TERAPIA ENDOSCOPICA

IN ACHALAZIA CARDIEI

Dr..Cristian Balahura, Dr. Cosmina Vladut

Dr

Laboratorul de
Endoscopie digestiva diagnostica si terapeutica
”Delta”Hospital

Achalazia cardiei

 tulburare motorie primara a esofagului

 relaxarea incompleta a LES dupa deglutitie

 absenta peristalticii la nivelul corpului esofagului.

 cauza: degenerarea celulelor ganglionare din

plexul mienteric la nivelul corpului esofagului si
LES
 mecanism autoimun cu trigger viral?

Diagnostic
 Criterii clinice

 Criterii paraclinice-
paraclinice- cel putin doua metode
paraclinice necesare:
 stadii incipiente:
incipiente: aspecte endoscopice si radiologice normale
 aspect radiologic tipic / criterii manometrice insuficiente

 tranzit baritat esofagian:

esofagian: 66% aspect diagnostic

 endoscopia digestiva superioara:

superioara: 33% aspect diagnostic

 manometrie esofagiana – gold standard: 90% aspect

diagnostic
Vantrappen G, Hellemans J, DeloofWet al. Treatment of achalasia with pneumatic dilatations. Gut 1971; 12(4): 268 –275.
Howard PJ, Maher L, Pryde A et al. Five year prospective study of the incidence, clinical features, and diagnosis of achalasia
achalasi a in
Edinburgh. Gut 1992; 33(8): 1011–
1011 –1015

1
 Diagnostic paraclinic
Endoscopia digestiva superioara:
superioara: 33% aspect diagnostic
 esofag dilatat  staza salivara si alimentara
 LES contractat  permite pasajul endoscopului la presiunea
usoara
 normal endoscopic:
endoscopic: 40% din achalazii
 pseudoachalazia: 2-
2-4% / cancer esofagian asociat

Diagnostic paraclinic

 manometrie esofagiana – gold standard diagnostic-

diagnostic-
90%
90 % aspect diagnostic

 absenta peristatlismului la nivelul corpului esofagian

 uneori presiune intraesofagiana crescuta prin staza
 hipertonia LES cu o presiune de repaus > 45 mm Hg
 relaxarea deficitara a LES la deglutitie  presiune
reziduala > 10 mm Hg
 deglutitia poate declansa contractii simultane
nonpropulsive de amplitudine mare si morfologii diferite
la nivelul corpului esofagian  achalazie viguroasa

 Impedanta intraluminala multicanal cu manomerie

Pandolfino JE, Kahrilas PJ. AGA technical review on the clinical use of esophageal manometry. Gastroenterology 2005;128:209–
2005;128:209–224.

Tratamentul achalaziei
 Obiective:
 ameliorarea
ameliorarea simptomatica-
simptomatica- disfagia si regurgitatiile alimentare
 ameliorarea evacuarii esofagului
 prevenirea complicatiilor (megaesofag)

 Principiu: scaderea presiunii LES

LES/nu
/nu peristaltica esofagiana!

 Optiuni terapeutice – putine trialuri controlate:

controlate:
 tehnici endoscopice:
 dilatarea pneumatica cu balon rigid
 injecta
inject area de toxina botulinica (EBTI)
 POEM-- peroral endoscopic myotomy
POEM
 tehnici chirurgi
chirurgicale
cale - esofagocardiomiotomie extramucoasa tip
Heller + procedeu antireflux
 farmacoterapia – putin eficienta
Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy;42:265-271.

2
 Terapia endoscopica.
1. Dilatarea pneumatica cu balon

 principiu: dilatarea LES pana la un diametru de cel

putin 3 cm  fragmentarea fibrelor musculare din
musculara propria
 metode:
 dilatarea cu bujii sau cu balon TTS
TTS-- ineficiente
 dilatare cu balon pneumatic rigid – sigura si cost-
cost-eficienta
 dilatare pneumatica dupa miotomie-
miotomie- posibila

 contraindicatie relativa : risc chirurgical inalt  centre tertiare!

Kadakia SC, Wong RK. Graded pneumatic dilation using Rigiflex achalasia dilators in patients with primary esophageal achalasia.
achalasi a. Am J
Gastroenterol 1993;88:34–
1993;88:34–38.
Hulselmans M, Vanuytsel T, Degreef T, et al. Long-
Long-term outcome of pneumatic dilation in the treatment of achalasia. Clin Gastroenterol
Gastro enterol Hepatol
2010;8:30–
2010;8:30–35.

Dilatarea pneumatica cu balon rigid

 procedeul standard : balon

din polietilen Rigiflex
Microinvasive (Boston
Scientific Corp
Massachusetts, USA)
 diametre 30,35,40 mm
 marcaje radioopace
 insertie radiologic-
radiologic- ghidata

 dilatator Witzel - mai rar

 insertie endoscopic
ghidata

Dilatarea pneumatica cu balon-

balon- tehnica

 cateva zile: dieta

dieta lichidiana / a jeun 12 ore inaintea
procedurii

 sedare constienta

 alegerea diametrului balonului:

 30 mm
 35 mm la tineri, dilatari precedente esuate, postmiotomie

Kadakia SC, Wong RK. Graded pneumatic dilation using Rigiflex achalasia dilators in patients with primary esophageal achalasia.
achalasi a. Am J
Gastroenterol 1993;88:34–
1993;88:34–38.
Hulselmans M, Vanuytsel T, Degreef T, et al. Long-
Long-term outcome of pneumatic dilation in the treatment of achalasia. Clin Gastroenterol
Gastro enterol Hepatol
2010;8:30–
2010;8:30–35.

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 Dilatarea pneumatica cu balon - tehnica
Vizualizarea endoscopica a LES si plasarea unui marcaj
radioopac la acest nivel
 substanta de contrast radioopaca injectata in submucoasa
 hemoclip
 marker radiopac metalic plasat pe tegument

Dilatarea pneumatica cu balon-

balon- tehnica

Insertia endoscopica a
unui ghid Savary in
stomac

Dilatarea pneumatica cu balon-

balon- tehnica

Insertia balonului pe ghid

la nivelul LES

 ghidaj fluoroscopic/endoscopic

 marcajul de mijloc suprapus cu

“talia” balonului

4
 Dilatarea pneumatica cu balon-
balon- tehnica

Umflarea balonului:

 presiuni si durate variabile

 nu par sa influenteze
eficienta dilatarii

 pierderea “taliei” balonului

la evaluarea radiologica
dupa umflarea completa

 de ex. 7-
7-15 psi (0,5-
(0,5-1
atmosfere) timp de 15-
15-60
secunde

Richter JE, Boeckxstaens GE. Gut (2011). doi:10.1136/gut.2010.212423

Dilatarea pneumatica cu balon

 supraveghere dupa procedura ~ 6 ore
 febra
 durere toracica la realimentare
realimentare poate semnifica perforatia!
 toleranta la lichide= externare  in aceeasi zi

 reevaluare la 2-
2-4 saptamani:
 clinic
 paraclinic-- tranzit baritat/ manomerie
paraclinic
 o noua sedinta de dilatare “ on demand” cu diametru
consecutiv mai mare
 persistenta simptomelor
 evacuare esofagiana deficitara
 presiunea LES > 10 mm Hg
 esecul dilatarii cu balon de 40 mm  chirurgie
Zerbib F, Thetiot V, Richy F et al. Repeated pneumatic dilations as long-
long-term maintenance therapy for esophageal achalasia. Am J Gastroenterol
2006; 101(4): 692–
692–697.
Farhoomand K, Connor JT, Richter JE et al. Predictors of outcome of pneumatic dilation in achalasia. Clin Gastroenterol Hepatol
Hepat ol 2004; 2(5): 389–
389–
394.
Kadakia SC, Wong RK. Graded pneumatic dilation using Rigiflex achalasia dilators in patients with primary esophageal achalasia.
achalasi a. Am J
Gastroenterol 1993;88:34-
1993;88:34-8.

Complicatii
 in general minore
 durere toracica, sangerare usoara, febra pasagera,
aspiratia

 perforatii: 2%-
2%-6%
 diagnostic precoce/ defect limitat  tratament conservator
 miotomie chirurgicala de urgenta
 abordul laparoscopic de urgenta nu reprezinta standardul

 pe termen lung: BRGE 10-20%

10-
 simptome usoare-
usoare- raspund la PPI

 mortalitate < 1%
Richer JE. Update on the management of achalasia: balloons, surgery and drugs. Expert Rev Gastroenterol Hepatol 2008;2:435-
2008;2:435 -45
Reynolds JC, Parkman HP. Achalasia. Gastroenterol Clin North Am 1989;18:223–
1989;18:223–255.
Sanchez--Pernaute A, Aguirre EP, Talavera P, et al. Laparoscopic approach to esophageal perforation secondary to pneumatic dilation
Sanchez dilat ion for
achalasia. Surg Endosc 2009;23:1106–
2009;23:1106–1109.

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 Eficienta dilatarii pneumatice

 esecul probabil al dilatarii pneumatice

pneumatice
interventia chirurgicala per primam

 varsta tanara< 40 ani

 pacienti < 40 ani-
ani- eficienta la 5 ani: 16%
 pacienti > 40 ani-
ani- eficienta la 5 ani: 58%
 sex masculin
 presiune LES > 10 mm Hg dupa procedura
 esofag foarte dilatat
 nu se poate exclude pseudoachalazia

Eckardt VF, Gockel I & Bernhard G. Pneumatic dilation for achalasia: late results of a prospective follow up investigation. Gut
G ut 2004; 53(5): 629–
629–
633.
West RL, Hirsch DP, Bartelsman JF, et al. Long term results of pneumatic dilation in achalasia followed for more than 5 years. Am J Gastroenterol
2002;97:1346–
2002;97:1346 –1351.
Eckardt VF, Gockel I & Bernhard G. Pneumatic dilation for achalasia: late results of a prospective follow up investigation. Gut
G ut 2004; 53(5): 629–
629–
633

Terapia endoscopica
2. Injectarea de toxina botulinica (EBTI)

 principiu: inhibarea eliberarii de Ach din terminatiile

nervoase de la nivelul LES  relaxarea musculaturii

 indicatii:
 varstnici > 60 ani
 cost--eficienta la cei cu speranta de viata sub 2 ani
cost
 contraindicatia tratamentului conventional chirurgical sau
dilatarea pneumatica

 ac de scleroterapie  injectare la nivelul LES in

patru cadrane  doza totala 80-
80-100 IU

Injectarea de toxina botulinica

 ameliorare simptomatica
 la 1 luna: 80-
80-90%
 la 1 an: 54%
 reinjectarea la 6-
6-12 luni
 eficienta scade dupa reinjectare

 reactii adverse - rare:

 rash
 disconfort toracic  cateva zile:
zile: 16-
16-25%
 posibil creste dificultatea si eficienta unei miotomii
ulterioare
 rezervata pacientilor de varsta avansata sau care prezinta
comorbiditati semnificative

Fishman VM, Parkman HP, Schiano TD, et al. Symptomatic improvement in achalasia after botulinum toxin injection of the lower es esophageal
ophageal
sphincter. Am J Gastroenterol 1996;91:1724-
1996;91:1724-30.
Smith CD, Stival A, Howell DL, et al. Endoscopic therapy for achalasia before Heller myotomy results in worse outcomes than Hel
H eller
ler myotomy
alone. Ann Surg 2006;243:579–
2006;243:579–584.

6
 Dilatare pneumatica vs. EBTI

Metaanaliza Cochrane Reaparitia simptomatologiei

(2006) la 12 luni dupa tratament

 6 studii randomizate  dupa dilatare esofagiana: 30%

controlate
 178 pacienti  dupa EBTI: 74%!

Leyden JE, Moss AC, MacMathuna P. Endoscopic pneumatic dilation versus botulinum toxin injection in the management of primary
primar y achalasia. Cochrane
Database Syst Rev 2006:CD005046.

Dilatare pneumatica vs. miotomie

Dilatare pneumatica: Miotomie:

 posibila la orice varsta  indicata in special la barbati tineri

 pacient ambulator  spitalizarea redusa prin tehnica
laparoscopica
 BRGE minima sau absenta  BRGE frecventa-
frecventa-deteriorarea
 nu influenteaza rezultatele unei barierei antireflux
eventuale miotomii ulterioare  de obicei o singura interventie
 este mai ieftina decat miotomia chirurgicala

 tratamentul cu cost-
cost-eficienta
maxima la 5-
5-10 ani
Karanicolas PJ, Smith SE, Gafni A, et al. The cost of laparoscopic myotomy versus pneumatic dilatation for esophageal achalasia
achalas ia.. Surg Endosc
2007;21:1198-1206.
2007;21:1198-

Dilatare pneumatica vs. miotomie

Studiul Cleveland Clinic Dilatare vs. miotomie

(2006)::
(2006)  ameliorarea simptomelor
 la 6 luni: 96% versus 98%
 106 pacienti cu dilatari  la 6 ani: 44% versus 57%
pneumatice graduale
 73 pacienti cu miotomie  cauzele reaparitiei
laparoscopica simptomelor:
 tratament incomplet:
96% vs. 64%
 BRGE: 4% versus 36%

Vela MF, Richter JE, Khandwala F, et al. The long-

long-term efficacy of pneumatic dilatation and Heller myotomy for the treatment of achalasia. Clin
Gastroenterol Hepatol 2006;4:580–
2006;4:580–587

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 Dilatare pneumatica vs. miotomie
The European achalasia trial Dilatare vs. miotomie
(2010) la 2 ani

 94 pacienti cu dilatare
 ameliorarea simptomelor
pneumatica progresiva  la 2 ani:
ani: 92% vs. 87%

 106 pacienti cu miotomie

laparoscopica si fundoplicatura
 ameliorari similare ale presiunii
LES si tranzitului esofagian

Eficienta similara a celor doua metode terapeutice!

Boeckxstaens GE, Annese V, Bruley des Varannes S, et al. Pneumodilation versus laparoscopic Heller myotomy for idiopathic achalasia. N Engl J Med
2010 (in press)

Abordarea pacientului cu achalazie

Risc chirurgical scazut

Varsta< 40 ani Varsta> 40 ani

Miotomie
Dilatare pneumatica
laparoscopica

Centru tertiar Repetare la nevoie

Dilatare pneumatica

Repetarea miotomiei

Esofagectomie

Risc chirurgical inalt

Centru tertiar

Dilatare pneumatica EBTI

Repetare la nevoie Repetare la nevoie

Terapie medicametoasa

Richter JE, Boeckxstaens GE. Gut (2011). doi:10.1136/gut.2010.212423