일차성 식도운동질환에서 내시경치료

Endoscopic Treatment of Primary Esophageal Motility Disorders

  • 이준성 (순천향대학교 의과대학 내과학교실, 소화기연구소)
  • Lee, Joon-Seong (Department of Internal Medicine, Institute for Digestive Research, Soonchunhyang University College of Medicine)
  • 발행 : 2011.06.30

초록

일차성 식도운동질환, 특히 식도이완불능증에서의 치료는 많은 발전을 해왔다. 이들 환자에서 입증된 치료의 대부분은 내시경적 방법이다. 현재 식도이완불능증에서 내시경적 풍선확장술과 복강경하 근절개술 및 부분 추벽성형술은 둘 모두 유용한 치료법이다. 특히 젊은 연령의 남성에서 높은 하부식도조임근압을 보인다면 복강경하 근절개술 및 부분 위바닥 주름성형술의 가장 좋은 적응증일 것이다. 수술적 고위험군이나 고령, 또는 강력한 식도이완불능증인 경우는 내시경적 보툴리늄 독소 주입법의 좋은 적응증이 될 것이다. 그외의 경우에는 일차치료로 내시경적 풍선확장술이 주된 치료로 이용될 것이다. 식도이완불능증 이외의 경직성식도운동질환에서 가장 좋은 치료법은 현재 내시경적 보툴리늄 독소 주입법일 것이다. 미래에는 신경성줄기세포를 내시경적으로 주입하는 방법이 식도이완불능증의 주된 근본적인 치료법이 될 수 있을 것으로 생각한다.

Treatment of primary esophageal motility disorders, particularly achalasia, has developed enormously. The proven treatments for these patients include mostly endoscopic methods. Currently, pneumatic dilatation and laparoscopic myotomy with partial fundoplication are both useful for treating achalasia. A young man with high lower esophageal sphincter pressure might be best indicated for a laparoscopic myotomy with fundoplication, whereas an older patient with a high risk for surgery or vigorous achalasia may for a candidate for an endoscopic botulinum toxin injection. Pneumatic balloon dilatation is the choice of treatment for other cases of achalasia. The best treatment option for a nonachalasia spastic motor disorder of the esophagus may be endoscopic injection of botulinum toxin. In the future, endoscopic injection of neuronal stem cells could be the best treatment option for achalasia.

키워드

참고문헌

  1. Leite LP, Johnston BT, Barrett J, Castell JA, Castell DO. Ineffective esophageal motility (IEM): the primary finding in patients with nonspecific esophageal motility disorder. Dig Dis Sci 1997;42:1859-1865. https://doi.org/10.1023/A:1018802908358
  2. Adler DG, Romero Y. Primary esophageal motility disorders. Mayo Clin Proc 2001;76:195-200.
  3. Facco M, Brun P, Baesso I, et al. T cells in the myenteric plexus of achalasia patients show a skewed TCR repertoire and react to HSV-1 antigens. Am J Gastroenterol 2008;103:1598-1609. https://doi.org/10.1111/j.1572-0241.2008.01956.x
  4. Boeckxstaens GE. Achalasia: virus-induced euthanasia of neurons? Am J Gastroenterol 2008;103:1610-1612. https://doi.org/10.1111/j.1572-0241.2008.01967.x
  5. Pasricha PJ, Ravich WJ, Hendrix TR, Sostre S, Jones B, Kalloo AN. Intrasphincteric botulinum toxin for the treatment of achalasia. N Engl J Med 1995;332:774-778. https://doi.org/10.1056/NEJM199503233321203
  6. Pasricha PJ, Rai R, Ravich WJ, Hendrix TR, Kalloo AN. Botulinum toxin for achalasia: long-term outcome and predictors of response. Gastroenterology 1996;110:1410-1415. https://doi.org/10.1053/gast.1996.v110.pm8613045
  7. Annese V, Bassotti G, Coccia G, et al. A multicentre randomized study of intrasphincteric botulinum toxin in patients with oesophageal achalasia. GISMAD Achalasia Study Group Gut 2000;46:597-600. https://doi.org/10.1136/gut.46.5.597
  8. Kolbasnik J, Waterfall WE, Fachnie B, Chen Y, Tougas G. Long-term efficacy of Botulinum toxin in classical achalasia: a prospective study. Am J Gastroenterol 1999;94:3434-3439.
  9. D'Onofrio V, Miletto P, Leandro G, Iaquinto G. Long-term follow-up of achalasia patients treated with botulinum toxin. Dig Liver Dis 2002;34:105-110. https://doi.org/10.1016/S1590-8658(02)80238-9
  10. Ham JS, Jang JY, Choi WB, et al. Clinical trial of endoscopic botulinum toxin injection for the treatment of primary achalasia. Korean J Gastrointest Endosc 1997;17:750-759.
  11. Portale G, Constantini M, Rizzetto C, et al. Long-term outcome of laparoscopic Heller-Dor surgery for achalasia: possible detrimental role of previous endoscopic treatment. J Gastrointest Surg 2005;9:1332-1339. https://doi.org/10.1016/j.gassur.2005.10.001
  12. Vela MF, Richter JE, Khandwala F, et al. The long-term efficacy of pneumatic dilatation and Heller myotomy for the treatment of achalasia. Clin Gastroenterol Hepatol 2006;4:580-587. https://doi.org/10.1016/S1542-3565(05)00986-9
  13. Radaelli F, Paggi S, Terreni N, Toldi A, Terruzzi V. Acute reversible gastroparesis and megaduodenum after botulinum toxin injection for achalasia. Gastrointest Endosc 2010;71:1326-1327. https://doi.org/10.1016/j.gie.2009.10.034
  14. Cheatham JG, Wong RK. Current approach to the treatment of achalasia. Curr Gastroenterol Rep 2011;13:219-225. https://doi.org/10.1007/s11894-011-0190-z
  15. Francis DL, Katzka DA. Achalasia: update on the disease and Its treatment. Gastroenterology 2010;139:369-374. https://doi.org/10.1053/j.gastro.2010.06.024
  16. Kadakia SC, Wong RK. Graded pneumatic dilation using Rigiflex achalasia dilators in patients with primary esophageal achalasia. Am J Gastroenterol 1993;88:34-38.
  17. Chuah SK, Wu KL, Hu TH, Tai WC, Changchien CS. Endoscope-guided pneumatic dilation for treatment of esophageal achalasia. World J Gastroenterol 2010;16:411-417. https://doi.org/10.3748/wjg.v16.i4.411
  18. Richter JE, Boeckxstaens GE. Management of achalasia: surgery or pneumatic dilation. Gut 2011;60:869-876. https://doi.org/10.1136/gut.2010.212423
  19. Hulselmans M, Vanuytsel T, Degreef T, et al. Long-term outcome of pneumatic dilation in the treatment of achalasia. Clin Gastroenterol Hepatol 2010;8:30-35. https://doi.org/10.1016/j.cgh.2009.09.020
  20. Vela MF, Richter JE, Khandwala F, et al. The long-term efficacy of pneumatic dilation and Heller myotomy for the treatment of achalasia. Clin Gastroenterol Hepatol 2006;4:580-587. https://doi.org/10.1016/S1542-3565(05)00986-9
  21. Zerbib F, Thetiet V, Richy F, Benajah DA, Message L, Lamouliatte H. Repeated pneumatic dilations as long-term maintenance therapy for esophageal achalasia. Am J Gastroenterol 2006;101:692-697. https://doi.org/10.1111/j.1572-0241.2006.00385.x
  22. Eckardt VF, Aignherr C, Bernhard G. Predictors of outcome in patients with achalasia treated by pneumatic dilation. Gastroenterology 1992;103:1732-1738.
  23. Vantrappen G, Hellemans J, Deloof W, Valembois P, Vandenbroucke J. Treatment of achalasia with pneumatic dilations. Gut 1971;12:268-275. https://doi.org/10.1136/gut.12.4.268
  24. Eckardt VF, Kanzler G, Westermeier T. Complications and their impact after pneumatic dilation for achalasia: prospective long-term follow-up study. Gastrointest Endosc 1997;45:349-353. https://doi.org/10.1016/S0016-5107(97)70142-1
  25. Ghoshal UC, Kumar S, Saraswat VA, Aggarwal R, Misra A, Choudhuri G. Long-term follow-up after pneumatic dilation for achalasia of the cardia: factors associated with treatment failure and recurrence. Am J Gastroenterol 2004;99:2304-2310. https://doi.org/10.1111/j.1572-0241.2004.40099.x
  26. Vaezi MF, Baker ME, Achkar E, Richter JE. Timed barium esophagram: better predictor of long-term success after pneumatic dilation than symptom assessment. Gut 2002;50:765-770. https://doi.org/10.1136/gut.50.6.765
  27. 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. https://doi.org/10.1097/SLA.0b013e31818e43ab
  28. Vela MF, Richter JE, Wachsberger D, Connor J, Rice TW. Complexities of managing achalasia at a tertiary referral center: use of pneumatic dilatation, Heller myotomy, and botulinum toxin injection. Am J Gastroenterol 2004;99:1029-1036. https://doi.org/10.1111/j.1572-0241.2004.30199.x
  29. Metman EH, Lagasse JP, d'Alteroche L, Picon L, Scotto B, Barbieux JP. Risk factors for immediate complications after progressive pneumatic dilation for achalasia. Am J Gastroenterol 1999;94:1179-1185. https://doi.org/10.1111/j.1572-0241.1999.01062.x
  30. Boeckxstaens GE, Annese V, des Varannes SB, et al. Pneumatic dilation versus laparoscopic Heller's myotomy for idiopathic achalasia. N Engl J Med 2011;364:1807-1816. https://doi.org/10.1056/NEJMoa1010502
  31. Richer JE. Update on the management of achalasia: balloons, surgery and drugs. Expert Rev Gastroenterol Hepatol 2008;2:435-445. https://doi.org/10.1586/17474124.2.3.435
  32. De Palma GD, lovino P, Masone S, Persico M, Persico G. Self-expanding metal stents for endoscopic treatment of esophageal achalasia unresponsive to conventional treatments. Long-term results in eight patients. Endoscopy 2001;33:1027-1030. https://doi.org/10.1055/s-2001-18933
  33. Zhu YQ, Cheng YS, Tang GY, Li MH, Zhao JG, Li F. Comparison of temporary stent insertion with pneumatic dilation of the same diameter in the treatment of achalasia patients: a retrospective study. J Gastroenterol Hepatol 2010;25:499-505. https://doi.org/10.1111/j.1440-1746.2009.06107.x
  34. Zhao JG, Li YD, Cheng YS, et al. Long-term safety and outcome of a temporary self-expanding metallic stent for achalasia: a prospective study with a 13-year single-center experience. Eur Radiol 2009;19:1973-1980. https://doi.org/10.1007/s00330-009-1373-y
  35. Li YD, Cheng YS, Li MH, Chen NW, Chen WX, Zhao JG. Temporary self-expanding metallic stents and pneumatic dilation for the treatment of achalasia: a prospective study with a long-term follow-up. Dis Esophagus 2010;23:361-367.
  36. Zaninotto G, Rizzetto C, Zambon P, Guzzinati S, Finotti E, Costantini M. Long-term outcome and risk of oesophageal cancer after surgery for achalasia. Br J Surg 2008;95:1488-1494. https://doi.org/10.1002/bjs.6413
  37. Rosen MJ, Novitsky YW, Cobb WS, Kercher KW, Heniford BT. Laparoscopic Heller myotomy for achalasia in 101 patients: can successful symptomatic outcomes be predicted? Surg Innov 2007;14:177-183. https://doi.org/10.1177/1553350607307876
  38. Rebecchi F, Giaccone C, Farinella E, Campaci R, Morino M. Randomized controlled trial of laparoscopic Heller myotomy plus Dor fundoplication versus Nissen fundoplication for achalasia: long-term results. Ann Surg 2008;248:1023-1030. https://doi.org/10.1097/SLA.0b013e318190a776
  39. Melvin WS, Needleman BJ, Krause KR, Wolf RK, Michler RE, Ellison EC. Computer-assisted robotic Heller myotomy: initial case report. J Laparoendosc Adv Surg Tech A 2001;11:251-253. https://doi.org/10.1089/109264201750539790
  40. Malthaner RA, Tood TR, Miller L, Pearson FG. Long-term results in surgically managed esophageal achalasia. Ann Thorac Surg 1994;58:1343-1346. https://doi.org/10.1016/0003-4975(94)91910-0
  41. Kilic A, Schuchert MJ, Pennathur A, Gilbert S, Landreneau RJ, Luketich JD. Long-term outcomes of laparoscopic Heller myotomy for achalasia. Surgery 2009;146:826-831. https://doi.org/10.1016/j.surg.2009.06.049
  42. Wang YR, Dempsey DT, Friedenberg FK, Richter JE. Trends of Heller myotomy hospitalizations for achalasia in the United States, 1993-2005: effect of surgery volume on perioperative outcomes. Am J Gastroenterol 2008;103:2454-2464. https://doi.org/10.1111/j.1572-0241.2008.02049.x
  43. Costantini MI, Zaninotto G, Guirroli E, et al. The laparoscopic Heller-Dor operation remains effective treatment for esophageal achalasia at a minimum of 6 year follow-up. Surg Endosc 2005;19:345-351. https://doi.org/10.1007/s00464-004-8941-7
  44. Gockel I, Junginger T, Eckardt VF. Long-term results of conventional myotomy in patients with achalasia: a prospective 20 year analysis. J Gastrointest Surg 2006;10:1400-1408. https://doi.org/10.1016/j.gassur.2006.07.006
  45. Bonatti H, Hinder RA, Klocker J, et al. Long-term results of laparoscopic Heller myotomy with partial fundoplication for the treatment of achalasia. Am J Surg 2005;190:874-878.
  46. Eldaif SM, Mutrie CJ, Rutledge WC, et al. The risk of esophageal resection after esophagomyotomy for achalasia. Ann Thorac Surg 2009;87:1558-1562. https://doi.org/10.1016/j.athoracsur.2009.02.078
  47. Csendes A, Braghetto I, Burdiles P, Korn O, Csendes P, Henriquez A. Very late results of esophagomyotomy for patients with achalasia: clinical, endoscopic, histologic, manometric, and acid reflux studies in 67 patients for a mean follow-up of 190 months. Ann Surg 2006;243:196-203. https://doi.org/10.1097/01.sla.0000197469.12632.e0
  48. Leeuwenburgh I, Haringsma J, Van Dekken H, Scholten P, Siersema PD, Kuipers EJ. Long-term risk of oesophagitis, Barrett's oesophagus and oesophageal cancer in achalasia patients. Scand J Gastroenterol Suppl 2006;243:7-10.
  49. 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. https://doi.org/10.1055/s-2007-966764
  50. Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010;42:265-271. https://doi.org/10.1055/s-0029-1244080
  51. Gutschow CA, Holscher AH. Myotomy for esophageal achalasia - laparoscopic versus peroral endoscopic approach. Endoscopy 2010;42:318-319. https://doi.org/10.1055/s-0029-1244071
  52. Stavropoulos SN, Harris MD, Hida S, Brathwaite C, Demetriou C, Grendell J. Endoscopic submucosal myotomy for the treatment of achalasia (with video). Gastrointest Endosc 2010;72:1309-1311. https://doi.org/10.1016/j.gie.2010.04.016
  53. Perretta S, Dallemagne B, Allemann P, Marescaux J. Heller myotomy and intraluminal fundoplication: a NOTES technique. Surg Endosc 2010;24:2903. https://doi.org/10.1007/s00464-010-1073-3
  54. Micci MA, Kahrig KM, Simmons RS, Sarna SK, Espejo-Navarro MR, Pasricha PJ. Neural stem cell transplantation in the stomach rescues gastric function in neuronal nitric oxide synthase-deficient mice. Gastroenterology 2005;129:1817-1824. https://doi.org/10.1053/j.gastro.2005.08.055
  55. Miller LS, Parkman HP, Schiano TD, et al. Treatment of symptomatic nonachalasia esophageal motor disorders with botulinum toxin injection at the lower esophageal sphincter. Dig Dis Sci 1996;41:2025-2031. https://doi.org/10.1007/BF02093606
  56. Nebendahl JC, Brand B, von Schrenck T, et al. Treatment of diffuse esophageal spasm with botulinum toxin: a prospective study with 6 month follow up. Gastroenterology 1999;116(abstr):802A.
  57. Storr M, Allescher HD, Rosch T, Born P, Weigert N, Classen M. Treatment of symptomatic diffuse esophageal spasm by endoscopic injection of botulinum toxin: a prospective study with long term follow-up. Gastrointest Endosc 2001;54:754-759. https://doi.org/10.1067/mge.2001.119256
  58. Miller LS, Pullela SV, Parkman HP, et al. Treatment of chest pain in patients with noncardiac, nonreflux, nonachalasia spastic esophageal motor disorders using botulinum toxin injection into the gastroesophageal junction. Am J Gastroenterol 2002;97:1640-1646. https://doi.org/10.1111/j.1572-0241.2002.05821.x
  59. Storr M, Roesch T, Born P, et al. Long-term treatment of symptomatic diffuse esophageal spasm by injection of botulinum toxin (BTX). Gastroenterology 2003;124:P237.
  60. Vanuytsel T, Bisschps R, Holvoet L, et al. A sham-controlled study of injection of botulinum toxin in non-achalasia esophageal motility disorder. Gastroenterology 2009;136:P131. https://doi.org/10.1053/j.gastro.2008.09.033
  61. Bashashati M, Andrews C, Ghosh S, Storr M. Botulinum toxin in the treatment of diffuse esophageal spasm. Dis Esophagus 2010;23:554-560. https://doi.org/10.1111/j.1442-2050.2010.01065.x