diagnostic and therapeutic endoscopy for Achalasia and GERD

1. ROLE OF ENDOSCOPY
IN
ACHALASIA& GERD
Dr.Easwaramoorthy MS FRCS
Lotus hospital, Erode,TN
Vice President, IAGES South Zone
Convener, EFIAGES Fellowship Course

2. Role of Endoscopy in Achalasia:
Learning Objectives
 Role of endoscopy in diagnosis of Achalasia
 Endo therapy forAchalasia
 Endoscopy during laparoscopic Heller’s
Myotomy

3. Endoscopy Findings in Achalasia
•Food & fluid in esophagus
•Dilated esophagus
•Spastic LES
•No Peristalsis
Pseudo achalasia

4. Barium Swallow
Bird Beak Sigmoid esophagus

5. High resolution Manometry

6. Achalasia : Manometry

7. Endotherapy for Achalasia
 Pneumatic balloon dilatation
 BoTox injection
 POEM

8. Rigiflex Pneumatic Dilator
Pneumatic balloon
- 30mm ,35mm/10cm
-with radio- opaque markers
Pressure Gauge
Guide wire

9. Under Imaging
Disappearance ofWaist

10. Lap Heller’s Myotomy

11. Lap Heller’s Myotomy &
Intra operative Endoscopy
•Help to locate OG junction
•To confirm adequacy of myotomy
•Test for any leak/mucosal breach
Optional
Or
Essential
Mark Bloomston et al
Videoscopic Heller Myotomy with
Intraoperative Endoscopy
Promotes Optimal Outcomes
JSLS JSLS. 2002 Apr-Jun; 6(2): 133–13

12. Per Oral Endoscopic Myotomy

13. Requirements
 Expertise
 Equipments
 HDVideo endoscopy
 Good diathermy Unit
 Accessories: Hybrid Knife
 Low Pressure Co2
insufflation
 Irrigation pump
 Environment
 OT
 Under GA

14. Steps of POEM
A. Mucosal incision
B. Submucosal tunnel
C. Myotomy
D. Closure of mucosal incision

15. Steps of POEM
A. Mucosal incision
B. Submucosal tunnel
C. Myotomy
D. Closure of mucosal incision

16. Steps of POEM
A. Mucosal incision
B. Submucosal tunnel
C. Myotomy
D. Closure of mucosal incision

17. Steps of POEM
A. Mucosal incision
B. Submucosal tunnel
C. Myotomy
D. Closure of mucosal incision

18. Comparative Studies
No C0mparison Balloon
dilatation
Lap Heller’s Myotomy POEM
1 Type of
procedure
Least invasive Most invasive Less invasive
2 Ease of
procedure
Very easy Easy to master Steep learning
curve
3 Effectiveness Short term Long term Long term
results awaited
4 Incidence of
reflux
Significant Less with anti reflux
procedures
Matter of debate

19. Advantages
 Less Invasive
 Less painful
 Preservation of natural anti reflux barriers
 Phreno esophageal ligament
 Angle of His
 Clasp fibresVs sling fibres

20. Key Messages
 SuspectAchalasia in cases of fluid filled oesophagus
 Exclude Pseudoachalasia prior to any intervention in
cases of achalasia
 Lap Heller’s myotomy with antireflux procedure
 Endotherapy for Achalasia is very promising

21. ROLE OF ENDOSCOPY IN GERD

22. GERD:
Learning Objectives
1. Endoscopy grading of esophagitis
2. Investigation for GERD prior to surgery
3. Endoscopy findings in various types of hiatus hernia
4. Endotherapy for GERD
5. Endoscopy after fundoplication

23. GERD
Clinical Presentation
Typical symptoms
•Heart burn
•Water brash
Atypical symptoms
•Atypical Chest pain
•Asthma, cough, LRI
•Laryngitis, URI
•Dental plaque, oral ulcers
Alarm Symptoms
•Dysphagia
•GI bleeding

24. Endoscopic findings in Cases of
GERD
Non erosive reflux disease

25. GERD
Investigation
Ba. Swallow
Endoscopy
24 hour PH monitoring
Manometry
Impedance

26. Complications of GERD
 Esophagitis
 Stricture
 Barrett’s esophagus
 Adeno carcinoma lower esophagus

27. Grades of Reflux Esophagitis:
Savary Miller Classification
1 32

28. Reflux Esophagitis
Savary Miller Classification: Grade IV
Peptic Stricture Barrett’s esophagusUlceration

29. Peptic stricture/Schatzki ring

30. Barrett’s Esophagus
 Specialised Intestinal Metaplasia
 High risk of adenocarcinoma
GORD Esophagitis
Barrett’s
Metaplasia Dysplasia Ca
Acid/Bile reflux Mutation

31. How to assess Barrett’s?
White light endoscopy
NBI
Chromoendoscopy
Confocal Laser
Endomicroscopy
Biopsy/HPE

32. Chromoendoscopy/NBI

33. How to Measure Barrett’s
GE Junction/TOGF
Circumferential part
Maximum tongue like projection

34. How to measure Barrett’s
with Hiatus hernia…

35. Barrett’s esophagus
Short Segment Long segment Early adeno ca
<3cm >3cm

36. Barrett’s esophagus
No dysplasia Indefinite for dysplasia Low grade dysplasia High grade dysplasia
3 years repeat yearly endoscopy 3month/therapy
4 quadrant biopsy at 2 cm interval

37. Hiatus Hernia
 Sliding
 Para esophageal
 Mixed

38. Endoscopy in Sliding Hiatus hernia
Level of Hiatus in cm
Level of LES
Level of Z line
Degree of Esophagitis
Size of hiatus hernia

39. Hill Classification of Hiatus
Normal edge of tissue
Closely approximated
to Scope
Less well defined ridge
Opens with respiration
Effaced ridge
Patulous hiatus
Hiatus wide open
Displaced axially
Grade I Grade II Grade III Grade IV

40. Endoscopy in Paraesophageal
Hiatus hernia

41. Types of Hiatus hernia

42. Stretta Procedure
Fass R et al, Systematic review and meta-analysis of controlled and prospective cohort efficacy
studies of endoscopic radiofrequency for treatment of gastroesophageal reflux disease Surg
Endosc. 2017 Feb 23. doi: 10.1007

43. TIF: Trans oral Incisionless Fundoplication
 Esophyx device
 Endoscopic stapling to
create 270 degree 4cm
wrap akin to Belsy’s
fundoplication
 Effective in selected cases
 Durable?
Velanovich, Endoscopic, endoluminal fundoplication for gastroesophageal reflux disease:
initial experience and lessons learned. Surgery 2010 Oct;148(4):646-51

44. Surgery for GERD
Types of Fundoplication

45. Endoscopy after
Fundoplication
Before After

46. Disrupted wrap

47. Slipped Nissen’s
Herniated fundus and wrap across
the diaphragm

48. Key Messages
 Grading of severity of Esophagitis
 Look for Barrett’s Esophagus and dysplasia
 Endoscopic findings in Hiatus hernia
 Endotherapy for GERD?