PRO - CONTRO Trattamento dell׳acalasia: endoscopia o

20° CONGRESSO NAZIONALE
delle Malattie Digestive Napoli, 19-22 Marzo 2014
PRO - CONTRO
Trattamento dell’acalasia:
endoscopia o chirurgia?
Sandro Mattioli
Unità Operativa di Chirurgia Toracica
Centro per lo Studio e la Terapia delle Malattie dell’Esofago
Alma Mater Studiorum - Università di Bologna
GVM Care & Research
Cotignola (Ra), Italy
Acalasia – Dilatazione Pneumatica
Rigiflex Achalasia dilator (Microvasive, Milford MA,
USA)
Esophageal Achalasia - Pneumatic Dilatation vs Heller-Dor
Retrospective comparative evaluation
Inclusion criteria
Heller-Dor and
Pneum.Dil groups:
PneumaticDilatation
and Surgical groups
Pre and post
Clinical interview
Upper GI endosc.
x-ray Barium swallow
Esophageal manometry
PD-reduction of > 70% LES
pressure after the procedure
Surgery
Heller-Dor (laparotomy)
36 cases/group homogeneous acc.to pre op RX
morphology
minimal FU > 48 months
1993
Esophageal Achalasia - Pneumatic Dilatation vs Heller-Dor
Global Results
Excellent
Pneumatic dilatation
Heller-Dor
(mean F.U. 70.1 months)
(mean F.U. 78.3 months)
5 / 13.9%
28 / 77.7%
22 / 61.1%
6 / 16.7%
DS0,RS0,E0
Good
DS1 or RS1,E0
Fair
4 / 11.1%
0
DS1,RS1,E1
Poor
5 / 13.9%
DS2-3,RS2-3,E2-3
1993
2 / 5.5%
Esophageal Achalasia - Pneumatic Dilatation vs Heller-Dor
conclusions
In the long run Pneumatic Dilatation and
Myotomy are both valid treatments for
esophageal achalasia, although only surgery
may achieve complete cure of dysphagia.
The gambler’s rule : risk more to obtain
more 1993
The cure of oesophageal achalasia
Dysphagia
GOR Reflux
Endoscopic evidence of GERD (erosive esophagitis) after POEM
Surg Endosc 2013; 27:3322–3338
Surgery for Achalasia
Long Abdominal
Myotomy
Latin Europeans Countries
Short Transthoracic
Myotomy
North America and
United Kingdom
Esophagomyotomy for Esophageal Achalasia:
Experimental, Clinical, and Manometric Aspects
Types of experimental myotomies
performed.
A) "Classic" Heller; B) 'long" Heller;
Ellis FH et al. Ann Surg 1967, 166:640-655
C) "short" Heller.
Center for the Study and Therapy
of Diseases of the Esophagus
University of Bologna
 1955-1970
85 Abdominal Heller Myotomy
(13 + Lortat Jacob)
Mean Follow up 155.8 months (r. 12-342 months)
 1973-1976
30 Transthoracic short Myotomy
acc. to F.H. Ellis
Mean Follow up 88.4 months (r. 36-130 months)
Dysphagia
9.6%
Reflux Esophagitis
22.6%
Dysphagia
23%
Reflux Esophagitis
21%
Causes of failure of the Heller Myotomy
• Periesophageal scarring
• Reflux Esophagitis
• Insufficient Myotomy
• Adenocarcinoma
Abdominal Myotomy
Transthoracic limited
Myotomy
Post Jatrogenic GER
• Squamous Cell Carcinoma
Sigmoid esophagus
IL RAZIONALE
Miotomia esofagogastrica lunga per abolire la HPZ
distale
Liebermann-Meffert D. Muscular equivalent of the lower esopgaheal sphincter
Gastroenterology 1979; 761:31–8
Surgical Therapy of Achalasia
Anti-Reflux
Fundoplication
A long and soft
fundoplication
To protect the
surface of the
myotomy
180°
270°
LONG MYOTOMY
Mattioli et al. Ann Surg 1993;218:635-9
Intraoperative Manometry and long term result
Relationship between pressure and length of the fundoplication and
presence or absence of reflux oesophagitis (31 pts mean f.u. 41.5 months)
Mattioli S. Min Chir 1991
Oesophageal Surgery and Scientific Literature 1999-2010
(http://www.ncbi.nlm.nih.gov/pubmed)
Journal Citation Reports Edition 2007
Achalasia 126 articles
Heller–Dor technique as procedure of choice = 76 (60.3%)
Rank
General Surgery Journals
1
ANN SURG
3
BRIT J SURG
10
ARCH SURG-CHICAGO
Rank
5
32
Rank
11
35
36
Endoscopic and Laparoscopic
Surgical Journals
ENDOSCOPY
SURG ENDOSC
Thoracic Surgery Journals
J THORAC CARDIOV SUR
ANN THORAC SURG
EUR J CARDIO-THORAC SURG
Articles 38
22
3
13
Impact Factor
7.446
4.304
3.485
Articles
55
Impact Factor
2
53
4.166
2.242
Articles
33
9
15
9
Impact Factor
3.354
2.022
2.011
Dysphagia symptom improvement and postoperative GER
Role of fundusplication
Systematic Review and Meta-Analysis
p=0,23
*
DYSPHAGIA
Campos G.M. et al. Ann Surg 2009;249: 45–57
Heller Myotomy Versus Heller Myotomy With Dor Fundoplication for
Achalasia. A Prospective Randomized Double-Blind Clinical Trial
Richards WO et al. Ann Surg 2004;240: 405–415
Endoscopic evidence of GERD (erosive esophagitis) after POEM
Surg Endosc 2013; 27:3322–3338
Latency of CLE, Dysplasia and Cancer after myotomy
21/343 pts. 16,3% F.U. med. 220 m.
Di Simone MP, Mattioli S, et al. Ann Thor Surg 1996
Mattioli S et al. Eur J Cardiothorac Surg. 2006; 29 (6): 914-9.
30 YEARS EXPERIENCE
HELLER–DOR OPERATION
1979 – 2009
262 patients
Mortality
Laparotomy
202 pts.
(97 men, median age
55.5 yrs. IQR 43.7-71)
Laparoscopy
60 pts.
(24 men, median age
46 yrs. IQR 36.2-63)
1/202
0/60
Morbility
Median
Follow-up
6.5%
96 months
(IQR 48-190.5)
8.3%
2 conversions
48 months
(IQR 27-69.5)
Mattioli S et al. J Thorac Cardiovasc Surg 2010;140:962-9
INTRAOPERATIVE
MANOMETRY
Laparotomy
102 cases
Laparoscopy
60 cases
100%
100%
Mean Length
DOR fundoplication
4.5 (±0.4) cm
4.5 (±0.5) cm
Mean Pressure
DOR fundoplication
13.3 (±2.2) mmHg
13.2 (±2.2) mmHg
Abolition HPZ
p=0.75
Mattioli S et al. J Thorac Cardiovasc Surg 2010;140:962-9
0
12
36
60
Clinical interview,
barium swallow x-ray,
manometry,
endoscopy.
Clinical interview,
barium swallow x-ray,
manometry,
endoscopy.
Clinical interview,
barium swallow x-ray,
manometry,
endoscopy.
Clinical interview,
barium swallow x-ray,
manometry,
endoscopy.
Surgery
Pre-surgery work-up
Long term results following Achalasia treatment
Follow - up protocol
120 months
RESULTS
Dysphagia
Laparotomy
201 pts.
Median follow-up
96 months (IQR, 48–190.5)
Laparoscopy
60 pts.
Median follow-up
48 months (IQR, 27–69.5)
Excellent
Good
Fair
Insufficient
90.5%
7.5%
2%
98.3%
1.7%
0%
Mattioli S et al. J Thorac Cardiovasc Surg 2010;140:962-9
RESULTS
Reflux esophagitis
Laparotomy
201 pts.
Median follow-up
96 months (IQR, 48–190.5)
Laparoscopy
60 pts.
Median follow-up
48 months (IQR, 27–69.5)
Excellent
Good
Fair
Insufficient
90%
2.5
7.5%
96.7%
0%
3.3%
Mattioli S et al. J Thorac Cardiovasc Surg 2010;140:962-9
Laparotomy
201 pts.
Laparoscopy
60 pts.
Median follow-up
96 months
(IQR, 48–190.5)
Median follow-up
48 months
(IQR, 27–69.5)
Excellent
113 (56.2%)
30 (50%)
Good
55 (27.4%)
27 (45%)
Fair
14 (6.9%)
1 (1.7%)
Insufficient
19 (9.5%)
2 (3.3%)
RESULTS
D0
RS0
E0
D1
RS1
E0
D2
RS2
E1
D3
RS3
E2-3-4 or L.A. A-B
Mattioli S et al. J Thorac Cardiovasc Surg 2010;140:962-9
Acalasia Sigmoide
Mattioli S et al. Eur J Cardiothor Surg 2007; 32: 827-833
SIGMOID ACHALASIA-PULL DOWN TECHNIQUE
Mattioli et al.European Journal of Cardio-thoracic Surgery 32 (2007) 827—833
SIGMOID ACHALASIA PULL DON TECHNIQUE
RESULTS
%
45
40
35
30
25
No Pull-Down
20
Pull-Down
15
P > 0.05
10
5
0
Excellent
Good
Fair
Insufficient
Mattioli et al.European Journal of Cardio-thoracic Surgery 32 (2007) 827—833
Pneumatic Dilation versus
Laparoscopic Heller’s Myotomy for
Idiopathic Achalasia
N Engl J Med 2011;364:1807-16.
•Exclusion criteria were…megaesophagus (diameter of >7 cm),
•and differences in the length of the cut in the myotomy between
our study and a 2003 study (in which the length of the cut
extended up to 3 cm in the stomach) may have led to differences
in the rates of therapeutic success.
Pneumatic Dilation versus Laparoscopic Heller’s Myotomy for Idiopathic Achalasia
Kaplan–Meier Curves for the Rate of
Treatment Success
N Engl J Med 2011;364:1807-16.
Esophageal Achalasia - Endoscopic vs Surgical Therapy
conclusions
In the long run Pneumatic Dilatation and Myotomy
are both valid treatments for esophageal achalasia,
although only surgery may achieve complete cure of
dysphagia.
a good dilation is better than a “not perfect “surgery
2014

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