Peroral endoscopic myotomy (POEM) for esophageal achalasia

Submucosal tunneling endoscopic resection of esophageal submucosal tumors originating from the muscularis propria layer: A retrospective analysis

AIM: To evaluate the safety and efficacy of submucosal tunneling endoscopic resection (STER) for esophageal submucosal tumors (SMTs) originating from the muscularis propria layer.

METHODS: Between April 2012 and August 2013, 5 patients with esophageal SMTs originating from the muscularis propria layer were treated by STER. The key steps were as follows: (1) creating a submucosal tunnel to uncover the tumor; (2) resecting the tumor en bloc by endoscopic resection techniques; and (3) closing the mucosal incision site after the tumor was removed.

RESULTS: STER was successfully performed in all 5 cases (success rate: 100%). The mean tumor size was 1.6 cm (range, 1.0-2.5 cm). The mean procedure time was 108.6 min (range, 80-138 min). The average hospital stay was 5.8 d (range, 5-7 d). The mean number of clips used was 7 (5-9). Pathological diagnosis of the tumors was leiomyoma (4/5) and mesenchymal tumor (1/5) with lateral and basal resection margins free of tumor tissue. During the procedure, one patient developed subcutaneous emphysema, who recovered after conservative treatment. No residual or recurrent tumors were detected during the 6-mo (4 patients) and 12-mo (1 patient) follow-up period.

CONCLUSION: STER seems to be a safe and effective procedure for treatment of esophageal SMTs originating from the muscularis propria layer, but its indications need to be further investigated.

Submucosal tunneling endoscopic resection for submucosal tumors of the esophagogastric junction originating from the muscularis propria layer: a feasibility study (with videos)

BACKGROUND

The esophagogastric junction (EGJ) is a difficult location for endoscopic resection due to its narrow lumen and sharp angle. Potential increased risks of perforation and mediastinal infection exist, especially for submucosal tumors (SMTs) originating from the muscularis propria (MP) layer. We previously demonstrated the safety and efficacy of submucosal tunneling endoscopic resection (STER) for upper gastrointestinal SMTs, but the feasibility of STER for the removal of SMTs at the EGJ requires systematic investigation. The aim of the investigation was to evaluate the clinical impact of STER on the removal of SMTs at the EGJ.

METHODS

A prospective study was carried out which included a consecutive cohort of 57 patients who underwent STER for 57 SMTs of the EGJ originating from the MP layer between July 2010 and August 2012 in a single academic medical center. Adverse events, en bloc resection rate, and local recurrence were evaluated.

RESULTS

The average maximum diameter of the lesions was 21.5 mm (range 6-35 mm). The en bloc resection rate was 100 % (57/57). No delayed hemorrhage or severe adverse events occurred in any of the 57 patients following STER. No local recurrence and distant metastasis occurred during 24 months' follow-up. Less subcutaneous emphysema and pneumomediastinum absorption time (p = 0.005) occurred with CO2 versus air insufflations.

CONCLUSIONS

Our study showed that STER was safe and effective, provided accurate histopathologic evaluation, and was curative for SMTs of the deep MP layers at the EGJ. CO2 gas insufflation is recommended.

Advances in the treatment of achalasia

OPINION STATEMENT

Achalasia, although rare, remains one of the most commonly diagnosed disorders of esophageal motility. It results from an idiopathic loss of ganglion cells responsible for esophageal motility and relaxation of the lower esophageal sphincter (LES). As a result, patients present with worsening dysphagia to both liquids and solids and often suffer from significant regurgitation of retained food in the esophagus. When the diagnosis of achalasia is suspected, patients should undergo evaluation with esophageal motility testing, endoscopic examination, and contrast esophagram. Once the diagnosis of achalasia has been established, options for treatment rely on controlling patient symptoms. Medical options are available, but their effectiveness is inconsistent. Endoscopic options include injection of botulinum toxin, which can achieve good short-term results, and pneumatic balloon dilation (PBD), considered the most effective non-surgical option. Surgical options, including laparoscopic, open, or endoscopic myotomy, and provide long-lasting results. This chapter will review achalasia and the treatment options available.

Paediatric laparoscopic Heller's cardiomyotomy: a single centre series

BACKGROUND

The optimal management of oesophageal achalasia remains unclear in the paediatric population due to the rarity of the disease. This study reviews the institutional experience of the laparoscopic Heller's cardiomyotomy (HC) procedure and attempts to define the most appropriate treatment.

METHODS

A retrospective review of children undergoing HC at a single institution was performed. Demographics, pre-operative investigations, and interventions were reviewed. Post-operative outcomes and follow up were evaluated. Data is expressed as median (range).

RESULTS

Twenty-eight children were included (13 male, 15 female) whose median age was 13 (3.2-17.4) years. Nine children underwent a pre-operative oesophageal balloon dilatation (OBD) a median of 1(1-6) times. Others included botulinum toxin injection (n=1) and Nifedipine (n=1). All had a pre-operative upper gastrointestinal contrast series, and twenty-five had upper gastrointestinal endoscopy and manometry. All had laparoscopic HC with no conversions, and ten had a concomitant fundoplication. Post-operative intervention occurred in eight (28%) incorporating OBD (n=7), of whom four required a redo HC. One patient underwent a redo without intervening OBD. Follow-up was for a median of 0.83 (0-5) years with fourteen children discharged from surgical follow-up. Twenty-seven have thus far had a good outcome.

CONCLUSION

This study comprises the largest series of paediatric laparoscopic HC reported to date. It is effective with or without a fundoplication and is the best long term treatment modality available. OBD for persisting symptoms following HC may obviate the need for redo myotomy.

Achalasia

Achalasia is a rare motility disorder of the oesophagus characterised by loss of enteric neurons leading to absence of peristalsis and impaired relaxation of the lower oesophageal sphincter. Although its cause remains largely unknown, ganglionitis resulting from an aberrant immune response triggered by a viral infection has been proposed to underlie the loss of oesophageal neurons, particularly in genetically susceptible individuals. The subsequent stasis of ingested food not only leads to symptoms of dysphagia, regurgitation, chest pain, and weight loss, but also results in an increased risk of oesophageal carcinoma. At present, pneumatic dilatation and Heller myotomy combined with an anti-reflux procedure are the treatments of choice and have comparable success rates. Per-oral endoscopic myotomy has recently been introduced as a new minimally invasive treatment for achalasia, but there have not yet been any randomised clinical trials comparing this option with pneumatic dilatation and Heller myotomy.

Analysis of a learning curve and predictors of intraoperative difficulty for peroral esophageal myotomy (POEM)

BACKGROUND

Peroral esophageal myotomy (POEM) is an endoscopic surgical operation for achalasia. Here, we analyze a single-series POEM learning curve and examine which preoperative patient factors are predictive of operative difficulty.

METHODS

Two surgeons performed all POEM procedures conjointly. Nonlinear regression was used to determine the learning curve for procedure time. Preoperative patient characteristics were correlated with outcomes.

RESULTS

Thirty-six POEM procedures were performed. Total operative time did not decrease over the course of the series (mean 112 ± 36 min). Time required to complete the procedural steps of submucosal access and myotomy did decrease with experience, both exhibiting a "learning rate" of seven cases. The incidence of inadvertent mucosal perforations and the number of clips required both decreased with experience. Postoperative Eckardt scores at 1-year follow-up decreased over the course of the series. Prior endoscopic treatment, symptom duration, and esophageal width were all independently predictive of longer procedure time. Preoperative symptom duration was also positively associated with inadvertent mucosal perforation and the number of clips required.

CONCLUSIONS

In this series, overall procedure time did not decrease with experience and may not be an important marker of procedural skill for POEM. Prior endoscopic treatment, longer symptom duration, and esophageal dilatation may result in increased operative difficulty during POEM.

Endoscopic clip closure of gastrointestinal perforations, fistulae, and leaks

Development of endoscopic devices to close perforations has certainly revolutionized endoscopy. Immediate closure of perforations eliminates the need for surgery, which allows us to push the limits of endoscopic surgery from the mucosal plane to deep submucosal layers and eventually transmurally. The present article focuses on endoscopic closure devices, closure techniques, followed by a review of animal and clinical studies on endoscopic closure of perforations.

Endoscopic myotomy for achalasia

POEM is an effective treatment of functional manometric esophageal outflow obstructive disorders with excellent relief of dysphagia. Reflux rates seem to be similar to that seen with traditional Heller myotomy with fundoplication. The POEM technique provides a true surgical esophageal myotomy without incisional pain. As such, POEM represents the first truly practical application of natural orifice surgery.

Peroral endoscopic myotomy for achalasia

BACKGROUND

Treatment of achalasia is complicated by symptom recurrence and a significant risk for severe complications. Endoscopic myotomy was developed in the search for a highly efficacious treatment with lower risks. Since its introduction in 2010, several centers have adopted the technique and published excellent short-term results of open label series. Randomized trials with long-term endpoint comparing per-oral endoscopic myotomy (POEM) with the established treatments such as balloon dilation and surgical myotomy are now warranted, before POEM can be regarded as the routine clinical care for achalasia patients.

PURPOSE

This review describes the development, technical aspects, efficacy, and complications of POEM.

Peroral endoscopic myotomy for esophageal achalasia: clinical impact of 28 cases

BACKGROUND

The aim of the present study was to clarify the efficacy of peroral endoscopic myotomy (POEM) for esophageal achalasia.

PATIENTS AND METHODS

Twenty-eight esophageal achalasia patients who underwent POEM in our institution between August 2010 and October 2012 were enrolled. Under general anesthesia with tracheal intubation, initial incision was made on the anterior wall of the esophagus after submucosal injection. Submucosal tunnel was created and extended below the lower esophageal sphincter (LES) onto the gastric cardia. Subsequently, myotomy was done using triangle tip knife. After confirmation of smooth passage of scope through the esophagogastric junction, the entry was closed. Esophagogram and manometry study was done before and after the procedure. Also, subjective symptom score and Eckardt score were assessed before and 3 months after POEM.

RESULTS

POEM was successfully done in all cases without any severe complications such as perforation and mediastinitis.Mean procedure time was 99.1 min (range 61-160) and mean myotomy length was 14.4 cm (range 10-18). Significant improvement was achieved in both esophagogram and endoscopic findings. Mean LES pressure was 71.2 mmHg (35.8-119.0) and 21.0 mmHg (6.7-41.0) before and after the procedure (P < 0.05), respectively. Mean Eckardt score was 6.7 (3-12, median 7) and 0.7 (0-3, median 1) before and 3 months after POEM, respectively (P < 0.05). Symptomatic gastroesophageal reflux disease that was easily controlled by the usual dose of proton pump inhibitor was seen in six cases (21.4%) after the procedure.

CONCLUSION

POEM could be a curative standard treatment of choice for esophageal achalasia.

Transcolonic peritoneoscopy by using submucosal endoscopy with mucosal flap for the detection of peritoneal bead targeting in the porcine survival model: a feasibility and effectiveness study

BACKGROUND

Staging peritoneoscopy is typically done by laparoscopy in the operating room. Natural orifice transluminal endoscopic surgery peritoneoscopy is an appealing alternative to the current approach. Transcolonic submucosal endoscopy with mucosal flap (SEMF) may provide natural orifice transluminal endoscopic surgery peritoneoscopy.

OBJECTIVE

The aim was to verify the feasibility and safety of transcolonic peritoneoscopy with SEMF (TCPS) in a porcine survival model.

DESIGN

Survival study.

SETTING

Animal research unit.

INTERVENTION

Seven target beads were placed in the peritoneal cavity by laparoscopy in each of 6 animals, and TCPS was performed to identify and touch beads to simulate biopsy. Animals were euthanized after 1 week, at which time, laparotomy was performed and the SEMF site was resected for histological analysis.

MAIN OUTCOME MEASUREMENTS

The number of beads identified and touched during peritoneoscopy, rate of successful completion of TCPS, procedure time, mortality equivalent 1 week after TCPS, adverse event rate, histological assessment of SEMF site.

RESULTS

All 7 beads in all 6 pigs were identified and touched during TCPS. The success rate of TCP was 100%. No major adverse events occurred during the procedure. The median procedure times for the creation of a submucosal tunnel, peritoneoscopy, closure of mucosal incision, and entire procedure were 19.5, 17, 9.5, and 45 minutes, respectively. All pigs survived until euthanasia, and there was no evidence of peritonitis or severe infection.

LIMITATIONS

Animal study, single endoscopist, small sample size.

CONCLUSION

Results of this study indicate that TCPS is feasible and safe in a porcine survival model.

Natural orifice transluminal endoscopic surgery and upper gastrointestinal tract

Since the first transgastric natural orifice transluminal endoscopic surgery was described, various applications and modified procedures have been investigated. Transgastric natural orifice transluminal endoscopic surgery for periotoneoscopy, cholecystectomy, and appendectomy all seem viable in humans, but additional studies are required to demonstrate their benefits and roles in clinical practice. The submucosal tunneling method enhances the safety of peritoneal access and gastric closure and minimizes the risk of intraperitoneal leakage of gastric air and juice. Submucosal tunneling involves submucosal tumor resection and peroral endoscopic myotomy. Peroral endoscopic myotomy is a safe and effective treatment option for achalasia, and the most promising natural orifice transluminal endoscopic surgery procedure. Endoscopic full-thickness resection is a rapidly developing natural orifice transluminal endoscopic surgery procedure for the upper gastrointestinal tract and can be performed with a hybrid natural orifice transluminal endoscopic surgery technique (combining a laparoscopic approach) to overcome some limitations of pure natural orifice transluminal endoscopic surgery. Studies to identify the most appropriate role of endoscopic full-thickness resection are anticipated. In this article, I review the procedures of natural orifice transluminal endoscopic surgery associated with the upper gastrointestinal tract.

Zenker's diverticulum complicating achalasia: a 'cup-and-spill' oesophagus

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.

[Peroral endoscopic full and partial-thickness myotomy. A viability study in an animal model]

BACKGROUND

Peroral endoscopic myotomy has recently been developed and performed on patients with good results.

AIMS

To evaluate the technical feasibility of peroral endoscopic full-thickness and partial thickness myotomy in a porcine model.

MATERIAL AND METHODS

Eighteen criollo pigs were randomly assigned to 2 groups: group A (partial-thickness myotomy) and group B (full-thickness myotomy). The mucosal defect proximal to the myotomy site was left open. On the seventh postoperative day the pig was euthanized and follow-up surgical exploration was performed. The duration of each procedure, postoperative progression of the animal, complications, and anatomopathologic findings were registered.

RESULTS

The procedure was viable in all the pigs. The mean surgery duration was 81±35.3min (group A 51.11±11.12, group B 111±22.61; P<.05). The main complication during myotomy was subcutaneous emphysema (16%). The histopathologic study of the group A surgical specimens reported complete circular myotomy in all cases, and complete circular and longitudinal myotomy was reported in 100% of the group B sample.

CONCLUSIONS

The endoscopic myotomy technique is feasible. Endoscopic partial-thickness myotomy was associated with shorter surgery duration and better results during the intraoperative period and the 7-day follow-up.

Laparoscopic Heller myotomy versus endoscopic balloon dilatation for the treatment of achalasia: a network meta-analysis

OBJECTIVE

Comparison of short- and long-term effects after laparoscopic Heller myotomy (LHM) and endoscopic balloon dilation (EBD) considering the need for retreatment.

BACKGROUND

Previously published studies have indicated that LHM is the most effective treatment for Achalasia. In contrast to that a recent randomized trial found EBD equivalent to LHM 2 years after initial treatment.

METHODS

A search in Medline, PubMed, and Cochrane Central Register of Controlled Trials was conducted for prospective studies on interventional achalasia therapy with predefined exclusion criteria. Data on success rates after the initial and repeated treatment were extracted. An adjusted network meta-analysis and meta-regression analysis was used, combined with a head-to-head comparison, for follow-up at 12, 24, and 60 months.

RESULTS

Sixteen studies including results of 590 LHM and EBD patients were identified. Odds ratio (OR) was 2.20 at 12 months (95% confidence interval: 1.18-4.09; P = 0.01); 5.06 at 24 months (2.61-9.80; P < 0.00001) and 29.83 at 60 months (3.96-224.68; P = 0.001). LHM was also significantly superior for all time points when therapy included re-treatments [OR = 4.83 (1.87-12.50), 19.61 (5.34-71.95), and 17.90 (2.17-147.98); P ≤ 0.01 for all comparisons) Complication rates were not significantly different. Meta-regression analysis showed that amount of dilations had a significant impact on treatment effects (P = 0.009). Every dilation (up to 3) improved treatment effect by 11.9% (2.8%-21.8%).

CONCLUSIONS

In this network meta-analysis, LHM demonstrated superior short- and long-term efficacy and should be considered first-line treatment of esophageal achalasia.

Peroral endoscopic myotomy for the treatment of achalasia in children

Peroral endoscopic myotomy (POEM) is a new endoscopic technique for the treatment of esophageal achalasia, with excellent results in adults. Three children with classic-type achalasia (mean age 9.6 years) underwent POEM in a single center. Mean basal lower esophageal sphincter pressure and Eckard score were 34.6 mmHg and 5.3, respectively. Mean length of myotomy was 10 cm. On average, POEM was completed in 60.6 minutes. No patients experienced postoperative complications or gastroesophageal reflux disease. In the 2 patients who completed a 12-month follow-up, complete symptoms relief was documented (Eckard score 0), as well as a significant drop of the basal lower esophageal sphincter pressure.

Peroral endoscopic myotomy: A short-term comparison with the standard laparoscopic approach

BACKGROUND

We report our short-term experience with peroral endoscopic myotomy (POEM) and compare perioperative outcomes with laparoscopic Heller myotomy (LHM) for achalasia.

METHODS

Patients from an institutional review board-approved protocol underwent POEM and were followed prospectively. Comparisons were made, in a prospective esophageal database, with patients who underwent LHM over the same period.

RESULTS

We studied 18 patients who underwent POEM and compared them to 21 who underwent LHM. Demographics, preoperative Eckardt scores, motility data, and prior intervention history were comparable. Operative time, myotomy length, and complication rates (1 perforation in each group) were equal. Postoperative pain was significantly different by visual analogue score (POEM 3.9 ± 0.6 versus LHM 5.7 ± 0.4, P = .02) and analgesic use (POEM 26.0 ± 13.7 versus LHM 90.0 ± 48.5 mg morphine, P = .02). Return to activities of daily living was significantly faster in the POEM group (2.2 ± 0.6 vs 6.4 ± 1.0 days, P = .03). Postoperative dysphagia and Eckardt scores were equally successful in both groups.

CONCLUSION

POEM results in similar relief of dysphagia with less postoperative pain and quicker return to normal activities.

Peroral esophageal myotomy (POEM) and laparoscopic Heller myotomy produce a similar short-term anatomic and functional effect

BACKGROUND

Peroral esophageal myotomy (POEM) differs from laparoscopic Heller myotomy (LHM) in that only the circular muscle layer of the esophagus is divided, the hiatus is not mobilized, and an antireflux procedure is not performed. The effect of these differences on anatomic and functional outcomes is unknown.

METHODS

Patients who underwent LHM or POEM and had both a pre- and postoperative timed barium esophagogram were selected for analysis. Timed barium esophagograms were performed with 200 mL of contrast, with radiographs taken at 1, 2, and 5 minutes.

RESULTS

A total o f 17 LHM and 12 POEM patients had undergone pre- and postoperative timed barium esophagograms. Both groups had decreased column heights postoperatively at 1, 2, and 5 minutes (LHM: pre, 15.6, 12.7, 11.3 cm vs post, 3.6, 2.5, 1.8 cm; P < .001 and POEM: pre, 14.7, 11, 9.4 cm vs post, 4.4, 2.5, 1.2 cm; P < .001). There was no difference between procedures in changes from baseline column height. Both operations resulted in decreased esophageal width and less angulation between the esophageal body and esophagogastric junction.

CONCLUSION

POEM and LHM produce a similar short-term anatomic and functional result at the esophagogastric junction. POEM results in a similar narrowing and straightening of the esophagus despite the fact that POEM does not involve hiatal mobilization.

Surgical treatment for achalasia of the esophagus: laparoscopic heller myotomy

Achalasia is an esophageal motility disorder that leads to dysphagia, chest pain, and weight loss. Its diagnosis is clinically suspected and is confirmed with esophageal manometry. Although pneumatic dilation has a role in the treatment of patients with achalasia, laparoscopic Heller myotomy is considered by many experts as the best treatment modality for most patients with newly diagnosed achalasia. This review will focus on the surgical treatment of achalasia, with special emphasis on laparoscopic Heller myotomy. We will also present a brief discussion of the evaluation of patients with persistent or recurrent symptoms after surgical treatment for achalasia and emerging technologies such as LESS, robot-assisted myotomy, and POEM.

Anesthetic management of peroral endoscopic myotomy for esophageal achalasia: a retrospective case series

Peroral endoscopic myotomy (POEM) is a newly developed, less invasive treatment for esophageal achalasia that requires general anesthesia under positive pressure ventilation. In this retrospective case series, we describe the anesthetic management of 28 consecutive patients who underwent POEM for esophageal achalasia. Anesthesia was maintained with sevoflurane and remifentanil under positive pressure ventilation through a tracheal tube. Retained contents in the esophagus were evacuated just before anesthesia induction to prevent regurgitation into the trachea. The POEM procedure was performed using an orally inserted flexible fiberscope. Elevation of end-tidal carbon dioxide after initiating esophageal carbon dioxide insufflation was observed in all patients and was treated by minute adjustments to the ventilation volume. Scopolamine butylbromide-induced tachycardia in one patient was treated with landiolol hydrochloride, which is a short-acting beta 1-selective blocker. Minor subcutaneous emphysema around the neck was observed in one patient. POEM was successfully completed, and tracheas were extubated immediately after the procedure in all patients. Our findings suggest that prevention of aspiration pneumonia during anesthesia induction, preparation for carbon dioxide insufflation-related complications, and treatment of scopolamine butylbromide-induced tachycardia play important roles in safe anesthesia management of POEM for esophageal achalasia.

Natural orifice transluminal endoscopic surgery (NOTES) for clinical management of intra-abdominal diseases

Clinical research on natural orifice transluminal endoscopic surgery (NOTES) has been increasingly reported over the past 5 years and more than 1200 patients have received various NOTES procedures. The present article reviews the clinical practice of NOTES for the treatment of intra-abdominal diseases, and was carried out through systematic search with specific keywords in major databases for NOTES-related clinical literature. The last date of the search was 15 August, 2012. Transvaginal cholecystectomy is the commonest NOTES procedure reported, and its clinical feasibility and safety was established through prospective case series and randomized trials. There is a regional difference in NOTES development with the majority of NOTES fromCaucasian countries being transvaginal cholecystectomy and most reports from Asian countries being NOTES-related procedures. Safe closure of gastrointestinal access remains challenging, and novel endoscopic instruments are essential to enhance future development of NOTES.

Peroral endoscopic myotomy for the treatment of achalasia: an analysis

Achalasia is a motility disorder of the esophagus, characterized by aperistalsis of the esophageal body and incomplete relaxation of the lower esophageal sphincter (LES). Treatment of achalasia is currently aimed at decreasing the resting pressure in the LES. Peroral endoscopic myotomy (POEM) is an emerging novel endoscopic procedure for the treatment of achalasia with initial data suggesting an acceptable safety profile, excellent short-term symptom resolution, low incidence of postprocedural gastroesophageal reflux (GER), and improvement in manometric outcomes. Further prospective randomized trials are required to evaluate the long-term effectiveness of this promising technique compared to other treatment modalities for achalasia. In this review we outline the technical aspects of POEM, summarize the available data on safety and outcomes, and suggest future directions for further advancement of this minimally invasive approach for the treatment of achalasia.

Novel diagnosis and treatment of esophageal granular cell tumor: report of 14 cases and review of the literature

BACKGROUND

Granular cell tumors (GCT), especially in the esophagus, are rare neoplasms originating from the nervous system. There is still some controversy regarding the diagnosis and treatment of esophageal GCT.

METHODS

We report 14 cases of esophageal GCT diagnosed and treated from January 2004 to March 2013. Their clinical manifestations, endoscopic image, endoscopic ultrasonography (EUS) appearance, pathology, immunohistochemistry, treatment, and prognosis were reviewed.

RESULTS

The typical images of EUS were hypoechoic, homogenous, and smooth-edged tumors restricted to deep mucosal and submucosal layers. However, there were 2 cases with tumors invading muscular layer. Endoscopic ultrasonography was valuable to assess the tumor size, location, depth of invasion, and nature. According to EUS manifestation, 11 cases with lesions 3 cm or less in diameter without muscular layer invasion underwent endoscopic resection without complication and the other 3 cases underwent surgical resection. A new technique of submucosal tunnel endoscopic resection was performed in 3 submucosal cases with lesions ranging from 2 cm to 3 cm in diameter. All of these cases were benign and histology was necessary for differential diagnosis.

CONCLUSIONS

Endoscopic ultrasonography plays an important guiding role in the diagnosis and treatment of esophageal GCT. Submucosal tunnel endoscopic resection is safe and effective. Further study is needed to determine whether this technique can be expanded into other applications.

Peroral endoscopic myotomy for treatment of achalasia cardia: Our experience with 7 cases

AIM: To evaluate the clinical efficacy of peroral endoscopic myotomy (POEM) in the treatment of achalasia cardia (AC).

METHODS: The clinical data for 7 patients who were diagnosed with AC and received POEM at our center from May 16, 2011 to May 30, 2013 were reviewed. They ranged in age from 20 to 48 years old, with a mean value of 30.4 years. The disease courses lasted for 2 to 15 years. Key procedures of POEM were esophageal mucosal incision, submucosal tunneling by endoscopic submucosal dissection, endoscopic myotomy of the circular muscle and closure of mucosal entry using hemostatic clips.

RESULTS: POEM was successful in all the patients. Mean operation time was 114 min (range, 55-180 min). Mean submucosal tunneling length was 11.7 cm (range, 10-13 cm). Mean length of endoscopic myotomy of the circular muscle was 9.2 cm (range, 8-11 cm). Two cases underwent full-thickness myotomy. Patients were followed for one year. Five cases of dysphagia were cured, and no obvious effect was observed in two cases.

CONCLUSION: POEM has good short-term efficacy in relieving dysphagia. Further observation is needed to evaluate long-term efficacy and complications.

Comparison of esophagogastric junction distensibility changes during POEM and Heller myotomy using intraoperative FLIP

BACKGROUND

Peroral endoscopic myotomy (POEM) is a novel endoscopic surgical procedure for the treatment of achalasia. The comparative effects of POEM and laparoscopic Heller myotomy (LHM) on esophagogastric junction (EGJ) physiology are unknown. A novel measurement catheter, the functional lumen imaging probe (FLIP), allows for intraoperative evaluation of EGJ compliance by measuring luminal geometry and pressure during volume-controlled distensions.

METHODS

Distensibility index (DI) (defined as the minimum cross-sectional area at the EGJ divided by pressure) was measured with FLIP intraoperatively in patients undergoing LHM and POEM. Separate measurements were taken after each operative step. During LHM, measurements were performed after: (1) induction of anesthesia, (2) insufflation of pneumoperitoneum, (3) hiatal dissection and esophageal mobilization, (4) myotomy, (5) partial fundoplication, and (6) deinsufflation. During POEM, they were performed after: (1) induction of anesthesia, (2) submucosal tunnel creation, and (3) myotomy.

RESULTS

Eleven LHM and 14 POEM patients underwent intraoperative FLIP. Baseline DI was similar between groups. LHM resulted in an overall increase in mean DI (pre 1.4 vs. post 7.6 mm(2)/mmHg, using a 40-ml distension volume; p < 0.001). Insufflation of pneumoperitoneum and hiatal dissection did not affect DI. Myotomy caused an increase in DI. Partial fundoplication (6 Toupet, 5 Dor) caused a decrease in DI, and deinsufflation caused an increase in DI. POEM also resulted in an overall increase in mean DI (pre 1.4 vs. post 7.9 mm(2)/mmHg; p < 0.001). Measured individually, both submucosal tunnel creation and myotomy caused increases in DI. When overall changes were compared, there were no differences in the amount of DI increase between LHM and POEM.

CONCLUSIONS

POEM and LHM result in a similar improvement in EGJ distensibility intraoperatively. Further study is needed to correlate intraoperative FLIP measurements with postoperative symptomatic and physiologic outcomes.

Per-oral endoscopic myotomy for achalasia: An American perspective

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.

Current status in the treatment options for esophageal achalasia

Recent advances in the treatment of achalasia include the use of high-resolution manometry to predict the outcome of patients and the introduction of peroral endoscopic myotomy (POEM). The first multicenter randomized, controlled, 2-year follow-up study conducted by the European Achalasia Trial group indicated that laparoscopic Heller myotomy (LHM) was not superior to pneumatic dilations (PD). Publications on the long-term success of laparoscopic surgery continue to emerge. In addition, laparoscopic single-site surgery is applicable to advanced laparoscopic operations such as LHM and anterior fundoplication. The optimal treatment option is an ongoing matter of debate. In this review, we provide an update of the current progress in the treatment of esophageal achalasia. Unless new conclusive data prove otherwise, LHM is considered the most durable treatment for achalasia at the expense of increased reflux-associated complications. However, PD is the first choice for non-surgical treatment and is more cost-effective. Repeated PD according to an "on-demand" strategy based on symptom recurrence can achieve long-term remission. Decision making should be based on clinical evidence that identifies a subcategory of patients who would benefit from specific treatment options. POEM has shown promise but its long-term efficacy and safety need to be assessed further.

Incidence, mechanisms, and outcomes of esophageal and gastric perforation during laparoscopic foregut surgery: a retrospective review of 1,223 foregut cases

BACKGROUND

Intraoperative perforation is a potentially major complication of laparoscopic (lap) foregut surgery. This study analyzed the incidence, mechanism, and outcomes of intraoperative perforations during these procedures in a large institutional experience.

METHODS

All patients who underwent lap foregut surgery including laparoscopic antireflux surgery (LARS), paraesophageal hernia (PEH) repair, Heller myotomy, and reoperative hiatal hernia (redo HH) repair at the authors' institution from August 2004 to September 2012 were reviewed retrospectively. Perforation events and postoperative outcomes were analyzed, and complications were graded by the modified Clavien system. All data are expressed as means ± standard deviations or as medians. Statistical analysis was performed using Fisher's exact test and the Mann-Whitney U test.

RESULTS

In this study, the repairs for 1,223 patients were analyzed (381 LARS procedures, 379 PEH repairs, 313 Heller myotomies, 150 redo HH repairs). Overall, 51 patients (4.2 %) had 56 perforations resulting from LARS (n = 4, 1 %), PEH repair (n = 7, 1.8 %), Heller myotomy (n = 18, 5.8 %), and redo HH repair (n = 22, 14.6 %). Redo HH was significantly more likely to result in perforations than LARS or PEH repair (p < 0.001). The locations of the perforations were esophageal in 13 patients (23.6 %), gastric in 40 patients (72.7 %), and indeterminate in 2 patients (3.6 %). The most common mechanisms of perforations were suture placement for LARS (75 %) and traction for PEH repair (43 %) and for Heller myotomy during the myotomy (72 %). The most redo HH perforations resulted from dissection/wrap takedown (73 %) and traction (14 %). Perforations were recognized and repaired intraoperatively in 43 cases (84 %) and postoperatively in eight cases (16 %). Perforations discovered postoperatively were more likely to require reoperation (75 vs 2 %; p < 0.001), to require more gastrointestinal and radiologic interventions (50 vs 2 %; p = 0.004), and to have higher morbidity (88 vs 26 %; p = 0.004) than perforations recognized intraoperatively.

CONCLUSIONS

In a high-volume center, intraoperative perforations are the most frequent with reoperative HH repair. If perforations are recognized and repaired intraoperatively, they require minimal postoperative intervention. Unrecognized perforations usually require reoperation and result in significantly greater morbidity.

What is the best primary therapy for achalasia: medical or surgical treatment? Who owns achalasia?

This article reviews the medical and surgical modalities for the treatment of esophageal achalasia. It compares and critically analyzes the short- and long-term outcomes of pneumatic dilatation and laparoscopic Heller myotomy. Today, laparoscopic Heller myotomy is considered in most centers to be the procedure of choice for the treatment of achalasia. Nevertheless, the success of either procedure is based on the careful selection of the patients and on the surgeon's and gastroenterologist's level of expertise.

Distal esophageal spasm: an update

Distal esophageal spasm (DES) is an esophageal motility disorder that presents clinically with chest pain and/or dysphagia and is defined manometrically as simultaneous contractions in the distal (smooth muscle) esophagus in ≥20% of wet swallows (and amplitude contraction of ≥30 mmHg) alternating with normal peristalsis. With the introduction of high resolution esophageal pressure topography (EPT) in 2000, the definition of DES was modified. The Chicago classification proposed that the defining criteria for DES using EPT should be the presence of at least two premature contractions (distal latency<4.5 s) in a context of normal EGJ relaxation. The etiology of DES remains insufficiently understood, but evidence links nitric oxide (NO) deficiency as a culprit resulting in a disordered neural inhibition. GERD frequently coexists in DES, and its role in the pathogenesis of symptoms needs further evaluation. There is some evidence from small series that DES can progress to achalasia. Treatment remains challenging due in part to lack of randomized placebo-controlled trials. Current treatment agents include nitrates (both short and long acting), calcium-channel blockers, anticholinergic agents, 5-phosphodiesterase inhibitors, visceral analgesics (tricyclic agents or SSRI), and esophageal dilation. Acid suppression therapy is frequently used, but clinical outcome trials to support this approach are not available. Injection of botulinum toxin in the distal esophagus may be effective, but further data regarding the development of post-injection gastroesophageal reflux need to be assessed. Heller myotomy combined with fundoplication remains an alternative for the rare refractory patient. Preliminary studies suggest that the newly developed endoscopic technique of per oral endoscopic myotomy (POEM) may also be an alternative treatment modality.

[Endoscopic submucosal dissection]

Endoscopic submucosal dissection (ESD) was developed in Japan but has now also become permanently established in various centers in Europe. ESD is an endoscopic en bloc mucosal resection technique for the treatment of early cancers with a diameter >1 cm and also superficial precancerous lesions, which could only be removed unsatisfactorily in several fragments or with uncertain lateral safety margins using previous loop excision procedures. Using ESD a lesion is excised after circular marking and generous submucosal injection with a safety margin of approximately 5 mm and subsequently resected at the level of the submucosa with a 1-3 mm short diathermic knife. ESD requires high technical skills in interventional endoscopy and is more time-consuming than snare resection techniques. However, numerous studies have shown a clear superiority for ESD with respect to the R0 resection rate and the local recurrence rate. The present article gives a current review of the use of ESD in the upper and lower gastrointestinal tract and demonstrates perspectives of the procedure.

Endoscopic approach to achalasia

Achalasia is a primary esophageal motor disorder. The etiology is still unknown and therefore all treatment options are strictly palliative with the intention to weaken the lower esophageal sphincter (LES). Current established endoscopic therapeutic options include pneumatic dilation (PD) or botulinum toxin injection. Both treatment approaches have an excellent symptomatic short term effect, and lead to a reduction of LES pressure. However, the long term success of botulinum toxin (BT) injection is poor with symptom recurrence in more than 50% of the patients after 12 mo and in nearly 100% of the patients after 24 mo, which commonly requires repeat injections. In contrast, after a single PD 40%-60% of the patients remain asymptomatic for ≥ 10 years. Repeated on demand PD might become necessary and long term remission can be achieved with this approach in up to 90% of these patients. The main positive predictors for a symptomatic response to PD are an age > 40 years, a LES-pressure reduction to < 15 mmHg and/or an improved radiological esophageal clearance post-PD. However PD has a significant risk for esophageal perforation, which occurs in about 2%-3% of cases. In randomized, controlled studies BT injection was inferior to PD and surgical cardiomyotomy, whereas the efficacy of PD, in patients > 40 years, was nearly equivalent to surgery. A new promising technique might be peroral endoscopic myotomy, although long term results are needed and practicability as well as safety issues must be considered. Treatment with a temporary self expanding stent has been reported with favorable outcomes, but the data are all from one study group and must be confirmed by others before definite recommendations can be made. In addition to its use as a therapeutic tool, endoscopy also plays an important role in the diagnosis and surveillance of patients with achalasia.

ACG clinical guideline: diagnosis and management of achalasia

Achalasia is a primary motor disorder of the esophagus characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. This results in patients' complaints of dysphagia to solids and liquids, regurgitation, and occasional chest pain with or without weight loss. Endoscopic finding of retained saliva with puckered gastroesophageal junction or barium swallow showing dilated esophagus with birds beaking in a symptomatic patient should prompt appropriate diagnostic and therapeutic strategies. In this ACG guideline the authors present an evidence-based approach in patients with achalasia based on a comprehensive review of the pertinent evidence and examination of relevant published data.

Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study

Pilot studies have indicated that peroral endoscopic myotomy (POEM) might be a safe and effective treatment for achalasia. We performed a prospective, international, multicenter study to determine the outcomes of 70 patients who underwent POEM at 5 centers in Europe and North America. Three months after POEM, 97% of patients were in symptom remission (95% confidence interval, 89%-99%); symptom scores were reduced from 7 to 1 (P < .001) and lower esophageal sphincter pressures were reduced from 28 to 9 mm Hg (P < .001). The percentage of patients in symptom remission at 6 and 12 months was 89% and 82%, respectively. POEM was found to be an effective treatment for achalasia after a mean follow-up period of 10 months.