A comprehensive appraisal of the surgical treatment of diffuse esophageal spasm

Nonachalasic esophageal motor disorders, from diagnosis to therapy

INTRODUCTION

Investigations conducted using conventional manometry and, recently, using high-resolution manometry (HRM), allowed us to explore the field of esophageal motility and understand the potential link between motor features and gastroesophageal reflux disease (GERD) pathogenesis. The management of patients with nonachalasic esophageal motor disorders is often challenging, due to the clinical heterogeneous presentation and the multifactorial nature of the mechanisms underlying symptoms.

AREAS COVERED

Several studies, carried out using HRM, have better interpreted the esophageal motor function in patients with esophagogastric junction outflow obstruction (EGJOO), distal esophageal spasm (DES), hypertensive esophagus, and hypomotility disorders. Moreover, HRM studies have shown a direct correlation between reduced esophageal motility, disruption of the esophagogastric junction, and gastroesophageal reflux burden.

EXPERT OPINION

Pathogenesis, clinical presentation, diagnosis, and treatment of nonachalasic esophageal motor disorders still represent a challenging area, requiring future evaluation by multicenter outcome studies carried out in a large cohort of patients and asymptomatic subjects. However, we believe that an accurate clinical, endoscopic, and HRM evaluation is, nowadays, helpful in addressing patients with nonachalasic esophageal motor disorders to optimal treatment options.

Heller myotomy perforation: robotic visualization decreases perforation rate and revisional surgery is a perforation risk

Minimally invasive surgery (MIS) has improved surgical access to the foregut. While the benefits of MIS versus open surgery are well accepted, the relative benefits of laparoscopic versus robotic approaches continue to be debated. Procedure-specific comparisons are difficult to obtain for Heller myotomy, due to the relative rarity of the procedure in most practices. A retrospective review of prospectively collected perioperative data of a single surgical practice from 2001 to 2019 was conducted for the rate of perforation during Heller myotomy laparoscopically compared to robotically. From 2001 through February 2012, a laparoscopic approach was employed and from October 2008 to 2019, a robotic approach was employed. All perforations were recorded, as well as secondary outcomes of perforation location (gastric or esophageal), postoperative imaging for evidence of leak, length of stay, and complications. Chi-square and simple t test were employed for data analysis. During the 11 years of laparoscopic Heller myotomy, 14 cases resulted in 7 instances of perforation (50%). During the 11 years of robotic Heller myotomy, 45 cases resulted in 11 instances of perforation (24%) (p value = 0.06). All perforations in both groups were tiny, recognized, and repaired immediately. The length of stay (LOS) was longer in the laparoscopic perforation group (3.4 days) compared to the laparoscopic non-perforation group (1.2 days) (p value = 0.06). LOS for robotic was not significantly longer in the perforation group (2.8 days) compared to the robotic non-perforation group (1.5 days) (p value = 0.18). First time Heller myotomies showed a higher rate of perforation with laparoscopic (50%) vs robotic (14%) (p value = 0.009) approach. In subgroup analysis of revisional procedures, all ten were performed robotically (p value < 0.001) with a 60% perforation rate (p value = 0.001) and one associated, radiographically confirmed leak. Primary laparoscopic Heller myotomy related to more than four times the frequency of perforation than did primary robotic myotomy. We propose that the robotic platform provided the surgeon with superior ability to avoid perforation. Interestingly, the robotic group in this study dealt with more complex redo cases. In fact, reoperation in the area of the hiatus was a separate risk factor for perforation during robotic Heller myotomy. We recommend further prospective trials be done to better evaluate the benefits of robotic platform in regard to revisional foregut surgery.

Distal esophageal spasm: Update on diagnosis and management in the era of high-resolution manometry

Distal esophageal spasm (DES) is a rare major motility disorder in the Chicago classification of esophageal motility disorders (CC). DES is diagnosed by finding of ≥ 20% premature contractions, with normal lower esophageal sphincter (LES) relaxation on high-resolution manometry (HRM) in the latest version of CCv3.0. This feature differentiates it from achalasia type 3, which has an elevated LES relaxation pressure. Like other spastic esophageal disorders, DES has been linked to conditions such as gastroesophageal reflux disease, psychiatric conditions, and narcotic use. In addition to HRM, ancillary tests such as endoscopy and barium esophagram can provide supplemental information to differentiate DES from other conditions. Functional lumen imaging probe (FLIP), a new cutting-edge diagnostic tool, is able to recognize abnormal LES dysfunction that can be missed by HRM and can further guide LES targeted treatment when esophagogastric junction outflow obstruction is diagnosed on FLIP. Medical treatment in DES mostly targets symptomatic relief and often fails. Botulinum toxin injection during endoscopy may provide a temporary therapy that wears off over time. Myotomy through peroral endoscopic myotomy or via surgical Heller myotomy can provide long term relief in cases with persistent symptoms.

The Mexican consensus on non-cardiac chest pain

INTRODUCTION

Non-cardiac chest pain is defined as a clinical syndrome characterized by retrosternal pain similar to that of angina pectoris, but of non-cardiac origin and produced by esophageal, musculoskeletal, pulmonary, or psychiatric diseases.

AIM

To present a consensus review based on evidence regarding the definition, epidemiology, pathophysiology, and diagnosis of non-cardiac chest pain, as well as the therapeutic options for those patients.

METHODS

Three general coordinators carried out a literature review of all articles published in English and Spanish on the theme and formulated 38 initial statements, dividing them into 3 main categories: (i)definitions, epidemiology, and pathophysiology; (ii)diagnosis, and (iii)treatment. The statements underwent 3rounds of voting, utilizing the Delphi system. The final statements were those that reached >75% agreement, and they were rated utilizing the GRADE system.

RESULTS AND CONCLUSIONS

The final consensus included 29 statements. All patients presenting with chest pain should initially be evaluated by a cardiologist. The most common cause of non-cardiac chest pain is gastroesophageal reflux disease. If there are no alarm symptoms, the initial approach should be a therapeutic trial with a proton pump inhibitor for 2-4weeks. If dysphagia or alarm symptoms are present, endoscopy is recommended. High-resolution manometry is the best method for ruling out spastic motor disorders and achalasia and pH monitoring aids in demonstrating abnormal esophageal acid exposure. Treatment should be directed at the pathophysiologic mechanism. It can include proton pump inhibitors, neuromodulators and/or smooth muscle relaxants, psychologic intervention and/or cognitive therapy, and occasionally surgery or endoscopic therapy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Surgical treatment of achalasia - endoscopic or laparoscopic? : Proposal for a tailored approach]

Primary idiopathic achalasia is the most common form of the rare esophageal motility disorders. A curative therapy which restores the normal motility does not exist; however, the therapeutic principle of cardiomyotomy according to Ernst Heller leads to excellent symptom control in the majority of cases. The established standard approach is Heller myotomy through the laparoscopic route (LHM), combined with Dor anterior fundoplication for reflux prophylaxis/therapy. At least four meta-analyses of randomized controlled trials (RCTs) have demonstrated superiority of LHM over pneumatic dilation (PD); therefore, LHM should be used as first line therapy (without prior PD) in all operable patients. Peroral endoscopic myotomy (POEM) is a new alternative approach, which enables Heller myotomy to be performed though the endoscopic submucosal route. The POEM procedure has a low complication rate and also leads to good control of dysphagia but reflux rates can possibly be slightly higher (20-30%). Long-term results of POEM are still scarce and the results of the prospective randomized multicenter trial POEM vs. LHM are not yet available; however, POEM seems to be the preferred treatment option for certain indications. Within the framework of the tailored approach for achalasia management of POEM vs. LHM established in Würzburg, we recommend long-segment POEM for patients with type III achalasia (spasmodic) and other hypercontractile motility disorders and potentially type II achalasia (panesophageal compression) with chest pain as the lead symptom, whereas LHM can also be selected for type I. For sigmoid achalasia, especially with siphon-like transformation of the esophagogastric junction, simultaneous hiatal hernia and epiphrenic diverticula, LHM is still the preferred approach. The choice of the procedure for revisional surgery in case of recurrent dysphagia depends on the suspected mechanism (morphological vs. functional/neuromotor).

Noncardiac chest pain: diagnosis and management

PURPOSE OF REVIEW

Noncardiac chest pain (NCCP) has been defined as recurrent chest pain that is indistinguishable from ischemic heart pain after excluding a cardiac cause. NCCP is a common and highly challenging clinical problem in Gastrointestinal practice that requires targeted diagnostic assessment to identify the underlying cause of the symptoms. Treatment is tailored according to the cause of NCCP: gastroesophageal reflux disease (GERD), esophageal dysmotility or functional chest pain. The purpose of this review is to discuss the current diagnosis and treatment of NCCP.

RECENT FINDINGS

Utilization of new diagnostic techniques such as pH-impedance and high-resolution esophageal manometry, and the introduction of a new definition for functional chest pain have helped to better diagnose the underlying mechanisms of NCCP. A better therapeutic approach toward GERD-related NCCP, the introduction of new interventions for symptoms due to esophageal spastic motor disorders and the expansion of the neuromodulator armamentarium for functional chest pain have changed the treatment landscape of NCCP.

SUMMARY

GERD is the most common esophageal cause of NCCP, followed by functional chest pain and esophageal dysmotility. The proton pump inhibitor test, upper endoscopy, wireless pH capsule and pH-impedance are used to identify GERD-induced NCCP. High-resolution esophageal manometry is the main tool to identify esophageal motor disorder in non-GERD-related NCCP. Negative diagnostic assessment suggests functional chest pain. Potent antireflux treatment is offered to patients with GERD-related NCCP; medical, endoscopic or surgical interventions are considered in esophageal dysmotility; and neuromodulators are prescribed for functional chest pain. Assessment and treatment of psychological comorbidity should be considered in all NCCP patients.

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

BACKGROUND AND STUDY AIMS

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Review article: the current treatment of non-cardiac chest pain

BACKGROUND

Non-cardiac chest pain is one of the most common functional gastrointestinal disorders. By recognising that gastro-oesophageal reflux disease (GERD), oesophageal dysmotility and oesophageal hypersensitivity are the main underlying mechanisms of NCCP, a more directed therapeutic approach has been developed.

AIM

To determine the value of the current therapeutic modalities for NCCP.

METHODS

Electronic (Pubmed/Medline/Cochrane central) and manual search.

RESULTS

Double-dose PPI treatment for two months is a reasonable first choice approach in patients with NCCP because GERD is the most common aetiology. Studies evaluating the role of medical therapy in NCCP patients with hypercontractile oesophageal motility suggest a limited value to muscle relaxants like calcium channel blockers (nifedipine, diltiazem), nitrates and sildenafil. While most trials evaluating pain modulators are small and many are not placebo-controlled, these type of medications appear efficacious in both patients with NCCP due to oesophageal dysmotility and those with functional chest pain. Cognitive behavioural therapy has been extensively studied in patients with functional chest pain with good results. Other psychological techniques such as hypnotherapy, group therapy or coping skills have been scarcely studied but appear to be effective in NCCP patients.

CONCLUSION

Medical, endoscopic and surgical therapeutic options are available for the treating physician, although some patients with non-cardiac chest pain may require a multimodal therapeutic approach.

Causes and treatments of achalasia, and primary disorders of the esophageal body

The following on achalasia and disorders of the esophageal body includes commentaries on controversies regarding whether patients with complete lower esophageal sphincter (LES) relaxation can be considered to exhibit early achalasia; the roles of different mucle components of the LES in achalasia; sensory neural pathways impaired in achalasia; indications for peroral endoscopic myotomy and advantages of the technique over laparoscopic and thorascopic myotomy; factors contributing to the success of surgical therapy for achalasia; modifications to the classification of esophageal body primary motility disorders in the advent of high-resolution manometry (HRM); analysis of the LES in differentiating between achalasia and diffuse esophageal spasm (DES); and appropriate treatment for DES, nutcracker esophagus (NE), and hypertensive LES (HTLES).

Distal esophageal spasm: an update

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

Presentation, diagnosis, and treatment of oesophageal motility disorders

Whilst the current treatment of achalasia is well understood, the management of other oesophageal disorders is still debated, as these are rare and the literature on their clinical presentation and management is scarce. The following review describes the clinical presentation of oesophageal motility disorders, gives an overview of their diagnosis in light of the new advances in oesophageal motility testing, and provides an evidence-based approach to their management with different forms of treatment (medical, endoscopic, and minimally invasive).

Achalasia and other esophageal motility disorders

Achalasia, diffuse esophageal spasm, nutcracker esophagus, and the hypertensive lower esophageal sphincter are considered primary esophageal motility disorder. These disorders are characterized by esophageal dysmotility that is responsible for the symptoms. While there is today a reasonable consensus about the pathophysiology, the diagnosis, and the treatment of achalasia, this has not occurred for the other disorders. A careful evaluation is therefore necessary before an operation is considered.

Botulinum toxin in the treatment of diffuse esophageal spasm

Diffuse esophageal spasm is a primary esophageal motility disorder. The prevalence is 3-10% in patients with dysphagia and treatment options are limited. This review summarizes the treatment of diffuse esophageal spasm, including pharmacotherapy, endoscopic treatment, and surgical treatment with a special focus on botulinum toxin injection. A PubMed search was performed to identify the literature using the search items diffuse esophageal spasm and treatment. Pharmacotherapy with smooth muscle relaxants, proton pump inhibitors, and antidepressants was suggested from small case series and uncontrolled clinical trials. Endoscopic injection of botulinum toxin is a well-studied treatment option and results in good symptomatic benefit in patients with diffuse esophageal spasm. Surgical treatment was reported in patients with very severe symptoms refractory to pharmacologic treatment. This article summarizes the present knowledge on the treatment of diffuse esophageal spasm with a special emphasis on botulinum toxin injection. Endoscopic injection of botulinum toxin is presently the best studied treatment option but many questions remain unanswered.

Benign esophageal disease in the elderly

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