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Chuah KH, Ramasami N, Mahendran HA, Shanmuganathan G, Koleth GG, Voon K, Gew LT, Jahit MS, Lau PC, Muthukaruppan R, Said RHM, Mahadeva S, Ho SH, Lim SY, Tee SC, Siow SL, Ooi WK, Lee YY. Malaysian joint societies' consensus recommendations on diagnosis and management of disorders of esophagogastric junction outflow. J Gastroenterol Hepatol 2024; 39:431-445. [PMID: 38087846 DOI: 10.1111/jgh.16403] [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: 05/04/2023] [Revised: 09/13/2023] [Accepted: 10/18/2023] [Indexed: 03/05/2024]
Abstract
Disorders of esophagogastric junction (EGJ) outflow, including achalasia and EGJ outflow obstruction, are motility disorders characterized by inadequate relaxation of lower esophageal sphincter with or without impaired esophageal peristalsis. Current guidelines are technical and less practical in the Asia-Pacific region, and there are still massive challenges in timely diagnosis and managing these disorders effectively. Therefore, a Malaysian joint societies' task force has developed a consensus on disorders of EGJ outflow based on the latest evidence, while taking into consideration the practical relevance of local and regional context and resources. Twenty-one statements were established after a series of meetings and extensive review of literatures. The Delphi method was used in the consensus voting process. This consensus focuses on the definition, diagnostic investigations, the aims of treatment outcome, non-surgical or surgical treatment options, management of treatment failure or relapse, and the management of complications. This consensus advocates the use of high-resolution esophageal manometry for diagnosis of disorders of EGJ outflow. Myotomy, via either endoscopy or laparoscopy, is the preferred treatment option, while pneumatic dilatation can serve as a secondary option. Evaluation and management of complications including post-procedural reflux and cancer surveillance are recommended.
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Affiliation(s)
- Kee Huat Chuah
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Naveen Ramasami
- Gastroenterology and Hepatology Unit, Department of Medicine, Sultanah Bahiyah Hospital, Alor Setar, Kedah, Malaysia
| | | | | | - Glenn George Koleth
- Gastroenterology and Hepatology Unit, Department of Medicine, Sultan Ismail Hospital, Johor Bahru, Johor, Malaysia
| | - Kelvin Voon
- Department of General Surgery, Penang General Hospital, George Town, Penang, Malaysia
| | - Lai Teck Gew
- Gastroenterology and Hepatology Unit, Department of Medicine, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia
| | | | - Peng Choong Lau
- Pantai Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
- Department of Surgery, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Raman Muthukaruppan
- Gastroenterology and Hepatology Unit, Department of Medicine, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Rosaida Hj Md Said
- Gastroenterology and Hepatology Unit, Department of Medicine, Serdang Hospital, Serdang, Selangor, Malaysia
| | - Sanjiv Mahadeva
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Shiaw-Hooi Ho
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Shyang Yee Lim
- Department of General Surgery, Penang General Hospital, George Town, Penang, Malaysia
| | - Sze Chee Tee
- Department of Surgery, National Cancer Institute, Putrajaya, Malaysia
| | - Sze Li Siow
- Department of General Surgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Wei Keat Ooi
- Department of Surgery, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia
- GI Function and Motility Unit, Universiti Sains Malaysia Hospital, Kota Bharu, Kelantan, Malaysia
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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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Vespa E, Pellegatta G, Chandrasekar VT, Spadaccini M, Patel H, Maselli R, Galtieri PA, Carlani E, Sharma P, Hassan C, Repici A. Long-term outcomes of peroral endoscopic myotomy for achalasia: a systematic review and meta-analysis. Endoscopy 2023; 55:167-175. [PMID: 35798336 DOI: 10.1055/a-1894-0147] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The long-term outcomes of esophageal peroral endoscopic myotomy (POEM) are still unknown. METHODS We searched electronic databases (MEDLINE/PubMed, EMBASE, Scopus) for studies assessing outcomes after POEM for esophageal achalasia with a minimum median follow-up duration of 36 months. Pooled rates of clinical success and postoperative reflux were calculated and compared with the same values at 12/24/36 months when available. Subgroup analyses were performed to explore the interstudy heterogeneity. RESULTS From 1528 initial records, 11 studies (2017-2021) were included. A total of 2342 patients (age 48.1 [SD 6.8] years; 50.1 % males) with a median follow-up of 48 months (interquartile range 45-60) were analyzed. The pooled clinical success rate was 87.3 % (95 %CI 83.6 %-91.0 %; I2 = 73.1 %). The symptomatic reflux pooled rate was 22.0 % (95 %CI 14.4 %-29.5 %; I2 = 92.7 %). Three cases of peptic strictures and one Barrett's esophagus were reported. The pooled rate of severe adverse events was 1.5 % (95 %CI 0.5 %-2.5 %; I2 = 52.8 %). CONCLUSIONS Long-term clinical efficacy of POEM persisted in 87 % of patients with achalasia. Post-POEM symptomatic reflux remained stable over time. The risk for Barrett's esophagus and peptic strictures appeared minimal.
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Affiliation(s)
- Edoardo Vespa
- Department of Gastroenterology and Hepatology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Gaia Pellegatta
- Department of Gastroenterology and Hepatology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | - Marco Spadaccini
- Department of Gastroenterology and Hepatology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Harsh Patel
- Department of Internal Medicine, Ochsner Clinic Foundation, New Orleans, Louisiana, United States
| | - Roberta Maselli
- Department of Gastroenterology and Hepatology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Piera A Galtieri
- Department of Gastroenterology and Hepatology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Elisa Carlani
- Department of Gastroenterology and Hepatology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Prateek Sharma
- Department of Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, Missouri, United States
| | - Cesare Hassan
- Department of Gastroenterology and Hepatology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Alessandro Repici
- Department of Gastroenterology and Hepatology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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Achalasia as an Unusual Cause of Acute Cellular Rejection of a Transplanted Heart. Case Rep Cardiol 2022; 2022:2054727. [PMID: 36254142 PMCID: PMC9569230 DOI: 10.1155/2022/2054727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 09/19/2022] [Indexed: 11/18/2022] Open
Abstract
A 68-year-old female with end-stage heart failure presented to the hospital for heart transplant. She was diagnosed with achalasia 14 months prior and treated with frequent botulinum toxin injections. She underwent orthotopic heart transplant on the day of admission and was extubated a few days later. She developed intractable nausea and vomiting. Her first endomyocardial biopsy revealed moderate, approaching severe rejection. She was treated with high-dose intravenous pulse steroids. Fluoroscopy at the time of follow-up biopsy showed undigested pills in her esophagus with narrowing at the distal end and thus failure to deliver immunosuppressive therapy. This case highlights achalasia as an etiology for acute rejection and its potential management.
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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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Redo laparoscopic Heller myotomy and Dor fundoplication versus rescue peroral endoscopic myotomy for esophageal achalasia after failed Heller myotomy: a single-institution experience. Surg Today 2021; 52:401-407. [PMID: 34535816 DOI: 10.1007/s00595-021-02376-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/06/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To compare the surgical outcomes of redo laparoscopic Heller-Dor procedure and rescue peroral endoscopic myotomy for patients with failed Heller myotomy. METHODS We identified patients who had undergone redo laparoscopic Heller-Dor procedure or rescue peroral endoscopic myotomy from August 1996 to September 2019 and assessed the patients' characteristics, timed barium swallow results, symptom scores before/after surgery, surgical outcomes, and postoperative outcomes. RESULTS Eleven patients underwent redo laparoscopic Heller-Dor procedure, and 14 underwent rescue peroral endoscopic myotomy. Blood loss (p = 0.001) and intraoperative complications rate (p = 0.003) were lower and the operative time (p > 0.001) and observation period (p = 0.009) shorter in patients who underwent rescue peroral endoscopic myotomy than in patients who underwent redo laparoscopic Heller-Dor procedure. Patients who underwent rescue peroral endoscopic myotomy had a higher rate of postoperative reflux esophagitis (p = 0.033) than those who underwent redo laparoscopic Heller-Dor procedure. After the interventions, the dysphagia symptoms were improved for both groups. Furthermore, both groups expressed satisfaction with their respective procedures. CONCLUSIONS Rescue peroral endoscopic myotomy was associated with better surgical outcomes than redo laparoscopic Heller-Dor for patients with failed Heller myotomy. However, rescue peroral endoscopic myotomy had higher rates of postoperative reflux esophagitis.
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Ieong K, Brown A, Yang J, Zhang X, Altieri MS, Spaniolas K, Pryor AD. The incidence of reintervention and reoperation following Heller myotomy across multiple indications. Surg Endosc 2021; 36:1619-1626. [PMID: 33733323 DOI: 10.1007/s00464-021-08357-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 02/04/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Achalasia is a debilitating primary esophageal motility disorder. Heller myotomy (HM) is a first-line therapy for the treatment of achalasia patients who have failed other modalities. Other indications for HM include diverticulum, diffuse esophageal spasm, and esophageal strictures. However, long-term outcomes of HM are unclear. This study aims to assess incidence of reintervention, either endoscopically or through minimally invasive or resectional procedures, in patients who underwent HM in New York State. METHODS The Statewide Planning and Research Cooperative System (SPARCS) administrative longitudinal database identified 1817 adult patients who underwent HM between 2000 and 2008 for achalasia, esophageal diverticulum, diffuse esophageal spasm, and esophageal strictures, based on ICD-9 and CPT codes. Through the use of unique identifiers, patients requiring reintervention were tracked up to 2016 (for at least 8 years follow-up). Primary outcome was incidence of subsequent procedures following HM. Secondary outcomes were time to reintervention and risk factors for reintervention. RESULTS Of the 1817 patients who underwent HM, 320 (17.6%) required subsequent intervention. Of the 320 patients, 234 (73.1%) underwent endoscopic reinterventions, 54 (16.9%) underwent minimally invasive procedures, and 32 (10%) underwent resectional procedures as their initial revisional intervention. Of the 234 patients who underwent endoscopic reintervention as their initial revisional procedure, only 40 (16.8%) required subsequent surgical procedures. Over a mean follow-up of 7.0 years, the mean time to a subsequent procedure was 4.3 ± 3.74 years. Reintervention rates after 10 years following HM for achalasia, diverticulum ,and other indication were 24.4%, 12.6%, and 37%, respectively. CONCLUSION The majority of HM reinterventions were managed solely by endoscopic procedures (60.6%). Heller myotomy remains an excellent procedure to prevent surgical reintervention for achalasia and diverticulum.
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Affiliation(s)
- Kelly Ieong
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA.
| | - Andrew Brown
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
| | - Jie Yang
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
| | - Xiaoyue Zhang
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
| | - Maria S Altieri
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
| | - Konstantinos Spaniolas
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
| | - Aurora D Pryor
- Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
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Kamal F, Ismail MK, Khan MA, Lee-Smith W, Sharaiha RZ, Sharma S, McDonough S, Tariq R, Marella HK, Khan Z, Heda RP, Tombazzi C, Howden CW, Adler DG. Efficacy and safety of peroral endoscopic myotomy in the management of recurrent achalasia after failed Heller myotomy: a systematic review and meta-analysis. Ann Gastroenterol 2021; 34:155-163. [PMID: 33654353 PMCID: PMC7903572 DOI: 10.20524/aog.2020.0563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 08/27/2020] [Indexed: 12/21/2022] Open
Abstract
Background Heller myotomy (HM) is an established treatment for achalasia but can fail in up to 10-20% of patients. Peroral endoscopic myotomy (POEM) may be an appropriate treatment for patients with failed HM. Methods We searched several databases to identify non-comparative studies evaluating the efficacy and/or safety of POEM after failed HM and comparative studies comparing the efficacy and/or safety of POEM in patients with and without prior HM. Outcomes assessed included clinical success, technical success, adverse events, post-treatment gastroesophageal reflux disease (GERD), and presence of esophagitis on endoscopy. We calculated weighted pooled rates with 95% confidence intervals (CI) for all outcomes in patients undergoing POEM with prior HM. We calculated pooled odds ratios with 95%CI to compare the outcomes between patients with and without previous HM who underwent POEM. Results We included 11 observational studies with 1205 patients. Weighted pooled rates (95%CI) for overall clinical success and technical success in patients with failed HM were 87% (81-91%) and 97% (94-99%), respectively. Weighted pooled rates (95%CI) for major adverse events, new-onset GERD and presence of esophagitis on endoscopy were 5% (2-10%), 33% (26-41%), and 38% (22-58%), respectively. There were no differences in clinical success, adverse events, post-treatment GERD and esophagitis between patients with and without previous HM. Conclusions POEM is safe and effective in patients with failed HM and should be considered in patients with recurrent achalasia after HM. Outcomes of POEM are comparable in patients with and without prior HM.
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Affiliation(s)
- Faisal Kamal
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, TN (Faisal Kamal, Mohammad K. Ismail, Claudio Tombazzi, Colin W. Howden)
| | - Mohammad K Ismail
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, TN (Faisal Kamal, Mohammad K. Ismail, Claudio Tombazzi, Colin W. Howden)
| | - Muhammad A Khan
- Division of Gastroenterology, University of Alabama at Birmingham, Birmingham, AL (Muhammad A. Khan)
| | - Wade Lee-Smith
- Mulford Medical Sciences Library, University of Toledo, Toledo, OH (Wade Lee-Smith)
| | - Reem Z Sharaiha
- Division of Gastroenterology, Weill Cornell Medical College, NY (Reem Z. Sharaiha)
| | - Sachit Sharma
- Department of Medicine, University of Toledo, Toledo, OH (Sachit Sharma)
| | - Stephanie McDonough
- Division of Gastroenterology, University of Utah, Salt Lake City, UT (Stephanie McDonough, Douglas G. Adler)
| | - Raseen Tariq
- Department of Medicine, Rochester General Hospital, Rochester, NY (Raseen Tariq)
| | - Hemnishil K Marella
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN (Hemnishil K. Marella)
| | - Zubair Khan
- Division of Gastroenterology, University of Texas-Houston, Houston, TX (Zubair Khan)
| | - Rajiv P Heda
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN (Rajiv P Heda), USA
| | - Claudio Tombazzi
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, TN (Faisal Kamal, Mohammad K. Ismail, Claudio Tombazzi, Colin W. Howden)
| | - Colin W Howden
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, TN (Faisal Kamal, Mohammad K. Ismail, Claudio Tombazzi, Colin W. Howden)
| | - Douglas G Adler
- Division of Gastroenterology, University of Utah, Salt Lake City, UT (Stephanie McDonough, Douglas G. Adler)
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Vosko S, Cohen DL, Neeman O, Matalon S, Broide E, Shirin H. Achalasia During Pregnancy: Proposed Management Algorithm Based on a Thorough Literature Review. J Neurogastroenterol Motil 2021; 27:8-18. [PMID: 33380552 PMCID: PMC7786086 DOI: 10.5056/jnm20181] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/30/2020] [Accepted: 11/10/2020] [Indexed: 12/15/2022] Open
Abstract
Fewer than 40 cases of achalasia occurring in pregnant woman have been reported in the literature. Given the rarity of achalasia during pregnancy, and the numerous treatment options that are available for achalasia in general, no guidelines exist for the management of achalasia during pregnancy. Diagnosis of new cases may be difficult as symptoms and physiological changes that occur during pregnancy may obscure the clinical presentation of achalasia. The management of achalasia in pregnancy is also challenging. Treatment decisions should be individualized for each case, considering both the welfare of the mother and the fetus. Since pregnant women suffering from achalasia represent a diagnostic and therapeutic challenge with complex maternal-fetal aspects to consider, we have reviewed the available literature on the subject and summarized current diagnostic and therapeutic options. Additionally, we present a management algorithm as a means to guide treatment of future cases. We recommend that a conservative approach should be adopted with bridging therapies performed until after delivery when definitive treatment of achalasia can be more safely performed.
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Affiliation(s)
- Sergei Vosko
- The Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir (Assaf Harofeh) Medical Center (associated with the Sackler School of Medicine, Tel Aviv University), Zerifin, Israel
| | - Daniel L Cohen
- The Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir (Assaf Harofeh) Medical Center (associated with the Sackler School of Medicine, Tel Aviv University), Zerifin, Israel
| | - Ortal Neeman
- Division of Maternal Fetal Medicine, Institute of Gynecology and Obstetrics, Assuta Hospital, Ashdod, Israel
| | - Shai Matalon
- The Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir (Assaf Harofeh) Medical Center (associated with the Sackler School of Medicine, Tel Aviv University), Zerifin, Israel
| | - Efrat Broide
- The Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir (Assaf Harofeh) Medical Center (associated with the Sackler School of Medicine, Tel Aviv University), Zerifin, Israel
| | - Haim Shirin
- The Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir (Assaf Harofeh) Medical Center (associated with the Sackler School of Medicine, Tel Aviv University), Zerifin, Israel
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Mendo R, Barreiro P, Rodrigues J, Félix C, O'Neill C, Carina I, Chivia J, Chagas C. Peroral Endoscopic Myotomy for Esophageal Achalasia in Portugal: Outcomes of the First Prospective Series. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 28:162-169. [PMID: 34056038 DOI: 10.1159/000511528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/16/2020] [Indexed: 11/19/2022]
Abstract
Background Peroral endoscopic myotomy (POEM) is an innovative achalasia treatment procedure that involves myotomy of the lower esophageal sphincter through a submucosal tunneling approach, combining the efficacy of surgical myotomy with the benefit of being a less invasive treatment. At this time, no data are available of POEM in Portugal. This study aimed to examine the safety and short-term outcomes of POEM in a Portuguese center. Methods Fifty POEM were performed on 49 consecutive patients at our institution between January 2017 and January 2020. A prospective study of a consecutive series of patients was conducted, including procedure time, myotomy location and length, adverse events and clinical success. An Eckardt score of ≤3 after POEM was deemed as a successful outcome. Gastroesophageal reflux disease (GERD) was evaluated based on symptoms and on upper endoscopy, which was performed at 3-6 months postoperatively to check for reflux esophagitis. Results POEM was successfully completed in all cases: 70% (n = 35) were naïve and 30% (n = 15) had previous treatments. The mean procedure time was 73.4 ± 22.6 min (range 45-125 min). There were no major adverse events. Minor adverse events were rare (8%), and there was no perioperative mortality. The Eckardt score significantly decreased from 6.9 ± 2.4 preoperatively to 0.5 ± 1.0 postoperatively (p < 0.05). Overall clinical success was documented in 98, 98 and 95.2% at 1, 3 and 6 months, respectively. These short-term outcomes after POEM were independent of previous treatments. Symptomatic GERD was seen in 22.4% of patients. Conclusions Our results confirm the safety and excellent short-term efficacy of POEM in a Portuguese center. This supports POEM as one of the first-line achalasia therapies in Portugal when performed by experienced operators.
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Affiliation(s)
- Rui Mendo
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
| | - Pedro Barreiro
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal.,Department of Gastroenterology, Hospital dos Lusíadas, Lisbon, Portugal
| | - José Rodrigues
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
| | - Catarina Félix
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
| | - Catarina O'Neill
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
| | - Iala Carina
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
| | - Joyce Chivia
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
| | - Cristina Chagas
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
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11
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Nurczyk K, Patti MG. Surgical management of achalasia. Ann Gastroenterol Surg 2020; 4:343-351. [PMID: 32724877 PMCID: PMC7382425 DOI: 10.1002/ags3.12344] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/03/2020] [Accepted: 04/13/2020] [Indexed: 12/17/2022] Open
Abstract
Esophageal achalasia is a primary esophageal motility disorder characterized by lack of peristalsis and by incomplete or absent relaxation of the lower esophageal sphincter in response to swallowing. The cause of the disease is unknown. The goal of treatment is to eliminate the functional outflow obstruction at the level of the gastroesophageal junction, therefore allowing emptying of the esophagus into the stomach. They include the laparoscopic Heller myotomy with partial fundoplication, pneumatic dilatation, and peroral endoscopic myotomy. Esophagectomy is considered as a last resort for patients who have failed prior therapeutic attempts. In this evidence and experience-based review, we will illustrate the technique and results of the surgical treatment of esophageal achalasia and compare it to the other available treatment modalities.
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Affiliation(s)
- Kamil Nurczyk
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNCUSA
- 2nd Department of General and Gastrointestinal Surgery, and Surgical Oncology of the Alimentary TractMedical University of LublinLublinPoland
| | - Marco G. Patti
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Department of MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
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12
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Life in a world with per oral endoscopic myotomy: The ever-changing landscape in management of achalasia. J Thorac Cardiovasc Surg 2020; 160:854-857. [PMID: 32387162 DOI: 10.1016/j.jtcvs.2020.01.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 12/25/2019] [Accepted: 01/19/2020] [Indexed: 11/20/2022]
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13
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Brewer Gutierrez OI, Moran RA, Familiari P, Dbouk MH, Costamagna G, Ichkhanian Y, Seewald S, Bapaye A, Cho JY, Barret M, Eleftheriadis N, Pioche M, Hayee BH, Tantau M, Ujiki M, Landi R, Invernizzi M, Yoo IK, Roman S, Haji A, Hedberg HM, Parsa N, Mion F, Fayad L, Kumbhari V, Agarwalla A, Ngamruengphong S, Sanaei O, Ponchon T, Khashab MA. Long-term outcomes of per-oral endoscopic myotomy in achalasia patients with a minimum follow-up of 4 years: a multicenter study. Endosc Int Open 2020; 8:E650-E655. [PMID: 32355884 PMCID: PMC7165007 DOI: 10.1055/a-1120-8125] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 01/27/2020] [Indexed: 12/15/2022] Open
Abstract
Background and study aims Per-oral endoscopic myotomy (POEM) is associated with a short-term clinical response of 82 % to 100 % in treatment of patients with achalasia. Data are limited on the long-term durability of the clinical response in these patients. The aim of this study was to determine the long-term outcomes of patients undergoing POEM for management of achalasia. Methods This was a retrospective multicenter cohort study of consecutive patients who underwent POEM for management of achalasia. Patients had a minimum of 4 years follow-up. Clinical response was defined by an Eckardt score ≤ 3. Results A total of 146 patients were included from 11 academic medical centers. Mean (± SD) age was 49.8 (± 16) years and 79 (54 %) were female. The most common type of achalasia was type II, seen in 70 (47.9 %) patients, followed by type I seen in 41 (28.1 %) patients. Prior treatments included: pneumatic dilation in 29 (19.9 %), botulinum toxin injection in 13 (8.9 %) and Heller myotomy in seven patients (4.8 %). Eight adverse events occurred (6 mucosotomies, 2 pneumothorax) in eight patients (5.5 %). Median follow-up duration was 55 months (IQR 49.9-60.6). Clinical response was observed in 139 (95.2 %) patients at follow-up of ≥ 48 months. Symptomatic reflux after POEM was seen in 45 (32.1 %) patients, while 35.3 % of patients were using daily PPI at 48 months post POEM. Reflux esophagitis was noted in 16.8 % of patients who underwent endoscopy. Conclusion POEM is a durable and safe procedure with an acceptably low adverse event rate and an excellent long-term clinical response.
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Affiliation(s)
| | - Robert A. Moran
- Department of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Pietro Familiari
- Digestive Endoscopy Unit – Gemelli University Hospital,Rome, Italy
| | - Mohamad H. Dbouk
- Division of gastroenterology and hepatology Johns Hopkins Hospital, Baltimore, United States
| | - Guido Costamagna
- Digestive Endoscopy Unit – Gemelli University Hospital,Rome, Italy
| | - Yervant Ichkhanian
- Division of gastroenterology and hepatology Johns Hopkins Hospital, Baltimore, United States
| | - Stefan Seewald
- Center of Gastroenterolgy Hirslanden Private Clinic Group Witellikerstrasse 40, 8032 Zürich
| | - Amol Bapaye
- Shivanand Desai Centre for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Centre, Pune, India
| | - Joo Young Cho
- Digestive Endoscopy Center, CHA Bundang Hospital, South Korea
| | | | | | - Mathieu Pioche
- Gastroenterology unit/unit of functional disease and digestive physiology, Edouard Herriot hospital, Lion, France
| | - Bu' Hussain Hayee
- Institute of Therapeutic Endoscopy, Kingʼs College Hospital NHS Foundation Trust, London, UK
| | - Marcel Tantau
- Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Michael Ujiki
- NorthShore University HealthSystem/University of Chicago Medical Center, Chicago, United States
| | - Rosario Landi
- Digestive Endoscopy Unit – Gemelli University Hospital,Rome, Italy
| | - Martina Invernizzi
- Center of Gastroenterolgy Hirslanden Private Clinic Group Witellikerstrasse 40, 8032 Zürich
| | - In Kyung Yoo
- Digestive Endoscopy Center, CHA Bundang Hospital, South Korea
| | - Sabine Roman
- Gastroenterology unit/unit of functional disease and digestive physiology, Edouard Herriot hospital, Lion, France
| | - Amyn Haji
- Institute of Therapeutic Endoscopy, Kingʼs College Hospital NHS Foundation Trust, London, UK
| | - H. Mason Hedberg
- NorthShore University HealthSystem/University of Chicago Medical Center, Chicago, United States
| | - Nasim Parsa
- Division of gastroenterology and hepatology Johns Hopkins Hospital, Baltimore, United States
| | - Francois Mion
- Gastroenterology unit/unit of functional disease and digestive physiology, Edouard Herriot hospital, Lion, France
| | - Lea Fayad
- Division of gastroenterology and hepatology Johns Hopkins Hospital, Baltimore, United States
| | - Vivek Kumbhari
- Division of gastroenterology and hepatology Johns Hopkins Hospital, Baltimore, United States
| | - Anant Agarwalla
- Division of gastroenterology and hepatology Johns Hopkins Hospital, Baltimore, United States
| | - Saowanee Ngamruengphong
- Division of gastroenterology and hepatology Johns Hopkins Hospital, Baltimore, United States
| | - Omid Sanaei
- Division of gastroenterology and hepatology Johns Hopkins Hospital, Baltimore, United States
| | - Thierry Ponchon
- Gastroenterology unit/unit of functional disease and digestive physiology, Edouard Herriot hospital, Lion, France
| | - Mouen A. Khashab
- Division of gastroenterology and hepatology Johns Hopkins Hospital, Baltimore, United States
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14
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Sediqi E, Tsoposidis A, Wallenius V, Axelsson H, Persson J, Johnsson E, Lundell L, Kostic S. Laparoscopic Heller myotomy or pneumatic dilatation in achalasia: results of a prospective, randomized study with at least a decade of follow-up. Surg Endosc 2020; 35:1618-1625. [DOI: 10.1007/s00464-020-07541-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/26/2020] [Indexed: 12/20/2022]
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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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16
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Pouyez C, Neshkova E, von Renteln D, Bouin M. Management of Esophageal Achalasia in Quebec. J Clin Med Res 2019; 11:682-689. [PMID: 31636782 PMCID: PMC6785282 DOI: 10.14740/jocmr3963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 09/12/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Esophageal achalasia is a defective relaxation of the lower esophageal sphincter with a loss of esophageal peristalsis causing dysphagia. Treatment can be Heller myotomy, pneumatic balloon dilation, Botox injections, peroral endoscopic myotomy (POEM) or medical. The main objective of the study was to measure the extent of post-treatment dysphagia depending on the type of treatment. METHODS This was a retrospective study conducted at the Centre Hospitalier de l'Universite de Montreal (CHUM) between 2011 and 2017. All patients with manometric diagnostic of achalasia in our department were included. Data were collected with the electronic health record and a standardized post-treatment telephone survey to evaluate the extent of dysphagia and the use of proton pump inhibitor (PPI). RESULTS A total of 169 patients were included. The most frequent treatments were Heller myotomy (60%), Botox injection (18%) and endoscopic balloon dilation (16%). There was a significant difference in the management of patients treated at the CHUM and outside the CHUM for the frequency of pneumatic dilation (28 vs. 7%; P = 0.001) and Heller myotomy (49 vs. 69%; P = 0.02). An Eckardt score ≤ 3 was found in 80% of patients. No significant score difference was found between the CHUM and outside CHUM groups or between the different treatments. The post-treatment use of PPI was of 49% and was not significantly different depending on the site or the type of treatment. CONCLUSION Heller myotomy stays the most frequent treatment, especially outside our tertiary center. The rate of post-treatment dysphagia is low no matter the treatment choice. The use of PPI stays frequent regardless of the management site or the type of treatment used.
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Affiliation(s)
- Catherine Pouyez
- Centre Hospitalier de l’Universite de Montreal (CHUM), 1051 Sanguinet St., Montreal, QC, Canada
| | - Elissaveta Neshkova
- Centre Hospitalier de l’Universite de Montreal (CHUM), 1051 Sanguinet St., Montreal, QC, Canada
| | - Daniel von Renteln
- Centre Hospitalier de l’Universite de Montreal (CHUM), 1051 Sanguinet St., Montreal, QC, Canada
| | - Mickael Bouin
- Centre Hospitalier de l’Universite de Montreal (CHUM), 1051 Sanguinet St., Montreal, QC, Canada
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17
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Ithurralde-Argerich J, Cuenca-Abente F, Faerberg A, Rosner L, Duque-Seguro C, Ferro D. Resection of the Gastroesophageal Junction and Roux-en-Y Reconstruction as a New Alternative for the Treatment of Recurrent Achalasia: Outcomes in a Short Series of Patients. J Laparoendosc Adv Surg Tech A 2019; 30:121-126. [PMID: 31161951 DOI: 10.1089/lap.2019.0300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Heller myotomy and laparoscopic fundoplication represents the best treatment option for esophageal achalasia, with effective short- and long-term success. However, treatment options in patients in whom primary surgery failed represent a real challenge. We present the resection of the gastroesophageal junction (GEJ) along with a Roux-en-Y reconstruction as a treatment alternative. Materials and Methods: We analyzed the course of 5 patients with achalasia undergoing the resection of the GEJ along with a Roux-en-Y reconstruction for recurrent dysphagia after Heller myotomy and fundoplication, with at least 1 year of follow-up. Symptoms questionnaire and minuted esophagogram before and after treatment were performed in all the patients. Results: Five patients underwent resection of the GEJ along with a Roux-en-Y reconstruction. All the patients had dysphagia and 60% had regurgitations. Eighty percent of the patients had more than one previous redo surgery and 100% had had multiple dilations. Preoperative contrast esophagram of 3 patients show Stage II disease (mild and mark dilated esophagus) and 2 patients with Stage III disease (one esophageal curve and severe dilation). Manometry confirmed the diagnosis. At a mean follow-up of 34 months, all the patients reported a marked improvement in dysphagia, with median overall satisfaction rating of 9 (range 7-10), no symptom of gastroesophageal reflux disease (GERD), and good esophageal emptying in the postoperative contrast esophagram. Conclusions: The resection of the GEJ and Roux-en-Y reconstruction is an excellent treatment for recurrent dysphagia after Heller myotomy. All the patients reported a marked improvement of their dysphagia. No symptoms of GERD were documented after the surgery. This procedure should be taken into account as an alternative to esophagectomy for recurrent dysphagia.
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Affiliation(s)
- Javier Ithurralde-Argerich
- Foregut Surgery Unit, Digestive Surgery Department, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Federico Cuenca-Abente
- Foregut Surgery Unit, Digestive Surgery Department, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Alejandro Faerberg
- Foregut Surgery Unit, Digestive Surgery Department, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Laura Rosner
- Foregut Surgery Unit, Digestive Surgery Department, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Camilo Duque-Seguro
- Foregut Surgery Unit, Digestive Surgery Department, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
| | - Diego Ferro
- Foregut Surgery Unit, Digestive Surgery Department, Hospital de Gastroenterología "Dr. Carlos Bonorino Udaondo," Ciudad Autónoma de Buenos Aires, Argentina
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18
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Yu YR, Rosenfeld EH, Chiou EH, Chumpitazi BP, Fallon SC, Brandt ML. High-resolution manometric guidance during laparoscopic Heller myotomy: Impact on quality of life and symptom severity for children with achalasia. J Pediatr Surg 2019; 54:1063-1068. [PMID: 30808541 DOI: 10.1016/j.jpedsurg.2019.01.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 01/27/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND High-resolution esophageal manometry (HREM) during laparoscopic Heller myotomy (LHM) with fundoplication for achalasia allows tailoring of myotomy length and wrap tightness. The purpose of this study is to quantify long-term postoperative symptom severity and quality of life using validated questionnaires. METHODS Children ≤18 years with achalasia who previously underwent LHM with intraoperative HREM from 2010 to 2017 were prospectively surveyed. Eckardt Symptom Score (ESS), Achalasia Severity Questionnaire (ASQ), Pediatric Quality of Life Inventory (PedsQL), and Pediatric GERD Symptom and Quality of Life (PGSQ) questionnaires were administered. Scores for historical controls were obtained from prior survey instrument validation studies as comparison. RESULTS Of 30 eligible patients, 12 (40%) completed the surveys. Mean age at time of surgery was 13 ± 3 years. Assessment was performed at least 10 months after surgery with mean time elapsed of 3.6 ± 2 years. Average premyotomy lower esophageal sphincter (LES) pressure, postmyotomy LES pressure, and postfundoplication LES pressure were 30 ± 10 mmHg, 14 ± 6 mmHg, and 18 ± 9, respectively. ESS (2.3/12), ASQ (39/100 ± 16), PGSQ (symptom: 0.6/4 ± 0.4, school: 0.4/4 ± 0.4), and overall PedsQL (82/100 ± 15) were similar to those of healthy historical controls. CONCLUSION Children with achalasia undergoing LHM with intraoperative HREM had sustained long-term symptom improvement and quality of life scores comparable to healthy patients. STUDY AND LEVEL OF EVIDENCE Retrospective, II.
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Affiliation(s)
- Yangyang R Yu
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Eric H Rosenfeld
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Eric H Chiou
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Bruno P Chumpitazi
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Sara C Fallon
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Mary L Brandt
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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19
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Di Corpo M, Farrell TM, Patti MG. Laparoscopic Heller Myotomy: A Fundoplication Is Necessary to Control Gastroesophageal Reflux. J Laparoendosc Adv Surg Tech A 2019; 29:721-725. [PMID: 31009312 DOI: 10.1089/lap.2019.0155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Achalasia is a rare esophageal motility disorder that causes progressive dysphagia and regurgitation. The aim of treatment for achalasia is to provide symptom relief by reducing esophageal outflow resistance by disrupting the muscles at the level of the esophagogastric junction to allow esophageal emptying by gravity. Methods: A review of the literature concerning laparoscopic treatment of esophageal achalasia. Results: Surgical myotomy with partial fundoplication is very effective in relieving symptoms, and is able to strike a balance between relief of symptoms and control of abnormal reflux. Conclusions: Since reflux of gastric contents into the aperistaltic esophagus can cause esophagitis, peptic strictures, Barrett's esophagus, and even esophageal carcinoma, the addition of a partial fundoplication is very important. The choice of partial fundoplication is based on surgeons' preference and expertise.
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Affiliation(s)
- Marco Di Corpo
- 1 Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Timothy M Farrell
- 1 Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Marco G Patti
- 1 Department of Surgery, University of North Carolina, Chapel Hill, North Carolina.,2 Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
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20
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Reintervention After Heller Myotomy for Achalasia: Is It Inevitable? Ann Thorac Surg 2019; 107:860-867. [DOI: 10.1016/j.athoracsur.2018.09.059] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 09/10/2018] [Accepted: 09/24/2018] [Indexed: 01/11/2023]
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21
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Bonifácio P, de Moura DTH, Bernardo WM, de Moura ETH, Farias GFA, Neto ACM, Lordello M, Korkischko N, Sallum R, de Moura EGH. Pneumatic dilation versus laparoscopic Heller's myotomy in the treatment of achalasia: systematic review and meta-analysis based on randomized controlled trials. Dis Esophagus 2019; 32:5149492. [PMID: 30380036 DOI: 10.1093/dote/doy105] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Achalasia is a primary esophageal motor disorder with a variety of causes. It is most common in Central and South America, where Chagas disease is endemic. In addition to the infectious etiology, achalasia can be idiopathic, autoimmune, or drug induced. It is an incurable, progressive condition that destroys the intramural nerve plexus, causing aperistalsis of the esophageal body and impaired relaxation of the lower esophageal sphincter. The literature on the treatment of achalasia comparing pneumatic dilation (PD) and laparoscopic Heller's myotomy (LHM) shows conflicting results. Therefore, a systemic review and meta-analysis are needed. A systematic review and meta-analysis of randomized controlled trials of PD and LHM, based on the preferred reporting items for systematic reviews and meta-analyses recommendations, was presented. The primary outcome was symptom remission based on the Eckardt score. Secondary outcomes were lower esophageal sphincter pressure (LESP), gastroesophageal reflux (GER), and perforation. A total of four studies were included in this analysis. The total number of patients was 404. Posttreatment symptom remission rates did not differ significantly between LHM and PD at 2 years (RD = 0.03, 95% CI [-0.05, 0.12], P = 0.62), or 5 years (RD = 0.13, 95% CI [-0.12, 0.39], P = 0.32). The posttreatment perforation rate was lower for LHM (RD = 0.04, 95% CI [-0.08, -0.01], P = 0.03). There was no significant difference in terms of LESP or GER. For the treatment of esophageal achalasia, LHM and PD were found to be similar in terms of their long-term efficacy, as well as in terms of the posttreatment GER rates. However, the perforation rate appears to be lower when LHM is employed.
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Affiliation(s)
- P Bonifácio
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - D T H de Moura
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - W M Bernardo
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - E T H de Moura
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - G F A Farias
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - A C M Neto
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - M Lordello
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - N Korkischko
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - R Sallum
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - E G H de Moura
- Gastroenterology Department, Endoscopy Unit, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
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22
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Chuah SK, Lim CS, Liang CM, Lu HI, Wu KL, Changchien CS, Tai WC. Bridging the Gap between Advancements in the Evolution of Diagnosis and Treatment towards Better Outcomes in Achalasia. BIOMED RESEARCH INTERNATIONAL 2019; 2019:8549187. [PMID: 30881999 PMCID: PMC6381566 DOI: 10.1155/2019/8549187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 01/02/2019] [Accepted: 01/20/2019] [Indexed: 02/05/2023]
Abstract
Over the past few decades, there was an encouraging breakthrough in bridging the gap between advancements in the evolution of diagnosis and treatment towards a better outcome in achalasia. The purpose of this review is to provide updated knowledge on how the current evidence has bridged the gap between advancements in the evolution of diagnosis and treatment of esophageal achalasia. The advent of high-resolution manometry and standardization based on the Chicago classification has increased early recognition of the disease. These 3 clinical subtypes of achalasia can predict the outcomes of patients, and the introduction of POEM has revolutionized the choice of treatment. Previous evidence has shown that laparoscopic Heller myotomy (LHM) and anterior fundoplication were considered the most durable treatments for achalasia. Based on the current evidence, POEM has been evolving as a promising strategy and is effective against all 3 types of achalasia, but the efficacy of POEM is based on short- and medium-term outcome studies from a limited number of centers. Types I and II achalasia respond well to POEM, LHM, and PD, while most studies have shown that type III achalasia responds better to POEM than to LHM and PD. In general, among the 3 subtypes of achalasia, type II achalasia has the most favorable outcomes after medical or surgical therapies. The long-term efficacy of POEM is still unknown. The novel ENDOFLIP measures the changes in intraoperative esophagogastric junction dispensability, which enables a quantitative assessment of luminal patency and sphincter distension; however, this technology is in its infancy with little data to date supporting its intraoperative use. In the future, identifying immunomodulatory drugs and the advent of stem cell therapeutic treatments, including theoretically transplanting neuronal stem cells, may achieve a functional cure. In summary, it is important to identify the clinical subtype of achalasia to initiate target therapy for these patients.
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Affiliation(s)
- Seng-Kee Chuah
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
| | - Chee-Sang Lim
- Department of Hepatology, Hospital Selayang, Lebuh Raya Selayang-Kepong, Batu Caves, Selangor, Malaysia
| | - Chih-Ming Liang
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
| | - Hung-I Lu
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 833 Kaohsiung, Taiwan
| | - Keng-Liang Wu
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
| | - Chi-Sin Changchien
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
| | - Wei-Chen Tai
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
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Whose patient is it? The path to multidisciplinary management of achalasia. J Surg Res 2018; 228:8-13. [DOI: 10.1016/j.jss.2018.02.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/20/2017] [Accepted: 02/22/2018] [Indexed: 02/06/2023]
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Arshava EV, Marchigiani RJ, Gerke H, El Abiad R, Weigel RJ, Parekh KR, Keech J. Per oral endoscopic myotomy: early experience and safety of a multispecialty approach. Surg Endosc 2018; 32:3357-3363. [PMID: 29349541 DOI: 10.1007/s00464-018-6056-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 01/11/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Per oral endoscopic myotomy (POEM) has gained increasing popularity for treating achalasia. A multidisciplinary approach may allow safe and early adoption of POEM into clinical practice. MATERIALS AND METHODS We performed a retrospective review of our initial POEM cases. All procedures were performed by a team of interventional gastroenterologist and thoracic surgeon. We analyzed demographics, comorbidities, achalasia subtypes, length of hospital stay, duration of surgery, morbidity, mortality, length of myotomy, preoperative and postoperative Eckardt scores. RESULTS Thirty-one consecutive patients underwent POEM during the 24-month period from January 2014 to December 2015. Eighteen patients (58%) had prior non-operative interventions. Average duration of follow-up was 9.6 months. Seventeen patients (66.8%) had follow-up of 12 months and longer. Average preoperative Eckardt score was 6.3 (3-10), median 6. Average postoperative Eckardt score was 1.4 (0-8), median 1, in 1 month and an average 2.2, median 1, in 1 year. Patients with type III achalasia were most refractory to treatment, while patients with type II had the best results. Average LOS was 1.3 days (1-5), median 1 day. Average DOS was 106 min (60-148), median 106. Average LOM was 13 cm (10-15), with median of 13 cm. We had one 30-day mortality secondary to coronary artery disease. Four patients had prior Heller myotomies and underwent a posterior myotomy during POEM, with outcomes similar to patients with no prior myotomy. CONCLUSIONS We demonstrated safety and efficiency of a multispecialty approach for achalasia with POEM with a low rate of complications.
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Affiliation(s)
- Evgeny V Arshava
- Division of Cardiothoracic Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Raffaele J Marchigiani
- Division of Cardiothoracic Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Henning Gerke
- Division of Gastroenterology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Rami El Abiad
- Division of Gastroenterology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Ronald J Weigel
- Division of Cardiothoracic Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Kalpaj R Parekh
- Division of Cardiothoracic Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - John Keech
- Division of Cardiothoracic Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA.
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Abstract
In 2008, a new treatment modality for esophageal achalasia was introduced—peroral endoscopic myotomy (POEM). POEM is a procedure performed endoscopically, which allows transection of the muscular fibers of the distal esophagus and of the lower esophageal sphincter. The procedure is therefore similar to a laparoscopic Heller myotomy without a fundoplication. Short-term studies have shown that POEM is very effective in relieving dysphagia and regurgitation, but concerns have been raised about the incidence of post-POEM gastroesophageal reflux. Prospective and randomized trials will be needed to determine the role of this new procedure in the treatment algorithm of esophageal achalasia.
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Affiliation(s)
- Daniel A. Kroch
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ian S. Grimm
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Rieder E, Asari R, Paireder M, Lenglinger J, Schoppmann SF. Endoscopic stent suture fixation for prevention of esophageal stent migration during prolonged dilatation for achalasia treatment. Dis Esophagus 2017; 30:1-6. [PMID: 28375470 DOI: 10.1093/dote/dow002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Indexed: 02/07/2023]
Abstract
The aim of this study is to compare endoscopic stent suture fixation with endoscopic clip attachment or the use of partially covered stents (PCS) regarding their capability to prevent stent migration during prolonged dilatation in achalasia. Large-diameter self-expanding metal stents (30 mm × 80 mm) were placed across the gastroesophageal junction in 11 patients with achalasia. Stent removal was scheduled after 4 to 7 days. To prevent stent dislocation, endoscopic clip attachment, endoscopic stent suture fixation, or PCS were used. The Eckardt score was evaluated before and 6 months after prolonged dilatation. After endoscopic stent suture fixation, no (0/4) sutured stent migrated. When endoscopic clips were used, 80% (4/5) clipped stents migrated (p = 0.02). Of two PCS (n = 2), one migrated and one became embedded leading to difficult stent removal. Technical adverse events were not seen in endoscopic stent suture fixation but were significantly correlated with the use of clips or PCS (r = 0.828, p = 0.02). Overall, 72% of patients were in remission regarding their achalasia symptoms 6 months after prolonged dilatation. Endoscopic suture fixation of esophageal stents but not clip attachment appears to be the best method of preventing early migration of esophageal stents placed at difficult locations such as at the naive gastroesophageal junction.
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Herbella FA, Moura EG, Patti MG. Achalasia 2016: Treatment Alternatives. J Laparoendosc Adv Surg Tech A 2017; 27:6-11. [DOI: 10.1089/lap.2016.0468] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Fernando A.M. Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil
| | - Eduardo G.H. Moura
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
| | - Marco G. Patti
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
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Crespin OM, Liu LWC, Parmar A, Jackson TD, Hamid J, Shlomovitz E, Okrainec A. Safety and efficacy of POEM for treatment of achalasia: a systematic review of the literature. Surg Endosc 2016; 31:2187-2201. [PMID: 27633440 DOI: 10.1007/s00464-016-5217-y] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 08/23/2016] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Peroral endoscopic myotomy (POEM) is a novel intervention for the treatment of achalasia, which combines the advantages of endoscopic access and myotomy. The purpose of this study was to perform a systematic review of the literature to evaluate the efficacy and safety of POEM. METHODS The systematic review was conducted following the PRISMA guidelines. Evidence-Based Medicine Reviews, Cochrane Central Register of Controlled Trials, Ovid MEDLINE (R) including in-process and non-indexed citations were searched for POEM studies using the keywords: esophageal achalasia, POEM, endoscopy, natural orifice surgery, laparoscopic Heller myotomy (LHM), and related terms. Eckardt score, lower esophageal sphincter (LES) pressure, and reported complications were the main outcomes. Two authors reviewed the search result independently. A third reviewer resolved all disagreements. Data abstraction was pilot-tested and approved by all authors. Data were examined for clinical, methodological, and statistical heterogeneity with the aim of determining whether evidence synthesis using meta- analysis was possible. RESULTS The search strategy retrieved 2894 citations. After removing duplicates and applying the exclusion criteria, 54 studies were selected for full-text review of which a total of 19 studies were considered eligible for further analysis. There were 10 retrospective and 9 prospective studies, including 1299 POEM procedures. No randomized control trial (RCT) was identified. Overall, the pre- and post-POEM Eckardt scores and LES pressure were significantly different. The most frequently reported complications were mucosal perforation, subcutaneous emphysema, pneumoperitoneum, pneumothorax, pneumomediastinum, pleural effusion, and pneumonia. The median follow-up was 13 months (range 3-24). CONCLUSION POEM is a safe and effective alternative for the treatment of achalasia. However, only short-term follow-up data compared with LHM are available. RCTs and long-term follow-up studies are needed to establish the efficacy and safety of POEM in the management of patients with achalasia.
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Affiliation(s)
- Oscar M Crespin
- Division of General Surgery, University Health Network, Toronto, ON, Canada. .,Department of Surgery, University of Toronto, Toronto, ON, Canada.
| | - Louis W C Liu
- Division of Gastroenterology, University Health Network, Toronto, ON, Canada
| | - Ambica Parmar
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Timothy D Jackson
- Division of General Surgery, University Health Network, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jemila Hamid
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Eran Shlomovitz
- Division of General Surgery, University Health Network, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of Interventional Radiology, University Health Network, Toronto, ON, Canada
| | - Allan Okrainec
- Division of General Surgery, University Health Network, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
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Andolfi C, Fisichella PM. Laparoscopic Heller Myotomy and Dor Fundoplication for Esophageal Achalasia: Technique and Perioperative Management. J Laparoendosc Adv Surg Tech A 2016; 26:916-920. [PMID: 27606723 DOI: 10.1089/lap.2016.0407] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Surgical correction of achalasia using laparoscopic Heller myotomy with Dor fundoplication is argued to be the gold standard treatment for patients with achalasia. The goal of this technical report is to illustrate our preferred approach to patients with achalasia and to provide the reader with a detailed description of our operative technique, its rationale, and our pre and postoperative management.
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Affiliation(s)
- Ciro Andolfi
- 1 Department of Surgery, University of Chicago , Chicago, Illinois
| | - P Marco Fisichella
- 2 Department of Surgery, Brigham and Women's Hospital , Boston VA, Boston, Massachusetts
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Ilczyszyn A, Hamaoui K, Cartwright J, Botha A. Intraoperative distensibility measurement during laparoscopic Heller's myotomy for achalasia may reduce the myotomy length without compromising patient outcome. Dis Esophagus 2016; 29:455-62. [PMID: 25765569 DOI: 10.1111/dote.12343] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Our study aimed to assess whether intraoperative esophagogastric junction (EGJ) distensibility measurement using the EndoFLIP EF325 catheter (Crospon Ltd., Galway, Ireland) could potentially be used to guide laparoscopic Heller's myotomy (LHM), potentially modifying the operation outcome and comparing this clinically to our previous technique of gastroscopic assessment. Following a full diagnostic assessment with manometry and endoscopy patients with achalasia were divided into two groups. A retrospective cohort of patients operated on between 2007 and 2010 had a gastroscopy-guided LHM (G-LHM) with a standardized myotomy of 8 cm on the esophagus and 3 cm on the stomach. From 2010, patients were prospectively studied with an EndoFLIP-guided LHM (E-LHM). The length of the myotomy was dictated by intraoperative distensibility monitoring of the EGJ. All patients with achalasia recorded Urbach quality of life scoring preoperatively and 6 months postoperatively. A further group of normal laparoscopic control patients (E-LC) without any esophageal pathology also underwent intraoperative EGJ distensibility monitoring. Thirty-eight patients took part, 15 in the E-LC group, 8 in G-LHM group and 15 in the E-LHM group. We revealed that patients with achalasia in the E-LHM group had a significantly smaller EGJ cross-sectional area and distensibility than the E-LC group. Myotomy and fundoplication increased the distensibility of the EGJ to a value greater than normal control patients. Patients in the G-LHM group had a standard myotomy of 11 cm; patients in the E-LHM group had a variable length myotomy of 6 cm (IQR 5.0-6.0). In both G-LHM and E-LHM groups, there was a significant improvement in patient's quality of life with no significant difference between the groups. Our study has shown that the EndoFLIP system was effective at measuring distensibility changes during LHM. LHM significantly increases the distensibility of the EGJ and also significantly improves patient symptoms. E-LHM may reduce the overall myotomy length, and this does not appear to compromise the clinical outcome.
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Affiliation(s)
- A Ilczyszyn
- Department of Upper GI Surgery, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - K Hamaoui
- Department of Surgery, Imperial College London, London, UK
| | - J Cartwright
- Department of Upper GI Surgery, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - A Botha
- Department of Upper GI Surgery, Guy's and St. Thomas' NHS Foundation Trust, London, UK
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31
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Abstract
Achalasia is a primary disorder of esophageal motility. It classically presents with dysphagia to both solids and liquids but may be accompanied by regurgitation and chest pain. The gold standard for the diagnosis of achalasia is esophageal motility testing with manometry, which often reveals aperistalsis of the esophageal body and incomplete lower esophageal sphincter relaxation. The diagnosis is aided by complimentary tests, such as esophagogastroduodenoscopy and contrast radiography. Esophagogastroduodenoscopy is indicated to rule out mimickers of the disease known as “pseudoachalasia” (eg, malignancy). Endoscopic appearance of a dilated esophagus with retained food or saliva and a puckered lower esophageal sphincter should raise suspicion for achalasia. Additionally, barium esophagography may reveal a dilated esophagus with a distal tapering giving it a “bird’s beak” appearance. Multiple therapeutic modalities aid in the management of achalasia, the decision of which depends on operative risk factors. Conventional treatments include medical therapy, botulinum toxin injection, pneumatic dilation, and Heller myotomy. The last two are defined as the most definitive treatment options. New emerging therapies include peroral endoscopic myotomy, placement of self-expanding metallic stents, and endoscopic sclerotherapy.
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Affiliation(s)
- Joseph T Krill
- Division of Gastroenterology, Hepatology, and Nutrition, Center for Swallowing and Esophageal Disorders, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rishi D Naik
- Division of Gastroenterology, Hepatology, and Nutrition, Center for Swallowing and Esophageal Disorders, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Center for Swallowing and Esophageal Disorders, Vanderbilt University Medical Center, Nashville, TN, USA
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Hamer PW, Holloway RH, Crosthwaite G, Devitt PG, Thompson SK. Update in achalasia: what the surgeon needs to know. ANZ J Surg 2016; 86:555-9. [DOI: 10.1111/ans.13497] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 01/06/2016] [Accepted: 01/19/2016] [Indexed: 01/15/2023]
Affiliation(s)
- Peter W. Hamer
- University of Adelaide Discipline of Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Richard H. Holloway
- Department of Gastroenterology and Hepatology; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Gary Crosthwaite
- Department of Surgery; The University of Melbourne; Parkville Victoria Australia
- Clinical Institute General Surgery and Gastroenterology Epworth Healthcare; Richmond Victoria Australia
| | - Peter G. Devitt
- University of Adelaide Discipline of Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Sarah K. Thompson
- University of Adelaide Discipline of Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
- University of South Australia; Adelaide South Australia Australia
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Hong D, Pescarus R, Khan R, Ambrosini L, Anvari M, Cadeddu M. Early clinical experience with the POEM procedure for achalasia. Can J Surg 2016; 58:389-93. [PMID: 26574830 DOI: 10.1503/cjs.017214] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Per oral endoscopic myotomy (POEM) is a viable alternative to standard Heller myotomy for surgical treatment of achalasia. Outcomes from the United States, Europe and Asia have been reported. We sought to report data after the initiation of POEM in a Canadian centre. METHODS We enrolled patients with achalasia in a research ethics board-approved pilot study. Surgeons learned the POEM procedure in a systematic manner that included visiting experts in POEM, practice in an animal laboratory and mentoring from POEM experts. Preoperative evaluation included manometry, 24-hour pH, barium swallow, endoscopy and Eckhardt Symptom Score. All patients underwent gastrograffin swallow on postoperative day 1. Patients were re-evaluated using the Eckhardt score on postoperative day 14. RESULTS Ten patients underwent POEM. Seven patients had previous endoscopic treatments: 6 had balloon dilatation and 1 had botulinum toxin injection. Mean preoperative Eckhardt score was 8.1 ± 2.4. Mean preoperative lower esophageal sphincter resting and residual pressure was 32.3 ± 9.2 and 20.8 ± 5.3, respectively. Mean duration of surgery was 141.3 ± 43.7 minutes. Mean length of hospital stay was 1 day. No major perioperative complications occurred. On postoperative day 14, the mean Eckhardt score was 1 ± 1.2. CONCLUSION Our approach to POEM introduction was systematic and deliberate. The procedure is safe, feasible and has good perioperative outcomes. Our early results are consistent with current literature.
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Affiliation(s)
- Dennis Hong
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
| | - Radu Pescarus
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
| | - Rana Khan
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
| | - Luciano Ambrosini
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
| | - Mehran Anvari
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
| | - Margherita Cadeddu
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
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Persson J, Johnsson E, Kostic S, Lundell L, Smedh U. Treatment of achalasia with laparoscopic myotomy or pneumatic dilatation: long-term results of a prospective, randomized study. World J Surg 2015; 39:713-20. [PMID: 25409838 DOI: 10.1007/s00268-014-2869-4] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND This study compares the long-term results of pneumatic dilatations versus laparoscopic myotomy using treatment failure as the primary outcome. The frequency and degree of dysphagia, the effects on quality of life (QoL), and health economy were also examined. METHODS Fifty-three patients with achalasia were randomized to laparoscopic myotomy with a posterior partial fundoplication [laparoscopic myotomy (LM) n = 25] or repetitive pneumatic dilatation [pneumatic dilatation (PD) n = 28]. The median observation period was 81.5 months (range 12-131). RESULTS At the minimal follow-up of 5 years, ten patients (36%) in the dilatation group and two patients (8%) in the myotomy group, including two patients lost to follow-up (one in each arm), were classified as failures (p = 0.016). The cumulative incidence of treatment failures was analyzed by survival statistics. Taking the entire follow-up period into account, a significant difference was observed in favor of the LM strategy (p = 0.02). Although both treatments resulted in significant improvements in dysphagia scores, LM was significantly favored over PD after 1 and 3 years, but not after 5 years. Health-related QoL assessed by the personal general well being score was higher in the LM group after 3 years, but the difference was not fully statistically significant at 5 years. Direct medical costs during the entire follow-up period were in median $13,421 for LM as compared to $5,558 for PD (p = 0.001). CONCLUSIONS This long-term follow-up of a randomized clinical study shows that LM is superior to repetitive PD treatment of newly diagnosed achalasia, albeit that this surgical strategy is burdened by high initial direct medical costs. www.ClinicalTrials.gov NCT 02086669.
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Affiliation(s)
- Jan Persson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital, Sahlgrenska Academy at the University of Gothenburg, 41345, Gothenburg, Sweden,
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Ren Y, Tang X, Zhi F, Liu S, Wu J, Peng Y, Jiang B, Gong W. A stepwise approach for peroral endoscopic myotomy for treating achalasia: from animal models to patients. Scand J Gastroenterol 2015; 50:952-958. [PMID: 25861971 DOI: 10.3109/00365521.2014.983152] [Citation(s) in RCA: 5] [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] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Peroral endoscopic myotomy (POEM) was initially developed for the treatment of achalasia. This study aimed to investigate the feasibility and safety of a stepwise approach for POEM in the management of achalasia. METHODS A total of five ex-vivo porcine esophagus-stomach training models were created and POEM was performed. Then, 25 patients with achalasia were treated similarly. The Eckardt score, barium esophagrams, and high-resolution manometry were used to evaluate its efficacy. RESULTS POEM procedures were completed in five stomach-esophagus models, with perforations in the initial three and success in the last two. A total of 25 achalasia patients (13 males, 12 females) with achalasia successfully underwent POEM. The mean operation time was 72.0 min (range, 45-180 min). There were two complications--one case each of severe bleeding and pneumothorax--that were both treated successfully. During the follow-up period, the median Eckardt score decreased dramatically from 8 to 1 (p = 0.000). The lower basal esophageal sphincter pressure decreased markedly (41.3 ± 12.6 vs. 11.3 ± 4.3 mmHg, p = 0.000), as well as the 4-s integrated relaxation pressure (37.1 ± 12.6 vs. 7.1 ± 2.4 mmHg, p = 0.000). Additionally, the maximum esophagus width was significantly reduced (mean reduced width: 1.6 ± 1.1 cm, p = 0.000). CONCLUSIONS The ex-vivo porcine esophagus-stomach can be used as a simple and cheap training model that mimics the POEM procedure. POEM is a safe and effective therapy for achalasia patients.
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Affiliation(s)
- Yutang Ren
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University , Guangzhou , China
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Luján-Sanchis M, Suárez-Callol P, Monzó-Gallego A, Bort-Pérez I, Plana-Campos L, Ferrer-Barceló L, Sanchis-Artero L, Llinares-Lloret M, Tuset-Ruiz JA, Sempere-Garcia-Argüelles J, Canelles-Gamir P, Medina-Chuliá E. Management of primary achalasia: The role of endoscopy. World J Gastrointest Endosc 2015; 7:593-605. [PMID: 26078828 PMCID: PMC4461934 DOI: 10.4253/wjge.v7.i6.593] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 01/28/2015] [Accepted: 02/09/2015] [Indexed: 02/05/2023] Open
Abstract
Achalasia is an oesophageal motor disorder which leads to the functional obstruction of the lower oesophageal sphincter (LES) and is currently incurable. The main objective of all existing therapies is to achieve a reduction in the obstruction of the distal oesophagus in order to improve oesophageal transit, relieve the symptomatology, and prevent long-term complications. The most common treatments used are pneumatic dilation (PD) and laparoscopic Heller myotomy, which involves partial fundoplication with comparable short-term success rates. The most economic non-surgical therapy is PD, with botulinum toxin injections reserved for patients with a higher surgical risk for whom the former treatment option is unsuitable. A new technology is peroral endoscopic myotomy, postulated as a possible non-invasive alternative to surgical myotomy. Other endoluminal treatments subject to research more recently include injecting ethanolamine into the LES and using a temporary self-expanding metallic stent. At present, there is not enough evidence permitting a routine recommendation of any of these three novel methods. Patients must undergo follow-up after treatment to guarantee that their symptoms are under control and to prevent complications. Most experts are in favour of some form of endoscopic follow-up, however no established guidelines exist in this respect. The prognosis for patients with achalasia is good, although a recurrence after treatment using any method requires new treatment.
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Inoue H, Sato H, Ikeda H, Onimaru M, Sato C, Minami H, Yokomichi H, Kobayashi Y, Grimes KL, Kudo SE. Per-Oral Endoscopic Myotomy: A Series of 500 Patients. J Am Coll Surg 2015. [PMID: 26206634 DOI: 10.1016/j.jamcollsurg.2015.03.057] [Citation(s) in RCA: 340] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND After the first case of per-oral endoscopic myotomy (POEM) at our institution in 2008, the procedure was quickly accepted as an alternative to surgical myotomy and is now established as an excellent treatment option for achalasia. This study aimed to examine the safety and outcomes of POEM at our institution. STUDY DESIGN Per-oral endoscopic myotomy was performed on 500 consecutive achalasia patients at our institution between September 2008 and November 2013. A review of prospectively collected data was conducted, including procedure time, myotomy location and length, adverse events, and patient data with short- (2 months) and long-term (1 and 3 years) follow-up. RESULTS Per-oral endoscopic myotomy was successfully completed in all patients, with adverse events observed in 3.2%. Two months post-POEM, significant reductions in symptom scores (Eckardt score 6.0 ± 3.0 vs 1.0 ± 2.0, p < 0.0001) and lower esophageal sphincter (LES) pressures (25.4 ± 17.1 vs 13.4 ± 5.9 mmHg, p < 0.0001) were achieved, and this persisted at 3 years post-POEM. Gastroesophageal reflux was seen in 16.8% of patients at 2 months and 21.3% at 3-year follow-up. CONCLUSIONS Per-oral endoscopic myotomy was successfully completed in all cases, even when extended indications (extremes of age, previous interventions, or sigmoid esophagus) were used. Adverse events were rare (3.2%), and there were no mortalities. Significant improvements in Eckardt scores and LES pressures were seen at 2 months, 1 year, and 3 years post-POEM. Based on our large series, POEM is a safe and effective treatment for achalasia; there are relatively few contraindications, and the procedure may be used as either first- or second-line therapy.
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Affiliation(s)
- Haruhiro Inoue
- Digestive Disease Center, Showa University, Northern Yokohama Hospital, Yokohama, Japan.
| | - Hiroki Sato
- Digestive Disease Center, Showa University, Northern Yokohama Hospital, Yokohama, Japan
| | - Haruo Ikeda
- Digestive Disease Center, Showa University, Northern Yokohama Hospital, Yokohama, Japan
| | - Manabu Onimaru
- Digestive Disease Center, Showa University, Northern Yokohama Hospital, Yokohama, Japan
| | - Chiaki Sato
- Digestive Disease Center, Showa University, Northern Yokohama Hospital, Yokohama, Japan
| | - Hitomi Minami
- Digestive Disease Center, Showa University, Northern Yokohama Hospital, Yokohama, Japan
| | - Hiroshi Yokomichi
- Division of Medicine, Graduate School Department of Interdisciplinary Research, University of Yamanashi, Yamanashi, Japan
| | | | - Kevin L Grimes
- Digestive Disease Center, Showa University, Koto Toyosu Hospital, Tokyo, Japan
| | - Shin-ei Kudo
- Digestive Disease Center, Showa University, Northern Yokohama Hospital, Yokohama, Japan
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Barkun A, Martel M, Mayrand S, Yaghoobi M. Response. Gastrointest Endosc 2015; 81:1058-9. [PMID: 25805491 DOI: 10.1016/j.gie.2014.12.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 12/21/2014] [Indexed: 02/08/2023]
Affiliation(s)
- Alan Barkun
- Division of Gastroenterology, Department of Epidemiology and Biostatistics and Occupational Health, McGill University Health Center, Montreal, Quebec, Canada
| | - Myriam Martel
- Division of Gastroenterology, McGill University Health Center, Montreal, Quebec, Canada
| | - Serge Mayrand
- Division of Gastroenterology, McGill University Health Center, Montreal, Quebec, Canada
| | - Mohammad Yaghoobi
- Division of Gastroenterology, McGill University Health Center, Montreal, Quebec, Canada
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Friedel D, Modayil R, Stavropoulos SN. Per-oral endoscopic myotomy: Major advance in achalasia treatment and in endoscopic surgery. World J Gastroenterol 2014; 20:17746-17755. [PMID: 25548473 PMCID: PMC4273125 DOI: 10.3748/wjg.v20.i47.17746] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 07/20/2014] [Accepted: 12/01/2014] [Indexed: 02/06/2023] Open
Abstract
Per-oral endoscopic myotomy (POEM) represents a natural orifice endoscopic surgery (NOTES) approach to laparoscopy Heller myotomy (LHM). POEM is arguably the most successful clinical application of NOTES. The growth of POEM from a single center in 2008 to approximately 60 centers worldwide in 2014 with several thousand procedures having been performed attests to the success of POEM. Initial efficacy, safety and acid reflux data suggest at least equivalence of POEM to LHM, the previous gold standard for achalasia therapy. Adjunctive techniques used in the West include impedance planimetry for real-time intraprocedural luminal assessment and endoscopic suturing for challenging mucosal defect closures during POEM. The impact of POEM extends beyond the realm of esophageal motility disorders as it is rapidly popularizing endoscopic submucosal dissection in the West and spawning offshoots that use the submucosal tunnel technique for a host of new indications ranging from resection of tumors to pyloromyotomy for gastroparesis.
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40
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Kim DH, Jung HY. The long-term outcome of balloon dilation versus botulinum toxin injection in patients with primary achalasia. Korean J Intern Med 2014; 29:727-9. [PMID: 25378969 PMCID: PMC4219960 DOI: 10.3904/kjim.2014.29.6.727] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 10/27/2014] [Indexed: 01/27/2023] Open
Affiliation(s)
- Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Cai MY, Zhou PH, Yao LQ, Xu MD, Zhong YS, Li QL, Chen WF, Hu JW, Cui Z, Zhu BQ. Peroral endoscopic myotomy for idiopathic achalasia: randomized comparison of water-jet assisted versus conventional dissection technique. Surg Endosc 2014; 28:1158-65. [PMID: 24232052 DOI: 10.1007/s00464-013-3300-1] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 08/30/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) has recently been introduced as a promising alternative to laparoscopic Heller myotomy for idiopathic achalasia. Several proposed technical modifications are yet to be tested in randomized trials. OBJECTIVE The objective of our study was to evaluate efficacy and safety of water-jet (WJ) assisted POEM versus the conventional (C) technique. The clinical trial registration number is NCT01742494. METHODS A prospective randomized trial was carried out in Zhongshan Hospital, Fudan University (Shanghai, China), in 100 consenting achalasia patients between August 2011 and April 2012. Patients eligible for POEM were randomized to use of either the HybridKnife (WJ group) or the conventional technique using injection and triangle tip knife interchangeably (C group). RESULTS A total of 100 patients with comparable characteristics between groups were included. Procedure time was significantly shorter for the WJ group (22.9 ± 6.7 vs. 35.9 ± 11.7 min; p < 0.0001), mostly due to less replacement of accessories (2.0 ± 2.4 vs. 19.2 ± 7.6; p < 0.0001). Injection volume was larger in the WJ group (45.3 ± 10.2 vs. 35.2 ± 9.5 ml; p < 0.0001) and was associated with fewer minor bleeding episodes (3.6 ± 1.8 vs. 6.8 ± 5.2; p < 0.0001). No severe complications occurred; one case of cutaneous emphysema occurred in the WJ group, and four cases occurred in the C group (p = 0.17), three cases of pneumonia were encountered in the C group and none in the WJ group (p = 0.24). Treatment success (Eckardt score ≤3) was achieved in 96.5 % of patients, with no significant differences between groups. CONCLUSIONS The use of the HybridKnife leads to a significant decrease in POEM procedure time and facilitates reinjection, possibly contributing to a lower rate of minor intra-procedural bleeding.
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Wang J, Tan N, Xiao Y, Chen J, Chen B, Ma Z, Zhang D, Chen M, Cui Y. Safety and efficacy of the modified peroral endoscopic myotomy with shorter myotomy for achalasia patients: a prospective study. Dis Esophagus 2014; 28:720-7. [PMID: 25214469 DOI: 10.1111/dote.12280] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Peroral endoscopic myotomy (POEM) has been developed as a minimally invasive endoscopic treatment for achalasia for years. However, the optimal length of submucosal tunnel and myotomy of muscle bundles during procedure of POEM has not yet been determined, so we aim to assess safety and efficacy of modified POEM with shorter myotomy of muscle bundles in achalasia patients. Consecutive achalasia patients had been performed modified POEM with shorter myotomy, and assessed by symptoms, high-resolution manometry, and barium swallow examinations before and 3 months after POEM for safety and efficacy evaluation. Modified POEM with shorter submucosal tunnel (mean length 6.8 cm) and endoscopic myotomy of muscle bundles (total mean length 5.4 cm) were completed in 46 consecutive achalasia patients. During the 3-month follow up in all cases, significant improvement of symptoms (a significant drop in the Eckardt score 8.4 ± 3.2 vs. 2.7 ± 1.9; P < 0.001), decreased lower esophageal sphincter pressure (39.4 ± 10.1 vs. 24.4 ± 9.1 mmHg; P < 0.001) and integrated relaxation pressure (38.6 ± 10.4 vs. 25.7 ± 9.6 mmHg; P < 0.01), and a drop in height of esophagus barium-contrast column (5.4 ± 3.1 vs. 2.6 ± 1.8 cm; P < 0.001) were observed. The frequencies of adverse events were lower in those under endotracheal anesthesia and CO2 insufflations compared with intravenous anesthesia and air insufflations. Only three patients were found to have gastroesophageal reflux disease on follow up. Modified POEM with shorter myotomy under endotracheal anesthesia and CO2 insufflations shows its good safety and excellent short-term efficacy in the treatment of achalasia. But further studies are warranted to assess the long-term efficacy.
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Affiliation(s)
- J Wang
- Department of Gastroenterology and Hepatology, and Endoscopy Center, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - N Tan
- Department of Gastroenterology and Hepatology, and Endoscopy Center, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Y Xiao
- Department of Gastroenterology and Hepatology, and Endoscopy Center, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - J Chen
- Department of Gastroenterology and Hepatology, and Endoscopy Center, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - B Chen
- Department of Gastroenterology and Hepatology, and Endoscopy Center, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Z Ma
- Digestive Department, Shantou Central Hospital, Shantou, Guangdong, China
| | - D Zhang
- Digestive Department, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - M Chen
- Department of Gastroenterology and Hepatology, and Endoscopy Center, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Y Cui
- Department of Gastroenterology and Hepatology, and Endoscopy Center, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
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Chen X, Li QP, Ji GZ, Ge XX, Zhang XH, Zhao XY, Miao L. Two-year follow-up for 45 patients with achalasia who underwent peroral endoscopic myotomy. Eur J Cardiothorac Surg 2014; 47:890-6. [PMID: 25193955 DOI: 10.1093/ejcts/ezu320] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 06/19/2014] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Achalasia is an oesophageal disorder characterized by abnormalities of peristalsis and impaired swallowing-induced relaxation. The therapeutic approach at present remains palliative. Peroral endoscopic myotomy (POEM) is thought to be less invasive and to maintain the function of the lower oesophageal sphincter postoperatively. However, the effects of POEM still need to be evaluated and understood. METHODS We analysed the outcome for 45 achalasia patients who underwent POEM in our centre, described the details of surgery and evaluated the effects by 4 s integrated relaxation pressure (4s-IRP). All patients were followed up for at least 2 years and were assessed by the dysphagia score, the Eckardt score, oesophageal manometry and the gastro-oesophageal reflux disease (GERD) Q-questionnaire. According to the new Chicago classification of oesophageal motility using high-resolution manometry, the patients were diagnosed and classified into types I, II and III. RESULTS The average age of the patients was 46.32 ± 19.04 years (range 26-72 years), and the ratio of women to men was 1.81. All patients were suffering from dysphagia; more than half of them experienced regurgitation. The data revealed that POEM considerably reduced the 4s-IRP, dysphagia score and Eckardt score postoperatively (all P < 0.05). The patients with type III achalasia had higher values of 4s-IRP than the others (type I, P = 0.025; type II, P = 0.022) before treatment and at 3 months after treatment (type I, P = 0.028; type II, P = 0.047). In type I patients, GERD symptoms were more likely to appear at 24 months after POEM than in type II and III patients (P = 0.001 and P < 0.001, respectively). CONCLUSIONS Peroral endoscopic myotomy provides definite relief of symptoms in these patients with achalasia and offers them long-term therapeutic benefit. Considering the risks of surgery, we believe that POEM is a better choice than surgery for achalasia patients and carries lower risk. However, our study is a preliminary exploration; therefore, larger-scale studies are needed for further research on POEM.
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Affiliation(s)
- Xia Chen
- The Medical Center for Digestive Diseases, the Second Affiliated Hospital of Nanjing Medical University, Digestive Endoscopy Institute, Nanjing Medical University, Nanjing, China
| | - Quan-Peng Li
- The Medical Center for Digestive Diseases, the Second Affiliated Hospital of Nanjing Medical University, Digestive Endoscopy Institute, Nanjing Medical University, Nanjing, China
| | - Guo-Zhong Ji
- The Medical Center for Digestive Diseases, the Second Affiliated Hospital of Nanjing Medical University, Digestive Endoscopy Institute, Nanjing Medical University, Nanjing, China
| | - Xian-Xiu Ge
- The Medical Center for Digestive Diseases, the Second Affiliated Hospital of Nanjing Medical University, Digestive Endoscopy Institute, Nanjing Medical University, Nanjing, China
| | - Xiu-Hua Zhang
- The Medical Center for Digestive Diseases, the Second Affiliated Hospital of Nanjing Medical University, Digestive Endoscopy Institute, Nanjing Medical University, Nanjing, China
| | - Xiang-Yang Zhao
- The Digestive Department, Lishui County People's Hospital, Nanjing, Jiangsu, China
| | - Lin Miao
- The Medical Center for Digestive Diseases, the Second Affiliated Hospital of Nanjing Medical University, Digestive Endoscopy Institute, Nanjing Medical University, Nanjing, China
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Zurita Macías Valadez LC, Pescarus R, Hsieh T, Wasserman L, Apriasz I, Hong D, Gmora S, Cadeddu M, Anvari M. Laparoscopic limited Heller myotomy without anti-reflux procedure does not induce significant long-term gastroesophageal reflux. Surg Endosc 2014; 29:1462-8. [DOI: 10.1007/s00464-014-3824-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 08/08/2014] [Indexed: 12/21/2022]
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Long-term outcome after laparoscopic myotomy for achalasia. J Thorac Cardiovasc Surg 2014; 147:730-6; Discussion 736-7. [DOI: 10.1016/j.jtcvs.2013.09.063] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 09/10/2013] [Accepted: 09/30/2013] [Indexed: 11/18/2022]
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Pasha SF, Acosta RD, Chandrasekhara V, Chathadi KV, Decker GA, Early DS, Evans JA, Fanelli RD, Fisher DA, Foley KQ, Fonkalsrud L, Hwang JH, Jue TL, Khashab MA, Lightdale JR, Muthusamy VR, Sharaf R, Saltzman JR, Shergill AK, Cash B. The role of endoscopy in the evaluation and management of dysphagia. Gastrointest Endosc 2014; 79:191-201. [PMID: 24332405 DOI: 10.1016/j.gie.2013.07.042] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 07/29/2013] [Indexed: 02/06/2023]
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Sayles M, Harrison L, McGlashan JA, Grant DG. Zenker's diverticulum complicating achalasia: a 'cup-and-spill' oesophagus. BMJ Case Rep 2013; 2013:bcr-2013-200702. [PMID: 24334471 DOI: 10.1136/bcr-2013-200702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 72-year-old woman presented with long-standing gastro-oesophageal reflux, regurgitation of swallowed food and worsening cervical dysphagia. Fluoroscopic barium oesophagography revealed a posterolateral pharyngeal pouch (Zenker's diverticulum (ZD)) complicating a 'cup and spill' oesophageal deformity with a smoothly tapered segment at the gastro-oesophageal junction. CT and high-resolution manometry confirmed that the underlying abnormality was a massively dilated oesophagus with aperistalsis and pan-oesophageal pressurisation, consistent with a diagnosis of oesophageal achalasia (type II). She underwent endoscopic stapled diverticulotomy, with good symptomatic relief. We discuss the aetiology of ZD, its management and the association here with oesophageal achalasia.
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Affiliation(s)
- Mark Sayles
- Department of Otolaryngology-Head and Neck Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
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48
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Per Oral Endoscopic Myotomy (POEM): Review of Current Techniques and Outcomes (Including Postoperative Reflux). CURRENT SURGERY REPORTS 2013. [DOI: 10.1007/s40137-013-0031-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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di Pietro M, Fitzgerald RC. Research advances in esophageal diseases: bench to bedside. F1000PRIME REPORTS 2013; 5:44. [PMID: 24167725 PMCID: PMC3790564 DOI: 10.12703/p5-44] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Over the last year, significant steps have been made toward understanding the pathogenesis of esophageal diseases and translating this knowledge to clinical practice. Gastroesophageal reflux disease (GERD) is the most common outpatient diagnosis in gastroenterology and has a high prevalence in the general population. As many as 40% of patients with GERD have incomplete response to medical therapy, and the pathophysiological mechanisms underlying lack of response are now better understood. Novel medical and minimally invasive interventions are available to optimize management of GERD. Esophageal cancer, regardless of the histological subtype, has among the worst survival statistics among all malignancies. Taking advantage of technological advances in genome sequencing, the mutational spectra in esophageal cancer are now emerging, offering novel avenues for targeted therapies. Early diagnosis is another strand for improving survival. While genome-wide association studies are providing insights into genetic susceptibility, novel approaches to early detection of cancer are being devised through the use of biomarkers applied to esophageal samples and as part of imaging technologies. Dysmotility and eosinophilic esophagitis are the differential diagnoses in patients with dysphagia. New pathophysiological classifications have improved the management of motility disorders. Meanwhile, exciting progress has been made in the endoscopic management of these conditions. Eosinophilic esophagitis is still a relatively new entity, and the pathogenesis remains poorly understood. However, it is now clear that an allergic reaction to food plays an important role, and dietary interventions as well as biologic agents to block the inflammatory cascade are novel, promising fields of clinical research.
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Friedel D, Modayil R, Iqbal S, Grendell JH, Stavropoulos SN. Per-oral endoscopic myotomy for achalasia: An American perspective. World J Gastrointest Endosc 2013; 5:420-427. [PMID: 24044040 PMCID: PMC3773853 DOI: 10.4253/wjge.v5.i9.420] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 08/06/2013] [Indexed: 02/05/2023] Open
Abstract
Achalasia is an uncommon esophageal motility disorder characterized by the selective loss of enteric neurons leading to absence of peristalsis and impaired relaxation of the lower esophageal sphincter. Per-oral endoscopic myotomy (POEM) is a novel modality for the treatment of achalasia performed by gastroenterologists and surgeons. It represents a natural orifice transluminal endoscopic surgery (NOTES) approach to Heller myotomy. POEM has the minimal invasiveness of an endoscopic procedure that can duplicate results of the surgical Heller myotomy. POEM is conceptually similar to a surgical myotomy without the inherent external incisions and post-operative care associated with surgery. Initial high success and low complications rates promise a great future for this technique. In fact, POEM has been successfully performed on patients with end-stage achalasia as an initial treatment reserving esophagectomy for those without good response. The volume of POEMs performed worldwide has grown exponentially. In fact, surgeons who have performed Heller myotomy have embraced POEM as the preferred intervention for achalasia. However, the niche of POEM remains to be defined and long term results are awaited. We describe our experience with POEM having performed the first POEM outside of Japan in 2009, the evolution of our technique, and give our perspective on its future.
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