frank zerbib bordeaux france - aquitaine gastro...disorders with egj outflow obstruction major...
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Frank ZERBIB
BordeauxFrance
Prise en charge des troubles moteurs de l’œsophage
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Lien d’intérêts
Given Imaging/Covidien/Medtronic
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Dysphagie
Dysphagie oropharyngée
Dysphagie oesophagienne
FOGD + biopsiesTOGD
Sténose maligne ténose bénigne
Œsophagite éosinophilesCompression extrinsèque
AchalasieSpasmes oesophagiens
ApéristaltismeŒsophage marteau Piqueur
Obstruction fonctionnelle JOG
TMO « mineurs »
Dysphagie « fonctionnelle »
Anormale Normale
Dysphagie obstructive
Manométrie (HR)
Dysphagie non obstructive
Zerbib and Omari, Nature Review GH, 2015
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Manométrie haute résolution
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Color scalein mm Hg
UES
LES
Esophageal Pressure Topography / “Clouse Plot”
Manométrie haute résolution
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0
5
10
15
20
25
30
35
Leng
th a
long
the
esop
hagu
s (c
m)
100
50
0
150mmHg
20
IRP = 4,2 mmHg 2 s
Time (s)
JOG
UES
Normal esophageal peristalsis
PRI(Pression de relaxation intégrée)
Lowest mean EGJ pressure for 4 contiguous or non-contiguous seconds of relaxation
N< 15 mmHg
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5 s
Transition zone
DCI= 3020 mmHg-s-cm
100
50
0
150mmHg
20
0
5
10
15
20
25
30
35
Leng
th a
long
the
esop
hagu
s (c
m)
ICD(intégrale de contraction distale)
Amplitude x duration x length (mm Hg-s-cm) of the distal esophageal contraction greater than 20 mm Hg from proximal (P) to distal (D) pressure troughs
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Latence distale
Pandolfino JE, et al. Gastroenterology 2011;141(2):469-75
Reflète l’intégrité de l’innervation inhibitrice de l’oesophage
Latence réduite = contraction prématurée= spasme
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CDP
5 s
DL
Latence distale
N > 4.5 sec
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Profils de pressurisation
100
50
0
150mmHg
30
2 s 2 s
0
5
10
15
20
25
30
35
Leng
th a
long
the
esop
hagu
s (c
m)
Time (s)
80-mmHg isobaric contourPressurisation
Contraction
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IRP ≥ ULN and 100% failed peristalsis or spasm
AchalasiaType I: no contractilityType II: ≥ 20% PEPType III: ≥ 20% spasm (DL<4.5 s)
IRP ≥ ULN and not type I-III achalasiaEGJ outflow obstruction•Incomplete achalasia•Mechanical obstruction
IRP normal and low DL or high DCI or 100% failed peristalsis
DES• ≥ 20% premature (DL<4.5 s)Jackhammer esophagus• ≥ 20% DCI >8,000 mmHg.s.cmAbsent Contractility• No scorable contraction• Consider achalasia
IRP normal and> 50% ineffective swallows
Ineffective Motility (IEM)• >50% ineffective swallowsFragmented peristalsis• >50% fragmented swallows and not ineffective
IRP normal and> 40% effective swallows
Disorders with EGJ outflow obstruction
Major disorders of peristalsis
(Entities not seen in normal subjects)
Minor disorders of peristalsis
(Impaired clearance)
Normal
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Classification de Chicago v3.0
P Kahrilas et al, 2015
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Achalasie
IRP ≥ ULN and 100% failed peristalsis or spasm
AchalasiaType I: no contractilityType II: ≥ 20% PEPType III: ≥ 20% spasm (DL<4.5 s)
IRP ≥ ULN and not type I-III achalasiaEGJ outflow obstruction•Incomplete achalasia•Mechanical obstruction
Disorders with EGJ outflow obstruction
Yes
Yes
No
Classification de Chicago v3.0
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100
50
0
150mmHg
30
0
5
10
15
20
25
30
35
Leng
th a
long
the
esop
hagu
s (cm
)
Impaired EGJ relaxation(IRP = 20,8 mmHg) 2 s
Time (s)
Distal pressurization
Normal esophageal peristalsisObstruction fonctionnelle
JOG
IRP ≥ ULN and 100% failed peristalsis or spasm
AchalasiaType I: no contractilityType II: ≥ 20% PEPType III: ≥ 20% spasm (DL<4.5 s)
IRP ≥ ULN and not type I-III achalasiaEGJ outflow obstruction•Incomplete achalasia•Mechanical obstruction
Disorders with EGJ outflow obstruction
Yes
Yes
No
Classification de Chicago v3.0
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IRP ≥ ULN and 100% failed peristalsis or spasm
AchalasiaType I: no contractilityType II: ≥ 20% PEPType III: ≥ 20% spasm (DL<4.5 s)
IRP ≥ ULN and not type I-III achalasiaEGJ outflow obstruction•Incomplete achalasia•Mechanical obstruction
IRP normal and low DL or high DCI or 100% failed peristalsis
DES• ≥ 20% premature (DL<4.5 s)Jackhammer esophagus• ≥ 20% DCI >8,000 mmHg.s.cmAbsent Contractility• No scorable contraction• Consider achalasia
Disorders with EGJ outflow obstruction
Major disorders of peristalsis
(Entities not seen in normal subjects)
Yes
Yes
Yes
No
No
Classification de Chicago v3.0
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IRP ≥ ULN and 100% failed peristalsis or spasm
AchalasiaType I: no contractilityType II: ≥ 20% PEPType III: ≥ 20% spasm (DL<4.5 s)
IRP ≥ ULN and not type I-III achalasiaEGJ outflow obstruction•Incomplete achalasia•Mechanical obstruction
IRP normal and low DL or high DCI or 100% failed peristalsis
DES• ≥ 20% premature (DL<4.5 s)Jackhammer esophagus• ≥ 20% DCI >8,000 mmHg.s.cmAbsent Contractility• No scorable contraction• Consider achalasia
IRP normal and> 50% ineffective swallows
Ineffective Motility (IEM)• >50% ineffective swallowsFragmented peristalsis• >50% fragmented swallows and not ineffective
IRP normal and> 40% effective swallows
Disorders with EGJ outflow obstruction
Major disorders of peristalsis
(Entities not seen in normal subjects)
Minor disorders of peristalsis
(Impaired clearance)
Normal
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Classification de Chicago v3.0
P Kahrilas et al, 2015
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Anomalies du transit du bolus mais fréquent chez sujets sains
Fréquents dans le RGO
Significativité douteuse
IRP normal and> 50% ineffective swallows
Ineffective Motility (IEM)• >50% ineffective swallowsFragmented peristalsis• >50% fragmented swallows and not ineffective
Minor disorders of peristalsis
(Impaired clearance)
Yes
No
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La manométrie HR est le « gold standard »
- Meilleure détection des dysfonctions du SIO
- Plus simple, plus rapide
- Standardisation
- Apprentissage plus simple ++
- Meilleur rendement diagnostique
P Gyawali, Manual of HRM, Unimed 2013
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Dysphagie
Dysphagie oropharyngée
Dysphagie oesophagienne
FOGD + biopsiesTOGD
Sténose maligne ténose bénigne
Œsophagite éosinophilesCompression extrinsèque
AchalasieSpasmes oesophagiens
ApéristaltismeŒsophage marteau Piqueur
Obstruction fonctionnelle JOG
TMO « mineurs »
Dysphagie « fonctionnelle »
Anormale Normale
Dysphagie obstructive
Manométrie (HR)
Dysphagie non obstructive
Zerbib and Omari, Nature Review GH, 2015
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Traitement de l’achalasie
Injections de toxine botulique
Myotomie de Heller
Dilatations pneumatiques
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Traitement de l’achalasie
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Taux de réponses en fonction du type d’achalasie
Pandolfino 2008
Traitement de l’achalasie
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Gastroenterology 2013
Traitement de l’achalasie
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63,60%
76,60%
25%
36,30%
23,30%
75%
0,00%
10,00%
20,00%
30,00%
40,00%
50,00%
60,00%
70,00%
80,00%
90,00%
Type 1 Type 2 Type 3
Pour
cent
age
de p
atie
nts
Types d'achalasie
Rémission en fonction du type d'achalasie
RémissionEchec
n=11 n=8
p=0,024
n=30
Suivi médian : 27 mois (5-48 mois)
Traitement de l’achalasie
Badat et al, 2015
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Traitement de l’achalasie par myotomie peroraleendoscopique
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Traitement de l’achalasie par myotomie peroraleendoscopique
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551 patients
Taux de faisabilité 97% (IC 94-98%)
Taux de succès 93% (IC 90-95%)
Œsophagite 13% (IC 10-17%)
Effets II 14% (IC 11-17%)
Chirurgie 0.2% (IC 0-0,5%)
Décès 0
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Traitement de l’achalasie type IIIComparaison POEM vs. Heller
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Achalasie
Haut risque chirurgical
Toxine botulique
Dérivés nitrésInhibiteurs calciques
Faible risque chirurgical
Type I-II
Dilatation pneumatique
Type III
Myotomie*Failure
échec
Répéter myotomie ou dilatation
Oesophagectomie ?
Zerbib, Roman, 2015* Endoscopique ou chirurgicale
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Traitement des troubles moteurs œsophagiens « hypercontractiles »
Règles HDAlimentation prudente, éviter les aliments “déclenchants”
Traitement médicalDérivés nitrés, inhibiteurs calciques, antispasmodiques, antidéprésseurs (douleurs)Aucune donnée solide
Dilatations oesophagiennesSéries rétrospectives, faibles effectifs
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Les injections intra-oesophagiennes de toxine botulique
Inhibition de la libération d’Ach au niveau de la jonction neuromusculaire
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Intra-sphincteric injection
Porter et al, 2011
36 patientsEtude non controlée58.3% avec réponse > 6 mois
Botox et obstruction fonctionnelle de la JOG
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Intra-sphincteric injection
Bashashati et al 2010
Esophageal body injection
Botox et spasmes oesophagiens
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Vanuytsel et al, CGH, 2013
22 patients DES/Nutcracker
ECR avec crossover
4x 12,5 UI 2 / 7cm de la JOG
Botox 50% vs Pla 10%
Botox et spasmes oesophagiens
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POEM et troubles moteurs hors achalasie
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POEM et troubles moteurs hors achalasie
Hoppo, 2015
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POEM et troubles moteurs hors achalasie
9 10 54
Khashab 2015
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Traitement des troubles moteurs œsophagiens « hypotoniques »
Règles HDBien mâcher, aliments “lisses”, eau gazeuse?
MédicamentsAucun traitement actuellement disponible pour stimuler la motricitéoesophagienne
Traiter le RGO ++
Kessing and Smout, Manual of HRM, 2013
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• La manométrie HR est devenue le gold standard pour le diagnostic des troubles moteurs œsophagiens
• La classification de Chicago repose sur l’évaluation de la relaxation de la JOG et la présence d’anomalies significatives du péristaltisme œsophagien
• L’identification des 3 principaux types d’achalasie a des implications thérapeutiques
• Les dilatations pneumatiques ne doivent plus être proposées en cas de type III
• La myotomie endoscopique pourraient être particulièrement utile (supérieure à la myotomie chirurgicale) dans les troubles moteurs spastiques (Type III, Jackhammer, spasmes)
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