SAGES Guidelines - Achalasia, Hiatal Hernia, GERD Flashcards
Patients with suspected achalasia should undergo what workup?
barium esophagram, an upper endoscopy, and esophageal manometry to confirm the diagnosis (+++, strong)
What does barium esophagram show for achalasia?
smooth tapering of the lower esophagus leading to the closed LES, resembling a “bird’s beak.”
Esophageal manometry establishes the diagnosis of achalasia showing what?
esophageal aperistalsis and insufficient LES relaxation with swallowing
In the workup of achalasia, what is the upper endoscopy meant to exclude?
pseudoachalasia arising from a tumor at the gastroesophageal junction
The pathological changes seen in achalasia?
myenteric inflammation with injury to and subsequent loss of ganglion cells and fibrosis of myenteric nerves; also a significant reduction in the synthesis of nitric oxide and vasoactive intestinal polypeptide. Possibly 2/2 autoimmune-mediated destruction of inhibitory neurons in response to an unknown insult in genetically susceptible individuals; however, a definite trigger has not been identified.
Role of pharmacotherapy in achalasia?
Pharmacotherapy plays a very limited role in the treatment of achalastic patients and should be used in very early stages of the disease, temporarily prior to more definitive treatments, or for patients who fail or are not candidates for other treatment modalities (++++, strong).
Smooth muscle relaxants such as calcium channel blockers and long-acting nitrates are effective in reducing LES pressure and temporally relieving dysphagia but do not improve LES relaxation or improve peristalsis. Since the prolonged esophageal transit and delayed esophageal emptying that characterize achalasia make the absorption kinetics and effectiveness of orally administered medications unpredictable, these agents are used sublingually. These drugs decrease LES pressure by approximately 50% with the long-acting nitrates having a shorter time to maximum effect (3-27 min) and symptom improvement in 53-87% of achalasia patients compared with sublingual nifedipine (30-120 min and 0-75% symptom improvement, respectively).
The main limitations of these agents are their short duration of action, the incomplete symptom relief, and decreased efficacy during long-term use. In addition, side-effects such as peripheral edema, headache, and hypotension occur in up to 30% of patients and further limit their use. The use of the available pharmacologic agents is, therefore, limited to symptomatic relief of patients with very early disease with a nondilated esophagus, or as a temporary measure for patients who are awaiting a more definite treatment option, or are high risk for or refuse more invasive options. In addition, the use of some medications may be useful in the case of severe achalasia-related chest pain.
What is the role for botox injections in achalasia?
Botulinum toxin injection can be administered safely, but its effectiveness is limited especially in the long term. It should be reserved for patients who are poor candidates for other more effective treatment options such as surgery or dilation (++++, strong).
Who should be offered endoscopic dilation for achalasia?
Among nonoperative treatment techniques endoscopic dilation is the most effective for dysphagia relief in patients with achalasia but is also associated with the highest risk of complications. It should be considered in selected patients who refuse surgery or are poor operative candidates (++++, strong).
POEM is a better alternative if can be done.
What is the role for esophageal stents in achalasia?
The use of esophageal stents cannot be recommended for the treatment of achalasia (++, strong).
Their use is clearly associated with high complication rates and even mortalities
How do you manage a hiatal hernia during a Heller myotomy for achalasia?
When there is a hiatus hernia, adequate mobilization of the esophagus to restore a normal intra-abdominal length is required, and the crura should be closed behind the esophagus making sure not to restrict the esophagus. Crural closure is typically performed after completion of the myotomy.
How do you manage the anterior vagus during a Heller myotomy for achalasia?
The epiphrenic fat pad is excised from the anterior LES starting to the left of the anterior vagus nerve to create adequate room to perform the myotomy on the stomach. The anterior vagus nerve is dissected off the distal esophagus so that the myotomy can be taken high up the esophagus beneath the nerve.
How do you manage the anterior vagus during a Heller myotomy for achalasia?
The epiphrenic fat pad is excised from the anterior LES starting to the left of the anterior vagus nerve to create adequate room to perform the myotomy on the stomach. The anterior vagus nerve is dissected off the distal esophagus so that the myotomy can be taken high up the esophagus beneath the nerve.
During a Heller myotomy for achalasia, describe the myotomy portion.
The surgeon and assistant each grasp one side of the esophagus and retract in opposite directions to provide better exposure and facilitate the myotomy. The esophageal muscle fibers are split and dissected laterally starting with the longitudinal fibers and entering the circular fibers until a small pocket is made between the circular fibers and the mucosa. The myotomy is continued up the esophagus for at least 4 cm and taken onto the stomach for approximately 2 cm. This dissection is tedious and should be done with care to avoid perforation of the esophageal mucosa. The change from esophageal to gastric muscle fibers can be seen as they change from a horizontal circular orientation to an oblique one and are more adhered to the mucosa. There is also bulging of the mucosa at the LES area. Injection of dilute epinephrine into the muscle before myotomy may be useful, as it minimizes bleeding and allows for better visualization of the mucosa.
During a Heller myotomy for achalasia, you are checking the mucosa and notice bubbles when insufflating the NGT/EGD. What do you do?
When bubbles are seen, the area from where they emanate should be oversewn with 4-0 Vicryl, and the subsequent fundoplication should be used to cover the area. In the context of perforation, consideration should also be given to drain placement.
What fundoplications are typically used during Heller myotomy? Why are they needed?
They prevent reflux and buttress the mucosa.
The most commonly used options for fundoplication after myotomy include an anterior Dor fundoplication or a posterior Toupet fundoplication. For the Dor fundoplication, the greater curvature of the stomach is pulled over the esophagus making sure it is redundant so as not to restrict the LES and is sutured to the crura where they meet anteriorly. Some surgeons also attach it to the edges of the myotomy to hold it open, and some attach the edges of the myotomy to the crura as well. When a Toupet fundoplication is used, the fundus is pulled behind the esophagus and attached to the left and right cut edges of the myotomy to keep it open.
What is the effect of prior endoscopic interventions for achalasia patients undergoing Heller myotomy?
Prior endoscopic treatment for achalasia may be associated with higher myotomy morbidity, but the literature is inconclusive.
Compare Heller myotomy to pneumatic dilation, botox, and VATS myotomy for achalasia.
Laparoscopic myotomy with partial fundoplication provides superior and longer-lasting symptom relief with low morbidity for patients with achalasia compared with EGD dilation, botox, and VATS achalasia and should be considered the procedure of choice to treat achalasia. (++++, strong).
What is the recommended length of the myotomy in lap Heller for achalasia?
The length of the esophageal myotomy should be at least 4 cm on the esophagus and 1-2 cm on the stomach (+, weak).
How do you manage epiphrenic diverticula associated with achalasia?
Epiphrenic diverticula should be treated surgically when symptomatic. Given their frequent association with achalasia, esophageal manometry should be pursued to confirm the diagnosis of achalasia when they are identified. A myotomy at the opposite side of the diverticulum that goes beyond the distal extent of the diverticulum should be performed when achalasia is present. In this situation, concomitant diverticulectomy may be indicated based on the size of the diverticulum. When diverticula are not resected, endoscopic surveillance is advised. The optimal approach for their treatment needs further study, and surgeons should be aware of the relatively high incidence of postoperative leaks (+, weak).
What are treatment options after a failed myotomy?
Endoscopic Botulinum toxin treatment can be applied safely and with equal effectiveness before or after myotomy (++, weak), but endoscopic balloon dilation after myotomy is currently considered hazardous by most experts (++, weak). Repeat myotomy may be superior to endoscopic treatment and should be undertaken by experienced surgeons (++, strong). Esophagectomy should be considered in appropriately selected patients after myotomy failure (+, weak).