatment are contraindicated. Key words: Achalasia, Heller's esophagomyotomy, pneumatic dilatationRésumé Contexte: L'achalasie est une rare anomalie motrice de l'oesophage. En raison de son étiologie incertaine, le traitement est seulement palliatif et vise la réduire la pression sphinctérienne du bas oesophage, l'amélioration de la vidange et le soulagement des symptômes de l'achalasie. Les options thérapeutiques courantes font appel aux moyens pharmacologiques, endoscopiques et chirurgicaux. Nous avons effectué une revue systématique de la littérature relative aux stratégies thérapeutiques actuellement disponibles pour l'achalasie. Méthode: Une recherche sur Medline, Pubmed et Cochrane a été faite a l'aide du logiciel Reference Manager 11. Les articles originaux et les rapports portant sur la prise en charge de l'achalasie et publiés en anglaise ont été passés en revue. L'accent a été mis sur les articles publiés au cours des dix dernières années et sur les essais contrôlés comparant les diverses formes de traitement. Résultats: La manométrie oesophagienne est la méthode de diagnostic standard pour l'achalasie. Le dia...

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“…However, the action only persist for 3 to 4 months, half of patients relapse and need reintervention at 6-24 months after the first injection, thus limiting the use in clinical practice. There is some evidence that repeated injections could affect the subsequent surgical miotomy, thus the use of Botox should be reserved to elderly patients or patients with associated pathology who have contraindications for endoscopic dilation or miotomy (28)(29)(30).…”

Section: Endoscopic Injection Of Botoxmentioning

confidence: 99%

High Resolution Manometry - A Mandatory Examination in the Pre and Postoperative Assessment of Patients with Achalasia

Dimitriu¹,

Gheorghe²

2018

chr

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RezumatManometria esofagiană cu rezoluţie înaltă este actual investigaţia gold-standard în diagnosticul acalaziei şi a bolilor esofagiene funcţionale. Această examinare este întotdeauna precedată de endoscopia digestivă superioară, care are scopul de a face diagnosticul diferenţial al acalaziei cu pseudoacalazia (formaţiuni tumorale de fornix gastric/esofag distal). La momentul actual, nu există tratament curativ pentru acalazie. Însă, cele 3 subtipuri de acalazie (conform clasificării Chicago) au răspuns diferit în ceea ce priveşte eficacitatea în tratamentului ales. Astfel, comparativ cu tipurile I şi III, tipul II de acalazie are cel mai bun răspuns la intervenţiile terapeutice invazive (dilatare pneumatică sau cardiomiotomie Heller). În schimb, în tipul III cardiomiotomia Heller este de ales ca prima abordare terapeutică. Miotomia endoscopică perorală (POEM) este o tehnică relativ recentă, care necesită însă studii pe termen lung în ceea ce priveşte siguranţa şi eficacitatea. Articolul prezent îşi propune să prezinte variantele actuale de tratament ale acalaziei, comparându-le pe baza eficacităţii şi siguranţei pe termen scurt şi lung, subliniind de asemenea rolul manometriei cu rezoluţie înaltă în diagnosticul, alegerea metodei terapeutice şi prognosticul acestor pacienţi. Review ArticleAbstract High resolution manometry (HRM) is currently the gold standard for the diagnosis of achalasia and other functional esophageal disorders. All patients accusing dysphagia should be endoscopically evaluated prior to manometric investigations in order to rule out pseudoachalasia. The Chicago HRM classification has led to a subclassification of three manometric types of achalasia that seem to have different results to treatment. None of the actual achalasia treatment options are curative. Type II achalasia patients respond best to all treatment options compared to those with types I and III. Pneumatic dilation (PD) or Heller miotomy (LHM) can be both chosen as initial therapy in type I and II as they have good outcome , while type III achalasia patients respond better to LHM as a first therapeutic option. Peroral endoscopic myotomy (POEM) is a promising new technique but long-term follow-up studies for its safety and efficacy must be performed. This article reviews the current therapeutic options in achalasia and other functional esophageal disorders, based on the differences in safety and efficacy between approaches, highlighting the impact of HRM to predict the outcome but also the role of the techinque in guiding antireflux surgery.

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Randomized Controlled Trial of Botulinum Toxin Versus Laparoscopic Heller Myotomy for Esophageal Achalasia

Abstract: Laparoscopic myotomy is as safe as BoTx treatment and is a 1-shot treatment that cures achalasia in most patients. BoTx should be reserved for patients who are unfit for surgery or as a bridge to more effective therapies, such as surgery or endoscopic dilation.

Cited by 235 publications

References 22 publications

Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

Achalasia: What is the best treatment?

High Resolution Manometry - A Mandatory Examination in the Pre and Postoperative Assessment of Patients with Achalasia

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