151
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Nabi Z, Ramchandani M, Reddy DN. Length of myotomy during peroral endoscopic myotomy: Are we ready to cut it short? Gastrointest Endosc 2021; 93:991-992. [PMID: 33741100 DOI: 10.1016/j.gie.2020.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 11/20/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India
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152
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Rodríguez de Santiago E, Shimamura Y, Pioche M, Eleftheriadis N, Albéniz E, Bechara R, Yan Chiu PW, Guarner-Argente C, Herreros de Tejada A, Uchima H, Fujiyoshi Y, Ponchon T, González-Gete G, Hew S, Murzi-Pulgar M, Matallana V, Parejo-Carbonell S, Estremera-Arévalo F, Moll F, Onimaru M, Inoue H. Safety and effectiveness of peroral endoscopic myotomy in patients on antiplatelet or anticoagulant therapy: an international multicenter case-control study. Gastrointest Endosc 2021; 93:839-849. [PMID: 32717366 DOI: 10.1016/j.gie.2020.07.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/14/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The risk of bleeding and thromboembolic events in patients undergoing peroral endoscopic myotomy (POEM) who are receiving antithrombotic therapy is unknown. Our primary aim was to assess the safety of POEM in this patient subset. Secondary outcomes were rates of clinical success, GERD, and procedure-related outcomes. METHODS This was an international, 1:1, case-control study performed at 10 centers using prospectively maintained databases. All consecutive patients who underwent POEM before November 2019 were considered for inclusion. Cases were patients on antiplatelet and/or anticoagulant therapy. Controls not receiving antithrombotics were matched for age and esophageal motility disorder. Primary outcomes were major bleeding and thromboembolic events on postprocedural day 30. RESULTS Of 2895 patients who underwent POEM, 126 cases (103 on antiplatelets, 35 anticoagulants, 12 both) and 126 controls were enrolled. The rate of major bleeding was higher for the antithrombotics users (5.6% vs 0.8%, P = .03). Anticoagulants and clopidogrel were temporarily interrupted in all cases. Aspirin was continued in 40.5% of users without increasing the bleeding risk. One thromboembolic event occurred in each group (0.79%; P = 1.00). No POEM-related deaths were noted. Rates of clinical success (91.7% vs 96% in controls, P = .20), postprocedural GERD, and technical-related outcomes were similar in both groups. Antithrombotic management was heterogeneous, and guidelines were not adhered to in 23.8% of cases. CONCLUSIONS POEM is safe and effective in patients receiving antithrombotic therapy although it is associated with a greater risk of major bleeding.
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Affiliation(s)
- Enrique Rodríguez de Santiago
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan; Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan
| | - Mathieu Pioche
- Service d'Hépato-Gastro-Entérologie et d'Endoscopie Digestive, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | | | - Eduardo Albéniz
- Endoscopy Unit, Gastroenterology Department, Complejo Hospitalario de Navarra, Navarrabiomed Biomedical Research Center, UPNA, IdiSNA, Pamplona, Spain
| | - Robert Bechara
- Queen's University, Division of Gastroenterology, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Philip Way Yan Chiu
- Department of Surgery, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong
| | - Carlos Guarner-Argente
- Department of Gastroenterology, Hospital of Santa Creu and Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - Alberto Herreros de Tejada
- Department of Gastroenterology IDIPHISA-Research Institute Segovia Arana Puerta de Hierro University Hospital, Madrid, Spain
| | - Hugo Uchima
- Endoscopy Unit, Gastroenterology Department, Hospital Germans Trias I Pujol, Badalona, Barcelona, Spain
| | - Yusuke Fujiyoshi
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan
| | - Thierry Ponchon
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - Gonzalo González-Gete
- Endoscopy Unit, Gastroenterology Department, Complejo Hospitalario de Navarra, Navarrabiomed Biomedical Research Center, UPNA, IdiSNA, Pamplona, Spain
| | - Simon Hew
- Queen's University, Division of Gastroenterology, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Marianette Murzi-Pulgar
- Department of Gastroenterology, Hospital of Santa Creu and Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - Virginia Matallana
- Department of Gastroenterology IDIPHISA-Research Institute Segovia Arana Puerta de Hierro University Hospital, Madrid, Spain
| | - Sofía Parejo-Carbonell
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - Fermín Estremera-Arévalo
- Endoscopy Unit, Gastroenterology Department, Complejo Hospitalario de Navarra, Navarrabiomed Biomedical Research Center, UPNA, IdiSNA, Pamplona, Spain
| | - Frederic Moll
- Service d'Hépato-Gastro-Entérologie et d'Endoscopie Digestive, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan
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153
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Pesce M, Sweis R. Advances and caveats in modern achalasia management. Ther Adv Chronic Dis 2021; 12:2040622321993437. [PMID: 33786159 PMCID: PMC7958157 DOI: 10.1177/2040622321993437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 01/15/2021] [Indexed: 12/18/2022] Open
Abstract
Achalasia is a rare esophageal motility disorder characterized by the incomplete
relaxation of the lower esophageal sphincter (LES) and impaired peristaltic
activity. The advent of high-resolution manometry (HRM) and the rapidly evolving
role of therapeutic endoscopy have revolutionized the approach to the diagnosis
and management of achalasia patients in the last decade. With advances in HRM
technology and methodology, fluoroscopy and EndoFlip, achalasia can be
differentiated into therapeutically meaningful phenotypes with a high degree of
accuracy. Further, the newest treatment option, per-oral endoscopic myotomy
(POEM), has become a staple therapy following the last 10 years of experience,
and recent randomized trials appear to show no difference between POEM, graded
pneumatic dilatation and surgical Heller myotomy in terms of short- and
long-term efficacy or complication rate. On the other hand, how treatment
outcomes are measured as well as the risk of reflux following therapy remain
areas of contention. This review aims to summarize the recent advancements in
achalasia testing and therapy, describes the recent randomized clinical trials
as well as their potential setbacks, and touches on the future of personalizing
achalasia treatment.
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Affiliation(s)
- Marcella Pesce
- Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Naples, Italy
| | - Rami Sweis
- University College London Hospital, GI Services, 235 Euston Rd, London, NW1 2BU, UK
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154
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Mandavdhare HS, Mishra S, Kumar A, Shah J, Samanta J, Gupta P, Singh H, Dutta U. Per-oral Endoscopic Myotomy and Other Applications of Third Space Endoscopy: Current Status and Future Perspectives. Surg Laparosc Endosc Percutan Tech 2021; 31:624-636. [PMID: 33710101 DOI: 10.1097/sle.0000000000000920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 01/13/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The modification of NOTES (natural orifice transluminal endoscopic surgery) by mucosal safety flap has introduced us to the world of third space endoscopy (TSE). POEM (per-oral endoscopic myotomy) for achalasia cardia being its first vista, the realm expanded so that we can now remove en bloc a subepithelial/intramural tumor by POET (per-oral endoscopic tumor resection), perform G-POEM (gastric per-oral endoscopic myotomy) for refractory gastroparesis, restore esophageal continuity in complete obstruction by performing POETRE (per-oral endoscopic tunneling for the restoration of the esophagus), divide the septum in Zenker diverticulum completely with negligible risk of perforation by Z-POEM (Zenker per-oral endoscopic myotomy) and relieve constipation in Hirschsprung disease by PREM (per-rectal endoscopic myotomy). However, the real potential of TSE became evident with the introduction of POEM with fundoplication. TSE has opened the gates of the peritoneal cavity. Improved expertise and equipment will make the role of endoscopist complimentary to the surgeon with the dawn of a new field in therapeutic endoscopy. AREAS COVERED This review intends to comprehensively discuss the various aspects of POEM for achalasia studied so far followed by a brief discussion about other applications of TSE and the future perspectives in this exciting field.
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Affiliation(s)
| | | | | | | | | | | | - Harjeet Singh
- Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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155
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Cook IJ. POEM for achalasia: Looking good, but the final verses are yet to be penned. Med J Aust 2021; 214:171-172. [PMID: 33641178 DOI: 10.5694/mja2.50945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/05/2021] [Accepted: 01/18/2021] [Indexed: 11/17/2022]
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156
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Dirks RC, Kohn GP, Slater B, Whiteside J, Rodriguez NA, Docimo S, Pryor A, Stefanidis D. Is peroral endoscopic myotomy (POEM) more effective than pneumatic dilation and Heller myotomy? A systematic review and meta-analysis. Surg Endosc 2021; 35:1949-1962. [PMID: 33655443 DOI: 10.1007/s00464-021-08353-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 02/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Achalasia is a rare, chronic, and morbid condition with evolving treatment. Peroral endoscopic myotomy (POEM) has gained considerable popularity, but its comparative effectiveness is uncertain. We aim to evaluate the literature comparing POEM to Heller myotomy (HM) and pneumatic dilation (PD) for the treatment of achalasia. METHODS We conducted a systematic review of comparative studies between POEM and HM or PD. A priori outcomes pertained to efficacy, perioperative metrics, and safety. Internal validity of observational studies and randomized trials (RCTs) was judged using the Newcastle Ottawa Scale and the Cochrane Risk of Bias 2.0 tool, respectively. RESULTS From 1379 unique literature citations, we included 28 studies comparing POEM and HM (n = 21) or PD (n = 8), with only 1 RCT addressing each. Aside from two 4-year observational studies, POEM follow-up averaged ≤ 2 years. While POEM had similar efficacy to HM, POEM treated dysphagia better than PD both in an RCT (treatment "success" RR 1.71, 95% CI 1.34-2.17; 126 patients) and in observational studies (Eckardt score MD - 0.43, 95% CI - 0.71 to - 0.16; 5 studies; I2 21%; 405 patients). POEM needed reintervention less than PD in an RCT (RR 0.19, 95% CI 0.08-0.47; 126 patients) and HM in an observational study (RR 0.33, 95% CI 0.16, 0.68; 98 patients). Though 6-12 months patient-reported reflux was worse than PD in 3 observational studies (RR 2.67, 95% CI 1.02-7.00; I2 0%; 164 patients), post-intervention reflux was inconsistently measured and not statistically different in measures ≥ 1 year. POEM had similar safety outcomes to both HM and PD, including treatment-related serious adverse events. CONCLUSIONS POEM has similar outcomes to HM and greater efficacy than PD. Reflux remains a critical outcome with unknown long-term clinical significance due to insufficient data and inconsistent reporting.
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Affiliation(s)
- Rebecca C Dirks
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall 125, Indianapolis, IN, 46202, USA.
| | - Geoffrey P Kohn
- Department of Surgery, Monash University Eastern Health Clinical School, Melbourne, VIC, Australia
| | - Bethany Slater
- Division of Pediatric Surgery, University of Chicago, Chicago, IL, USA
| | - Jake Whiteside
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall 125, Indianapolis, IN, 46202, USA
| | - Noe A Rodriguez
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Salvatore Docimo
- Department of Surgery, Stony Brook Medicine, Stony Brook, NY, USA
| | - Aurora Pryor
- Department of Surgery, Stony Brook Medicine, Stony Brook, NY, USA
| | - Dimitrios Stefanidis
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall 125, Indianapolis, IN, 46202, USA
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157
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Dacha S, Aihara H, Anand GS, Byrne KR, Chahal P, James T, Kowalski TE, Qayed E, Repaka A, Saadi M, Sheth SG, Taylor JR, Walsh CM, Williams RL, Wagh MS. Core curriculum for peroral endoscopic myotomy (POEM). Gastrointest Endosc 2021; 93:539-543. [PMID: 33422284 DOI: 10.1016/j.gie.2020.10.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 10/26/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Sunil Dacha
- Division of Gastroenterology, Underwood Center for Digestive Disorders, Houston Methodist Hospital, Houston, Texas, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gobind S Anand
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Kathryn R Byrne
- Division of Gastroenterology, University of Utah, Salt Lake City, Utah, USA
| | - Prabhleen Chahal
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Theodore James
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Thomas E Kowalski
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Emad Qayed
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Aparna Repaka
- Division of Gastroenterology, VA Boston Healthcare system, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Mohammed Saadi
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Jason R Taylor
- Division of Gastroenterology and Hepatology, St Louis University, St Louis, Missouri, USA
| | - Catharine M Walsh
- Division of Gastroenterology, Hepatology and Nutrition and the Research and Learning Institutes, Hospital for Sick Children, Department of Paediatrics and the Wilson Centre, University of Toronto, Toronto, Ontario, Canada
| | - Renee L Williams
- Division of Gastroenterology and Hepatology, NYU Langone Health, New York, New York, USA
| | - Mihir S Wagh
- Division of Gastroenterology, University of Colorado-Denver School of Medicine, Aurora, Colorado, USA
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158
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Kim MJ, Min YW. [Endoscopic Management of Dysphagia]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 77:77-83. [PMID: 33632998 DOI: 10.4166/kjg.2021.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 02/22/2021] [Accepted: 02/24/2021] [Indexed: 11/03/2022]
Abstract
Dysphagia is difficulty in swallowing that can be caused by a number of disorders that involve either the oropharynx or the esophagus. Specific endoscopic treatment for dysphagia depends on its etiology, whether the dysphagia is caused by mechanical narrowing or a motor disorder. Variable endoscopic treatment strategies can be used to manage dysphagia. Patient with dysfunction of the upper esophageal sphincter may benefit from esophageal dilationor injection of botulinum toxin. Pneumatic balloon dilation, injection of botulinum toxin, peroral endoscopic myotomy can be considered as treatment options for esophageal motility disorders. Endoscopic dilation is the treatment choice of esophageal stricture, while intraluminal steroid injection and temporary stent can be considered in refractory benign esophageal stricture. Self-expandable metal stent insertion can be considered for dysphagia with malignant cause.
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Affiliation(s)
- Min Ji Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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159
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Gupta S, Sidhu M, Banh X, Bradbear J, Byth K, Hourigan LF, Raftopoulos S, Bourke MJ. A prospective multicentre study of per-oral endoscopic myotomy (POEM) for achalasia in Australia. Med J Aust 2021; 214:173-178. [PMID: 33611796 DOI: 10.5694/mja2.50941] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 10/09/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To describe the clinical and procedural outcomes of per-oral endoscopic myotomy (POEM) for achalasia in Australia. DESIGN, SETTING Prospective observational study in three Australian tertiary referral centres, 5 May 2014 - 27 October 2019 (66 months). PARTICIPANTS Patients who had undergone POEM for achalasia. MAJOR OUTCOME MEASURES Eckardt scores calculated prior to POEM and six months, one year, and two years after POEM. The primary outcome was clinical success, defined as an Eckardt score of 3 or less without a second intervention. RESULTS 142 patients underwent POEM for achalasia; their mean age was 52 years (SD, 18 years), 83 were men (58%), and the median length of hospital stay two days (IQR, 1-3 days). Their mean Eckardt score before POEM was 8.0 (SD, 2.4) and 1.1 (SD, 1.6) six months after POEM; it did not change significantly between six months and two years after POEM (mean monthly increase, 0.014 points; 95% CI, -0.001 to 0.029). A total of 127 patients (89%) improved clinically after POEM. Intra-procedural capnoperitoneum was the only risk factor associated with treatment failure (adjusted hazard ratio, 2.85; 95% CI, 1.08-7.51). Previous treatments - botulinum toxin injection (25 patients, 18%), endoscopic balloon dilatation (69, 49%), and Heller myotomy (14, 10%) - did not affect POEM outcomes. Five patients (4%) experienced major adverse events, including pneumonia, oesophageal leak, empyema and melaena, that were managed during admission and without sequelae. CONCLUSIONS POEM is an effective treatment for achalasia. Significant reductions in Eckardt scores achieved by six months are sustained at two years. POEM can be both a first line definitive therapy and a salvage therapy for patients not helped by other treatments.
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Affiliation(s)
- Sunil Gupta
- Westmead Hospital, Sydney, NSW.,Westmead Clinical School, University of Sydney, Sydney, NSW
| | - Mayenaaz Sidhu
- Westmead Hospital, Sydney, NSW.,Westmead Clinical School, University of Sydney, Sydney, NSW
| | - Xuan Banh
- Princess Alexandra Hospital Health Service District, Brisbane, QLD
| | - Joseph Bradbear
- Princess Alexandra Hospital Health Service District, Brisbane, QLD
| | - Karen Byth
- Western Sydney Local Health District Research and Education Network, Sydney, NSW.,NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW
| | - Luke F Hourigan
- Princess Alexandra Hospital Health Service District, Brisbane, QLD.,Gallipoli Medical Research Institute, University of Queensland, Brisbane, QLD
| | | | - Michael J Bourke
- Westmead Hospital, Sydney, NSW.,Westmead Clinical School, University of Sydney, Sydney, NSW
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160
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Karyampudi A, Nabi Z, Ramchandani M, Darisetty S, Goud R, Chavan R, Kalapala R, Rao GV, Reddy DN. Gastroesophageal reflux after per-oral endoscopic myotomy is frequently asymptomatic, but leads to more severe esophagitis: A case-control study. United European Gastroenterol J 2021; 9:63-71. [PMID: 32723068 PMCID: PMC8259274 DOI: 10.1177/2050640620947645] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/08/2020] [Indexed: 12/12/2022] Open
Abstract
Background and aim The incidence of gastroesophageal reflux disease (GERD) is high after per‐oral endoscopic myotomy (POEM). GERD after POEM may be qualitatively different from GERD in patients without motility disorders. In this study, we aimed to analyze and compare different aspects of GERD between patients with post‐POEM GERD and nonachalasia GERD. Methods The data of patients with GERD after POEM (January 2018 to June 2019) were compared with that of a control group (nonachalasia GERD group), which included patients presenting with typical reflux symptoms without associated major motility disorders. Patients with lower esophageal sphincter pressure lower than 10 mmHg were excluded from the study. GERD was evaluated at 3 months after POEM. Esophageal acid exposure time higher than 4.2% was used to define GERD. The primary outcome of the study was comparison of GERD‐related quality of life and reflux symptom severity between the two groups. In addition, the severity of erosive esophagitis and reflux‐symptom association were also recorded in the two groups. Results A total of 100 patients were included in the study, with 50 patients in each group (post‐POEM GERD vs. controls). The baseline parameters were comparable between the two groups. Median interquartile range of GERD‐related quality of life score was significantly lower in the post‐POEM group (11 [0–23.3] versus 34 [24–44]; p < 0.001). The post‐POEM GERD group had significantly lower median heartburn (6.0 [0–16.3] versus 15.5 [7.5–24.8]; p = 0.001) and regurgitation scores (0 [0–6.0] versus 20.0 [12.3–25.0]; p < 0.001). Erosive esophagitis was more frequent in the post‐POEM group (28 [56%] versus 10 [20.4%], p = 0.001). Only three (6%) patients in the post‐POEM group had a positive reflux‐symptom association as compared with 28 (56%) patients in the control group (p < 0.001). Conclusion In selected patients with pH positive GERD after POEM, the symptoms are milder and reflux‐symptom association is poor in spite of more severe esophagitis as compared with controls.
What is known
Gastroesophageal reflux disease (GERD) after per‐oral endoscopic myotomy (POEM) is common and subclinical Data on GERD related quality of life and reflux‐symptom association after POEM is limited.
What is new here
Reflux symptoms after POEM are milder and have poor association with reflux episodes Triviality of symptoms despite high acid exposure and severe esophagitis suggests esophageal hyposensitivity
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Affiliation(s)
- Arun Karyampudi
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Zaheer Nabi
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mohan Ramchandani
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Santosh Darisetty
- Department of Anaesthesia, Asian Institute of Gastroenterology, Hyderabad, India
| | - Rajesh Goud
- Department of Biostatistics, Asian Institute of Gastroenterology, Hyderabad, India
| | - Radhika Chavan
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Rakesh Kalapala
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Guduru Venkat Rao
- Department of Gastrointestinal Surgery, Asian Institute of Gastroenterology, Hyderabad, India
| | - Duvvur Nageshwar Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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161
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Slone S, Kumar A, Jacobs J, Velanovich V, Richter JE. Accuracy of Achalasia Quality of Life and Eckardt scores for assessment of clinical improvement post treatment for achalasia. Dis Esophagus 2021; 34:5900199. [PMID: 32875315 DOI: 10.1093/dote/doaa080] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/23/2020] [Accepted: 05/03/2020] [Indexed: 02/07/2023]
Abstract
Achalasia Quality of Life (ASQ) and Eckardt scores are two patient-reported instruments widely used to assess symptom severity in achalasia patients. ASQ is validated and reliable. Although Eckardt is commonly used, it has not been rigorously assessed for validity or reliability. This study aims to evaluate (i) the accuracy of Eckardt and ASQ for assessing improvement post-treatment (predictive validity), (ii) accuracy of Eckardt and ASQ for assessing improvement post-treatment with pneumatic dilatation (PD) versus surgical myotomy (predictive validity), and (iii) convergent validity of Eckardt and ASQ tools. Patients with achalasia treated between 2011 and 2018 were eligible. Both instruments were administered by telephone. Treatment failure was determined by the review of medical records by two clinicians. The predictive ability of ASQ and Eckardt instruments in identifying treatment successes and failures was determined using receiver operating characteristics analysis and summarized as area under the curve (AUC). A total of 106 patients met inclusion criteria with 39 PD, 51 Heller myotomy, and 16 per-oral endoscopic myotomy. A review of medical records and esophageal testing revealed 13 failures (12%). AUC for Eckardt was 0.96 (95% confidence interval [CI] 0.87-0.99] and ASQ 0.97 (95% CI 0.92-0.99). The Eckardt cutoff 4, and ASQ, cutoff 15, were 94% and 87% accurate in identifying treatment successes versus failures, respectively. The correlation coefficient between the two tools was 0.85. In conclusions, (i) ASQ and Eckardt scores are valid and reliable tools to assess symptom severity in achalasia patients, (ii) both instruments accurately classify treatment successes versus failures, and (iii) the choice of tool should be informed by the physicians and patients' values and preferences and repeat physiologic testing may be reserved for treatment failures with either instrument and patients classified, as treatment successes may be spared routine physiologic testing in the long term.
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Affiliation(s)
| | | | - John Jacobs
- Division of Digestive Diseases and Nutrition.,Joy McCann Culverhouse Center for Swallowing Disorders
| | - Vic Velanovich
- Joy McCann Culverhouse Center for Swallowing Disorders.,Division of General Surgery, Morsani College of Medicine University of South Florida, Tampa, Florida, USA
| | - Joel E Richter
- Division of Digestive Diseases and Nutrition.,Joy McCann Culverhouse Center for Swallowing Disorders
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162
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Swei E, Wagh MS. Preoperative predictors of poor response to peroral endoscopic myotomy: Have we found the crystal ball? Gastrointest Endosc 2021; 93:406-408. [PMID: 33478663 DOI: 10.1016/j.gie.2020.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 08/02/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Eric Swei
- Division of Gastroenterology and Hepatology, University of Colorado-Denver School of Medicine, Aurora, Colorado, USA
| | - Mihir S Wagh
- Division of Gastroenterology and Hepatology, University of Colorado-Denver School of Medicine, Aurora, Colorado, USA
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Urakami S, Abe H, Tanaka S, Kawara F, Toyonaga T, Ariyoshi R, Sako T, Ikezawa N, Ueda C, Kodama Y. Development of a preoperative risk-scoring system for predicting poor responders to peroral endoscopic myotomy. Gastrointest Endosc 2021; 93:398-405. [PMID: 32565185 DOI: 10.1016/j.gie.2020.06.028] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/05/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) is an effective treatment for esophageal motility disorder. However, some people are poor responders who will probably need retreatments, such as endoscopic pneumatic dilation or re-POEM, and a scoring system for the prediction of poor responders preoperatively has not yet been established. We aimed to develop and validate a preoperative scoring system for predicting poor responders. METHODS Overall, 244 patients who underwent POEM for esophageal motility disorders in our hospital from April 2015 to March 2019 were retrospectively included in this study. Poor responders were defined as patients with any of following: (1) Eckardt score ≥3 at 1-year follow-up, (2) endoscopic findings of food retention at 1-year follow-up, and (3) retreatments within 1 year after POEM. A risk-scoring system for poor responders was developed based on multiple logistic regression analysis, and its performance was internally validated using bootstrapping. RESULTS Forty patients were diagnosed as poor responders at the 1-year follow-up. In the multivariate study, points for risk scores were assigned for 4 independent risk factors as follows: pretreatment Eckardt score (1-point increments), previous treatments (4 points), sigmoid-type esophagus (4 points), and esophageal dilation grade ≥II (4 points). The scoring system could predict an estimated risk for poor responders and provided satisfactory discrimination (area under the receiver operating characteristic curve, 0.78; 95% confidence interval, 0.68-0.88) and calibration (slope = 0.93; 95% confidence interval, 0.62-1.31). CONCLUSIONS A validated risk-scoring system for predicting poor responders preoperatively was established; this system could be useful for selecting treatment strategies and postoperative surveillance.
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Affiliation(s)
- Satoshi Urakami
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine. 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo
| | - Hirofumi Abe
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine. 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo
| | - Shinwa Tanaka
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine. 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo
| | - Fumiaki Kawara
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine. 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo; Division of Gastroenterology, Konan Hospital. 1-5-16, Kamokogahara, Higashinada-ku, Kobe, Hyogo
| | - Takashi Toyonaga
- Division of Endoscopic Medicine, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, Japan
| | - Ryusuke Ariyoshi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine. 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo
| | - Tomoya Sako
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine. 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo
| | - Nobuaki Ikezawa
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine. 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo
| | - Chise Ueda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine. 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine. 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo
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The Clinical Relevance of Manometric Esophagogastric Junction Outflow Obstruction Can Be Determined Using Rapid Drink Challenge and Solid Swallows. Am J Gastroenterol 2021; 116:280-288. [PMID: 33136563 DOI: 10.14309/ajg.0000000000000988] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/08/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Esophagogastric junction outflow obstruction (EGJOO) defined on high-resolution esophageal manometry (HRM) poses a management dilemma given marked variability in clinical manifestations. We hypothesized that findings from provocative testing (rapid drink challenge and solid swallows) could determine the clinical relevance of EGJOO. METHODS In a retrospective cohort study, we included consecutive subjects between May 2016 and January 2020 with EGJOO. Standard HRM with 5-mL water swallows was followed by provocative testing. Barium esophagography findings were obtained. Cases with structural obstruction were separated from functional EGJOO, with the latter categorized as symptom-positive or symptom-negative. Only symptom-positive subjects were considered for achalasia-type therapies. Sensitivity and specificity for clinically relevant EGJOO during 5-mL water swallows, provocative testing, and barium were calculated. RESULTS Of the 121 EGJOO cases, 76% had dysphagia and 25% had holdup on barium. Ninety-seven cases (84%) were defined as functional EGJOO. Symptom-positive EGJOO subjects were more likely to demonstrate abnormal motility and pressurization patterns and to reproduce symptoms during provocative testing, but not with 5-mL water swallows. Twenty-nine (30%) functional EGJOO subjects underwent achalasia-type therapy, with symptomatic response in 26 (90%). Forty-eight (49%) functional EGJOO cases were managed conservatively, with symptom remission in 78%. Although specificity was similar, provocative testing demonstrated superior sensitivity in identifying treatment responders from spontaneously remitting EGJOO (85%) compared with both 5-mL water swallows (54%; P < 0.01) and barium esophagography (54%; P = 0.02). DISCUSSION Provocative testing during HRM is highly accurate in identifying clinically relevant EGJOO that benefits from therapy and should be routinely performed as part of the manometric protocol.
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165
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Haisley KR, Swanström LL. The Modern Age of POEM: the Past, Present and Future of Per-Oral Endoscopic Myotomy. J Gastrointest Surg 2021; 25:551-557. [PMID: 33140317 DOI: 10.1007/s11605-020-04815-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 09/30/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Per-oral endoscopic myotomy (POEM) has gained widespread enthusiasm amongst foregut specialists since its introduction in the mid 2000s as an effective and less invasive treatment option for achalasia. As more than 6000 POEM procedures have been performed to date throughout the world, we aim to summarize the history and current state of POEM in the treatment of esophageal motility disorders. METHODS We performed a comprehensive review of the published literature focusing on the history and development of the POEM procedure, and its most current applications and outcomes. RESULTS Multiple favorable long-term studies have been published advocating for the use of POEM as a valid and perhaps the most valid treatment option for achalasia. The procedure is also increasingly being applied to a wider spectrum of esophageal motility disorders including type III achalasia, spastic esophageal disease or isolated lower esophageal sphincter (LES) dysfunction, as well as new endoluminal procedures such as submucosal tumor endoscopic resection (STER), endoscopic fundoplications (POEM-F) and peroral pyloromyotomy (POP or G-POEM). CONCLUSIONS While POEM is a proved and valid procedure, its further adoption is being threatened by external factors: challenges related to teaching, institutional support (politics) and insurance reimbursement. While this technique has come an incredible distance in its relatively short lifespan, the future of POEM in the USA will depend on the support from surgical societies to validate it as a valuable tool in the esophageal specialist's armamentarium, and to encourage a commitment to training in endoluminal surgery.
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Affiliation(s)
- Kelly R Haisley
- Division of Gastrointestinal and General Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Lee L Swanström
- IHU-Strasbourg Institute of Image-Guided Surgery, Strasbourg, France.,Providence Portland Medical Center, 4805 NE Glisan Street, Suite 6N60, Portland, OR, 97213, USA
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Reddy CA, Tavakkoli A, Abdul-Hussein M, Almazan E, Vosoughi K, Ichkhanian Y, Al-Hawary M, Chang AC, Chen JW, Korsnes S, Elmunzer BJ, Khashab MA, Law R. Clinical impact of routine esophagram after peroral endoscopic myotomy. Gastrointest Endosc 2021; 93:102-106. [PMID: 32504702 PMCID: PMC8783294 DOI: 10.1016/j.gie.2020.05.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/08/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS It is unclear whether the common practice of postoperative day (POD) 1 esophagram impacts clinical care or reliably identifies significant adverse events (AEs) related to peroral endoscopic myotomy (POEM). Therefore, we aimed to correlate the most clinically relevant esophagram findings with postoperative outcomes after POEM. METHODS Patients were retrospectively reviewed and included if they underwent POEM at 1 of the 3 study institutions between 2014 and 2018. Patient outcomes were assessed in relation to relevant POD 1 esophagram findings such as esophageal dissection or leak. RESULTS One hundred seventy post-POEM contrast esophagrams (139 fluoroscopy-based vs 31 CT-based) performed on POD 1 were included. Most esophagrams (n = 98) contained abnormal findings but only 5 showed esophageal leak or dissection. Confirmed postoperative AEs of leak or dissection occurred in 4 patients. In 2 patients, POD 1 esophagram appropriately identified the leak or dissection, but in the other 2 patients the initial esophagram was negative, and the AEs were not recognized before clinical deterioration. One patient had a false-positive leak and dissection noted on esophagram leading to an unremarkable endoscopy. CONCLUSIONS Despite the low AE rate after POEM, follow-up esophagram on POD 1 frequently shows expected, unremarkable postprocedural findings and occasionally fails to diagnose serious AEs. This results in pitfalls in accuracy regarding agreement between esophagram versus clinical and endoscopic findings. Relying exclusively on esophagram for post-POEM clinical decision-making can lead to unnecessary additional testing or missed AEs.
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Affiliation(s)
| | - Anna Tavakkoli
- Division of Gastroenterology, UT Southwestern, Dallas, Texas, USA
| | - Mustafa Abdul-Hussein
- Division of Gastroenterology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Erik Almazan
- Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kia Vosoughi
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Mahmoud Al-Hawary
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew C. Chang
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Joan W. Chen
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Sheryl Korsnes
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - B. Joseph Elmunzer
- Division of Gastroenterology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mouen A. Khashab
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ryan Law
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
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Ponds FA, Oors JM, Smout AJPM, Bredenoord AJ. Reflux symptoms and oesophageal acidification in treated achalasia patients are often not reflux related. Gut 2021; 70:30-39. [PMID: 32439713 PMCID: PMC7788183 DOI: 10.1136/gutjnl-2020-320772] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [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: 04/05/2020] [Accepted: 04/06/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE After treatment, achalasia patients often develop reflux symptoms. Aim of this case-control study was to investigate mechanisms underlying reflux symptoms in treated achalasia patients by analysing oesophageal function, acidification patterns and symptom perception. DESIGN Forty treated achalasia patients (mean age 52.9 years; 27 (68%) men) were included, 20 patients with reflux symptoms (RS+; Gastro-Oesophageal Reflux Disease Questionnaire (GORDQ) ≥8) and 20 without reflux symptoms (RS-: GORDQ <8). Patients underwent measurements of oesophagogastric junction distensibility, high-resolution manometry, timed barium oesophagogram, 24 hours pH-impedance monitoring off acid-suppression and oesophageal perception for acid perfusion and distension. Presence of oesophagitis was assessed endoscopically. RESULTS Total acid exposure time during 24 hours pH-impedance was not significantly different between patients with (RS+) and without (RS-) reflux symptoms. In RS+ patients, acid fermentation was higher than in RS- patients (RS+: mean 6.6% (95% CI 2.96% to 10.2%) vs RS-: 1.8% (95% CI -0.45% to 4.1%, p=0.03) as well as acid reflux with delayed clearance (RS+: 6% (95% CI 0.94% to 11%) vs RS-: 3.4% (95% CI -0.34% to 7.18%), p=0.051). Reflux symptoms were not related to acid in both groups, reflected by a low Symptom Index. RS+ patients were highly hypersensitive to acid, with a much shorter time to heartburn perception (RS+: 4 (2-6) vs RS-:30 (14-30) min, p<0.001) and a much higher symptom intensity (RS+: 7 (4.8-9) vs RS-: 0.5 (0-4.5) Visual Analogue Scale, p<0.001) during acid perfusion. They also had a lower threshold for mechanical stimulation. CONCLUSION Reflux symptoms in treated achalasia are rarely caused by gastro-oesophageal reflux and most instances of oesophageal acidification are not reflux related. Instead, achalasia patients with post-treatment reflux symptoms demonstrate oesophageal hypersensitivity to chemical and mechanical stimuli, which may determine symptom generation.
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Affiliation(s)
- Fraukje A Ponds
- Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jacobus M Oors
- Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - André J P M Smout
- Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Albert J Bredenoord
- Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Mundre P, Black CJ, Mohammed N, Ford AC. Efficacy of surgical or endoscopic treatment of idiopathic achalasia: a systematic review and network meta-analysis. Lancet Gastroenterol Hepatol 2021; 6:30-38. [DOI: 10.1016/s2468-1253(20)30296-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/22/2020] [Accepted: 08/24/2020] [Indexed: 02/07/2023]
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Sanaka MR, Chadalavada P, Covut F, Khoudari G, Gabbard S, Thota PN, Raja S. Clinical Success and Correlation of Eckardt Scores with Barium Esophagram After Peroral Endoscopic Myotomy in Achalasia. J Gastrointest Surg 2021; 25:278-281. [PMID: 32885362 DOI: 10.1007/s11605-020-04763-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/19/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Madhusudan R Sanaka
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | | | - Fahrettin Covut
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - George Khoudari
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Scott Gabbard
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Prashanthi N Thota
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Siva Raja
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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170
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Shanbhag AB, Thota PN, Sanaka MR. Recent advances in third space or intramural endoscopy. World J Gastrointest Endosc 2020; 12:521-531. [PMID: 33362905 PMCID: PMC7739143 DOI: 10.4253/wjge.v12.i12.521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 10/18/2020] [Accepted: 11/29/2020] [Indexed: 02/06/2023] Open
Abstract
Third space endoscopy or intramural endoscopy is based on the principle that the deeper layers of the gastrointestinal tract can be accessed by tunneling in the submucosal space and maintaining the integrity of the overlying mucosa. The era of third space endoscopy started with peroral endoscopic myotomy (POEM) for treatment of achalasia and has expanded to treat various other gastrointestinal disorders. The technique is also currently used for treatment of refractory gastroparesis, Zenker’s diverticulum (ZD), resection of subepithelial tumors and early cancers of the gastrointestinal tract and Hirschsprung’s disease (HD). These procedures are rapidly emerging as minimally invasive alternatives to conventional surgery. They are safe and effective with excellent outcomes. This review focuses on the evolution and current applications of third space endoscopy in various gastrointestinal disorders. Key points: (1) Third space or intramural endoscopy initially started with the POEM procedure for treatment of achalasia; (2) Advancements in procedural techniques have expanded its application to treat other gastrointestinal disorders such as refractory gastroparesis, ZD, HD, resection of subepithelial tumors and early gastrointestinal cancers; (3) These procedures are highly effective with excellent outcomes and low complication rates; and (4) Third space endoscopic procedures are rapidly emerging as minimally invasive alternatives to conventional surgery.
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Affiliation(s)
- Akshay B Shanbhag
- Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Prashanthi N Thota
- Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Madhusudhan R Sanaka
- Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
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171
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Kolb JM, Jonas D, Funari MP, Hammad H, Menard-Katcher P, Wagh MS. Efficacy and safety of peroral endoscopic myotomy after prior sleeve gastrectomy and gastric bypass surgery. World J Gastrointest Endosc 2020; 12:532-541. [PMID: 33362906 PMCID: PMC7739145 DOI: 10.4253/wjge.v12.i12.532] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/10/2020] [Accepted: 11/29/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Per-oral endoscopic myotomy (POEM) is safe and effective for the treatment of achalasia. There is limited data on performance of POEM in patients with altered upper gastrointestinal anatomy, especially after bariatric surgery. Outcomes in patients with prior sleeve gastrectomy have not been reported.
AIM To assess the efficacy and safety of POEM in patients with prior bariatric surgery.
METHODS A prospective POEM database was reviewed from 3/2017-5/2020 to identify patients who underwent POEM after prior bariatric surgery. Efficacy was assessed by technical success (defined as the ability to successfully complete the procedure) and clinical success [decrease in Eckardt score (ES) to ≤ 3 post procedure]. Safety was evaluated by recording adverse events.
RESULTS Six patients (50% male, mean age 48 years) with a history of prior bariatric surgery who underwent POEM were included. Three had prior sleeve gastrectomy (SG) and three prior Roux-en-Y gastric bypass (RYGB). Four patients had achalasia subtype II and 2 had type I. Most (4) patients had undergone previous achalasia therapy. Technical success was 100%. Clinical success was achieved in 4 (67%) patients at mean follow-up of 21 mo. In one of the clinical failures, EndoFLIP evaluation demonstrated adequate treatment and candida esophagitis was noted as the likely cause of dysphagia. There were no major adverse events.
CONCLUSION POEM is technically feasible after both RYGB and SG and offers an effective treatment for this rare group of patients where surgical options for achalasia are limited.
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Affiliation(s)
- Jennifer M Kolb
- Division of Gastroenterology, University of Colorado-Denver, Aurora, CO 80045, United States
| | - Daniel Jonas
- Department of Internal Medicine, University of Colorado Hospital, Aurora, CO 80045, United States
| | - Mateus Pereira Funari
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São paulo 05403000, São paulo, Brazil
| | - Hazem Hammad
- Division of Gastroenterology, University of Colorado-Denver, Aurora, CO 80045, United States
| | - Paul Menard-Katcher
- Division of Gastroenterology, University of Colorado-Denver, Aurora, CO 80045, United States
| | - Mihir S Wagh
- Interventional Endoscopy, Division of Gastroenterology, University of Colorado-Denver, Aurora, CO 80045, United States
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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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Kim JY, Min YW. Peroral Endoscopic Myotomy for Esophageal Motility Disorders. Clin Endosc 2020; 53:638-645. [PMID: 33212547 PMCID: PMC7719430 DOI: 10.5946/ce.2020.223] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/22/2020] [Indexed: 12/11/2022] Open
Abstract
Peroral endoscopic myotomy (POEM) is one of the most clinically successful tunnel-based minimally invasive endoscopic treatments. The classic indications of POEM include achalasia of all types, including failed prior treatments, and expanded indications include the non-achalasia esophageal motility disorders, such as esophagogastric junction outflow obstruction, diffuse esophageal spasm, and jackhammer esophagus. For achalasia treatment, POEM has achieved a comparable surgical efficacy and a safety outcome and, therefore, has emerged as a first-line treatment. For non-achalasia esophageal motility disorders, POEM has also shown high clinical response rates. The complication rate of POEM for esophageal motility disorders is low and most complications are managed with conservative treatment. Currently, POEM is a representative procedure of natural orifice transluminal endoscopic surgery, which has shown a good clinical efficacy with low complication rates for esophageal motility disorders including achalasia. However, further studies are needed to treat non-achalasia motility disorder via POEM.
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Affiliation(s)
- Jun Young Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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174
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Chadalavada P, Thota PN, Raja S, Sanaka MR. Peroral Endoscopic Myotomy as a Novel Treatment for Achalasia: Patient Selection and Perspectives. Clin Exp Gastroenterol 2020; 13:485-495. [PMID: 33173323 PMCID: PMC7648548 DOI: 10.2147/ceg.s230436] [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: 07/30/2020] [Accepted: 10/19/2020] [Indexed: 12/12/2022] Open
Abstract
Achalasia is a rare esophageal motility disorder characterized by esophageal aperistalsis and impaired relaxation of lower esophageal sphincter. There is no cure for achalasia and all the current treatments are aimed at palliation of symptoms by reducing the lower esophageal sphincter pressure. Currently, laparoscopic Heller myotomy (LHM) with partial fundoplication is considered the most effective and durable treatment option owing to its superiority over other treatments such as pneumatic dilation. Advancements in interventional endoscopy led to a novel minimally invasive endoscopic alternative to LHM, namely peroral endoscopic myotomy (POEM). In the last decade since its inception, POEM expanded rapidly throughout the world due to excellent safety profile and its efficacy comparable to LHM. The main drawback of POEM is gastroesophageal reflux disease since it is not combined with an anti-reflux procedure. The current review focuses on the indications, contraindications, technique, outcomes of POEM in various patient populations, and complications along with its effectiveness in comparison to LHM and pneumatic dilation.
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Affiliation(s)
| | - Prashanthi N Thota
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Siva Raja
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Madhusudhan R Sanaka
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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175
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Affiliation(s)
- Ravinder Mittal
- From the Division of Gastroenterology, Department of Medicine, University of California, San Diego, San Diego (R.M.); and the Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville (M.F.V.)
| | - Michael F Vaezi
- From the Division of Gastroenterology, Department of Medicine, University of California, San Diego, San Diego (R.M.); and the Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville (M.F.V.)
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176
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Drexel S, Kishawi S, Marks J. Peroral Esophageal Myotomy. Surg Clin North Am 2020; 100:1183-1192. [PMID: 33128887 DOI: 10.1016/j.suc.2020.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Achalasia is a neurodegenerative disorder of the lower esophagus characterized by high lower esophageal pressures and aperistalsis of the esophageal body. It remains a difficult to treat disease with significant burden on patients due to difficulty swallowing leading to malnutrition. Peroral endoscopic myotomy (POEM) is a newer endoscopic treatment of achalasia. It involves dividing the muscular layer of the esophagus through a submucosal tunnel. Ten-year data show POEM is a safe and effective treatment of achalasia. However, postoperative gastroesophageal reflux disease remains an important consideration.
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Affiliation(s)
- Sabrina Drexel
- Northwest Minimally Invasive Surgery, 2222 Northwest Lovejoy Street, Suite 322, Portland, OR 97210, USA.
| | - Sami Kishawi
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5047, USA
| | - Jeffrey Marks
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5047, USA
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177
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Peroral endoscopic myotomy versus pneumatic dilation for achalasia: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2020; 32:1413-1421. [PMID: 32516175 DOI: 10.1097/meg.0000000000001800] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Presently, the primary endoscopic options for the treatment of achalasia are peroral endoscopic myotomy (POEM) and pneumatic dilation. But the clinical outcomes of POEM and pneumatic dilation for achalasia have not yet to be fully evaluated. So, we aimed to compare the clinical outcomes between the two treatment modalities. We searched all the relevant studies published up to September 2019 examining the comparative efficacy between POEM and pneumatic dilation. Outcomes included success rate, Eckardt score, lower esophageal sphincter pressure and adverse events. Outcomes were documented by pooled risk ratios and mean difference with 95% confidence interval (CI) using Review Manager 5.3. Seven studies with a total of 619 patients were identified. There were 298 patients underwent POEM treatment and 321 patients underwent pneumatic dilation treatment. The clinical success rate was higher in the POEM group than that in the pneumatic dilation group at 6, 12 and 24 months' follow-up, with a risk ratio of 1.14 (95% CI, 1.06-1.22, P = 0.0002, I= 0%), 1.34 (95% CI, 1.24-1.45, P < 0.00001, I= 17%) and 1.35 (95% CI, 1.10-1.65, P = 0.004, I= 70%), respectively. The change of Eckardt scores was more obvious in the POEM group than in the pneumatic dilation group, with a mean difference of 1.19 (95% CI, 0.78-1.60, P < 0.00001, I= 70%). The rate of gastroesophageal reflux and other complications for POEM was significantly higher than for pneumatic dilation, with a risk ratio of 4.17 (95% CI, 1.52-11.45, P = 0.006, I= 61%) and 3.78 (95% CI, 1.41-10.16, P = 0.008, I= 0%). Our current evidence suggests that the long-term efficacy of POEM was superior to that of pneumatic dilation, but accompanied by higher complications.
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178
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Jawaid S, Draganov PV, Yang D. Esophageal POEM: the new standard of care. Transl Gastroenterol Hepatol 2020; 5:47. [PMID: 33073042 DOI: 10.21037/tgh.2019.12.17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 12/19/2019] [Indexed: 01/06/2023] Open
Abstract
Since its introduction into clinical practice nearly a decade ago, per-oral endoscopic myotomy (POEM) has now become an accepted minimally invasive approach for the treatment of achalasia with excellent short- and mid-term clinical outcomes in both treatment naïve and those who have failed prior therapy. POEM is comparable to laparoscopic Heller myotomy (LHM) in terms of efficacy and safety, with less procedural pain and faster recovery time. Recent data also reveals that POEM may be more effective and durable than pneumatic dilation (PD) for the treatment of achalasia, with similar safety profile. Preliminary data on POEM for spastic esophageal disorders (SED) is promising yet scarce. Post-POEM gastroesophageal reflux disease (GERD) is common but asymptomatic in most patients, further highlighting the need for ongoing research in this field and the importance of long-term surveillance of these patients.
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Affiliation(s)
- Salmaan Jawaid
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida Health, Gainesville, FL, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida Health, Gainesville, FL, USA
| | - Dennis Yang
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida Health, Gainesville, FL, USA
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179
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Low EE, Yadlapati R. A multidisciplinary personalised paradigm for achalasia. Lancet Gastroenterol Hepatol 2020; 6:3-5. [PMID: 33035471 DOI: 10.1016/s2468-1253(20)30312-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 09/14/2020] [Indexed: 01/21/2023]
Affiliation(s)
- Eric E Low
- Division of Gastroenterology, University of California, San Diego, La Jolla, CA 92093, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego, La Jolla, CA 92093, USA.
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180
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An evaluation of the complication risks following peroral endoscopic myotomy in patients on antithrombotic therapy. Surg Endosc 2020; 35:5620-5625. [PMID: 33033912 DOI: 10.1007/s00464-020-08065-7] [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: 07/17/2020] [Accepted: 09/29/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Per oral endoscopic myotomy (POEM) is used to treat a variety of esophageal motility disorders and is associated with relatively few complications. However, complications in patients on antithrombotic therapy (AT) is not well-studied. We hypothesize AT patients have a higher risk of post-operative bleeding and 30-day complication rate compared to all other patients, even when these medications are held peri-operatively. METHODS A single-institution retrospective review of a prospectively collected database of patients who underwent POEM procedures January 2011-July 2019 was performed. All 30-day complications were recorded, as well as management of AT medications peri-operatively. Demographic and clinical characteristics were compared using t test, Chi-Square, and Fisher's exact test as appropriate. Multivariate logistic regression was performed to examine factors associated with post-operative complications. RESULTS A total of 219 POEM procedures were performed. 50.2% of patients were male, and AT patients tended to be older (66.9 vs. 55.4, p = 0.01). The major complication rate was higher among AT patients (36.8% vs. 9.0%, p = 0.01), as was the rate of post-operative bleeding (10.5% vs. 1.0%, p = 0.04). After adjusting for gender and age, the use of antithrombotic therapy was significantly associated with 30-day complications (OR 6.03, p = 0.001). CONCLUSIONS Patients on AT who undergo POEM are significantly more likely to experience complications, including bleeding, within 30 days of surgery. Safe timing of post-operative resumption of antithrombotic medications remains a difficult decision that must be carefully considered by the endoscopist.
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182
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Oude Nijhuis RAB, Bergman JJGHM, Takkenberg RB, Fockens P, Bredenoord AJ. Non-surgical treatment of esophageal perforation after pneumatic dilation for achalasia: a case series. Scand J Gastroenterol 2020; 55:1248-1252. [PMID: 32924655 DOI: 10.1080/00365521.2020.1817541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Esophageal perforation is the most serious complication of pneumatic dilation for achalasia and is traditionally managed by conservative therapy or surgical repair. We present four achalasia patients who underwent pneumatic dilatation, complicated by an esophageal perforation. All patients were treated successfully with endoscopic treatment: two patients with Eso-SPONGE® vacuum therapy, in the other two patients, esophageal defects were closed endoscopically using Endoclips. The time between dilatation and detection of the perforation was less than 24 h in all cases. Non-surgical treatment resulted in a relatively short hospital stay, ranging from 5 to 10 days, and an uneventful recovery in all patients. Based on our experience, endoscopic clipping and/or vacuum therapy are relatively new, valuable, minimally invasive techniques in the management of patients with small, well-defined esophageal tears with contained leakage and should be considered as primary therapeutic option for iatrogenic perforation in achalasia.
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Affiliation(s)
- Renske A B Oude Nijhuis
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - R Bart Takkenberg
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Paul Fockens
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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183
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Fajardo RA, Petrov RV, Bakhos CT, Abbas AE. Endoscopic and Surgical Treatments for Achalasia: Who to Treat and How? Gastroenterol Clin North Am 2020; 49:481-498. [PMID: 32718566 PMCID: PMC7387747 DOI: 10.1016/j.gtc.2020.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Achalasia is a progressive neurodegenerative disorder characterized by failure of relaxation of the lower esophageal sphincter (LES) and altered motility of the esophagus. The traditional, highly effective, surgical approach to relieve obstruction at the LES includes cardiomyotomy. Fundoplication is added to decrease risk of postoperative reflux. Per oral endoscopic myotomy is a new endoscopic procedure that allows division of the LES via transoral route. It has several advantages including less invasiveness, cosmesis, and tailored approach to the length on the myotomy. However, it is associated with increased rate of post-procedural reflux. Various endoscopic interventions are used to address this problem.
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Affiliation(s)
- Romulo A. Fajardo
- Department of General Surgery, Temple University Hospital, Philadelphia, PA, USA, 3401 N Broad St, C-401, Philadelphia, PA 19140
| | - Roman V. Petrov
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA, 3401 N Broad St, C-501, Philadelphia, PA 19140
| | - Charles T. Bakhos
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA, 3401 N Broad St, C-501, Philadelphia, PA 19140
| | - Abbas E. Abbas
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA, 3401 N Broad St, C-501, Philadelphia, PA 19140
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184
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Abstract
Achalasia is an esophageal motility disorder characterized by aberrant peristalsis and insufficient relaxation of the lower esophageal sphincter. Patients most commonly present with dysphagia to solids and liquids, regurgitation, and occasional chest pain with or without weight loss. High-resolution manometry has identified 3 subtypes of achalasia distinguished by pressurization and contraction patterns. Endoscopic findings of retained saliva with puckering of the gastroesophageal junction or esophagram findings of a dilated esophagus with bird beaking are important diagnostic clues. In this American College of Gastroenterology guideline, we used the Grading of Recommendations Assessment, Development and Evaluation process to provide clinical guidance on how best to diagnose and treat patients with achalasia.
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185
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Paspatis GA, Arvanitakis M, Dumonceau JM, Barthet M, Saunders B, Turino SY, Dhillon A, Fragaki M, Gonzalez JM, Repici A, van Wanrooij RLJ, van Hooft JE. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement - Update 2020. Endoscopy 2020; 52:792-810. [PMID: 32781470 DOI: 10.1055/a-1222-3191] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
1: ESGE recommends that each center implements a written policy regarding the management of iatrogenic perforations, including the definition of procedures that carry a higher risk of this complication. This policy should be shared with the radiologists and surgeons at each center. 2 : ESGE recommends that in the case of an endoscopically identified perforation, the endoscopist reports its size and location, with an image, and statement of the endoscopic treatment that has been applied. 3: ESGE recommends that symptoms or signs suggestive of iatrogenic perforation after an endoscopic procedure should be rapidly and carefully evaluated and documented with a computed tomography (CT) scan. 4 : ESGE recommends that endoscopic closure should be considered depending on the type of the iatrogenic perforation, its size, and the endoscopist expertise available at the center. Switch to carbon dioxide (CO2) endoscopic insufflation, diversion of digestive luminal content, and decompression of tension pneumoperitoneum or pneumothorax should also be performed. 5 : ESGE recommends that after endoscopic closure of an iatrogenic perforation, further management should be based on the estimated success of the endoscopic closure and on the general clinical condition of the patient. In the case of no or failed endoscopic closure of an iatrogenic perforation, and in patients whose clinical condition is deteriorating, hospitalization and surgical consultation are recommended.
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Affiliation(s)
- Gregorios A Paspatis
- Gastroenterology Department, Venizelion General Hospital, Heraklion, Crete-Greece
| | - Marianna Arvanitakis
- Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme Hospital, Universite Libre de Bruxelles, Brussels, Belgium
| | - Jean-Marc Dumonceau
- Gastroenterology Service, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | | | - Brian Saunders
- St Mark's Hospital, Wolfson Unit for Endoscopy, North West London Hospitals University Trust, Harrow, London, UK
| | | | - Angad Dhillon
- St Mark's Hospital, Wolfson Unit for Endoscopy, North West London Hospitals University Trust, Harrow, London, UK
| | - Maria Fragaki
- Gastroenterology Department, Venizelion General Hospital, Heraklion, Crete-Greece
| | | | - Alessandro Repici
- Department of Gastroenterology, Digestive Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, AG&M Research Institute, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, The Netherlands
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186
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Khashab MA. Reflux After Peroral Endoscopic Myotomy. Gastroenterol Hepatol (N Y) 2020; 16:417-419. [PMID: 34035747 PMCID: PMC8132660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Mouen A Khashab
- Director of Therapeutic Endoscopy Associate Professor of Medicine Division of Gastroenterology and Hepatology Johns Hopkins Hospital Baltimore, Maryland
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187
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Babaei A, Shad S, Massey BT. Diagnostic differences in the pharmacologic response to cholecystokinin and amyl nitrite in patients with absent contractility vs type I Achalasia. Neurogastroenterol Motil 2020; 32:e13857. [PMID: 32350982 DOI: 10.1111/nmo.13857] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 02/22/2020] [Accepted: 03/26/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Absent esophageal contractility (AC) is distinguished from type 1 achalasia (ACH1) during high-resolution manometry (HRM) on the basis of normal or elevated deglutitive integrated relaxation pressure (IRP) values. However, IRP measurements are subject to pressure recording error. We hypothesized that distinctive responses to pharmacologic provocation using amyl nitrite (AN) and cholecystokinin (CCK) could reliably distinguish AC patients from those with ACH1. AIM To compare esophageal response with AN and CCK in a well-defined cohort of ACH1 and AC patients. METHOD All available clinical, radiographic, endoscopic, and manometric information in 34 patients with aperistalsis was reviewed to determine the final diagnosis of ACH1 and AC. The differences in response to provocative challenges with the rapid drink challenge (RDC) test and administration of AN and CCK were compared between these two groups. RESULTS Eighteen patients were diagnosed with ACH1 and sixteen with AC. While IRP values were significantly higher in ACH1, the standard criterion value misclassified four AC patients as having ACH1 and five ACH1 patients as having AC. IRP values on the RDC did not accurately segregate AC from ACH1, but we were able to identify AN and CCK esophageal motor response criteria that allowed correct classification of ACH1 and AC patients. CONCLUSIONS Nearly a quarter of AC and ACH1 patients may be misdiagnosed based on manometric IRP criteria alone. Differences in the esophageal motor responses to AN and CCK have the potential to facilitate the correct diagnosis in these challenging patients.
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Affiliation(s)
- Arash Babaei
- Division of Gastroenterology, Department of Medicine, National Jewish Health, Denver, CO, USA.,Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sadaf Shad
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Benson T Massey
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
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Felix VN, Murayama KM, Bonavina L, Park MI. Achalasia: what to do in the face of failures of Heller myotomy. Ann N Y Acad Sci 2020; 1481:236-246. [PMID: 32713020 DOI: 10.1111/nyas.14440] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/07/2020] [Accepted: 06/25/2020] [Indexed: 12/21/2022]
Abstract
Achalasia is a primary motility disorder of the esophagus, and while there are several treatment options, there is no consensus regarding them. When therapeutic intervention for achalasia fails, a careful evaluation of the cause of the persistent or recurrent symptoms using upper endoscopy, esophageal manometry, and contrast radiologic studies is required to understand the cause of therapy failure and guide plans for subsequent treatment. Options for reintervention are the same as for primary intervention and include pneumatic dilation, botulinum toxin injection, peroral endoscopic myotomy, or redo esophageal myotomy. When reintervention fails or if the esophagus is not amenable to intervention and the disease is considered end-stage, esophagectomy is the last option to manage recurrent achalasia.
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Affiliation(s)
- Valter N Felix
- Nucleus of General and Specialized Surgery - São Paulo and Department of Gastroenterology - Surgical Division - São Paulo University, FMUSP, Sao Paulo, Brazil
| | - Kenric M Murayama
- Department of Surgery, John A. Burns School of Medicine, the University of Hawaii at Manoa, Honolulu, Hawaii
| | - Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, The University of Milan, San Donato Milanese, Italy
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
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189
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Lottrup C, Khan A, Rangan V, Clarke JO. Esophageal physiology-an overview of esophageal disorders from a pathophysiological point of view. Ann N Y Acad Sci 2020; 1481:182-197. [PMID: 32648992 DOI: 10.1111/nyas.14417] [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: 03/31/2020] [Revised: 05/25/2020] [Accepted: 06/03/2020] [Indexed: 11/30/2022]
Abstract
The esophagus serves the principal purpose of transporting food from the pharynx into the stomach. A complex interplay between nerves and muscle fibers ensures that swallowing takes place as a finely coordinated event. Esophageal function can be tested by a variety of methods, endoscopy, manometry, and reflux monitoring being some of the most important. Regarding pathophysiology, motor disorders, such as achalasia, often cause dysphagia and/or chest pain. Functional esophageal disorders are a heterogeneous group with hypersensitivity as a dominant pathophysiological factor. Gastroesophageal reflux disease often causes symptoms, such as heartburn and regurgitation, and a spectrum of disease, ranging from minimal mucosal damage visible only in the microscope to esophageal ulcers and strictures in the most severe cases. Eosinophilic esophagitis is an immune-mediated condition that can result in significant dysphagia and associated luminal narrowing. In the following, we will provide an overview of the most common esophageal disorders from a combined pathophysiological and clinical view.
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Affiliation(s)
- Christian Lottrup
- Department of Medicine, Aalborg University Hospital, Hobro, Denmark.,Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Abraham Khan
- Department of Medicine, New York University School of Medicine, New York, New York
| | - Vikram Rangan
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - John O Clarke
- Division of Gastroenterology, Department of Medicine, Stanford University, Stanford, California
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190
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Ivashkin VT, Mayev IV, Trukhmanov AS, Storonova OA, Abdulkhakov SA, Andreev DN, Bordin DS, Valitova ER, Klyaritskaya IL, Krivoy VV, Kucheryavyi YA, Lapina TL, Morozov SV, Sablin OA, Semenikhina EV, Uspenskiy YP, Sheptulin AA. Recommendations of the Russian Gastroenterological Association on Clinical Use of High-Resolution Manometry in Diagnosis of Esophageal Disorders. RUSSIAN JOURNAL OF GASTROENTEROLOGY, HEPATOLOGY, COLOPROCTOLOGY 2020. [DOI: 10.22416/1382-4376-2020-30-3-61-88] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Aim. Current recommendations of the Russian Gastroenterological Association on clinical use of high-resolution manometry in diagnosis of esophageal disorders are intended to assist in clinical decision making, terminology standardisation and interpretation of clinical data.Key points. In 2018, a joint meeting of the Russian Gastroenterological Association and Russian Neurogastroenterology and Motility Group approved unified terminology and classification of esophageal motor function disorders for high-resolution manometry diagnosis.Gastrointestinal patient complaints typically concern esophageal disorders such as dysphagia, regurgitation, heart-burn, chest pain or belching. To exclude erosive and ulcerative lesions, eosinophilic esophagitis and organic changes, esophagogastroduodenoscopy and biopsy are recommended in pre-treatment. Upon excluding mucosal lesions and esophageal lumen obstruction as causal for symptoms, use of high-resolution manometry is recommended. This method of esophageal examination has become the “gold standard” in diagnosis of motor disorders.High-resolution manometry enables detailed investigation of integral quantitative and qualitative characteristics of esophagus motor function and specific related disorders, analysis of esophageal contractile propagation and strictly coordinated synchronous peristalsis of upper esophageal sphincter, esophagus and lower esophageal sphincter, which malfunction may provoke development of achalasia, esophagospasm, hiatal hernia, ineffective eso pha geal motility and other motor disorders.Conclusion. High-resolution manometry is a relatively new method for study of esophagus motor function gaining increasingly wide application in clinical practice. It enables a medical professional to obtain evidence that may critically affect the choice of optimal patient care strategy and effective treatment. Current recommendations are based on an extensive review of up-to-date information and will be updated with new corpus of clinical data and assessment emerging in evidential medicine to provide gastroenterologists country-wide with latest scientific and practical guidelines.
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Affiliation(s)
- V. T. Ivashkin
- Sechenov First Moscow State Medical University (Sechenov University)
| | - I. V. Mayev
- Moscow State University of Medicine and Dentistry
| | - A. S. Trukhmanov
- Sechenov First Moscow State Medical University (Sechenov University)
| | - O. A. Storonova
- Sechenov First Moscow State Medical University (Sechenov University)
| | | | | | - D. S. Bordin
- Moscow State University of Medicine and Dentistry; Loginov Moscow Clinical Scientific Center; Tver State Medical University
| | | | | | | | | | - T. L. Lapina
- Sechenov First Moscow State Medical University (Sechenov University)
| | - S. V. Morozov
- Federal Research Center for Nutrition, Biotechnology and Food Safety
| | - O. A. Sablin
- Nikiforov All-Russian Center for Emergency and Radiation Medicine
| | | | - Yu. P. Uspenskiy
- Saint-Petersburg State Pediatric Medical University; Pavlov First Saint-Petersburg State Medical University
| | - A. A. Sheptulin
- Sechenov First Moscow State Medical University (Sechenov University)
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191
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Bajaj JS, Brenner DM, Cai Q, Cash BD, Crowell M, DiBaise J, Gallegos-Orozco JF, Gardner TB, Gyawali CP, Ha C, Holtmann G, Jamil LH, Kaplan GG, Karsan HA, Kinoshita Y, Lebwohl B, Leontiadis GI, Lichtenstein GR, Longstreth GF, Muthusamy VR, Oxentenko AS, Pimentel M, Pisegna JR, Rubenstein JH, Russo MW, Saini SD, Samadder NJ, Shaukat A, Simren M, Stevens T, Valdovinos M, Vargas H, Spiegel B, Lacy BE. Major Trends in Gastroenterology and Hepatology Between 2010 and 2019: An Overview of Advances From the Past Decade Selected by the Editorial Board of The American Journal of Gastroenterology. Am J Gastroenterol 2020; 115:1007-1018. [PMID: 32618649 DOI: 10.14309/ajg.0000000000000709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- J S Bajaj
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - D M Brenner
- Northwestern University, Chicago Illinois, USA
| | - Q Cai
- Emory University, Atlanta, Georgia, USA
| | - B D Cash
- McGovern Medical School, Houston, Texas, USA
| | - M Crowell
- Mayo Clinic, Scottsdale, Arizona, USA
| | - J DiBaise
- Mayo Clinic, Scottsdale, Arizona, USA
| | | | - T B Gardner
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - C Ha
- Inflammatory Bowel Diseases Center, Cedars-Sinai Medical Center, Los Angeles CA, USA
| | - G Holtmann
- University of Queensland, Brisbane, Australia, USA
| | - L H Jamil
- Beaumont Health-Royal Oak, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan, USA
| | - G G Kaplan
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - H A Karsan
- Atlanta Gastroenterology Associates and Emory University, Atlanta, Georgia, USA
| | - Y Kinoshita
- Steel Memorial Hirohata Hospital and Himeji Brain and Heart Center, Himeji, Japan
| | - B Lebwohl
- Columbia University Irving Medical Center, New York, New York, USA
| | | | | | - G F Longstreth
- Kaiser Permanente Southern California, San Diego, California, USA
| | - V R Muthusamy
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | | | - M Pimentel
- Inflammatory Bowel Diseases Center, Cedars-Sinai Medical Center, Los Angeles CA, USA
| | - J R Pisegna
- Department of Veterans Affairs, VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA Los Angeles, California, USA
| | - J H Rubenstein
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan, USA
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - M W Russo
- Carolinas Medical Center-Atrium Health, Charlotte, North Carolina, USA
| | - S D Saini
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan, USA
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - A Shaukat
- Minneapolis Veterans Affairs Medical Center and University of Minnesota, Minneapolis, Minnesota, USA
| | - M Simren
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - T Stevens
- Cleveland Clinic, Cleveland, Ohio, USA
| | - M Valdovinos
- Instituto Nacional de Ciencias Médicas y Nutricion S.Z., Mexico City, Mexico
| | - H Vargas
- Mayo Clinic, Scottsdale, Arizona, USA
| | - B Spiegel
- Inflammatory Bowel Diseases Center, Cedars-Sinai Medical Center, Los Angeles CA, USA
| | - B E Lacy
- Mayo Clinic, Jacksonville, Florida, USA
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192
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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: 1.8] [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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193
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Mandavdhare HS, Samanta J, Varma P, Kumar-M P, Gupta P, Singh H, Dutta U, Kochhar R. Per oral endoscopic myotomy with fundoplication is a technically feasible NOTES for achalasia cardia. MINIM INVASIV THER 2020; 31:319-324. [PMID: 32608297 DOI: 10.1080/13645706.2020.1783320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Background: Per-oral endoscopic myotomy (POEM) has become the standard of care for the endoscopic management of achalasia but its major long-term adverse effect has been the development of reflux-associated symptoms and sequelae.Aim: This study was conducted to assess the feasibility and reproducibility of the technique of POEM with fundoplication (POEM + F), a pure Natural Orifice Transluminal Endoscopic Surgery (NOTES) procedure in achalasia.Material and methods: Between November 2019 and January 2020, three patients with achalasia cardia were subjected to POEM + F. Various parameters such as technical feasibility, procedure time, adverse events and post-procedure follow-up were noted.Results: POEM + F was successfully completed in all three patients. Other than intra-operative capno-peritoneum, no major adverse events were noted. On follow-up at one month, maintenance of wrap was noted.Conclusion: POEM + F is a technically feasible and a reproducible pure NOTES procedure.
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Affiliation(s)
- Harshal S Mandavdhare
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Prerna Varma
- Department of Anesthesiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Praveen Kumar-M
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Gupta
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harjeet Singh
- Department of Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Usha Dutta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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194
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Feng Z, Liu ZM, Yuan XL, Ye LS, Wu CC, Tan QH, Hu B. Peroral endoscopic myotomy for management of gastrointestinal motility disorder. World J Clin Cases 2020; 8:2116-2126. [PMID: 32548141 PMCID: PMC7281049 DOI: 10.12998/wjcc.v8.i11.2116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/27/2020] [Accepted: 04/27/2020] [Indexed: 02/05/2023] Open
Abstract
Achalasia is a type of esophageal motility disorder, consisting of relaxation dysfunction of the lower esophagus and disturbed esophageal peristalsis. Related clinical symptoms include dysphagia, regurgitation, chest pain, and weight loss. Traditional treatment options include endoscopic botulinum toxin injection, endoscopic pneumatic dilation, and laparoscopic Heller’s myotomy. These therapies mainly relieve symptoms by reducing the pressure on the lower esophageal sphincter and reducing blood flow resistance at the esophagogastric junction. Based on endoscopic submucosal dissection and natural orifice transluminal endoscopic surgery, peroral endoscopic myotomy (POEM) is a purely endoscopic method of myotomy with minimal invasiveness and a low rate of adverse events when performed by experienced operators. Since then, numerous studies have shown the significant clinical efficacy and safety of POEM. The purpose of this article is to introduce different modified POEMs, special indications for different POEMs, and their advantages as well as disadvantages.
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Affiliation(s)
- Zhe Feng
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Zi-Ming Liu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xiang-Lei Yuan
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Lian-Song Ye
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Chun-Cheng Wu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Qing-Hua Tan
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Bing Hu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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195
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Saugel B, Vokuhl C, Pinnschmidt HO, Rösch T, Petzoldt M, Löser B. Cardiovascular dynamics during peroral endoscopic myotomy for esophageal achalasia: a prospective observational study using non-invasive finger cuff-derived pulse wave analysis. J Clin Monit Comput 2020; 35:827-834. [PMID: 32504156 DOI: 10.1007/s10877-020-00541-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 05/26/2020] [Indexed: 11/24/2022]
Abstract
Peroral endoscopic myotomy (POEM) is natural orifice transluminal endoscopic surgery to treat esophageal achalasia. During POEM, cardiovascular dynamics can be impaired by capnoperitoneum, capnomediastinum, and systemic carbon dioxide accumulation. We systematically investigated changes in cardiovascular dynamics during POEM. We included 31 patients having POEM in this single-center prospective observational study. Before and every 5 min during POEM we measured mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), stroke volume index (SVI), and systemic vascular resistance index (SVRI) using non-invasive finger cuff-derived pulse wave analysis. During POEM, the median MAP was higher than the median baseline MAP of 77 (67;86) mmHg. HR (median at baseline: 67 (60;72) bpm), CI (2.8 (2.5;3.2) L/min/m2), SVI (42 (34;51) mL/m2), and SVRI (1994 (1652; 2559) dyn × s × cm-5 × m-2) remained stable during POEM. Mixed model-derived 95% confidence limits of hemodynamic variables during POEM were 72 to 106 mmHg for MAP, 65 to 79 bpm for HR, 2.7 to 3.3 L/min/m2 for CI, 37 and 46 mL/m2 for SVI, and 1856 and 2954 dyn × s × cm-5 × m-2 for SVRI. POEM is a safe procedure with regard to cardiovascular dynamics as it does not markedly impair MAP, HR, CI, SVI, or SVRI.
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Affiliation(s)
- Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Outcomes Research Consortium, Cleveland, OH, USA
| | - Christina Vokuhl
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans O Pinnschmidt
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Petzoldt
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Löser
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medicine Rostock, Schillingallee 35, 18057, Rostock, Germany.
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196
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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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197
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Sugihara Y, Sakae H, Hamada K, Okada H. Peroral endoscopic myotomy is an effective treatment for diffuse esophageal spasm. Clin Case Rep 2020; 8:927-928. [PMID: 32477548 PMCID: PMC7250992 DOI: 10.1002/ccr3.2755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 01/30/2020] [Accepted: 02/05/2020] [Indexed: 12/23/2022] Open
Abstract
Diffuse esophageal spasm (DES) causes symptoms such as dysphagia. However, DES is sometimes difficult to diagnose. DES can be diagnosed based on a characteristic image through esophageal radiography. As in the present case, DES is considered a good indication for peroral endoscopic myotomy.
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Affiliation(s)
- Yuusaku Sugihara
- Department of Gastroenterology and HepatologyOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical SciencesOkayamaJapan
| | - Hiroyuki Sakae
- Department of Gastroenterology and HepatologyOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical SciencesOkayamaJapan
| | - Kenta Hamada
- Department of Gastroenterology and HepatologyOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical SciencesOkayamaJapan
| | - Hiroyuki Okada
- Department of Gastroenterology and HepatologyOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical SciencesOkayamaJapan
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198
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Runge TM, Ichkhanian Y, Khashab MA. POEM for achalasia: endoscopic myotomy enters its golden age, and we are taking NOTES. Gastrointest Endosc 2020; 91:1045-1049.e1. [PMID: 32327117 DOI: 10.1016/j.gie.2020.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 01/06/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Thomas M Runge
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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199
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Richter JE. Tailoring Therapy for Achalasia. Gastroenterol Hepatol (N Y) 2020; 16:249-257. [PMID: 34035727 PMCID: PMC8132639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Achalasia is a rare esophageal motility disorder with impaired lower esophageal sphincter (LES) opening and aperistalsis. The disease cannot be cured and aperistalsis cannot be corrected, but good long-term symptom relief results from some degree of destruction to the obstruction of the LES. The presence of multiple treatment options with excellent scientific efficacy now offers the opportunity to tailor therapy for patients with achalasia. Drug therapy, especially botulinum toxin A, should be reserved for elderly patients with short life expectancy. Pneumatic dilation and surgical myotomy are equally effective for patients with types I and II achalasia. Pneumatic dilation offers a less morbid, cheaper outpatient procedure, especially for older patients and women, but redilation may be needed. Surgical myotomy is effective across all groups, especially young men. Laparoscopic Heller myotomy with fundoplication is preferred in patients with megaesophagus, diverticulum, or hiatal hernia. Peroral endoscopic myotomy is the treatment of choice for patients with type III achalasia, but requires advanced endoscopic skills, and the risk of gastroesophageal reflux disease is high. This article reviews the various treatments currently available for achalasia and discusses how to tailor therapy for patients.
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Affiliation(s)
- Joel E Richter
- Dr Richter is a professor of medicine, Hugh F. Culverhouse Chair for Esophageal Disorders, director of the Division of Digestive Diseases and Nutrition, and director of the Joy McCann Culverhouse Center for Esophageal and Swallowing Disorders at the University of South Florida Morsani College of Medicine in Tampa, Florida
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200
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Ramchandani M, Pal P. Management of achalasia in 2020: Per-oral endoscopic myotomy, Heller’s or dilatation? INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii200012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Mohan Ramchandani
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Partha Pal
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
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