Achalasia: Physician versus Surgeon
Two European experts give their opposing views on the best treatment option for achalasia
Oesophageal achalasia is a rare motility disorder, in which peristalsis is impaired or absent and the lower oesophageal sphincter fails to relax. Symptoms of achalasia include dysphagia, regurgitation of undigested food, coughing and choking, chest pain and chest infections.
We invited two European experts to give their opposing viewpoints—physician versus surgeon—on the best treatment option for achalasia.
A Physician's Viewpoint—Paul FockensAlthough the title of this blog quickly attracted your attention, it is actually not a choice between physician and surgeon but a choice between peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM). From a patient's point of view, the natural orifice approach will be preferred as it diminishes complications and reduces recovery time. But are both treatments equal in their efficacy and safety profile? There are many studies that suggest the efficacy of both POEM and LHM is excellent, but POEM has not been around very long so less evidence is available. Two large randomized controlled trials presented in abstract form and awaiting full publication both demonstrate the high efficacy of POEM, which seems equal to LHM and superior to a set of two pneumatic dilations. But how about safety? POEM is significantly less invasive, and thereby safer, than LHM; complications are very rare and usually mild. Therefore, with comparable efficacy and improved safety when compared with LHM, POEM seems to have a bright future. Is there any disadvantage to POEM? Yes, there is one issue and that is reflux. POEM can currently not be combined with an endoscopic antireflux procedure, so a significant percentage of patients will have to use proton pump inhibitors after POEM. It is up to the patient, after care has been taken to inform them about all available treatment options, to come to a shared decision with their doctor. Without a doubt in my mind, I believe POEM will frequently be the patient's favourite choice! References
- Ponds FA, et al. Peroral endoscopic myotomy (POEM) versus pneumatic dilatation in therapy-naive patients with achalasia: results of a randomized controlled trial [abstract 637]. Gastroenterology 2017; 152 (suppl 1): S139.
- Werner YB, et al. Endoscopic versus surgical myotomy in patients with primary idiopathic achalasia [abstract LB08]. United European Gastroenterology Journal 2018; 6: 1590.
A Surgeon's Viewpoint—Giovanni ZaninottoSurgical treatment of oesophageal achalasia divides the muscle fibresof the distal oesophagus and cardia, leaving the underlying mucosa intact. Consequently, resistance of the lower oesophageal sphincter to the flow of the bolus is diminished. Heller myotomy, named for the German surgeon who performed it first (in 1913), has been completed laparoscopically (LHM) since 1990, with a partial wrap of the fundus added to prevent iatrogenic gastro-oesophageal reflux disease (GORD). LHM has gained vast popularity because of its efficacy in reducing dysphagia (89% and 85% of patients are asymptomatic at 5 and 10 years, respectively) while maintaining a very good safety profile (mortality <0.1%, morbidity <7%). Postoperative reflux is observed in 10–20% of patients when a partial fundoplication is added to LHM. Three randomized controltrials and three meta-analyses have compared the efficacy of LHM with that of pneumatic dilation, revealing that pneumatic dilation can achieve the same efficacy as LHM only after multiple, sequential dilations. Moreover, LHM is more effective than pneumatic dilation for treatment of type III spastic achalasia. There are no randomized control trials published in full that compare LHM with POEM, though two meta-analyses show that POEM achieves slightly (but significantly) better symptomatic control than LHM, especially for type III achalasia. However, the duration of the patient follow-up was shorter for POEM, and POEM presented a higher risk of postoperative reflux (20–40%). I believe five small abdominal scars are preferable to an increased risk of GORD, and that LHM remains the 'single-shot' better option for achalasia patients. References
- Boeckxstaens G, Zaninotto G and Richter JE. Achalasia. Lancet 2013; 383: 83–93.
- Zaninotto G, et al. The 2018 ISDE achalasia guidelines. Dis Esoph 2018; 9: 1–31.
Dealing with nutrition, diet, microbiota and IBS
Nutrition expert Heidi Staudacher speaks about advances in IBS research.
Heidi Staudacher is a research dietician at the University of Queensland in Australia.With Rune Stensvold from the UEG E-learning Team, she speaks about advances in IBS research and how it can be used to help IBS patients. Have also a look at Heidi Staudacher's presentation "The low FODMAP diet: Selecting the right candidate" at UEG Week Vienna 2018
UEG Image Hub
A new source of GI images online, freely available to download.
As an editor I’m clearly a big fan of words, but I’m also a big fan of images and the way they can add value and visual interest. As part of our work, the UEG E-learning Team is always thinking about how best to illustrate our content, be it on online courses (and their summary infographics), “Mistakes in…” articles or our latest news blogs. Although we necessarily do use third-party figures or photos, as often as possible we work with our art editor and authors to develop original images, such as the few shared here in this blog.
Mistakes in the management of carbohydrate intolerance and how to avoid them
Carbohydrates not absorbed in the small intestine are fermented by colonic bacteria to organic acids and gases1 (e.g. carbon dioxide, hydrogen and methane), part of which is absorbed in the colon, the other part remaining in the lumen.2,3 Large interindividual differences have been demonstrated for the production of such acids and gas.4,5 Carbohydrate malabsorption can be diagnosed by using the hydrogen breath test, because the gases produced after administration of a provocative dose of carbohydrate are unique products of bacterial carbohydrate fermentation.6,7
A rare biopsy finding with many possible causes
What's causing epigastric abdominal pain and nausea in this 55-year-old man?
A 55-year-old man was referred to our general gastroenterology clinic by colleagues from the renal transplant unit for evaluation of persistent epigastric abdominal pain and nausea that had been present for the past 6 months and had started to interfere with his quality of life.The patient’s past medical history included allogeneic renal transplantation 3 years prior, secondary to progressive hypertensive kidney disease. His current immunosuppression regimen was mycophenolate mofetil, cyclosporine, everolimus and steroids, while his hypertension was being controlled with nebivolol. The only other drug taken on a regular basis was oral iron supplementation to manage mild hypochromic anaemia. His symptoms had failed to resolve with a proton pump inhibitor (PPI) trial administered by a gastroenterologist in private practice. He had also undergone noninvasive testing (urea breath test) for the presence of Helicobacter pyloriinfection, with the result being negative. He denied weight loss, vomiting, changes in bowel habit, fever or any other accompanying symptoms in the same time period as his main complaints. No significant information was elicited from his family or regarding his social history (including travels and sexual behaviour). Physical examination findings were unremarkable. The patient had recently undergone blood tests that revealed no significant changes from his previous baseline values. In view of the above symptoms and history an upper gastrointestinal endoscopy was scheduled and performed. The endoscopic findings included erythema with small erosions of the gastric mucosa. Multiple biopsy samples were obtained from areas with findings and also from macroscopically normal mucosa. Histological findings are shown in figure 1. Figure 1 | Histological findings in the stomach of the case patient. Haematoxylin and eosin (H&E) staining. Magnification x400.
Case Question 1WHAT IS THE HISTOLOGICAL DIAGNOSIS? A. MALT lymphoma B. H. pylori-associated chronic gastritis C. Granulomatous gastritis D. Gastric adenocarcinoma E. Collagenous gastritis
Case Question 2IN VIEW OF THE PAST HISTORY OF THIS PATIENT, WHAT WAS THE UNDERLYING CAUSE OF THE SYMPTOMS OBSERVED? A. Sarcoidosis B. Granulomatosis with polyangiitis C. Crohn’s disease D. Tuberculosis E. Histoplasmosis F. A drug-induced reaction G. Helicobacter pyloriinfection H. Whipple’s disease
Case Question 3HOW SHOULD WE PROCEED REGARDING THE MANAGEMENT OF THIS PATIENT? A. Acid suppression with PPIs B. Investigate other possible causes C. Stop iron supplementation and take repeat biopsy samples D. Stop iron supplementation and investigate other possible causes
Apply for a UEG Activity Grant to produce an online course
Developing an online course is not as complicated as you may think.
Mistakes in enteral stenting and how to avoid them
Indications include stenosis (oesophageal and colonic) and gastric outlet obstruction
Gastrointestinal stent placement was introduced at the end of the nineteenth century when it was performed in patients who had a malignant oesophageal obstruction.1 Nowadays, gastrointestinal stents are placed for multiple indications, such as oesophageal stenosis (Figure 1), gastric outlet obstruction (Figure 2) and colonic stenosis (Figure 3).
Tough but doable
8 Tips for passing the European Specialty Examination in Gastroenterology and Hepatology
Anthea Pisani is a gastroenterology trainee in Mater Dei Hospital in Malta. She passed the European Specialty Examination in Gastroenterology and Hepatology in April 2018 and gave a talk about “Tough but doable: A personal view on the exam” in the Young GI Lounge at the subsequent UEG Week in Vienna. Her presentation was very much appreciated, so we asked Anthea to share her top tips for passing the exam in the GI Hive.
So, you have decided to sit for the European Specialty Examination in Gastroenterology and Hepatology. Perhaps this was a voluntary decision on your behalf in order to broaden your horizons, or it may be a mandatory aspect of your training. It may be your first attempt or maybe a re-attempt and you might be at the beginning of your training or at the end of it. Either way, good luck with your preparations. Here are some points to help guide you towards becoming a European board certified Gastroenterologist.
Learn about Autoimmune Pancreatitis
From bench to the UEG floor
A personal experience from an young gastroenterologist from Egypt and how UEG helped him to achieve his goals.
Mohammed Khorshid, a young gastroenterologist, tells us his personal success story of being invited to give an oral presentation at UEG Week.
The London Neurogastroenterology Course
Learn about pathophysiology and evidence-based treatment of functional GI disorders
13th EDS Postgraduate Course
EDS aims to support young surgeons and gastroenterologists during their residency training.
UEG Classroom Courses
These educational events are perfect opportunities to increase your GI knowledge.
Radislav Nakov, member of the YTG and the Education Committee explains what’s happening at UEG’s classroom courses and who should attend them.These educational events are perfect opportunities to increase your GI knowledge but also to expand your professional network. Find out more about the courses and how to apply.
An incidental diagnosis by endoscopic ultrasound
What has been detected by follow-up EUS in a patient with a multifocal IPMN?
An asymptomatic 66-year-old male patient with a multifocal intraductal papillary mucinous neoplasm (IPMN) underwent a follow-up EUS examination with a linear array echoendoscope. His medical history included diabetes, hypertension and smoking. While advancing the echoendoscope in the oesophagus, the endoscopic ultrasound (EUS) image shown was captured.WHAT IS YOUR DIAGNOSIS? A. Oesophageal duplication cyst B. Aortic aneurism C. Mediastinal cyst D. Aortic dissection
Work-life balance: 10 tips from the UEG Week 2018 experience
A list of Dos and Dont's that came out of the Career Chat.
Carolina Ciacci is a full Professor of Gastroenterology at University of Salerno (Italy), a member of the UEG Equality & Diversity Taskforce and a mother of two adult children. At UEG Week 2018, she participated in the session “Career Chat: Women as educators” and in the Facebook live chat “How to improve work-life balance for doctors?”. Based on these discussions and her own personal experience she shares her ten tips for work life balance in this edition of the GI Hive.
Here is a list of Do's and Dont's that came out of the Career Chat:
- Make a careful analysis of your potential and find out how to empower yourself, both at work and within the family.
- Set up your priorities, short and long-term goals. Get the skills you need to succeed. Look around, find a spot for you in your working setting, fill up the empty space with expertise and knowledge. Live up to your potential!
- Choose your family partner carefully. This will help to share your family duties with him/her. Make a written list of each of your tasks. Try to set a routine for chores but know that you both need to be flexible.
- Ask for help! Outsourcing is not a shame. It is hard to be on the same day on call, a mother, and a good housekeeper. Hire all the help you can afford, even if you have to pay a fee.
- Make a careful plan of your expenses, since outsourcing is expensive. In some periods of your life, it is more important to spend less on entertaining and more on babysitting or housekeeping.
- Be efficient! Consider reducing commuting by living close to the workplace, or the kindergarten/ school. Find a gym next to your working place and go whenever you can. Check on your smartphone the time you spend on social media. You will be surprised how much time you waste scrolling the screen of your phone (yet it is sane to do that for some time!)
- Keep healthy! Eat well, train your body, and get a good night´s sleep. Don’t forget to look after your mind. Have a little quiet time alone. Enjoy small moments of harmony. It is vital to be fit for the daily challenges of your life.
- Learn to say “no”! Saying “no” is difficult; however, you need to protect yourself from unnecessary and unfair demands that will add nothing to your personal growth and career. Be firm and protect your space.
- Failure is not an option (Gene Kranz, Apollo 13). Accept the possibility that sometimes in your life your career might slow down temporarily because of family engagements. Use your time at home cleverly; you might find a way to write a review or improve your knowledge in a particular field.
- Do not mix up family and work. When you are at work, focus on what you are doing. Do not make unnecessary phone calls or waste time discussing your family life with your colleagues. Remember also that your colleagues may have supported you when you were on parental leave, so be helpful and available for them, too. On the other hand, if you are at home with your family limit checking your emails, or answering phone calls as much as possible. Multitasking will not work if you are striving for excellence in both fields.
- World Economic Forum. The Global Gender Gap Report 2017
Mistakes in chronic diarrhoea and how to avoid them
Chronic diarrhoea is a common condition with a wide variety of possible causes