Achalesia Guideline.docx

Achalesia Guideline.docx

《Achalesia Guideline.docx》由会员分享，可在线阅读，更多相关《Achalesia Guideline.docx（10页珍藏版）》请在冰豆网上搜索。

AchalesiaGuideline

GUIDELINETITLE

Esophagealachalasia.

BIBLIOGRAPHICSOURCE（S）

∙SocietyforSurgeryoftheAlimentaryTract（SSAT）.Esophagealachalasia.Manchester（MA）:

SocietyforSurgeryoftheAlimentaryTract（SSAT）;2003.3p.

GUIDELINESTATUS

Thisisthecurrentreleaseoftheguideline.

Thisguidelineupdatesthepreviouslyissuedversion:

SocietyforSurgeryoftheAlimentaryTract.Achalasia.Manchester（MA）:

SocietyforSurgeryoftheAlimentaryTract（SSAT）;1996-2000.4p.

COMPLETESUMMARYCONTENT

 SCOPE

 METHODOLOGY-includingRatingSchemeandCostAnalysis

 RECOMMENDATIONS

 EVIDENCESUPPORTINGTHERECOMMENDATIONS

 BENEFITS/HARMSOFIMPLEMENTINGTHEGUIDELINERECOMMENDATIONS

 QUALIFYINGSTATEMENTS

 IMPLEMENTATIONOFTHEGUIDELINE

 INSTITUTEOFMEDICINE（IOM）NATIONALHEALTHCAREQUALITYREPORTCATEGORIES

 IDENTIFYINGINFORMATIONANDAVAILABILITY

 DISCLAIMER

SCOPE

DISEASE/CONDITION（S）

Esophagealachalasia

GUIDELINECATEGORY

Diagnosis

RiskAssessment

Treatment

CLINICALSPECIALTY

FamilyPractice

Gastroenterology

InternalMedicine

Surgery

INTENDEDUSERS

Physicians

GUIDELINEOBJECTIVE（S）

Toguideprimarycarephysicianstotheappropriateutilizationofsurgicalproceduresonthealimentarytractorrelatedorgans

TARGETPOPULATION

Patientswithsymptomaticesophagealachalasia

INTERVENTIONSANDPRACTICESCONSIDERED

Diagnosis

1.Bariumswallow

2.Endoscopy

3.Esophagealmanometry

4.ProlongedpHmonitoring

5.Endoscopicultrasound

6.Computedtomography

Treatment

1.Pneumaticdilatation

2.Intrasphinctericinjectionofbotulinumtoxin（Botox）

3.LaparoscopicHellermyotomyandpartialfundoplication

4.Esophagectomy（reservedforfailuresaftermyotomy）

5.Surveillanceendoscopyasfollow-up

MAJOROUTCOMESCONSIDERED

∙Symptomrelief

∙Symptomrecurrence,gastroesophagealrefluxfollowinginterventions

∙Mortalityratesassociatedwithesophagealmyotomy

Top^

METHODOLOGY

METHODSUSEDTOCOLLECT/SELECTEVIDENCE

SearchesofElectronicDatabases

DESCRIPTIONOFMETHODSUSEDTOCOLLECT/SELECTTHEEVIDENCE

Notstated

NUMBEROFSOURCEDOCUMENTS

Notstated

METHODSUSEDTOASSESSTHEQUALITYANDSTRENGTHOFTHEEVIDENCE

Notstated

RATINGSCHEMEFORTHESTRENGTHOFTHEEVIDENCE

Notapplicable

METHODSUSEDTOANALYZETHEEVIDENCE

Review

DESCRIPTIONOFTHEMETHODSUSEDTOANALYZETHEEVIDENCE

Notapplicable

METHODSUSEDTOFORMULATETHERECOMMENDATIONS

ExpertConsensus

DESCRIPTIONOFMETHODSUSEDTOFORMULATETHERECOMMENDATIONS

TheSocietyforSurgeryoftheAlimentaryTract（SSAT）guidelinesarebasedonstatementsandrecommendationsthatwereoverwhelminglysupportedbyclinicalevidence.Eachrepresentsaconsensusofopinionandisconsideredareasonableplanforaspecificclinicalcondition.

（SeecompaniondocumentGadaczTR,TraversoLW,FriedGM,StabileB,LevineBA.Practiceguidelinesforpatientswithgastrointestinalsurgicaldiseases.JGastrointestSurg1998;2:

483-484.）

RATINGSCHEMEFORTHESTRENGTHOFTHERECOMMENDATIONS

Notapplicable

COSTANALYSIS

Aformalcostanalysiswasnotperformedandpublishedcostanalyseswerenotreviewed.

METHODOFGUIDELINEVALIDATION

InternalPeerReview

DESCRIPTIONOFMETHODOFGUIDELINEVALIDATION

Theguidelineswerereviewedbyseveralcommitteemembersandthenbytheentirecommitteeonseveraloccasions.Eachguidelinewasthensentbacktotheoriginalauthorforfinalcommentandreviewedagainbythecommittee.EachguidelinewasapprovedbytheBoardofTrusteesoftheSocietyforSurgeryoftheAlimentaryTractandfinalcommentswerereviewedbythecommittee.

（SeecompaniondocumentGadaczTR,TraversoLW,FriedGM,StabileB,LevineBA.Practiceguidelinesforpatientswithgastrointestinalsurgicaldiseases.JGastrointestSurg1998;2:

483-484.）

RECOMMENDATIONS

MAJORRECOMMENDATIONS

Diagnosis

Inadditiontocarefulsymptomaticevaluation,thefollowingtestsshouldberoutinelyperformed:

Bariumswallowusuallyshowsnarrowingatthelevelofthegastroesophagealjunction（"birdbeak"）andvariousdegreesofesophagealdilatation.Endoscopyisimportanttoruleoutthepresenceofapepticstrictureorcancerandgastroduodenalpathology.Esophagealmanometryisthekeytestforestablishingthediagnosis.Theclassicmanometricfindingsare:

（a）absenceofesophagealperistalsisand（b）hypertensiveornormotensiveloweresophagealsphincter（LES）thatfailstorelaxcompletelyinresponsetoswallowing.

ProlongedpHmonitoringmaybehelpfulpreoperativelyinpatientswhohavepreviouslyfailedtreatmentwithpneumaticdilatation,Botulinumtoxin（Botox）,orsurgicalmyotomy,forwhomamyotomyisplanned.Demonstrationofrefluxclearlyindicatestheneedforafundoplicationinadditiontothemyotomy.

Inpatientsolderthan60yearsofagewithrecentonsetofdysphagiaandexcessiveweightloss,secondaryorpseudo-achalasiashouldberuledout.Becauseacancerofthegastroesophagealjunctionisthemostcommoncauseofpseudo-achalasia,anendoscopicultrasoundoracomputedtomography（CT）scanofthegastroesophagealjunctioncanhelptoestablishthediagnosis.

Treatment

Treatmentispalliative,anditisdirectedtowardeliminationoftheoutflowresistanceatthelevelofthegastroesophagealjunction.Thefollowingtreatmentmodalitiesareavailabletoachievethisgoal:

Pneumaticdilatationhasasuccessratebetween70and80%.Gastroesophagealrefluxoccursafterdilatationin25to35%ofpatients.Upto5%ofpatientsmaysustainaperforationatthetimeofadilatation.Thesepatientsmayrequireopensurgerytoclosetheperforationandperformamyotomy.

Intrasphinctericinjectionofbotulinumtoxinresultsininitialreliefofsymptomsinabout60%ofpatients,butthisistransitoryandsymptomswillreturninthemajorityofpatientswithinayear.Subsequentinjectionsarelesseffectiveandthebenefitisofbrieferduration.Inaddition,thistreatmentmaycauseaninflammatoryreactionatthelevelofthegastroesophagealjunction,whichobliteratestheanatomicplanes.Consequently,amyotomyismoredifficult,amucosalperforationoccursmorefrequently,andthereliefofdysphagiaislesspredictable.Becauseoftheseshortcomings,botulinumtoxinshouldbereservedforelderlyorhigh-riskpatientswhoarepoorcandidatesfordilatationorsurgery.

Traditionally,pneumaticdilatationhasbeenthefirstlineoftreatmentforesophagealachalasia,whilesurgerywasreservedforpatientswhohadpersistentdysphagiaaftermultipledilatationsorwhohadsufferedaperforationduringdilatation.

Today,minimallyinvasivesurgeryhascompletelychangedthistreatmentalgorithmandalaparoscopicHellermyotomyandpartialfundoplicationispreferredbymostgastroenterologistsandsurgeonsastheprimarytreatmentmodality.Criticaldetailsoftheoperationincludeagenerousmyotomyoftheloweresophagus,extendingwellontothegastricwall.Becauseofthelackofesophagealperistalsis,apartial（DororToupet）,ratherthanatotalfundoplicationisfrequentlyaddedtopreventreflux.Patientscanusuallyeatthemorningofthefirstpostoperativedayandcanbedischargedhomeafteroneortwodays.

Theneedforesophagectomyforachalasiaisveryuncommon,eveninthepresenceofadilatedesophagus,andshouldbereservedforfailuresaftermyotomy.

Allpatientsundergoingtreatmentforachalasiashouldbefollowedbysurveillanceendoscopy,becausetheyareatincreasedriskfordevelopmentofbothsquamousandadenocarcinoma.

ExpectedOutcomes

About90%ofpatientshavelong-termreliefofdysphagiaafteramyotomy,withalowincidenceofsymptomaticacidreflux.Patientsshouldundergo24-hourpHtestingroutinelyaftersurgery,asrefluxisoftenasymptomatic,andshouldbetreatedwithprotonpumpinhibitorsifabnormalacidrefluxispresent.

QualificationsforPerformingOperationsforAchalasia

Ataminimum,surgeonswhoarecertifiedoreligibleforcertificationbytheAmericanBoardofSurgery,theRoyalCollegeofPhysiciansandSurgeonsofCanada,ortheirequivalentshouldperformoperationsforachalasia.Thequalificationsofasurgeonperforminganyoperativeprocedureshouldbebasedontraining,experience,andoutcomes.

CLINICALALGORITHM（S）

Noneprovided

EVIDENCESUPPORTINGTHERECOMMENDATIONS

TYPEOFEVIDENCESUPPORTINGTHERECOMMENDATIONS

Thetypeofsupportingevidenceisnotspecificallystatedforeachrecommendation.

BENEFITS/HARMSOFIMPLEMENTINGTHEGUIDELINERECOMMENDATIONS

POTENTIALBENEFITS

∙Pneumaticdilatationhasasuccessratebetween70and80%.

∙Intrasphinctericinjectionofbotulinumtoxinresultsininitialreliefofsymptomsinabout60%patients,althoughreliefistransitoryandsymptomswillreturninthemajorityofpatientswithinayear.

∙About90%ofpatientshavelong-termreliefofdysphagiaafteramyotomy,withalowincidenceofsymptomaticacidreflux.

POTENTIALHARMS

∙Pneumaticdilatation.Gastroesophagealrefluxoccursafterdilatationin25to35%ofpatients.Upto5%ofpatientsmaysustainaperforationatthetimeofadilatation.

∙Intrasphinctericinjectionofbotulinumtoxinresultsininitialreliefofsymptoms,butthisreliefistransitoryandsymptomswillreturninthemajorityofpatientswithinayear.Subsequentinjectionsarelesseffectiveandthebenefitisofbrieferduration.Inaddition,thistreatmentmaycauseaninflammatoryreactionatthelevelofthegastroesophagealjunction,whichobliteratestheanatomicplanes.Consequently,amyotomyismoredifficult,amucosalperforationoccursmorefrequently,andthereliefofdysphagiaislesspredictable.

∙Aspirationofretainedfoodintheesophagusatthetimeofinductionofanesthesiaandperforationoftheesophagealmucosa