laparoscopy heller myotomy with fundoplication associated versus peroral endoscopic myotomy (poem)

Conditions: Dysphagia; Achalasia

Summary: achalasia is a disorder benign esophageal motor, which is characterized by failure to relax the lower esophageal sphincter ( les) in response to swallowing associated with lack of peristalsis of the esophageal body. its most common clinical presentation is dysphagia , and occasionally chest pain , regurgitation , aspiration pneumonia and weight loss , resulting in a large impact on daily activities and quality of life of affected individuals . there is currently considered curative treatment for achalasia , dysphagia relief being the primary therapeutic target and is forced to relax the les by endoscopy or surgery. thus , the most commonly used endoscopic treatments are forced dilatation of the cardia and botulinum toxin. laparoscopic heller myotomy with antireflux procedure with therapy is considered "gold standard " because of excellent results and minimal invasiveness. currently , pneumatic dilation and surgical treatment with the heller myotomy with fundoplication are strongly associated with the best therapeutic options available . in recent years, the possibility of using endoluminal access in the treatment of achalasia patients through the technique originally described as natural orifices translumenal endoscopic surgery ( notes) and continuing advances in the submucosal dissection has enabled the concomitant development of a new approach described as perioral endoscopic myotomy . in 2007, pasricha et al , described the feasibility of endoscopic esophageal myotomy through a submucosal tunnel initially in an animal model . the first performance of this procedure in humans was described by inoue et al , in 2010 , introducing the concept of transluminal endoscopic surgery through natural orifices , with the objective of minimizing the trauma and all the stress resulting from open surgical procedure . these authors call the procedure as poem ( per oral endoscopic myotomy ) .

achalasia is a disorder benign esophageal motor, which is characterized by failure to relax the lower esophageal sphincter ( les) in response to swallowing associated with lack of peristalsis of the esophageal body . its most common clinical presentation is dysphagia , and occasionally chest pain , regurgitation , aspiration pneumonia and weight loss , resulting in a large impact on daily activities and quality of life of affected individuals . epidemiological data show an incidence in the united states and europe , approximately 1/200.000 and no predilection for sex, age group (mean between 25 and 60 years) was observed , as well as any other demographic group . in brazil , the incidence is approximate 7-13/100.000 inhabitants . large proportion of patients with symptomatic achalasia require additional tests for diagnosis. endoscopy ( eda ) despite being regarded as a major test for initial evaluation of dysphagia , presents serious limitations to evaluate esophageal motility , especially in early stages . some contrast studies , highlighting the esophagogram barium ( dse ) , provide additional anatomical findings as esophageal shape and size , as well as functional : peristalsis , the les function and bolus clearance through the esophagogastric junction ( teg ) . another useful method of diagnosis is the esophageal manometry , with characteristic (chicago classification of distal esophageal motility disorders ) : aperistalsis the esophageal body and failure to relax the les , currently best characterized by high resolution manometry . idiopathic achalasia is confined to the esophagus and has no established etiology , with agenesis of the myenteric plexus or viral infections , in particular herpes simplex ( hsv - 1 ) , the most likely hypothesis . in brazil , the secondary achalasia caused by chagas disease predominantly among other etiologies , involves but is expressed primarily systemic disease with esophageal involvement . infected patients typanossoma cruzi, the causative agent of chagas disease , 7-10 % have esophageal involvement, and due to its chronic nature the most common clinical presentation is megaesophagus , to varying degrees . there is currently considered curative treatment for achalasia , dysphagia relief being the primary therapeutic target and is forced to relax the les by endoscopy or surgery . thus , the most commonly used endoscopic treatments are forced dilatation of the cardia and botulinum toxin. laparoscopic heller myotomy with antireflux procedure with therapy is considered "gold standard " because of excellent results and minimal invasiveness . currently , pneumatic dilation and surgical treatment with the heller myotomy with fundoplication are strongly associated with the best therapeutic options available . many studies have validated the efficacy of pneumatic dilation in some cases exceeding 90%, but with the limitation of the need for serial dilations , the main complication being perforation , around 8 % . with the introduction of minimally invasive surgery , surgical approach has gained great clinical importance , especially for laparoscopic heller myotomy with antireflux valve ( fundoplication ) . with a success rate ranging between 89 and 100 % in recent studies , provide a more lasting relief of symptoms without the need for additional interventions , compared to pneumatic dilation . in recent years, the possibility of using endoluminal access in the treatment of achalasia patients through the technique originally described as natural orifices translumenal endoscopic surgery ( notes) and continuing advances in the submucosal dissection has enabled the concomitant development of a new approach described as perioral endoscopic myotomy . in 2007, pasricha et al , described the feasibility of endoscopic esophageal myotomy through a submucosal tunnel initially in an animal model . the first performance of this procedure in humans was described by inoue et al , in 2010 , introducing the concept of transluminal endoscopic surgery through natural orifices , with the objective of minimizing the trauma and all the stress resulting from open surgical procedure . these authors call the procedure as poem ( per oral endoscopic myotomy ) . objective the primary objective of this protocol is to compare the efficacy between surgical approach through laparoscopic myotomy with fundoplication associated heller myotomy and endoscopic peroral ( poem ) in the treatment of patients with achalasia regardless of its etiology .

Eligibility criteria:
inclusion criteria: * patients between 18 and 70 years diagnosed with symptomatic achalasia (dysphagia score ≥ ii and eckardt\> 3) all grades including rezende classification and chicago classification. * patients who agree to participate in the study and signed an informed consent. exclusion criteria: * treatment (s) prior (s) achalasia. * patients with a history of esophageal, mediastinal and / or gastric surgery (except for gastric perforation). * patients with liver cirrhosis and / or esophageal varices, barrett's esophagus, esophageal stricture, premalignant or malignant esophageal lesions and coagulopathy. * patients with severe cardiopulmonary disease or other serious illness that results in a high surgical risk. * patients diagnosed with pseudoachalasia * patients diagnosed with diverticulum in the distal esophagus. * pregnancy and lactation.

Keywords: achalasia megaesophagus peropal endoscopic myotomy(poem) laparoscopic heller myotomy