Özofagus Motilite Bozuklukları ve Klinik Bulguları
Özet
Özofagus motilite bozuklukları, hastaların yaşam kalitesini ciddi derecede düşüren, nadir ve zor tanı konulan patolojilerdir. Bu hastalıkların en önemli ve ortak belirtisi yutma güçlüğü olarak bilinen disfajidir; buna göğüs ağrısı, yeme alışkanlıklarında değişiklikler ve kilo kaybı gibi semptomlar da eşlik eder. Chicago Sınıflaması kapsamında yüksek çözünürlüklü manometri (YRM) altın standart olarak kullanılarak primer ve sekonder olarak iki gruba ayrılan bu bozukluklar; akalazya, diffüz özofageal spazm, nutcracker özofagus ve hipertansif alt özofagus sfinkteri (AÖS) gibi türleri içerir. En sık görülen motilite bozukluğu nutcracker özofagus iken, cerrahi ve endoskopik tedavilerden en çok fayda gören ve premalign bir durum olan hastalık ise akalazyadır. Akalazya hastalarında sıvı ve katı gıdalara karşı disfaji, regürjitasyon ve kilo kaybı triadı izlenir. Medikal tedaviler genellikle geçici rahatlama sağlarken ve başarı oranları düşükken; balon dilatasyonu, botulinum toksin enjeksiyonu, laparoskopik modifiye Heller miyotomisi ve son yıllarda popülerleşen peroral endoskopik miyotomi (POEM) gibi invaziv yöntemler uzun vadede yüksek başarı oranları sunmaktadır.
Esophageal motility disorders are rare and difficult-to-diagnose pathologies that severely impair patients' quality of life. The most critical and common sign of these diseases is dysphagia, known as difficulty swallowing, which is accompanied by symptoms such as chest pain, changes in eating habits, and weight loss. These disorders, classified into primary and secondary groups within the framework of the Chicago Classification using high-resolution manometry (HRM) as the gold standard, include types such as achalasia, diffuse esophageal spasm, nutcracker esophagus, and hypertensive lower esophageal sphincter (LES). While nutcracker esophagus is the most frequently encountered motility disorder, achalasia, which is a premalignant condition, is the disease that benefits the most from surgical and endoscopic treatments. Achalasia patients exhibit a classic triad of dysphagia to both liquids and solids, regurgitation, and weight loss. While medical treatments generally offer temporary relief and have low success rates; invasive methods such as balloon dilation, botulinum toxin injection, laparoscopic modified Heller myotomy, and peroral endoscopic myotomy (POEM), which has become popular in recent years, offer high success rates in the long term.
Referanslar
Blair A. Jobe, John G. Hunter, David I. Watson. Esophagus and Diaphragmatic Hernia. Schwartz’s Principles of Surgery. Tenth edition. McGraw-Hill Education; 2015
Duranceau A. Disorders of the pharyngoesophageal junction. In: Yeo CJ, ed. Shackelford’s Surgery of the Alimentary Tract. Vol. 1. 6th ed. Philadelphia: Saunders; 2007:374-390.
Cook IJ, Gabb M, Panagopoulos V, Jamieson GG, Dodds WJ, Dent J, et al. Pharyngeal (Zenker’s) diverticulum is a disorder of upper esophageal sphincter opening. Gastoenterology. 1992; 103(4):1229-1235.
Ghosh RK, Pandolfino JE, Zhang Q, Jarosz A, Kahrilas PJ. Deglutitive upper esophageal sphincter relaxation: a study of 75 volunteer subjects using solid-state high-resolution manometry. Am J Physiol Gastrointest Liver Physiol. 2006;291(3):G525-G531.
Pandolfino JE, Leslie E, Luger D, Mitchell B, Kwiatek MA, Kahrilas PJ. The contractile deceleration point:an important physşologic landmark on oesophageal pressure topography. Neurogastroenterol Motil. 2010;22:395-400.
Pandolfino JE, Roman S, Carlson D, Luger D, Bidari K, Boris L, et al. Distal esophageal spasm in high-resolution esophageal pressure topography: defining clinical phenotypes. Gastroenterology. 2011; 141:469-475.
Lin Z, Pandolfino JE, Xiao Y, Carlson D, Bidari K, Escobar G, et al. Localizing the contractile deceleration point(CDP) in patients with abnormal esophageal pressure topograhy. Neurogastroenterol Motil. 2012;24:972-975.
Roman S, Lin Z, Pandolfino JE, Kahrilas PJ. Distal contraction latency: a measure of propagation velocity optimized for esophageal pressure topography studies. Am J Gastroenterol. 2011;106:443-451.
Ghosh SK, Pandolfino JE, Zhang Q, Jarosz A, Shah N, Kahrilas PJ. Quantifiying esophageal peristalsis with high-resolution manometry: a study of 75 asymptomatic volunteers. Am J Physiol. 2006; 290(5): G988-G997.
Roman S, Gyawali CP, Xiao Y, Pandolfino JE, Kahrilas PJ. The Chicago classification of motility disorders: an update Gastrointest Endosc Clin N Am. 2014;24:545-561.
Kahrilas PJ, Bredenoord AJ, Fox M, Gyawali CP, Roman S, Smout AJPM, et al. The Chicago Classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil 2015; 27:160-174
Roman S, Gyawali CP, Xiao Y, Xiao Y, Pandolfino JE, Kahrilas PJ. The Chicago classification of motility disorders. Gastrointest Endosc Clin N Am 24:545–561, 2014.
Code CF, Schlegel JF, Kelley ML Jr, Olsen AM, Ellis FH Jr. Hypertensive gastroesophageal sphincter. Proc Staff Meet Mayo Clin 35:391-399, 1960.
Stavropoulos SN, Desilets DJ, Fuchs KH, Gostout CJ, Haber G, Inoue H, et al: Per-oral endoscopic myotomy white paper summary. Surg Endosc 28:2005-2019, 2014.
Sadowski DC, Ackah F, Jiang B, Svenson LW. Achalasia: incidence, prevalence and survival. A population-based study. Neurogastroenterol Motil. 2010;22(9):e256-e261.
Farrukh A, DeCaestecker J, Mayberry JF. An epidemiological study of achalasia among the South Asian population of Leicester, 1986-2005. Dysphagia. 2008;23(2): 161- 164.
Sonnenberg A. Hospitalization for achalasia in the United States 1997-2006. Dig Dis Sci. 2009;54(8):1680-1685.
De Oliveira RB, Rezende Filho J, Dantas RO, Iazigi N. The spectrum of esophageal motor disorders in Chagas’ disease. Am J Gastroenterol. 1995;90(7):1119-1124.
Fisichella PM, Raz D, Palazzo F, Niponmick I, Patti MG. Clinical, radiological, and manometric profile in 145 patients with untreated achalasia. World J Surg. 2008;32(9):1974-1979.
Eckardt VF, Stauf B, Bernhard G. Chest pain in achalasia: patient characteristics and clinical course. Gastroenterology. 1999;116(6):1300-1304.
Gupta M, Ghoshal UC, Jindal S, Misra A, Nath A, Saraswat VA. Respiratory dysfunction is common in patients with achalasia and improves after pneumatic dilation. Dig Dis Sci. 2014;59(4):744-752.
Gelfond M, Rozen P, Gilat T. Isosorbide dinitrate and nifedipine treatment of achalasia: a clinical, manometric and radionuclide evaluation. Gastroenterology. 1982;83(5):963-969.
Bortolotti M, Coccia G, Brunelli F, Sarti P, Mazza M, Magnato F, et al. Isosorbide dinitrate or nifedipine: which is preferable in the medical therapy of achalasia? Ital J Gastroenterol. 1994;26(8):379-382.
Campos GM, Vittinghoff E, Rabl C, Takata M, Gadenstätter M, Lin F, et al. Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis. Ann Surg. 2009;249(1):45-57.
Leyden JE, Moss AC, MacMathuna P. Endoscopic pneumatic dilation versus botulinum toxin injection in the management of primary achalasia. Cochrane Database Syst Rev. 2014;12:CD005046.
Smith CD, Stival A, Howell DL, Swafford V. Endoscopic therapy for achalasia before Heller myotomy results in worse outcomes than heller myotomy alone. Ann Surg. 2006;243(5):579-584; discussion 584-586
Ali A, Pellegrini CA. Laparoscopic myotomy: technique and efficacy in treating achalasia.Gastrointest Endosc Clin N Am. 2001;11(2):347-358, vii.
Inoue H, Minami H, Kobayashi Y, Sato Y, Kaga M, Suzuki M, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010;42(4):265-271.
Mohan BP, Ofosu A, Chandan S, Ramai D, Khan SR, Ponnada S, et al. Anterior versus posterior approach in peroral endoscopic myotomy (POEM): a systematic review and meta-analysis. Endoscopy. 2020; Apr;52(4):251-258.
