Konventionelle endoskopische Therapie der Achalasie

Widmung

Diese Arbeit ist Herrn Prof. Dr. Volker F. Eckardt zum 70. Geburtstag gewidmet, der wissenschaftlich Wesentliches zur Diagnostik und Therapie der Achalasie beigetragen hat.

Zusammenfassung

Da die Ursache der Achalasie bis heute letztlich ungeklärt ist, sind sämtliche derzeit verfügbaren Therapieverfahren rein palliativ-symptomatisch ausgerichtet und zielen im Wesentlichen auf eine Schwächung des unteren Ösophagussphinkters (UÖS). Medikamentös ist v. a. durch Nitrate und Calciumantagonisten eine UÖS-Drucksenkung zu erzielen, der symptomatische Effekt bei Achalasie-Patienten ist jedoch gering, sodass diese Therapie allenfalls für eine kurzfristige Überbrückung zu anderen Therapieverfahren geeignet ist. Durch lokale Injektion von Botulinus-Toxin (BTX) in die Kardia wird eine profunde Drucksenkung am UÖS erzielt, bei Achalasie-Patienten kann hierdurch eine mehrmonatige (ca. 3 – 9 Monate) Beschwerdebesserung erreicht werden. Hiernach tritt durch Re-Innervationsprozesse ein Wirkungsverlust auf, welche dann wiederholte Injektionen erforderlich macht. Das Verfahren ist letztlich nur für Patienten mit reduzierter Lebenserwartung und für solche mit anatomischen Risikofaktoren (z. B. großes epiphrenisches Divertikel) sinnvoll. Die pneumatische Dilatation (PD) der Kardia führt hingegen zu einem längerfristigen Ansprechen (> 5 – 10 Jahre) bei ca. 50 % der Patienten, bei den übrigen Patienten kann durch Re-Dilatationen meist gleichfalls eine Beschwerdebesserung erzielt werden (insgesamt ist ein symptomatischer Benefit in nahezu 85 % d.F. zu erwarten). Als positive Prädiktoren für ein symptomatisches Ansprechen auf eine PD wurden ein Lebensalter > 45 Jahre, eine UÖS-Druckreduktion < 15 mmHg und/oder eine verbesserte radiologische Ösophagus-Clearance post PD ermittelt. Wesentliches Risiko der PD ist eine Ösophagusperforation, die in ca. 2 – 3 % d.F. auftritt. In randomisierten Vergleichsstudien war die BTX-Injektion der PD und der operativen Kardiomyotomie unterlegen, während die PD der Operation, bei Patienten > 40 J., nahezu gleichwertig ist.

Abstract

Since the cause of achalasia is still unknown, all currently available therapies are palliative intended and gained to essentially weaken the lower esophageal sphincter (LES). Some drugs like nitrates and calcium antagonists are able to lower the LES-pressure, however, the symptomatic improvement obtained in patients with achalasia is low, so that this strategy is at best suitable for short-term bridging to other therapies. By local injection of botulinum toxin (BTX) in the gastric cardia, a profound reduction in the LES-pressure can be achieved. Symptomatic improvement lasts for several months (about 3 – 9 months), however, due to re-innervation a loss of efficacy occurs, which then makes repeated injections necessary. Therefore, this treatment is indicated mainly for patients with a reduced life expectancy and/or those with anatomic risk factors (e. g. large epiphrenic diverticulum). Pneumatic dilation (PD) of the cardia, however, leads to a longer-term response (> 5 – 10 years) in about 50 % of patients, in the remaining patients a symptomatic response can usually be achieved by subsequent re-dilations (overall symptomatic improvement can be expected in almost 85 %). As positive predictors for a symptomatic response to PD an age> 45 years, a LES-pressure reduction < 15 mmHg and/or an improved radiological esophageal clearance post-PD were identified. PD has a significant risk for esophageal perforation, which occurs in about 2 – 3 % of cases. In randomized, controlled studies BTX injection was inferior to PD and surgical cardiomyotomy, while the efficacy of PD, in patients > 40 years, was nearly equivalent to surgery.

Schlüsselwörter

Achalasie - Pneumatische Dilatation - Botulinus-Toxin-Injektion - Kardiomyotomie

Key words

Achalasia - Pneumatic dilation - Botulinum-toxin-injection - Cardiomyotomy

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