Clinical Endoscopy

The Korean Society of Gastrointestinal Endoscopy (대한소화기내시경학회)
권호 표지
DOI QR코드

DOI QR Code

Role of endoscopy in patients with achalasia

  • So Young Han (Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine) ;
  • Young Hoon Youn (Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine)
  • Received : 2022.11.25
  • Accepted : 2023.03.31
  • Published : 2023.09.30
Download PDF
⟨ Previous Next ⟩

Abstract

Achalasia is an esophageal motility disorder characterized by impaired lower esophageal sphincter relaxation and peristalsis of the esophageal body. With the increasing prevalence of achalasia, interest in the role of endoscopy in its diagnosis, treatment, and monitoring is also growing. The major diagnostic modalities for achalasia include high-resolution manometry, esophagogastroduodenoscopy, and barium esophagography. Endoscopic assessment is important for early diagnosis to rule out diseases that mimic achalasia symptoms, such as pseudo-achalasia, esophageal cancer, esophageal webs, and eosinophilic esophagitis. The major endoscopic characteristics suggestive of achalasia include a widened esophageal lumen and food residue in the esophagus. Once diagnosed, achalasia can be treated either endoscopically or surgically. The preference for endoscopic treatment is increasing owing to its minimal invasiveness. Botulinum toxins, pneumatic balloon dilation, and peroral endoscopic myotomy (POEM) are important endoscopic treatments. Previous studies have demonstrated excellent treatment outcomes for POEM, with >95% improvement in dysphagia, making POEM the mainstay treatment option for achalasia. Several studies have reported an increased risk of esophageal cancer in patients with achalasia. However, routine endoscopic surveillance remains controversial owing to the lack of sufficient data. Further studies on surveillance methods and duration are warranted to establish concordant guidelines for the endoscopic surveillance of achalasia.

Keywords

References

  1. Pomenti S, Blackett JW, Jodorkovsky D. Achalasia: diagnosis, management and surveillance. Gastroenterol Clin North Am 2021;50:721-736. 
  2. Pohl D, Tutuian R. Achalasia: an overview of diagnosis and treatment. J Gastrointestin Liver Dis 2007;16:297-303. 
  3. Vaezi MF, Pandolfino JE, Yadlapati RH, et al. ACG clinical guidelines: diagnosis and management of achalasia. Am J Gastroenterol 2020;115:1393-1411. 
  4. O'Neill OM, Johnston BT, Coleman HG. Achalasia: a review of clinical diagnosis, epidemiology, treatment and outcomes. World J Gastroenterol 2013;19:5806-5812. 
  5. Park W, Vaezi MF. Etiology and pathogenesis of achalasia: the current understanding. Am J Gastroenterol 2005;100:1404-1414. 
  6. Sadowski DC, Ackah F, Jiang B, et al. Achalasia: incidence, prevalence and survival. A population-based study. Neurogastroenterol Motil 2010;22:e256-e261. 
  7. Kim E, Lee H, Jung HK, et al. Achalasia in Korea: an epidemiologic study using a national healthcare database. J Korean Med Sci 2014;29:576-580. 
  8. Birgisson S, Richter JE. Achalasia in Iceland, 1952-2002: an epidemiologic study. Dig Dis Sci 2007;52:1855-1860. 
  9. Samo S, Carlson DA, Gregory DL, et al. Incidence and prevalence of achalasia in central Chicago, 2004-2014, since the widespread use of high-resolution manometry. Clin Gastroenterol Hepatol 2017;15:366-373. 
  10. Su B, Callahan ZM, Novak S, et al. Using impedance planimetry (EndoFLIP) to evaluate myotomy and predict outcomes after surgery for achalasia. J Gastrointest Surg 2020;24:964-971. 
  11. Mari A, Abu Baker F, Pellicano R, et al. Diagnosis and management of achalasia: updates of the last two years. J Clin Med 2021;10:3607. 
  12. Gockel I, Eckardt VF, Schmitt T, et al. Pseudoachalasia: a case series and analysis of the literature. Scand J Gastroenterol 2005;40:378-385. 
  13. Desai TK, Stecevic V, Chang CH, et al. Association of eosinophilic inflammation with esophageal food impaction in adults. Gastrointest Endosc 2005;61:795-801. 
  14. Potter JW, Saeian K, Staff D, et al. Eosinophilic esophagitis in adults: an emerging problem with unique esophageal features. Gastrointest Endosc 2004;59:355-361. 
  15. Mandaliya R, DiMarino AJ, Cohen S. Association of achalasia and eosinophilic esophagitis. Indian J Gastroenterol 2013;32:54-57. 
  16. Schizas D, Syllaios A, Vailas M, et al. Eosinophilic esophagitis and achalasia: two distinct nosologic entities or a possible etiopathogenic association? Dig Dis 2021;39:553-560. 
  17. Japan Esophageal Society. Descriptive rules for achalasia of the esophagus, June 2012: 4th edition. Esophagus 2017;14:275-289. 
  18. Howard PJ, Maher L, Pryde A, et al. Five year prospective study of the incidence, clinical features, and diagnosis of achalasia in Edinburgh. Gut 1992;33:1011-1015. 
  19. Minami H, Isomoto H, Miuma S, et al. New endoscopic indicator of esophageal achalasia: "pinstripe pattern". PLoS One 2015;10:e0101833. 
  20. Iwakiri K, Hoshihara Y, Kawami N, et al. The appearance of rosette-like esophageal folds ("esophageal rosette") in the lower esophagus after a deep inspiration is a characteristic endoscopic finding of primary achalasia. J Gastroenterol 2010;45:422-425. 
  21. Gomi K, Inoue H, Ikeda H, et al. New endoscopic classification of the cardiac orifice in esophageal achalasia: champagne glass sign. Dig Endosc 2016;28:645-649. 
  22. Payne WS. Heller's contribution to the surgical treatment of achalasia of the esophagus. 1914. Ann Thorac Surg 1989;48:876-881. 
  23. Pasricha PJ, Ravich WJ, Kalloo AN. Effects of intrasphincteric botulinum toxin on the lower esophageal sphincter in piglets. Gastroenterology 1993;105:1045-1049. 
  24. Pasricha PJ, Ravich WJ, Hendrix TR, et al. Treatment of achalasia with intrasphincteric injection of botulinum toxin. A pilot trial. Ann Intern Med 1994;121:590-591. 
  25. Pasricha PJ, Ravich WJ, Hendrix TR, et al. Intrasphincteric botulinum toxin for the treatment of achalasia. N Engl J Med 1995;332:774-778. 
  26. Ramzan Z, Nassri AB. The role of botulinum toxin injection in the management of achalasia. Curr Opin Gastroenterol 2013;29:468-473. 
  27. Neubrand M, Scheurlen C, Schepke M, et al. Long-term results and prognostic factors in the treatment of achalasia with botulinum toxin. Endoscopy 2002;34:519-523. 
  28. Cuilliere C, Ducrotte P, Zerbib F, et al. Achalasia: outcome of patients treated with intrasphincteric injection of botulinum toxin. Gut 1997;41:87-92. 
  29. Kolbasnik J, Waterfall WE, Fachnie B, et al. Long-term efficacy of Botulinum toxin in classical achalasia: a prospective study. Am J Gastroenterol 1999;94:3434-3439. 
  30. Richter JE, Boeckxstaens GE. Management of achalasia: surgery or pneumatic dilation. Gut 2011;60:869-876. 
  31. van Hoeij FB, Prins LI, Smout AJ, et al. Efficacy and safety of pneumatic dilation in achalasia: a systematic review and meta-analysis. Neurogastroenterol Motil 2019;31:e13548. 
  32. Mikaeli J, Bishehsari F, Montazeri G, et al. Pneumatic balloon dilatation in achalasia: a prospective comparison of safety and efficacy with different balloon diameters. Aliment Pharmacol Ther 2004;20:431-436. 
  33. 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. 
  34. 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. 
  35. Vanuytsel T, Lerut T, Coosemans W, et al. Conservative management of esophageal perforations during pneumatic dilation for idiopathic esophageal achalasia. Clin Gastroenterol Hepatol 2012;10:142-149. 
  36. Yamashita H, Ashida K, Fukuchi T, et al. Predictive factors associated with the success of pneumatic dilatation in Japanese patients with primary achalasia: a study using high-resolution manometry. Digestion 2013;87:23-28. 
  37. Pratap N, Kalapala R, Darisetty S, et al. Achalasia cardia subtyping by high-resolution manometry predicts the therapeutic outcome of pneumatic balloon dilatation. J Neurogastroenterol Motil 2011;17:48-53. 
  38. Eckardt VF, Aignherr C, Bernhard G. Predictors of outcome in patients with achalasia treated by pneumatic dilation. Gastroenterology 1992;103:1732-1738. 
  39. Rohof WO, Salvador R, Annese V, et al. Outcomes of treatment for achalasia depend on manometric subtype. Gastroenterology 2013;144:718-725. 
  40. Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010;42:265-271. 
  41. Youn YH, Minami H, Chiu PW, et al. Peroral endoscopic myotomy for treating achalasia and esophageal motility disorders. J Neurogastroenterol Motil 2016;22:14-24. 
  42. Stavropoulos SN, Modayil R, Friedel D. Achalasia. Gastrointest Endosc Clin N Am 2013;23:53-75. 
  43. Maselli R, Inoue H, Ikeda H, et al. Microvasculature of the esophagus and gastroesophageal junction: lesson learned from submucosal endoscopy. World J Gastrointest Endosc 2016;8:690-696. 
  44. 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. 
  45. Crespin OM, Liu LW, 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. 
  46. Lee JY, Lim CH, Kim DH, et al. Adverse events associated with peroral endoscopic myotomy affecting extended hospital stay: a multi-center retrospective study in South Korea. J Neurogastroenterol Motil 2022;28:247-254. 
  47. Ren Z, Zhong Y, Zhou P, et al. Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases). Surg Endosc 2012;26:3267-3272. 
  48. 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. 
  49. Repici A, Fuccio L, Maselli R, et al. GERD after per-oral endoscopic myotomy as compared with Heller's myotomy with fundoplication: a systematic review with meta-analysis. Gastrointest Endosc 2018;87:934-943. 
  50. Bapaye A, Dashatwar P, Dharamsi S, et al. Single-session endoscopic fundoplication after peroral endoscopic myotomy (POEM+F) for prevention of post gastroesophageal reflux: 1-year follow-up study. Endoscopy 2021;53:1114-1121. 
  51. Inoue H, Ueno A, Shimamura Y, et al. Peroral endoscopic myotomy and fundoplication: a novel NOTES procedure. Endoscopy 2019;51:161-164. 
  52. Li QL, Wu QN, Zhang XC, et al. Outcomes of per-oral endoscopic myotomy for treatment of esophageal achalasia with a median follow-up of 49 months. Gastrointest Endosc 2018;87:1405-1412. 
  53. Brewer Gutierrez OI, Moran RA, Familiari P, et al. Long-term outcomes of per-oral endoscopic myotomy in achalasia patients with a minimum follow-up of 4 years: a multicenter study. Endosc Int Open 2020;8:E650-E655. 
  54. Nabi Z, Ramchandani M, Darisetty S, et al. Impact of prior treatment on long-term outcome of peroral endoscopic myotomy in pediatric achalasia. J Pediatr Surg 2020;55:1552-1555. 
  55. Xu S, Chai N, Tang X, et al. Outcomes of peroral endoscopic myotomy in challenging achalasia patients: a long-term follow-up study. Surg Endosc 2021;35:3732-3743. 
  56. Podboy AJ, Hwang JH, Rivas H, et al. Long-term outcomes of per-oral endoscopic myotomy compared to laparoscopic Heller myotomy for achalasia: a single-center experience. Surg Endosc 2021;35:792-801. 
  57. Shiwaku H, Inoue H, Onimaru M, et al. Multicenter collaborative retrospective evaluation of peroral endoscopic myotomy for esophageal achalasia: analysis of data from more than 1300 patients at eight facilities in Japan. Surg Endosc 2020;34:464-468. 
  58. Ponds FA, Fockens P, Lei A, et al. Effect of peroral endoscopic myotomy vs pneumatic dilation on symptom severity and treatment outcomes among treatment-naive patients with achalasia: a randomized clinical trial. JAMA 2019;322:134-144. 
  59. 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. 
  60. 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. 
  61. Eckardt AJ, Eckardt VF. Editorial: cancer surveillance in achalasia. Better late than never? Am J Gastroenterol 2010;105:2150-2152. 
  62. Leeuwenburgh I, Scholten P, Alderliesten J, et al. Long-term esophageal cancer risk in patients with primary achalasia: a prospective study. Am J Gastroenterol 2010;105:2144-2149. 
  63. Sandler RS, Nyren O, Ekbom A, et al. The risk of esophageal cancer in patients with achalasia. A population-based study. JAMA 1995;274:1359-1362. 
  64. Zendehdel K, Nyren O, Edberg A, et al. Risk of esophageal adenocarcinoma in achalasia patients, a retrospective cohort study in Sweden. Am J Gastroenterol 2011;106:57-61. 
  65. Leeuwenburgh I, Scholten P, Calje TJ, et al. Barrett's esophagus and esophageal adenocarcinoma are common after treatment for achalasia. Dig Dis Sci 2013;58:244-252. 
  66. Ide E, Carneiro FO, Frazao MS, et al. Endoscopic detection of early esophageal squamous cell carcinoma in patients with achalasia: narrow-band imaging versus Lugol's staining. J Oncol 2013;2013:736756. 
  67. Ponds FA, Moonen A, Smout AJ, et al. Screening for dysplasia with Lugol chromoendoscopy in longstanding idiopathic achalasia. Am J Gastroenterol 2018;113:855-862.