Comparison of early outcomes and quality of life after laparoscopic Heller's cardiomyotomy to peroral endoscopic myotomy for treatment of achalasia

Current status of achalasia management: a review on diagnosis and treatment

BACKGROUND

Achalasia is a rare esophageal motility disorder that is characterized by loss of peristalsis and failure of relaxation of the lower esophageal sphincter (LES), particularly during swallowing. This review focuses on the diagnosis of esophageal motility disorders as defined by the Chicago Classification ver 3.0, and presents management options with regard to per-oral endoscopic myotomy (POEM) as the treatment of choice.

METHODS

A concise review of literature was performed for articles related to the management of achalasia, and this was contrasted with our institution's current practice.

RESULTS

Achalasia is still incompletely understood, and management is focused on establishing a proper diagnosis, and relieving the obstructive symptoms.

CONCLUSIONS

Achalasia should be considered when dysphagia is present, and not otherwise caused by an obstruction or inflammation, and when criteria is met as per the Chicago Classification ver 3.0. Lowering LES tone and disruption of LES can be accomplished by various methods, most notably pneumatic balloon dilatation and surgical myotomy. POEM has been gaining momentum as a first line therapy for achalasia symptoms, and can be considered an important tool for motility disorders of the esophagus.

Efficacy and safety of peroral esophageal myotomy vs laparoscopic Heller's myotomy for treatment of achalasia: A meta-analysis

AIM

to add convincing evidence to the best treatment of achalasia by comparing peroral esophageal myotomy (POEM) with laparoscopic Heller's myotomy (LHM) with regard to clinical efficacy and safety.

METHODS

The databases including PubMed, EMBASE, the Cochrane Library, Web of Science, CNKI and China Science and Technology Journal Database were fully searched for relevant articles published in Chinese and English form database inception to February 20, 2016. The data were analyzed using Review Manager version 5.3 software. To assess the variation across studies, heterogeneity was measured with the I² index and Q test.

RESULTS

Eight non-randomized comparative studies that included a total of 574 patients (245 in the POEM group and 329 in the LHM group) met our research criteria and were assessed. Meta-analysis results were showed as follows: (1) clinical effect: the POEM group had a better result than the LHM group (RR = 1.14, 95%CI: 1.02-1.27, P = 0.02) with high between-study homogeneity (P = 0.60, I² = 0%); (2) major complications: There was no difference between the POEM group and LHM group (RR = 1.16, 95%CI: 0.76-1.78, P = 0.49) with high between-study homogeneity (P = 0.43, I² = 0%); (3) all complications: No significant difference was detected between the POEM group and LHM group (RR = 0.99, 95%CI: 0.72-1.36, P = 0.94). Moderate heterogeneity existed among the included studies (P = 0.12, I² = 39%); (4) length of hospital stay: There was no statistical difference between the two groups (MD = -0.46, 95%CI: -1.09-0.16, P = 0.14) with high between-study heterogeneity (P = 0.0007, I² = 76%); (5) operative time: The outcome showed no significant difference between the POEM group and LHM group (MD = -35.45, 95%CI: -87.01-16.10, P = 0.18) with high heterogeneity (P < 0.00001, I² = 98%).

CONCLUSION

POEM is superior to LHM in terms of short-term clinical efficacy. It is still inconclusive on whether POEM is the best therapy for achalasia or not. Long-time follow-up studies are needed to solve this issue in the future.

DDW 2016 review: Advances in therapeutic upper gastrointestinal endoscopy

This is a review of the abstracts presented at Digestive Disease Week 2016, 21-24 May 2016 in San Diego, CA, USA, focusing on novel advances in therapeutic endoscopy of the upper gastrointestinal tract.

Peroral endoscopic myotomy achieves similar clinical response but incurs lesser charges compared to robotic heller myotomy

BACKGROUND/AIM

Several uncontrolled studies comparing peroral endoscopic myotomy (POEM) and Heller myotomy have demonstrated equivalent short-term efficacy and safety. However, no data exists rergarding the cost of POEM and how it compares to that of robotic Heller myotomy (RHM). The primary aim of this study was to compare the inpatient charges incurred in patients who underwent POEM or RHM for the treatment of achalasia.

PATIENTS AND METHODS

A retrospective single center review was conducted among 52 consecutive POEM patients (2012-2014) and 52 consecutive RHM patients (2009-2014). All RHM procedures included a Toupet fundoplication and were performed via a transabdominal approach. All POEM procedures were performed by a gastroenterologist in the endoscopy unit. Clinical response was defined by improvement of symptoms and decrease in Eckardt stage to ≤I. All procedural and facility charges were obtained from review of the hospital finance records.

RESULTS

There was no difference between POEM and RHM with regards to age, gender, symptom duration, achalasia subtype, manometry findings, or Eckardt symptom stage. There was no significant difference in the rate of adverse events (19.2% vs 9.6%, P = 0.26) or the length of stay (1.9 vs. 2.3, P = 0.18) between both groups. Clinical response rate of patients in the POEM groups was similar to that in the RHM group (94.3% vs. 88.5%, P = 0.48). POEM incurred significantly less total charges compared to LHM ($14481 vs. $17782, P = 0.02).

CONCLUSIONS

POEM when performed in an endoscopy unit was similar in efficacy and safety to RHM. However, POEM was associated with significant cost savings ($3301/procedure).

A Matched Comparison of Per Oral Endoscopic Myotomy to Laparoscopic Heller Myotomy in the Treatment of Achalasia

BACKGROUND

Per oral endoscopic myotomy (POEM) is increasingly utilized to treat patients with achalasia. Early results have demonstrated significant improvement of symptoms, but there are concerns about postoperative reflux. With only limited comparative data available, we sought to compare POEM to laparoscopic Heller myotomy (LHM) with partial fundoplication.

METHODS

This is a retrospective review of 42 POEM and 84 LHM patients undergoing primary myotomy for achalasia. Patients were matched by achalasia type, by Eckardt and dysphagia scores, and by quality of life (QOL) metrics. Analysis at 6-12-month follow-up evaluated these metrics, PPI use, pH, manometric, and endoscopic data.

RESULTS

We matched 25 patients with achalasia types I (6), II (13), and III (6). Follow-up was longer for LHM at 158.1 (36.5-272.9) weeks versus 36.2 (22.2-41.2) weeks (p = 0.001). Eckardt scores, QOL metrics, and dysphagia significantly improved in both groups. DeMeester scores and total percent time less than 4 were abnormal in both groups and comparable (p = 0.925 and p = 0.838). Esophagitis was seen in 53.4 % (POEM) and 31.6 % (LHM) (Yates' p = 0.91), and PPI use was equivalent at 36 %.

CONCLUSION

Early clinical outcomes are excellent with POEM and comparable to the standard of care LHM. Long-term follow-up is required as concerns for reflux persist.

Achalasia: A case report on its effect during surgical decision making for laparoscopic sleeve gastrectomy in the young morbidly obese patient

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Treatment of achalasia in addition to morbid obesity is multifactorial without a gold standard treatment plan for both.

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Surgical treatment in the young adult female needs to be thoroughly deliberated due to additional risk and lifestyle factors, such as pregnancy.

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While Heller myotomy is considered the gold standard treatment for achalasia, a POEM better spares the surgical architecture for a future bariatric surgery.

Introduction

Achalasia is a condition that occurs when the lower esophageal sphincter (LES) fails to properly relax, combined with slowing/failure of esophageal peristalsis. This is seen clinically by not allowing solids and liquids to pass easily into the stomach. Achalasia is not historically associated with morbid obesity, yet dual treatment of morbid obesity and achalasia is becoming more prominent due to the worldwide obesity epidemic.

Presentation of case

Achalasia is typically a disease that affects non-obese adults over the age of 55, which makes the discussion of this case report unique in that our patient is a 23 year-old woman who successfully underwent per-oral endoscopic myotomy (POEM) in preparation for a future laparoscopic sleeve gastrectomy. There is sparse literature on combining laparoscopic Heller myotomy (LHM) and partial fundoplication versus POEM with either restrictive or malabsorptive minimally invasive bariatric procedures.

Discussion

LHM and partial fundoplication have long been considered the gold standard surgical treatment for achalasia by disrupting both the longitudinal and circular muscle layers of the LES. The newer, less invasive, POEM technique will be compared to the gold standard LHM and Dor fundoplication in this uncharacteristically young morbidly obese achalasia patient. The decision to pursue a laparoscopic sleeve gastrectomy over a laparoscopic Roux-en-Y gastric bypass was multifactorial due to the patient's concerns regarding malabsorption of vitamins and nutrients in the event of a future pregnancy.

Conclusion

The patient has already undergone a POEM procedure, which was chosen to maintain the gastric fundus, cardia, and gastroesophageal junction (GEJ) architecture as opposed to a LHM with Dor fundoplication, which would have altered the anatomy, thus making a concomitant laparoscopic sleeve gastrectomy an unfeasible option.

High-resolution manometric subtypes as a predictive factor for the treatment of achalasia: A meta-analysis and systematic review

OBJECTIVE

To assess manometric subtypes as predictive factors for the treatment efficacies of pneumatic balloon dilatation (PBD) and laparoscopic Heller myotomy (LHM) in patients with achalasia.

METHODS

A systematic search of the Pubmed, Embase and Cochrane Library database was conducted to identify relevant publications on high-resolution manometric subtypes and different therapies for achalasia with predefined inclusion and exclusion criteria. Data on the success rates after PBD or LHM for different manometric subtypes were extracted. The pooled odds ratio (OR) and 95% confidence interval (CI) for different manometric subtypes were estimated using STATA 13.0.

RESULTS

In all, nine studies met the inclusion criteria. A total of 298 patients having achalasia receiving PBD and 429 undergoing LHM were included in the meta-analysis. The pooled OR between the subtypes of achalasia after PBD or LHM showed that the best and worse treatment outcomes were found in patients with type II and III achalasia, respectively (type I vs type II after PBD: OR 0.16, 95% CI 0.08-0.36, P = 0.000; type I vs type III after PBD: OR 3.64, 95% CI 1.55-8.53, P = 0.003; type II vs type III after PBD: OR 27.18, 95% CI 9.08-81.35, P = 0.000; type I vs type II after LHM: OR 0.26, 95% CI 0.12-0.56, P = 0.001; type I vs type III after LHM: OR 1.89, 95% CI 0.80-4.50, P = 0.148; type II vs type III after LHM: OR 6.86, 95% CI 2.72-17.28, P = 0.000).

CONCLUSION

Type II achalasia shows the best prognosis after PBD and LHM, while type III achalasia has the worst prognosis.

POEM, the Prototypical "New NOTES" Procedure and First Successful NOTES Procedure

Peroral endoscopic myotomy (POEM) was first performed in 2008 as a novel treatment of achalasia. It is now performed globally, demonstrating the evolution of the first successful natural orifice transluminal endoscopic surgery (NOTES) procedure. There is extensive data demonstrating the safety and efficacy of POEM, and now long-term data has emerged demonstrating that the efficacy is durable. POEM is also being used to successfully treat diffuse esophageal spasm (DES) and jackhammer esophagus. With jackhammer esophagus and DES, inclusion of the lower esophageal sphincter in the myotomy minimizes the risk of symptom development from iatrogenic ineffective esophageal motility.

Per Oral Endoscopic Myotomy for Achalasia: A Detailed Description of the Technique and Review of the Literature

Historically, the most robust outcomes in treatment of achalasia were seen with surgical myotomy. Per oral endoscopic myotomy (POEM) introduced an endoscopic method for creating a surgical myotomy. Thousands of cases of POEM have been performed; however, there is no standard technique, and the rates of clinical success and adverse events vary widely among centers. This article presents a detailed description of the POEM technique, including the rationale and potential pitfalls of the main variations, in the context of the international literature.

Peroral Endoscopic Myotomy for Treating Achalasia and Esophageal Motility Disorders

Peroral endoscopic myotomy (POEM) is the application of esophageal myotomy to the concept of natural orifice transluminal surgery (NOTES) by utilizing a submucosal tunneling method. Since the first case of POEM was performed for treating achalasia in Japan in 2008, this procedure is being more widely used by many skillful endosopists all over the world. Currently, POEM is a spotlighted, emerging treatment option for achalasia, and the indications for POEM are expanding to include long-standing, sigmoid shaped esophagus in achalasia, even previously failed endoscopic treatment or surgical myotomy, and other spastic esophageal motility disorders. Accumulating data about POEM demonstrate excellent short-term outcomes with minimal risk of major adverse events, and some existing long-term data show the efficacy of POEM to be long lasting. In this review article, we review the technical details and clinical outcomes of POEM, and discuss some considerations of POEM in special situations.