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Zentralbl Chir 2019; 144(02): 163-170
DOI: 10.1055/a-0863-4917
Übersicht
Georg Thieme Verlag KG Stuttgart · New York

Aktuelle Therapie der Achalasie 2019

Current Treatment of Achalasia 2019
Burkhard H. A. von Rahden
Universitätsklinik für Chirurgie, Salzburger Landeskliniken, Salzburg, Österreich
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Publication History

Publication Date:
12 April 2019 (online)

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Zusammenfassung

Die Therapie der primär idiopathischen Achalasie, der häufigsten der seltenen Ösophagusmotilitätsstörungen, unterliegt derzeit einem Wandel. Zunehmend setzt sich das Prinzip der „Heller-Myotomie“ als Standard durch. Mit der von dem deutschen Chirurgen Ernst Heller im Jahr 1913 erstbeschriebenen Kardiomyotomie lässt sich meist eine sehr gute Symptomkontrolle erzielen. Metaanalysen randomisierter Studien (Level-1A-Evidenz) zeigen die Überlegenheit der laparoskopischen Heller-Myotomie (LHM) gegenüber der pneumatischen Dilatation (PD). Protagonisten der PD beziehen sich zumeist auf die Ergebnisse der europäischen Multicenterstudie, die mit häufig wiederholten PD vergleichbare Ergebnisse wie die LHM erzielt hat, mit allerdings einer (nicht Intention-to-treat inkludierten) initialen PD-Serie mit inakzeptabel hoher Perforationsrate (33%). Zur Prävention eines postoperativen gastroösophagealen Refluxes (GER) nach LHM ist die Hinzunahme einer Fundoplicatio obligat. Die Manschette der Wahl ist die anteriore 180°-Fundoplicatio nach Dor. Allerdings wird dieser Standard (LHM + Dor-Prozedur) nun bereits wieder herausgefordert. Die 2010 durch Haruhiro Inoue eingeführte und seither weltweit klinisch erprobte perorale endoskopische Myotomie (POEM) ermöglicht die Durchführung der „Heller-Myotomie“ auf rein endoskopischem Wege. Die Komplikationsraten von POEM sind gering, die Symptomkontrolle ist in systematischen Reviews der publizierten Serien zur LHM vergleichbar oder sogar diskret überlegen. Vorteile der POEM sind u. a. die Möglichkeit, eine lange Myotomie (erforderlichenfalls des gesamten Ösophagus) durchzuführen und die relativ freie Wählbarkeit der Lokalisation der Myotomie (anteriores/posteriores POEM). Nachteile von POEM sind die bewiesen höhere postoperative Refluxrate nach POEM im Vergleich zur LHM, bei allerdings meist guter Behandelbarkeit des Refluxes mit PPI, erforderlichenfalls (selten) nachträglicher laparoskopischer Dor-Fundoplicatio. (Vorläufige) Ergebnisse von 2 prospektiv randomisierten Studien zeigen die Überlegenheit der POEM gegenüber der PD und Gleichwertigkeit der POEM zu LHM + Dor-Prozedur, bei erhöhtem GER. Im eigenen Vorgehen werden POEM und LHM in einem „Tailored Approach“ (maßgeschneidert) verwendet: POEM wird bevorzugt bei Typ III und Typ II mit Brustschmerzen, LHM bei sigmoidaler Achalasie und morphologischen Begleitveränderungen (Hernie, Divertikel etc.), ansonsten liberalere Verfahrenswahl.

Abstract

Treatment of primary idopathic achalasia, the most common of the rare oesophageal motility disorders, is currently changing. The therapeutic priciple of Hellerʼs myotomy is increasingly accepted as standard. In 1913, the German surgeon Ernst Heller described the cardiomyotomy named after him, faciliating excellent symptom control. Meta-analyses of randomised trials (level 1A evidence) demonstrate superiority of laparoscopic Heller myotomy (LHM) over endoscopic pneumatic dilatation (PD). However, some surgeons still advocate the PD strategy, based on the results of the randomised European Multicenter study PD vs. LHM, suggesting that the two procedures achieve similar symptom control after 2 and 5 years. However, an initial series of PDs was excluded from “intention-to-treat” analysis, as the oesophageal perforation rate was unacceptably high (33.3%). To prevent postoperative gastroesophageal reflux (GER) after LHM, addition of a fundoplication is established as standard. The anterior 180° Dor is the wrap type of choice. This standard (LHM + Dor procedure) has now been challenged: Peroral endoscopic myotomy (POEM) was introduced into clinical practice by Harihiro Inoue in 2010, and has now been intensively investigated in specialised centres worldwide. This allows creation of a “Heller myotomy” through the endoscopic route. Complication rates are low, symptom control is excellent and systematic reviews of published series show similar or slightly superior dysphagia control with POEM than with LHM. Advantages of POEM are the possibility to perform a long-myotomy (of the entire length of the oesophagus if necessary) and the relatively free choice of the localisation of the myotomy (anterior/posterior POEM). The disadvantage is the increased postoperative GER after POEM; however this sequel is managed with PPI in most cases, or a laparoscopic fundoplication, if necessary. Preliminary results of two prospectively randomised trials show the superiority of POEM over PD, as well as the non-inferiority to LHM, but increased postoperative GER. The author uses a tailored approach, with preference of POEM for achalasia type III and type II with chest pain and LHM + Dor for sigmoid achalasia and other associated morphological changes. The procedure in all other patients is depends on individual personal preferences.

Schlüsselwörter

Achalasie - Ösophagusmotilitätsstörung - perorale endoskopische Myotomie - Heller-Myotomie - Ballondilatation - pneumatische Dilatation

Key words

achalasia - esophageal motility disorders - peroral endoscopic myotomy - Heller myotomy - ballon dilatation - pneumatic dilatation
 

  • Literatur

  • 1 Duffield JA, Hamer PW, Heddle R. et al. Incidence of achalasia in South Australia based on esophageal manometry findings. Clin Gastroenterol Hepatol 2017; 15: 360-365 doi:10.1016/j.cgh.2016.05.036
    CrossrefPubMedGoogle Scholar
  • 2 von Rahden BHA, Filser J, Al-Nasser M. et al. Operative Therapie bei Achalasie – endoskopisch oder laparoskopisch? Vorschlag für die maßgeschneiderte Verfahrenswahl. Chirurg 2017; 88: 204-210 [Erratum: Chirurg 2017; 88 210]
    CrossrefPubMedGoogle Scholar
  • 3 von Rahden BHA. Achalasie. In: Germer CT, Keck T, Grundmann RT. Hrsg. Evidenzbasierte Viszeralchirurgie benigner Erkrankungen. Berlin: Springer; 2017: 53-66
    CrossrefGoogle Scholar
  • 4 von Rahden BHA. Achalasie und Ösophagusdivertikel. Allgemein- und Viszeralchirurgie up2date 2018; 12: 171-193 doi:10.1055/s-0043-109365
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 von Rahden BHA, Filser J, Seyfried F. et al. Diagnostik and Therapie of Achalasie. Chirurg 2014; 85: 1055-1063 doi:10.1007/s00104-014-2803-1
    CrossrefPubMedGoogle Scholar
  • 6 Eckardt VF. Clinical presentations and complications of achalasia. Gastrointest Endosc Clin N Am 2001; 11: 281-292 vi
    CrossrefPubMedGoogle Scholar
  • 7 Pandolfino JE, Kwiatek MA, Nealis T. et al. Achalasia: a new clinically relevant classification by high-resolution manometry. Gastroenterology 2008; 135: 1526-1533 doi:10.1053/j.gastro.2008.07.022
    CrossrefPubMedGoogle Scholar
  • 8 Kahrilas PJ, Bredenoord AJ. Fox Met al. The Chicago Classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil 2015; 27: 160-174 doi:10.1111/nmo.12477
    CrossrefPubMedGoogle Scholar
  • 9 Campos GM, Vittinghoff E, Rabl C. et al. Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis. Ann Surg 2009; 249: 45-57
    CrossrefPubMedGoogle Scholar
  • 10 Yaghoobi M, Mayrand S, Martel M. et al. Laparoscopic Hellerʼs myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized, controlled trials. Gastrointest Endosc 2013; 78: 468-475
    CrossrefPubMedGoogle Scholar
  • 11 Wang L, Li YM, Li L. Meta-analysis of randomized and controlled treatment trials for achalasia. Dig Dis Sci 2009; 54: 2303-2311
    CrossrefPubMedGoogle Scholar
  • 12 Schoenberg MB, Marx S, Kersten JF. et al. Laparoscopic Heller myotomy versus endoscopic balloon dilatation for the treatment of achalasia: a network meta-analysis. Ann Surg 2013; 258: 943-952
    CrossrefPubMedGoogle Scholar
  • 13 Boeckxstaens GE, Annese V, des Varannes SB. et al. Pneumatic dilation versus laparoscopic Hellerʼs myotomy for idiopathic achalasia. N Engl J Med 2011; 364: 1807-1816
    CrossrefPubMedGoogle Scholar
  • 14 Novais PA, Lemme EM. 24-h pH monitoring patterns and clinical response after achalasia treatment with pneumatic dilation or laparoscopic Heller myotomy. Aliment Pharmacol Ther 2010; 32: 1257-1265
    CrossrefPubMedGoogle Scholar
  • 15 Kostic S, Kjellin A, Ruth M. et al. Pneumatic dilatation or laparoscopic cardiomyotomy in the management of newly diagnosed idiopathic achalasia. Results of a randomized controlled trial. World J Surg 2007; 31: 470-478
    CrossrefPubMedGoogle Scholar
  • 16 Moonen A, Annese V, Belmans A. et al. Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut 2016; 65: 732-739
    CrossrefPubMedGoogle Scholar
  • 17 Richards WO, Torquati A, Holzman MD. et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg 2004; 240: 405-412
    CrossrefPubMedGoogle Scholar
  • 18 Salvador R, Pesenti E, Gobbi L. et al. Postoperative gastroesophageal reflux after laparoscopic Heller-Dor for achalasia: true incidence with an objective evaluation. J Gastrointest Surg 2016; 1: 17-22 doi:10.1007/s11605-016-3188-x
    CrossrefPubMedGoogle Scholar
  • 19 Rebecchi F, Giaccone C, Farinella E. et al. Randomized controlled trial of laparoscopic Heller myotomy plus Dor fundoplication versus Nissen fundoplication for achalasia: long-term results. Ann Surg 2008; 248: 1023-1030
    CrossrefPubMedGoogle Scholar
  • 20 Rawlings A, Soper NJ, Oelschlager B. et al. Laparoscopic Dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomized-controlled trial. Surg Endosc 2012; 26: 18-26
    CrossrefPubMedGoogle Scholar
  • 21 Kumagai K, Kjellin A, Tsai JA. et al. Toupet versus Dor as a procedure to prevent reflux after cardiomyotomy for achalasia: results of a randomised clinical trial. Int J Surg 2014; 12: 673-680
    CrossrefPubMedGoogle Scholar
  • 22 Tomasko JM, Augustin T, Tran TT. et al. Quality of life comparing dor and toupet after heller myotomy for achalasia. JSLS 2014; 18: pii:e2014.00191 doi:10.4293/JSLS.2014.00191
    CrossrefPubMedGoogle Scholar
  • 23 Portale G, Costantini M, Rizzetto C. et al. Long-term outcome of laparoscopic Heller-Dor surgery for esophageal achalasia: possible detrimental role of previous endoscopic treatment. J Gastrointest Surg 2005; 9: 1332-1339
    CrossrefPubMedGoogle Scholar
  • 24 Patti MG, Feo CV, Arcerito M. et al. Effects of previous treatment on results of laparoscopic Heller myotomy for achalasia. Dig Dis Sci 1999; 44: 2270-2276
    CrossrefPubMedGoogle Scholar
  • 25 Bonavina L, Incarbone R, Reitano M. et al. Does previous endoscopic treatment affect the outcome of laparoscopic Heller myotomy?. Ann Chir 2000; 125: 45-49
    CrossrefPubMedGoogle Scholar
  • 26 Smith CD, Stival A, Howell DL. et al. Endoscopic therapy for achalasia before Heller myotomy results in worse outcomes than Heller myotomy alone. Ann Surg 2006; 243: 579-584
    CrossrefPubMedGoogle Scholar
  • 27 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
    Article in Thieme ConnectPubMedGoogle Scholar
  • 28 Pasricha PJ, Hawari R, Ahmed I. et al. Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy 2007; 39: 761-764
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Tan Y, Lv L, Wang X. et al. Efficacy of anterior versus posterior per-oral endoscopic myotomy for treating achalasia: a randomized, prospective study. Gastrointest Endosc 2018; 88: 46-54 doi:10.1016/j.gie.2018.03.009
    CrossrefPubMedGoogle Scholar
  • 30 Ramchandani M, Nabi Z, Reddy DN. et al. Outcomes of anterior myotomy versus posterior myotomy during POEM: a randomized pilot study. Endosc Int Open 2018; 6: E190-E198 doi:10.1055/s-0043-121877
    Article in Thieme ConnectPubMedGoogle Scholar
  • 31 Li QL, Chen WF, Zhou PH. et al. Peroral endoscopic myotomy for the treatment of achalasia: a clinical comparative study of endoscopic full-thickness and circular muscle myotomy. J Am Coll Surg 2013; 217: 442-451
    CrossrefPubMedGoogle Scholar
  • 32 Li C, Gong A, Zhang J. et al. Clinical outcomes and safety of partial full-thickness myotomy versus circular muscle myotomy in peroral endoscopic myotomy for achalasia patients. Gastroenterol Res Pract 2017; 2017: 2676513
    PubMedGoogle Scholar
  • 33 Wang XH, Tan YY, Zhu HY. et al. Full-thickness myotomy is associated with higher rate of postoperative gastroesophageal reflux disease. World J Gastroenterol 2016; 22: 9419-9426
    CrossrefPubMedGoogle Scholar
  • 34 Stavropoulos SN, Modayil RJ, Friedel D. et al. The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience. Surg Endosc 2013; 27: 3322-3338 doi:10.1007/s00464-013-2913-8
    CrossrefPubMedGoogle Scholar
  • 35 Tanaka S, Kawara F, Toyonaga T. et al. Two penetrating vessels as a novel indicator of the appropriate distal end of peroral endoscopic myotomy. Dig Endosc 2018; 30: 206-211
    CrossrefPubMedGoogle Scholar
  • 36 Shiwaku H, Yamashita K, Hasegawa S. Double-scope method for creating a straight submucosal tunnel during peroral endoscopic myotomy. Dig Endosc 2018; 30: 267-268
    PubMedGoogle Scholar
  • 37 Hong HJ, Song GW, Ko WJ. et al. Double-scope peroral endoscopic myotomy (POEM) for esophageal achalasia: the first trial of a new double-scope POEM. Clin Endosc 2016; 49: 383-386
    CrossrefPubMedGoogle Scholar
  • 38 Yeung F, Wong IYH, Chung PHY. et al. Peroral endoscopic myotomy with EndoFLIP and double-endoscope: novel techniques for achalasia in pediatric population. J Laparoendosc Adv Surg Tech A 2018; 28: 343-347 doi:10.1089/lap.2017.0268
    CrossrefPubMedGoogle Scholar
  • 39 Grimes KL, Inoue H, Onimaru M. et al. Double-scope per oral endoscopic myotomy (POEM): a prospective randomized controlled trial. Surg Endosc 2016; 30: 1344-1351
    CrossrefPubMedGoogle Scholar
  • 40 Ngamruengphong S, von Rahden BHA, Filser J. et al. Intraoperative measurement of esophagogastric junction cross-sectional area by impedance planimetry correlates with clinical outcomes of peroral endoscopic myotomy for achalasia: a multicenter study. Surg Endosc 2016; 30: 2886-2894 doi:10.1007/s00464-015-4574-2
    CrossrefPubMedGoogle Scholar
  • 41 Hungness ES, Sternbach JM, Teitelbaum EN. et al. Per-oral endoscopic myotomy (POEM) after the learning curve: durable long-term results with a low complication rate. Ann Surg 2016; 264: 508-517 doi:10.1097/SLA.0000000000001870
    CrossrefPubMedGoogle Scholar
  • 42 Zhang XC, Li QL, Xu MD. et al. Major perioperative adverse events of peroral endoscopic myotomy: a systematic 5-year analysis. Endoscopy 2016; 48: 967-978
    Article in Thieme ConnectPubMedGoogle Scholar
  • 43 Bechara R, Ikeda H, Inoue H. Peroral endoscopic myotomy for Jackhammer esophagus: to cut or not to cut the lower esophageal sphincter. Endosc Int Open 2016; 4: E585-E588 doi:10.1055/s-0042-105204
    Article in Thieme ConnectPubMedGoogle Scholar
  • 44 Crespin OM, Liu LWC, Parmar A. et al. Safety and efficacy of POEM for treatment of achalasia: a systematic review of the literature. Surg Endosc 2017; 31: 2187-2201
    CrossrefPubMedGoogle Scholar
  • 45 Barbieri LA, Hassan C, Rosati R. et al. Systematic review and meta-analysis: efficacy and safety of POEM for achalasia. United European Gastroenterol J 2015; 3: 325-334
    CrossrefPubMedGoogle Scholar
  • 46 Werner YB, von Renteln D, Noder T. et al. Early adverse events of peroral endoscopic myotomy. Gastrointest Endosc 2017; 85: 708-718
    CrossrefPubMedGoogle Scholar
  • 47 Haito-Chavez Y, Inoue H, Beard KW. et al. Comprehensive analysis of adverse events associated with per oral endoscopic myotomy in 1826 patients: an international multicenter study. Am J Gastroenterol 2017; 112: 1267-1276
    CrossrefPubMedGoogle Scholar
  • 48 Schlottmann F, Luckett DJ, Fine J. et al. Laparoscopic Heller myotomy versus peroral endoscopic myotomy (POEM) for achalasia: a systematic review and meta-analysis. Ann Surg 2018; 267: 451-460
    CrossrefPubMedGoogle Scholar
  • 49 Khan MA, Kumbhari V, Ngamruengphong S. et al. Is POEM the answer for management of spastic esophageal disorders? A systematic review and meta-analysis. Dig Dis Sci 2017; 62: 35-44 doi:10.1007/s10620-016-4373-1
    CrossrefPubMedGoogle Scholar
  • 50 Kumbhari V, Tieu AH, Onimaru M. et al. Peroral endoscopic myotomy (POEM) vs. laparoscopic Heller myotomy (LHM) for the treatment of Type III achalasia in 75 patients: a multicenter comparative study. Endosc Int Open 2015; 3: E195-E201 doi:10.1055/s-0034-1391668
    Article in Thieme ConnectPubMedGoogle Scholar
  • 51 Khashab MA, Messallam AA, Onimaru M. et al. International multicenter experience with peroral endoscopic myotomy for the treatment of spastic esophageal disorders refractory to medical therapy (with video). Gastrointest Endosc 2015; 81: 1170-1177 doi:10.1016/j.gie.2014.10.011
    CrossrefPubMedGoogle Scholar
  • 52 Kumbhari V, Familiari P, Bjerregaard NC. et al. Gastroesophageal reflux after peroral endoscopic myotomy: a multicenter case-control study. Endoscopy 2017; 49: 634-642 doi:10.1055/s-0043-105485
    Article in Thieme ConnectPubMedGoogle Scholar
  • 53 Repici A, Fuccio L, Maselli R. et al. GERD after per-oral endoscopic myotomy as compared with Hellerʼs myotomy with fundoplication: a systematic review with meta-analysis. Gastrointest Endosc 2018; 87: 934-943.e18 doi:10.1016/j.gie.2017.10.022
    CrossrefPubMedGoogle Scholar
  • 54 Ponds FA, Fockens P, Neuhaus H. et al. Peroral endoscopic myotomy (POEM) versus pneumatic dilatation in therapy-naive patients with achalasia: results of a randomized controlled trial. Gastroenterology 2017; 152: S139
    PubMedGoogle Scholar