Page 156 - Read Online

de Moura et al. PBD and POEM in dilated megaesophagus

is total or partial destruction of the intramural motor the radiologic and manometric findings of 43 patients
plexus (Auerbach plexus and Meissner plexus), leading suffering from chagasic megaesophagus with positive
to esophageal aperistalsis and relaxation of the lower tests for Chagas disease. There was a significant reduction
esophageal sphincter (LES). in the high pressure levels of the body of the esophagus
related to the stage of the disease: stage I/II - 42.9 mmHg,
With this underlying pathology, the patients present with stage III - 23.6 mmHg, and stage IV - 15.6 mmHg. It
progressive dysphagia, retrosternal pain, regurgitation, was observed that five (35.7%) stage III patients had
and weight loss . high pressure levels below 20 mmHg presenting with
[6]
advanced megaesophagus and underwent a subtotal
There are several treatments for this pathology, including esophagectomy following esophagogastroplasty
medication, surgical and endoscopic treatments. All instead of cardiomyotomy with anti-reflux valve. The
are palliative because the disease has an unknown manometric study in stage III patients with chagasic
pathogenesis with an evolutionary characteristic. megaesophagus was considered helpful to indicate
which surgical procedure would be best for these
In patients with chagasic disease, the esophagus patients.
can dilate to a large caliber. In this circumstance, a
well-renowned Brazilian doctor, Ferreira-Santos , Several methods to evaluate the efficacy of the
[7]
developed a radiological classification defined by procedure, such as high resolution or conventional
the transverse diameter of the esophagus image manometry to measure the LES pressure and the body
contrasted in the antero-posterior incidence, and by motility, upper endoscopy, and emptying timed barium
the stasis time, that helps with the orientation of the esophagogram (to measure the width and the height
treatment to be used. of barium column) pre and post-treatment should be
done.
Grade I - Moderate dilatation, up to 4 cm of transverse
diameter. Small stasis at 5 min. In addition, some scales can also be used to evaluate
the efficacy of the treatment, such as: the Eckardt et al.
[12]
Grade II - Dilation up to 7 cm of transverse diameter. scale [Table 1], visual analog scale [13] and quality life
Stasis at 30 min. SF 36 questionnaire [14] .

Grade III - Dilation up to 10 cm of transverse diameter In regards to endoscopic treatments, there are three
with sigmoid-shaped esophagus. Persistence of stasis types available: injection of botulinum toxin in the
after 30 min. LES, pneumatic balloon dilatation (PBD) and peroral
endoscopic myotomy (POEM).
Grade IV - Dilation greater than 10 cm of transverse
diameter with deviation of the longitudinal axis of the The use of botulinum toxin is not common outside the
esophagus. USA and Europe due to its high cost and also because
the durability is very low, lower than the PBD. Some
The sigmoid-shaped esophagus (Grade III and authors defend that esophageal botox injections seems
Grade IV) is considered to be the advanced stage particularly appropriate for high-risk patients, but
of achalasia, in which the esophageal lumen is should not be considered a completely safe procedure,
significantly dilated, swerved, and rotated. Up to 10% with complications rates up to 7.9% in the largest case
of all patients with long-standing achalasia (defined as series available [15] .
more than 10 years after first diagnosis) developed a
sigmoid-shaped esophagus and/or megaesophagus. In this chapter we will discuss the most available and
Endoscopic treatment of advanced achalasia with used two types of endoscopic treatment for achalasia:
sigmoid type esophagus is still controversial. Most PBD and POEM.
of the people recommend esophagectomy, mainly in
Grade IV, while others recommend myotomy as the Table 1: Grading system for evaluating clinical symptoms
first step. Successful treatment of sigmoid-shaped of achalasia, Eckardt et al. [12]
esophagus with laparoscopic Heller myotomy has been Weight Retroesternal
demonstrated by several studies [8-10] . Score loss Dysphagia pain Regurgitation
0 None None None None
A Brazilian group led by Crema et al. [11] , published a 1 < 5 kg Occasional Occasional Occasional
paper that assists physicians in managing patients with 2 8-10 kg Daily Daily Daily
sigmoid-shaped esophagus Grade III. They analyzed 3 > 10 kg Each meal Each meal Each meal
Mini-invasive Surgery ¦ Volume 1 ¦ December 28, 2017 149