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1.
Zhongguo Zhen Jiu ; 40(2): 119-22, 2020 Feb 12.
Artigo em Chinês | MEDLINE | ID: mdl-32100494

RESUMO

OBJECTIVE: To observe the clinical effect of electronic moxibustion on dysphagia in patients with achalasia of cricopharyngeus muscle after stroke. METHODS: Sixty patients with dysphagia of achalasia of cricopharyngeus muscle were randomly divided into an observation group and a control group, 30 cases in each group. One patient in the observation group and 2 cases in the control group dropped off. The patients in the control group were treated with routine medical treatment, acupuncture treatment and swallowing rehabilitation training; the patients in the observation group were additionally treated with electronic moxibustion at Lianquan (CV 23), Tiantu (CV 22), Tianding (LI 17) and Futu (LI 18), 30 min each treatment. Both groups were treated 5 times a week for 4 weeks. The musculoskeletal ultrasound (MSUS) was applied to test the activity of parapharyngeal wall and the dysphagia score of Ichiro Fujishima was compared before and after 4-week treatment. RESULTS: After treatment, the activity of the parapharyngeal wall and the dysphagia score of Ichiro Fujishima were increased in both groups (P<0.01, P<0.05). The changes of activity of parapharyngeal wall and dysphagia score of Ichiro Fujishima in the observation group were greater than the control group (P<0.05, P<0.01). CONCLUSION: Electronic moxibustion can improve the impaired swallowing function and reconstruct the normal swallowing process.


Assuntos
Acalasia Esofágica/terapia , Esfíncter Esofágico Superior/fisiopatologia , Moxibustão , Acidente Vascular Cerebral/complicações , Pontos de Acupuntura , Transtornos de Deglutição , Humanos , Resultado do Tratamento
2.
Zhongguo Zhen Jiu ; 39(10): 1027-33, 2019 Oct 12.
Artigo em Chinês | MEDLINE | ID: mdl-31621251

RESUMO

OBJECTIVE: To screen the optimal acupuncture regimen for cricopharyngeal achalasia (CPA) after brain stem infarction and compare the therapeutic effect between the combined therapy of catheter balloon dilation and acupuncture and the simple application of catheter balloon dilation. METHODS: The patients suffering from neuropathic dysphagia in CPA after brain stem infarction were selected as the subjects. After confirmed in the diagnosis with video fluoroscopic swallowing study (VFSS), they were randomized into 6 groups, 15 cases in each one, named group A (routine treatment), group B (catheter balloon dilation), group C1 (treated with acupuncture in local area), group C2 (treated with acupuncture based on zangfu differentiation), group C3 (treated with acupuncture at the local area and the acupoints based on zangfu differentiation) and group D (catheter balloon dilation combined with the optimal acupuncture). Two phases were included in the study. In the first phase of study, the therapeutic effect was compared among the three acupuncture groups, named C1, C2 and C3 group, so as to screen the optimal acupuncture regimen. In the group C1, the main acupoints included Fengchi (GB 20), Wangu (GB 12), Yifeng (TE 17) and three-tongue points (Extra). In the group C2, the main acupoints were Neiguan (PC 6), Tongli (HT 5), Zusanli (ST 36) and Sanyinjiao (SP 6) as well as the supplementary acupoints in accordance with the syndrome differentiation. In the group C1 and group C2, after deqi, the electroacupuncture was used, with continuous dense wave, 5 to 8 Hz in frequency. The needles were retained for 30 min. Acupuncture was given once a day, 5 treatments a week. Before treatment, in 6 weeks of treatment or after removal of gastric tube, the rehabilitation was evaluated. In the group C3, the acupoints, manipulation and treating course were same as the group C1 and group C2. In the 2nd phase of study, theresults of rehabilitation treatment were compared among the group A, group B and group D. The treatment was given once a day, 5 times a week. Before treatment, after gastric tube removal or in 6 weeks of treatment, the evaluation was conducted. The feeding-swallowing function grade and VFSS were adopted in the evaluation among the above 6 groups. RESULTS: ① In the VFSS comparison at 1st phase of study after treatment, the food transporting ability at oral dysphagia, the results in the group C3 and group C1 were better obviously than the group C2 (both P<0.05). For the improvement in aspiration, the result in the group C3 was better obviously than the group C2 (P<0.05). In comparison of the three acupuncture groups with the group A, the difference was not significant statisticallys in the extubation rate among the four groups (P>0.05). The severity of dysphagia in the group C3 was milder than the group C2 and group A (both P<0.05). ② In the VFSS comparison at the 2nd phase of study, for the food transporting ability, the results in the group D and the group B were obviously better than the group A (both P<0.05). Regarding the function at the pharyngeal dysphagia and aspiration, the results in the group D were better than the group B and group A, those in the group B were better than the group A (all P<0.05). The difference in the extubation rate among the group A, group B and group D after treatment was significant statistically (P<0.01), of which, the extubation rate in the group D was the highest and the rate in the group A was the lowest. The dysphagia degree in the group D was milder than the group B and group A and that in the group B was milder than the group A (all P<0.05). CONCLUSION: In the study of the different acupuncture methods, the acupuncture at the local acupoints and the acupoints selected based on zangfu differentiation is the optimal acupuncture regimen for cricopharyngeal achalasia after brain stem infarction. The catheter balloon dilation combined with acupuncture present the synergistc effect on cricopharyngeal achalasia after brain stem infarction, obviously relieve dysphagia and reduce aspiration.


Assuntos
Terapia por Acupuntura , Infartos do Tronco Encefálico , Acalasia Esofágica , Pontos de Acupuntura , Terapia por Acupuntura/métodos , Infartos do Tronco Encefálico/complicações , Cateterismo , Dilatação , Acalasia Esofágica/etiologia , Acalasia Esofágica/terapia , Humanos , Resultado do Tratamento
3.
JAMA ; 322(2): 134-144, 2019 07 09.
Artigo em Inglês | MEDLINE | ID: mdl-31287522

RESUMO

Importance: Case series suggest favorable results of peroral endoscopic myotomy (POEM) for treatment of patients with achalasia. Data comparing POEM with pneumatic dilation, the standard treatment for patients with achalasia, are lacking. Objective: To compare the effects of POEM vs pneumatic dilation as initial treatment of treatment-naive patients with achalasia. Design, Setting, and Participants: This randomized multicenter clinical trial was conducted at 6 hospitals in the Netherlands, Germany, Italy, Hong Kong, and the United States. Adult patients with newly diagnosed achalasia and an Eckardt score greater than 3 who had not undergone previous treatment were included. The study was conducted between September 2012 and July 2015, the duration of follow-up was 2 years after the initial treatment, and the final date of follow-up was November 22, 2017. Interventions: Randomization to receive POEM (n = 67) or pneumatic dilation with a 30-mm and a 35-mm balloon (n = 66), with stratification according to hospital. Main Outcomes and Measures: The primary outcome was treatment success (defined as an Eckardt score ≤3 and the absence of severe complications or re-treatment) at the 2-year follow-up. A total of 14 secondary end points were examined among patients without treatment failure, including integrated relaxation pressure of the lower esophageal sphincter via high-resolution manometry, barium column height on timed barium esophagogram, and presence of reflux esophagitis. Results: Of the 133 randomized patients, 130 (mean age, 48.6 years; 73 [56%] men) underwent treatment (64 in the POEM group and 66 in the pneumatic dilation group) and 126 (95%) completed the study. The primary outcome of treatment success occurred in 58 of 63 patients (92%) in the POEM group vs 34 of 63 (54%) in the pneumatic dilation group, a difference of 38% ([95% CI, 22%-52%]; P < .001). Of the 14 prespecified secondary end points, no significant difference between groups was demonstrated in 10 end points. There was no significant between-group difference in median integrated relaxation pressure (9.9 mm Hg in the POEM group vs 12.6 mm Hg in the pneumatic dilation group; difference, 2.7 mm Hg [95% CI, -2.1 to 7.5]; P = .07) or median barium column height (2.3 cm in the POEM group vs 0 cm in the pneumatic dilation group; difference, 2.3 cm [95% CI, 1.0-3.6]; P = .05). Reflux esophagitis occurred more often in the POEM group than in the pneumatic dilation group (22 of 54 [41%] vs 2 of 29 [7%]; difference, 34% [95% CI, 12%-49%]; P = .002). Two serious adverse events, including 1 perforation, occurred after pneumatic dilation, while no serious adverse events occurred after POEM. Conclusions and Relevance: Among treatment-naive patients with achalasia, treatment with POEM compared with pneumatic dilation resulted in a significantly higher treatment success rate at 2 years. These findings support consideration of POEM as an initial treatment option for patients with achalasia. Trial Registration: Netherlands Trial Register number: NTR3593.


Assuntos
Dilatação/métodos , Acalasia Esofágica/terapia , Esfíncter Esofágico Inferior/cirurgia , Esfincterotomia/métodos , Adulto , Dilatação/efeitos adversos , Acalasia Esofágica/classificação , Acalasia Esofágica/cirurgia , Feminino , Seguimentos , Refluxo Gastroesofágico/etiologia , Humanos , Masculino , Manometria , Pessoa de Meia-Idade , Cirurgia Endoscópica por Orifício Natural , Qualidade de Vida , Índice de Gravidade de Doença , Esfincterotomia/efeitos adversos , Resultado do Tratamento
5.
Rev Gastroenterol Peru ; 39(1): 70-73, 2019.
Artigo em Espanhol | MEDLINE | ID: mdl-31042239

RESUMO

Achalasia in pregnancy is an infrequent, poorly understood condition and its treatment is not clearly defined. The repercussions on the patients nutritional status are serious and in a pregnant woman have serious implications for the course of gestation, with high risk of intrauterine growth restriction, preterm delivery and even fetal loss; there are symptoms that can be confused with hyperemesis gravidarum delaying the diagnosis. The therapeutic options are medical treatment, endoscopic and surgical interventions; to decide what is the best treatment, we should be taken into account the severity, gestational age and patient conditions. Within the spectrum mentioned in the management include calcium antagonists and nitrates, however these have restrictions in pregnancy, another options are botulinum toxin, endoscopic pneumatic dilation, laparoscopic Heller myotomy and recently POEM. In pregnancy there is a few evidence in the literature and in this moment there are about 40 reported cases, some with complications such as fetal loss and maternal death. We present our experience at the San Ignacio University Hospital in Bogotá, Colombia, with a 26-year-old woman with a novo diagnosis of achalasia type II during the first trimester of pregnancy, with a clinical history of severe dysphagia associated with malnutrition. She was management with enteral nutrition support with nasogastric tube to achieve repletion of the body mass index (BMI) and after that, she had a endoscopic management with Rigiflex balloon dilation. It allowed to successfully carry out pregnancy without adverse effects on the mother or the fetus, with adequate evolution and oral tolerance without dysphagia. We consider that nutritional support is important prior to taking a desicion with this type of patient, in addition that endoscopic management with balloon dilation can be safe and effective for the management of achalasia in pregnancy.


Assuntos
Dilatação/métodos , Acalasia Esofágica/terapia , Esofagoscopia/métodos , Complicações na Gravidez/terapia , Adulto , Índice de Massa Corporal , Terapia Combinada , Transtornos de Deglutição/etiologia , Nutrição Enteral , Acalasia Esofágica/diagnóstico por imagem , Feminino , Humanos , Intubação Gastrointestinal , Desnutrição/complicações , Manometria , Gravidez
6.
Wiad Lek ; 72(4): 682-684, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31055556

RESUMO

OBJECTIVE: Introduction: Esophageal achalasia is a neuromuscular disease, which is characterized by persistent impaired reflex opening of esophageal sphincter. Disease incidence is 0.6-2.0 per 100 000 population with no tendency to decrease. The aim of the study was to improve the results of treatment in patients with achalasia of cardia by differentiated approach in the choice of therapy method. PATIENTS AND METHODS: Materials and methods:148 patients with esophageal achalasia aged 18 - 67 were studied between 2003 and 2018. The following degrees of the disease were determined (by Petrovskyi's classification): first - in 8, second - in 59, third - in 70, fourth - in 11 patients. Drug therapy was administered in achalasia of first degree, and cardiodilatation courses - in second and third degree of the disease. Indications for surgical treatment were: impossibility to perform cardiodilatation, S-shaped esophageal deformation (stage IV), complications associated with cardiodilatation, achalasia combined with other surgical pathology, recurrence of disease. RESULTS: Review: Cardiodilatation therapy resulted in sustained clinical effect in stages I and II of the disease. In case of unsatisfactory results of cardiodilatation patients underwent elective operations. 18 patients underwent Heller-Dor plastic surgery, 4 - Heller-Petrovskiy operation, 1 - Besley plastic repair, 2 - Nissen fundoplication. In early postoperative period no failure or perforation of the esophagus occurred. The following complications developed: seroma - in 3 patients, postoperative wound infection - in 1 case. In one patient (4%) the recurrence of disease was due to scar deformation of esophagogastric junction after Heller-Petrovskiy operation on the cardia. CONCLUSION: Conclusions: Cardiodilatation is an effective method of conservative therapy in stages I and II of the disease, while in stages III and IV it is warranted as preoperative preparation measure. We think Heller-Dor operation to be the best method of plastic repair in esophageal achalasia.


Assuntos
Dilatação , Acalasia Esofágica/terapia , Fundoplicatura , Adolescente , Adulto , Idoso , Acalasia Esofágica/classificação , Humanos , Pessoa de Meia-Idade , Resultado do Tratamento , Adulto Jovem
7.
Z Gastroenterol ; 57(3): 304-311, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30861554

RESUMO

BACKGROUND AND AIMS: On the basis of lesser rates of major adverse events and a short-term efficacy as Heller's myotomy, there is a growing enthusiasm in favor of peroral endoscopic myotomy (POEM), whereas study comparing POEM and pneumatic dilatation (PD) is quite rare. The aim of this study was to evaluate the efficacy of POEM and PD in Chinese achalasia patients in a retrospectively designed study. METHODS: Patients with achalasia, who underwent either PD (n = 26) or POEM (n = 40) were retrospectively recruited from September 2010 through March 2016 at a single tertiary center. During the 1-year follow-up, clinical outcome and functional data of lower esophageal sphincter (LES) were recruited. Clinical symptoms were assessed by use of the Eckardt score. The primary outcome was therapeutic success (Eckardt score ≤ 3). Functional data of LES (4-second integrated relaxation pressure [4s-IRP], LES relax rate, and LESP) at baseline and 1 month after treatment were also evaluated. Data was analyzed by SPSS 13.0 version using a significance level of p < 0.05. RESULTS: The success rates were 24/26 (92.31 %), 25/26 (96.15 %), and 24/26 (92.31 %), respectively, with POEM, as compared with 35/40 (87.50 %), 29/40 (72.50 %), and 23/40 (57.50 %), respectively, with PD, 1 month, 3 months, and 1 year after treatment. Statistically significant difference was observed between the 2 therapies (at 3 months, Fisher's exact test, p = 0.01; at 1 year, Fisher's exact test, p < 0.0001). Compared with PD, the Eckardt score was lower with POEM 1 month, 3 months, and 1 year after treatment. More patients in POEM group reported gastroesophageal reflux symptoms (after 3 months 7/26 (26.92 %) vs. 2/40 (5.00 %), Fisher's exact test, p = 0.01; after 1 year 6/26 (19.23 %) vs. 1/35 (2.86 %), Fisher's exact test, p = 0.02). The postoperative 4s-IRP and LESP were both lower with POEM than with PD, respectively. Type I achalasia had a better response with POEM than with PD. CONCLUSION: In this retrospective analysis with 1-year follow-up, POEM presents with a higher success rate and more reflux symptoms compared with PD. Change on LES function after treatment may explain the outcome in part. Type I achalasia may respond better to therapies compared with type II.


Assuntos
Dilatação , Acalasia Esofágica , Esfíncter Esofágico Inferior , Miotomia , Esfincterotomia , Adulto , Dilatação/efeitos adversos , Acalasia Esofágica/cirurgia , Acalasia Esofágica/terapia , Esfíncter Esofágico Inferior/cirurgia , Esofagoscopia , Feminino , Seguimentos , Humanos , Masculino , Manometria , Miotomia/efeitos adversos , Cirurgia Endoscópica por Orifício Natural/efeitos adversos , Cirurgia Endoscópica por Orifício Natural/métodos , Estudos Retrospectivos , Esfincterotomia/efeitos adversos , Resultado do Tratamento
8.
Biomed Res Int ; 2019: 8549187, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30881999

RESUMO

Over the past few decades, there was an encouraging breakthrough in bridging the gap between advancements in the evolution of diagnosis and treatment towards a better outcome in achalasia. The purpose of this review is to provide updated knowledge on how the current evidence has bridged the gap between advancements in the evolution of diagnosis and treatment of esophageal achalasia. The advent of high-resolution manometry and standardization based on the Chicago classification has increased early recognition of the disease. These 3 clinical subtypes of achalasia can predict the outcomes of patients, and the introduction of POEM has revolutionized the choice of treatment. Previous evidence has shown that laparoscopic Heller myotomy (LHM) and anterior fundoplication were considered the most durable treatments for achalasia. Based on the current evidence, POEM has been evolving as a promising strategy and is effective against all 3 types of achalasia, but the efficacy of POEM is based on short- and medium-term outcome studies from a limited number of centers. Types I and II achalasia respond well to POEM, LHM, and PD, while most studies have shown that type III achalasia responds better to POEM than to LHM and PD. In general, among the 3 subtypes of achalasia, type II achalasia has the most favorable outcomes after medical or surgical therapies. The long-term efficacy of POEM is still unknown. The novel ENDOFLIP measures the changes in intraoperative esophagogastric junction dispensability, which enables a quantitative assessment of luminal patency and sphincter distension; however, this technology is in its infancy with little data to date supporting its intraoperative use. In the future, identifying immunomodulatory drugs and the advent of stem cell therapeutic treatments, including theoretically transplanting neuronal stem cells, may achieve a functional cure. In summary, it is important to identify the clinical subtype of achalasia to initiate target therapy for these patients.


Assuntos
Acalasia Esofágica/diagnóstico , Acalasia Esofágica/terapia , Esofagoscopia/métodos , Miotomia de Heller/métodos , Acalasia Esofágica/patologia , Humanos , Manometria , Resultado do Tratamento
10.
Khirurgiia (Mosk) ; (2): 72-77, 2019.
Artigo em Russo | MEDLINE | ID: mdl-30855594

RESUMO

Prevalence, clinical manifestations and of modern classifications of achalasia are reviewed in the article. Diagnosis and treatment of this pathology were analyzed by using of 58 references.


Assuntos
Acalasia Esofágica , Acalasia Esofágica/classificação , Acalasia Esofágica/diagnóstico , Acalasia Esofágica/epidemiologia , Acalasia Esofágica/terapia , Humanos , Prevalência
11.
Dis Esophagus ; 32(5)2019 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-30809653

RESUMO

The objective of this study is to identify the incidence of and risk factors associated with the development of esophageal cancer in treated achalasia patients in a national cohort. Patients with esophageal achalasia diagnosed and receiving a treatment between 2002 and 2012 were identified in England. Patient and treatment factors were compared between individuals who developed esophageal cancer and those that did not using univariate and multivariate analyses. A total of 7487 patients receiving an interventional treatment for esophageal achalasia were included and 101 patients (1.3%) developed esophageal cancer. The incidence of esophageal cancer was 205 cases per 100,000 patient years at risk. Patients who developed esophageal cancer were older and more commonly primarily treated with pneumatic dilation (82.2% vs. 60.3%; P < 0.001). In the esophageal cancer group, there was an increase in the number of patients requiring reinterventions (47.5% vs. 38.0%; P = 0.041) and the average total number of reinterventions per patient (1.2 vs. 0.8; P = 0.026). Multivariate analysis suggested associations between increased reintervention following both surgical myotomy (HR = 5.1; 95%CI 1.12-23.16) and pneumatic dilation (HR = 1.48; 95%CI 0.95-2.29), and esophageal cancer risk. Increasing patient age and reintervention following primary achalasia treatment are important potential risk factors for the development of esophageal cancer. Treated achalasia patients with symptom recurrence should be carefully evaluated for potential development of esophageal cancer prior to considering reintervention, and increased vigilance may help diagnose esophageal cancer in these individuals at an early stage.


Assuntos
Acalasia Esofágica/terapia , Neoplasias Esofágicas/epidemiologia , Retratamento/estatística & dados numéricos , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Dilatação/estatística & dados numéricos , Inglaterra/epidemiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Miotomia/estatística & dados numéricos , Fatores de Risco
12.
Br J Surg ; 106(4): 332-341, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30690706

RESUMO

BACKGROUND: The introduction of high-resolution manometry and the Chicago classification has made it possible to diagnose achalasia and predict treatment response accurately. The aim of this study was to compare the effect of the different treatments available on symptomatic outcomes across all achalasia subtypes. METHODS: The study was conducted according to PRISMA and MOOSE guidelines. A literature search of PubMed and MEDLINE databases was undertaken to identify all relevant articles reporting clinical outcomes of patients with achalasia after botulinum toxin injection, pneumatic dilatation, laparoscopic Heller myotomy (LHM) and peroral endoscopic myotomy (POEM) based on manometric subtypes. Patients were grouped according to the Chicago classification and the success rate in treating symptoms was measured as the primary endpoint. RESULTS: Twenty studies (1575 patients) were selected, and data on botulinum toxin, pneumatic dilatation, LHM and POEM were extracted. Success rates for LHM in type I, II and III achalasia were 81, 92 and 71 per cent respectively. Those for POEM were 95, 97 and 93 per cent respectively. POEM was more likely to be successful than LHM for both type I (odds ratio (OR) 2·97, 95 per cent c.i. 1·09 to 8·03; P = 0·032) and type III (OR 3·50, 1·39 to 8·77; P = 0·007) achalasia. The likelihood of success of POEM and LHM for type II achalasia was similar. CONCLUSION: Pneumatic dilatation had a lower but still acceptable success rate compared with POEM or LHM in patients with type II achalasia. POEM is an excellent treatment modality for type I and type III achalasia, although it did not show any superiority over LHM for type II achalasia.


Assuntos
Dilatação/métodos , Acalasia Esofágica/diagnóstico , Acalasia Esofágica/terapia , Miotomia/métodos , Toxinas Botulínicas Tipo A/uso terapêutico , Esofagoscopia/métodos , Feminino , Humanos , Laparoscopia/métodos , Masculino , Manometria/métodos , Prognóstico , Medição de Risco , Índice de Gravidade de Doença , Resultado do Tratamento
13.
Gastrointest Endosc ; 89(2): 264-273.e3, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-29684386

RESUMO

BACKGROUND AND AIMS: Unclear reimbursement for new and innovative endoscopic procedures can limit adoption in clinical practice despite effectiveness in clinical trials. The aim of this study was to determine maximum cost-effective reimbursement for per-oral endoscopic myotomy (POEM) in treating achalasia. METHODS: We constructed a decision-analytic model assessing POEM versus laparoscopic Heller myotomy with Dor fundoplication (LHM) in managing achalasia from a payer perspective over a 1-year time horizon. Reimbursement data were derived from 2017 Medicare data. Responder rates were based on clinically meaningful improvement in validated Eckardt scores. Validated health utility values were assigned to terminal health states based on data previously derived with a standard gamble technique. Contemporary willingness-to-pay (WTP) levels per quality-adjusted life year (QALY) were used to estimate maximum reimbursement for POEM using threshold analysis. RESULTS: Effectiveness of POEM and LHM was similar at 1 year of follow-up (0.91 QALY). Maximum cost-effective reimbursement for POEM was $8033.37 to $8223.14, including all professional and facility fees. This compares favorably with contemporary total reimbursement of 10 to 15 total relative value units for advanced endoscopic procedures. Rates of postprocedural GERD did not affect the preference for POEM compared with LHM, assuming at least 10% cost savings with POEM compared with LHM in cost-minimization analysis, or at least 44% cost savings in cost-effectiveness analysis (WTP = $100,000/QALY). LHM was only preferred over POEM if both procedures were reimbursed similarly, and these findings were primarily driven by lower rates of postprocedural GERD. The rate of conversion to open laparotomy due to perforation or bleeding was infrequent in published clinical practice experience, thus did not significantly affect reimbursement. DISCUSSION: POEM is an example of an innovative and potentially disruptive endoscopic technique offering greater cost-effective value and similar outcomes to the established surgical standard at contemporary reimbursement levels.


Assuntos
Acalasia Esofágica/terapia , Piloromiotomia/economia , Mecanismo de Reembolso , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Economia , Acalasia Esofágica/economia , Fundoplicatura/economia , Refluxo Gastroesofágico/epidemiologia , Miotomia de Heller/economia , Humanos , Invenções/economia , Medicare , Pessoa de Meia-Idade , Cirurgia Endoscópica por Orifício Natural , Complicações Pós-Operatórias/epidemiologia , Anos de Vida Ajustados por Qualidade de Vida , Resultado do Tratamento , Estados Unidos
14.
J Gastrointest Surg ; 23(1): 23-35, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30238248

RESUMO

BACKGROUND: The aim of this study was to assess the long-term outcome of laparoscopic Heller-Dor (LHD) myotomy to treat achalasia at a single high-volume institution in the past 25 years. METHODS: Patients undergoing LHD from 1992 to 2017 were prospectively registered in a dedicated database. Those who had already undergone surgical or endoscopic myotomy were ruled out. Symptoms were collected and scored using a detailed questionnaire; barium swallow, endoscopy, and manometry were performed before and after surgery; and 24-h pH monitoring was done 6 months after LHD. RESULTS: One thousand one patients underwent LHD (M:F = 536:465), performed by six staff surgeons. The surgical procedure was completed laparoscopically in all but 8 patients (0.8%). At a median of follow-up of 62 months, the outcome was positive in 896 patients (89.5%), and the probability of being cured from symptoms at 20 years exceeded 80%. Among the patients who had previously received other treatments, there were 25/182 failures (13.7%), while the failures in the primary treatment group were 80/819 (9.8%) (p = 0.19). All 105 patients whose LHD failed subsequently underwent endoscopic pneumatic dilations with an overall success rate of 98.4%. At univariate analysis, the manometric pattern (p < 0.001), the presence of a sigmoid megaesophagus (p = 0.03), and chest pain (p < 0.001) were the factors that predicted a poor outcome. At multivariate analysis, all three factors were independently associated with a poor outcome. Post-operative 24-h pH monitoring was abnormal in 55/615 patients (9.1%). CONCLUSIONS: LHD can durably relieve achalasia symptoms in more than 80% of patients. The pre-operative manometric pattern, the presence of a sigmoid esophagus, and chest pain represent the strongest predictors of outcome.


Assuntos
Deglutição , Acalasia Esofágica/diagnóstico por imagem , Acalasia Esofágica/terapia , Miotomia de Heller , Adulto , Idoso , Idoso de 80 Anos ou mais , Dor no Peito/etiologia , Dilatação , Endoscopia Gastrointestinal , Acalasia Esofágica/complicações , Feminino , Humanos , Masculino , Manometria , Pessoa de Meia-Idade , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
15.
Am J Ther ; 26(4): e452-e461, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-28953511

RESUMO

BACKGROUND: Because achalasia subtype is associated with therapeutic response, it is possible that regional differences in subtype distribution could lead to differences in therapeutic outcomes. STUDY QUESTION: We aimed to evaluate and compare high-resolution manometry (HRM) profiles among the different subtypes of achalasia and to elucidate predictive factors associated with treatment outcomes. STUDY DESIGN: Patients who were diagnosed with achalasia using HRM at 4 Korean university hospitals were retrospectively identified and analyzed. Sixty-four patients with untreated achalasia were divided into 3 subtypes using the Chicago classification system. MEASURES AND OUTCOMES: Clinical characteristics, manometric features, and treatment outcomes were compared. RESULTS: Among 64 patients diagnosed with achalasia, 31 patients were classified as type I, 27 as type II, and 6 as type III. Regarding HRM parameters, there were statistically significant differences in basal lower esophageal sphincter pressure, 4-second-integrated relaxation pressure, residual upper esophageal sphincter pressure, body amplitude, and maximal intrabolus pressure between subtypes. Regarding therapeutic outcome, type II patients (overall success rate of 80.0%) were more likely to respond than type I (55.2%) or type III (33.2%) patients. Multivariate analysis demonstrated that achalasia subtype (type I vs. III, P = 0.072; type II vs. III, P = 0.005), therapeutic modality (dilation vs. pharmacologic, P = 0.013; laparoscopic Heller's myotomy vs. pharmacologic, P = 0.006), and HRM-measured esophageal length (<27.5 vs. ≥27.5 cm, P = 0.014) are independent predictive factors for therapeutic failure. CONCLUSIONS: Patients with type II achalasia had better treatment outcomes than patients with other achalasia subtypes. Achalasia subtype, therapeutic modality, and esophageal length are independent predictive factors of therapeutic outcome.


Assuntos
Acalasia Esofágica/diagnóstico , Esôfago/fisiopatologia , Manometria/métodos , Adulto , Idoso , Cateteres , Acalasia Esofágica/fisiopatologia , Acalasia Esofágica/terapia , Feminino , Humanos , Masculino , Manometria/instrumentação , Pessoa de Meia-Idade , Prognóstico , República da Coreia , Estudos Retrospectivos , Resultado do Tratamento
16.
Neurogastroenterol Motil ; 31(3): e13522, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30536798

RESUMO

BACKGROUND AND AIMS: Idiopathic Esophago-gastric outflow obstruction (EGJOO) is a new clinical entity resulting in delayed esophageal emptying secondary to a poorly relaxing lower esophageal sphincter. Little is known about treatment outcomes of idiopathic EGJOO patients. The aim of this study was to investigate the clinical response of pneumatic dilation (PD) in idiopathic EGJOO patients with a standing barium column and/or with pill arrest on timed barium esophagram (TBE) before and after undergoing PD. METHODS: Idiopathic EGJOO patients with retained liquid barium on TBE at 1 minute and/or with pill arrest in esophagus at 5 minutes were included. Patients were treated with PD and evaluated with post-procedural TBE. RESULTS: A total of 33 patients with Idiopathic EGJOO and poor esophageal emptying on TBE were treated with PD. 67% of Idiopathic EGJOO patients reported subjective symptom relief, 18% improved and symptoms later recurred, 6% were lost to follow up, and 9% reported no change. TBE results of pre-PD showed 1 minute average barium column height of 11.0 cm and 1 minute barium column width of 1.7 cm. There was significant decrease in 1 minute liquid barium column height and width (P < 0.001 and <0.001, respectively) as well as significant improvement in pill passing (P < 0.006) after undergoing PD. No complications occurred after PD. CONCLUSION: PD is an effective initial treatment for Idiopathic EGJOO patients with abnormal TBE. Pneumatic dilation relieved symptoms and improved esophageal emptying in Idiopathic EGJOO patients on TBE.


Assuntos
Dilatação/métodos , Acalasia Esofágica/terapia , Junção Esofagogástrica/fisiopatologia , Esôfago/fisiopatologia , Gastropatias/terapia , Idoso , Sulfato de Bário , Acalasia Esofágica/diagnóstico por imagem , Acalasia Esofágica/fisiopatologia , Esfíncter Esofágico Inferior , Junção Esofagogástrica/diagnóstico por imagem , Esofagoscopia , Esôfago/diagnóstico por imagem , Feminino , Gastroscopia , Humanos , Masculino , Satisfação do Paciente , Gastropatias/diagnóstico por imagem , Gastropatias/fisiopatologia , Inquéritos e Questionários , Resultado do Tratamento
17.
Harefuah ; 157(10): 668-671, 2018 Oct.
Artigo em Hebraico | MEDLINE | ID: mdl-30343548

RESUMO

INTRODUCTION: Achalasia is a rare idiopathic disease, associated with significant morbidity and negative impact on life quality. The disorder is characterized by impairments in the esophageal motility and loss of the lower esophageal sphincter (LES) relaxation. Achalasia symptoms include dysphagia, regurgitations, chest pain, vomiting and weight loss. Diagnosis of achalasia is based on an appropriate clinical presentation and typical findings on complementary tests. These tests include endoscopy showing a dilated esophageal lumen containing fluid or food, High-resolution manometry (HRM) shows evidence of obstruction at the gastro-esophageal junction and motility failure, and barium swallow shows esophageal dilation and distal narrowing. The recent advent of HRM has permitted more precise diagnosis of achalasia and three subtype designations, based on the pattern of esophageal motility disorders, as per the Chicago Classification. Treatment options include: drugs, endoscopic by means of Botox injection or balloon dilation, and the traditional surgery, laparoscopic Heller myotomy (LHM). The new advent in treatment is the novel per-oral endoscopic myotomy (POEM), a less invasive therapy, approaching the traditional LHM. Since the first POEM procedure performed in 2008, massive amounts of evidence are accumulating regarding the high efficacy and safety profiles of POEM, introducing it as an excellent first line treatment. The current review discusses the diagnosis and management of achalasia, with special highlights on the recent progress of HRM and POEM.


Assuntos
Transtornos de Deglutição , Acalasia Esofágica , Transtornos de Deglutição/diagnóstico , Transtornos de Deglutição/etiologia , Transtornos de Deglutição/terapia , Endoscopia , Acalasia Esofágica/complicações , Acalasia Esofágica/diagnóstico , Acalasia Esofágica/terapia , Esfíncter Esofágico Inferior , Humanos , Manometria , Resultado do Tratamento
18.
Kyobu Geka ; 71(9): 676-679, 2018 09.
Artigo em Japonês | MEDLINE | ID: mdl-30185741

RESUMO

A 61-year-old man was admitted to our hospital for an abnormal chest shadow. Computed tomography (CT) showed a pulmonary nodular shadow in the right middle lobe. He was diagnosed with stage cT2aN0M0 (IB) pulmonary adenocarcinoma and was treated with surgery of right middle lobectomy and mediastinal lymph node dissection. On 2nd day after surgery, he got aspiration pneumonia. CT showed consolidation of left lower lobe, stenosis of lower esophagus with dilation of the oral side and stagnation of residual foods. Esophagogram showed stenosis of the lower esophagus and stagnation of the contrast medium. He was diagnosed with esophageal achalasia. Balloon dilation was performed and the obstruction was improved. He has been well without recurrence of achalasia.


Assuntos
Adenocarcinoma/cirurgia , Acalasia Esofágica/diagnóstico por imagem , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pulmonares/cirurgia , Complicações Pós-Operatórias/diagnóstico por imagem , Adenocarcinoma/diagnóstico por imagem , Dilatação/métodos , Acalasia Esofágica/etiologia , Acalasia Esofágica/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Pneumonia Aspirativa/etiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Tomografia Computadorizada por Raios X
19.
Dis Esophagus ; 31(9)2018 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-30169645

RESUMO

Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.


Assuntos
Acalasia Esofágica/diagnóstico , Acalasia Esofágica/terapia , Adulto , Toxinas Botulínicas/uso terapêutico , Criança , Dilatação/métodos , Dilatação/normas , Gerenciamento Clínico , Acalasia Esofágica/fisiopatologia , Esofagoscopia/métodos , Esofagoscopia/normas , Medicina Baseada em Evidências , Feminino , Humanos , Masculino , Miotomia/métodos , Miotomia/normas , Fatores de Risco , Índice de Gravidade de Doença , Avaliação de Sintomas/métodos , Avaliação de Sintomas/normas
20.
Dis. Esoph. ; 31(9): 1-29, September 2018.
Artigo em Inglês | BIGG | ID: biblio-994481

RESUMO

Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.


Assuntos
Humanos , Acalasia Esofágica , Acalasia Esofágica/diagnóstico , Acalasia Esofágica/terapia
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