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Nakamura J, Hikichi T, Hashimoto M, Kato T, Yanagita T, Takagi T, Ohira H. Pull-back myotomy to prevent mucosal injury during peroral endoscopic myotomy for jackhammer esophagus. Endoscopy 2024; 56:E362-E363. [PMID: 38657672 PMCID: PMC11042875 DOI: 10.1055/a-2301-8035] [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] [Indexed: 04/26/2024]
Affiliation(s)
- Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Minami Hashimoto
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Tsunetaka Kato
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Takumi Yanagita
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Tadayuki Takagi
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
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Wessels EM, Nullens S, Bastiaansen BA, Fockens P, Masclee GM, Bredenoord AJ. Routine esophagram to detect early esophageal leakage after peroral endoscopic myotomy. Endosc Int Open 2024; 12:E604-E612. [PMID: 38681147 PMCID: PMC11052647 DOI: 10.1055/a-2294-8607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 03/21/2024] [Indexed: 05/01/2024] Open
Affiliation(s)
- Elise M. Wessels
- Gastroenterology & Hepatology, Amsterdam UMC, Amsterdam, Netherlands
| | - Sara Nullens
- Department of Gastroenterology and Hepatology, University Hospital Antwerp, Edegem, Belgium
- Department of Gastroenterology and Hepatology, GZA Hospitals, Wilrijk, Belgium
| | | | - Paul Fockens
- Gastroenterology & Hepatology, Amsterdam UMC, Amsterdam, Netherlands
| | - Gwen M.C. Masclee
- Gastroenterology & Hepatology, Amsterdam UMC, Amsterdam, Netherlands
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Latha Kumar A, Sadagopan A, Mahmoud A, Begg M, Tarhuni M, N Fotso M, Gonzalez NA, Sanivarapu RR, Osman U, Nath TS. Comparison of the Clinical Efficacy, Safety, and Postoperative Outcomes Between Peroral Esophageal Myotomy and Laparoscopic Heller's Myotomy With Fundoplication: A Systematic Review. Cureus 2023; 15:e44877. [PMID: 37818506 PMCID: PMC10561531 DOI: 10.7759/cureus.44877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/07/2023] [Indexed: 10/12/2023] Open
Abstract
Achalasia, a neurodegenerative disease caused by the progressive destruction of ganglion cells in the myenteric plexus, is accompanied by incomplete relaxation of the lower esophageal sphincter. Laparoscopic Heller's myotomy (LHM) coupled with fundoplication has been the gold standard procedure for achalasia. Peroral esophageal myotomy (POEM) has recently gained popularity as it is minimally invasive, has fewer adverse events, and has excellent short-term outcomes. So, we aimed to compare the clinical efficacy, safety, and postoperative outcomes between LHM and POEM. We did a systematic review by following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines for 2020 and exploring research databases such as PUBMED and PMC Central, Google Scholar, and Research Gate. After appropriate screenings, articles relevant to the review were scrutinized based on the eligibility criteria. Quality assessment tools such as the Newcastle-Ottawa Scale (NOS) and the assessment of multiple systematic reviews (AMSTAR) were used to finalize the articles. A total of 11 articles (seven observational studies, two RCTs, and two systematic reviews) were included in the review after a quality check. The study included 2127 patients, classified into 981 for POEM and 1146 for LHM, who had undergone treatment for achalasia. Most of the studies had a follow-up of ≤ two years. Comparing efficacy, POEM had similar results to LHM in terms of Eckardt scores. However, abnormal DeMeester scores were found in POEM. Adverse events were significantly higher in LHM when compared to POEM in terms of safety. Peroral esophageal myotomy also stood out as having a shorter procedure time, a shorter hospital stay, and lesser odds of being a clinical failure. As for postoperative outcomes, despite treatment with proton pump inhibitors, LHM was more effective in preventing the development of esophagitis compared to POEM due to partial fundoplication. Postoperative reflux and the development of esophagitis remain certain with POEM and need to be followed up with more studies with longer follow-ups. However, POEM still stands as a better choice compared to LHM in terms of efficacy and safety.
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Affiliation(s)
- Abishek Latha Kumar
- Internal Medicine and Pediatrics, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Aishwarya Sadagopan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Anas Mahmoud
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Maha Begg
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Mawada Tarhuni
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Monique N Fotso
- Obstetrics and Gynecology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Natalie A Gonzalez
- Pediatrics, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Raghavendra R Sanivarapu
- Pulmonary and Critical Care Medicine, Texas Tech University Health Sciences Center, Midland and Odessa, USA
- Pulmonary and Critical Care Medicine, Nassau University Medical Center, East Meadow, USA
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Usama Osman
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Geriatrics, Michigan State University College of Human Medicine, East Lansing, USA
| | - Tuheen Sankar Nath
- Surgical Oncology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Ciomperlik H, Dhanani NH, Mohr C, Hannon C, Olavarria OA, Holihan JL, Liang MK. Systematic Review of Treatment of Patients with Achalasia: Heller Myotomy, Pneumatic Dilation, and Peroral Endoscopic Myotomy. J Am Coll Surg 2023; 236:523-532. [PMID: 36382896 DOI: 10.1097/xcs.0000000000000484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The aim of this systematic review is to assess all comparative randomized controlled trials evaluating Heller myotomy, pneumatic dilation, and peroral endoscopic myotomy. STUDY DESIGN Achalasia is an esophageal motility disorder associated with degeneration of the myenteric plexus; it causes significant symptoms and impacts patient quality of life (QOL). The optimal treatment for patients with achalasia and the impact of these interventions on QOL remain unclear. PubMed, Embase, Scopus, and Cochrane were searched from inception to April 2020. Randomized controlled trials that compared the 3 interventions were included. Primary outcome was QOL at 12 to 36 months after the operation. Secondary outcomes included reintervention, dysphagia, leak/perforation, and GERD recurrence. RESULTS Nine publications of 6 studies were included. Of the 9 publications, there was no significant difference in QOL at 12 to 36 months except for one study in which QOL was significantly higher in patients who underwent Heller myotomy as opposed to pneumatic dilation at 3 years; however, at 5 years there was no difference. Pneumatic dilation was associated with the highest rates of dysphagia recurrence and reintervention, but peroral endoscopic myotomy had the lowest. CONCLUSIONS The treatment of achalasia should be chosen in accordance with patient goals. After any of the 3 interventions, QOL appears to be similar. However, peroral endoscopic myotomy may be associated with the lowest rates of perforation/leak, dysphagia, and reintervention and may be the lowest risk option. However, there are barriers to widespread use due to challenges in training and adoption.
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Affiliation(s)
- Hailie Ciomperlik
- From the Department of Surgery, McGovern Medical School at UTHealth, Houston, TX (Ciomperlik, Dhanani, Mohr, Hannon, Olavarria, Holihan)
| | - Naila H Dhanani
- From the Department of Surgery, McGovern Medical School at UTHealth, Houston, TX (Ciomperlik, Dhanani, Mohr, Hannon, Olavarria, Holihan)
| | - Cassandra Mohr
- From the Department of Surgery, McGovern Medical School at UTHealth, Houston, TX (Ciomperlik, Dhanani, Mohr, Hannon, Olavarria, Holihan)
| | - Craig Hannon
- From the Department of Surgery, McGovern Medical School at UTHealth, Houston, TX (Ciomperlik, Dhanani, Mohr, Hannon, Olavarria, Holihan)
| | - Oscar A Olavarria
- From the Department of Surgery, McGovern Medical School at UTHealth, Houston, TX (Ciomperlik, Dhanani, Mohr, Hannon, Olavarria, Holihan)
| | - Julie L Holihan
- From the Department of Surgery, McGovern Medical School at UTHealth, Houston, TX (Ciomperlik, Dhanani, Mohr, Hannon, Olavarria, Holihan)
| | - Mike K Liang
- the Department of Surgery, HCA Healthcare Kingwood, University of Houston, Kingwood, TX (Liang)
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Olivier R, Brochard C, des Varannes SB, Ropert A, Wallenhorst T, Reboux N, Quénéhervé L, Coron E. Peroral endoscopic myotomy: is it better to perform it in naive patients or as second-line therapy? Results of an open-label-controlled study in 105 patients. Surg Endosc 2023; 37:3760-3768. [PMID: 36670217 PMCID: PMC10156842 DOI: 10.1007/s00464-021-08767-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 10/09/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Whether Peroral Endoscopic Myotomy (POEM) can be proposed as a second-line treatment in patients with achalasia remains to be confirmed in real-life series. OBJECTIVE This study aimed to compare the efficacy, feasibility and safety of POEM between treatment-naïve patients and patients who had prior endoscopic or surgical therapies for achalasia. METHODS All consecutive patients who underwent a POEM procedure for achalasia in our centre from June 2015 to September 2018 were included in this retrospective study. They were classified into treatment-naïve patients (POEM1) and patients who had at least one previous endoscopic and/or surgical treatment for achalasia (POEM2). RESULTS A total of 105 patients were included, 52 in the POEM1 group and 53 in the POEM2 group. Clinical success (defined as an Eckardt score ≤ 3) at 6 months was observed in 93% of POEM1 patients and 84% of POEM2 patients (p = 0.18). Technical success rate was not significantly different between the two groups (100% vs 96%, respectively; p = 0.50). No significant difference was noted in terms of adverse event rate (19% vs 19%, respectively; p = 1.00). Post-procedure pain occurred in 12% of treatment-naive and 9% of non-naïve patients (p = 0.76). The median length of hospital stay was 3 days in both groups (p = 0.17). Symptomatic gastroesophageal reflux occurred in 25% of POEM1 patients and 16% of POEM2 patients (p = 0.24). CONCLUSION Efficacy, feasibility and safety of POEM are not different between treatment-naïve and non-naïve patients. POEM is a valuable second-line approach in patients with persistent symptoms of achalasia after surgical or endoscopic treatments.
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Affiliation(s)
- Raphael Olivier
- Service de Gastroentérologie, CHU de Poitiers, Poitiers, France
- Institut des Maladies de l'Appareil Digestif, IMAD, CHU Nantes, Hôpital Hôtel-Dieu, 1 place Ricordeau, 44093, Nantes cedex, France
| | - Charlène Brochard
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennes 1, Rennes, France
- Service d'Explorations Fonctionnelles Digestives, CHU Pontchaillou, Université de Rennes 1, Rennes, France
- CIC 1414, INPHY, Université de Rennes 1, Rennes, France
| | - Stanislas Bruley des Varannes
- Institut des Maladies de l'Appareil Digestif, IMAD, CHU Nantes, Hôpital Hôtel-Dieu, 1 place Ricordeau, 44093, Nantes cedex, France
| | - Alain Ropert
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennes 1, Rennes, France
- Service d'Explorations Fonctionnelles Digestives, CHU Pontchaillou, Université de Rennes 1, Rennes, France
| | - Timothée Wallenhorst
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennes 1, Rennes, France
| | - Noémi Reboux
- Service de Gastroentérologie, CHRU de Brest, Brest, France
| | - Lucille Quénéhervé
- Institut des Maladies de l'Appareil Digestif, IMAD, CHU Nantes, Hôpital Hôtel-Dieu, 1 place Ricordeau, 44093, Nantes cedex, France
- Service de Gastroentérologie, CHRU de Brest, Brest, France
| | - Emmanuel Coron
- Institut des Maladies de l'Appareil Digestif, IMAD, CHU Nantes, Hôpital Hôtel-Dieu, 1 place Ricordeau, 44093, Nantes cedex, France.
- Department of Gastroenterology and Hepatology, University Hospital of Geneva (HUG), rue Gabrielle Perret- Gentil 4, Genève, 1205-1211, Switzerland.
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Sharma P, Stavropoulos SN. Is peroral endoscopic myotomy the new gold standard for achalasia therapy? Dig Endosc 2023; 35:173-183. [PMID: 36385512 DOI: 10.1111/den.14477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/15/2022] [Indexed: 11/18/2022]
Abstract
Our review focuses on critical analysis of the literature to determine whether peroral endoscopic myotomy (POEM) is poised to replace laparoscopic Heller myotomy (LHM) as the new "gold standard" for achalasia therapy. POEM matches or exceeds the efficacy of LHM. The difference in objective gastroesophageal reflux disease (GERD) between POEM and LHM is modest at best and dissipates with time. Post-POEM GERD can be easily managed medically in most patients without long-term GERD sequelae or the need for surgical fundoplication. Emerging POEM technique modifications can further decrease GERD. Endoscopic antireflux procedures such as transoral incisionless fundoplication (TIF) or POEM + F (POEM + fundoplication) can be used in the rare cases of medication-refractory GERD, but their long-term efficacy remains in question. In this comprehensive review, we summarize the current status of POEM with emphasis on GERD evaluation, prevention, treatment, and comparative data vs. LHM. Based on this analysis, it appears that POEM is indeed the new gold standard in the therapy of achalasia.
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Affiliation(s)
- Prabin Sharma
- Department of Gastroenterology, Hartford Health Care-St. Vincent's Medical Center, Bridgeport, USA
| | - Stavros N Stavropoulos
- Division of Gastroenterology, John D. Archbold Memorial Hospital, Digestive Disease Center, Thomasville, USA
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Karanfilian B, Kahaleh M. New Applications for Submucosal Tunneling in Third Space Endoscopy: A Comprehensive Review. J Clin Gastroenterol 2022; 56:465-477. [PMID: 35357336 DOI: 10.1097/mcg.0000000000001694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Third space endoscopy (TSE), a type of natural orifice transluminal endoscopic surgery, was first introduced a decade ago, and since then, has revolutionized the field of therapeutic endoscopy. TSE involves tunneling into the submucosal space between the intestinal mucosa and the muscularis propria. By accessing this "third space," endoscopists can perform minimally invasive myotomies, resections, and dissections while maintaining the mucosa and preventing full-thickness perforation. TSE procedures can be used to treat motility disorders as well as neoplasms throughout the gastrointestinal tract, which were traditionally conditions that would require open or laparoscopic surgery. The main TSE procedures include peroral endoscopic myotomy, gastric peroral endoscopic myotomy, Zenker peroral endoscopic myotomy, submucosal tunneling for endoscopic resection, endoscopic submucosal tunnel dissection, peroral endoscopic tunneling for restoration of the esophagus, and per-rectal endoscopic myotomy. Some of those procedures have now been accepted as viable alternative to surgical techniques due to their limited invasiveness, safety and cost. This review will explore the different techniques recently added to our arsenal while describing their potential efficacy and limitations.
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Affiliation(s)
- Briette Karanfilian
- Division of Gastroenterology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
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Shiwaku H, Inoue H, Shiwaku A, Okada H, Hasegawa S. Safety and effectiveness of sling fiber preservation POEM to reduce severe post-procedural erosive esophagitis. Surg Endosc 2022; 36:4255-4264. [PMID: 34716481 DOI: 10.1007/s00464-021-08763-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 10/04/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is standard treatment for achalasia. Gastroesophageal reflux disease (GERD) after POEM has been an important challenge since the early days of POEM implementation. The esophagogastric junction anti-reflux barrier consists of internal lower esophageal sphincter (LES) (i.e., intrinsic muscles of distal esophagus with sling fibers) and external LES (crural diaphragm and phrenoesophageal ligament anchors the distal esophagus to the crural diaphragm). During conventional POEM, the entire internal LES is unintentionally dissected. Preservation of the sling fiber may reduce post-POEM GERD, but its safety and effectiveness have been unclear. In this study, we investigated the safety and effectiveness of sling fiber preservation POEM (SP-POEM) for reducing severe post-procedural erosive esophagitis. METHODS We analyzed data of 236 patients who underwent POEM; of these, 203 patients underwent posterior myotomy without (Group 1) or with attempted (Group 2) sling fiber preservation. Group 1 (N = 79; sling fiber excision, N = 68) and Group 2 (N = 90; sling fiber preservation, N = 81) were compared. Post-procedural erosive esophagitis (Los Angeles classification) were assessed and the area (direction and length) of mucosal break was also investigated. The gastroesophageal flap valve was evaluated by Hill's classification. RESULTS Severe erosive esophagitis exceeding grade C (Los Angeles classification) occurred in 44.1% of patients (30/68) in Group 1 and in 18.5% of patients (15/81) in Group 2. In mapping of erosive esophagitis, mucosal breaks appeared widely in all directions in Group 1; they tended to be limited in Group 2 (especially in the 2 o'clock direction). Assessment using the Hill's classification showed that the gastroesophageal flap valve was preserved after SP-POEM. CONCLUSION SP-POEM is safe and effective, with a success rate of 90%. The rate of severe erosive esophagitis can be decreased by preserving sling fibers.
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Affiliation(s)
- Hironari Shiwaku
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, 7-45-1, Nanakuma, Jyounan-ku, Fukuoka, 814-0180, Japan.
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Akio Shiwaku
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, 7-45-1, Nanakuma, Jyounan-ku, Fukuoka, 814-0180, Japan
| | - Hiroki Okada
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, 7-45-1, Nanakuma, Jyounan-ku, Fukuoka, 814-0180, Japan
| | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, 7-45-1, Nanakuma, Jyounan-ku, Fukuoka, 814-0180, Japan
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Okada H, Shiwaku H, Ohmiya T, Shiwaku A, Hasegawa S. Efficacy and safety of peroral endoscopic myotomy in 100 older patients. Esophagus 2022; 19:324-331. [PMID: 34626277 DOI: 10.1007/s10388-021-00881-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 09/10/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is a standard treatment for achalasia. Several reports have described the efficacy and safety of POEM for elderly patients, but none has reported the efficacy and safety of POEM in a large number of elderly patients for > 3 years postoperatively. In this study, we examined the safety and outcome of POEM for 3 years postoperatively in 100 elderly patients. METHODS One hundred consecutive patients aged > 65 years who underwent POEM from September 2011 to March 2020 were included in this study. In analysis 1, we retrospectively investigated the safety and efficacy of POEM in all patients. In analysis 2, the efficacy and safety of POEM were statistically compared between two groups: the early elderly (65-74 years of age, 55 patients) and late elderly (≥ 75 years of age, 45 patients). RESULTS The technical success rate of POEM was 100%. In analysis 1, the 3-month, 1-year, 2-year, and 3-year efficacies of POEM (Eckardt score of ≤ 3) were 100% (92/92 cases), 100% (91/91 cases), 97.8% (88/90 cases), and 100% (92/92 cases), respectively. Procedure-related adverse events occurred in 11% of patients, but none was fatal. Two late elderly patients developed aspiration pneumonia due to delirium and underwent long-term hospitalization. In analysis 2, there were no significant differences in the efficacy and safety of POEM between the two age groups. CONCLUSIONS POEM is effective and safe for elderly patients. However, precautions are needed regarding the risk of adverse events associated with delirium when POEM is performed in elderly patients.
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Affiliation(s)
- Hiroki Okada
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, 7-45-1 Nanakuma, Jyounan-ku, Fukuoka, 814-0180, Japan
| | - Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, 7-45-1 Nanakuma, Jyounan-ku, Fukuoka, 814-0180, Japan.
| | - Toshihiro Ohmiya
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, 7-45-1 Nanakuma, Jyounan-ku, Fukuoka, 814-0180, Japan
| | - Akio Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, 7-45-1 Nanakuma, Jyounan-ku, Fukuoka, 814-0180, Japan
| | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, 7-45-1 Nanakuma, Jyounan-ku, Fukuoka, 814-0180, Japan
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Peng W, Li H, Xu Y, Yan L, Tang Z, Tang X, Fu X. Near-focus mode for accurate operation during endoscopic submucosal tunneling procedure. MINIM INVASIV THER 2022; 31:99-106. [PMID: 32449398 DOI: 10.1080/13645706.2020.1768408] [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: 10/24/2022]
Abstract
INTRODUCTION When using the endoscopic submucosal tunnel technique (ESTT), the working space in the submucosal tunnel is limited, and the visual field is obscured during close inspection or hemostasis. We aimed to evaluate the efficacy and safety of near-focus mode technique for accurate operation during the submucosal tunneling endoscopic procedure. MATERIAL AND METHODS A retrospective two-center study was designed. A total of 51 patients undergoing ESTT procedures with near-focus mode (n = 29) or traditional mode (n = 22) between February 2016 and May 2019 were included in this study. RESULTS When using the near-focus mode during the ESTT procedure, it is convenient to ensure a clear image and accurate operation. Adverse events occurred more frequently in the traditional group than in the near-focus group (45.5% vs 17.2%, p = .036). The near-focus group exhibited a lower rate of bleeding compared to the traditional group (0 vs 18.2%, p = .029). Furthermore, the mean hospital stay after the procedure was shorter in the near-focus group than in the traditional group (5.7 days vs 6.7 days, p = .013). CONCLUSIONS The visual field is more clearly exposed during submucosal tunneling when using the near-focus mode than when using traditional procedures. This technique appears to be more efficient and secure than the traditional ESTT procedure.
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Affiliation(s)
- Wei Peng
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Sichuan, China
| | - Huan Li
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Sichuan, China
| | - Yun Xu
- Department of Gastroenterology, the People's Hospital of Guangan City, Sichuan, China
| | - Li Yan
- Digestive Endoscopy Center, the Affiliated Hospital of North Sichuan Medical College, Sichuan, China
| | - Zhenzhen Tang
- Digestive Endoscopy Center, the Affiliated Hospital of North Sichuan Medical College, Sichuan, China
| | - Xiaowei Tang
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Sichuan, China
| | - Xiangsheng Fu
- Department of Gastroenterology, the Affiliated Hospital of Southwest Medical University, Sichuan, China.,Digestive Endoscopy Center, the Affiliated Hospital of North Sichuan Medical College, Sichuan, China
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Yuan X, Feng Z, Zhao Y, Zeng X, Ye L, Liu W, Hu B. Per-oral endoscopic dual myotomy for the treatment of achalasia. Esophagus 2021; 18:941-947. [PMID: 34273019 PMCID: PMC8387258 DOI: 10.1007/s10388-021-00863-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/12/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Repeat per-oral endoscopic myotomy is occasionally performed for persistent/recurrent symptoms in patients with achalasia, and yields favorable outcomes. We investigated a novel technique, per-oral endoscopic dual myotomy (dual-POEM), where a second myotomy was performed during a single session to augment the efficacy and avoid repeat interventions. The aim of this study was to evaluate its feasibility, safety and efficacy. METHODS Consecutive patients diagnosed with achalasia who underwent dual-POEM (1/2018-5/2019) were prospectively collected and retrospectively analyzed. Patients with baseline Eckardt score ≥ 9, ≥ 10 years of symptoms, and/or having prior interventions other than myotomy received dual-POEM. The primary outcome was clinical success (Eckardt score ≤ 3). Secondary outcomes were procedure-related adverse events, change in lower esophageal sphincter (LES) pressure, and reflux complications. RESULTS Seventeen patients received dual-POEM. Procedure-related adverse events were observed in 2 (11.8%) patients (mucosal injury and pneumonitis). Both were minor in severity. During a median follow-up of 33 months (interquartile range, IQR [31,35]; range, 19-36), clinical success was achieved in 16 (94.1%) patients. The median Eckardt score decreased from 9 (IQR [8, 11.5]; range 7-12) to 1 (IQR [1, 2]; range 0-4) (P < 0.001), and LES pressure decreased from 25.8 mmHg (IQR [21.7, 33.5]; range 17.7-46.3) to 7.4 mmHg (IQR [6.3, 10.4]; range 2.2-12.6) (P < 0.001). Seven (41.2%) patients developed postprocedural reflux either by gastroesophageal reflux disease questionnaire or esophagitis endoscopically, all successfully treated with proton pump inhibitors. CONCLUSION Dual-POEM preliminarily demonstrated high efficacy with a favorable safety profile in patients with achalasia with predictors of treatment failure.
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Affiliation(s)
- Xianglei Yuan
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Zhe Feng
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Yanshi Zhao
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Loma Linda University, Loma Linda, USA
| | - Xianhui Zeng
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Liansong Ye
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Wei Liu
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China
| | - Bing Hu
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041, Sichuan, China.
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12
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Liu X, Yao L, Cheng J, Xu M, Chen S, Zhong Y, He M, Chen W, Zhang Y, Qin W, Hu J, Cai M, Yao L, Zhou P, Li Q. Landscape of Adverse Events Related to Peroral Endoscopic Myotomy in 3135 Patients and a Risk-Scoring System to Predict Major Adverse Events. Clin Gastroenterol Hepatol 2021; 19:1959-1966.e3. [PMID: 33905769 DOI: 10.1016/j.cgh.2021.04.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS This article systemically describes the landscape of peroral endoscopic myotomy (POEM)-related adverse events (AEs) and compares the different grading systems; and establishes and validates a combined risk factor model and a simplified risk-scoring system to predict POEM-related major AEs. METHODS A total of 3135 patients with achalasia treated with POEM were included and the AEs were systemically described and graded. A predictive model and risk-scoring system was developed using logistic regression and then internally validated using bootstrapping approaches. RESULTS A total of 258 out of 3135 patients, accounting for 8.23% of the total patients, presented with 297 AEs. According to Clavien-Dindo grading, 175 (67.83%), 23 (8.91%), 56 (21.71%), 4 (1.55%), and 0 (0.00%) patients were graded as grade I-V, respectively. By American Society of Gastrointestinal Endoscopy lexicon, 175 (67.83%) patients were classified with mild AE, 66 (25.58%) were classified with moderate AE, and 17 (6.59%) were classified with severe AE, respectively. Sixty-eight (2.17%) patients were classified with major AE. Air insufflation, selective myotomy, mucosal injury, and long operation time were selected into the predictive model with an area under the curve of 0.795. They were assigned with scores of 18, 5, 3, and 5 in the risk-scoring system, respectively. By applying the risk scoring system, patients with higher scores had higher rates of major AEs. The model showed little evidence for overfitting and was well-calibrated. CONCLUSIONS Based on a systematic landscape analysis, POEM is a safe procedure with low rates of severe AEs. Our prediction model and risk-scoring system demonstrated good performance in predicting major AEs.
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Affiliation(s)
- Xinyang Liu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lu Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jing Cheng
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Meidong Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shiyao Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yunshi Zhong
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Mengjiang He
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Weifeng Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yiqun Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenzheng Qin
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jianwei Hu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Mingyan Cai
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Liqing Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Pinghong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Quanlin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
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13
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Yurtlu DA, Aslan F. Challenges in Anesthesia Management for Peroral Endoscopic Myotomy: A Retrospective Analysis. Surg Laparosc Endosc Percutan Tech 2021; 31:729-733. [PMID: 34310556 DOI: 10.1097/sle.0000000000000978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 06/04/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is used to treat achalasia with efficacy and reliability. However, during the procedure potential complications require attention in terms of anesthesia. This study aimed to investigate complications of the POEM procedure and its effects on arterial blood gas (ABG) parameters, peak airway pressures (PIP), hemodynamics, and postoperative analgesia requirements. METHODS Data from 220 patients who underwent POEM between 2014 and 2017 were retrospectively assessed. During the procedure, ABG samples, PIP, mean arterial pressure, and heart rate were recorded. The effects of the procedure and paracentesis on ABG, PIP, mean arterial pressure, heart rate, perioperative complications, and postoperative analgesia requirements were assessed. RESULTS Data from 220 POEM patients were analyzed. During the procedure, the mean PaCO2 was 48.27±6.34 mm Hg, which was significantly higher than the PaCO2 values before and after the procedure. The mean increase in maximum PIP was 5.90±3.49 cmH2O during the procedure. However, there was a significant decrease in PaCO2 and PIP values in cases with paracentesis compared with those without paracentesis. With regards to complications, subcutaneous emphysema (48, 21.8%), pneumoperitoneum requiring decompression (66, 30%), pneumothorax (1, 0.5%), aspiration pneumonia (1, 0.5%), and bronchospasm (5, 2.2%) were observed during the procedure. In the postoperative period, 58 patients (26%) had additional analgesia requirements because of visual analog scale values >3. CONCLUSION Periprocedural abdominal decompression with veress needle led to a reduction in arterial PaCO2 and PIP, and improved postoperative analgesia. Serious complications because of perioperative aspiration and CO2 insufflation were observed during the POEM procedure.
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Affiliation(s)
- Derya A Yurtlu
- Department of Anesthesiology and Reanimation, Izmir Atatürk Training and Research Hospital, Katip Çelebi University, İzmir
| | - Fatih Aslan
- Department of Gastroenterology, Koç University Hospital, Zeytinburnu/İstanbul, Turkey
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14
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Ujiie N, Sato C, Taniyama Y, Koseki K, Takaya K, Okamoto H, Fukutomi T, Unno M, Kamei T. Characteristics of esophageal achalasia in geriatric patients over 75 years of age and outcomes after peroral endoscopic myotomy. Geriatr Gerontol Int 2021; 21:788-793. [PMID: 34250704 DOI: 10.1111/ggi.14235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/04/2021] [Accepted: 06/14/2021] [Indexed: 01/11/2023]
Abstract
AIM As the population ages, the proportion aged ≥75 years is expected to increase. Many studies on peroral endoscopic myotomy (POEM) as treatment for esophageal achalasia have already been reported; however, few studies have been designed on patients aged ≥75 years. The purpose of this study is to describe the characteristics of esophageal achalasia in patients >75 years and to evaluate the outcomes of POEM. METHODS This study included 121 patients who underwent POEM for esophageal achalasia, which was divided into the geriatric (n = 18) group aged ≥75 and the young (n = 103) group ≤74 years. The characteristics of esophageal achalasia and the short-term outcomes after POEM in the geriatric group compared with the young group were retrospectively investigated. RESULTS The median age of the geriatric group was 78 years, and two patients were initially diagnosed with refractory pneumonia, and esophageal achalasia was initially overlooked. The preoperative Eckardt score of the geriatric group was significantly lower than that of the young group (4 vs. 6, P = 0.007), particularly in the regurgitation score. The Eckardt score and integrated relaxation pressure of both groups were significantly improved after POEM (P < 0.001). There were no cases of perioperative complications in the geriatric group. CONCLUSIONS POEM for esophageal achalasia is a safe and effective treatment even in geriatric patients >75 years of age. In geriatric patients with recurrent or intractable pneumonia, it is important to rule out esophageal achalasia. Geriatr Gerontol Int 2021; 21: 788-793.
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Affiliation(s)
- Naoto Ujiie
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Chiaki Sato
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yusuke Taniyama
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ken Koseki
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kai Takaya
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroshi Okamoto
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toshiaki Fukutomi
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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15
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Achem SR, Vazquez-Elizondo G, Fass R. Jackhammer Esophagus: Current Concepts and Dilemmas. J Clin Gastroenterol 2021; 55:369-379. [PMID: 33337637 DOI: 10.1097/mcg.0000000000001472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/23/2020] [Indexed: 12/27/2022]
Abstract
Jackhammer esophagus (JE) is a recently recognized esophageal motility disorder that is characterized by hypercontractile peristalsis. More than 500 cases have been reported in the literature. Among patients referred for esophageal motility disorders, the prevalence of JE ranges from 0.42% to 9%, with most series describing a prevalence of 2% to 4%. Most cases are women (60.5%). The mean reported age of patients with JE is 65.2 years, and patients commonly have dysphagia (62.8%). Reflux symptoms occur in ∼40% of patients, and chest pain affects more than one-third of patients (36.4%). JE is a heterogenous disorder that is associated with several conditions, including obesity, opioid use, lung transplantation, eosinophilic infiltration of the esophagus, neoplasia, and systemic diseases. The cause and pathogenesis remain unknown, but several observations suggest that it is the result of multiple conditions that likely precipitate increased excitation and abnormal inhibition of neuromuscular function. The natural course of JE also is unknown, but progression to achalasia has been observed in a few patients. Treatment is challenging, in part because of the insufficient understanding of the disorder's underlying mechanisms. Various therapeutic modalities have been used, ranging from observation only to pharmacologic and endoscopic interventions (eg, botulinum toxin injection) to peroral endoscopic myotomy. Treatment efficacy remains largely anecdotal and insufficiently studied.
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Affiliation(s)
- Sami R Achem
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL
| | | | - Ronnie Fass
- Division of Gastroenterology and Hepatology, Metro Health Medical Center, Cleveland, OH
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16
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Delliturri A, Wiesel O, Shaw J, Brichkov I. A Narrative Review of update in per oral endoscopic myotomy (POEM) and endoscopic esophageal surgery. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:909. [PMID: 34164543 PMCID: PMC8184417 DOI: 10.21037/atm-20-5057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The field of endoscopic esophageal surgery is based on the concept of natural orifice transluminal endoscopic surgery (NOTES). Submucosal space surgery or third space surgery with the use of flexible endoscopy allows for decreased morbidity and hospital length of stay with equivalent outcomes for patients. In the case of achalasia, per oral endoscopic myotomy (POEM) allows for management of refractory cases in setting of previous Heller Myotomy or in patients whom laparoscopic or thoracoscopic surgery is contraindicated. Lastly, POEM more directly divides circular muscular layer of esophagus without destroying surrounding structures that exist to prevent reflux. The innovations in endoscopic surgery began in the animal lab with experiments in the porcine model to develop a way to access the peritoneal cavity through an entry point in the gastric mucosa. Over the last 10 years, the biggest treatment innovations in endoscopy have focused on management of achalasia with the use of POEM. POEM became possible as technology was developed that revolutionized the use of flexible technology and the methods of mucosal closure. In addition to benign esophageal disease, endoscopic methods improved in management of esophageal malignancy with endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). The innovations of endoscopic surgery have been developed through the utilization of the submucosal space as a method to ensure adequate closure of the mucosal entry point into the peritoneal cavity. The goal of this review paper is to explore POEM and other techniques in endoscopic esophageal surgery for the management of esophageal diverticulum, submucosal tumors, gastroparesis, and gastrointestinal esophageal reflux disease.
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Affiliation(s)
| | - Ory Wiesel
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Jason Shaw
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Igor Brichkov
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
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17
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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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18
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Thoracoscopic repair of congenital diaphragmatic hernia: a new anatomical reconstructive concept for tension dispersal at primary closure. Surg Endosc 2020; 35:3279-3284. [PMID: 32617656 DOI: 10.1007/s00464-020-07764-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Several measures were implemented among authors striving to tail off recurrence rates of thoracoscopic congenital diaphragmatic hernia repair. In the presented study, we extended the use of rib-anchoring stitches to reorient the diaphragmatic muscle leaflets in the types B&C diaphragmatic hernias, to achieve tension dispersal at primary thoracoscopic repair. PATIENTS AND METHODS Included in this study were early and late-onset lateral congenital diaphragmatic hernia patients, who had been operated upon in the years 2012 through 2018. A preliminary stitch was taken between posterior muscle edge and rib cage to reorient the diaphragmatic defect into a reversed C-shaped line. The lateral portion was closed by additional rib-anchoring stitches, while the medial one necessitated muscle to muscle stitches. Primary outcome being validated was the recurrence rate within a year post repair. RESULTS In the 7-year inclusion period, 36 congenital diaphragmatic hernia cases were managed using the described approach. The repair was accomplished thoracoscopically in all but two cases, who were excluded from the study. Mean operative time was 76 min. No pledgets or synthetic patches were applied. Mean length of hospital stay was 7.6 days. Early postoperative course was uneventful in all but four cases; two ventilatory barotrauma and two mortalities. After a mean follow-up period of 29 months, five recurrences were reported (16%). Ipsilateral chest wall deformity was noticed in one case 3 years post repair. CONCLUSION In the presented study, authors adopted thoracoscopic reorientation of diaphragmatic muscle leaflets in lateral congenital diaphragmatic hernia cases to achieve tension dispersal at primary repair. Short and mid-term results supported the efficacy and reproducibility of the described approach. However, long-term comparative studies seemed a necessity to validate this outcome.
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19
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Rai M, Woo M, Bechara R. The Canadian POEM Experience: The First 50 Patients. J Can Assoc Gastroenterol 2020; 4:110-114. [PMID: 34056528 PMCID: PMC8158644 DOI: 10.1093/jcag/gwaa018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Indexed: 02/07/2023] Open
Abstract
Background and Aims Peroral endoscopic myotomy (POEM) has emerged as a less invasive technique for performing myotomy in patients with achalasia. This study aims to assess the safety and efficacy of POEM in a Canadian tertiary care center. Methods All consecutive patients who underwent POEM between March 2016 and May 2018 at a tertiary center were included. The primary outcome of the study was clinical success rate of POEM defined as a post-POEM Eckardt score ≤3 at ≥3 months. Adverse events were recorded according to the Clavien-Dindo grading system. Results A total of 50 consecutive patients underwent 51 POEM procedures with a mean procedure length of 85.6 ± 29.6 min. Post-POEM Eckardt scores of ≤3 at ≥3 months was achieved in 98% of patients. The incidence of pathologic reflux post-poem was 23%. The median length of hospital stay was 1 day. No major adverse events occurred. Interpretation POEM is a safe and effective procedure for the treatment of achalasia. At a median follow-up of 19.5 months, 98% of patients had sustained clinical response (Eckardt score ≤3).
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Affiliation(s)
- Mandip Rai
- Division of Gastroenterology, Queen’s University, Ontario, Canada
| | - Matthew Woo
- Division of Gastroenterology, University of Calgary, Alberta, Canada; Division of Gastroenterology, Queen’s University, Ontario, Canada
| | - Robert Bechara
- Division of Gastroenterology, Queen’s University, Ontario, Canada
- Correspondence: Robert Bechara, HonBSc, MD, FRCPC, Department of Gastroenterology, Hotel Dieu Hospital, Queen’s University, 166 Brock Street Kingston, Ontario K7L 5G2, Canada, e-mail:
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20
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Shiwaku H, Inoue H, Sato H, Onimaru M, Minami H, Tanaka S, Sato C, Ogawa R, Okushima N, Yokomichi H. Peroral endoscopic myotomy for achalasia: a prospective multicenter study in Japan. Gastrointest Endosc 2020; 91:1037-1044.e2. [PMID: 31759035 DOI: 10.1016/j.gie.2019.11.020] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 11/04/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) is an available treatment modalities for achalasia. The reported efficacy of POEM in the only prospective multicenter study was 82%; however, a retrospective multicenter study in Japan reported a higher efficacy rate of 95%. The aim of this study was to prospectively verify treatment outcomes after POEM at multiple facilities in Japan. METHODS This was a prospective single-arm trial of POEM for achalasia at 8 facilities in Japan between April 2016 and March 2018 to evaluate its safety and efficacy. Patients were re-evaluated at 3 months and up to 1 year after POEM. RESULTS Among the 233 patients with achalasia who underwent POEM, procedure-related adverse events occurred in 24 patients (10.3%), none of whom required surgical intervention. In the 207 patients satisfying the inclusion criteria, the efficacy rate of POEM, defined by an Eckardt score ≤3 at 1 year, was 97.4% (95% CI, 95.3%-99.7%). The Eckardt score decreased significantly from 6.6 ± 2.0 preoperatively to 1.1 ± 1.1, 1 year after POEM. Postoperative reflux esophagitis, severe reflux esophagitis, and symptomatic GERD were reported in 54.2%, 5.6%, and 14.7%, respectively, and proton pump inhibitors were administered in 21.1%. CONCLUSIONS Our prospective multicenter study in Japan showed greater efficacy of POEM for achalasia compared with the results of a previous prospective multicenter study. POEM is safe and highly effective for at least 1 year. (Clinical trial registration number: UMIN 000021550.).
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Affiliation(s)
- Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hiroki Sato
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hitomi Minami
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Shinwa Tanaka
- Department of Gastroenterology, Kobe University Hospital, Hyogo, Japan
| | - Chiaki Sato
- Department of Surgery, Tohoku University School of Medicine, Miyagi, Japan
| | - Ryo Ogawa
- Department of Gastroenterology, Oita University Faculty of Medicine, Oita, Japan
| | | | - Hiroshi Yokomichi
- Division of Medicine, Graduate School Department of Interdisciplinary Research, University of Yamanashi, Yamanashi, Japan
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Foisy H, Pioche M, Chabrun E, Ponchon T, Zerbib F, Rivory J, Mion F, Roman S. Role of Rapid Drink Challenge During Esophageal High-resolution Manometry in Predicting Outcome of Peroral Endoscopic Myotomy in Patients With Achalasia. J Neurogastroenterol Motil 2020; 26:204-214. [PMID: 32027787 PMCID: PMC7176508 DOI: 10.5056/jnm19135] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 11/01/2019] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Peroral endoscopy myotomy (POEM) is effective to treat achalasia. We aim to determine POEM effect on esophageal function and search for predictive factors of response to POEM and co-occurrence of gastroesophageal reflux disease (GERD). Methods A total of 64 untreated achalasia patients who underwent high-resolution manometry (HRM) before and 3 months after POEM were retrospectively included. Response to treatment was defined as an Eckardt score < 3. Reflux symptoms and patient's satisfaction were evaluated. Data were compared using paired t test, Chi-square test or log rank test. Results The 2-year success rate in response to POEM was 90%. All responders reported being satisfied while only 33% of non-responders did (P < 0.001) and 64% of patients with reflux symptoms were satisfied versus 96% of those without (P = 0.009). On HRM, the integrated relaxation pressure and the contractile pattern changed significantly after POEM but were not predictive of response. Between pre and post POEM HRM, a decrease in maximal esophageal pressurization during rapid drink challenge (RDC) was associated with a better response rate than an increase of pressurization (91% vs 50%, P = 0.004). As evidenced by pH monitoring performed after POEM, GERD was pathological or borderline in 50% of patients (18/36) while only 19% (11/59) reported clinically significant reflux symptoms. On post POEM HRM, maximal esophageal pressurization during RDC was lower in patients with pathological or borderline GERD compared to those without (P = 0.054). Conclusions Esophageal HRM parameters changed significantly after POEM. Maximal esophageal pressurization during RDC may be useful to predict outcome.
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Affiliation(s)
- Hélène Foisy
- Université de Lyon, Hospices Civils de Lyon, Gastroenterology, Hopital E Herriot, Lyon, France.,Université de Lyon, Lyon I University, Digestive Physiology, Lyon, France
| | - Mathieu Pioche
- Université de Lyon, Hospices Civils de Lyon, Gastroenterology, Hopital E Herriot, Lyon, France.,Université de Lyon, Inserm U1032, Labtau, Lyon, France
| | - Edouard Chabrun
- Université de Bordeaux, CHU de Bordeaux, Gastroenterology, Hôpital Haut Leveque, Pessac, France
| | - Thierry Ponchon
- Université de Lyon, Hospices Civils de Lyon, Gastroenterology, Hopital E Herriot, Lyon, France.,Université de Lyon, Inserm U1032, Labtau, Lyon, France
| | - Frank Zerbib
- Université de Bordeaux, CHU de Bordeaux, Gastroenterology, Hôpital Haut Leveque, Pessac, France
| | - Jérôme Rivory
- Université de Lyon, Hospices Civils de Lyon, Gastroenterology, Hopital E Herriot, Lyon, France
| | - François Mion
- Université de Lyon, Lyon I University, Digestive Physiology, Lyon, France.,Université de Lyon, Inserm U1032, Labtau, Lyon, France.,Université de Lyon, Hospices Civils de Lyon, Digestive Physiology, Hôpital E Herriot, Lyon, France
| | - Sabine Roman
- Université de Lyon, Lyon I University, Digestive Physiology, Lyon, France.,Université de Lyon, Inserm U1032, Labtau, Lyon, France.,Université de Lyon, Hospices Civils de Lyon, Digestive Physiology, Hôpital E Herriot, Lyon, France
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Liu XY, Cheng J, Chen WF, Liu ZQ, Wang Y, Xu MD, Chen SY, Zhong YS, Zhang YQ, Yao LQ, Zhou PH, Li QL. A risk-scoring system to predict clinical failure for patients with achalasia after peroral endoscopic myotomy. Gastrointest Endosc 2020; 91:33-40.e1. [PMID: 31421076 DOI: 10.1016/j.gie.2019.07.036] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS We aimed to establish a predictive model and develop a simple risk-scoring system (Zhongshan POEM Score) to help clinicians to characterize high-risk patients for clinical failure after peroral endoscopic myotomy (POEM). METHODS A total of 1538 patients with achalasia treated with POEM with available follow-up data were included in this study and were randomly classified to the training cohort (n = 769) or internal validation cohort (n = 769). A risk-scoring system was developed using multivariate Cox regression analysis in the training cohort. The system was then internally validated by survival analysis in the validation cohort. RESULTS During a median follow-up time of 42 months, 109 patients had clinical failure. In the training stage, 3 risk factors for clinical failure were weighted with point values: previous treatment (2 points), intraprocedural mucosal injury (2 points for type I and 6 points for type II), and clinical reflux (3 points). The patients were categorized into low-risk and high-risk groups. In the validation stage, Kaplan-Meier curves differed significantly between the 2 groups. Patients in the high-risk group had a significantly higher risk of clinical failure than those in the low-risk group (hazard ratio, 3.99; 95% confidence interval, 2.31-6.91; P < .001). Satisfactory discrimination and calibration were shown. CONCLUSIONS This risk-scoring system demonstrated good performance in predicting clinical failure in patients who underwent POEM.
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Affiliation(s)
- Xin-Yang Liu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jing Cheng
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wei-Feng Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zu-Qiang Liu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun Wang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Mei-Dong Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shi-Yao Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun-Shi Zhong
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi-Qun Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li-Qing Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
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Tanaka S, Toyonaga T, Kawara F, Watanabe D, Hoshi N, Abe H, Ariyoshi R, Ohara Y, Takao T, Morita Y, Umegaki E, Kodama Y. Novel per-oral endoscopic myotomy method preserving oblique muscle using two penetrating vessels as anatomic landmarks reduces postoperative gastroesophageal reflux. J Gastroenterol Hepatol 2019; 34:2158-2163. [PMID: 31373050 DOI: 10.1111/jgh.14814] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 06/21/2019] [Accepted: 07/20/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM One of the main concerns related to peroral endoscopic myotomy (POEM) is postoperative gastroesophageal reflux (GER). The two penetrating vessels (TPVs) that are found at the boundary between the circular and oblique muscles in the posterior cardia wall have been suggested to be a good indicator of the optimal distal extent of POEM. However, the effect of performing myotomy using the TPVs as an anatomical reference on the frequency of post-POEM GER has not been studied. METHODS This study involved consecutive patients who underwent POEM for the treatment of achalasia between April 2015 and June 2017. All enrolled patients underwent POEM in the 5 o'clock position and were divided into two groups: the conventional line group (CL group, n = 31), in which the TPVs were not exposed during submucosal tunnel dissection in the cardia, and the TPVs line group (TPVs group, n = 83), in which the TPVs were exposed and gastric myotomy was performed along the right side of the TPVs to preserve the oblique muscle. Examinations for post-POEM GER were conducted 3 months after the POEM. RESULTS The frequency of grade B or higher reflex esophagitis was 26/83 (31.3%) in the TPVs group and 18/31 (58.1%) in the CL group (P = 0.017). Nine of 83 patients (10.8%) had GER symptoms in the TPVs group, and six of 31 (19.4%) had GER symptoms in the CL group (P = 0.23). CONCLUSIONS The novel myotomy method preserving oblique muscle using TPVs as anatomical landmarks significantly reduced the frequency of post-POEM GER.
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Affiliation(s)
- Shinwa Tanaka
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | | | - Fumiaki Kawara
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Daisuke Watanabe
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Namiko Hoshi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hirohumi Abe
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryusuke Ariyoshi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshiko Ohara
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Toshitatsu Takao
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshinori Morita
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Eiji Umegaki
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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Shiwaku H, Inoue H, Onimaru M, Minami H, Sato H, Sato C, Tanaka S, Ogawa R, Okushima N. Multicenter collaborative retrospective evaluation of peroral endoscopic myotomy for esophageal achalasia: analysis of data from more than 1300 patients at eight facilities in Japan. Surg Endosc 2019; 34:464-468. [PMID: 31183791 DOI: 10.1007/s00464-019-06833-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 05/15/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is a novel, minimally invasive treatment for esophageal achalasia. We retrospectively examined and evaluated the results following POEM to verify the technique's efficacy and safety. METHODS We retrospectively analyzed data for patients who underwent POEM at eight Japanese facilities between September 2008 and October 2015. Pre- and postoperative assessments 3 months and 1 year after POEM included patient interviews, endoscopy, and manometry. RESULTS A total of 1346 patients underwent POEM during the study period. Achalasia was the straight type in 1105 patients (82%) and the sigmoid type in 241 patients (18%). The average patient age was 47.2 years (range 3-95 years); 617 patients (46%) were men and 729 (54%) were women. Previous treatment included balloon dilatation in 381 patients (28%) and Heller-Dor operation in 43 patients (3%). The average operation time was 99.6 min. The mean length of the myotomy in the esophageal body was 10.8 cm, and the myotomy extended into the stomach a mean of 2.8 cm. The response rate (Eckardt score ≤ 3) was 95.1% 3 months postoperatively and 94.7% 1 year postoperatively. We noted 50 adverse events (3.7%) of Clavien-Dindo classification grade ≤ IIIa, and all resolved with conservative treatment. There were no Clavien-Dindo classification grade ≥ IIIb adverse events. After POEM, erosive esophagitis according to the Los Angeles classification was absent in 37% of the patients, grade A in 33%, B in 24%, C in 6%, and D in 0.2%. Symptomatic gastroesophageal reflux disease after POEM was confirmed in 14.8% of the patients; both erosive esophagitis and symptomatic gastroesophageal reflux disease responded to treatment with a proton-pump inhibitor. CONCLUSION Our results confirmed the safety and efficacy of POEM in a large patient series and support POEM as the first-line and standard treatment for esophageal achalasia.
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Affiliation(s)
- Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan.
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hitomi Minami
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Hiroki Sato
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Chiaki Sato
- Department of surgery, Tohoku University School of Medicine, Miyagi, Japan
| | - Shinwa Tanaka
- Department of Gastroenterology, Kobe University Hospital, Hyogo, Japan
| | - Ryo Ogawa
- Department of Gastroenterology, Oita University Faculty of Medicine, Oita, Japan
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Abstract
PURPOSE OF REVIEW Peroral endoscopic myotomy (POEM) was developed in Japan as a less invasive treatment for esophageal achalasia requiring general anesthesia under positive pressure ventilation. In 2018, the Japan Gastroenterological Endoscopy Society published the first guidelines describing the standard care for POEM. Based on these guidelines, we discuss the typical approach to anesthesia during POEM for the management of esophageal achalasia in Japan. RECENT FINDINGS Prior cleansing of the esophagus is essential to prevent both aspiration during induction of anesthesia and contamination of the mediastinum and thoracic/abdominal cavity by esophageal remnants after endoscopic resection of the esophageal mucosa. Although rare, adverse events related to intraoperative carbon dioxide insufflation occur. These are treated through percutaneous needle decompression and insertion of a chest drainage tube for pneumoperitoneum and pneumothorax, respectively. Caution should be exercised regarding the development of subcutaneous emphysema and its involvement in airway obstruction. SUMMARY Prevention of aspiration pneumonia and adverse events related to the insufflation of carbon dioxide is essential in the management of esophageal achalasia through POEM. Close cooperation between gastrointestinal endoscopic surgeons and anesthesiologists is indispensable in POEM.
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Wang Y, Liu ZQ, Xu MD, Chen SY, Zhong YS, Zhang YQ, Chen WF, Qin WZ, Hu JW, Cai MY, Yao LQ, Zhou PH, Li QL. Clinical and endoscopic predictors for intraprocedural mucosal injury during per-oral endoscopic myotomy. Gastrointest Endosc 2019; 89:769-778. [PMID: 30218646 DOI: 10.1016/j.gie.2018.09.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/03/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Mucosal injury (MI) is one of the most common perioperative adverse events of per-oral endoscopic myotomy (POEM). Severe undertreated MI may lead to contamination of the tunnel and even mediastinitis. This study explored the characteristics, predictors, and management approaches of intraoperative MI. METHODS A retrospective review of the prospectively collected database at a large tertiary referral endoscopy unit was conducted for all patients undergoing POEM between August 2010 and March 2016. MI was graded according to the difficulty of repair (I, easy to repair; II, difficult to repair). The primary outcomes were the incidence and predictors of intraoperative MI. Secondary outcomes were MI details and the corresponding treatment. RESULTS POEM was successfully performed in 1912 patients. A total of 338 patients experienced 387 MIs, for an overall frequency of 17.7% (338/1912). Type II MI was rare, with a frequency of 1.7% (39/1912). Major adverse events were more common in patients with MI than in those without MI (6.2% vs 2.5%, P < .001). On multivariable analysis, MI was independently associated with previous Heller myotomy (odds ratio [OR], 2.094; P = .026), previous POEM (OR, 2.441; P = .033), submucosal fibrosis (OR, 4.530; P < .001), mucosal edema (OR, 1.834; P = .001), and tunnel length ≥13 cm (OR, 2.699; P < .001). Previous POEM (OR, 5.005; P = .030) and submucosal fibrosis (OR, 12.074; P < .001) were significant predictors of type II MI. POEM experience >1 year was a protective factor for MI (OR, .614; P = .042) and type II MI (OR, .297; P = .042). CONCLUSIONS MI during POEM is common, but type II injury is rare. Previous POEM and submucosal fibrosis were significant predictors of type II mucosal injury. POEM experience after the learning curve reduces the risk of MI.
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Affiliation(s)
- Yun Wang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zu-Qiang Liu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Mei-Dong Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shi-Yao Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun-Shi Zhong
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi-Qun Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wei-Feng Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen-Zheng Qin
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jian-Wei Hu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ming-Yan Cai
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li-Qing Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
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27
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Maydeo A. A good mountaineer is one who knows how to come back safely. Gastrointest Endosc 2019; 89:779-781. [PMID: 30902202 DOI: 10.1016/j.gie.2018.11.033] [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: 11/19/2018] [Accepted: 11/28/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Amit Maydeo
- Baldota Institute of Digestive Sciences, Global Hospital, Mumbai, India
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28
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Long-Term Efficacy of Peroral Endoscopic Myotomy for Patients with Achalasia: Outcomes with a Median Follow-Up of 36 Months. Dig Dis Sci 2019; 64:803-810. [PMID: 30478767 DOI: 10.1007/s10620-018-5373-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 11/08/2018] [Indexed: 02/06/2023]
Abstract
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.
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Li H, Peng W, Huang S, Ren Y, Peng Y, Li Q, Wu J, Fu X, Tang X. The 2 years' long-term efficacy and safety of peroral endoscopic myotomy for the treatment of achalasia: a systematic review. J Cardiothorac Surg 2019; 14:1. [PMID: 30606216 PMCID: PMC6318943 DOI: 10.1186/s13019-018-0811-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 12/03/2018] [Indexed: 02/08/2023] Open
Abstract
AIM In this retrospective review, we aimed to investigate the long-term efficacy and safety of POEM with follow-up period over 2 years. MATERIALS AND METHODS A systematic review related to POEM for achalasia was conducted. A literature search was performed in Pubmed, Medline, Ovid, Cochrane and EBSCO databases on November 2017. The following postoperative outcomes were extracted: Eckardt score, lower esophageal sphincter pressure, complications and clinical success. RESULTS The total number of patients was 373. The mean operative time was 66.7 min and the overall rate of complications was 21.2%. The mean follow-up period was 30.0 months. The overall clinical success rate was 92.9% and the rate of gastroesophageal reflux disease was 10.2%. Rate of mortality after POEM was 0. CONCLUSIONS Our study demonstrated that POEM is effective and safe for treating achalasia during the long-term followed up over 2 years.
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Affiliation(s)
- Huan Li
- Department of Gastroenterology, Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099 Sichuan Province China
| | - Wei Peng
- Department of Gastroenterology, Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099 Sichuan Province China
| | - Shu Huang
- Department of Gastroenterology, the People’s Hospital of Lianshui, Huaian, China
| | - Yutang Ren
- Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China
| | - Yan Peng
- Department of Gastroenterology, Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099 Sichuan Province China
| | - Qing Li
- Department of Gastroenterology, Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099 Sichuan Province China
| | - Jiao Wu
- Department of Gastroenterology, Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099 Sichuan Province China
| | - Xiangsheng Fu
- Department of Gastroenterology, Affiliated Hospital of North Sichuan Medical College, Road Wenhua 63#, Region Shunqing, Sichuan, 637000 China
| | - Xiaowei Tang
- Department of Gastroenterology, Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099 Sichuan Province China
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30
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Evensen H, Kristensen V, Larssen L, Sandstad O, Hauge T, Medhus AW. Outcome of peroral endoscopic myotomy (POEM) in treatment-naive patients. A systematic review. Scand J Gastroenterol 2019; 54:1-7. [PMID: 30650313 DOI: 10.1080/00365521.2018.1549271] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Achalasia is a primary motility disorder of the esophagus characterized by aperistalsis and failure of lower esophageal sphincter (LES) relaxation. Treatment of achalasia aims at reducing LES pressure. The common treatment modalities are laparoscopic Heller myotomy and pneumatic dilatation, but during the last decade, a promising treatment, per oral endoscopic myotomy (POEM), has been introduced. The aim of the present study was to perform a systematic review of the literature to assess the outcome of POEM in treatment-naive patients. MATERIALS AND METHODS A systematic literature search in PubMed, Embase and Cochrane databases was performed using the terms 'Achalasia AND (POEM OR peroral endoscopic myotomy OR per-oral endoscopic myotomy)'. Inclusion criteria were: original article; English language; n ≥ 20 with ≥90% treatment-naive patients; follow-up ≥3 months; and outcome evaluation of POEM including symptom score and objective tests. Exclusion criteria were: reviews and meta-analyses; pediatric data; duplicates; and articles with overlapping data material. RESULTS Of the 1641 articles identified, seven were included. The included studies all reported a short-term clinical success of >90%. Clinical success including post-POEM reflux was mainly estimated by symptom scorings. There were few procedure-related complications. CONCLUSIONS The studies of treatment-naive patients indicate a high rate of clinical success. Nevertheless, a more systematic and standardized evaluation is recommended to improve the reports on outcome of POEM. The follow-up rate should be high and the evaluation protocol should include both symptom scoring and objective testing with predefined treatment goals.
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Affiliation(s)
- Helge Evensen
- a Department of Gastroenterology , Oslo University Hospital.,b Faculty of Medicine , University of Oslo
| | | | - Lene Larssen
- a Department of Gastroenterology , Oslo University Hospital
| | - Olav Sandstad
- a Department of Gastroenterology , Oslo University Hospital
| | - Truls Hauge
- a Department of Gastroenterology , Oslo University Hospital.,b Faculty of Medicine , University of Oslo
| | - Asle W Medhus
- a Department of Gastroenterology , Oslo University Hospital
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31
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Okada H, Shiwaku H, Yamashita K, Ohmiya T, Inoue H, Hasegawa S. Patient with mediastinitis caused by delayed mucosal damage after peroral endoscopic myotomy. Asian J Endosc Surg 2019; 12:107-110. [PMID: 29656451 DOI: 10.1111/ases.12481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 01/17/2018] [Accepted: 02/15/2018] [Indexed: 12/20/2022]
Abstract
Peroral endoscopic myotomy (POEM) is a groundbreaking procedure for treating esophageal achalasia, and many reports from various facilities have described its safety and efficacy. However, there have been few reports on adverse events. Here, we report a case of a patient with mediastinitis caused by delayed mucosal damage after POEM. This case was the most severe among all POEM cases at our hospital. A 58-year-old man had experienced dysphagia and chest tightness since he was around 50 years old. At a previous hospital, he had been diagnosed with nonerosive reflux disease and had undergone fundoplication. As his symptoms did not improve, he was referred to our department. POEM was able to be finished but a stable visual field could not be maintained throughout procedure because of strong esophageal contractions. From findings of endoscopy and esophagography after POEM, the patient was diagnosed mediastinitis caused by delayed esophageal perforation. In this case, conservative treatment (fasting, antibiotic therapy, and enteral feeding) was successful. However, the option to administer surgical treatment, such as drainage, must not be overlooked.
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Affiliation(s)
- Hiroki Okada
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Kanefumi Yamashita
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Toshihiro Ohmiya
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
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32
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Sanaka MR, Thota PN, Parikh MP, Hayat U, Gupta NM, Gabbard S, Lopez R, Murthy S, Raja S. Peroral endoscopic myotomy leads to higher rates of abnormal esophageal acid exposure than laparoscopic Heller myotomy in achalasia. Surg Endosc 2018; 33:2284-2292. [PMID: 30341655 DOI: 10.1007/s00464-018-6522-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 10/11/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) may be associated with higher rates of gastroesophageal reflux disease (GERD) than laparoscopic Heller's myotomy with fundoplication (LHM), since POEM is not combined with a fundoplication. However, peri-esophageal anti-reflux barriers are preserved in POEM, which might prevent GERD. Hence, we sought to compare the objective esophageal pH study findings in achalasia patients after POEM and LHM. METHODS Achalasia patients undergoing POEM from 2014 to 2015 at our institution were matched 1:3 with LHM patients using propensity score matching. Demographics, prior interventions, pre-treatment and 2-month post-treatment timed barium esophagram (TBE), high-resolution esophageal manometry (HREM) and 24-h esophageal pH study findings were compared between the two groups. RESULTS Thirty-one patients in the POEM group and 88 patients in the LHM group were included. Larger proportion of POEM patients had prior interventions for achalasia as compared to LHM patients (overall: 71% vs. 44.3%; p = 0.012). Esophageal acid exposure was significantly higher in POEM as compared to LHM patients (abnormal total acid exposure: 48.4% vs. 13.6%; p < 0.001, abnormal DeMeester score 54.8% vs. 17.4%; p = 0.005 respectively). In sub-group analysis, similar results were noted on 24-h pH study after exclusion of the POEM patients with prior LHM and corresponding matches. There was no significant difference in the rate of GERD symptoms between POEM and LHM. There was no significant correlation between the post-treatment basal lower esophageal sphincter pressure and integrated relaxation pressure with abnormal acid exposure in either POEM or LHM. CONCLUSIONS In patients with achalasia, POEM leads to significantly higher rates of abnormal esophageal acid exposure, without an increase in the rate of GERD symptoms, when compared to LHM with fundoplication. Interestingly, prior LHM has no impact on post-POEM pH study findings. Potential of increased esophageal acid exposure and possible consequences should be discussed with all patients prior to POEM. Further studies are needed to determine the long-term effects of increased acid exposure after POEM.
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Affiliation(s)
- Madhusudhan R Sanaka
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA.
| | - Prashanthi N Thota
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Malav P Parikh
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Umar Hayat
- Department of Gastroenterology and Hepatology, University of Minnesota, Minneapolis, MN, USA
| | - Niyati M Gupta
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Scott Gabbard
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Rocio Lopez
- Department of Quantitative Health Science and Bio-statistics, Cleveland Clinic, Cleveland, OH, USA
| | - Sudish Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Siva Raja
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
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Inoue H, Shiwaku H, Iwakiri K, Onimaru M, Kobayashi Y, Minami H, Sato H, Kitano S, Iwakiri R, Omura N, Murakami K, Fukami N, Fujimoto K, Tajiri H. Clinical practice guidelines for peroral endoscopic myotomy. Dig Endosc 2018; 30:563-579. [PMID: 30022514 DOI: 10.1111/den.13239] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 07/17/2018] [Indexed: 12/11/2022]
Abstract
Peroral endoscopic myotomy (POEM) is a novel clinical technique developed in Japan used to treat esophageal achalasia and esophageal motility disorders. This technique has been rapidly accepted and widely disseminated throughout our clinical practice because of its low invasiveness, technical novelty, and high efficacy. Since the advent of POEM, there have been no clinical guidelines that clearly indicated its standard of care, and these guidelines have been anticipated both nationally and internationally by clinicians who engage in POEM practice. In 2017, to meet these needs, the Japan Gastroenterological Endoscopy Society (JGES) launched the guideline committee for POEM. Based on the guideline development process proposed by the Medical Information Network Distribution Service (MINDS), the guideline committee initially created research questions on POEM and conducted a systematic review and meta-analysis on each topic. The clinical research extracted from databases for these clinical questions and the systematic review mainly comprised a few retrospective studies with a small number of participants and short trial periods; hence, the strength of the evidence and recommendations derived from these results was low. Throughout this process, the guideline committee met thrice: once on May 13, 2017, and again on September 17, 2017, to formulate the draft. A consensus meeting was then held on January 14, 2018, in Tokyo to establish the guideline statements and finalize the recommendations using the modified Delphi method. This manuscript presents clinical guidelines regarding current standards of practice and recommendations in terms of the nine chief topics in POEM.
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Affiliation(s)
- Haruhiro Inoue
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | | | - Manabu Onimaru
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Hitomi Minami
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Hiroki Sato
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Seigo Kitano
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Nobuo Omura
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Norio Fukami
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Hisao Tajiri
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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Li QL, Wu QN, Zhang XC, Xu MD, Zhang W, Chen SY, Zhong YS, Zhang YQ, Chen WF, Qin WZ, Hu JW, Cai MY, Yao LQ, Zhou PH. Outcomes of per-oral endoscopic myotomy for treatment of esophageal achalasia with a median follow-up of 49 months. Gastrointest Endosc 2018; 87:1405-1412.e3. [PMID: 29108981 DOI: 10.1016/j.gie.2017.10.031] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 10/13/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Per-oral endoscopic myotomy (POEM) has received wide acceptance as a highly effective and safe treatment for esophageal achalasia. Short-term and small-scale studies are ample, but long-term large-scale studies are few. The aim of the study was to systematically analyze our long-term results of POEM, with particular emphasis on POEM failures and associated risk factors. METHODS In this single-center study, consecutive patients treated with POEM between August 2010 and December 2012 were included. The Kaplan-Meier survival function was used to estimate clinical success rate at each year. The Cox proportional hazards model was used to analyze risk factors related to recurrence. RESULTS A total of 564 patients were included. Major perioperative adverse events occurred in 36 patients (6.4%). After a median follow-up of 49 months (range, 3-68), the Eckardt score and lower esophageal sphincter (LES) pressure were significantly decreased (median Eckardt score, 8 to 2 [P < .05]; median LES pressure, 29.7 mm Hg to 11.9 mm Hg [P < .05]). Fifteen failures occurred within 3 months, 23 between 3 months and 3 years, and 10 after 3 years. The estimated clinical success rates at 1, 2, 3, 4, and 5 years were 94.2%, 92.2%, 91.1%, 88.6%, and 87.1%, respectively. Multivariate Cox regression revealed long disease duration (≥10 years) and history of prior interventions to be risk factors for recurrence. Clinical reflux occurred in 37.3% of patients (155/ 416). CONCLUSIONS POEM is a highly safe and effective treatment for esophageal achalasia with favorable long-term outcomes.
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Affiliation(s)
- Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qiu-Ning Wu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiao-Cen Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Mei-Dong Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wei Zhang
- Department of Biostatistics, Shanghai Medical College, Fudan University, Shanghai, China
| | - Shi-Yao Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun-Shi Zhong
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi-Qun Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wei-Feng Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen-Zheng Qin
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jian-Wei Hu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ming-Yan Cai
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li-Qing Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
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Chen YI, Inoue H, Ujiki M, Draganov PV, Colavita P, Mion F, Romanelli J, Chiu P, Balassone V, Patel L, Abbas A, Yang D, Dunst C, Pioche M, Roman S, Rivory J, Ponchon T, Desilets D, Maselli R, Onimaru M, Nakamura J, Hata Y, Hajiyeva G, Ismail A, Ngamruengphong S, Bukhari M, Chavez YH, Kumbhari V, Repici A, Khashab MA. An international multicenter study evaluating the clinical efficacy and safety of per-oral endoscopic myotomy in octogenarians. Gastrointest Endosc 2018; 87:956-961. [PMID: 28235595 DOI: 10.1016/j.gie.2017.02.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 02/10/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Per-oral endoscopic myotomy (POEM) for achalasia is particularly appealing in the elderly because it is minimally invasive. However, data in patients aged ≥80 years are scarce. The aim of this study was to assess the clinical outcome of POEM in octogenarians. METHODS This was a multicenter retrospective study at 8 centers. Consecutive octogenarians with achalasia who underwent POEM between 2010 and 2016 were included. Rates of technical success (completion of myotomy), clinical response (Eckardt score ≤3), and adverse events (severity graded as per American Society for Gastrointestinal Endoscopy lexicon) were assessed. RESULTS A total of 76 patients (47.4% female, mean age 84 years) underwent POEM for treatment of achalasia: type I, 17.1%; type II, 35.5%; type III, 17.1%; and unspecified, 30.3%. Overall, 41.1% were treatment naïve, whereas others had previous botulinum toxin injection and/or pneumatic dilation. The mean (± standard deviation [SD]) age-adjusted Charlson comorbidity index score was 6.2 ± 2.4, with the majority of patients having American Society of Anesthesiologists Physical Status Classification System (ASA) scores of II/III. Technical success was 93.4%, with a median follow-up of 256 days. Fourteen adverse events occurred in 11 patients (14.5%). There were 3 inadvertent mucosotomies, 6 cases of symptomatic capnoperitoneum and/or capnomediastinum, 2 esophageal leaks, 1 cardiac arrhythmia, and 2 other). The severities of these adverse events were mild (78.6%), moderate (14.3%), and severe (7.1%). Clinical success was achieved in 90.8% of patients, with a mean (± SD) Eckardt score reduction from 7.0 ± 2.3 to 0.8 ± 0.1 (P < .001), a median follow-up of 256 days, and interquartile range of 66 to 547. CONCLUSION Although the rate of technical success may be somewhat lower and the rate of adverse events slightly higher than previously reported, our data suggest that POEM in octogenarians is safe and effective, supporting its role as a primary modality for achalasia in this patient population.
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Affiliation(s)
- Yen-I Chen
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan
| | - Michael Ujiki
- Department of Surgery, Section of Minimally Invasive Surgery, NorthShore University Health System, Evanston, Illinois, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Paul Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, The Oregon Clinic, Portland, Oregon, USA
| | - Francois Mion
- Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France
| | - John Romanelli
- Baystate Medical Center, University of Massachusetts School of Medicine, Springfield, Massachusetts, USA
| | - Philip Chiu
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Valerio Balassone
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan
| | - Lava Patel
- Department of Surgery, Section of Minimally Invasive Surgery, NorthShore University Health System, Evanston, Illinois, USA
| | - Ali Abbas
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Dennis Yang
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Christy Dunst
- Division of Gastrointestinal and Minimally Invasive Surgery, The Oregon Clinic, Portland, Oregon, USA
| | - Mathieu Pioche
- Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France
| | - Sabine Roman
- Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France
| | - Jérôme Rivory
- Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France
| | - Thierry Ponchon
- Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France
| | - David Desilets
- Baystate Medical Center, University of Massachusetts School of Medicine, Springfield, Massachusetts, USA
| | - Roberta Maselli
- Digestive Endoscopy Unit, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan
| | - Jun Nakamura
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan
| | - Yoshitaka Hata
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan
| | - Gulara Hajiyeva
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Amr Ismail
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Saowanee Ngamruengphong
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Majidah Bukhari
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Yamile Haito Chavez
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Mouen A Khashab
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Shiwaku H, Yamashita K, Inoue H, Hasegawa S. Closure of a mucosal entry using the clip-with-line method. Ann Gastroenterol 2018; 31:252. [PMID: 29507478 PMCID: PMC5825961 DOI: 10.20524/aog.2018.0230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 12/11/2017] [Indexed: 11/24/2022] Open
Affiliation(s)
- Hironari Shiwaku
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka (Hironari Shiwaku, Kanefumi Yamashita, Suguru Hasegawa), Japan
| | - Kanefumi Yamashita
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka (Hironari Shiwaku, Kanefumi Yamashita, Suguru Hasegawa), Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo (Haruhiro Inoue), Japan
| | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka (Hironari Shiwaku, Kanefumi Yamashita, Suguru Hasegawa), Japan
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Shiwaku H, Yamashita K, Hasegawa S. Double-scope method for creating a straight submucosal tunnel during peroral endoscopic myotomy. Dig Endosc 2018; 30:267-268. [PMID: 29226475 DOI: 10.1111/den.13000] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Hironari Shiwaku
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Kanefumi Yamashita
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
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Tanaka S, Kawara F, Toyonaga T, Inoue H, Bechara R, Hoshi N, Abe H, Ohara Y, Ishida T, Morita Y, Umegaki E. Two penetrating vessels as a novel indicator of the appropriate distal end of peroral endoscopic myotomy. Dig Endosc 2018; 30:206-211. [PMID: 28846807 DOI: 10.1111/den.12957] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 08/22/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM One of the challenges during peroral endoscopic myotomy (POEM) is ensuring the appropriate length of myotomy on the gastric side. To determine the appropriate distal end of the gastric myotomy, we focused on the two penetrating vessels (TPVs) found in the gastric cardia during POEM. In the present study, we evaluated whether the TPVs could serve as an accurate indicator of the appropriate distal end of the gastric myotomy. METHODS All patients who underwent POEM between March and August 2016 were included for this study. When making the submucosal tunnel in the 5 o'clock direction into the stomach, two vessels penetrating through the circular muscle along the edge of oblique muscle in the cardia can be exposed. We designated these two vessels as TPVs. The myotomy was extended until the second TPVs was exposed. The anal end of the submucosal tunnel was confirmed by the double-scope POEM technique, and the length from the gastroesophageal junction to the anal side end of the myotomy was measured by the scale on the endoscope. RESULTS Among 37 patients who underwent myotomy in the 5 o'clock position, TPVs were found in 34 patients (91.2%). Sufficient submucosal tunneling on the gastric side was confirmed by the double-scope POEM technique in these 34 patients. Median length of the gastric myotomy was 3.0 cm (range 2-4 cm). CONCLUSION TPVs appears to be a simple and reliable indicator to determine the appropriate distal end of myotomy.
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Affiliation(s)
- Shinwa Tanaka
- Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Fumiaki Kawara
- Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | | | - Haruhiro Inoue
- Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Robert Bechara
- Gastrointestinal Diseases Research Unit, Queens University, Kingston, Canada
| | - Namiko Hoshi
- Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Hirohumi Abe
- Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Yoshiko Ohara
- Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Tsukasa Ishida
- Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Yoshinori Morita
- Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Eiji Umegaki
- Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
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Yamashita-Ichimura M, Toyama E, Sasoh M, Shiwaku H, Yamashita K, Yamashita Y, Yamaura K. Bladder pressure monitoring and CO 2 gas-related adverse events during per-oral endoscopic myotomy. J Clin Monit Comput 2018; 32:1111-1116. [PMID: 29488045 DOI: 10.1007/s10877-018-0122-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 02/23/2018] [Indexed: 11/29/2022]
Abstract
Per-oral endoscopic myotomy (POEM) is a minimally invasive treatment for esophageal achalasia. However, POEM has the potential risk of inducing carbon dioxide (CO2) gas-related adverse events, such as pneumoperitoneum, pneumomediastinum, and pneumothorax. The aim of this study was to evaluate the usability of bladder pressure monitoring as an index of CO2 gas-related pneumoperitoneum. The monitoring of bladder pressure and lung compliance and the incidence of iatrogenic pneumoperitoneum were retrospectively studied in 20 patients who underwent POEM between June 2013 and March 2015. The bladder pressure was measured using a Foley catheter. Abdominal distention was found in nine patients. The bladder pressure was significantly higher in the nine patients with the distention findings compared with patients without distention [7 (6-9) mmHg vs. 1 (0-2) mmHg; P < 0.05]; however, the decrease in dynamic lung compliance was not significantly different compared with patients without distention [- 7 (- 9.3 to - 5.1) vs. - 5 (- 10.2 to - 1.3) ml/cmH2O; P = 0.62]. Based on postoperative changes on CT scans; the following were the observations: pneumomediastinum (55%), minor pneumothorax (5%), pleural effusion (45%), atelectasis (15%), pneumoperitoneum (85%), and subcutaneous emphysema (15%). No significant clinical status was found among the patients postoperatively. Bladder pressure monitoring might be useful for detecting pneumoperitoneum during POEM.
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Affiliation(s)
- Mari Yamashita-Ichimura
- Department of Anesthesiology, Fukuoka University Hospital, 7-45-1 Nanakuma, Fukuoka, Japan.,Department of Anesthesiology, Showa University Hospital, 1-5-8 Hatanodai, Shinagawa, Tokyo, Japan
| | - Emiko Toyama
- Department of Anesthesiology, Fukuoka University Hospital, 7-45-1 Nanakuma, Fukuoka, Japan
| | - Makoto Sasoh
- Department of Anesthesiology, Fukuoka University Hospital, 7-45-1 Nanakuma, Fukuoka, Japan
| | - Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, 7-45-1 Nanakuma, Fukuoka, Japan
| | - Kanefumi Yamashita
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, 7-45-1 Nanakuma, Fukuoka, Japan
| | - Yuichi Yamashita
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, 7-45-1 Nanakuma, Fukuoka, Japan
| | - Ken Yamaura
- Department of Anesthesiology, Fukuoka University Hospital, 7-45-1 Nanakuma, Fukuoka, Japan. .,Department of Anesthesiology, Fukuoka University School of Medicine, 7-45-1 Nanakuma, Fukuoka, Japan.
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40
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Cho YK, Kim SH. Current Status of Peroral Endoscopic Myotomy. Clin Endosc 2018; 51:13-18. [PMID: 29397656 PMCID: PMC5806926 DOI: 10.5946/ce.2017.165] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/16/2017] [Accepted: 01/10/2018] [Indexed: 12/17/2022] Open
Abstract
Peroral endoscopic myotomy (POEM) has been established as an optional treatment for achalasia. POEM is an endoluminal procedure that involves dissection of esophageal muscle fibers followed by submucosal tunneling. Inoue first attempted to use POEM for the treatment of achalasia in humans. Expanded indications of POEM include classic indications such as type I, type II, type III achalasia, failed prior treatments, including Botulinum toxin injection, endoscopic balloon dilation, laparoscopic Heller myotomy, and hypertensive motor disorders such as diffuse esophageal spasm, jackhammer esophagus. Contraindications include prior radiation therapy to the esophagus and prior extensive esophageal mucosal resection/ablation involving the POEM field. Most of the complications are minor and self-limited and can be managed conservatively. As POEM emerged as the main treatment for achalasia, various adaptations to tunnel endoscopic surgery have been attempted. Tunnel endoscopic surgery includes POEM, peroral endoscopic tumor resection, gastric peroral endoscopic pyloromyotomy. POEM has been widely accepted as a treatment for all types of achalasia, even for specific cases such as achalasia with failed prior treatments, and hypertensive motor disorders.
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Affiliation(s)
- Young Kwan Cho
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Eulji University College of Medicine, Seoul, Korea
| | - Seong Hwan Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Eulji University College of Medicine, Seoul, Korea
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Abstract
INTRODUCTION In Japan, colorectal endoscopic submucosal dissection (ESD) is being conducted safely and effectively as shown by the increased number of the cases, however, it is still regarded as a complicated and challenging procedure. Therefore, piecemeal endoscopic mucosal resection (p-EMR) is still regarded as an appropriate treatment, rather than ESD for large colorectal tumors, especially in Western countries. Areas covered: There are several factors those are responsible for colorectal ESD difficulty. Firstly, there is no adequate traction or counter-traction in colorectal ESD. Secondly, it is challenging to handle the colonoscope in a redundant and narrow colonic lumen. Thirdly, the risk of perforation is estimated to be relatively higher compared to the stomach or esophagus Expert commentary: To overcome these difficulties, various traction and counter-traction methods have been reported and finally, the new concept of the Master and Slave Transluminal Endoscopic Robot (MASTER) has been developed and is soon to be available for clinical use. The authors have reviewed the history of colorectal ESD and MASTER in this paper.
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Affiliation(s)
- Yutaka Saito
- a Director of Endoscopy Center, Chief of Endoscopy Division , National Cancer Center Hospital , Tokyo , Japan
| | - Kazuki Sumiyama
- b Department of Endoscopy , Jikei University School of Medicine , Tokyo , Japan
| | - Philip Wai-Yan Chiu
- c Department of Surgery, Institute of Digestive Disease , The Chinese University of Hong Kong
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Nabi Z, Reddy DN, Ramchandani M. Adverse events during and after per-oral endoscopic myotomy: prevention, diagnosis, and management. Gastrointest Endosc 2018; 87:4-17. [PMID: 28987545 DOI: 10.1016/j.gie.2017.09.029] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 09/20/2017] [Indexed: 02/08/2023]
Abstract
Per-oral endoscopic myotomy (POEM) has surfaced as an effective endoscopic treatment modality for achalasia cardia (AC). Promising results in short- and mid-term follow-up studies have increased the use of POEM for the management of AC. POEM can be safely performed in an endoscopy suit, and major adverse events (AEs) are uncommon. AEs encountered during POEM or during the perioperative period principally include insufflation-related AEs, mucosal injuries, bleeding, pain, and aspiration pneumonia. Most insufflation-related AEs do not require an active intervention and therefore should not be considered as AEs in the true sense. When management of AEs is required, most intraoperative AEs can be managed at the same time without untoward consequences. Occurrences of AEs lessen after completion of the learning curve. However, experience alone does not ensure "zero" incidence of AEs, and early recognition remains essential. Postoperative AEs, like leaks, delayed bleeding, and delayed mucosal perforations, may pose special challenges for diagnosis and management. There is no standardized classification system for grading the severity of AEs associated with POEM, resulting in wide variation in their reported occurrences. Uniform reporting of AEs is not only crucial to comprehensively analyze the safety of POEM but also for comparison with other established treatment modalities like Heller's myotomy. GERD is an important long-term AE after POEM. Unlike the perioperative AEs, little is known regarding the intraoperative or patient-related factors that influence the occurrence of post-POEM GERD. Large prospective studies with long-term follow-up are required to determine the procedural factors associated with GERD after POEM.
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Affiliation(s)
- Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - D Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mohan Ramchandani
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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Tsuboi K, Omura N, Yano F, Hoshino M, Yamamoto SR, Akimoto S, Masuda T, Kashiwagi H, Yanaga K. Impact of preoperative balloon dilatation on outcomes of laparoscopic surgery in young patients with esophageal achalasia. Esophagus 2018; 15:39-46. [PMID: 29892807 DOI: 10.1007/s10388-017-0593-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 09/13/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND Balloon dilatation is reportedly less effective for young patients with esophageal achalasia than for older patients. However, there is no consensus on the impact of prior balloon dilatation on outcomes of surgical treatment. This study investigated the significance of preoperative balloon dilatation on surgical outcomes in young patients with esophageal achalasia. METHODS Of patients aged less than 40 years who had undergone a laparoscopic Heller-Dor operation for esophageal achalasia, 201 with a postoperative follow-up period of at least 1 year were included. They were divided into two groups with and without a history of balloon dilatation, and compared preoperative pathological conditions and surgical outcomes. RESULTS This study included 100 men and 101 women with a median age of 31 years, of whom 158 patients without a history of pneumatic dilatation (79%, non-PD group) and 43 with a history of pneumatic dilatation (21%, PD group) The preoperative symptom scores for dysphagia and regurgitation were significantly higher in the non-PD group. Although no differences were observed in surgical outcomes or postoperative course, the esophageal clearance rates calculated on preoperative and postoperative timed barium esophagograms were lower in terms of both height and width of the barium column in the PD group than in the non-PD group. Subjectively, both groups expressed equally high satisfaction. CONCLUSIONS In patients aged less than 40 years with esophageal achalasia, although preoperative balloon dilatation did not affect subjective levels of satisfaction with surgery, postoperative improvement in esophageal clearance in the lower esophagus was inhibited.
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Affiliation(s)
- Kazuto Tsuboi
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Nobuo Omura
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Fumiaki Yano
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Masato Hoshino
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Se-Ryung Yamamoto
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Shunsuke Akimoto
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Takahiro Masuda
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hideyuki Kashiwagi
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Katsuhiko Yanaga
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
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Mejía M. R, Donoso D. A, Manríquez A. E, Sáez B. J, Crovari E. F, Gabrielli N. M, Norero M. E, Pimentel M. F, Ceroni V. M, Muñoz C. R, Sharp P. A. Miotomía endoscópica por vía oral (POEM) para el tratamiento de la acalasia. Experiencia clínica inicial y resultados a corto plazo. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.rchic.2017.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Haito-Chavez Y, Inoue H, Beard KW, Draganov PV, Ujiki M, Rahden BHA, Desai PN, Pioche M, Hayee B, Haji A, Saxena P, Reavis K, Onimaru M, Balassone V, Nakamura J, Hata Y, Yang D, Pannu D, Abbas A, Perbtani YB, Patel LY, Filser J, Roman S, Rivory J, Mion F, Ponchon T, Perretta S, Wong V, Maselli R, Ngamruengphong S, Chen YI, Bukhari M, Hajiyeva G, Ismail A, Pieratti R, Kumbhari V, Galdos-Cardenas G, Repici A, Khashab MA. Comprehensive Analysis of Adverse Events Associated With Per Oral Endoscopic Myotomy in 1826 Patients: An International Multicenter Study. Am J Gastroenterol 2017; 112:1267-1276. [PMID: 28534521 DOI: 10.1038/ajg.2017.139] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 03/02/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The safety of peroral endoscopic myotomy (POEM) is still debated since comprehensive analysis of adverse events (AEs) associated with the procedure in large multicenter cohort studies has not been performed. To study (1) the prevalence of AEs and (2) factors associated with occurrence of AEs in patients undergoing POEM. METHODS Patients who underwent POEM at 12 tertiary-care centers between 2009 and 2015 were included in this case-control study. Cases were defined by the occurrence of any AE related to the POEM procedure. Control patients were selected for each AE case by matching for age, gender, and disease classification (achalasia type I and II vs. type III/spastic esophageal disorders). RESULTS A total of 1,826 patients underwent POEM. Overall, 156 AEs occurred in 137 patients (7.5%). A total of 51 (2.8%) inadvertent mucosotomies occurred. Mild, moderate, and severe AEs had a frequency of 116 (6.4%), 31 (1.7%), and 9 (0.5%), respectively. Multivariate analysis demonstrated that sigmoid-type esophagus (odds ratio (OR) 2.28, P=0.05), endoscopist experience <20 cases (OR 1.98, P=0.04), use of a triangular tip knife (OR 3.22, P=0.05), and use of an electrosurgical current different than spray coagulation (OR 3.09, P=0.02) were significantly associated with the occurrence of AEs. CONCLUSIONS This large study comprehensively assessed the safety of POEM and highly suggests POEM as a relatively safe procedure when performed by experts at tertiary centers with an overall 7.5% prevalence of AEs. Severe AEs are rare. Sigmoid-type esophagus, endoscopist experience, type of knife, and current used can be considered as predictive factors of AE occurrence.
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Affiliation(s)
- Yamile Haito-Chavez
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | | | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Michael Ujiki
- Department of Surgery, NorthShore University Health System, Evanston, Illinois, USA
| | - Burkhard H A Rahden
- Department of General, Visceral, Vascular and Pediatric Surgery, University Medical Center, Wìrzburg, Germany
| | | | - Mathieu Pioche
- Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France
| | - Bu Hayee
- Department of Gastroenterology, King's College Hospital NHS Foundation Trust, London, UK
| | - Amyn Haji
- Department of Gastroenterology, King's College Hospital NHS Foundation Trust, London, UK
| | - Payal Saxena
- Department of Gastroenterology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | | | - Manabu Onimaru
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Valerio Balassone
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Jun Nakamura
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Yoshitaka Hata
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Davinderbir Pannu
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Ali Abbas
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Yaseen B Perbtani
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Lava Y Patel
- Department of Surgery, NorthShore University Health System, Evanston, Illinois, USA
| | - Jorg Filser
- Department of General, Visceral, Vascular and Pediatric Surgery, University Medical Center, Wìrzburg, Germany
| | - Sabine Roman
- Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France
| | - Jerome Rivory
- Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France
| | - Francois Mion
- Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France
| | - Thierry Ponchon
- Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France
| | - Silvana Perretta
- Department of Gastrointestinal and Endocrine Surgery, University of Strasbourg, Strasbourg, France
| | - Vivien Wong
- Department of Gastrointestinal and Endocrine Surgery, University of Strasbourg, Strasbourg, France
| | - Roberta Maselli
- Gastroenterology, Humanitas Clinical and Research Hospital, IRCCS, Rozzano, Italy
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Majidah Bukhari
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Gulara Hajiyeva
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Amr Ismail
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Renata Pieratti
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Gerson Galdos-Cardenas
- The International Health Department-Global Disease Epidemiology and Control-The Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Alessandro Repici
- Gastroenterology, Humanitas Clinical and Research Hospital, IRCCS, Rozzano, Italy
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Tanaka S, Toyonaga T, Kawara F, Grimm IS, Hoshi N, Abe H, Ohara Y, Morita Y, Umegaki E, Azuma T. Peroral endoscopic myotomy using FlushKnife BT: a single-center series. Endosc Int Open 2017; 5:E663-E669. [PMID: 28691051 PMCID: PMC5500118 DOI: 10.1055/s-0043-111721] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 04/10/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Peroral endoscopic myotomy (POEM) is an evolving new treatment strategy for achalasia. Although several kinds of electrosurgical knives have been used in performing POEM, the best device has yet to be determined. The FlushKnife BT is a waterjet-emitting short needle-knife with a small ball tip (BT) that offers the potential to perform all aspects of POEM with a single device. In this study, we evaluated the safety and efficiency of the FlushKnife BT for POEM. PATIENTS AND METHODS A total of 54 consecutive patients with achalasia and other spastic esophageal motility disorders, such as jackhammer esophagus or distal esophageal spasm, who underwent POEM between January 2016 and August 2016, were included in this retrospective study. RESULTS The median operation time was 73.0 minutes (range 39 - 184 minutes). All procedures were completed using only the FlushKnife BT without changing to any other electrosurgical instrument. The median number of additional submucosal injections with an injection needle was 0 (range 0 - 1). Endoscopic vessel sealing was performed a mean of 3 times (range 0 - 7). The median number of bleeding episodes requiring treatment with hemostatic forceps was 0 (range 0 - 5). There were no significant adverse events. Seven of 52 patients (13.5 %) reported symptoms of gastroesophageal reflux disease such as heartburn or acid reflux at 3 month follow-up. CONCLUSIONS The FlushKnife BT enabled POEM to be performed with very few device exchanges, either for re-injection or to control intraoperative bleeding. In this uncontrolled case series, the ability of the FlushKnife BT to perform nearly all aspects of the POEM procedure seems to make it particularly well suited to this procedure.
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Affiliation(s)
- Shinwa Tanaka
- Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Takashi Toyonaga
- Department of Endoscopy, Kobe University Hospital, Kobe, Japan,Corresponding author Takashi Toyonaga, MD Department of EndoscopyKobe University Hospital7-5-1 Chu-o-kuKusunoki-Cho, KobeHyogo 650-0017Japan+81-78-3826309
| | - Fumiaki Kawara
- Department of Endoscopy, Kobe University Hospital, Kobe, Japan
| | - Ian S. Grimm
- Division of Gastroenterology and Hepatology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Namiko Hoshi
- Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Hirofumi Abe
- Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Yoshiko Ohara
- Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Yoshinori Morita
- Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Eiji Umegaki
- Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Takeshi Azuma
- Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
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Zhang WG, Linghu EQ, Chai NL, Li HK. Ling classification describes endoscopic progressive process of achalasia and successful peroral endoscopy myotomy prevents endoscopic progression of achalasia. World J Gastroenterol 2017; 23:3309-3314. [PMID: 28566891 PMCID: PMC5434437 DOI: 10.3748/wjg.v23.i18.3309] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 02/01/2017] [Accepted: 03/31/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To verify the hypothesis that the Ling classification describes the endoscopic progressive process of achalasia and determine the ability of successful peroral endoscopic myotomy (POEM) to prevent endoscopic progression of achalasia.
METHODS We retrospectively reviewed the endoscopic findings, symptom duration, and manometric data in patients with achalasia. A total of 359 patients (197 women, 162 men) with a mean age of 42.1 years (range, 12-75 years) were evaluated. Symptom duration ranged from 2 to 360 mo, with a median of 36 mo. Patients were classified with Ling type I (n = 119), IIa (n = 106), IIb (n = 60), IIc (n = 60), or III (n = 14), according to the Ling classification. Of the 359 patients, 349 underwent POEM, among whom 21 had an endoscopic follow-up for more than 2 years. Pre-treatment and post-treatment Ling classifications of these 21 patients were compared.
RESULTS Symptom duration increased significantly with increasing Ling classification (from I to III) (P < 0.05), whereas lower esophageal sphincter pressure decreased with increasing Ling type (from I to III) (P < 0.05). There was no difference in sex ratio or onset age among the Ling types, although the age at time of diagnosis was higher in Ling types IIc and III than in Ling types I, IIa, and IIb. Of the 21 patients, 19 underwent high-resolution manometry both before and after treatment. The mean preoperative and postoperative lower esophageal sphincter pressure were 34.6 mmHg (range, 15.3-59.4 mmHg) and 15.0 mmHg (range, 2.1-21.6 mmHg), respectively, indicating a statistically significant decrease after POEM. All of the 21 patients were treated successfully by POEM (postoperative Eckardt score ≤ 3) and still had the same Ling type during a mean follow-up period of 37.8 mo (range, 24-51 mo).
CONCLUSION The Ling classification represents the endoscopic progressive process of achalasia and may be able to serve as an endoscopic assessment criterion for achalasia. Successful POEM (Eckardt score ≤ 3) seems to have the ability to prevent endoscopic evolvement of achalasia. However, studies with larger populations are warranted to confirm our findings.
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Zhang W, Linghu EQ. Peroral Endoscopic Myotomy for Type III Achalasia of Chicago Classification: Outcomes with a Minimum Follow-Up of 24 Months. J Gastrointest Surg 2017; 21:785-791. [PMID: 28315151 DOI: 10.1007/s11605-017-3398-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 03/07/2017] [Indexed: 02/06/2023]
Abstract
INTRODUCTION There are only few studies about the outcomes of peroral endoscopic myotomy (POEM) for type III achalasia in a relatively large population to date. The purpose of this study was to explore the long-term efficacy of POEM for patients with type III achalasia. METHODS There were a total of 32 consecutive patients with type III achalasia undergoing POEM in our hospital from July 2012 to October 2014. Clinical date of general characteristics, procedure-related parameters and adverse events, symptom relief, and the high-resolution manometry outcomes before and during the periodic follow-up were retrospectively collected and analyzed. RESULTS All of the 32 patients underwent POEM successfully with a median operation time of 34.9 min (range 17.9-88.6 min). No serious complications related to POEM were encountered. Treatment success was achieved in 90.6% cases during a median follow-up period of 27.0 months (range 24-51 months). The mean pretreatment and post-treatment Eckardt scores were 7.2 and 1.4, respectively (P < 0.001), and mean LES pressure also decreased from a mean of 39.2 to 19.0 mmHg after the procedure (P < 0.001). Both of the gas-related complication and clinical reflux complication rates were 18.8%. CONCLUSION Our results confirm that POEM for type III achalasia of Chicago Classification is effective with a long-term symptom relief in 90.6% cases. But a further, prospective study is needed to evaluate whether POEM outcome could be correlated with manometric subtypes according to Chicago Classification.
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Affiliation(s)
- Wengang Zhang
- Department of Gastroenterology, Chinese PLA General Hospital, No. 28, Fuxing Road, Haidian District, Beijing, 100853, China
| | - En-Qiang Linghu
- Department of Gastroenterology, Chinese PLA General Hospital, No. 28, Fuxing Road, Haidian District, Beijing, 100853, China.
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Zhang WG, Linghu EQ, Li HK. Fibrin sealant for closure of mucosal penetration at the cardia during peroral endoscopic myotomy: A retrospective study at a single center. World J Gastroenterol 2017; 23:1637-1644. [PMID: 28321165 PMCID: PMC5340816 DOI: 10.3748/wjg.v23.i9.1637] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 01/22/2017] [Accepted: 02/08/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the efficacy and safety of fibrin sealant for closure of mucosal penetration at the cardia during peroral endoscopic myotomy (POEM).
METHODS Twenty-four patients who underwent POEM and experienced mucosal injury of the cardia during the procedure were retrospectively identified. Of the 24 patients, 21 had mucosal penetration and 3 had only slight mucosal damage without penetration. The 21 patients with mucosal penetration received fibrin sealant for closure at the site of penetration. Penetration-related characteristics, treatment, and recovery were reviewed for all 21 patients to assess the efficacy and safety of fibrin sealant for closure of mucosal penetration at the cardia. Clinical data, including general characteristics, procedure-related parameters, Eckardt scores, lower esophageal sphincter pressures (LESP), and esophagogastroduodenoscopy (EGD) results, were analyzed to determine their influence on treatment success after mucosal penetration during POEM.
RESULTS All 21 patients had a solitary mucosal penetration in the cardia (12 in esophageal region of the cardia, 9 in the stomach region of the cardia, and 1 in both the esophageal and stomach regions). Twelve had a hole-like penetration and 9 had a linear penetration. For those with a hole-like penetration, the mean size was 0.14 cm2 (0.02-0.32 cm2). For those with a linear penetration, the median size was 0.37 cm (0.10-1.00 cm). Closure of the mucosal penetration using fibrin sealant was performed successfully in all 21 patients (two patients required 5 mL fibrin sealant, and the remaining 19 patients required 2.5 mL). Two patients had a nasogastric tube placed for five days after POEM; the remaining 19 patients were kept fasting for 3 d. All 21 patients were discharged after a median of 5 d (range: 5-7 d) postoperatively. During a median 42 mo (range: 9-62 mo) follow-up, all 21 patients with a mucosal penetration successfully healed without the occurrence of infection, ulcer, or esophagitis. Furthermore, the median LESP decreased from 31.9 mmHg (range: 21.9-67.1 mmHg) preoperatively to 20.3 mmHg (range: 6.0-41.0 mmHg) postoperatively (P < 0.05). The median preoperative and postoperative Eckardt scores were 5.0 (range; 4-10) and 1.0 (range: 0-4), respectively (P < 0.05). Of the 21 patients with mucosal penetration, symptom remission, which is defined as a postoperative Eckardt score ≤ 3, was achieved in 20 patients (95.2%) indicating that mucosal penetration did not influence the success of POEM treatment if closed successfully using fibrin sealant.
CONCLUSION Fibrin sealant is safe and effective for closure of mucosal penetration during POEM. Mucosal penetrations do not appear to influence the treatment success of POEM if closed successfully using fibrin sealant. Additional studies regarding the feasibility, efficacy, and safety of fibrin sealant for closure of larger mucosal penetrations is warranted.
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Abu Gazala M, Wexner SD. Re-appraisal and consideration of minimally invasive surgery in colorectal cancer. Gastroenterol Rep (Oxf) 2017; 5:1-10. [PMID: 28567286 PMCID: PMC5444240 DOI: 10.1093/gastro/gox001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 01/03/2017] [Indexed: 12/13/2022] Open
Abstract
Throughout history, surgeons have been on a quest to refine the surgical treatment options for their patients and to minimize operative trauma. During the last three decades, there have been tremendous advances in the field of minimally invasive colorectal surgery, with an explosion of different technologies and approaches offered to treat well-known diseases. Laparoscopic surgery has been shown to be equal or superior to open surgery. The boundaries of laparoscopy have been pushed further, in the form of single-incision laparoscopy, natural-orifice transluminal endoscopic surgery and robotics. This paper critically reviews the pathway of development of minimally invasive surgery, and appraises the different minimally invasive colorectal surgical approaches available to date.
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Affiliation(s)
- Mahmoud Abu Gazala
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Steven D. Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
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