Achalasia: What You Should Know

[Music] hello everyone and welcome to this webinar about achalasia and what you need to know my name is Ali cetera and I'm a gastroenterologist at UCLA don't forget that you can ask questions via social media at Twitter and Facebook so we're gonna talk about a few things here what is a collegiate to find it how do you diagnose it I was it treated and what's new in the management and this is something that we're very excited about and my particular area of expertise in achalasia is a procedure called poem and I'll tell you more about that so what is a kaliesha it's defined as incomplete relaxation of the lower esophageal sphincter in a response to a swallow and an absence of normal peristalsis or normal muscle activity of the body of the esophagus and that results in food not being able to get from the mouth into the stomach because the esophagus doesn't do what it's supposed to the esophagus is normally a conduit for food to get from the mouse to the esophagus and it does that a very coordinated way and then when it's disturbed you have severe symptoms it's important to realize that to diagnose a collision you have to exclude other obstructing lesions such as tumors or scar tissue over the background achalasia is relatively rare one and two patients out of a hundred thousand will have it the cause is unknown it's a result of inflammation and degeneration of nerves in the esophageal wall but what causes that injury is an entirely clear it may be an immune response to a previously exposed virus zoster has been implicated so-called shingles virus measles herpes simplex these have been hypothesized but nothing is certain for a primary collision there are secondary causes of achalasia that are much less common but but are important and other parts of the world just South America secondary causes Chagas disease which is called by the parasite driven Trypanosoma cruzi i was transmitted by the kissing bug which is depicted here that's rare in this country but common in the developed or developing world another reason for a collision are secondary that are secondary causes or paraneoplastic syndromes and what that means is a tumor such as a lung cancer can secrete antibodies and mimic the pattern of achalasia other secondary causes pseudo achalasia is a tumor of the esophagus or the stomach causing findings that are similar take elesia a lot of the testing in a patient that we suspect has the collisions is looking to exclude some of these other diagnosis males and females are affected equally affects all ages as young as toddlers and the oldest patient that I've seen was 94 there's no cure meaning that we can't make the motility or the muscle go back to normal but we can do a lot to fix the symptoms and and get you back to very close to normal quality of life so how do you know if you have a clay sure the chief symptom is dysphasia meaning I can't swallow it's often progressive meaning it gets worse over a period of time it's often - both liquids and solids and it can be rare disturbing food gets stuck and the in the mid chest and upper throat the location may be variable and may not indicate where the actual level of obstruction is but that tends to be the chief symptom and all these other symptoms are really kind of a result of undigested food not exiting the esophagus to enter the stomach so you can have regurgitation of liquid music mucus or undigested food weight loss because nutrients aren't getting where they're supposed to go there can be pain in the chest pressure fullness there can be aspiration or choking sensations especially when food comes up at night and can enter the lungs I can be very disturbing and can even cause pneumonia that can be serious heartburn is possible it's usually atypical and chiefly doesn't respond to normal antacids it's often initially sometimes difficult to distinguish achalasia in the early stage just based on symptoms alone from normal acid reflux which is far more common the heartburn that people get in a collegiate though is not due to acid it's usually due to fermentation of food in the esophagus it's very important that specific testing is needed to diagnose a collision even in the presence of all these symptoms so how do you know if you have reflux which is much more common versus achalasia the bottom line is that you need to be tested you can't tell just from talking or examining you but some alarm symptoms and pay patients that have reflux warrant further investigation the main one is that most patients that have reflux difficulty swallowing is usually not a dominant symptom and if it is that should be investigated it may not mean that there's a collegiate present there may be something else present but that needs to be investigated weight loss is an important alarm symptom a red flag regurgitation as we talked about the presence of anemia or bleeding is important and of course if there's a family history of cancer or other gastrointestinal disorders now that needs to be investigated so how do i how do I figure out a few out of achalasia there's a couple of tests the the first three there are the main ones an upper endoscopy where a camera is inserted into the mouth and into the upper digestive tract to examine the esophagus stomach and first part of the small intestine that's that's an important test to to look for causes of difficulty swallowing and the software gram is a type of x-ray where you swallow some dye and a radiologist takes pictures as the dye moves down the digestive tract and there's specific patterns that are present in a normal esophagus versus achalasia versus other disorders of the esophagus manometry especially the recent advent of high-resolution manometry and we'll go over what that is is a way to measure the pressure and the esophagus during a swallow and those patterns are very specific to the diagnosis of achalasia and sensitive to picking up that diagnosis especially when combined with these other tests and that's important that achalasia is a syndrome that's diagnosed in combination with your history your physical exam and a variety of tests there's no one single test that says you have a collision with certainty and some patients other testing is necessary to exclude other disorders CT scans for example to to look for a tumor that may mimic achalasia especially in older patients or patients who smoke pH testing is sometimes required when there's difficulty distinguishing motility disorders of the esophagus versus reflux and and overlapping types and some syndromes so I'm going to show you here what a normal endoscopy of the esophagus looks like this is just a quick short video that we'll play and this is basically just the endoscope going down you can see the esophagus is relatively straight there's minimal to no fluid and the esophagus opens very easily without spasm into the stomach so just keep that image in mind and you'll see what an ACO Lygia patient's esophagus looks like in a second this is a normal esophagram the patient's swallowed a column of die often barium or other types of dye and x-rays are taken and it's a straight tube relatively all the way down and contrast passes easily into the stomach this is normal and abnormal esophagus this is a patient of mine that has a collegiate it's pretty typical of achalasia the esophagus is more dilated the contrast tends to stay in the esophagus and doesn't really enter except in a delayed way into the stomach and it comes down to a pinch and this is the [ __ ] area of the lower esophageal sphincter that's preventing food and liquids to go down and this so-called point is called the bird's beak which is somewhat typical of a collision this is a more severe patient of mine who you know has progressed over a little bit of time you can see not only is the esophagus very dilated but contrast is is kind of filling around all this shaggy stuff which is food that has been retained despite this patient fasting the esophagus in addition to becoming dilated is now tortuous it's become what we call decompensated and generally once you get to these stages the symptoms are more severe this is a patient who doesn't have a collision but has esophageal spasm and you can see these areas where there the contrast is being squeezed these are simultaneous non propulsive meaning that they don't move the contrast down but they spasm in a way that can be very painful and cause difficulties following so this is not a collision but it's a different dis motility disorder of the esophagus that this happens to be jackhammer esophagus is what we call it there are different types of achalasia that are categorized based on the manometric pattern and it's important for us to know what type you have because your treatment may be slightly different and we primarily figure out what type of achalasia that you have based on manometry so this is a normal high-resolution manometry color is pressure low pressure is blue so for example here in the stomach there's not too much pressure high pressure is in the reds and purples this band going across is the upper esophageal sphincter in the neck and the way that this kind of graph works is that this is distance and this is time so if we're starting here a swallow happens the this opening is the upper esophageal sphincter and then with time the esophagus is transporting the bolus down into the lower esophageal sphincter and into the stomach and importantly with the swallow the lower esophageal spring finked air pressure relaxes so you can see here the pressure has relaxed and it goes back to normal but in between when the swallowing has happened the lower esophageal sphincter opens this is encountered a distinction to a patient with a kaliesha he's made a swallow the upper esophageal sphincter which is under voluntary control has opened but nothing happened in the esophagus there's zero pressure this is a peristaltic classic achalasia the lower esophageal sphincter also has stayed closed it didn't open at all so this patient probably has pretty severe symptoms this is what's called type 2 achalasia there's also a closed esophagus in response to a swallow but there's some pressure this is called pressurization it's important for us to know because this has some prognostic implications patients with type 2 achalasia tend to do better with with whatever treatment they get but this has a little bit of pressure so there's still some squeeze left in the esophagus these patients tend to have symptoms but they're probably on the more mild side of the spectrum though they can also be severe this is Type three achalasia a swallow again the lower esophageal sphincter again didn't open but what's important here is that there's a very high amplitude non propulsor e spasm of the body of the esophagus so you can see here that these numbers are very very high so type 3 achalasia is also called [ __ ] achalasia and often patients with type 3 achalasia have chest pain type 3 achalasia is important because the spasm goes very high that was previously harder to treat with surgery until poem came along and made it a little bit more effective to treat these patients so what's the treatment for a collegian so this is just kind of a history for your interest a collegiate was was diagnose described four or five hundred years ago by Sir Thomas Willis who's pictured up there he called a cardio spasm and he treated these patients by taking a whale bone that he fashioned into a stiff dilating rod and basically hopefully gently passed that into the patient's gullet and stretched the muscle open and that was pretty much what happened for 300 years until dr. Ernest Heller showed us how to do a myotomy which is a surgical way to cut the muscle to relieve the spasm and then over you know the 20th century some some progress has been made modifying the surgery making things laparoscopic adding what's called a fundoplication which is an anti reflux procedure to the myotomy a little bit later the balloon dilation was introduced in the 21st century poem was introduced so for about six years dr. in away professor anyway from Japan taught us how to do poem in humans and he was the first to do that in humans so a medical management is usually not all that effective medications work about half the time but generally they have intolerable side-effects and so their use is limited by those side effects and you have to kind of keep taking those medications so what are those medications they're generally medications whose side effect is relaxation of smooth muscle we use those occasionally but not very often Botox botulinum toxin is a a protein that basically paralyzes muscle we probably are all very familiar with it's cosmetic use it's also used in other parts of the body and it's it was injected or it is injected into the lower esophageal sphincter to allow it to relax and it's effective it's safe it's very easy and quick to do an outpatient type of procedure but the problem is that it's temporary and so you have to be a little bit careful in who you select to have Botox in general it's not a very good effect long-term effective option for an otherwise healthy person that can tolerate a different modality which we'll go over so Botox is useful in patients that are too ill to undergo other procedures or if the diagnosis is in doubt sometimes we'll inject Botox as what's called a therapeutic trial to see if your symptoms get better with paralysis of the muscle and that may indicate to us that for example cutting the muscle with the surgery may be effective what's important is that repeated injections lose their efficacy so after maybe two or three injections that may not work as well or at all the injections are temporary generally weeks to months is what's typical and then the symptoms come back to where they were and important for us as physicians to treat achalasia is you have Botox too many times the scar tissue can make more definitive therapy such as surgery or poem a little more difficult and a little less safe so if if Botox has been offered to you you should kind of maybe ask why something else hasn't been offered and and seek care in a place that we can we can take care of you more definitively pneumatic dilation has been around for for a few years it's the standard of care in a lot of parts of the world in a lot of parts of this country still and it's a good option a balloon and it's a special balloon it's a large diameter stiff balloon and it's important to know if you're getting a pneumatic dilation versus a and what I call a regular dilation or a gentle dilation most gastroenterologist are very comfortable doing a through the scope small-caliber dilation we do it all the time for narrowings in the GI tract pneumatic dilation is a little bit special because it's a larger stiffer it has a little bit of special training required to do it properly and it has a little bit higher risk so if you were told that you're getting a dilation for your three achalasia you should know which kind it is pneumatic dilation is effective and it can be durable other types of dilation are generally ineffective or very temporarily effective what's nice about it is is that it's easy to do it's an outpatient procedure it's quick what the disadvantage is that you may need several dilations to achieve relief of your symptoms and then you may need over your life several dilations to maintain that efficacy so for that reason it's fallen a little bit I have a favor in addition there's about a four percent risk of damaging the esophagus that may require emergency surgery and so that often scares both patients and physicians away though I have to say that in our experience that rate is probably a lot lower than that so here's just a quick cartoon you know the balloons pass through it's inflated it stretches that muscle and doesn't quite break the muscle it seems to just stretch it out of the way which is which is why for the most part most patients over their life may have recurrent symptoms requiring repeated dilation this is a Heller myotomy this is the standard in most parts of this country and increasingly around the world it's usually done laparoscopically with about four or five incisions that are tiny in the abdomen and this is just a schematic where the muscle layer here is cut this is the stomach this is the esophagus this is the diaphragm and that muscle that [ __ ] is cut for a few centimeters on the stomach side a few centimeters on the Safa geo side and including the lower esophageal sphincter and in this case a posterior toupee wrap has been done and that's basically to reinforce the cut muscle and it serves as an anti reflux procedure this is important if you if you like you can kind of think of achalasia and reflux as the opposite you know in reflux the lower esophageal sphincter relaxes inappropriately and allows acid to go into the esophagus and achalasia it's too tight and doesn't let food go down so if you treat achalasia there's some real risk of replacing that with reflux to deal with that surgeons perform a rap where part of the are part of the stomach is around the esophagus to reinforce it to allow acid to stay down it's not a hundred percent effective but it's pretty clear that the risk of reflux is less if you do a Heller myotomy with a fundoplication now may not be appropriate for all patients to have one on a case-by-case basis but probably most complications are generally low one to five percent is the coded leak our surgeons are excellent at this and and they're probably on the lower side of that spectrum it generally requires a few days in the hospital for pain control recovery a bowel function Venson of diet etc but it's a very good option for a lot of patients the disadvantage of this operation chiefly in terms of technically is that when the when the surgeon comes from the abdomen he can't go very high in the esophagus so for patients that have a lot of spasm in the esophagus as diagnosed by their manometry even if he goes as high as you can there may be portions here that are uncut and symptoms may persist an important thing about this diagram is that in terms of the reflux when the surgeon goes into to do this mahtim he has to undo a lot of the normal connections that protect against reflux so a lot of the bodies and anti reflux barriers not just the sphincter but it's the connections of the stomach and the lower esophagus to the surrounding structures so when the surgeon goes in the sex all this out he has to basically fix it a little bit or put it back together to prevent reflux and so this is in distinction to poem which we'll talk about shortly so a last-resort sometimes for some patients a very very small minority of patients who have severe dilated tortuous so-called end-stage stage for late stage sigmoid esophagus these are different terms requires surgical remover of the entire esophagus and hooking up the stomach kind of higher up in the chest it's obviously a major operation it's usually only considered for someone who has failed other interventions so meaning myotomy has been attempted but was ineffective that's a major operation we try to obviously avoid it the good news is you say with fantastic thoracic surgeons and they have very good outcomes so if you're one of those patients that require that you'll be in good hands we want to try to capture you before you get to that stage so what's new and achalasia this is what kind of my my specialty is is poem / oral endoscopic myotomy poor oral means it goes through the mouth and the scopic means it's with an endoscope the standard endoscope that we use every day and myotomy means cutting the muscle so it's basically a way to make a really great surgery which is the Heller myotomy a little bit better and a little bit maybe less invasive so it's a less invasive means of achieving the same thing with the surgery so it's incisionless it's less invasive in my experience I think there's less recovery and people kind of get back on their feet and out of the hospital quicker it's a very effective greater than 90% in most studies and the risk of complications is is very low and it's so it's been remarkably safe it's been around for about six years and it's been widely adopted throughout the world thousands and thousands of patients have had poem throughout the world including the United States and it's had an excellent safety and efficacy record so we're very very excited about that and we're excited to be able to offer it to our patients here UCLA so who can have a poem basically poem is designed for achalasia and so anyone that has a collation of the different types especially type 3 is appropriate there's expanded indications if you like for for patients that have non achalasia [ __ ] disorders of the esophagus and those patients sometimes are a little bit more difficult to manage the people with esophageal spasm Nutcracker jackhammer those patients may be potentially candidates for poem poem is doable after previous surgery so if you had a hell of myotomy years ago but you have recurrent symptoms which happens in a small minority of patients we can still do a poem it can be done or at least attempted with very severe achalasia and sigmoid esophagus the efficacy is probably a little bit lower but it's still pretty encouraging and and something to consider especially before Assaf rejected me and it's been performed in extremes of age it's been described as young as toddlers and one or two years old my oldest patient was 92 I want to say 93 so age is not necessarily a reason not to not to do it but there are some reasons when you can't so if there's severe longer liver disease that's an important kind of stop but if there's problems with clotting of the blood whether that's from a primary disorder of the blood or from medications that can't be held or discontinued blood thinners etc then we we may not be able to do a poem importantly if there is severe scarring in the esophagus and that may be from radiation from a prior tumor in the chest or it may be from removing a tumor endoscopically like a polyp or a little mass in the esophagus or a bleeding or burning something in the esophagus such as Barrett's esophagus that may make a poem on not feasible because of the scar tissue so how do we prepare you for a poem well you come and you see me in the office and I tell you all about it and we first decide if you're an appropriate candidate for all the reasons that I kind of mentioned and then we have to make sure that it's safe for you to undergo anesthesia so a lot of what we do is a preoperative anesthesia assessment to make sure that we can safely anesthetize you in terms of your heart and lung health etc if you're on blood thinners those need to be managed aspirin is probably okay other blood thinners probably need to be stopped if if possible and we'd have to work closely with your internist cardiologists neurologists hematologist whoever is managing prior to the poem it's very important to have the esophagus cleared out and so for 72 hours you'll need to be on a liquid diet and that seems like a lot but you'll be surprised what your esophagus may have despite liquids for three days sometimes will give about a week of an antifungal it's called a nice statin to basically kill any fungus that may be there a lot of patients with a khaleja get colonized with yeast so it's like a thrush or a candida infection of the of the esophagus and then obviously nothing to eat or drink prior to the procedure at midnight it's under general anesthesia you're paralyzed to keep you nice and still and safe you're even IV antibiotics for infection prevention you're given IV steroids to help with swelling you're given potentially an arterial line which is like an intravenous line but goes in the artery to monitor blood pressure we don't do that in everyone but the anesthesiologist may do that to help manage you while you're asleep and we take precautions against aspiration one of the main risks of anesthesia in patients with a collision is that when you fall asleep the food that you think is not in your esophagus but is and has been there for a few days may come up and go in your lung so we can take some precautions and we've done very well with that so far so this is a poem this is just kind of a cartoon this is the endoscope this is the esophagus into the stomach and the endoscope is tunneled in the wall of the esophagus all the way down to the stomach and then the muscle is cut this takes advantage of the layers of the esophagus there's a mucosal layer that touches the food that's superficial the deep layer is the muscle layer that's what we're trying to get to and in between is submucosa and the submucosal separation or delamination as we call it is what we depend on to safely do this procedure and so what's separating us from the muscle is this mucosal flap and that's what the tunnel as we call it is made up on one side is mucosa on the other side is muscle and we're basically tunneling very carefully through the submucosa so here's just a quick video of a poem just so you can see how it's done so this is a patient with a khaleja very [ __ ] it takes a little bit of pressure to push through this is the initial injection or the entry site into the esophagus we inject a fluid to separate the mucosa from the muscle and allow us to safely cut which is what you're going to see here so roughly one inch or so a couple centimeters incision is made with an electric cautery knife down into the esophagus to allow an entry point into the wall and that's what we're doing here that blue dye that you'll see faintly we use that so that we can distinguish the layers visually a little bit better it's so it's just an inert benign dye that's inject did with the Saline that we used to irrigate and then these little gauzy wispy fibers these are subcostal fibers and we're kind of trimming and cutting those so we can enter the tunnel and this is Nauti the tunnel starting to be entered here is now the muscle this is the submucosa and if you can imagine three dimensionally this area will be the mucosa so now we're injecting some fluid to expand that layer so that we can safely tunnel through it and you can start to see now these circular muscle fibers running across these white ones and you can see where the dye helps you visually distinguish where the muscle is and the submucosa is and so this allows you to safely do the procedure so we're using electric cautery to very carefully cut fiber by fiber the submucosa to give you an idea of size this shaft of this knife this thickness is about half a millimeter so this is very very fine stuff everything is very magnified here the part of the dissection here involves identification of blood vessels these blood vessels can bleed and so we need to isolate them very carefully like we're doing here and and cauterize them prophylactically so they don't bleed so we have instruments to do that this is a coagulation forceps and we very gently capture the vessel and cauterize it so we can safely proceed without bleeding so if you're bleeding happens in a very small minority one or two percent or less and is usually manageable and this cop eclis if we need to so now the tunnel is complete this is the mucosa this is the muscle the submucosa has been dissected away this is the lower esophageal sphincter and it's gone a few centimeters into the stomach and so now we're ready to cut the muscle so this is the muscle layer being cut this is the circular muscle running this way so the esophagus is kind of like this okay so there's an inner circular layer there's an outer longitudinal layer for the length of the esophagus we focus on the circular layer once we get to the lower stuff but you'll figure we cut a full thickness myotomy or all the layers of the muscle that's now you can see here this is the longitudinal muscles here on the other side of this of the thoracic and structures heart and lungs things like this here's the lower esophageal sphincter going down and getting cut oops looks like we pause by accident up there to the trophy so now the muscle is cut completely and you'll see on this side is mucosa this is all the muscle cut completely all the way down to the stomach and once we come to the end we just basically close that entry site so now you can see a little bit more clearly the muscle is divided or cut all the way down to now this the spasm will be relaxed and this length of muscle that's cut is variable it can be as long or as short as we wanted depending on what your manometry tells us is necessary so that's the entry site we can go down now into the esophagus and you can compare now how open this is compared to what it used to be this is a nice open it used to be nice and [ __ ] like that now after the myotomy it's open so you can imagine before if we couldn't go down and now can and then we closed our opening with clips to basically uh similar to suturing close that incision and that's the last step and our our closure is pretty robust and prevents leakage and that's what it looks like when it's closed and these clips fall off usually within a week or two you won't probably even notice them they just kind of pass into the digestive tract and so that's it so after the poem you get admitted to the hospital overnight it's an observation outpatient type of setting we just basically you have a boring night of watching TV and us making sure that you don't have any complications nothing to eat or drink and we give you pain medicine if you need it nausea medicine whether you think you need it or not it's important not to throw up thing that first day the pain medicine remarkably very few people need a lot or any narcotic some people have zero pain which is which is pretty pretty remarkable your even antibiotics and then that next morning we repeat these software Graham you swallow the diet chiefly to look for a leak if no leak is present you're fed and if you do well you know how many pain when you eat you go you're discharged on a soft diet and that's important so you may think you can eat a lot more after your poem but it's important to only eat the soft diet for two weeks soft means anything you can swallow without chewing too much anybody's for a couple days and then we assume that you're going to get reflux whether you do or not and I'll tell you about reflux after poem in a second but we send you home on an antacid after two weeks you can advance your diet and then I see you in the office in a couple months and then we do our post poem testing endoscopy etc as necessary there so in terms of outcomes it's it's very very promising and encouraging people are very excited about poem more than 90% of patients do fantastic with resolution or near complete resolution of their symptoms and their lives are completely changed they can do what they want to they gain weight and generally very happy it seems to be comparable to Heller myotomy and maybe for some types of achalasia better potentially for type 3 and there's ongoing comparative trials looking at poem versus other other other modalities the main side effect is acid reflux and anywhere from 15 to 40 percent of patients can have acid reflux and we'll talk about that so we briefly mentioned that other non achalasia disorders of the esophagus may be treated with the poem the efficacy is probably a little bit less but it's still much better than what we previously had to offer so you may or may not be a candidate it's definitely something to ask your doctor about adverse events serious adverse events are very rare 1 or 2% or less minor stuff that we can manage is also relatively rare on the order of 10 to 15% in general the prognosis of achalasia is progressive meaning that'll get worse if you don't do anything and it can get difficult to manage about 10% or so of patients can progress despite treatment or they can recur and require additional treatment in general though recurrent treatment after a myotomy whether that's poem or hell it is treatable and importantly if you've had previously a Heller you can have a poem there's evidence that in patients that have a collegiate there's a higher than normal risk of esophageal cancer and that tends to scare people understandably a lot we don't understand that a hundred percent there's no evidence that screening necessarily picks up those patients so we don't know for example if you should have a yearly endoscopy after Asia has been diagnosed or after it's been treated that remains to be seen but most people would probably say that at some point you should have your doctor at least see you in the office and discuss screening for cancer so achalasia is rare but important motility is sort of the esophagus that can lead to significant symptoms specific testing is needed for us to know if you got equalizer and to and to type it see if you have type 1 2 or 3 or another [ __ ] disorder there's no cure but there's a lot of good options and especially a new option for most patients a myotomy is probably the best option whether that's a hell are my oughtta me by a surgeon or a poem by a gastroenterologist is often a personal choice but there are some some instances where a poem may be superior and there are definitely some instances where a elder may be superior so poem is exciting it's new it's less invasive and it's something that we're very excited to offer at UCLA we've been doing this for the last year we've had some really good outcomes and very happy people acid reflux is the main side effect of myotomy and I tell patients that sometimes you're going to trade one disorder for another one but a disorder that's more easy to treat so reflux is generally a lot easier to manage than achalasia is for poem we touched on this a couple of times no one knows exactly if poem or Heller myotomy is better at preventing or better in terms of a side effect of a co-leader so no one knows for sure if Heller or a poem has more more more reflux I should say for the most part we think it's about the same those are some some important details that you can talk to your doctor about or if you have any questions on Twitter or Facebook you can let me know I can go in some more detail but the good news is that even if you do have reflux it's manageable with medications it's important that about half of patients that have reflux post to myotomy won't have symptoms that's why we send you home on a on an antacid after your poem and that's why we test for acid a few months after your poem to identify you for asymptomatic or silent reflux and decide if he should be treated even if you don't have her it's very important to emphasize that a multidisciplinary approach is key so we're very lucky at UCLA to have a lot of smart people around us much smarter than me who who can help us manage very difficult patients so surgeons that are really good at their jobs gastroenterologist that are really good at their jobs radiologists physiologists all these kind of people come together and we have a weekly or bi-weekly a esophageal conference where we go over endoscopy images manometry for individual patients and try to come up with a group consensus about the best management options and that's pretty much it remind you the to submit your questions to Facebook and Twitter and be happy to answer them and thanks very much for tuning in and joining and I look forward to to seeing you so here's some questions so the first one here is reflux more common after hella rare poem okay that's a good question so we'll go in a little more detail so the rate of reflux after a Heller myotomy without a fundoplication without an anti reflux procedure is up to 30 40 percent when a surgeon adds that fundoplication which is probably pretty standard for most patients that risk is reduced to maybe ten percent or less however the problem is how do you define reflux and a lot of those older studies where those numbers came from reflux was described primarily by symptoms and we know that half of patients don't have symptoms so those numbers may be under estimating if you go by a little bit more stricter definition there may be higher numbers and the same applies to poem the risk of poem the risk of reflux after poem is probably on the order of 15 to 40 percent depending on how you measure it and the real answer is that it probably depends so probably people that have a hiatal hernia which is when the stomach is into the chest and obese patients those patients probably have a higher risk of reflux those patients may be more appropriate for a Heller myotomy than a poem because then the hypo hernia can also be fixed at the same time alternately a poem can be done and if reflux is a problem a hiatal are near a player can always be done afterwards as a backup option if for example antacids don't work so the true answer is is somewhat unknown which causes more reflux we think they're probably about the same and some patients poem may cause more reflux than others but certainly a Heller doesn't guarantee against reflux either so I think it's a little bit of a personal choice in a case by case basis which kinda brings us to the next question how should I choose between Heller and a poem for standard type 1 or type 2 achalasia it's mostly a personal choice the main advantages are that it seems to be less invasive quicker recovery back to kind of normal life out of the hospital a couple days sooner so generally a 23 hour or less observation stay in the house versus maybe one or two or three days my experienced patients with poem have less pain requiring narcotics in the hospital and afterwards than patients that have a Heller myotomy and that's the consideration that's important for a healthy person that wants to get on with their life but that's also a personal choice that's the main medical medical issue it's incisionless some people are you know don't want surgery you know in scars and things like this I don't think a cosmetic issue should make your decision for you and I would consider poem and endoscopic surgery so it's it's as you know rare of a major side effects just like surgery but the less invasiveness is appealing to a lot of people poem is probably better for patients that have [ __ ] disorders of the body of the esophagus so type 3 ecclesia jackhammer esophagus these types probably Heller myotomy seems to do less well because the surgeon just can't get up into the esophagus as well so I think it's it's a little bit of a personal a case-by-case type of a decision and we often make those decisions at that multidisciplinary conference here you see how it what's my risk of cancer so the the risk of cancer with achalasia is has been described in a couple of population-based series that risk can be up to 15 or more fold compared to the normal population or a lifetime risk of about 3% has been quoted however we don't know what to do with that number so we don't understand the physiology of it we think it may be related to stasis it may be related to something primary that has to do with achalasia what hasn't been clear though is that what what should we do to prevent it is it something that we should screen all patients with a collision meaning that at some arbitrary interval every year every two years every five years do an endoscopy to look for early cancers that can be treatable no one really knows my practice is probably to offer that to patients have a frank discussion like we're having now and say if you would like I'm happy to take a look in a year or two it probably doesn't need to be yearly probably doesn't need to be even every two years at least not long term but maybe every three to five years it seems like that risk you know can persist even after treatment so even if you had a poem or a Heller there may still be a slightly elevated risk compared to the normal population it's important that when we're talking about this cancer in terms of achalasia that we're talking about patients who truly had primary achalasia and then develop cancer later a minority of patients at diagnosis have cancer those are more the pseudo a collegiate or secondary a collegiate patient's and a lot of the testing that we do is to try to make sure with you know endoscopy and a scopic ultrasound CT scans everything that we need to do so as best we can decide that it's unlikely that you have cancer as the cause of the symptoms that last question here is will my insurance cover poem that's a good question it's difficult to answer and the answer is mostly yes it's a newer procedure so a lot of insurance companies haven't quite figured out how to put that in their algorithm of payment so we have a pre-authorization process or office works very closely with you in your insurance company to get approval so that you don't have to worry too much about it if there's a problem I advocate on your behalf make phone calls write a letter or whatever I have to do to help sometimes in that situation we are still unsuccessful in that situation the options are basically to appeal independent review either through the state of California or through your insurance company to pay out-of-pocket or to look for an alternative treatment and that could include a Hellman myotomy so that's it I guess we'll stop there I look forward to hearing from you have any additional questions feel free to contact us at our UCLA website you're on social media and looking forward to hearing from you thanks very much [Music] you

Channel: David Geffen School of Medicine at UCLA

Views: 118,218

Keywords: Gastroenterologist

Id: r7vjMEn6JHo

Length: 43min 12sec (2592 seconds)

Published: Thu Dec 15 2016