Achalasia
is a rare motility disorder of the esophagus with evidence for an
auto-immune etiology as auto-immune thyroid diseases appear more common
in patients with achalasia. However this observation has not led to
causative treatment. Treatment is still purely symptomatic at lowering
the lower esophageal sphincter pressure.
Pneumatic dilatation is an effective LES pressure lowering treatment
module, however young age, classic achalasia, high LES-pressure 3 months
after PD and incomplete obliteration of the balloon's waist are
important predictors for the need of repeated treatment and alternative
treatment as surgery should in these cases be considered.
Patients with achalasia have a considerable risk to develop esophageal
carcinoma (HR 28), which is often detected in a late incurable state.
Efforts should be made to define those patients with the highest risk,
who could benefit from a more intense surveillacne protocol. Long
lasting disease, p53 overexpression and inflammation in esophageal
surveillance biopsy samples, food stasis at endoscopy and development of
Barrett's metaplasia appeared to be independent risk factors. Future
research should focus on the best surveillance interval and strategy.
The patients with risk factors should be offered a, probably annual,
surveillance endoscopy starting 10 years after onset of symptoms. To
improve the yield of surveillance endoscopy the esophagus should be
properly cleaned by prescribing the patients with food stasis a liquid
diet 2-3 days before endoscopy.
In case of severe food stasis at endoscopy or severe inflammation in the
surveillance biopsy samples retreatment should be considered even in
the absece of deterioration of symptoms as these are important risk
factors.
To prove this strategy, a prospective randomized study is needen but
will be hard to perform. Therefore it is important to cluster and follow
achalasia patients by a strict protocol, to study the cancer risk as
follow-up lengthens and to study the outcome of a more intensive
surveillance and treatment protocol.
No comments:
Post a Comment