High resolution manometry sub-classification of Achalasia: does it really matter? Does Achalasia sub-classification matter?

Long-term outcomes of peroral endoscopic myotomy for Chicago classification type I vs type III achalasia in treatment-naive patients

The efficacy of peroral endoscopic myotomy (POEM) for achalasia has potential associations with Chicago classification by high-resolution manometry (HRM). Type II achalasia demonstrates the best response to POEM of all subtypes, while there remain controversies between type I and type III. Moreover, previous treatment history might cause discrepancy in direct comparison. We aimed to compare the clinical outcome of POEM for type I vs type III in treatment-naive patients. In total, 82 patients with type I or type III achalasia (45 type I, 37 type III) from February 2015 to December 2018 were enrolled and POEM was carried out as the initial treatment. Clinical success, change of Eckardt scores and HRM parameters were analyzed and compared between type I and type III group. About, 43 (95.6%) patients and 34 (91.9%) patients in type I and type III group acquired the clinical success (P = 0.821). Eckardt score and HRM results after POEM treatment decreased significantly in either group (P<0.01). Compared to type III group, higher reduction rates of Eckardt score (type I vs type III, 78.6 vs 66.9%, P = 0.034) and basal LES pressure (type I vs type III, 58.9 vs 40.4%, P = 0.040) were observed in type I group. Type I achalasia patients showed better response to POEM with more favorable clinical remission in Eckardt score and HRM outcomes than type III.

ACG Clinical Guidelines: Diagnosis and Management of Achalasia

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.

British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring

These guidelines on oesophageal manometry and gastro-oesophageal reflux monitoring supersede those produced in 2006. Since 2006 there have been significant technological advances, in particular, the development of high resolution manometry (HRM) and oesophageal impedance monitoring. The guidelines were developed by a guideline development group of patients and representatives of all the relevant professional groups using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. A systematic literature search was performed and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) tool was used to evaluate the quality of evidence and decide on the strength of the recommendations made. Key strong recommendations are made regarding the benefit of: (i) HRM over standard manometry in the investigation of dysphagia and, in particular, in characterising achalasia, (ii) adjunctive testing with larger volumes of water or solids during HRM, (iii) oesophageal manometry prior to antireflux surgery, (iv) pH/impedance monitoring in patients with reflux symptoms not responding to high dose proton pump inhibitors and (v) pH monitoring in all patients with reflux symptoms responsive to proton pump inhibitors in whom surgery is planned, but combined pH/impedance monitoring in those not responsive to proton pump inhibitors in whom surgery is planned. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG.

Use of a report card to evaluate outcomes of achalasia surgery: beyond the Eckardt score

BACKGROUND

Achalasia outcome is primarily defined using the Eckardt score with failure recognized as > 3. However, patients experience many changes after myotomy including new onset GERD, swallowing difficulties, and potential need for additional treatment. We aim to devise a comprehensive assessment tool to demonstrate the extent of patient-reported outcomes, objective changes, and need for re-interventions following myotomy.

METHODS

We performed a retrospective chart review of surgically treated primary achalasia patients. We identified 185 patients without prior foregut surgery who underwent either per oral endoscopic myotomy (POEM) or Heller myotomy from 2005 to 2017. Eight outcome measures in subjective, objective, and interventional categories formulated a global postoperative assessment tool. These outcomes included Eckardt score, Dakkak Dysphagia score, GERD-HRQL score, normalization of pH scores and IRP, esophagitis, timed barium clearance at 5 min, and the most invasive re-intervention performed.

RESULTS

Of 185 patients, achalasia subtypes included Type I = 42 (23%), II = 109 (59%), and III = 34 (18%). Patients underwent minimally invasive myotomy in 114 (62%), POEM in 71 (38%). Median proximal myotomy length was 4 cm (IQR 4-5) and distal 2 cm (IQR 2-2.5). Based on postoperative Eckardt score, 135/145 (93%) had successful treatment of achalasia. But, only 47/104 (45%) reported normal swallowing, and 78/108 (72%) had GERD-HRQL score ≤ 10. Objectively, IRP was normalized in 48/60 (80%), whereas timed barium clearance occurred in 51/84 (61%). No evidence of esophagitis was documented in 82/115 (71%). Postoperative normal DeMeester scores occurred in 38/76 (50%). No additional treatments were required in 110/139 (79%) of patients.

CONCLUSIONS

Use of the Eckardt score alone to assess outcomes after achalasia surgery shows outstanding results. Using patient-reported outcomes, objective measurements, re-intervention rates, organized into a report card provides a more comprehensive and informative view.

Long-Term Efficacy of Peroral Endoscopic Myotomy for Patients with Achalasia: Outcomes with a Median Follow-Up of 36 Months

OBJECTIVE

This study aimed to evaluate the long-term efficacy of peroral endoscopic myotomy (POEM) for patients with achalasia.

METHODS

Prospective data collected from 115 patients (median age 45 years; interquartile range 34-57) with achalasia who underwent POEM at the First Affiliated Hospital of ZheJiang Chinese Medical University with a median follow-up of 36 months were retrospectively analyzed. The Eckardt score and lower esophageal sphincter pressure changes were analyzed, and the gastroesophageal reflux was observed.

RESULTS

During the final follow-up, the mean Eckardt score reduced from 7.5 ± 1.9 preoperatively to 2.3 ± 1.4 after 1 month of surgery (P < 0.001). Treatment success was observed in 91.3% [confidence interval (CI) 86.2-96.4], 90.3% (CI 84.8-95.8), 89.0% (CI 83.1-94.9), 83.7% (CI 75.7-91.7), and 80.1% (CI 69.7-90.5) of patients after 12, 24, 36, 48, and 60 months, respectively. A total of 16 (13.9%) failures occurred. Four patients were nonresponders (failure within 3 months), eight had an early recurrence (between 3 months and 3 years), and four had a late recurrence (after 3 years). Further, 21 (20.6%) patients had symptoms of reflux during the two-year follow-up. Only one patient with symptomatic reflux was newly added during the subsequent three-year follow-up. Moreover, 71 (61.7%) patients underwent gastroscopy after POEM, and 13 (18.3%) patients were diagnosed with reflux esophagitis.

CONCLUSION

POEM is safe and effective in treating achalasia and has a favorable long-term efficacy.

Myotomy length informed by high-resolution esophageal manometry (HREM) results in improved per-oral endoscopic myotomy (POEM) outcomes for type III achalasia

INTRODUCTION

High-resolution esophageal manometry (HREM) is essential in characterizing achalasia subtype and the extent of affected segment to plan the myotomy starting point during per-oral endoscopic myotomy (POEM). However, evidence is lacking that efficacy is improved by tailoring myotomy to the length of the spastic segment on HREM. We sought to investigate whether utilizing HREM to dictate myotomy length in POEM impacts postoperative outcomes.

METHODS

Comparative analysis of HREM-tailored to non-tailored patients from a prospectively collected database of all POEMs at our institution January 2011 through July 2017. A tailored myotomy is defined as extending at least the length of the diseased segment, as initially measured on HREM.

RESULTS

Forty patients were included (11 tailored versus 29 non-tailored). There were no differences in patient age (p = 0.6491) or BMI (p = 0.0677). Myotomy lengths were significantly longer for tailored compared to non-tailored overall (16.6 ± 2.2 versus 13.5 ± 1.8; p < 0.0001), and for only type III achalasia (15.9 ± 2.4 versus 12.7 ± 1.2; p = 0.0453), likely due to more proximal starting position in tailored cases (26.0 ± 2.2 versus 30.0 ± 2.7; p < 0.0001). Procedure success (Eckardt < 3) was equivalent across groups overall (p = 0.5558), as was postoperative Eckardt score (0.2 ± 0.4 versus 0.8 ± 2.3; p = 0.4004). Postoperative Eckardt score was significantly improved in the tailored group versus non-tailored for type III only (0.2 ± 0.4 versus 1.3 ± 1.5; p = 0.0435). A linear correlation was seen between increased length and greater improvement in Eckardt score in the non-tailored group (p = 0.0170).

CONCLUSIONS

Using HREM to inform surgeons of the proximal location of the diseased segment resulted in longer myotomies, spanning the entire affected segment in type III achalasia, and in lower postoperative Eckardt scores. Longer myotomy length is often more easily achieved with POEM than with Heller myotomy, which raises the question of whether POEM results in better outcomes for type III achalasia, as types I and II do not generally have measurable spastic segments.

Achalasia-an unnecessary long way to diagnosis

Although achalasia presents with typical symptoms such as dysphagia, regurgitation, weight loss, and atypical chest pain, the time until first diagnosis often takes years and is frustrating for patients and nevertheless associated with high costs for the healthcare system. A total of 563 patients were interviewed with confirmed diagnosis of achalasia regarding their symptoms leading to diagnosis along with past clinical examinations and treatments. Included were patients who had undergone their medical investigations in Germany. Overall, 527 study subjects were included (male 46%, female 54%, mean age at time of interview 51 ± 14.8 years). Dysphagia was present in 86.7%, regurgitation in 82.9%, atypical chest pain in 79%, and weight loss in 58% of patients before diagnosis. On average, it took 25 months (Interquartile Range (IQR) 9-65) until confirmation of correct diagnosis of achalasia. Though, diagnosis was confirmed significantly quicker (35 months IQR 9-89 vs. 20 months IQR 8-53; p < 0.01) in the past 15 years. The majority (72.1%) was transferred to three or more specialists. Almost each patient underwent at least one esophagogastroduodenoscopy (94.2%) and one radiological assessment (89.3%). However, esophageal manometry was performed in 70.4% of patients only. The severity of symptoms was independent with regard to duration until first diagnosis (Eckardt score 7.14 ± 2.64 within 12 months vs. 7.29 ± 2.61 longer than 12 months; P = 0.544). Fifty-five percent of the patients primarily underwent endoscopic dilatation and 37% a surgical myotomy. Endoscopic dilatation was realized significantly faster compared to esophageal myotomy (1 month IQR 0-4 vs. 3 months IQR 1-11; p < 0.001). Although diagnosis of achalasia was significantly faster in the past 15 years, it still takes almost 2 years until the correct diagnosis of achalasia is confirmed. Alarming is the fact that although esophageal manometry is known as the gold standard to differentiate primary motility disorders, only three out of four patients had undergone this diagnostic pathway during their diagnostic work-up. Better education of medical professionals and broader utilization of highly sensitive diagnostic tools, such as high-resolution manometry, are strictly necessary in order to correctly diagnose affected patients and to offer therapy faster.

Per-oral endoscopic myotomy for achalasia

Symptoms in patients with achalasia are produced by outflow obstruction at the level of the lower esophageal sphincter (LES). As a consequence of neural destruction the LES does not undergo normal swallow-induced relaxation. In addition, the esophageal body loses normal peristaltic function and esophageal emptying is on the basis of gravity. All therapies for achalasia are palliative in that normal LES or esophageal body function cannot be restored. The efficacy of any therapy for achalasia is directly related to its ability to reduce the outflow obstruction at the LES. The three main treatment options are pneumatic dilatation, laparoscopic myotomy and partial fundoplication and per-oral endoscopic myotomy or per-oral esophageal myotomy (POEM). Details of the procedures and outcomes will be discussed.

Achalasia symptom response after Heller myotomy segregated by high-resolution manometry subtypes

BACKGROUND

Achalasia is classified into three HRM subtypes that predict outcomes from diverse management strategies. We assessed if symptomatic response varied when a single management strategy-Heller myotomy (HM)-is employed.

METHODS

Treatment-naive subjects with achalasia referred for HM were followed in this observational cohort study. Chicago criteria designated achalasia subtypes (subtype I: no esophageal pressurization; subtype II: panesophageal pressurization in ≥20 % swallows; subtype III: premature contractions in ≥20 % swallows). Symptom questionnaires assessed symptom burden before and after HM on five-point Likert scales (0 = no symptoms, 4 = severe symptoms) and on 10-cm visual analog scales (global symptom severity, GSS); satisfaction with HM was recorded similarly. Data were analyzed to determine predictors of GSS change across subtypes.

RESULTS

Sixty achalasia subjects (56.1 ± 2.4 years, 55 % female) fulfilled inclusion criteria, 15 % with subtype I, 58 % with subtype II, and 27 % with subtype III achalasia. Baseline symptoms included dysphagia (solids: 85 %, liquids: 73 %), regurgitation (84 %), and chest pain (35 %); mean GSS was 7.1 ± 0.3. Upon follow-up 2.1 ± 0.2 years after HM, GSS declined to 1.9 ± 0.4 (p < 0.001), with surgical satisfaction score of 8.7 ± 0.3 out of 10; these were similar across achalasia subtypes. On univariate analysis, female gender, Eckardt score, severity of transit symptoms, and maximal IRP predicted linear GSS improvement; female gender (p = 0.003) and dysphagia for liquids (p = 0.043) remained predictive on multivariate analysis.

CONCLUSIONS

When a uniform surgical approach is utilized, symptomatic outcome and satisfaction with therapy are similar across achalasia subtypes. Female gender and severity of dysphagia for solids may predict better HM outcome.

Peroral endoscopic myotomy

Peroral endoscopic myotomy (POEM) incorporates concepts of natural orifice translumenal endoscopic surgery and achieves endoscopic myotomy by utilizing a submucosal tunnel as an operating space. Although intended for the palliation of symptoms of achalasia, there is mounting data to suggest it is also efficacious in the management of spastic esophageal disorders. The technique requires an understanding of the pathophysiology of esophageal motility disorders as well as knowledge of surgical anatomy of the foregut. POEM achieves short term response in 82% to 100% of patients with minimal risk of adverse events. In addition, it appears to be effective and safe even at the extremes of age and regardless of prior therapy undertaken. Although infrequent, the ability of the endoscopist to manage an intraprocedural adverse event is critical as failure to do so could result in significant morbidity. The major late adverse event is gastroesophageal reflux which appears to occur in 20% to 46% of patients. Research is being conducted to clarify the optimal technique for POEM and a personalized approach by measuring intraprocedural esophagogastric junction distensibility appears promising. In addition to esophageal disorders, POEM is being studied in the management of gastroparesis (gastric pyloromyotomy) with initial reports demonstrating technical feasibility. Although POEM represents a paradigm shift the management of esophageal motility disorders, the results of prospective randomized controlled trials with long-term follow up are eagerly awaited.

Optimizing Patient Selection and Outcomes for Surgical Treatment of GERD and Achalasia

OPINION STATEMENT

Gastroesophageal reflux disease is a common disorder in the United States and other western countries. In addition to troublesome symptoms, this condition is associated with impaired quality of life and the potential for disease progression to esophageal adenocarcinoma. Acid suppression medications are extremely effective for the relief of heartburn symptoms, but don't address the physiologic derangements that cause reflux. The goal of an antireflux procedure is to correct these defects and abolish the dietary and lifestyle compromises that accompany medical therapy for gastroesophageal reflux. The Nissen fundoplication has a long and well-established track record and new options such as the LINX magnetic sphincter augmentation device allow correction of reflux with fewer side-effects than a fundoplication in appropriate patients. These options should be considered in patients incompletely satisfied on medical therapy and in those with risk factors for disease progression. The role of these therapies in patients with gastroesophageal reflux disease will be reviewed in this chapter. Achalasia is an uncommon motility disorder of the esophagus that leads to profound dysphagia symptoms and greatly impaired alimentary satisfaction. Pneumatic dilation offers an endoscopic approach to the management of these patients, but often requires repeated dilatations due to the inconsistent disruption of the lower esophageal sphincter with this technique. An alternative is a laparoscopic Heller myotomy, which offers precise division of the muscle of the lower esophageal sphincter, but requires incisions and lifestyle restrictions while healing. A new therapy, per-oral endoscopic myotomy, allows the precise division of the lower esophageal sphincter muscle as in a laparoscopic myotomy, but is done endoscopically with no external incisions. The role of these therapies in patients will be reviewed in this chapter.