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Operative Therapie bei Achalasie – endoskopisch oder laparoskopisch?

Vorschlag für die maßgeschneiderte Verfahrenswahl

Surgical treatment of achalasia – endoscopic or laparoscopic?

Proposal for a tailored approach

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An Erratum to this article was published on 22 February 2017

Zusammenfassung

Die primär idiopathische Achalasie ist die häufigste der seltenen Ösophagusmotilitätsstörungen. Eine die normale Motilität wiederherstellende kurative Therapie gibt es nicht. Allerdings ermöglicht das Therapieprinzip der Kardiomyotomie nach Ernst Heller in fast allen Fällen eine sehr gute Symptomkontrolle. Etablierter Standard ist die Heller-Myotomie über die laparoskopische Route (LHM), kombiniert mit einer anterioren Fundoplikation nach Dor zur Refluxprophylaxe/-therapie. Die Überlegenheit der LHM gegenüber der pneumatischen Dilatation (PD) wird inzwischen von mindestens vier Metaanalysen randomisierter Studien aufgezeigt, weshalb die Operation als Erstlinientherapie (ohne zuvorige PD) empfohlen wird. Die perorale endoskopische Myotomie (POEM) ermöglicht alternativ die Durchführung der Heller-Myotomie auf endoskopischem Wege. POEM ist komplikationsarm, führt ebenfalls zu einer sehr guten Dysphagiekontrolle, mit möglicherweise etwas höheren Refluxraten (20–30 %). Langzeitergebnisse und die Ergebnisse der prospektiv randomisierten Multicenterstudie zum Vergleich POEM vs. LHM stehen allerdings bislang aus. Trotzdem scheint POEM bereits jetzt bei bestimmten Indikationen zu bevorzugen zu sein. Im Rahmen eines in Würzburg etablierten Konzeptes zur „maßgeschneiderten“ Verfahrenswahl LHM vs. POEM empfehlen wir bei Typ III (spasmodische Form) und anderen hyperkontraktilen Motilitätsstörungen, ggf. auch bei Typ II mit Brustschmerzen (panösophageale Kompression) ein (langstreckiges) POEM, während beim Typ I auch die LHM gewählt werden kann. Bei sigmoidaler Achalasie, insbesondere bei siphonartiger Transformation des ösophgogastralen Übergangs sowie bei simultaner Hiatushernie und simultanem epiphrenischem Divertikel bevorzugen wir weiter die LHM. Beim Revisionseingriff bei Dysphagierezidiv hängt die Verfahrenswahl vom vermuteten Mechanismus (mechanisch vs. funktionell/motorisch) ab.

Abstract

Primary idiopathic achalasia is the most common form of the rare esophageal motility disorders. A curative therapy which restores the normal motility does not exist; however, the therapeutic principle of cardiomyotomy according to Ernst Heller leads to excellent symptom control in the majority of cases. The established standard approach is Heller myotomy through the laparoscopic route (LHM), combined with Dor anterior fundoplication for reflux prophylaxis/therapy. At least four meta-analyses of randomized controlled trials (RCTs) have demonstrated superiority of LHM over pneumatic dilation (PD); therefore, LHM should be used as first line therapy (without prior PD) in all operable patients. Peroral endoscopic myotomy (POEM) is a new alternative approach, which enables Heller myotomy to be performed though the endoscopic submucosal route. The POEM procedure has a low complication rate and also leads to good control of dysphagia but reflux rates can possibly be slightly higher (20–30%). Long-term results of POEM are still scarce and the results of the prospective randomized multicenter trial POEM vs. LHM are not yet available; however, POEM seems to be the preferred treatment option for certain indications. Within the framework of the tailored approach for achalasia management of POEM vs. LHM established in Würzburg, we recommend long-segment POEM for patients with type III achalasia (spasmodic) and other hypercontractile motility disorders and potentially type II achalasia (panesophageal compression) with chest pain as the lead symptom, whereas LHM can also be selected for type I. For sigmoid achalasia, especially with siphon-like transformation of the esophagogastric junction, simultaneous hiatal hernia and epiphrenic diverticula, LHM is still the preferred approach. The choice of the procedure for revisional surgery in case of recurrent dysphagia depends on the suspected mechanism (morphological vs. functional/neuromotor).

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Authors and Affiliations

  1. Klinik für Allgemein-, Viszeral, Gefäß- und Kinderchirurgie, Zentrum für operative Medizin (ZOM), Universitätsklinikum Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Deutschland

    B. H. A. von Rahden, J. Filser, M. Al-Nasser & C.-T. Germer

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  1. B. H. A. von Rahden
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  2. J. Filser
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  3. M. Al-Nasser
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  4. C.-T. Germer
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Correspondence to B. H. A. von Rahden.

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Interessenkonflikt

B. H. A. von Rahden, J. Filser, M. Al-Nasser und C.-T. Germer weisen auf folgende Beziehung hin: Die Einführung von POEM in Würzburg wurde unterstützt von der KARL STORZ GmbH.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Ein Erratum zu diesem Beitrag ist unter http://dx.doi.org/10.1007/s00104-017-0403-6 zu finden.

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Rahden, B.H.A.v., Filser, J., Al-Nasser, M. et al. Operative Therapie bei Achalasie – endoskopisch oder laparoskopisch?. Chirurg 88, 204–210 (2017). https://doi.org/10.1007/s00104-016-0365-0

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