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Ahmed K, Rauf SA, Hussain T, Siddiqui A, Ahmed R, Khan NA, Shah HH, Haque MA. Evolving therapeutic approaches in achalasia: a comprehensive review of peroral endoscopic myotomy (POEM) vs. Heller's myotomy. Ann Med Surg (Lond) 2025; 87:2855-2867. [PMID: 40337384 PMCID: PMC12055194 DOI: 10.1097/ms9.0000000000003271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2025] [Accepted: 03/28/2025] [Indexed: 05/09/2025] Open
Abstract
This comprehensive narrative review thoroughly explores the treatment landscape for achalasia, a rare esophageal motility disorder. Beginning with an introduction outlining the anatomical and clinical aspects of achalasia, the review delves into its historical perspective, tracing the evolution of treatment options from early nonsurgical methods to advanced surgical techniques such as Heller's myotomy and peroral endoscopic myotomy (POEM). Technical perspectives on surgical interventions, including key steps, clinical practice guidelines, and modifications to POEM techniques, are extensively discussed. A comparative analysis between POEM and Heller's myotomy elucidates their indications, contraindications, efficacy, outcomes, and interventions for persistent symptoms or complications. Furthermore, the review explores the adverse events associated with both procedures, highlighting their safety profiles and management strategies. Finally, from a financial perspective, considerations such as operative time, hospital stay length, readmission rates, and quality-adjusted life years are examined, emphasizing the implications for patient decision-making. This review underscores the importance of a multidimensional approach to understanding and managing achalasia, advocating for further research to enhance treatment efficacy and reduce adverse effects.
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Affiliation(s)
- Khadija Ahmed
- Dow University of Health Sciences, Karachi, Pakistan
| | | | - Tooba Hussain
- Dow University of Health Sciences, Karachi, Pakistan
| | | | | | | | | | - Md Ariful Haque
- Department of Public Health, Atish Dipankar University of Science and Technology, Dhaka, Bangladesh
- Voice of Doctors Research School, Dhaka, Bangladesh
- Department of Orthopaedic Surgery, Yan’an Hospital Affiliated to Kunming Medical University, Kunming, Yunnan, China
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El Abiad R, Ashat M, Khashab M. Complications related to third space endoscopic procedures. Best Pract Res Clin Gastroenterol 2024; 71:101908. [PMID: 39209411 DOI: 10.1016/j.bpg.2024.101908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/06/2024] [Accepted: 03/19/2024] [Indexed: 09/04/2024]
Abstract
Third space endoscopy (TSE) encompasses a breadth of procedures for the treatment of a variety of GI disorders. The widespread use of per-oral endoscopic myotomy (POEM) and its diversification to include extended indications and at locations other than the oesophagus has provided an insight into the potential complications encountered. The most common adverse events associated with POEM, the epitome of TSE procedures, include insufflation related injuries, bleeding, failure of mucosal barrier, infections, pain, blown out myotomy and gastroesophageal reflux disease. The purpose of this review is to highlight the pitfalls and to identify the risk factors that may lead to adverse events, and to recommend appropriate salvage interventions in the scope of the current evidence.
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Affiliation(s)
- Rami El Abiad
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
| | - Munish Ashat
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Mouen Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD, USA
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Tobón A, Cantillo Nassar GR, Hani AC, Herrera Leaño NM, Pulgarin C, Muñoz OM. Clinical outcomes and manometry results of peroral endoscopic myotomy in patients with achalasia: experience in a Latin American referral centre. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:734-741. [PMID: 38316173 DOI: 10.1016/j.gastrohep.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 02/07/2024]
Abstract
INTRODUCTION Currently there is little information in Latin America on the clinical outcome and manometric evolution of patients with Achalasia undergoing peroral endoscopic myotomy (POEM). PRIMARY OUTCOME Evaluate the manometric and clinical changes in adult patients with achalasia after peroral endoscopic myotomy at a referral center in Bogotá, Colombia. METHODS Observational, analytical, longitudinal study. Adult patients with achalasia according to the Chicago 4.0 criteria were included. Sociodemographic, clinical and manometric variables were described. To compare the pre- and post-surgical variables, the Student's or Wilcoxon's t test was used for the quantitative variables according to their normality, and McNemar's chi-square for the qualitative variables. RESULTS 29 patients were included, 55.17% (n=16) women, with a mean age at the time of surgery of 48.2 years (±11.33). The mean post-procedure evaluation time was 1.88±0.81 years. After the procedure, there was a significant decrease in the proportion of patients with weight loss (37.93% vs 21.43% p 0.0063), chest pain (48.28% vs 21.43, p 0.0225) and the median Eckardt score (8 (IQR 8 -9) vs 2(IQR 1-2), p <0.0001). In addition, in fourteen patients with post-surgical manometry, significant differences were found between IRP values (23.05±14.83mmHg vs 7.69±6.06mmHg, p 0.026) and in the mean lower esophageal sphincter tone (9.63±7.2mmHg vs 28.8±18.60mmHg, p 0.0238). CONCLUSION Peroral endoscopic myotomy has a positive impact on the improvement of symptoms and of some manometric variables (IRP and LES tone) in patients with achalasia.
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Affiliation(s)
- Angélica Tobón
- Departamento de Gastroenterología, Pontificia Universidad Javeriana, Bogotá, Colombia.
| | | | - Albis Cecilia Hani
- Departamento de Gastroenterología y Endoscopia Digestiva, Hospital Universitario San Ignacio, Bogotá, Colombia
| | | | - Cristiam Pulgarin
- Departamento de Gastroenterología, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Oscar Mauricio Muñoz
- Departamento de Medicina Interna, Hospital Universitario San Ignacio, Bogotá, Colombia
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Ďuriček M, Demeter M, Bánovčin P. POEM in the esophagus - How to deal with the post-POEM reflux. Best Pract Res Clin Gastroenterol 2024; 71:101917. [PMID: 39209415 DOI: 10.1016/j.bpg.2024.101917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/10/2024] [Accepted: 05/02/2024] [Indexed: 09/04/2024]
Abstract
Reflux after peroral endoscopic myotomy (POEM) is arguably one of the greatest concerns related to the procedure. The exact incidence is difficult to establish as reflux symptoms, esophagitis, and abnormal acid exposure correlate poorly, warranting thorough diagnostic investigation. The incidence is, however, higher than after Heller myotomy or pneumatic dilatation across all these three parameters. Although PPI are effective in the resolution of symptoms and healing of esophagitis, refractory patients exist. Esophageal hypersensitivity and acidic fermentation/esophageal stasis are most likely causes and could be diagnosed by manual analysis of pH metry tracings. Long-term complications like peptic stricture and Barrett's esophagus are rare and reported sporadically. Modifications of POEM procedure aiming to decrease post-POEM reflux led to no conclusive preferred technique. Modern investigations like endoluminal functional lumen imaging probe might help to personalize myotomy to the desired distensibility of the lower esophageal sphincter and decrease reflux.
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Affiliation(s)
- Martin Ďuriček
- Clinic of Internal Medicine - Gastroenterology, Jessenius Faculty of Medicine in Martin (JFM CU), Comenius University in Bratislava, Kollárova 2, 03659, Martin, Slovakia.
| | - Michal Demeter
- Clinic of Internal Medicine - Gastroenterology, Jessenius Faculty of Medicine in Martin (JFM CU), Comenius University in Bratislava, Kollárova 2, 03659, Martin, Slovakia.
| | - Peter Bánovčin
- Clinic of Internal Medicine - Gastroenterology, Jessenius Faculty of Medicine in Martin (JFM CU), Comenius University in Bratislava, Kollárova 2, 03659, Martin, Slovakia.
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Sobral J, Machado M, Barbosa JP, Barbosa J. Achalasia: laparoscopic Heller myotomy with fundoplication versus peroral endoscopic myotomy-a systematic review and meta-analysis. Esophagus 2024; 21:298-305. [PMID: 38775883 PMCID: PMC11199208 DOI: 10.1007/s10388-024-01063-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 05/14/2024] [Indexed: 06/27/2024]
Abstract
There are various therapeutic options for achalasia. Nevertheless, peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy with fundoplication (LHM) are distinguished by their efficacy and low incidence of complications. Compare POEM and LHM regarding several outcomes in patients with achalasia. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An exhaustive literature search was performed using PubMed, Web of Science, and Cochrane Library databases. Studies comparing several outcomes between POEM and LHM in patients with achalasia were included. Data on clinical success, operative time, intraoperative complications, length of stay, reintervention rates, postoperative pain, overall complications, occurrence of GERD symptoms, use of proton bomb inhibitors and esophagitis were extracted. Quality assessment of the included studies was performed using the MINORS scale. We included 20 retrospective observational studies with a combined total of 5139 participants. The results demonstrated that there was no statistically significant difference in terms of intraoperative complications, postoperative complications, reintervention rate, occurrence of GERD symptoms, GERD HRQL, use of proton pump inhibitors, and esophagitis between POEM and LHM groups. Conversely, POEM was associated with higher clinical success and shorter operative time, length of stay, and postoperative pain. This meta-analysis concludes that both POEM and LHM, are effective and safe treatments for achalasia. However, POEM demonstrates better results regarding clinical success, operative time, length of stay, postoperative pain, and a tendency towards lower recurrence.
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Affiliation(s)
- Joana Sobral
- Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.
| | - Miguel Machado
- Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
- Department of General Surgery, São João University Hospital Center, Porto, Portugal
| | - José Pedro Barbosa
- Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
- Department of Community Medicine, Information and Decision in Health, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Stomatology, São João University Hospital Center, Porto, Portugal
| | - José Barbosa
- Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
- Department of General Surgery, São João University Hospital Center, Porto, Portugal
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
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Samejima Y, Yoshimura S, Okata Y, Sakaguchi H, Abe H, Tanaka S, Kodama Y, Bitoh Y. Peroral Endoscopic Myotomy in Pediatric Patients with Achalasia up to 12 Years of Age: A Pilot Study in a Single-Center Experience in Japan. Eur J Pediatr Surg 2024; 34:97-101. [PMID: 37595633 DOI: 10.1055/a-2156-5099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
INTRODUCTION Peroral endoscopic myotomy (POEM) is a minimally invasive endoscopic procedure for achalasia; its indication has expanded from adults to children. We aimed to evaluate the postoperative efficacy and antireflex status of POEM in young children with achalasia aged 12 years or younger. PATIENTS AND METHODS: Pediatric patients with achalasia aged 18 years or younger who underwent POEM in our hospital between 2016 and 2021 were included and divided into two age groups: group A (≤ 12 years) and group B (13-18 years). The success rate (Eckardt score ≤ 3), endoscopic reflux findings, and antiacid use at 1 year postoperatively were compared between the groups. RESULTS Ten patients (four boys and six girls; Chicago classification type I: five, type II: four, and unclassified: one) were included. Mean age and preoperative Eckardt scores in groups A (n = 4) and B (n = 6) were 9.2 ± 3.0 versus 15.6 ± 0.6 years (p = 0.001) and 5.5 ± 3.9 versus 7.2 ± 3.7 (p = 0.509), respectively, and mean operative time and myotomy length were 51.3 ± 16.6 versus 52.5 ± 13.2 minutes (p = 0.898) and 10.8 ± 4.6 versus 9.8 ± 3.2 cm (p = 0.720), respectively. The 1-year success rate was 100% in both groups. Mild esophagitis (Los Angeles classification B) was endoscopically found in one patient in each group (16.7 vs. 25.0%, p = 0.714), and antiacid use was required in three patients (group A, two; group B, one; 50.0 vs. 16.7%, p = 0.500). CONCLUSION The success rate of POEM within 1 year in young children with achalasia aged 12 years or younger was equal to that in adolescent patients. However, young children tended to require antiacids 1 year postoperatively; therefore, long-term follow-up is necessary.
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Affiliation(s)
- Yoshitomo Samejima
- Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Shohei Yoshimura
- Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yuichi Okata
- Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Hiroya Sakaguchi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Hirofumi Abe
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Shinwa Tanaka
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
- Department of Internal Medicine, Tanaka Clinic, Kobe, Japan
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yuko Bitoh
- Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
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Mikulski MF, Morley TJ, Debbink KP, Desilets DJ, Romanelli JR. Impedance planimetry during per-oral endoscopic myotomy is associated with decreased inadvertent capnoperitoneum. Surg Endosc 2024; 38:280-290. [PMID: 37989889 DOI: 10.1007/s00464-023-10526-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 10/12/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Per-oral endoscopic myotomy (POEM) has become an accepted minimally invasive alternative to Heller myotomy for the treatment of achalasia and other disorders of esophageal dysmotility. One associated adverse event is the inadvertent creation of capnoperitoneum. A proposed mechanism is that extension of the submucosal tunnel below the esophageal hiatus and onto the gastric wall leads to transmural perforation. We hypothesized that the use of impedance planimetry with the endoscopic functional luminal imaging probe (EndoFLIP) more accurately identifies the esophagogastric junction and helps to better define the myotomy's ideal limits, thus lowering the incidence of inadvertent capnoperitoneum. METHODS This is a single-center, retrospective review of consecutive POEM cases from 06/11/2011 to 08/08/2022, with EndoFLIP introduced in 2017. Patient and procedural characteristics, including the incidence of clinically significant capnoperitoneum and decompression, were analyzed using univariate and multivariable linear regression statistics. RESULTS There were 140 POEM cases identified, 74 (52.9%) of which used EndoFLIP. Clinically significant capnoperitoneum was encountered in 26 (18.6%) cases, with no differences in patient characteristics between those who had capnoperitoneum and those who did not. There was a decreased incidence of capnoperitoneum in cases using EndoFLIP compared to those without (n = 6, 23% vs n = 20, 77%, p = 0.001), with zero instances in the final 56 cases. After adjusting for potentially confounding factors, EndoFLIP use was associated with a - 15.93% (95% confidence interval - 30.68%, - 1.18%) decrease in procedure duration. CONCLUSIONS The routine use of EndoFLIP during POEM was associated with decreased incidence of clinically significant capnoperitoneum, potentially due to improved myotomy tailoring and decreased duration of insufflation with shorter procedure times.
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Affiliation(s)
- Matthew F Mikulski
- Department of Surgery, University of Massachusetts Chan Medical School - Baystate, Springfield, MA, USA.
- Baystate Medical Center, Surgery Education Office, 759 Chestnut Street, Springfield, MA, 01199, USA.
| | - Timothy J Morley
- Department of Surgery, University of Massachusetts Chan Medical School - Baystate, Springfield, MA, USA
| | - Kaitlin P Debbink
- Department of Surgery, University of Massachusetts Chan Medical School - Baystate, Springfield, MA, USA
| | - David J Desilets
- Department of Gastroenterology, University of Massachusetts Chan Medical School - Baystate, Springfield, MA, USA
| | - John R Romanelli
- Department of Surgery, University of Massachusetts Chan Medical School - Baystate, Springfield, MA, USA
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Prado Junior FPP, Machado IFS, Prado MPLP, Leite RBC, Gurgel SM, Gomes JWF, Garcia JHP. PERORAL ENDOSCOPIC MYOTOMY FOR ACHALASIA: SAFETY PROFILE, COMPLICATIONS AND RESULTS OF 94 PATIENTS. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2023; 36:e1784. [PMID: 38088729 PMCID: PMC10712919 DOI: 10.1590/0102-672020230066e1784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 10/10/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Achalasia is an esophageal motility disorder, with clinical presentation of dysphagia and regurgitation. This is a chronic condition with no cure. Current treatment options aim to reduce lower esophageal sphincter tone by pharmacological, endoscopic or surgical means, with the aim of improving patients' symptoms. Peroral endoscopic myotomy (POEM) is an alternative endoscopic surgery to Heller cardiomyotomy, in which the procedure is performed orally, by endoscopy, offering efficacy comparable to surgical myotomy, with relative ease and minimal invasion, without external incisions. AIMS To study the safety of POEM by analyzing its results, adverse events and perioperative complications and the main ways to overcome them, in addition to evaluating the effectiveness of the procedure and the short-term postoperative quality of life. METHODS A qualitative and quantitative, observational and cross-sectional study that analyzed patients who underwent the POEM in a reference center, from December 2016 to December 2022, maintaining the technical standard of pre-, peri- and postoperative protocol. RESULTS A total of 94 patients were included in the study, and only three had postoperative complications. The average early postoperative Eckardt score was 0.93 and the late 1.40, with a mean improvement of 7.1 in early results and 6.63 in late results (p<0.05). CONCLUSIONS POEM can be reproduced with an excellent safety profile, significant relief of symptoms and improvement in esophageal emptying, and in quality of life.
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Chaudhry H, Sohal A, Patel J, Dukovic D, Singh I, Kalra S, Yang J. Frailty Predicts Perioperative Outcomes in Patients Undergoing Peroral Endoscopic Myotomy. J Gastrointest Surg 2023; 27:2574-2576. [PMID: 37369967 DOI: 10.1007/s11605-023-05745-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023]
Affiliation(s)
- Hunza Chaudhry
- Department of Internal Medicine, University of California, 155 N. Fresno St, Fresno, San Francisco, CA, 93701, USA.
| | | | - Jay Patel
- Department of Internal Medicine, Orange Park Medical Center, Orange Park, FL, USA
| | - Dino Dukovic
- Ross University School of Medicine, Bridgetown, Barbados
| | | | - Shivam Kalra
- Dayanand Medical College and Hospital, Punjab, India
| | - Juliana Yang
- Department of Gastroenterology and Hepatology, University of California, Fresno, CA, USA
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Denzer U, Müller M, Kreuser N, Thieme R, Hoffmeister A, Feisthammel J, Niebisch S, Gockel I. [Therapy of esophageal motility disorders]. Laryngorhinootologie 2023; 102:824-838. [PMID: 37263277 DOI: 10.1055/a-1949-3583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2020 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.
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Affiliation(s)
- Ulrike Denzer
- Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Germany
| | - Michaela Müller
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - Nicole Kreuser
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - René Thieme
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Juergen Feisthammel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Stefan Niebisch
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
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Morley TJ, Mikulski MF, Zalewski A, Desilets DJ, Romanelli JR. What role does the submucosa play in the pathophysiology and treatment of achalasia? An analysis of impedance planimetry during POEM. Surg Endosc 2023; 37:7923-7932. [PMID: 37433913 DOI: 10.1007/s00464-023-10260-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 06/27/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND It is thought the therapeutic benefit of per-oral endoscopic myotomy (POEM) in the treatment of esophageal dysmotility disorders is from longitudinal myotomy creation, but it is unknown if the submucosa contributes to the pathophysiology. This study investigates if submucosal tunnel (SMT) dissection alone contributes to POEM's luminal changes as measured by EndoFLIP. METHODS A single-center, retrospective review of consecutive POEM cases from June 1, 2011 to September 1, 2022 with intraoperative luminal diameter and distensibility index (DI) data as measured by EndoFLIP. Patients with diagnoses of achalasia or esophagogastric junction outflow obstruction were grouped by those with pre-SMT and post-myotomy measurements (Group 1) and those with a third measurement post-SMT dissection (Group 2). Outcomes and EndoFLIP data were analyzed using descriptive and univariate statistics. RESULTS There were 66 patients identified, of whom 57 (86.4%) had achalasia, 32 (48.5%) were female, and median pre-POEM Eckardt score was 7 [IQR: 6-9]. There were 42 (64%) patients in Group 1, and 24 (36%) patients in Group 2, with no differences in baseline characteristics. In Group 2, SMT dissection changed luminal diameter by 2.15 [IQR: 1.75-3.28]cm, which comprised 38% of the median 5.6 [IQR: 4.25-6.3]cm diameter of complete POEM change. Similarly, the median post-SMT change in DI of 1 [IQR: 0.5-1.2]units comprised 30% of the median 3.35 [2.4-3.98]units overall change in DI. Post-SMT diameters and DI were both significantly lower than the full POEM. CONCLUSIONS Esophageal diameter and DI are significantly affected by SMT dissection alone, though not equaling the magnitude of diameter or DI changes from full POEM. This suggests that the submucosa does play a role in achalasia, presenting a future target for refining POEM and developing alternative treatment strategies.
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Affiliation(s)
- Timothy J Morley
- Department of Surgery, University of Massachusetts Chan Medical School, Baystate Medical Center, Surgery Education Office, 759 Chestnut Street, Springfield, MA, 01199, USA.
| | - Matthew F Mikulski
- Department of Surgery, University of Massachusetts Chan Medical School, Baystate Medical Center, Surgery Education Office, 759 Chestnut Street, Springfield, MA, 01199, USA
| | - Alicja Zalewski
- Department of Surgery, University of Massachusetts Chan Medical School, Baystate Medical Center, Surgery Education Office, 759 Chestnut Street, Springfield, MA, 01199, USA
| | - David J Desilets
- Department of Gastroenterology, University of Massachusetts Chan Medical School-Baystate, Springfield, MA, USA
| | - John R Romanelli
- Department of Surgery, University of Massachusetts Chan Medical School, Baystate Medical Center, Surgery Education Office, 759 Chestnut Street, Springfield, MA, 01199, USA
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Familiari P, Borrelli de Andreis F, Landi R, Mangiola F, Boskoski I, Tringali A, Perri V, Costamagna G. Long versus short peroral endoscopic myotomy for the treatment of achalasia: results of a non-inferiority randomised controlled trial. Gut 2023; 72:1442-1450. [PMID: 37072180 DOI: 10.1136/gutjnl-2021-325579] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 04/05/2023] [Indexed: 04/20/2023]
Abstract
OBJECTIVE Peroral endoscopic myotomy (POEM) has become standard treatment for achalasia with comparable efficacy to surgery. In most of published series, the length of myotomy is 12-13 cm. Shorter cuts could have the advantage of shorter procedure time and possibly reduced gastro-oesophageal reflux disease (GORD) rate. DESIGN This single-centre, patient-blinded, randomised, non-inferiority clinical trial included 200 patients, who were randomly allocated, to receive either a long-POEM (13 cm; 101 patients) or a short-POEM (8 cm; 99 patients). Primary outcome was defined as an Eckardt symptom score of ≤3 at 24 months after the procedure; a non-inferiority design was chosen with an accepted success range of 6% between the two treatments. Secondary outcomes included operating time, complication rate, postoperative manometry, GORD rate and quality of life. RESULTS In the intention-to-treat analysis, clinical success rates were 89.1% in the long-POEM and 98.0% in the short-POEM group, resulting in an absolute between-group difference of -8.9% (90% CI -14.5 to -3.3).Procedure time was significantly reduced in the short-POEM as compared with the long-POEM group (40 vs 50 min, p<0.0001). Severe adverse events occurred in one patient in both groups.No differences were observed in postoperative GORD: acid exposure >6% on pH monitoring study at 6 months was seen in 34.3% (long-POEM) vs 31.1% (short-POEM), while endoscopic oesophagitis was diagnosed in 37.6% vs 51.5% at 6 months and in 21% vs 24.5% at 24 months. Regular proton pump inhibitor use was not different either (36.8% vs 37.5%). CONCLUSIONS Our study demonstrates non-inferiority of a shorter cut length of POEM as compared with the standard treatment, which saved some procedural time. GORD rate was not reduced by reducing cutting length. TRIAL REGISTRATION NUMBER NCT03450928.
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Affiliation(s)
- Pietro Familiari
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Federica Borrelli de Andreis
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Rosario Landi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
| | - Francesca Mangiola
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Ivo Boskoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Vincenzo Perri
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
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13
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Zhang H, Zeng X, Huang S, Shi L, Xia H, Jiang J, Ren W, Peng Y, Lü M, Tang X. Mid-Term and Long-Term Outcomes of Peroral Endoscopic Myotomy for the Treatment of Achalasia: A Systematic Review and Meta-Analysis. Dig Dis Sci 2023; 68:1386-1396. [PMID: 36260203 DOI: 10.1007/s10620-022-07720-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 10/03/2022] [Indexed: 04/14/2023]
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) achieves a satisfactory short-term clinical response in patients with achalasia. However, data on mid- and long-term clinical outcomes are limited. We aimed to assess the mid- and long-term efficacy and safety of POEM in achalasia patients. METHODS Using the pre-designed search strategy, we identified relevant studies that evaluated the efficacy and safety of POEM with a minimum of 2-year follow-up in the Embase, Cochrane, and PubMed databases from inception to January 2021. Primary outcome was pooled mid- and long-term clinical success rate based on the Eckardt score. Secondary outcome was pooled long-term reflux-related adverse events. RESULTS A total of 21 studies involving 2,698 patients were included. Overall, the pooled clinical success rates with 2-, 3-, 4-, and 5-year follow-ups were 91.3% (95% confidence interval [CI] 88.4-93.6%), 90.4% (95% CI 88.1-92.2%), 89.8% (95% CI 83.6-93.9%), and 82.2% (95% CI 76.6-86.7%), respectively. Besides, the pooled long-term clinical success rates for type I, II, and III achalasia were 86.1% (95% CI 80.9-90.1%; I2 = 0%), 87.9% (95% CI 84.2-90.8%; I2 = 48.354%), and 83.9% (95% CI 72.5-91.2%; I2 = 0%), respectively. Moreover, the pooled incidence of symptomatic reflux and reflux esophagitis was 23.9% (95% CI 18.7-29.9%) and 16.7% (95% CI 11.9-23.1%), respectively. CONCLUSIONS POEM is associated with a long-term clinical success of 82.2% after 5 years of follow-up. Randomized control trials comparing POEM with laparoscopic Heller myotomy or pneumatic dilation with longer follow-up periods are needed to further demonstrate the long-term safety and efficacy of POEM.
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Affiliation(s)
- Han Zhang
- Department of Gastroenterology, The Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan, China
| | - Xinyi Zeng
- Department of Gastroenterology, The Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan, China
| | - Shu Huang
- Department of Gastroenterology, The People's Hospital of Lianshui, Huaian, China
| | - Lei Shi
- Department of Gastroenterology, The Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan, China
| | - Huifang Xia
- Department of Gastroenterology, The Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan, China
| | - Jiao Jiang
- Department of Gastroenterology, The Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan, China
| | - Wensen Ren
- Department of Gastroenterology, The Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan, China
| | - Yan Peng
- Department of Gastroenterology, The Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan, China
| | - Muhan Lü
- Department of Gastroenterology, The Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan, China
| | - Xiaowei Tang
- Department of Gastroenterology, The Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan, China.
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14
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Simkova D, Mares J, Vackova Z, Hucl T, Stirand P, Kieslichova E, Ryska O, Spicak J, Drazilova S, Veseliny E, Martinek J. Periprocedural safety profile of peroral endoscopic myotomy (POEM)-a retrospective analysis of adverse events according to two different classifications. Surg Endosc 2023; 37:1242-1251. [PMID: 36171448 DOI: 10.1007/s00464-022-09621-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 09/11/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is nowadays a standard method for treatment of achalasia; nevertheless, it remains an invasive intervention with corresponding risk of adverse events (AEs). The classification and grading of AEs are still a matter of discussion. The aim of our retrospective study was to assess the occurrence of all "undesirable" events and "true" adverse events in patients undergoing POEM and to compare the outcomes when either Clavien-Dindo classification (CDC) or American Society of Gastrointestinal Endoscopy (ASGE) lexicon classification applied. METHODS This was a retrospective analysis of prospectively managed database of all patients who had undergone POEM between December 2012 and August 2018. We assessed the pre-, peri-, and early-postoperative (up to patient's discharge) undesirable events (including those not fulfilling criteria for AEs) and "true" AEs according the definition in either of the classifications. RESULTS A total of 231 patients have successfully undergone 244 POEM procedures (13 × re-POEM). Twenty-nine procedures (11.9%) passed uneventfully, while in 215 procedures (88.1%), a total of 440 undesirable events occurred. The CDC identified 27 AEs (17 minor, 10 major) occurring in 23/244 (9.4%) procedures. The ASGE lexicon identified identical 27 AEs (21 mild or moderate, 6 severe or fatal) resulting in the severity distribution of AEs being the only difference between the two classifications. Only the absence of previous treatment was found to be a risk factor [p = 0.047, OR with 95% CI: 4.55 (1.02; 20.25)] in the combined logistic regression model. CONCLUSION Undesirable events are common in patients undergoing POEM but the incidence of true AEs is low according to both classifications. Severe adverse events are infrequent irrespective of the classification applied. CDC may be more appropriate than ASGE lexicon for classifying POEM-related AEs given a surgical nature of this procedure.
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Affiliation(s)
- Dagmar Simkova
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine IKEM, Videnska 1921, 140 21, Prague 4, Czech Republic
| | - Jan Mares
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine IKEM, Videnska 1921, 140 21, Prague 4, Czech Republic
| | - Zuzana Vackova
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine IKEM, Videnska 1921, 140 21, Prague 4, Czech Republic
| | - Tomas Hucl
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine IKEM, Videnska 1921, 140 21, Prague 4, Czech Republic
| | - Petr Stirand
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine IKEM, Videnska 1921, 140 21, Prague 4, Czech Republic
| | - Eva Kieslichova
- Department of Anesthesiology and Intensive Care, Institute for Clinical and Experimental Medicine IKEM, Videnska 1921, 140 21, Prague, Czech Republic
| | - Ondrej Ryska
- Royal Lancaster Infirmary, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, UK
| | - Julius Spicak
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine IKEM, Videnska 1921, 140 21, Prague 4, Czech Republic
| | - Sylvia Drazilova
- 2Nd Department of Internal Medicine, PJ Safarik University and L. Pasteur University Hospital, Trieda SNP 1, 040 11, Kosice, Slovakia
| | - Eduard Veseliny
- 2Nd Department of Internal Medicine, PJ Safarik University and L. Pasteur University Hospital, Trieda SNP 1, 040 11, Kosice, Slovakia
| | - Jan Martinek
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine IKEM, Videnska 1921, 140 21, Prague 4, Czech Republic. .,Institute of Physiology, 1St Faculty of Medicine, Charles University, Prague, Czech Republic. .,Faculty of Medicine, Ostrava University, Ostrava, Czech Republic.
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15
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Denzer UW, Müller M, Kreuser N, Thieme R, Hoffmeister A, Feisthammel J, Niebisch S, Gockel I. [Therapy of esophageal motility disorders]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:183-197. [PMID: 35835360 DOI: 10.1055/a-1833-9299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2020 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.
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Affiliation(s)
- Ulrike W Denzer
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - Michaela Müller
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - Nicole Kreuser
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - René Thieme
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Juergen Feisthammel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Stefan Niebisch
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
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16
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Morley TJ, Mikulski MF, Rade M, Chalhoub J, Desilets DJ, Romanelli JR. Per-oral endoscopic myotomy for the treatment of non-achalasia esophageal dysmotility disorders: experience from a single high-volume center. Surg Endosc 2023; 37:1013-1020. [PMID: 36097093 DOI: 10.1007/s00464-022-09596-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/25/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Achalasia is a rare disorder of esophageal motility that induces progressive intolerance to oral intake. Other esophageal dysmotility disorders include esophagogastric junction outflow obstruction (EGJOO), distal esophageal spasm (DES), hypercontractile esophagus (HE), and other minor disorders of peristalsis (MDP) and can present similarly to achalasia despite different pathophysiologies. Prior studies have demonstrated the safety and efficacy of POEM in the treatment of achalasia, but little is reported regarding POEM's role in treating non-achalasia esophageal dysmotility disorders (NAEDD). This study aims to assess the safety and efficacy of POEM in the treatment of NAEDD. STUDY DESIGN This is a retrospective review of consecutive POEM cases from June 1, 2011, to February 1, 2021. NAEDD were characterized according to the Chicago classification. Primary outcome measure was the resolution of preoperative symptoms. Secondary outcomes include preoperative diagnosis, myotomy length, conversion to laparoscopic or open procedure, operative time, and length of stay (LOS). Technical success was defined as the completion of an 8 cm myotomy including the esophagogastric junction (EGJ) and extending 2 cm distal to the EGJ. Clinical success was defined as a postoperative Eckardt score ≤ 3. RESULTS Of 124 cases of POEM performed during the study period, 17 were performed for NAEDD. Technical success was achieved in all 17 patients (100%). Of the fifteen patients that had documented postoperative Eckardt scores, 13 were ≤ 3, achieving a clinical success rate of 87%. Subgroup analysis (HE/MDP/DES vs. EGJOO) showed no significant differences in the preoperative or postoperative Eckardt scores between groups, and both groups demonstrated a significant decrease in Eckardt scores after POEM. No cases were aborted for technical or clinical reasons, and there were no adverse outcomes. CONCLUSION POEM is a safe and efficacious treatment modality for NAEDD. Further work is needed to develop optimal treatment strategies for this complex group of diseases.
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Affiliation(s)
- Timothy J Morley
- Surgery, UMass Chan Medical School - Baystate, Springfield, MA, USA.
- Baystate Medical Center, 759 Chestnut Street, Springfield, MA, 01199, USA.
| | | | - Matthew Rade
- Surgery, UMass Chan Medical School - Baystate, Springfield, MA, USA
| | - Jean Chalhoub
- Gastroenterology, UMass Chan Medical School - Baystate, Springfield, MA, USA
| | - David J Desilets
- Gastroenterology, UMass Chan Medical School - Baystate, Springfield, MA, USA
| | - John R Romanelli
- Surgery, UMass Chan Medical School - Baystate, Springfield, MA, USA
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17
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Hayat M, Yang D, Draganov PV. Third-space endoscopy: the final frontier. Gastroenterol Rep (Oxf) 2023; 11:goac077. [PMID: 36632624 PMCID: PMC9831051 DOI: 10.1093/gastro/goac077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 01/11/2023] Open
Abstract
Over the years, our growing experience with endoscopic submucosal dissection along with technological advances has solidified our comfort and knowledge on working in the submucosa, also referred to as the "third space." Per-oral endoscopic myotomy (POEM) was the first prototype third-space endoscopy (TSE) procedure, demonstrating the feasibility and clinical utility of endoscopic esophagogastric myotomy via submucosal tunneling. The launch of POEM accelerated the evolution of TSE from a vanguard concept to an expanding field with a wide range of clinical applications. In this review, we discuss the status and future directions of multiple TSE interventions.
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Affiliation(s)
- Maham Hayat
- Center for Interventional Endoscopy, AdventHealth, Orlando, FL, USA
| | - Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Orlando, FL, USA
| | - Peter V Draganov
- Corresponding author. Division of Gastroenterology, Hepatology and Nutrition, University of Florida, 1329 SW 16th Street, Room #5254, Gainesville, FL 32608, USA. Tel: +1-352-273-9474; Fax: +1-352-627-9002;
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18
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Sharma P, Stavropoulos SN. Is peroral endoscopic myotomy the new gold standard for achalasia therapy? Dig Endosc 2023; 35:173-183. [PMID: 36385512 DOI: 10.1111/den.14477] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/15/2022] [Indexed: 11/18/2022]
Abstract
Our review focuses on critical analysis of the literature to determine whether peroral endoscopic myotomy (POEM) is poised to replace laparoscopic Heller myotomy (LHM) as the new "gold standard" for achalasia therapy. POEM matches or exceeds the efficacy of LHM. The difference in objective gastroesophageal reflux disease (GERD) between POEM and LHM is modest at best and dissipates with time. Post-POEM GERD can be easily managed medically in most patients without long-term GERD sequelae or the need for surgical fundoplication. Emerging POEM technique modifications can further decrease GERD. Endoscopic antireflux procedures such as transoral incisionless fundoplication (TIF) or POEM + F (POEM + fundoplication) can be used in the rare cases of medication-refractory GERD, but their long-term efficacy remains in question. In this comprehensive review, we summarize the current status of POEM with emphasis on GERD evaluation, prevention, treatment, and comparative data vs. LHM. Based on this analysis, it appears that POEM is indeed the new gold standard in the therapy of achalasia.
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Affiliation(s)
- Prabin Sharma
- Department of Gastroenterology, Hartford Health Care-St. Vincent's Medical Center, Bridgeport, USA
| | - Stavros N Stavropoulos
- Division of Gastroenterology, John D. Archbold Memorial Hospital, Digestive Disease Center, Thomasville, USA
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19
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Liu X, Zhou Y, Jiang X, Liu L, Zhao D, Ma H, Tian H, Jiang H. Superselective arterial microcoil embolization for delayed bleeding after peroral endoscopic myotomy. J Int Med Res 2022; 50:3000605221135475. [PMID: 36348613 PMCID: PMC9659941 DOI: 10.1177/03000605221135475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 10/11/2022] [Indexed: 08/30/2023] Open
Abstract
Peroral endoscopic myotomy (POEM) has been shown to be an effective treatment for achalasia and with few adverse events. Only a few cases of delayed bleeding have been described. This current case report describes a patient with delayed bleeding in the submucosal tunnel on the eighth day after POEM. The patient was a 21-year-old woman with a 4-month history of dysphagia, vomiting and excessive weight loss. Achalasia was diagnosed according to her symptoms, barium oesophagogram, oesophageal manometry and endoscopy examination. POEM was performed by an experienced operator. On the eighth day after POEM, the patient suddenly developed continuous haematemesis presented with vomiting of fresh blood and melena. An emergency exploratory esophagogastroduodenoscopy was performed. A large number of blood clots were found at the wound and a long haematoma was found along the lining of the submucosal tunnel. Re-entry into the submucosal tunnel and exposure of the haemorrhagic site was attempted but failed because of severe submucosal tissue adhesion. An emergency angiography was undertaken and haemostasis was achieved with superselective arterial microcoil embolization.
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Affiliation(s)
- Xuechen Liu
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Hebei Clinical Research Centre for Digestive Diseases, Shijiazhuang, Hebei Province, China
| | - Yonghong Zhou
- Department of Nutrition, Shijiazhuang Maternity and Child Healthcare Hospital, Shijiazhuang, Hebei Province, China
| | - Xiaoyu Jiang
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Hebei Clinical Research Centre for Digestive Diseases, Shijiazhuang, Hebei Province, China
| | - Li Liu
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Hebei Clinical Research Centre for Digestive Diseases, Shijiazhuang, Hebei Province, China
| | - Dongqiang Zhao
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Hebei Clinical Research Centre for Digestive Diseases, Shijiazhuang, Hebei Province, China
| | - Huihui Ma
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Hebei Clinical Research Centre for Digestive Diseases, Shijiazhuang, Hebei Province, China
| | - Hui Tian
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Hebei Clinical Research Centre for Digestive Diseases, Shijiazhuang, Hebei Province, China
| | - Huiqing Jiang
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Hebei Clinical Research Centre for Digestive Diseases, Shijiazhuang, Hebei Province, China
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20
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Sarkis Y, Al-Haddad MA, Siwiec R, Kessler WR, Wo JM, Stainko S, Perkins A, DeWitt JM. Safety of same-day discharge after peroral endoscopic myotomy. Dis Esophagus 2022; 36:6747074. [PMID: 36190182 DOI: 10.1093/dote/doac068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/21/2022] [Accepted: 09/04/2022] [Indexed: 12/11/2022]
Abstract
There are limited data on the safety of same-day discharge (SDD) after peroral endoscopic myotomy (POEM). The aim of our study is to assess the frequency and relationship to POEM for emergency department (ED) visits and hospitalizations after SDD in these patients. We retrospectively identified consecutive patients between November 2019 and August 2021 who underwent POEM with SDD and at least 6 months follow-up. Criteria for SDD includes: (1) no serious procedure-related adverse event; (2) post-POEM esophagram without leak; (3) stable vital signs; (4) ability to take liquids orally; (5) pain controlled without IV analgesia; (6) adequate social support; (7) American Society of Anesthesiologists (ASA) class I-III. A causative relationship between POEM and ED visits and hospitalizations was assigned by consensus. Out of 185 POEMs performed, 78 (41.7%, 42M, mean 51±16 years) had SDD. Within 30 days of POEM, 8 ED visits occurred in 7/78 (9%) patients and 2 (25%) were considered related to POEM; hospitalization was required in 3 (38%). After 30 days, 11 ED visits occurred in 10/78 (12.8%) patients and 1 (9%) was considered related to POEM; hospitalization was required in 5 (45%). In this study of consecutive SDD patients after POEM, 3/19 (16%) ED visits and 2/8 (25%) hospitalizations within 6 months were considered related to the procedure. Therefore, eligible patients who follow and fulfill a strict protocol after POEM may be safely discharged the same day.
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Affiliation(s)
- Yara Sarkis
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - Mohammad A Al-Haddad
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - Robert Siwiec
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - William R Kessler
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - John M Wo
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - Sarah Stainko
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - Anthony Perkins
- Department of Biostatistics, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - John M DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
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21
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Abstract
Esophageal achalasia is a relatively rare disease in children that has been treated with balloon dilatation, botulinum toxin injection, and Heller myotomy. Peroral endoscopic myotomy (POEM) is another treatment that has been successfully employed to treat adults with achalasia for over a decade and has been increasingly used in children. This State of the Art Review from the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Endoscopy Committee reviews the current literature in pediatric POEM including the technique, success rate, complications as well as training guidelines. Though there is limited data, POEM in children has shown encouraging success rates and with further study may become the mainstay of pediatric achalasia treatment.
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Snyder DL, Katzka DA. Complex Gastroesophageal Reflux Disease. GASTRO HEP ADVANCES 2022; 1:420-430. [PMID: 39131678 PMCID: PMC11307939 DOI: 10.1016/j.gastha.2022.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/15/2022] [Indexed: 08/13/2024]
Abstract
Gastroesophageal reflux disease (GERD) is the most prevalent gastrointestinal disorder posing diagnostic and therapeutic challenges. Diagnosis should be objectively defined with endoscopy and pH testing, while novel metrics may augment diagnosis for inconclusive GERD cases, including the postreflux swallow-induced peristaltic wave index and esophageal mucosal impedance. Conditions that overlap with or mimic GERD should be considered such as achalasia, rumination, and eosinophilic esophagitis. Genetic testing for proton pump inhibitor metabolism is an option for precision therapy in complex persistent GERD. Proton pump inhibitor refractory GERD may require medical, surgical, or endoscopic therapies. The presence of GERD should be objectively evaluated in achalasia patients treated with peroral endoscopic myotomy, and further studies are needed to determine timing of this evaluation. Patients with scleroderma are at a high risk for GERD owing to abnormal esophageal motility and should be managed with aggressive medical therapy and lifestyle changes given the high prevalence of esophagitis and Barrett's esophagus in this population. Further studies are needed to understand the complex mechanisms of GERD in idiopathic pulmonary fibrosis and lung transplantation.
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Esophageal Achalasia: Pros and Cons of the Treatment Options. World J Surg 2022; 46:1554-1560. [PMID: 35238987 PMCID: PMC9174302 DOI: 10.1007/s00268-022-06495-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2022] [Indexed: 11/05/2022]
Abstract
Achalasia is a primary esophageal motility disorder of unknown origin. The goal of treatment is to reduce the resistance caused by a lower esophageal sphincter that fails to relax and is frequently hypertensive. Many treatment options are available to achieve this goal. In this review, we discuss the pros and cons of each therapeutic approach.
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Allakhverdyan AS, Anipchenko AN, Anipchenko NN, Chernogorova EV. [Laparoscopic transhiatal resection of the lower third of the esophagus for late recurrence of achalasia cardia after laparoscopic esophagocardiomyotomy: a 12-year follow-up]. Khirurgiia (Mosk) 2022:69-74. [PMID: 36223153 DOI: 10.17116/hirurgia202210169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The choice of treatment for recurrence after esophagocardiomyotomy is individual. Repeated esophagocardiomyotomy is appropriate in patients without malignancy and significant deposition of food masses in distal esophagus followed by severe pulmonary complications. Esophagectomy is desirable in case of unadvisable or failed repeated esophagocardiomyotomy. The authors presents laparoscopic transhiatal resection of the lower third of the esophagus (2019) in a patient with recurrent achalasia of the cardia stage 3-4 and cicatricial peptic stricture of the lower third of the esophagus after previous laparoscopic esophagocardiomyotomy with fundoplication (2009). The immediate results of redo surgery and physical status of the patient after 3 years (12-year follow-up) are described.
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Affiliation(s)
- A S Allakhverdyan
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - A N Anipchenko
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - N N Anipchenko
- Vladimirsky Moscow Regional Research Clinical Institute, Moscow, Russia
| | - E V Chernogorova
- Vladimirsky Moscow Regional Research Clinical Institute, Moscow, Russia
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AGA Clinical Practice Update on Endoscopic Management of Perforations in Gastrointestinal Tract: Expert Review. Clin Gastroenterol Hepatol 2021; 19:2252-2261.e2. [PMID: 34224876 DOI: 10.1016/j.cgh.2021.06.045] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/18/2021] [Accepted: 06/23/2021] [Indexed: 02/07/2023]
Abstract
BEST PRACTICE ADVICE 1: For all procedures, especially procedures carrying an increased risk for perforation, a thorough discussion between the endoscopist and the patient (preferably together with the patient's family) should include details of the procedural techniques and risks involved. BEST PRACTICE ADVICE 2: The area of perforation should be kept clean to prevent any spillage of gastrointestinal contents into the perforation by aspirating liquids and, if necessary, changing the patient position to bring the perforation into a non-dependent location while minimizing insufflation of carbon dioxide to avoid compartment syndrome. BEST PRACTICE ADVICE 3: Use of carbon dioxide for insufflation is encouraged for all endoscopic procedures, especially any endoscopic procedure with increased risk of perforation. If available, carbon dioxide should be used for all endoscopic procedures. BEST PRACTICE ADVICE 4: All endoscopists should be aware of the procedures that carry an increased risk for perforation such as any dilation, foreign body removal, any per oral endoscopic myotomy (Zenker's, esophageal, pyloric), stricture incision, thermal coagulation for hemostasis or tumor ablation, percutaneous endoscopic gastrostomy, ampullectomy, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), endoluminal stenting with self-expanding metal stent (SEMS), full-thickness endoscopic resection, endoscopic retrograde cholangiopancreatography (ERCP) in surgically altered anatomy, endoscopic ultrasound (EUS)-guided biliary and pancreatic access, EUS-guided cystogastrostomy, and endoscopic gastroenterostomy using a lumen apposing metal stent (LAMS). BEST PRACTICE ADVICE 5: Urgent surgical consultation should be highly considered in all cases with perforation even when endoscopic repair is technically successful. BEST PRACTICE ADVICE 6: For all upper gastrointestinal perforations, the patient should be considered to be admitted for observation, receive intravenous fluids, be kept nothing by mouth, receive broad-spectrum antibiotics (to cover Gram-negative and anaerobic organisms), nasogastric tube (NGT) placement (albeit some exceptions), and surgical consultation. BEST PRACTICE ADVICE 7: For upper gastrointestinal tract perforations, a water-soluble upper gastrointestinal series should be considered to confirm the absence of continuing leak at the perforation site before initiating a clear liquid diet. BEST PRACTICE ADVICE 8: Endoscopic closure of esophageal perforations should be pursued when feasible, utilizing through-the-scope clips (TTSCs) or over-the-scope clips (OTSCs) for perforations <2 cm and endoscopic suturing for perforations >2 cm, reserving esophageal stenting with SEMS for cases where primary closure is not possible. BEST PRACTICE ADVICE 9: Endoscopic closure of gastric perforations should be pursued when feasible, utilizing TTSCs or OTSCs for perforations <2 cm and endoscopic suturing or combination of TTSCs and endoloop for perforations >2 cm. BEST PRACTICE ADVICE 10: For large type 1 duodenal perforations (lateral duodenal wall tear >3 cm), being cognizant of the difficulty in closing them endoscopically, urgent surgical consultation should be made while the feasibility of endoscopic closure is assessed. BEST PRACTICE ADVICE 11: Because type 2 periampullary (retroperitoneal) perforations are subtle and can be easily missed, the endoscopist should carefully assess the gas pattern on fluoroscopy to avoid delays in treatment and request a computed tomography scan if there is a concern for such a perforation; identified perforations of this type at the time of ERCP may be closed with TTSCs if feasible and/or by placing a fully covered SEMS into the bile duct across the ampulla. BEST PRACTICE ADVICE 12: For the management of large duodenal polyps, endoscopic mucosal resection (EMR) should only be performed by experienced endoscopists and endoscopic submucosal dissection (ESD) only by experts because both EMR and ESD in the duodenum require proficiency in resection and mucosal defect closure techniques to manage immediate and/or delayed perforations (caused by the proteolytic enzymes of the pancreas). BEST PRACTICE ADVICE 13: Endoscopists should be aware that colon perforations occurring during diagnostic colonoscopy are most commonly located in the sigmoid colon due to direct trauma from forceful advancement of the colonoscope. Such tears recognized at the time of colonoscopy may be closed by TTSCs or OTSCs if the bowel preparation is good and the patient is stable. BEST PRACTICE ADVICE 14: Although colon perforation is responsive to various endoscopic tools such as TTSC, OTSC, and endoscopic suturing, perforations in the right colon, especially in the cecum, have been relegated to using only TTSCs because of inability to reach the site of the perforation with an endoscopic suturing device or OTSC if the colon is tortuous or unclean. Recently a new suture-based device for defect closure has been introduced allowing deep submucosal and intramuscular enhanced fixation through a standard gastroscope or colonoscope. BEST PRACTICE ADVICE 15: Patients with perforations who are hemodynamically unstable or who have suffered a delayed perforation with peritoneal signs or frank peritonitis should be surgically managed without any attempt at endoscopic closure. BEST PRACTICE ADVICE 16: In any adverse event including perforation, it is paramount to ensure accurate documentation, prompt discussion with the patient and family, and swift reporting to the quality officer (or equivalent) and risk management team of the institution (in major adverse events).
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Gou K, Baek S, Lutnesky MMF, Han HC. Growth-profile configuration for specific deformations of tubular organs: A study of growth-induced thinning and dilation of the human cervix. PLoS One 2021; 16:e0255895. [PMID: 34379659 PMCID: PMC8357173 DOI: 10.1371/journal.pone.0255895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 07/26/2021] [Indexed: 12/02/2022] Open
Abstract
Growth is a significant factor that results in deformations of tubular organs, and particular deformations associated with growth enable tubular organs to perform certain physiological functions. Configuring growth profiles that achieve particular deformation patterns is critical for analyzing potential pathological conditions and for developing corresponding clinical treatments for tubular organ dysfunctions. However, deformation-targeted growth is rarely studied. In this article, the human cervix during pregnancy is studied as an example to show how cervical thinning and dilation are generated by growth. An advanced hyperelasticity theory called morphoelasticity is employed to model the deformations, and a growth tensor is used to represent growth in three principle directions. The computational results demonstrate that both negative radial growth and positive circumferential growth facilitate thinning and dilation. Modeling such mixed growth represents an advancement beyond commonly used uniform growth inside tissues to study tubular deformations. The results reveal that complex growth may occur inside tissues to achieve certain tubular deformations. Integration of further biochemical and cellular activities that initiate and mediate such complex growth remains to be explored.
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Affiliation(s)
- Kun Gou
- Department of Mathematical, Physical, and Engineering Sciences, Texas A&M University-San Antonio, San Antonio, Texas, United States of America
- * E-mail:
| | - Seungik Baek
- Department of Mechanical Engineering, Michigan State University, East Lansing, Michigan, United States of America
| | - Marvin M. F. Lutnesky
- Department of Life Sciences, Texas A&M University-San Antonio, San Antonio, Texas, United States of America
| | - Hai-Chao Han
- Department of Mechanical Engineering, The University of Texas at San Antonio, San Antonio, Texas, United States of America
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Zhong C, Tan S, Huang S, Peng Y, Lü M, Tang X. Clinical outcomes of peroral endoscopic myotomy for achalasia in children: a systematic review and meta-analysis. Dis Esophagus 2021; 34:doaa112. [PMID: 33316041 DOI: 10.1093/dote/doaa112] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/03/2020] [Accepted: 09/29/2020] [Indexed: 12/11/2022]
Abstract
Peroral endoscopic myotomy (POEM) is a novel minimally invasive intervention, which has shown to be effective and safe for treating achalasia in adults. Presently, POEM was also reported to be effective for achalasia in children. So we conducted this study to explore the clinical outcomes of POEM for pediatric achalasia. A systematic literature search in PubMed, Embase, and Cochrane databases was performed, which covered the period from January 2009 to June 2020. Selecting studies and collecting data was independently by two reviewers according to predefined criteria. The statistical analysis was carried out using Comprehensive Meta-Analysis software version 2 and Review Manager 5.3. A total of 11 studies with 389 children were identified in the final analysis. Pooled technical success of POEM treatment achalasia was achieved in 385 children (97.4%; 95% confidence interval [CI], 94.7%-98.7%), and the pooled clinical success was achieved in 348 children (92.4%; 95% CI, 89.0%-94.8%). After POEM, the Eckardt score was significantly decreased by 6.76 points (95% CI, 6.18-7.34, P < 0.00001), and the lower esophageal sphincter pressure was significantly reduced by 19.38 mmHg (95% CI, 17.54-21.22, P < 0.00001). The pooled major adverse events rate related to POEM was 12.8% (95% CI, 4.5%-31.5%) and the gastroesophageal reflux rate was 17.8% (95% CI, 14.2%-22.0%). Our current study demonstrated that the POEM was an effective and safe technique for treating achalasia in children. Further randomized comparative studies of POEM and other therapeutic methods are warranted to determine the most effective treatment modality for achalasia in children.
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Affiliation(s)
- Chunyu Zhong
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shali Tan
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shu Huang
- Department of Gastroenterology, the People's Hospital of Lianshui, Huaian, China
| | - Yan Peng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Muhan Lü
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaowei Tang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
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Zhong C, Huang S, Xia H, Tan S, Lü M, Peng Y, Tang X. Role of Peroral Endoscopic Myotomy in Geriatric Patients with Achalasia: A Systematic Review and Meta-Analysis. Dig Dis 2021; 40:106-114. [PMID: 33752208 DOI: 10.1159/000516024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 03/18/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is a particularly attractive intervention for achalasia. Presently, POEM has been reported to be effective and safe for achalasia in geriatric patients. Herein, this systematic review was conducted to explore the role of POEM in geriatric patients with achalasia. METHOD PubMed, Embase, and Cochrane Library were searched to identify studies evaluating the clinical outcome of POEM in geriatric patients with achalasia during January 2009 to October 2020. The primary outcomes were technical and clinical success. Secondary outcomes included postoperative Eckardt score, lower esophageal sphincter (LES) pressure, adverse events, and clinical reflux. RESULTS There were 7 studies with a total of 469 geriatric patients, and the pooled technical success of POEM treatment was 98.1% (95% confidence interval [CI], 95.1-99.3%), and the pooled clinical success was 92.5% (95% CI, 89.3-94.8%). After POEM, the Eckardt score significantly decreased by 6.09 points (95% CI, 5.44-6.74, p < 0.00001), and the LES pressure significantly reduced by 13.53 mm Hg (95% CI, 5.14-21.91, p = 0.002). The pooled adverse events rate was 9.0% (95% CI, 4.3-17.9%), and the post-POEM clinical reflux rate was 17.4% (95% CI, 12.9-23.2%). CONCLUSION Our current study demonstrated that POEM was an effective and safe technique for achalasia in geriatric patients.
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Affiliation(s)
- Chunyu Zhong
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shu Huang
- Department of Gastroenterology, the People's Hospital of Lianshui, Huaian, China
| | - Huifang Xia
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shali Tan
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Muhan Lü
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yan Peng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaowei Tang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
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29
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Cook IJ. POEM for achalasia: Looking good, but the final verses are yet to be penned. Med J Aust 2021; 214:171-172. [PMID: 33641178 DOI: 10.5694/mja2.50945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/05/2021] [Accepted: 01/18/2021] [Indexed: 11/17/2022]
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30
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Drexel S, Kishawi S, Marks J. Peroral Esophageal Myotomy. Surg Clin North Am 2020; 100:1183-1192. [PMID: 33128887 DOI: 10.1016/j.suc.2020.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Achalasia is a neurodegenerative disorder of the lower esophagus characterized by high lower esophageal pressures and aperistalsis of the esophageal body. It remains a difficult to treat disease with significant burden on patients due to difficulty swallowing leading to malnutrition. Peroral endoscopic myotomy (POEM) is a newer endoscopic treatment of achalasia. It involves dividing the muscular layer of the esophagus through a submucosal tunnel. Ten-year data show POEM is a safe and effective treatment of achalasia. However, postoperative gastroesophageal reflux disease remains an important consideration.
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Affiliation(s)
- Sabrina Drexel
- Northwest Minimally Invasive Surgery, 2222 Northwest Lovejoy Street, Suite 322, Portland, OR 97210, USA.
| | - Sami Kishawi
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5047, USA
| | - Jeffrey Marks
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5047, USA
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31
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Hashimoto R, Inoue H, Shimamura Y, Sakuraba A, Tomizawa Y. Per oral endoscopic myotomy as salvage therapy in patients with achalasia refractory to endoscopic or surgical therapy is technically feasible and safe: Systematic review and meta-analysis. Dig Endosc 2020; 32:1042-1049. [PMID: 32012360 DOI: 10.1111/den.13643] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 01/31/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUNDS AND AIMS Per oral endoscopic myotomy (POEM) has been reported as an effective and safe salvage therapy for achalasia but there is limited composite data. We performed a systematic review and meta-analysis of studies that reported the rates of clinical success and adverse events among patients who underwent POEM after failed conventional endoscopic or surgical therapy. METHODS Electronic literature search was conducted from inception through December 2018 for articles reporting the efficacy and safety of POEM in patients with achalasia who failed endoscopic or surgical therapy. Primary outcome was the pooled estimated rates of clinical success, defined as Eckardt score ≤ 3 after POEM. Secondary outcomes were procedural time, the rates of POEM-related gastroesophageal reflux disease (GERD) and procedure-related adverse events. RESULTS Seven studies reporting outcomes on 487 patients met our criteria. Pooled estimated rate of clinical success of POEM was 88% (95% confidence interval (CI) 79-94%). Mean procedural time was 64 minutes (95% CI 44-85 minutes). POEM-related GERD was found in 20% (95% CI 16-24%) of patients. Estimated incidence of overall adverse events was 10% (95% CI 5-18%) with individual risk of bleeding, mucosotomy, pneumothorax, pneumoperitoneum hydrothorax/mediastinitis, and subcutaneous emphysema ranging from 1 to 4%. CONCLUSIONS Per oral endoscopic myotomy after failed endoscopic or surgical therapy in patients with achalasia is an effective and safe treatment. Further long-term follow-up studies in a larger number of patients are warranted to validate the sustainable efficacy of POEM for achalasia.
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Affiliation(s)
- Rintaro Hashimoto
- Division of Gastroenterology, University of California Irvine Medical Center, Orange, USA
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Atsushi Sakuraba
- Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, USA
| | - Yutaka Tomizawa
- Division of Gastroenterology, Harborview Medical Center, University of Washington, Seattle, USA
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32
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Tat C, Barajas-Gamboa JS, Kroh M. Principles of Intramural Surgery. Surg Clin North Am 2020; 100:1169-1182. [PMID: 33128886 DOI: 10.1016/j.suc.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Intramural surgery is a minimally invasive surgical technique based on flexible endoscopy. The first step involves the initial mucosal incision for entry point. Then a submucosal tunnel is dissected to the site of the target anatomy. The procedure performed may include myotomy or lesion removal. When complete, the initial mucosal incision is closed. This technique separates the mucosal flap from the surgical site, minimizing the risk of full-thickness perforation and gastrointestinal leakage. Peroral endoscopic myotomy is the most studied application of intramural surgery but other procedures have emerged. This article explores principles of intramural surgery and summarizes its applications.
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Affiliation(s)
- Christine Tat
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, PO Box 112412, Abu Dhabi, United Arab Emirates
| | - Juan S Barajas-Gamboa
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, PO Box 112412, Abu Dhabi, United Arab Emirates
| | - Matthew Kroh
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Cleveland Clinic Lerner College of Medicine, PO Box 112412, Abu Dhabi, United Arab Emirates.
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Jawaid S, Draganov PV, Yang D. Esophageal POEM: the new standard of care. Transl Gastroenterol Hepatol 2020; 5:47. [PMID: 33073042 DOI: 10.21037/tgh.2019.12.17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 12/19/2019] [Indexed: 01/06/2023] Open
Abstract
Since its introduction into clinical practice nearly a decade ago, per-oral endoscopic myotomy (POEM) has now become an accepted minimally invasive approach for the treatment of achalasia with excellent short- and mid-term clinical outcomes in both treatment naïve and those who have failed prior therapy. POEM is comparable to laparoscopic Heller myotomy (LHM) in terms of efficacy and safety, with less procedural pain and faster recovery time. Recent data also reveals that POEM may be more effective and durable than pneumatic dilation (PD) for the treatment of achalasia, with similar safety profile. Preliminary data on POEM for spastic esophageal disorders (SED) is promising yet scarce. Post-POEM gastroesophageal reflux disease (GERD) is common but asymptomatic in most patients, further highlighting the need for ongoing research in this field and the importance of long-term surveillance of these patients.
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Affiliation(s)
- Salmaan Jawaid
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida Health, Gainesville, FL, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida Health, Gainesville, FL, USA
| | - Dennis Yang
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida Health, Gainesville, FL, USA
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Paspatis GA, Arvanitakis M, Dumonceau JM, Barthet M, Saunders B, Turino SY, Dhillon A, Fragaki M, Gonzalez JM, Repici A, van Wanrooij RLJ, van Hooft JE. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement - Update 2020. Endoscopy 2020; 52:792-810. [PMID: 32781470 DOI: 10.1055/a-1222-3191] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
1: ESGE recommends that each center implements a written policy regarding the management of iatrogenic perforations, including the definition of procedures that carry a higher risk of this complication. This policy should be shared with the radiologists and surgeons at each center. 2 : ESGE recommends that in the case of an endoscopically identified perforation, the endoscopist reports its size and location, with an image, and statement of the endoscopic treatment that has been applied. 3: ESGE recommends that symptoms or signs suggestive of iatrogenic perforation after an endoscopic procedure should be rapidly and carefully evaluated and documented with a computed tomography (CT) scan. 4 : ESGE recommends that endoscopic closure should be considered depending on the type of the iatrogenic perforation, its size, and the endoscopist expertise available at the center. Switch to carbon dioxide (CO2) endoscopic insufflation, diversion of digestive luminal content, and decompression of tension pneumoperitoneum or pneumothorax should also be performed. 5 : ESGE recommends that after endoscopic closure of an iatrogenic perforation, further management should be based on the estimated success of the endoscopic closure and on the general clinical condition of the patient. In the case of no or failed endoscopic closure of an iatrogenic perforation, and in patients whose clinical condition is deteriorating, hospitalization and surgical consultation are recommended.
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Affiliation(s)
- Gregorios A Paspatis
- Gastroenterology Department, Venizelion General Hospital, Heraklion, Crete-Greece
| | - Marianna Arvanitakis
- Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme Hospital, Universite Libre de Bruxelles, Brussels, Belgium
| | - Jean-Marc Dumonceau
- Gastroenterology Service, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | | | - Brian Saunders
- St Mark's Hospital, Wolfson Unit for Endoscopy, North West London Hospitals University Trust, Harrow, London, UK
| | | | - Angad Dhillon
- St Mark's Hospital, Wolfson Unit for Endoscopy, North West London Hospitals University Trust, Harrow, London, UK
| | - Maria Fragaki
- Gastroenterology Department, Venizelion General Hospital, Heraklion, Crete-Greece
| | | | - Alessandro Repici
- Department of Gastroenterology, Digestive Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, AG&M Research Institute, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, The Netherlands
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Masadeh M, Nau P, Chandra S, Klair J, Keech J, Parekh K, Abiad RE, Gerke H. Experience with Peroral Endoscopic Myotomy for Achalasia and Spastic Esophageal Motility Disorders at a Tertiary U.S. Center. Clin Endosc 2020; 53:321-327. [PMID: 31744270 PMCID: PMC7280846 DOI: 10.5946/ce.2019.110] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 08/18/2019] [Accepted: 09/16/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS Peroral endoscopic myotomy (POEM) is a novel procedure for the treatment of achalasia and spastic esophageal disorders. Experience with POEM is limited, but its reported outcomes are excellent. It is deemed safe even for patients with prior interventions. METHODS This retrospective review included patients who underwent POEM at a tertiary US center. POEM was performed in a multidisciplinary approach by advanced endoscopists and foregut surgeons. Clinical success was defined as a post-POEM Eckardt score ≤3. RESULTS A total of 125 patients were included. Median follow-up period was 18 months (interquartile range, 10-22 months). Clinical success was achieved in 92% of patients and persisted at 12 months in 88% of patients. Mucosal barrier failure (MBF) occurred in 7 patients, 2 of whom required surgical intervention. MBF was more common in patients with prior laparoscopic Heller myotomy (19% vs. 3%, p=0.015). MBF requiring surgical intervention occurred early in the learning curve. CONCLUSION POEM is safe and effective in the treatment of achalasia and spastic esophageal disorders even after failed prior interventions.
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Affiliation(s)
- Maen Masadeh
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Peter Nau
- Division of Minimally Invasive and Bariatric Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Subhash Chandra
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Jagpal Klair
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - John Keech
- Division of Thoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Kalpaj Parekh
- Division of Thoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Rami El Abiad
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Henning Gerke
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Zou BC, Zhang L, Qin B, Wang SH, Cheng Y, Zhao HL. Effects of Peroral Endoscopic Myotomy on Esophageal Function in the Treatment of Achalasia. Surg Innov 2020; 27:333-341. [PMID: 32274966 DOI: 10.1177/1553350620913133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Peroral endoscopic myotomy (POEM) is a new technique to treat achalasia, but the effects on esophageal motor function and structure are still unclear. This study aimed to examine the esophageal function and anatomical changes of patients with achalasia treated with POEM. This was a retrospective study of 43 patients with achalasia treated with POEM between January 2013 and January 2016 at the Second Affiliated Hospital of Xi'an Jiaotong University. The patients were grouped as previous treatments for achalasia (n = 19) versus no previous treatment (n = 24). Surgical success (defined as Eckardt score ≤3 points or decreased by >3 points compared with baseline), recurrence, and reintervention were analyzed. Three patients (7.0%) were Eckardt grade I, 16 (37.2%) were grade II, and 24 (55.8%) were grade III. Operation time was 35 to 150 (median = 49) minutes. Both groups showed improvements in the Eckardt score after surgery (both P < .001), without a difference between the 2 groups (P = .749). The maximal mean diameter of the esophagus was reduced, and the lower esophageal sphincter pressure was improved after surgery (both groups, all P < .001), without difference between the 2 groups (all P > .05). One case of failure was probably due to the presence of an esophageal stent. POEM has a high success rate and is possibly unaffected by previous treatments, except maybe stent implantation. Clinical symptoms of achalasia are significantly relieved by POEM; the function of the esophageal sphincter and the esophagus structure are improved. Previous esophageal stent implantation could increase failure likelihood, but this will have to be confirmed.
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Affiliation(s)
- Bai Cang Zou
- The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Li Zhang
- The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Bin Qin
- The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Shen Hao Wang
- The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yan Cheng
- The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Hong Li Zhao
- The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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de Heer J, Desai M, Boeckxstaens G, Zaninotto G, Fuchs KH, Sharma P, Schachschal G, Mann O, Rösch T, Werner Y. Pneumatic balloon dilatation versus laparoscopic Heller myotomy for achalasia: a failed attempt at meta-analysis. Surg Endosc 2020; 35:602-611. [PMID: 32180002 DOI: 10.1007/s00464-020-07421-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 02/10/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The advent of peroral endoscopic myotomy (POEM) shed some light on the role of the current standards in the treatment of idiopathic achalasia, namely endoscopic pneumatic dilatation (PD) and laparoscopic Heller myotomy (LHM). We analyzed the quality of the current evidence comparing LHM and PD. METHODS A systematic literature search was performed in Pubmed/Medline, Web of Science, Google Scholar and Cochrane for meta-analyses/systematic reviews comparing PD and LHM or open surgery, limited to English language full-text articles. After a detailed review of these meta-analyses, all studies included were analyzed further in depth with respect to treatment protocol, assessment of success, complications and sequelae such as gastroesophageal reflux (GER), as well as follow-up details. RESULTS Six randomized controlled trials (RCT), 5 with LHM and 1 with open surgery, were found, published in 10 papers. In contrast to a rather homogeneous LHM technique, PD regimens as well as the clinical dysphagia scores were different in every RCT; most RCTs also showed methodological limitations. There were nine meta-analyses which included a variable number of these RCTs or other cohort studies. Meta-analyses between 2009 and 2013 favored surgery, while the 4 most recent ones reached divergent conclusions. The main difference might have been whether repeated dilatation was regarded as part of the PD protocol or as failure. CONCLUSIONS The variability in PD techniques and in definition of clinical success utilized in the achalasia RCTs on PD versus LHM render the conclusions of meta-analyses unreliable. Further randomized studies should be based on uniform criteria; in the meantime, publication of even more meta-analyses should be avoided.
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Affiliation(s)
- Jocelyn de Heer
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Madhav Desai
- Department of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas, MO, USA
| | - Guy Boeckxstaens
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | | | - Karl-Hermann Fuchs
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Prateek Sharma
- Department of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas, MO, USA
| | - Guido Schachschal
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Oliver Mann
- Department of General and Abdominal Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Yuki Werner
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Costantini A, Familiari P, Costantini M, Salvador R, Valmasoni M, Capovilla G, Landi R, Mangiola F, Provenzano L, Briscolini D, Merigliano S, Costamagna G. Poem Versus Laparoscopic Heller Myotomy in the Treatment of Esophageal Achalasia: A Case-Control Study from Two High Volume Centers Using the Propensity Score. J Gastrointest Surg 2020; 24:505-515. [PMID: 31848870 DOI: 10.1007/s11605-019-04465-w] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 11/04/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND POEM has recently had a widespread diffusion, aiming at being the treatment of choice for esophageal achalasia. The results of ongoing RCTs against laparoscopic myotomy are not available, yet. We, therefore, designed this propensity score (PS) case-control study with the aim of evaluating how POEM compares to the long-standing laparoscopic Heller myotomy + Dor fundoplication (LHD) and verifying if it may really replace the latter as the first-line treatment for achalasia. METHODS Two groups of consecutive patients undergoing treatment for primary achalasia from January 2014 to November 2017 were recruited in two high-volume centers, one with extensive experience with POEM and one with LHD. Patients with previous endoscopic treatment were included, whereas patients with previous LHD or POEM were excluded. A total of 140 patients in both centers were thus matched. LHD and POEM were performed following established techniques. The patients were followed with clinical (Eckardt score), endoscopic, and pH-manometry evaluations. RESULTS The procedure was successfully completed in all the patients. POEM required a shorter operation time and postoperative stay compared to LHD (p < 0.001). No mortality was recorded in either group. Seven complications were recorded in the POEM group (five mucosal perforations) and 3 in the LHD group (3 mucosal perforations)(p = 0.33). Two patients in the POEM group and one in the LHD were lost to follow-up. One patient in both groups died during the follow-up for unrelated causes. At a median follow-up of 24 months [15-30] for POEM and 31 months [15-41] for LHD (p < 0.05), 99.3% of the POEM patients and 97.7% of the LHD patients showed an Eckardt score ≤ 3 (p < 0.12). Four years after the treatment, the probability to have symptoms adequately controlled was > 90% for both groups (p = 0.2, Log-rank test). HR-Manometry showed a similar reduction in the LES pressure and 4sIRP; 24-h pH-monitoring showed however an abnormal exposure to acid in 38.4% of POEM patients, as compared to 17.1% of LHD patients (p < 0.01) and esophagitis was found in 37.4% of the POEM and 15.2% of LHD patients (p < 0.05). CONCLUSION POEM provides the same midterm results as LHD. This study confirms, however, a higher incidence of postoperative GERD with the former, even if its real significance needs to be further evaluated.
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Affiliation(s)
- Andrea Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, Clinica Chirurgica 3, Università di Padova, 35128, Padova, Italy
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Center for Endoscopic Research, Therapeutics and Training (CERTT), Rome, 00168, Italy
| | - Pietro Familiari
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Center for Endoscopic Research, Therapeutics and Training (CERTT), Rome, 00168, Italy
| | - Mario Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, Clinica Chirurgica 3, Università di Padova, 35128, Padova, Italy.
| | - Renato Salvador
- Department of Surgical, Oncological and Gastroenterological Sciences, Clinica Chirurgica 3, Università di Padova, 35128, Padova, Italy
| | - Michele Valmasoni
- Department of Surgical, Oncological and Gastroenterological Sciences, Clinica Chirurgica 3, Università di Padova, 35128, Padova, Italy
| | - Giovanni Capovilla
- Department of Surgical, Oncological and Gastroenterological Sciences, Clinica Chirurgica 3, Università di Padova, 35128, Padova, Italy
| | - Rosario Landi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Center for Endoscopic Research, Therapeutics and Training (CERTT), Rome, 00168, Italy
| | - Francesca Mangiola
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Center for Endoscopic Research, Therapeutics and Training (CERTT), Rome, 00168, Italy
| | - Luca Provenzano
- Department of Surgical, Oncological and Gastroenterological Sciences, Clinica Chirurgica 3, Università di Padova, 35128, Padova, Italy
| | - Dario Briscolini
- Department of Surgical, Oncological and Gastroenterological Sciences, Clinica Chirurgica 3, Università di Padova, 35128, Padova, Italy
| | - Stefano Merigliano
- Department of Surgical, Oncological and Gastroenterological Sciences, Clinica Chirurgica 3, Università di Padova, 35128, Padova, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Center for Endoscopic Research, Therapeutics and Training (CERTT), Rome, 00168, Italy
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Inoue H, Shiwaku H, Kobayashi Y, Chiu PWY, Hawes RH, Neuhaus H, Costamagna G, Stavropoulos SN, Fukami N, Seewald S, Onimaru M, Minami H, Tanaka S, Shimamura Y, Santi EG, Grimes K, Tajiri H. Statement for gastroesophageal reflux disease after peroral endoscopic myotomy from an international multicenter experience. Esophagus 2020; 17:3-10. [PMID: 31559513 PMCID: PMC6976544 DOI: 10.1007/s10388-019-00689-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 08/28/2019] [Indexed: 02/07/2023]
Abstract
It has been 10 years since peroral endoscopic myotomy (POEM) was reported for the first time, and POEM has currently become the standard treatment for achalasia and related disorders globally because it is less invasive and has a higher curative effect than conventional therapeutic methods. However, there are limited studies comparing the long-term outcomes of POEM with those of conventional therapeutic methods, particularly in the occurrence of gastroesophageal reflux disease (GERD) after therapy. With this background, we held a consensus meeting to discuss the pathophysiology and management of GERD after POEM based on published papers and experiences of each expert and to discuss the prevention of GERD and dealing with anti-acid drug refractory GERD. This meeting was held on April 27, 2018 in Tokyo to establish statements and finalize the recommendations using the modified Delphi method. This manuscript presents eight statements regarding GERD after POEM.
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Affiliation(s)
- Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Toyosu 5-1-38, Koto-Ku, Tokyo, 135-8577 Japan
| | - Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, 7-45-1, Nanakuma, Jyonan-ku, Fukuoka, 814-0180 Japan
| | - Yasutoshi Kobayashi
- Department of Gastroenterology and Hepatology, Jichi Medical University, Shimotsuke, Tochigi Japan
| | - Philip W. Y. Chiu
- The Institute of Digestive Disease, Faculty of Medicine of the Chinese University of Hong Kong, Hong Kong, China
| | - Robert H. Hawes
- Center for Interventional Endoscopy, Florida Hospital Orlando, Orlando, Florida USA
| | - Horst Neuhaus
- Department of Internal Medicine, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Stavros N. Stavropoulos
- Division of Gastroenterology, Hepatology, and Nutrition, NYU-Winthrop Hospital, New York, USA
| | - Norio Fukami
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ USA
| | - Stefan Seewald
- Centre of Gastroenterology, Klinik Hirslanden, Zurich, Switzerland
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Toyosu 5-1-38, Koto-Ku, Tokyo, 135-8577 Japan
| | - Hitomi Minami
- Department of Gastroenterology and Hepatology, Nagasaki University, Nagasaki, Japan
| | - Shinwa Tanaka
- Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Toyosu 5-1-38, Koto-Ku, Tokyo, 135-8577 Japan
| | - Esperanza Grace Santi
- Section of Gastroenterology and Digestive Endoscopy, De La Salle University Medical Center, Dasmarinas City, Philippines
| | - Kevin Grimes
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Hisao Tajiri
- Department of Innovative Interventional Endoscopy Research, The Jikei University School of Medicine, Tokyo, Japan
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Cappell MS, Stavropoulos SN, Friedel D. Updated Systematic Review of Achalasia, with a Focus on POEM Therapy. Dig Dis Sci 2020; 65:38-65. [PMID: 31451984 DOI: 10.1007/s10620-019-05784-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 08/07/2019] [Indexed: 02/06/2023]
Abstract
AIM To systematically review clinical presentation, diagnosis, and therapy of achalasia, focusing on recent developments in high-resolution esophageal manometry (HREM) for diagnosis and peroral endoscopic myotomy (POEM) for therapy. METHODS Systematic review of achalasia using computerized literature search via PubMed and Ovid of articles published since 2005 with keywords ("achalasia") AND ("high resolution" or "HREM" or "peroral endoscopic myotomy" or "POEM"). Two authors independently performed literature searches and incorporated articles into this review by consensus according to prospectively determined criteria. RESULTS Achalasia is an uncommon esophageal motility disorder, usually manifested by dysphagia to solids and liquids, and sometimes manifested by chest pain, regurgitation, and weight loss. Symptoms often suggest more common disorders, such as gastroesophageal reflux disease (GERD), thus often delaying diagnosis. Achalasia is a predominantly idiopathic chronic disease. Diagnosis is typically suggested by barium swallow showing esophageal dilation; absent distal esophageal peristalsis; smoothly tapered narrowing ("bird's beak") at esophagogastric junction; and delayed passage of contrast into stomach. Diagnostic findings at high-resolution esophageal manometry (HREM) include: distal esophageal aperistalsis and integrated relaxation pressure (trough LES pressure during 4 s) > 15 mmHg. Achalasia is classified by HREM into: type 1 classic; type 2 compartmentalized high pressure in esophageal body, and type 3 spastic. This classification impacts therapeutic decisions. Esophagogastroduodenoscopy is required before therapy to assess esophagus and esophagogastric junction and to exclude distal esophageal malignancy. POEM is a revolutionizing achalasia therapy. POEM creates a myotomy via interventional endoscopy. Numerous studies demonstrate that POEM produces comparable, if not superior, results compared to standard laparoscopic Heller myotomy (LHM), as determined by LES pressure, dysphagia frequency, Eckardt score, hospital length of stay, therapy durability, and incidence of GERD. Other therapies, including botulinum toxin injection and pneumatic dilation, have moderately less efficacy and much less durability than POEM. CONCLUSION This comprehensive review suggests that POEM is equivalent or perhaps superior to LHM for achalasia in terms of cost efficiency, hospital length of stay, and relief of dysphagia, with comparable side effects. The data are, however, not conclusive due to sparse long-term follow-up and lack of randomized comparative clinical trials. POEM therapy is currently limited by a shortage of trained endoscopists.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology and Hepatology, MOB #602, William Beaumont Hospital, 3535 W. Thirteen Mile Rd, Royal Oak, MI, 48073, USA.
- Oakland University William Beaumont School of Medicine, MOB #602, William Beaumont Hospital, 3535 W. Thirteen Mile Rd, Royal Oak, MI, 48073, USA.
| | | | - David Friedel
- Division of Gastroenterology, New York University Winthrop Medical Center, Mineola, NY, 11501, USA
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Ichkhanian Y, Benias P, Khashab MA. Case of early Barrett cancer following peroral endoscopic myotomy. Gut 2019; 68:2107-2110. [PMID: 31358575 DOI: 10.1136/gutjnl-2019-318950] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/08/2019] [Accepted: 07/12/2019] [Indexed: 01/15/2023]
Affiliation(s)
- Yervant Ichkhanian
- Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Petros Benias
- Division of Gastroenterology, Department of Medicine, Hofstra Northwell School of Medicine, Northwell Health System, North Shore University Hospital, Manhasset, New York, USA
| | - Mouen A Khashab
- Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Tanaka S, Toyonaga T, Kawara F, Watanabe D, Hoshi N, Abe H, Ariyoshi R, Ohara Y, Takao T, Morita Y, Umegaki E, Kodama Y. Novel per-oral endoscopic myotomy method preserving oblique muscle using two penetrating vessels as anatomic landmarks reduces postoperative gastroesophageal reflux. J Gastroenterol Hepatol 2019; 34:2158-2163. [PMID: 31373050 DOI: 10.1111/jgh.14814] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 06/21/2019] [Accepted: 07/20/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM One of the main concerns related to peroral endoscopic myotomy (POEM) is postoperative gastroesophageal reflux (GER). The two penetrating vessels (TPVs) that are found at the boundary between the circular and oblique muscles in the posterior cardia wall have been suggested to be a good indicator of the optimal distal extent of POEM. However, the effect of performing myotomy using the TPVs as an anatomical reference on the frequency of post-POEM GER has not been studied. METHODS This study involved consecutive patients who underwent POEM for the treatment of achalasia between April 2015 and June 2017. All enrolled patients underwent POEM in the 5 o'clock position and were divided into two groups: the conventional line group (CL group, n = 31), in which the TPVs were not exposed during submucosal tunnel dissection in the cardia, and the TPVs line group (TPVs group, n = 83), in which the TPVs were exposed and gastric myotomy was performed along the right side of the TPVs to preserve the oblique muscle. Examinations for post-POEM GER were conducted 3 months after the POEM. RESULTS The frequency of grade B or higher reflex esophagitis was 26/83 (31.3%) in the TPVs group and 18/31 (58.1%) in the CL group (P = 0.017). Nine of 83 patients (10.8%) had GER symptoms in the TPVs group, and six of 31 (19.4%) had GER symptoms in the CL group (P = 0.23). CONCLUSIONS The novel myotomy method preserving oblique muscle using TPVs as anatomical landmarks significantly reduced the frequency of post-POEM GER.
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Affiliation(s)
- Shinwa Tanaka
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | | | - Fumiaki Kawara
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Daisuke Watanabe
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Namiko Hoshi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hirohumi Abe
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryusuke Ariyoshi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshiko Ohara
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Toshitatsu Takao
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshinori Morita
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Eiji Umegaki
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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Sheng XF. Relationship between night reflux and sleep disturbance in elderly patients with gastroesophageal reflux disease in a tertiary hospital. Shijie Huaren Xiaohua Zazhi 2019; 27:1339-1343. [DOI: 10.11569/wcjd.v27.i21.1339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The reflux symptoms of gastroesophageal reflux disease (GERD) seriously affect the quality of life of patients. Daytime reflux is obvious, but the duration of reflux is short, which has little impact on the quality of life. Although the frequency of nocturnal regurgitation is low, its duration is long, which seriously affects the sleep quality of patients. Therefore, GERD nocturnal regurgitation has become one of clinical research hotspots and an important problem to be solved.
AIM To observe the relationship between night reflux and sleep disturbance in elderly patients with GERD in a tertiary hospital.
METHODS Two hundred and forty elderly patients with gastroesophageal reflux admitted to the Second Jinhua Hospital of Zhejiang Province from February 2017 to August 2019 were selected as subjects for investigation of the incidence of nocturnal reflux symptoms, manifestations of sleep disorders, and the relationship between nocturnal reflux and sleep disorders.
RESULTS Of 240 cases of GERD included, 36 (15.0%) had no nocturnal reflux and 204 (85.0%) had. In the past 1 mo, nocturnal reflux developed on average once a week or less in 34 (16.67%) of 204 patients with nocturnal reflux, twice a week in 78 (38.24%), and > 2 times in 52 (25.49%). Of 36 cases without nocturnal reflux symptoms, 9 (25.0%) had a sleep disorder, while all 204 (100.0%) cases with nocturnal reflux suffered from a sleep disorder. The incidence of sleep disorder was significantly higher in patients with nocturnal reflux than in those without (P < 0.05). Approximately 77.94% of the patients had decreased sleep quality. Daytime residual effect was found in 70.10% of patients. Sleep latency was prolonged in 55.88% of patients. When the latency was prolonged, the time to sleep was mainly 30-40 min. The total sleep time was shortened in 53.92% of patients, most of whom had a sleep time of 4-5 h. Among the 204 GERD patients, 106 (51.96%) needed drug therapy for nocturnal reflux, including 36 (33.96%) patients taking rabeprazole orally, 20 (18.87%) taking omeprazole orally, 30 (28.30%) taking cimetidine orally, and 20 (18.87%) taking sleeping pills orally, with an effective rate of 96.23% (102/106).
CONCLUSION Nocturnal reflux may be one of the reasons affecting sleep disorders in elderly GERD patients. Proton pump inhibitor therapy can be administered in clinical practice.
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Affiliation(s)
- Xue-Fen Sheng
- Jinhua Second Hospital of Zhejiang Province, Jinhua 321000, Zhejiang Province, China
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Per-oral endoscopic myotomy (POEM) for a sigmoid type of achalasia: short-term outcomes and changes in the esophageal angle. Surg Endosc 2019; 34:4124-4130. [PMID: 31605214 DOI: 10.1007/s00464-019-07180-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 09/30/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Per-oral endoscopic myotomy (POEM) is an endoscopic procedure whereby the esophageal muscle is incised in order to lower the lower esophageal sphincter (LES) pressure. Since the time it was first performed in 2008 and subsequently reported on in 2010 by Inoue et al., POEM has been shown to be safe and effective for straight type of achalasia. On the other hand, the efficacy of POEM had been controversial for patients with achalasia of the sigmoid type, in which a high LES pressure is accompanied by morphological changes, including dilation, acute angulation, and rotation. The aim of this study is to evaluate the safety and efficacy of POEM in patients with sigmoid type of achalasia. METHODS Between May 2015 and December 2017, 16 patients with a sigmoid type of achalasia underwent POEM in our institute. The POEM procedure was the same as that for the straight type of achalasia. The double-scope technique was used to check the distal end of the submucosal tunnel from the gastric side. The primary endpoint was improvement of Eckardt score at 2 months after POEM. The secondary endpoints comprised operating time, change in the esophageal angulation, and adverse events. RESULTS All patients underwent POEM without severe adverse events. The respective parameters before and after POEM significantly differed in terms of mean (SD) Eckardt score [4.9 (2.0) vs. 0.4 (0.6), p < 0.01], LES pressure [19.4 (10.2) vs. 9.2 (6.4), p < 0.01], and integrated relaxation pressure [17.6 (9.2) vs. 7.9 (5.5), p < 0.01]. The average operation time was 94.7 ± 31.4 min. The average esophageal angulation was 88.4° ± 23.1° before POEM and 109.5° ± 16.7° after POEM (p < 0.01). Four patients had postoperative complications that were treated conservatively. CONCLUSIONS POEM can improve both LES pressure and esophageal angulation in patients with sigmoid achalasia.
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Olson MT, Triantafyllou T, Singhal S. A Decade of Investigation: Peroral Endoscopic Myotomy Versus Laparoscopic Heller Myotomy for Achalasia. J Laparoendosc Adv Surg Tech A 2019; 29:1093-1104. [PMID: 31313957 DOI: 10.1089/lap.2019.0242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Although laparoscopic Heller myotomy (LHM) with partial fundoplication has long been considered the gold standard for treatment of patients with achalasia, peroral endoscopic myotomy (POEM) has emerged in the last decade as a viable alternative. Methods: A collective review of literature concerning investigations that have reported patient outcomes and treatment success of LHM and POEM for all achalasia subtypes. Results: While POEM has shown excellent short-term safety and efficacy in the relief of symptoms, the long-term symptomatic outcomes after the intervention are yet to be concluded. Further evaluation of patients' interpretations and answers on subjective questionnaires is warranted before determining treatment success for POEM. Use of more reliable and disease-specific health-related quality-of-life questionnaires are better justified when comparing a new endoscopic procedure to an established gold standard. The need for objective parameters to measure reflux, longer follow-up studies, and randomized trials comparing POEM to LHM is particularly important when assessing the outcome of this new technique. High incidence of post-POEM pathologic reflux and indication for daily proton pump inhibitor use is of concern, and the lack of more long-term, objective evidence leaves the clinical value of the procedure in a state of uncertainty. Conclusions: The LHM combined with partial fundoplication is still considered to be the gold standard treatment modality for achalasia, but as the POEM procedure rapidly becomes common practice, this treatment may be performed in the majority of achalasia cases. Given the number of flaws overlooked in seminal investigations, careful consideration should be given to the patients being selected for this therapy.
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Affiliation(s)
- Michael T Olson
- University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Tania Triantafyllou
- Hippocration General Hospital of Athens, University of Athens, Athens, Greece
| | - Saurabh Singhal
- Department of GI Surgery and Liver Transplantation, Indraprastha Apollo Hospital, New Delhi, India
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Prieto RG, Prieto JE, Casas F, Ballén H. Acalasia, una visión actual. REVISTA COLOMBIANA DE CIRUGÍA 2019. [DOI: 10.30944/20117582.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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2007-2019: a "Third"-Space Odyssey in the Endoscopic Management of Gastrointestinal Tract Diseases. ACTA ACUST UNITED AC 2019; 17:202-220. [PMID: 31037613 DOI: 10.1007/s11938-019-00233-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW The main scope of this review article is to introduce readers to the innovative field of third-space endoscopy and offer a closer look at its history, milestones, and procedure spectrum while discussing ongoing and future challenges arising from its increasing adoption worldwide. RECENT FINDINGS Over the past few years, third-space endoscopy has been utilized in various diagnostic and interventional procedures performed throughout the gastrointestinal tract: obliteration of Zenker's diverticulum, myotomy for achalasia, gastroparesis or Hirschsprung's disease, biopsy or removal of subepithelial tumors, stricture management, post-per-oral endoscopic myotomy endoscopic fundoplication, and mediastino-, thoraco-, and peritoneoscopy. Third-space endoscopic interventions have revolutionized the management of esophageal motility disorders, gastroparesis, and gastrointestinal tract subepithelial tumors. Despite the high efficacy and safety of such interventions, some common (e.g., the high level of necessary endoscopic skill) and unique for each procedure (e.g., post-procedure gastroesophageal reflux or poor outcomes in patient subgroups) challenges still remain. Through a dedicated endoscopic training, a rigorous pre-procedure patient evaluation and selection, and the application of modified or new techniques, challenges can be overcome thus establishing existing procedures and paving the way for additional breakthroughs in the field of third-space endoscopy.
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Wang Y, Liu ZQ, Xu MD, Chen SY, Zhong YS, Zhang YQ, Chen WF, Qin WZ, Hu JW, Cai MY, Yao LQ, Zhou PH, Li QL. Clinical and endoscopic predictors for intraprocedural mucosal injury during per-oral endoscopic myotomy. Gastrointest Endosc 2019; 89:769-778. [PMID: 30218646 DOI: 10.1016/j.gie.2018.09.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/03/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Mucosal injury (MI) is one of the most common perioperative adverse events of per-oral endoscopic myotomy (POEM). Severe undertreated MI may lead to contamination of the tunnel and even mediastinitis. This study explored the characteristics, predictors, and management approaches of intraoperative MI. METHODS A retrospective review of the prospectively collected database at a large tertiary referral endoscopy unit was conducted for all patients undergoing POEM between August 2010 and March 2016. MI was graded according to the difficulty of repair (I, easy to repair; II, difficult to repair). The primary outcomes were the incidence and predictors of intraoperative MI. Secondary outcomes were MI details and the corresponding treatment. RESULTS POEM was successfully performed in 1912 patients. A total of 338 patients experienced 387 MIs, for an overall frequency of 17.7% (338/1912). Type II MI was rare, with a frequency of 1.7% (39/1912). Major adverse events were more common in patients with MI than in those without MI (6.2% vs 2.5%, P < .001). On multivariable analysis, MI was independently associated with previous Heller myotomy (odds ratio [OR], 2.094; P = .026), previous POEM (OR, 2.441; P = .033), submucosal fibrosis (OR, 4.530; P < .001), mucosal edema (OR, 1.834; P = .001), and tunnel length ≥13 cm (OR, 2.699; P < .001). Previous POEM (OR, 5.005; P = .030) and submucosal fibrosis (OR, 12.074; P < .001) were significant predictors of type II MI. POEM experience >1 year was a protective factor for MI (OR, .614; P = .042) and type II MI (OR, .297; P = .042). CONCLUSIONS MI during POEM is common, but type II injury is rare. Previous POEM and submucosal fibrosis were significant predictors of type II mucosal injury. POEM experience after the learning curve reduces the risk of MI.
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Affiliation(s)
- Yun Wang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zu-Qiang Liu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Mei-Dong Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shi-Yao Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun-Shi Zhong
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi-Qun Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wei-Feng Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen-Zheng Qin
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jian-Wei Hu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ming-Yan Cai
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li-Qing Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
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Maydeo A. A good mountaineer is one who knows how to come back safely. Gastrointest Endosc 2019; 89:779-781. [PMID: 30902202 DOI: 10.1016/j.gie.2018.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 11/28/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Amit Maydeo
- Baldota Institute of Digestive Sciences, Global Hospital, Mumbai, India
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Rees CJ, Koo S, Oppong KW. Future directions in therapeutic gastrointestinal endoscopy. Lancet Gastroenterol Hepatol 2019; 3:663-664. [PMID: 30215355 DOI: 10.1016/s2468-1253(18)30200-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 06/07/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Colin J Rees
- Newcastle University, Newcastle Upon Tyne, UK; South Tyneside District Hospital, South Shields, Tyne and Wear, UK.
| | - Sara Koo
- South Tyneside District Hospital, South Shields, Tyne and Wear, UK
| | - Kofi W Oppong
- Newcastle University, Newcastle Upon Tyne, UK; Freeman Hospital, Newcastle Upon Tyne, UK
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