Pneumatic Dilation Research Articles

S2443 Achalasia in a 16-Year-Old: Diagnostic Dilemma

Introduction: Achalasia is a disorder, particularly rare in children, with an incidence of 0.11/100000 in the pediatric population. It is a motility disorder of the esophagus characterized by inadequate esophageal peristalsis and failure of the esophageal sphincter to relax. Symptoms include but are not limited to dysphagia, vomiting, and weight loss. Barium esophagogram and manometry are the tools used for diagnosis. Treatment options among children include laparoscopic Heller myotomy and peroral endoscopic myotomy. Case Description/Methods: Our patient was a 16-year-old child who presented with persistent vomiting and weight loss for 6 to 8 months. The patient underwent an EGD at an outside hospital which was inconclusive. Initially, there were concerns about an eating disorder, but it was ruled out. The patient had episodes of hypokalemia and syncope, requiring admissions to the hospitals on numerous occasions. The patient had to be started on TPN for nutrition. During our hospital admission, the patient underwent an EGD, which showed dilated esophagus suspected of a motility disorder. Esophagram showed findings consistent with an early stage of achalasia (Figure). Subsequently patient had endoscopy-guided placement of a manometry probe, and she was diagnosed with Achalasia type 1. The patient underwent POEM, which resulted in significant improvement of her symptoms. Her electrolyte abnormalities resolved as she started to tolerate a diet without emesis. Discussion: Achalasia is a rare disorder that usually presents between the age of 25 and 40. Establishing an early diagnosis in children can be challenging since more than half of the cases are diagnosed at an older age creating a diagnostic dilemma for pediatricians and gastroenterologists. Nonspecific symptoms can lead to a misdiagnosis posing significant health risks to the patient if left untreated. Our patient had 50 pounds of weight loss and was started on TPN for nutrition even before the diagnosis. Given the rarity of the case, it helps increase awareness among pediatricians and gastroenterologists to consider motility disorders early on, with esophageal manometry considered the gold standard for diagnosis.Figure 1.: Manometry and esophagram.

Anesthetic Management of a Patient with Epidermolysis Bullosa for Esophageal Dilatation: A Case Report

Anesthetic Management of a Patient with Epidermolysis Bullosa for Esophageal Dilatation: A Case Report

Achalasia: Current therapeutic options.

Achalasia is an esophageal motor disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and absent peristalsis in the smooth muscle esophageal body. As a result, patients typically experience dysphagia, regurgitation, chest pain, and weight loss. Over the past 10-15 years, there has been a resurgence of interest in the evaluation of therapies for achalasia. Unfortunately, little progress in the development of effective pharmacological treatments has been made. Botulinum toxin injection provides some relief of symptoms in many patients but requires periodic reinjection that may provide progressively less benefit over time. There are now three well-established, safe, and effective therapies for the treatment of achalasia: pneumatic dilation (PD), laparoscopic Heller myotomy (LHM), and peroral endoscopic myotomy (POEM) which can lead to marked symptom improvement in most patients. Each treatment has a specific constellation of risks, benefits, and recurrence rate. The first-line treatment used will depend on patient preference, achalasia subtype, and local expertise. The recent impressive advances in both the art and science of achalasia therapy are explored with a comprehensive review of the various treatment modalities and comparative controlled clinical trials. In addition, key technical pearls of the procedural treatments are demonstrated.

573. DOES CHEST PAIN AFFECT THE LONG TERM OTCOME OF SURGERY FOR ESOPHAGEAL ACHALASIA?

Abstract Literature supporting the adoption of POEM in place of the standard Heller myotomy in the presence of significant chest pain associated with typical symptoms like in case of Achalasia Type III according to the Chicago classification, generally reports on outcome data collected after short follow up periods. We aimed to assess behaviors of chest pain in the long term in a case series of patients submitted to the Heller-Dor operation. Between 1978 and 2021,394 achalasia patients underwent the Heller-Dor operation. Chest pain was evaluated according to its frequency (0: absent; 1: occasional; 2: weekly; 3: daily): 81 preoperatively complained of chest pain (score 2-3) (CP group), 313 did not (score 0-1) (NCP group). Patients were followed up according to a timed protocol based on clinical assessment of dysphagia (D0 absent – D3 each meal), GERD symptoms (RS0 absent-RS3 each meal). Barium swallow and endoscopy (E0: normal, E1: mild esophagitis, E2-3: erosive/ulcerative esophagitis) were performed at each planned control. CP and NCP were compared. CP group had shorter duration of dysphagia (p=0.03), smaller esophageal diameter and lower barium column (p<0.05). At a median follow-up of 10 years for CP and 11 years for NCP (p=0.166), the frequency of dysphagia (p=0.05), GERD symptoms (p=0.3) and esophagitis (p=0.27) was similar in the two groups. Chest pain progressively attenuated in intensity and frequency.; median chest pain score preoperatively was 3, at follow-up it was 0 (p<0.01). Clinical results obtained in CP patients (satisfactory D0–2, RS0–2, and E1 in 95%) were not inferior to those obtained in NCP patients (satisfactory in 93%) (p=0.05). According to our single center case series, in the long term chest pain does not influence negatively HD outcome which is absolutely competitive with that generally reported for POEM and pneumatic dilation. Results presented in this study must be verified: as new randomized prospective studies would require a too long lag time, valid retrospective multi center studies should be performed.

598. EPIPHRENIC DIVERTICULUM CAUSING GASTROESOPHAGEAL JUNCTION OUTFLOW OBSTRUCTION (EGJOO)

Abstract Oesophageal diverticulum is a rare cause of dysphagia. They are classified based on location- Zenker’s diverticulum distal to the cricopharyngeus; epiphrenic diverticulum above the lower oesophageal sphincter (LES)- or pathophysiology – traction vs pulsion. The prevalence of epiphrenic pulsion diverticulum ranges from 0.2% to 0.8%. We present a case of epiphrenic diverticulum and its management. A 68 year old lady presents with dysphagia to solids and liquids, belching, food regurgitation, and acid brash for 10 years. She had no loss of weight, but experienced daily regurgitation and occasional retrosternal pain. Physical examination was unremarkable. We worked her up with further investigations and scans. A CT abdomen reported a hiatus hernia and mural thickening of distal oesophagus with upstream oesophageal distension. A oesophagogastroduodenoscopy showed residual food in oesophagus. The lower oesophagus was dilated and the LES appeared tight with no masses. There was no hiatus hernia on endoscopy. Barium swallow revealed the lower oesophageal dilatation to be an epiphrenic diverticulum. Manometry studies showed oesophago-gastric junction outflow obstruction. She underwent laparoscopic excision of esophageal diverticulum, cardiomyotomy and anterior partial fundoplication. The video serves to highlight the surgical key steps. She was discharged on post-operative day 3 without complications and barium swallow pre/post op as shown. Oesophageal diverticulum, although rare, remains a differential for dysphagia. For epiphrenic diverticulum, it is important to understand that this is a pulsion diverticulum, with an accompanying gastro-oesophageal outflow obstruction. In addition to surgical management with a laparoscopic diverticulectomy, a cardiomyotomy and partial fundoplication to treat underlying motility disorder is important. This case study and video serves to highlight the condition and present minimally invasive surgical management.

223. INTRAOPERATIVE PYLOROPLASTY DURING OESOPHAGECTOMY: A 12 YEAR TERTIARY CENTRE EXPERIENCE

Abstract Delayed gastric emptying (DGE) is a known complication following oesophagectomy with gastric conduit reconstruction. Pyloroplasty is often performed to mitigate the consequences of DGE. It remains contentious whether performing a pyloroplasty has a significant role in reducing DGE. We discuss our twelve-year experience at a single centre routinely performing Heineke-Mikulicz pyloroplasty for all oesophagectomies. This retrospective study employed an electronic database containing information on all patients who underwent elective Ivor Lewis oesophagectomies from April 2009 to December 2021 in a tertiary upper gastrointestinal cancer centre. Across six surgeons in the centre, a standardised pyloroplasty technique was performed. DGE was defined as patients who had high nasogastric output (> 1.5 litres per day) after ten post-operative days or required endoscopic pyloric balloon dilatation within one year following oesophagectomy. 578 patients underwent Ivor Lewis oesophagectomy during the study period. The mean age was sixty years and the male to female ratio was 1.8:1. The median length of stay was 13 days (3–148). DGE was seen in 9.9% (n = 57) patients. Of these patients, 39.7% (n = 29) cases required oesophageal dilatation within 12 months after their oesophagectomy. 50.8% (n = 21) required in-patient endoscopic dilatation, 14.0% (n = 8) required out-patient endoscopic dilatation. From those who developed DGE, the 30- and 90-day mortality was nil. There were 1.2% (n = 7) leaks specifically from the pyloroplasty which were all managed conservatively. The rate of delayed gastric emptying is reported to be approximately 15% (Zhang & Zhang, 2018). Our study demonstrates that performing a pyloroplasty reduces this risk to 9.9% and is worthwhile as the complication rate from pyloroplasty is low. Although there are various methods employed in overcoming pyloric sphincter denervation following oesophagectomy (pyloroplasty, pyloromyotomy, digital or instrumental pyloric stretching or intra-operative balloon dilatation), the most effective method of reducing DGE warrants a randomised control trial.

602. LONG-TERM OUTCOME OF COLON INTERPOSITION IN SEVERE CORROSIVE UPPER DIGESTIVE TRACT INJURY

Abstract Long-term outcome of colonic interposition in patients with severe corrosive upper gastrointestinal tract injury is less known. Patients diagnosed of severe corrosive upper digestive tract injury were included. Patients with full-thickness organ necrosis underwent emergent surgical resection without primary reconstruction. Subsequent esophageal reconstruction with substernal colonic interposition approximately 6 months after the ingestion was undertaken in physically and mentally fit patients. Esophageal dilatation program was applied as first line treatment in all patients with esophageal stricture at a median duration of 5 weeks after the injury. Esophageal replacement procedure was offered to the patients who had failed dilatation. Late complications, swallow function, nutritional autonomy and overall survival in patients who underwent colonic interposition were evaluated. There were 70 patients undergoing colonic interposition. Of 70 patients, 50 (71%) had cervical pharyngo-colonic and 20 had cervical esophago-colonic anastomoses. There was one (1.4%) 90-day hospital mortality. Anastomosis leakage was 8%. At median follow up of 58 months, late deaths were observed in 6 patients causing by nesidioblastosis (2), resuicidal attempt (2) and intestinal volvulus (2). Adhesive small intestinal obstruction requiring laparotomy was observed in 7(10%). Nutritional autonomy was achieved in 55 of 60 (92%) patients. Strictures were developed in 10 (16%) and dumping syndrome in 20 (30%) patients. Five- and ten-year overall survival were 72% and 61%, respectively. Colonic interposition in patients with severe corrosive upper digestive tract injury was safe and effective. Long-term survival, function and nutritional outcome are good regardless of the proximal level of cervical anastomosis. However, the late negative impact of the reconstructive procedure on metabolic derangement and small intestinal obstruction cannot be overemphasized.

Recurrent dysphagia after myotomy for achalasia: pneumatic dilation or POEM? : Which modality offers superior outcomes?

Myotomy is the gold standard treatment for achalasia, yet long-term failure rates approach 15%. Treatment options for recurrent dysphagia include pneumatic dilation (PD), laparoscopic redo myotomy, per oral endoscopic myotomy (POEM), or esophagectomy. We employ both PD and POEM as first-line treatment for these patients. We evaluated operative success and patient reported outcomes for patients who underwent PD or POEM for recurrent dysphagia after myotomy. We identified patients with achalasia who underwent PD or POEM for recurrent dysphagia after previous myotomy within a foregut database at our institution between 2013 and 2021. Gastroesophageal Reflux Disease-Health-Related quality of Life (GERD-HRQL) and Eckardt scores, and overall change in each were compared across PD and POEM groups. Successful treatment of dysphagia was defined by Eckardt scores ≤ 3. 103 patients underwent myotomy for achalasia. Of these, 19 (18%) had either PD or POEM for recurrent dysphagia. Nine were treated with PD and 10 with POEM. The mean change in Eckardt and GERD-HRQL scores did not differ between groups. 50% of the PD group and 67% of the POEM group had resolution of their dysphagia symptoms (p = 0.65). Mean procedure length was greater in the POEM group (267 vs 72min, p < 0.01) as was mean length of stay (1.56 vs 0.3days, p < 0.01). There was one adverse event after PD and three adverse events after POEM. After PD, 7 patients (70%) required additional procedures compared to four patients (44%) in the POEM group, consisting mostly of repeat PD. Patients undergoing PD or POEM for recurrent dysphagia after myotomy have similar rates of dysphagia resolution and reflux symptoms. Patients undergoing PD enjoy a shorter length of stay and shorter procedure time but may require more subsequent procedures.

Esophageal Dilation in Children: A State of the Art Review.

Esophageal dilations in children are performed by several pediatric and adult professionals. We aim to summarize improvements in safety and new technology used for the treatment of complex and refractory strictures, including triamcinolone injection, endoscopic electro-incisional therapy, topical mitomycin-C application, stent placement, functional lumen imaging probe assisted dilation, and endoscopic vacuum-assisted closure in the pediatric population.

Achalasia cardia: A Case Report and a Brief Review

Achalasia cardia (AC) is one of the rarely seen disorders of esophagus motility which happens as a result of degeneration of neurons which is irreversible. Treatment is mainly of palliative nature, and no complete curative treatment is available as of now. The diagnostics and therapeutics in this direction has strengthened mainly due to high-resolution manometry and per-oral endoscopic myotomy, referred to as Peroral endoscopic myotomy (POEM).The characterization of type of achalasia cardia is made easier by high-resolution manometry as we have mentioned, which also has an important therapeutic role. Achalasia has to be managed for each patient individually, and the role of pneumatic balloon dilatation, POEM, or Heller’s myotomy needs to be reconsidered. In our case report and brief review, we discussed the main aspects of diagnosing an OPD-based patient and a brief review of achalasia cardia.

The Impact of Obesity on the Fibrostenosis Progression of Eosinophilic Esophagitis in a U.S. Veterans Cohort.

Whether obesity is protective against progression of EoE is unknown. The aimof this study was to assess factors that alter the progression of EoE anddetermine if BMI is correlated with reduced disease severity. In this retrospective analysis of the Department of Veterans Affairs electronic health records, patients with EoE who received at least one dilation were identified using ICD and CPT codes. Kaplan-Meier curves determined the relationship between BMI and time to second esophageal dilation as a measurement of severity of disease. Cox proportional hazards models assessed the risk of second dilation adjusted for potential confounders. Of 2890 patients with EoE and at least one dilation, 40% were obese (n = 1165). There were no clinically significant differences in demographics between obese and non-obese patients. Non-obese patients were more likely to be smokers and had a higher mean average of the number of dilation visits compared to obese patients (p < 0.05). When stratified by obesity, non-obese individuals had a median time to next dilation of 6.53years (95% CI (5.83, 7.79)) compared to 9.24years for obese individuals (95% CI (7.40, 15.04)). When stratified by six BMI categories, median time to second dilation increased with increasing BMI. The hazard ratio of second dilation for obese individuals was 0.81 (95% CI (0.72-0.92)). EoE patients with a higher BMI were less likely to undergo a second dilation compared to those with a lower BMI. Obesity may have a protective role in EoE or severe strictures may lead to malnourishment. Further research into these possibilities is needed.

Endoscopic electroincision of challenging benign biliopancreatic strictures

Background and study aims Endoscopic drainage of benign biliary and pancreatic strictures can be challenging, especially when tightness of the stenosis does not allow passage of mechanical and pneumatic dilation catheters. Electroincision of benign biliopancreatic can be considered in selected cases. Patients and methods Three male patients (mean age 33 years, range 9–60) underwent endoscopic retrograde cholangiopancreatography to drain anastomotic biliary stricture (ABS) following orthotopic liver transplantation (n = 2) and pancreatic duct stenosis due to abdominal trauma (n = 1). The biliopancreatic strictures could be passed only with a thin 0.020-inch hydrophilic guidewire. Conventional mechanical and pneumatic dilators failed to pass the strictures due to weakness of the guidewire. Therefore, electrosurgical incision by over-the-wire 6Fr cystotome or needle-knife was attempted using pure cut current. Results The two cases of ABS were approached also by cholangioscopy and the 6Fr cystotome easily passed the strictures, allowing subsequent pneumatic dilatation and insertion of multiple plastic stents. The patient with a pancreatic duct stricture underwent electrosurgical incision using a thin needle knife over-the-wire, resulting in insertion of a 7Fr pancreatic stent. No adverse events occurred; all the patients were discharged within 24 to 48 hours. Conclusions Electrosurgical incision of benign biliopancreatic strictures could be considered in selected patients whom conventional dilation techniques fail.

Reintervention for Achalasia: A Review of the Literature

Achalasia is a complex, debilitating, and incurable disease. Several treatment modalities exist for palliation of symptoms. Up to 25% of patients will require reintervention yet no gold standard treatment for reintervention has emerged. Cumulative experience suggests reoperative Heller esophagomyotomy (HM) is a safe and viable option after previous myotomy or pneumatic dilation. Peroral endoscopic myotomy (POEM) has shown promising results for index treatment and reintervention. Single center studies suggest HM after POEM carries a lower success rate and should be chosen in select situations. Disease progression, sigmoid or megaesophagus favor esophagectomy as a definitive option.

Does Achalasia Subtype III Need to be Treated Differently Than Type I and II? Pro Argument

Type III achalasia, previously known as spastic achalasia, has been a rare but challenging diagnosis to treat. While it is included in the same diagnostic and treatment paradigm of types I and II achalasia, conventional therapies such as Botulinum Toxin A injection, pneumatic dilation, and Heller myotomy have yielded poor outcomes. Given the longer segment of spastic esophageal muscle, per oral endoscopic myotomy (POEM) is emerging as the dominant treatment paradigm. As such, it behooves us to treat type III achalasia as the unique entity that it is rather than the “garden variety” achalasia.

Achalasia in Children and Adolescents

Pediatric achalasia is a rare disorder of the esophagus that results in functional obstruction at gastroesophageal junction and impedes antegrade movement of bolus into stomach. Children present with vomiting/regurgitation, dysphagia, weight loss, and nocturnal and respiratory symptoms. Diagnosis may be delayed as symptoms mimic common pediatric disorders. Diagnosis follows adult diagnostic pathways yet remains challenging given absence of normative values in children. Treatment goals are to reduce symptoms, improve esophageal emptying, and prevent megaesophagus. Laparoscopic myotomy, pneumatic dilation, and peroral endoscopic myotomy are definite treatment options in children. Follow-up is necessary to monitor/treat reflux and complications, disease recurrence/persistence, and megaesophagus.

A Simulation Study to Investigate the Usefulness of a Novel Stricture Tool for Training Wire Guided Balloon Dilation

Abstract Background and Aims The training in esophageal stricture dilation is difficult to obtain and have few simulation models. The aim of the study was to evaluate a novel stricture simulation for training a wire-guided, controlled radial expansile (CRE) balloon dilation. Methods The study was a pretest–posttest design without a control group involving a novel simulation device for esophageal stricture. The training session involved 12 final year gastroenterology fellows from five different centers. The trainees received 2 hours of education sessions featuring didactic content, a live demonstration of step-by-step demonstration of wire-guided CRE balloon dilation and a study material on the procedure. The simulation device used was a single-use hose pipe along with a red color nonhardening modeling clay with a 5.0-to-8.0-mm hole in the center. Results All the trainees and instructor uniformly rated the model as excellent or good with simulation device being mild stiffer in haptics than of the real tissue. The mean (%) pretest scores of 39 (21.6%) improved significantly to 160 (88.8%) in mean (%) posttest questionnaire (p &lt; 0.05). There was a significant improvement in the questionnaire of the dilation procedure after the simulation training episode. Conclusion The novel stricture simulation model had good performance evaluation and can be used to train CRE balloon dilation procedure.

Impact of Percutaneous Endoscopic Gastrostomy Tube Feeding on Nutritional Status in Patients Undergoing Chemoradiotherapy for Oesophageal Cancer

Introduction: Oesophageal cancer causes dysphagia and weight loss. Malnutrition further worsens with multimodal treatment. Aim: The aim of the study was to evaluate the impact of percutaneous endoscopic gastrostomy (PEG) placement in the nutritional status of patients with oesophageal cancer requiring chemoradiotherapy (CRT). Methods: A comparative study with a prospective arm and a historical cohort was conducted. Oesophageal cancer patients undergoing CRT with dysphagia grade >2 and/or weight loss >10% were submitted to PEG-tube placement (pull method) before CRT. Stoma seeding was evaluated through a swab obtained after placement and, in surgical patients, the resected stoma. A matched historical cohort without PEG placement was used as control (trial ACTRN12616000697482). Results: Twenty-nine patients (intervention group, IG) were compared to 30 patients (control group, CG). Main outcomes did not differ in the IG and CG: weight loss during CRT 8.1 ± 5.5 kg versus 9.1 ± 4.2 kg (p = 0.503); 6-month mortality after CRT or surgery 17.2% versus 26.7% (p = 0.383); perioperative complication rate 54.5% versus 55.6% (p = 1.000); unplanned hospital admissions 34.5% versus 40.0% (p = 0.661). In the CG, during CRT, 14 (46.7%) patients presented with dysphagia grade 3–4, of whom 12 required nasogastric tube feeding (n = 10), surgical gastrostomy (n = 1), and oesophageal dilation (n = 1). In the IG, 89.7% used the PEG tube during CRT, sometimes exclusively in 51.7%. Adverse events were mainly minor (n = 12, 41.4%), mostly late peristomal infections, 1 major complication (exploratory laparotomy due to suspected colonic interposition, not confirmed). There was no cytological or histological evidence of stomal tumour seeding. Conclusion: Weight loss, hospital admissions, surgical complications, and mortality were identical in oesophageal cancer patients referred for CRT, regardless of prophylactic PEG. However, half of the patients required exclusive enteral nutritional support, making PEG-tube placement an alternative to consider.

512 Megaoesophagus Presenting as Stridor: A Case Report and Review of Literature

Abstract Introduction Megaoesophagus, dilatation of the oesophagus, is a recognised late complication of achalasia cardia, Chagas disease and, less commonly, dysmotility disorders. Megaoesophagus often presents with dysphagia, regurgitation of food and chest pain. Here, we describe a case of a patient presenting with stridor secondary to chronic dysmotility in the absence of dysphagia. Case Report An 85-year-old female presented to the Emergency Department with stridor, and a history of breathlessness and intermittent coughing episodes. Flexible laryngoscopy revealed the larynx to be rotated to the right, corresponding with a palpable swelling of the left neck. A chest X-ray showed a markedly dilated oesophagus. Computed tomography revealed severe oesophageal dilatation causing compression of the tracheobronchial tree and larynx. The patient received nebulised adrenaline and intravenous dexamethasone, resulting in resolution of her stridor. A barium swallow demonstrated marked cricopharyngeal spasm causing significant luminal narrowing but no holdup of barium. The remainder of the oesophagus was chronically dilated to the gastro-oesophageal junction and appeared atonic. The findings were atypical of achalasia, there were no obstructing lesions identified and chronic dysmotility was considered most likely, which was subsequently confirmed by a gastroenterology opinion. Discussion Megaoesophagus is rare, most frequently presents with dysphagia and regurgitation of food and is most commonly caused by achalasia. A literature search identified only one previous case of obstructing megaoesophagus secondary to idiopathic dysmotility disorder; however, this case revealed the stridor to be secondary to an impacted food bolus, whereas our case did not demonstrate any obstructing lesions.

Palliation of dysphagia in patients with non-curable esophageal cancer - a retrospective Danish study from a highly specialized center.

A majority of the patients with esophageal cancer (EC) suffer from dysphagia. Several endoscopic treatment options are available such as stent placement, argon plasma coagulation, and esophageal dilatation. This study aimed to map the use of endoscopic dysphagia relieving interventions and secondly investigate possible impact on survival. Data was collected at the Dept. of Surgery & Transplantation, Rigshospitalet, Denmark. Patients with non-curable EC referred from 2016 to 2019 were included. Type of dysphagia treatment, complications and the need for repeated treatments, and survival were registered. In the study, 601 patients were included. Forty-five percent were treated with an endoscopic procedure due to dysphagia (82% had a stent placed). The median time from diagnosis to intervention was 24days. The overall complication rate was 35% (38% in the stent group and 20% in the non-stent group, p = 0.03) and 13% of the patients were readmitted due to a complication. After 26% of the procedures, a repeated treatment was required. Patients having an endoscopic intervention had a worsened survival prognosis compared with the patients in the non-intervention group (HR: 2.17, 95% CI: 1.80-2.61, p < 0.001). In the sub analysis where only patients who had an intervention was included, a survival difference in favor of the non-stent group was found (HR: 0.61, 95% CI: 0.43-0.86, p = 0.005). In this cohort, the incidence of endoscopic procedures was high, complication rates were considerable, and many the patients required a second treatment. A survival difference was seen, where the patients who had a stent placed seemed to have the worst survival outcomes. However, the causal relationship is yet to be determined why the results must be interpreted carefully. New interventions and tailored approaches that may positively affect functional and long-term oncological outcomes are highly warranted and this should preferably be investigated in randomized clinical trials.

SP6.1.2 Endoscopic versus Laparoscopic Surgical Management of Achalasia: A Decision Analysis

Abstract Aims To compare achalasia treatment outcomes at one and two years post intervention. Methods A decision-tree model was populated with data from 36 randomised controlled trials to compare: pneumatic dilation, botulinum toxin injection, Heller myotomy (+/- Dor or Toupet), Dor and peroral endoscopic myotomy (POEM). Freeman-Tukey arcsine square root transformation under random effects model, to account for heterogeneity, was used to calculate weighted pooled model transition probabilities. Utility was 1, 0.5 and 0 for treatment success without significant complication, success with significant complications and treatment failure respectively. Deterministic sensitivity analysis and Monte Carlo Probabilistic Sensitivity Analysis (PSA) set to 10000 iterations tested model uncertainty. Results Laparoscopic Heller myotomy had marginally superior utility over POEM but only if the risk of significant complications remained less than 7.2% and 7.9% at one and two years respectively. Conclusion Superior treatment selection depends on individual risk of complications. Future research should therefore focus on personalised risk stratification and cost-effectiveness implications.