Comparison of medical and minimally invasive surgical therapy for primary esophageal motility disorders

When less is more: lower esophageal sphincter-preserving peroral endoscopic myotomy is effective for non-achalasia esophageal motility disorders

BACKGROUND

Non-achalasia esophageal motility disorders (NAEMDs), encompassing distal esophageal spasm (DES) and hypercontractile esophagus (HCE), are rare conditions. Peroral endoscopic myotomy (POEM) is a promising treatment option. In NAEMDs, unlike with achalasia, the lower esophageal sphincter (LES) functions normally, suggesting the potential of LES preservation during POEM.

METHODS

This retrospective two-center observational study focused on patients undergoing LES-preserving POEM (LES-POEM) for NAEMD. Eckardt scores were assessed pre-POEM and at 6, 12, and 24 months post-POEM, with follow-up endoscopy at 6 months to evaluate for reflux esophagitis. Clinical success, defined as an Eckardt score ≤3, served as the primary outcome.

RESULTS

227 patients were recruited over 84 months until May 2021. Of these, 16 underwent LES-POEM for an NAEMD (9 with HCE and 7 with DES). The median pre-POEM Eckardt score was 6.0 (interquartile range [IQR] 5.0-7.0), which decreased to 1.0 (IQR 0.0-1.8; P<0.001) 6 months post-POEM. This was sustained at 24 months, with an Eckardt score of 1.0 (IQR 0.0-1.8; P<0.001). Two patients (12.5%) developed Los Angeles grade A or B esophagitis.

CONCLUSIONS

LES-POEM for NAEMD demonstrates favorable clinical outcomes, with infrequent esophagitis and reintervention for LES dysfunction rarely required.

Long-term efficacy of peroral endoscopic myotomy for achalasia under different criteria

BACKGROUND

Peroral endoscopic myotomy (POEM) has emerged as a widely accepted treatment for achalasia, with limited studies for over 2 years. Additionally, traditional measurements of achalasia after POEM have deficiencies. The study aimed to analyze the long-term outcomes of POEM under different criteria.

METHODS

Patients with achalasia who received POEM between November 2012 and March 2021 were recruited. Patients and characteristics were shown, and risk factors related to two novel definitions of recurrence, symptomatic reflux, and reflux esophagitis were analyzed.

RESULTS

Three hundred and twenty-one patients were included. At a median follow-up of 52 months, twenty-three failures happened (7.17%) under the modified criterion, and forty-seven failures occurred (14.64%) under the normal standard. Hospitalization (P = 0.027) and esophageal myotomy length (P = 0.039) were significantly associated with long-term efficacy under the modified and normal criteria, respectively. Fifty-two patients (16.20%) reported reflux symptoms and endoscopy performed in 88 patients revealed reflux esophagitis in 22 cases (25.00%). There were no predictors in the analysis of symptomatic reflux and gender (P = 0.010), LESP (P = 0.013), IRP (P = 0.015), and the esophageal myotomy length (P = 0.032) were statistically related to reflux esophagitis.

CONCLUSION

POEM is an extremely safe and effective treatment for achalasia with long-term follow-up. Shorter hospitalization and shorter esophageal myotomy length may decrease the incidence of recurrence under the modified and normal criteria, respectively. Long-term outcomes of POEM are unpredictable. No risk factors were related to symptomatic reflux, and male patients with low preoperative LESP and IRP needed relatively shorter esophageal myotomy to prevent reflux esophagitis.

Risk scoring system for the preprocedural prediction of the clinical failure of peroral endoscopic myotomy: a multicenter case-control study

BACKGROUND

 Peroral endoscopic myotomy (POEM) is effective for the management of achalasia and its variants; however, it can be ineffective in some patients. We aimed to develop and validate a risk scoring system to predict the clinical failure of POEM preoperatively.

METHODS

 Consecutive patients who underwent POEM in 14 high volume centers between 2010 and 2020 were enrolled in this study. Clinical failure was defined as an Eckardt score of ≥ 4 or retreatment. A risk scoring system to predict the short-term clinical failure of POEM was developed using multivariable logistic regression and internally validated using bootstrapping and decision curve analysis.

RESULTS

 Of the 2740 study patients, 112 (4.1 %) experienced clinical failure 6 months after POEM. Risk scores were assigned for three preoperative factors as follows: preoperative Eckardt score (1 point), manometric diagnosis (-4 points for type II achalasia), and a history of prior treatments (1 point for pneumatic dilation or 12 points for surgical/endoscopic myotomy). The discriminative capacity (concordance statistics 0.68, 95 %CI 0.62-0.72) and calibration (slope 1.15, 95 %CI 0.87-1.40) were shown. Decision curve analysis demonstrated its clinical usefulness. Patients were categorized into low (0-8 points; estimated risk of clinical failure < 5 %) and high risk (9-22 points; ≥ 5 %) groups. The proportions of clinical failure for the categories were stratified according to the mid-term outcomes (log-rank test, P < 0.001).

CONCLUSIONS

 This risk scoring system can predict the clinical failure of POEM preoperatively and provide useful information when making treatment decisions.

Peroral Endoscopy Myotomy (POEM) for Esophageal Motility Disorders

PURPOSE OF REVIEW

This review aims to provide an overview of the current role of per oral endoscopic myotomy (POEM) in the management of primary esophageal motility disorders and treatment of Zenker's diverticulum.

RECENT FINDINGS

POEM has been shown to be an effective treatment for achalasia. Recent research has suggested that the length of myotomy may be tailored to the disease phenotype and that short myotomy may be equally effective compared to long myotomy. The role of intra-operative EndoFLIP has shown promise as a tool to assess of the adequacy of myotomy. Further research is needed to determine the role of POEM in other esophageal motility disorders and for treatment of Zenker's diverticulum. Per oral endoscopic myotomy has been shown to be an effective and durable treatment option for achalasia with additional potential roles for the treatment of other esophageal motility disorders and Zenker's diverticulum.

The Combination of Two Bioactive Constituents, Lactoferrin and Linolenic Acid, Inhibits Mouse Xenograft Esophageal Tumor Growth by Downregulating Lithocholyltaurine and Inhibiting the JAK2/STAT3-Related Pathway

The addition of lactoferrin and three unsaturated fatty acids, oleic acid, docosahexaenoic acid (DHA), and linolenic acid, to dairy products was approved in recent years. Research into the biological activities of lactoferrin and these three unsaturated fatty acids has revealed anti-inflammatory, antiviral, antioxidant, antitumor, antiparasitic, and antibiotic effects. However, investigations and comparisons of lactoferrin + oleic acid/DHA/linolenic acid combinations in an esophageal cancer cell model and in xenograft tumor models have not been extensively reported, and the related mechanism of these combinations remains elusive. In the present study, the effects of lactoferrin and the three fatty acids on KYSE450 cell viability, migration, and invasion were investigated to choose the proper doses and effective combination in vitro. A tumor-bearing nude mouse model was established to investigate the role of selected combinations in inhibiting esophageal tumor formation in vivo. Metabonomics detection and data analysis were performed to screen special metabolites and related pathways, which were validated by western blotting. The results demonstrated that lactoferrin, the three unsaturated fatty acids, and their combinations inhibited the viability, migration, and invasion of KYSE450 cells and induced apoptosis and the lactoferrin + linolenic acid combination exhibited the strongest activity in suppressing KYSE450 tumor formation in vivo. The lactoferrin + linolenic acid combination inhibited phosphorylation in the JAK2/STAT3-related pathway by downregulating the special metabolite lithocholyltaurine, thereby suppressing formation of KYSE450 tumors.

Videofluoroscopic and Manometric Evaluation of Oropharyngeal and Esophageal Motility Disorders

BACKGROUND

Esophageal motility studies are performed in patients who have dysphagia that is not explained by stenosis. Diagnosis can be challenging and requires expertise in the interpretation of tests and symptoms.

AIMS

Our aim is to investigate the diagnostic value of videofluoroscopic swallowing study (VFSS) in combination with esophageal manometry.

STUDY DESIGN

This study has a prospective study design.

METHODS

73 patients with dysphagia underwent videofluoroscopy in a standing position. Each subject swallowed barium boluses and findings were correlated with manometry findings.

RESULTS

The study cohort was categorized into five groups according to their disease as achalasia (31.1%), presbyesophagus (4.1%), scleroderma (5.5%), neurogenic dysphagia (6.8%), and other diseases (54.4%), which included gastroesophageal reflux, diffuse esophageal spasm, cricopharyngeal achalasia, and diseases with nonspecific VFSS patterns. When evaluating VFSS, the perfect agreement was observed between two observers in the final diagnosis. (kappa: 0.91, p<0,001).

CONCLUSION

Although it does not replace manometry, VFSS is important as an additional useful imaging method in EMDs.

Clinical efficacy of per-oral endoscopic myotomy (POEM) for spastic esophageal disorders: a systematic review and meta-analysis

BACKGROUND

POEM has been successfully performed in patients with spastic esophageal disorders (SED), such as diffuse esophageal spasm, jackhammer esophagus, and type 3 achalasia. We performed a systematic review and meta-analysis to evaluate its efficacy in these patients and if total average myotomy length and prior medical or endoscopic treatments affected clinical success.

METHODS

PubMed, EMBASE, Google-Scholar, Scopus, and Cochrane Review were searched for studies on POEM in SED from 2008 to September 2018. Clinical success was determined by Eckardt score (≤ 3) at follow-up. Sub-group analysis was performed based on myotomy length and evaluates the effect of prior treatments on clinical success.

RESULTS

9 studies with 210 patients were included in the final analysis. We found that the pooled rate of clinical success for POEM was 89.6% (95% CI 83.5-93.1, 95% PI 83.4-93.7, I² = 0%). In three studies (50 patients), where total myotomy length was < 10 cm, the pooled rate of clinical success was 91.1% (95% CI 79.5-96.4, I² = 0%). In six studies (160 patients), the length was > 10 cms and the pooled rate of clinical success was 89.1% (95% CI 83.0-93.2, I² = 0%). The difference between these results was not statistically significant (p = 0.69). Additionally, a meta-regression analysis showed that prior treatment status did not significantly affect the primary outcome (p = 0.43).

CONCLUSIONS

While it is well known that POEM is a safe and effective treatment for spastic esophageal disorders, we conclude that variation in total myotomy length and prior endoscopic or medical treatments did not have a significant effect on clinical success.

Predictors of Hiatal Hernia Recurrence After Laparoscopic Anti-reflux Surgery with Hiatal Hernia Repair: a Prospective Database Analysis

BACKGROUND

The aim of this study is to identify factors that can predict hiatal hernia recurrence (HHR) in patients after anti-reflux surgery with hiatal hernia (HH) repair.

METHODS

A single-institution, prospectively collected database was reviewed (January 2002-October 2015) with inclusion criteria of GERD and laparoscopic anti-reflux (AR) surgery with HH repair. Demographics, esophageal symptom scores, and pre- and post-upper gastrointestinal imaging (UGI) were collected. Mesh usage, HH type (sliding, paraesophageal (HH) or type IV), and size were evaluated, and patients who had HHR versus those who did not (NHHR) were compared. Statistical analysis was performed using IBM SPSS v.23.0.0, with α = 0.05.

RESULTS

Three hundred twenty-two patients met inclusion criteria. Mean age was 56.9 ± 14.8 years (60.9% female), and mean follow-up was 19.9 ± 23.8 months. 88.2% underwent total fundoplication and 11.8% underwent partial fundoplication. HHR rate was 15.5%. HHR patients had larger HH than the NHHR group. There was no significant difference between groups for age, gender, BMI, race, and mesh usage. Only 3 patients (10.3%) with HHR reported mild-to-moderate heartburn, regurgitation, and solid or liquid dysphagia at 12-month follow-up. Overall reoperation rate was 1% in this population.

CONCLUSIONS

HHR is correlated with large hernia size. Mesh use and patient BMI were not predictors, and no correlation was identified between HHR and presence of GERD symptoms. Recurrence after repair is not uncommon, but is asymptomatic in most cases. Reoperation is rare and mesh is not routinely needed. Large asymptomatic HHs in the elderly often do not require intervention.

Long-term outcomes following POEM for non-achalasia motility disorders of the esophagus

BACKGROUND

Optimal treatment for symptomatic patients with non-achalasia motility disorders (NAD) such as diffuse esophageal spasm, esophagogastric junction outlet obstruction, and hypercontractile disorder is not well established. POEM has been offered to these patients since it is a less invasive and less morbid procedure but long-term outcomes remain undetermined. The aim of this study was to assess long-term outcomes of POEM for patients with NAD.

METHODS

Records of 40 consecutive patients undergoing POEM for NAD from May 2011 to January 2016 at a single center were retrospectively reviewed. Preoperative and 6-month postoperative symptom scores, high-resolution manometry, pH testing, and timed barium swallow (TBS) data were collected. Patients were contacted by phone to obtain long-term symptom assessment. Symptoms were assessed using a standardized symptom questionnaire with scores for symptoms graded according to frequency and the Eckardt score.

RESULTS

Ten percent had minor complications with no postoperative sequelae. 90% of patients had significant improvement in their mean Eckardt scores (5.02 vs. 1.12, p < 0.001) at early follow-up. Improvements in chest pain (1.02-0.36, p = 0.001) and dysphagia (2.20 vs. 0.40, p = 0.001) were seen. Significant improvements in manometric pressures and esophageal emptying on TBS were observed across groups. 38% (10/26) of patients had a postoperative pH score > 14.72. Long-term (median 48 months) symptom scores were obtained from 29 (72.5%) patients. 82% of patients (24/29) had sustained symptom improvement. A small increase in the dysphagia scores was reported in the long-term follow-up compared to the immediate postoperative period (0.36-0.89, p = 0.046).

CONCLUSIONS

Chest pain and dysphagia are effectively palliated with POEM in patients with non-achalasia disorders of the esophagus. Significant improvements are durable in long-term follow-up. Despite earlier reports by our group suggesting possible inferior outcomes from POEM for this difficult group of patients, this study is far more encouraging. POEM should be considered in the treatment of patients with non-achalasia disorders of the esophagus.

Understanding the Chicago Classification: From Tracings to Patients

Current parameters of the Chicago classification include assessment of the esophageal body (contraction vigour and peristalsis), lower esophageal sphincter relaxation pressure, and intra-bolus pressure pattern. Esophageal disorders include achalasia, esophagogastric junction outflow obstruction, major disorders of peristalsis, and minor disorders of peristalsis. Sub-classification of achalasia in types I, II, and III seems to be useful to predict outcomes and choose the optimal treatment approach. The real clinical significance of other new parameters and disorders is still under investigation.

Per-oral endoscopic myotomy (POEM): a new endoscopic treatment for achalasia

BACKGROUND/AIMS

Per-oral endoscopic myotomy (POEM) is a new minimally invasive technique to treat achalasia.

METHODS

We performed a review of the literature of POEM with a special focus on technical details and the results obtained with this technique in patients with achalasia and other esophageal motility disorders.

RESULTS

Thousands of POEM procedures have been performed worldwide since its introduction in 2008. The procedure is based on the creation of a mucosal entry point in the proximal esophagus to reach the cardia through a submucosal tunnel and then perform a myotomy of the muscular layers of the cardia, esophagogastric junction and distal esophagus, as performed in a Heller myotomy. The clinical remission rate ranges from 82 to 100%. Although no randomized studies exist and available data are from single-center studies, no differences have been found between laparoscopic Heller myotomy (LHM) and POEM in terms of perioperative outcomes, short-term outcomes (12 months) and long-term outcomes (up to three years). Procedure time and length of hospital stay were lower for POEM. Post-POEM reflux is a concern, and controversial data have been reported compared to LHM. The technique is safe, with no reported deaths related to the procedure and an adverse event rate comparable to surgery. Potential complications include bleeding, perforation, aspiration and insufflation-related adverse events. Thus, this is a complex technique that needs specific training even in expert hands. The indication for this procedure is widening and other motor hypercontractil esophageal disorders have been treated by POEM with promising results. POEM can be performed in complicated situations such as in pediatric patients, sigmoid achalasia or after failure of previous treatments.

CONCLUSIONS

POEM is an effective treatment for achalasia and is a promising tool for other motor esophageal disorders. It is a safe procedure but, due to its technical difficulty and possible associated complications, the procedure should be performed in referral centers by trained endoscopists.

Primary Esophageal Motility Disorders: Beyond Achalasia

The best-defined primary esophageal motor disorder is achalasia. However, symptoms such as dysphagia, regurgitation and chest pain can be caused by other esophageal motility disorders. The Chicago classification introduced new manometric parameters and better defined esophageal motility disorders. Motility disorders beyond achalasia with the current classification are: esophagogastric junction outflow obstruction, major disorders of peristalsis (distal esophageal spasm, hypercontractile esophagus, absent contractility) and minor disorders of peristalsis (ineffective esophageal motility, fragmented peristalsis). The aim of this study was to review the current diagnosis and management of esophageal motility disorders other than achalasia.

The role of Heller myotomy and POEM for nonachalasia motility disorders

The best-defined primary esophageal motor disorder is achalasia. However, symptoms such as dysphagia, regurgitation and chest pain can be caused by other esophageal motility disorders such as Diffuse Esophageal Spasm (DES), Nutcracker Esophagus (NE) and the Hypertensive Lower Esophageal Sphincter (HTN-LES). Most patients with DES and HTN-LES who complain of dysphagia improve after a myotomy. Patients with NE whose main complaint is chest pain, often do not have relief of the pain and can even develop dysphagia as a consequence of the myotomy. POEM is a relatively new procedure, and there are no studies with long-term follow-up and no prospective and randomized trials comparing it to surgical myotomy. Overall, the key to success is based on a complete evaluation and a careful patient selection. The best results, regardless of the technique, are in fact obtained in patients with outflow obstruction and impaired esophageal emptying, a picture similar to achalasia.

Is POEM the Answer for Management of Spastic Esophageal Disorders? A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Spastic esophageal disorders (SEDs) include spastic achalasia (type III), diffuse esophageal spasm (DES), and nutcracker/jackhammer esophagus (JH). Per-oral endoscopic myotomy (POEM) has demonstrated efficacy and safety in the treatment of achalasia. Recently, POEM has been indicated for the treatment of SEDs. We conducted a systematic review and meta-analysis to determine the clinical success and safety of POEM in SEDs.

METHODS

We searched several databases from 01/01/2007 to 01/10/2016 to identify studies (with five or more patients) on POEM for the treatment of SEDs. Weighted pooled rates (WPRs) for clinical success and adverse events (AEs) were calculated for all SEDs. Clinical success was defined as Eckardt scores of ≤3 and/or improvement in severity of dysphagia based on achalasia disease-specific health-related quality of life questionnaire. The WPRs for clinical success and AEs were analyzed using fixed- or random-effects model based on heterogeneity. The proportionate difference in clinical success and post-procedure adverse event rates among individual types of SEDs was also calculated.

RESULTS

A total of eight observational studies with 179 patients were included in the final analysis. Two studies were of good quality and six were of fair quality based on the National Institutes of Health quality assessment tool. The WPR with 95% confidence interval (CI) for cumulative clinical success of POEM in all SEDs was 87% (78, 93%), I ² = 37%. The total number of patients for individual disorders, i.e., type III achalasia, JH, and DES, was 116, 37, and 18, respectively. The WPRs for clinical success of POEM for type III achalasia, DES, and JH were 92, 88, and 72%, respectively. Proportion difference of WPR for clinical success was significantly higher for type III achalasia in comparison with JH (20%, P = 0.01). The WPR with 95% CI for AEs of POEM in all SEDs was 14% (9, 20%), I ² = 0%. The WPRs for post-procedure adverse events for type III achalasia, DES, and JH were 11, 14, and 16%, respectively. There was no difference in safety of POEM among individual SEDs.

CONCLUSION

POEM is an effective and safe therapeutic modality for the treatment of spastic esophageal disorders.

Esophageal hypermotility: cause or effect?

Nutcracker esophagus (NE), Jackhammer esophagus (JHE), distal esophageal spasm (DES), and hypertensive lower esophageal sphincter (HTLES) are defined by esophageal manometric findings. Some patients with these esophageal motility disorders also have abnormal gastroesophageal reflux. It is unclear to what extent these patients' symptoms are caused by the motility disorder, the acid reflux, or both. The aim of this study was to determine the effectiveness of laparoscopic Nissen fundoplication (LNF) on esophageal motility disorders, gastroesophageal reflux, and patient symptoms. Between 2007 and 2013, we performed high-resolution esophageal manometry on 3400 patients, and 221 patients were found to have a spastic esophageal motility disorder. The medical records of these patients were reviewed to determine the manometric abnormality, presence of gastroesophageal symptoms, and amount of esophageal acid exposure. In those patients that underwent LNF, we compared pre- and postoperative esophageal motility, gastroesophageal symptom severity, and esophageal acid exposure. Of the 221 patients with spastic motility disorders, 77 had NE, 2 had JHE, 30 had DES, and 112 had HTLES. The most frequently reported primary and secondary symptoms among all patients were: heartburn and/or regurgitation, 69.2%; respiratory, 39.8%; dysphagia, 35.7%; and chest pain, 22.6%. Of the 221 patients, 192 underwent 24-hour pH monitoring, and 103 demonstrated abnormal distal esophageal acid exposure. Abnormal 24-hour pH monitoring was detected in 62% of patients with heartburn and regurgitation, 49% of patients with respiratory symptoms, 36.8 % of patients with dysphagia, and 32.6% of patients with chest pain. Sixty-six of the 103 patients with abnormal 24-hour pH monitoring underwent LNF. Thirty-eight (13NE, 2JHE, 6 DES, and 17 HTLES) of these 66 patients had a minimum of 6-month postoperative follow-up that included clinical evaluation, esophageal manometry, and 24-hour pH monitoring. Postoperatively, all 38 patients had normal distal esophageal acid exposure. Of these 38 patients, symptoms resolved in 28 and improved in 10. Of six patients (one with NE, two JHE, and three with HTLES) that underwent postoperative esophageal manometry, five exhibited normal motility. Typical reflux symptoms are common among patients with esophageal hypermotility disorders. Abnormal 24-hour pH monitoring is present in the majority of patients with who report typical reflux symptoms and almost half of patients who report respiratory symptoms. Conversely, the majority of patients who report dysphagia or chest pain have normal distal esophageal acid exposure. Based on a small number of patients in this study, it also appears that motility disorders often improve after LNF. LNF is associated with resolution or improvement in reflux related symptoms and esophageal motility parameters in patients exhibiting abnormal esophageal acid exposure. This suggests that patient symptoms are due to abnormal acid exposure and not the motility disorder.

Peroral endoscopic myotomy for Jackhammer esophagus: to cut or not to cut the lower esophageal sphincter

BACKGROUND AND STUDY AIMS

With the success of peroral endoscopic myotomy (POEM) in treatment of achalasia, its successful application to other spastic esophageal motility disorders such as Jackhammer esophagus has been noted. The question of whether the lower esophageal sphincter (LES) should be included in the myotomy for Jackhammer esophagus is a topic of current debate. Here, we report our experience and results with four patients with Jackhammer esophagus treated with POEM. The clinical and manometric results are presented and their potential implications are discussed.

PATIENTS AND METHODS

Between January 2014 and July 2015, four patients underwent POEM for treatment of Jackhammer esophagus at our center. Manometry was performed prior to and after POEM. All patients met the Chicago classification criteria for Jackhammer esophagus and received a barium esophagram and endoscopic examination before having POEM.

RESULTS

All patients had uneventful procedures without any intraoperative or post-procedure complications. Patients in which the LES was included during POEM had resolution or significant improvement in symptoms. One patient in whom the LES was preserved had resolution of chest pain but developed significant dysphagia and regurgitation. Subsequently this individual received a repeat POEM which included the LES, resulting in symptom resolution.

CONCLUSIONS

POEM is a suitable treatment for patients with Jackhammer esophagus. Until there are larger-scale randomized studies, we speculate that based on our clinical experience and physiologic and manometric observations, obligatory inclusion of the LES is justified to reduce the risk of symptom development from iatrogenic ineffective esophageal motility or subsequent progression to achalasia.

Jackhammer esophagus treated by a peroral endoscopic myotomy

A 49-year-old woman visited our hospital with dysphagia and chest pain. In another hospital, she was diagnosed as reflux esophagitis. Although she had taken proton pump inhibitor and prokinetics drugs for a long time, she was not relieved of any symptoms. On the basis of high resolution manometry and endoscopic ultrasonography findings, Jackhammer esophagus was diagnosed. In this patient, peroral endoscopic myotomy (POEM) was performed for long myotomy of thickened circular muscle. During the procedure, there were no significant complications and she was discharged uneventfully. Symptoms were completely improved during three months after POEM. Here, we report on a case of Jackhammer esophagus treated by POEM.

Peroral Endoscopic Myotomy for Treating Achalasia and Esophageal Motility Disorders

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

Peroral endoscopic myotomy: an evolving treatment for achalasia

Peroral endoscopic myotomy (POEM) was first performed in Japan in 2008 for uncomplicated achalasia. With excellent results, it was adopted by highly skilled endoscopists around the world and the indications for POEM were expanded to include advanced sigmoid achalasia, failed surgical myotomy, patients with previous endoscopic treatments and even other spastic oesophageal motility disorders. With increased uptake and performance of POEM, variations in technique and improved management of adverse events have been developed. Now, 6 years since the first case and with >3,000 procedures performed worldwide, long-term data has shown the efficacy of POEM to be long-lasting. A growing body of literature also exists pertaining to the learning curve, application of novel technologies, extended indications and physiologic changes with POEM. Ultimately, this once experimental procedure is evolving towards becoming the preferred treatment for achalasia and other spastic oesophageal motility disorders.

Peroral endoscopic myotomy (POEM) vs laparoscopic Heller myotomy (LHM) for the treatment of Type III achalasia in 75 patients: a multicenter comparative study

BACKGROUND AND STUDY AIMS

Type III achalasia is characterized by rapidly propagating pressurization attributable to spastic contractions. Although laparoscopic Heller myotomy (LHM) is the current gold standard management for type III achalasia, peroral endoscopic myotomy (POEM) is conceivably superior because it allows for a longer myotomy. Our aims were to compare the efficacy and safety of POEM with LHM for type III achalasia patients.

PATIENTS AND METHODS

A retrospective study of 49 patients who underwent POEM for type III achalasia across eight centers were compared to 26 patients who underwent LHM at a single institution. Procedural data were abstracted and pre- and post-procedural symptoms were recorded. Clinical response was defined by improvement of symptoms and decrease in Eckardt stage to ≤ 1. Secondary outcomes included length of myotomy, procedure duration, length of hospital stay, and rate of adverse events.

RESULTS

Clinical response was significantly more frequent in the POEM cohort (98.0 % vs 80.8 %; P = 0.01). POEM patients had significantly shorter mean procedure time than LHM patients (102 min vs 264 min; P < 0.01) despite longer length of myotomy (16 cm vs 8 cm; P < 0.01). There was no significant difference between POEM and LHM in the length of hospital stay (3.3 days vs 3.2 days; P = 0.68), respectively. Rate of adverse events was significantly less in the POEM group (6 % vs 27 %; P < 0.01).

CONCLUSIONS

POEM allows for a longer myotomy than LHM, which may result in improved clinical outcomes. POEM appears to be an effective and safe alternative to LHM in patients with type III achalasia.

Therapeutic options in oesophageal dysphagia

High-resolution manometry enables the categorization of patients with oesophageal dysphagia caused by oesophageal motility disorders into diagnostic categories according to the Chicago Classification. This Review provides an overview of the literature concerning treatment options for patients with dysphagia associated with achalasia, hypercontractile disorders and hypocontractility disorders of the oesophagus. In achalasia, pharmacotherapy and botulinum toxin are less effective than pneumatic dilation or surgical Heller myotomy, which had comparable efficacy in the largest controlled trial to date. Peroral endoscopic myotomy is a novel therapeutic modality that is currently being evaluated in controlled trials versus pneumatic dilation or surgical myotomy. A variety of medical treatments have been evaluated in hypermotility disorders, but only botulinum toxin injection yielded favourable results in a single controlled trial. Few studies have addressed the treatment of dysphagia in patients with oesophageal hypomotility. A variety of prokinetic agents have been studied, but there is no evidence of clinically relevant efficacy from controlled trials.

Esophageal hypomotility and spastic motor disorders: current diagnosis and treatment

Esophageal hypomotility (EH) is characterized by abnormal esophageal peristalsis, either from a reduction or absence of contractions, whereas spastic motor disorders (SMD) are characterized by an increase in the vigor and/or propagation velocity of esophageal body contractions. Their pathophysiology is not clearly known. The reduced excitation of the smooth muscle contraction mediated by cholinergic neurons and the impairment of inhibitory ganglion neuronal function mediated by nitric oxide are likely mechanisms of the peristaltic abnormalities seen in EH and SMD, respectively. Dysphagia and chest pain are the most frequent clinical manifestations for both of these dysfunctions, and gastroesophageal reflux disease (GERD) is commonly associated with these motor disorders. The introduction of high-resolution manometry (HRM) and esophageal pressure topography (EPT) has significantly enhanced the ability to diagnose EH and SMD. Novel EPT metrics in particular the development of the Chicago Classification of esophageal motor disorders has enabled improved characterization of these abnormalities. The first step in the management of EH and SMD is to treat GERD, especially when esophageal testing shows pathologic reflux. Smooth muscle relaxants (nitrates, calcium channel blockers, 5-phosphodiesterase inhibitors) and pain modulators may be useful in the management of dysphagia or pain in SMD. Endoscopic Botox injection and pneumatic dilation are the second-line therapies. Extended myotomy of the esophageal body or peroral endoscopic myotomy (POEM) may be considered in highly selected cases but lack evidence.

International multicenter experience with peroral endoscopic myotomy for the treatment of spastic esophageal disorders refractory to medical therapy (with video)

BACKGROUND

Limited data exist on the use of peroral endoscopic myotomy (POEM) for therapy of spastic esophageal disorders (SEDs).

OBJECTIVE

To study the efficacy and safety of POEM for the treatment of patients with diffuse esophageal spasm, jackhammer esophagus, or type III (spastic) achalasia.

DESIGN

Retrospective study.

SETTING

International, multicenter, academic institutions.

PATIENTS

All patients who underwent POEM for treatment of SEDs refractory to medical therapy at 11 centers were included.

INTERVENTIONS

POEM.

MAIN OUTCOME MEASUREMENTS

Eckardt score and adverse events.

RESULTS

A total of 73 patients underwent POEM for treatment of SEDs (diffuse esophageal spasm 9, jackhammer esophagus 10, spastic achalasia 54). POEM was successfully completed in all patients, with a mean procedural time of 118 minutes. The mean length of the submucosal tunnel was 19 cm, and the mean myotomy length was 16 cm. A total of 8 adverse events (11%) occurred, with 5 rated as mild, 3 moderate, and 0 severe. The mean length of hospital stay was 3.4 days. There was a significant decrease in Eckardt scores after POEM (6.71 vs 1.13; P = .0001). Overall, clinical response was observed in 93% of patients during a mean follow-up of 234 days. Chest pain significantly improved in 87% of patients who reported chest pain before POEM. Repeat manometry after POEM was available in 44 patients and showed resolution of initial manometric abnormalities in all cases.

LIMITATIONS

Retrospective design and selection bias.

CONCLUSION

POEM offers a logical therapeutic modality for patients with SEDs refractory to medical therapy. Results from this international study suggest POEM as an effective and safe platform for these patients.

Fluoroscopically guided balloon dilatation for the treatment of achalasia: long-term outcomes

To report the immediate and long-term outcomes following the fluoroscopically guided balloon dilatations performed in our department for the treatment of achalasia. We reviewed retrospectively all patients that underwent a fluoroscopically guided balloon dilatation because of achalasia in our department between April 2007 and September 2010. The follow-up was performed by interviews and/or investigation of the patient's medical and imaging records. The primary endpoints of the study were technical success, clinical success, major complication rates, and repeat dilatation rates because of recurrence of clinical symptomatology. Secondary endpoints were the rate of minor complications and the dilatation-free interval. Various parameters that could affect the clinical outcome were also analyzed. Thirty-nine consecutive patients (20 female) with a mean age 44 ± 17 years underwent 69 dilatations, while 10/39 (25.6%) patients had a history of a previous laparoscopic myotomy. The most common symptom was dysphagia (64/69, 92.7%), while regurgitation and/or retrosternal pain were present in 12/39 (30.7%) and 9/39 (23%) of the cases, respectively. Technical success was achieved in 98.5% (68/69). There were no procedure-related major complications. The mean balloon diameter used was 30 ± 3.9 mm, and the mean period of follow-up was 27.7 ± 16.0 months. Excellent or good initial responses were noted in 54/66 cases (81.8%). A repeated dilatation to deal with recurrence of symptoms was performed in 69.4% of the cases (25/36). In the majority of the cases, two dilatations were needed in order to achieve long-term relief from symptoms. A dilatation-free interval of 4 years was observed in 26.4%. Clinical success was achieved in 30/36 patients (83.3%). Subgroup analysis did not detect significantly different recurrence rates in patients with and without previous laparoscopic myotomy (50% vs. 69% respectively), those of young age (75% < 21 years vs. 68.8% > 21 years), and male gender (71.4% male vs. 55.0% females). The high redilatation rate was attributed to the utilization of smaller balloons by less experienced operators. Fluoroscopically guided balloon dilatation is a safe and effective method for the treatment of achalasia. Young age and prior Heller's laparoscopic myotomy were not associated with increased rates of recurrence rate or clinical failure.

Management of spastic disorders of the esophagus

The concept of esophageal spastic disorders encompasses spastic achalasia, distal esophageal spasm, and jackhammer esophagus. These are conceptually distinct in that spastic achalasia and distal esophageal spasm are characterized by a loss of neural inhibition, whereas jackhammer esophagus is associated with hypercontractility. Hypercontractility may also occur as a result of esophagogastric junction outflow obstruction or inflammation. The diagnosis of jackhammer esophagus as a primary motility disorder is based on the characteristic manometric findings after ruling out mechanical obstruction and eosinophilic esophagitis. Despite the differences in pathophysiology among the esophageal spastic disorders, their management is similar.

Surgical treatment for nonspecific esophageal motility disorders

PURPOSE

Nonspecific esophageal motility disorder (NEMD) is a vague category that includes patients with poorly defined contraction abnormalities observed during esophageal manometry. This study investigated the therapeutic effects of the video-assisted thoracoscopic surgery (VATS) approach using long myotomy and fundopexy for NEMD.

METHODS

The VATS approach using myotomy and fundopexy was performed for 4 patients of NEMD between 2005 and 2008. A total of 4 patients with NEMD that underwent treatment at our institution were analyzed retrospectively.

RESULTS

The patients included 2 males and 2 females with a median age of 48 years (range 21-74 years). The median duration of NEMD symptoms was 58 months (range 4-108 months). Dysphagia was a primary symptom in all patients. Chest pain was a primary symptom in 3 of 4 patients (75 %). Treatment with medication was attempted before the operation. The median operative time was 344.5 min (range 210-476 min). The median time before starting oral feeding was 2.5 days (range 2-22 days). All patients achieved a significant improvement of their previous condition.

CONCLUSIONS

The VATS approach using myotomy and fundopexy for NEMD is a good treatment in cases resistant to medication and balloon dilation.

Diffuse esophageal spasm: the surgical approach

Diffuse esophageal spasm (DES) is a rare primary motility disorder of unknown cause, that can be found in patients complaining of chest pain and dysphagia and in whom ischemic heart disease and GERD have been excluded. The manometric hallmark of DES is the presence of simultaneous contractions in the distal esophagus alternating with a normal peristalsis. Even at specialized esophageal motility laboratories, DES is considered an uncommon diagnosis. In this review, the authors discuss the clinical and diagnostic aspects of this disease, as well as the possible therapeutic options (medical, endoscopic or surgical therapy). Surgery (esophageal myotomy performed through a thoracotomy or with a thoracoscopic access) seems to have a better outcome than medical or endoscopic treatment, and it is considered "the last resource" in these patients. However, satisfactory results are reported, from highly skilled centers, in only about 70% of treated cases, certainly inferior to those achieved in other esophageal disorders. The role of surgery in this disease requires therefore further study, even if controlled trials are probably difficult to perform, due to the rarity of the disease.

Balloon dilatation of esophageal strictures/achalasia

Achalasia is an esophageal motor disorder characterized by increased lower esophageal sphincter (LES) pressure, diminished-to-absent peristalsis in the distal portion of the esophagus composed of smooth muscle, and lack of a coordinated LES relaxation in response to swallowing. These abnormalities are recognized radiographically by aperistalsis, esophageal dilatation, and decreased opening of the LES, with a characteristic "bird-beak" appearance. The principal symptom of this disorder is dysphagia and pneumatic dilatation is designed to alleviate or cure this symptom.

Benign esophageal disease in the elderly

For the most part, the management of benign esophageal disease in all patients is in evolution. Advances in laparoscopic, thoracoscopic, and endoscopic techniques have lessened the morbidity and mortality associated with the traditional approaches to this pathology. Our understanding of the pathophysiology of primary motor disorders remains incomplete but is certainly more advanced than our understanding just a decade ago. As research continues in this area, our knowledge will increase. Persistent development efforts with industry will continue to provide less invasive options for the management of these patients, and, eventually, the results associated with these techniques will improve as well. For the management of these pathologies in the elderly, the critical issues are the associated comorbidities, the current quality of life, the life expectancy, and the desired quality of life. The optimal treatment strategy may be determined by consideration of all of these factors along with the relative effectiveness and durability of each treatment strategy for the individual elderly patient.

Oesophageal achalasia: an argument for primary surgical management

INTRODUCTION

Achalasia is a primary oesophageal motility disorder resulting from damage to the ganglion cells of the myenteric plexus. Impaired relaxation of the lower oesophageal sphincter and aperistalsis causes its cardinal symptoms of dysphagia, chest pain and reflux-type symptoms. Management is somewhat controversial, with options including systemic and local pharmacotherapy, dilatation and oesophagomyotomy. We review the presentation, investigation and management of oesophageal achalasia and make an argument for primary surgical management.

METHODS

We performed a Medline search of the term 'achalasia', limiting the search to clinical trials and meta-analyses. We then selected articles based on their abstracts using four main criteria: previously unreported findings, previously unreported techniques, size of patient cohort and journal impact factor. References in selected articles were manually searched for other relevant articles.

FINDINGS

Achalasia has been managed using a variety of techniques including systemic and local pharmacotherapy, forced dilatation and oesophagomyotomy. Success rates vary widely between techniques. Mechanical disruption ofthe lower oesophageal sphincter is most successful.

DISCUSSION

In achalasia, mechanical disruption of the lower oesophageal sphincter using forced dilatation or surgical myotomy offers the only realistic prospect of long-term symptom relief. Recent evidence suggests that previous medical treatment or dilatation makes oesophagomyotomy more difficult and increases the risk of complications. As the morbidity associated with surgery continues to decrease with improvements in minimal access techniques, the argument for primary management of achalasia with oesophagomyotomy becomes more compelling.

Evaluating long-term results of modified Heller limited esophagomyotomy in children with esophageal achalasia

BACKGROUND/PURPOSE

Modified Heller esophagomyotomy has become the initial treatment of choice for esophageal achalasia in children. However, only limited and not objective data are currently available on the long-term results of modified Heller limited esophagomyotomy (LEM). This retrospective study was undertaken to objectively assess the long-term results of LEM in childhood esophageal achalasia.

METHODS

Medical records of 15 patients with a median age of 9.5 years (range, 6-13 years) who underwent an LEM without an antireflux procedure from January 1991 to December 2005 were reviewed. Clinical scores, barium esophagogram, flexible upper alimentary endoscopy, 24-hour esophageal pH monitoring, and esophageal manometry before and 0.5 to 15 years after surgery were analyzed.

RESULTS

An excellent to good outcome was observed in 14 (93.3%) patients. One patient (6.7%) required reoperation 8 months after surgery because of persistent dysphagia. The late barium esophagogram showed a significant decrease (from 4.2 +/- 0.95 to 2.4 +/- 1.1 cm, P < .01) of esophageal diameter, as compared with preoperative values. Only 1 patient had grade II esophagitis on flexible upper alimentary endoscopy. Twenty-four- hour esophageal pH monitoring showed an abnormal acid exposure in 1 patient. The late esophageal manometry showed a significant decrease (from 31.7 +/- 7.9 to 7.8 +/- 3.7 mm Hg; < .05) of lower esophageal sphincter (LES) pressure, and only insignificant increase (from 18.8 +/- 6.2 to 21.4 +/- 8.4 mm Hg; NS) of amplitude of esophageal contractions over preoperative values.

CONCLUSIONS

Transabdominal LEM without an antireflux procedure is an effective and safe treatment of esophageal achalasia in children because of its long-term high rate of symptoms relief and low incidence of postoperative complications, despite the lack of esophageal motility restoration to normal.

A comprehensive appraisal of the surgical treatment of diffuse esophageal spasm

Diffuse esophageal spasm is a motility disorder of undetermined cause. The optimal treatment remains controversial, and evidence-based data are lacking. Several medical treatment modalities have been proposed, but none has emerged as the treatment of choice. Patients who do not respond to medical therapy may be considered for surgical treatment. The surgical treatment of diffuse esophageal spasm is based on similar principles to the treatment of achalasia. A long esophageal myotomy is done to divide the hypertrophied circular muscle that is frequently noted in diffuse esophageal spasm. To protect against postoperative reflux, an antireflux procedure may be added. However, the surgical treatment of diffuse esophageal spasm has not been subjected to randomized clinical trials. The purpose of this article is to provide a review of the available literature regarding the surgical management of the diffuse esophageal spasm. In particular, we offer an appraisal of surgical outcomes, the effects of surgery on manometric and radiologic parameters (when available), complications, and mortality.

Surgical treatment of primary esophageal motility disorders

Named primary esophageal motility disorders (PEMD) present with specific manometric patterns classified as: (1) hypertensive lower esophageal sphincter, (2) nutcracker esophagus (also hypercontratile, hypertensive, or hypercontracting esophagus), (3) diffuse esophageal spasm, and (4) achalasia. These conditions, with the exception of achalasia, are rare, poorly understood, and inadequately studied. Treatment of these conditions is based on symptoms and aimed at symptomatic improvement. The authors reviewed current literature on surgical treatment of non-achalasia PEMD. The review shows that: (a) surgical therapy may be an attractive alternative in patients with PEMD; (b) proper selection of patients based on symptoms evaluation and esophageal function tests is essential; (c) laparoscopic myotomy with proximal extent tailored to manometric findings seems to be the ideal surgical therapy; and (d) esophagectomy may be necessary as a last resource due to multiple failures of surgical conservative treatment.

Diffuse esophageal spasm

The purpose of this article is to review the clinical features, pathophysiology, diagnosis, and management of patients with diffuse esophageal spasm (DES). The PubMed database was searched with a focus on recent publications, using keywords "DES," plus "epidemiology," "prevalence," "diagnosis," "pathogenesis," "calcium channel blocker," "nitrates," "botulinum toxin," "antidepressants," "dilation," and "myotomy." The reference lists of papers identified in the initial PubMed search were reviewed for further relevant publications.

Laparoscopic esophagomyotomy for achalasia without a complementary antireflux procedure

BACKGROUND

Achalasia is a progressive motility disorder of the esophagus, without a definitive cure. The principal method of palliation is myotomy of the distal esophagus. We analyzed the 5-year experience at our institution with laparoscopic Heller myotomy without an antireflux procedure to determine its results, particularly regarding postoperative gastroesophageal reflux.

MATERIALS AND METHODS

Thirty-three patients, mean age 43 years (range, 29-62 years) with clinical, manometric, x-ray, and endoscopic proof of achalasia were operated on and followed up for 24 months. Prior to being referred to surgery they had all undergone at least one pneumatic balloon dilation. The operative technique was a 7-cm myotomy that included the lower esophageal sphincter but did not exceed 5 mm of the gastric cardia. Follow-up consisted of clinical observation, cineesophagography, and 24-hour pHmetry.

RESULTS

All patients reported satisfactory to excellent results regarding dysphagia and no heartburn two years after the operation. The 24-hour pHmetry and the radiographic investigation showed no evidence of gastroesophageal reflux.

CONCLUSION

It seems that the risk of gastroesophageal reflux is very low when the cardiomyotomy does not exceed the length of 5 mm. Our results are in accordance with other observational studies as well as larger cohort and meta-analysis studies. Prospective randomized studies are needed to clarify the role of an antireflux procedure after laparoscopic Heller myotomy.

A total fundoplication is not an obstacle to esophageal emptying after heller myotomy for achalasia: results of a long-term follow up

OBJECTIVE

The aim of this study was to evaluate the role and efficacy of a total 360 degrees wrap, Nissen-Rossetti fundoplication, after esophagogastromyotomy in the treatment of esophageal achalasia.

SUMMARY BACKGROUND DATA

Surgery actually achieves the best results in the treatment of esophageal achalasia; the options vary from a short extramucosal esophagomyotomy to an extended esophagogastromyotomy with an associated partial fundoplication to restore the main antireflux barrier. A total 360 degrees fundoplication is generally regarded as an obstacle to esophageal emptying.

MATERIALS AND METHODS

Since 1992 to November 2003, a total of 195 patients (91 males, 104 females), mean age 45.2 years (range, 12-79 years), underwent laparoscopic treatment of esophageal achalasia. Intervention consisted of Heller myotomy and Nissen-Rossetti fundoplication with intraoperative endoscopy and manometry.

RESULTS

In 3 patients (1.5%), a conversion to laparotomy was necessary. Mean operative time was 75 +/- 15 minutes. No mortality was observed. Overall major morbidity rate was 2.1%. Mean postoperative hospital stay was 3.6 +/- 1.1 days (range, 1-12 days). At a mean clinical follow up of 83.2 +/- 7 months (range, 3-141 months) on 182 patients (93.3%), an excellent or good outcome was observed in 167 patients (91.8%) (dysphagia DeMeester score 0-1). No improvement of dysphagia was observed in 4 patients (2.2%). Gastroesophageal pathologic reflux was absent in all the patients.

CONCLUSIONS

Laparoscopic Nissen-Rossetti fundoplication after Heller myotomy is a safe and effective treatment of esophageal achalasia with excellent results in terms of dysphagia resolution, providing total protection from the onset of gastroesophageal reflux.

Long-term outcome of pneumatic dilation in the treatment of achalasia

OBJECTIVE

Achalasia is a well-defined esophageal motor disorder for which pneumatic dilation is an established therapeutic method. Even though it has been used for several years, there are limited data on the long-term outcomes of patients treated with this procedure. Hence, we aimed to evaluate the long-term efficacy of pneumatic dilation to control the symptoms of achalasia.

METHODS

The medical records of all patients treated in our unit for achalasia with pneumatic dilation were reviewed. We identified the long-term result of the initial procedure, the date of the first dilation, and the time interval between dilation and retreatment.

RESULTS

Of 260 patients who were treated with pneumatic dilation, 153 (67 men, 86 women) were followed up for more than 5 yr. The mean follow-up period was 11.09 +/- 3.91 yr, and the success rate of the dilation was 75.8%. Among these patients, 35 (19 men, 16 women) had follow-up periods of more than 15 yr. The mean follow-up time of those patients was 16.56 +/- 1.09 yr, and the success rate was 51.4%. Kaplan-Meier survival analysis showed that, overall, 50% of patients develop recurring symptoms after 10.92 yr.

CONCLUSIONS

Although 51.4% of patients continued to be in clinical remission more than 15 yr after the initial pneumatic dilation, the long-term success rate of pneumatic dilation seems to drop progressively with time.

Cardiaplasty and Roux-en-Y partial gastrectomy (Serra-Dória procedure) for reoperation of achalasia

BACKGROUND

After cardiomyotomy for the treatment of megaesophagus, recurrence of symptoms occur in up to 15% of the patients, but only some require a reoperation.

AIM

To evaluate the results of reoperation -- cardioplasty with Roux-en-Y partial gastrectomy, a technique proposed by Serra-Dória.

CASUISTIC AND METHODS

Twenty patients with achalasia previously treated by cardiomyotomy, were retrospectively studied. The etiology of symptoms recurrence was reflux esophagitis in nine (45.0%) patients, healing of the myotomy in five (25.0%), end staging megaesophagus in five (25.0%) and incomplete myotomy in one (5%). Intra and postoperative complications were analyzed. The patients were studied by clinical (dysphagia, regurgitation, heartburn and weight gain), radiological and endoscopic evaluation, in the pre- and postoperative period.

RESULTS

Five (25.0%) patients had complications in the immediate postoperative period. No deaths were observed. Dysphagia improved in all the patients. Regurgitation and heartburn almost disappeared in the whole group. Weight was maintained or increased in 64.7% of the patients. Radiological studies showed a decrease in the caliber of the esophagus in 53.0%, while the remaining patients maintained the pre-operative diameter. Endoscopy, performed during the late postoperative period in 17 patients, showed that 6 among the 9 with reflux esophagitis improved; 2 among the 8 with a normal esophagus during the preoperative period, developed esophagitis.

CONCLUSIONS

The Serra-Dória procedure for the treatment of megaesophagus in patients who had already undergone cardiomyotomy and whose symptoms recurred, presented a low morbidity and no mortality. It offered a significant relief of symptoms with a decrease of the caliber of the esophagus in several patients. The patients also improved with regards to reflux esophagitis. In some cases reflux was still present after surgery. Others with normal esophagus in the preoperative period developed esophagitis.

Laparoscopic Heller myotomy and fundoplication: findings and predictive value of early postoperative radiographic studies

BACKGROUND

We describe the findings on esophagography, the frequency and appearance of leaks after laparoscopic Heller myotomy and fundoplication, and the utility of early postoperative studies for predicting clinical outcome.

METHODS

Our study group consisted of 40 patients who underwent laparoscopic Heller myotomy and fundoplication in whom radiographic studies were performed during the early postoperative period. The radiographic reports and images were reviewed to determine the esophageal diameter, visualization or nonvisualization of the wrap, and the presence or absence of a leak. The esophageal diameter subsequently was correlated with the clinical findings to determine whether this was a useful parameter for predicting clinical outcome.

RESULTS

Two patients (5%) had small, sealed-off leaks on radiographic studies, and four (10%) had pseudo-leaks resulting from trapping of contrast material alongside the fundoplication wrap. Twelve (60%) of 20 patients with a dilated esophagus had esophageal symptoms on short-term follow-up versus three (15%) of 20 with a normal-caliber esophagus (p = 0.008), and five (56%) of nine patients with a dilated esophagus had symptoms on long-term follow-up versus six (43%) of 14 with a normal-caliber esophagus (p = 0.68).

CONCLUSION

Radiographic studies are useful for showing leaks after laparoscopic Heller myotomy and fundoplication, but radiologists should differentiate true leaks from trapping of contrast material alongside the fundoplication wrap. The caliber of the esophagus on early postoperative studies is also a useful parameter for predicting short-term clinical outcome in these patients.

Early results of laparoscopic Heller myotomy do not necessarily predict long-term outcome

BACKGROUND

We sought to evaluate how patients' symptoms evolve after laparoscopic Heller myotomy.

METHODS

Before and after laparoscopic Heller myotomy, 88 patients graded dysphagia and heartburn on a Likert scale (0 = none; 5 = severe). Patients graded outcomes as excellent, good, fair, or poor. Outcomes were compared in the same patients at 1 and 3 years of follow-up.

RESULTS

At early follow-up (10.6 +/- 7.8 months) significant reductions were noted in dysphagia (11% versus 100%), dysphagia scores (0.6 +/- 1.1 versus 4.7 +/- 0.7), heartburn (31% versus 72%), and heartburn scores (1.2 +/- 1.6 versus 2.7 +/- 1.9). By late follow-up (37.6 months +/- 18.0) these values increased (47%, 1.9 +/- 1.7, 48%, 1.8 +/- 1.5, respectively) but remained significantly reduced compared with before operation. Excellent/good outcomes at early and late follow-up were 89% and 85%, respectively (P = not significant).

CONCLUSIONS

Laparoscopic Heller myotomy is highly effective at palliating the symptoms of achalasia. With time, symptoms may recur owing to esophageal dysmotility, mandating continued surveillance.

Treatment of epiphrenic and mid-esophageal diverticula

Thoracic esophageal diverticula are uncommon. They account for less than 30% of esophageal diverticula. The majority of patients are asymptomatic or have minimal symptoms. About one third of patients present with severe symptoms. Occasionally, pulmonary symptoms can be the sole manifestation of the disease and can be life threatening. Dysphagia, food regurgitation, chest pain, weight loss, and reflux symptoms are the most commonly encountered gastrointestinal symptoms. Malignancy is a rare complication of esophageal diverticula; therefore, patients should be educated regarding this complication. Appropriate diagnostic tests should be arranged promptly if alarming symptoms develop. Esophageal motor disorders are found in the majority of patients and need to be taken into account when planning therapy. Medical and endoscopic therapies have limited roles in treatment. Surgery is the standard of care for patients with pulmonary or incapacitating symptoms related to an epiphrenic diverticulum, and myotomy is the cornerstone of surgery. To ensure complete relief of the obstruction, the myotomy should extend distally at least 1.5 to 2 cm into the stomach and proximally at least to the neck of diverticulum. Adding a nonobstructing entireflux procedure is recommended to prevent the development of gastroesophageal reflux disease. Occasionally, a specific treatment such as a diverticulectomy or diverticulopexy needs to be directed to the diverticulum. Preliminary treatment results from minimally invasive surgery, especially laparoscopy, have been promising. In the future with increased experience, minimally invasive surgery may become the standard of care.

Electrical stimulation of the vagus nerve restores motility in an animal model of achalasia

Esophageal peristalsis generally does not return to normal after surgical treatment of achalasia. Direct electrical stimulation of the vagus nerve is known to stimulate antegrade peristalsis in the normal esophagus; however, it is not known whether electrical stimulation will induce return of peristalsis once an achalasia-like disorder has been established. The objective of this study was to perform quantitive and qualitative measurements of motility during electrical stimulation of the vagal nerve in an animal model of achalasia. An already established and verified animal achalasia model using adult North American opossums (Didelphis virginiana) was used. Fifteen opossums were divided into three groups. Sham surgery was performed on three animals (group 1). In group 2 (n=6) a loose Gore-Tex band (110% of the esophageal circumference) was placed around the gastroesophageal junction to prevent relaxation of the lower esophageal sphincter during swallowing. In group 3 (n=6) a relatively tighter band (90% of the esophageal circumference) was used to further elevate the lower esophageal sphincter pressure. At 6 weeks, after manometric and radiolologic confirmation of achalasia, electrical stimulation of the esophagus was performed before and after removal of the band using a graduated square-wave electrical stimulus. Changes in esophageal neural plexi were assessed histologically. Pre- and postoperative manometric data were compared using standard statistical techniques. No difference was observed in esophageal characteristics and motility after sham surgery in group 1. Animals in group 2 demonstrated a vigorous variety of achalasia (high-amplitude, simultaneous, repetitive contractions), moderate esophageal dilatation, and degeneration of 40% to 60% of intramuscular nerve plexi. Animals in group 3 developed amotile achalasia with typical low-amplitude simultaneous (mirror image) contractions, severely dilated ("bird beak") esophagus, and degeneration of 50% to 65% of nerve plexi. Vagal stimulation in group 2 demonstrated a significant increase in the amplitude of contractions (P<0.001) and return of peristaltic activity in 49% of swallows before band removal. After band removal, all of the contractions were peristaltic. In group 3 vagal stimulation before and after removal of the band demonstrated a significant increase in amplitude of contractions (P<0.0001) but no return of propagative peristalsis before band removal, however, 44% of contractions were progressive in the smooth portion of the esophagus after removal of the band. Electrical stimulation of the vagus nerve improved the force of esophageal contractions irrespective of the severity of the disease; however, peristaltic activity completely returned to normal only in the vigorous (early) variety of achalasia. Removal of the functional esophageal outlet obstruction, as with a surgical myotomy, may be necessary to obtain significant peristalsis with vagal pacing in severe achalasia.