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Chadu Junior JB, Oliveira JAD, Faion AG, Zilberstein B. SHORT AND LONG-TERM RESULTS OF LAPAROSCOPIC ESOPHAGOCARDIOMYOTOMY WITH FUNDOPLICATION (HELLER-PINOTTI SURGERY) IN THE TREATMENT OF NON-ADVANCED ACHALASIA (MEGAESOPHAGUS). ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2024; 37:e1803. [PMID: 38896699 DOI: 10.1590/0102-6720202400010e1803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 02/01/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Videolaparoscopic esophagocardiomyotomy with fundoplication has been a widely used technique for the treatment of achalasia. This study analyzes the safety and effectiveness of the technique in the treatment of non-advanced achalasia (megaesophagus) in a Brazilian federal university public hospital. AIMS To evaluate the short- and long-term results of videolaparoscopic treatment of non-advanced megaesophagus in a public university hospital in Brazil, employing the esophagocardiomyotomy technique with fundoplication. METHODS The medical records of 44 patients who underwent surgical treatment for non-advanced achalasia at the Clinical Hospital of Federal University of Uberlândia (UFU-MG), Minas Gerais, from January 2001 to July 2021 were analyzed. The following data were evaluated: gender, age, etiology, radiological classification of Rezende-Alves and Ferreira-Santos, immediate and late complications (mean follow-up of 31.4 months), need or not for conversion to open access, postoperative reflux, performance or not of endoscopic esophageal dilation in the preoperative period, postoperative mortality, frequency of pre and postoperative symptoms (persistent dysphagia, regurgitation, heartburn, vomiting, odynophagia, and weight loss), surgery time, hospital stay, duration of dysphagia, pre and postoperative weight, and Eckardt score. RESULTS Among the analyzed patients, 23 (52.3%) were male, and 21 (47.7%) were female, with a mean age of 50.8 years. No early complications were recorded and there were 27.2% cases of late gastroesophageal reflux. Postoperative weight gain was 81.8% and the success rate of surgery according to the Eckardt score was 84.1%. CONCLUSIONS Esophagocardiomyotomy with fundoplication is an effective and safe technique for the treatment of non-advanced achalasia.
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Affiliation(s)
- João Bosco Chadu Junior
- Universidade Federal de Uberlândia, Digestive Surgery Unit - Uberlândia (MG), Brazil
- Faculdade São Leopoldo Mandic, Minimally Invasive Surgery, Master of Medical Sciences - Campinas (SP), Brazil
| | | | - Adilson Gomes Faion
- Universidade Federal de Uberlândia, Digestive Surgery Unit - Uberlândia (MG), Brazil
| | - Bruno Zilberstein
- Faculdade São Leopoldo Mandic, Minimally Invasive Surgery, Master of Medical Sciences - Campinas (SP), Brazil
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Kim RK, Kim JW, Angelotti T, Esquivel M, Tsui BC, Hwang JH. Magnesium and Esophageal Pain After Peroral Endoscopic Myotomy of the Esophagus: A Randomized, Double-Blind, Placebo-Controlled Trial. Anesth Analg 2024:00000539-990000000-00837. [PMID: 38848261 DOI: 10.1213/ane.0000000000006990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
BACKGROUND Postoperative esophageal pain occurs in 67% of patients after peroral endoscopic esophageal myotomy (POEM). Magnesium can act as a smooth muscle relaxant. This study investigated whether intraoperative magnesium can reduce postoperative esophageal pain in patients undergoing POEM. METHODS In this double-blind, placebo-controlled trial, 92 patients were randomized to receive either magnesium sulfate as a 50 mg.kg-1 (total body weight) bolus followed by an infusion at 25 mg.kg-1.hr-1, or 0.9% saline. Intraoperative analgesia was standardized in all patients. The primary outcome was the score from a validated, modified Esophageal Symptoms Questionnaire (ESQ) in the postanesthesia care unit (PACU). Pain scores, opioid requirements, and questionnaire scores were collected through postoperative day 1. RESULTS ESQ scores were significantly lower in the magnesium group in the PACU (median [25th-75th], 24 [18-31] vs 35 [28-42]; median difference [95% confidence interval, CI], 10 [6-13]; P < .0001) and on postoperative day 1 (16 [14-23] vs 30 [24-35]; P < .0001). Less opioids were needed in the magnesium group in the PACU (mean ± standard deviation [SD] [99% CI], 4.7 ± 10 [1-9] mg vs 29 ± 21 [21-37] mg; P < .0001) and on postoperative day 1 (1 ± 3.7 [0-2.5] mg vs 13 ± 23 [4-23] mg; P = .0009). Pain scores were lower in the magnesium group in the PACU (0 [0-3] vs 5 [5-7]; P < .0001) and on postoperative day 1 (0 [0-2] vs 4 [3-5]; P < .0001). CONCLUSIONS Patients undergoing POEM randomized to receive intraoperative magnesium had sustained reductions in esophageal discomfort severity and opioid requirements 24 hours after surgery.
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Affiliation(s)
- Richard K Kim
- From the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - James W Kim
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Timothy Angelotti
- From the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Micaela Esquivel
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Ban C Tsui
- From the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Joo H Hwang
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California
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Reddy AT, Lee JP, Leiman DA. Measuring and improving quality in esophageal care and swallowing disorders. Dis Esophagus 2024; 37:doae013. [PMID: 38458618 DOI: 10.1093/dote/doae013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 02/13/2024] [Indexed: 03/10/2024]
Abstract
Evaluating clinical care through quality-related metrics is increasingly common. There are now numerous quality statements and indicators related to the medical management of benign and pre-malignant esophageal diseases. Expert consensus leveraging evidence-based recommendations from published society guidelines has been the most frequently used basis for developing esophageal quality statements. While surgical care of patients with esophageal malignancies, including squamous cell carcinoma, has also been developed, those related to benign esophageal disease now include domains of diagnosis, treatment, and monitoring for gastroesophageal reflux disease, eosinophilic esophagitis (EoE), achalasia, and Barrett's esophagus (BE). Several recent studies evaluating adherence to quality metrics affirm substantial variation in practice patterns with opportunities for improvement in care across esophageal diseases. In particular, patient education regarding treatment options in achalasia, frequency of esophageal biopsies among patients with dysphagia to evaluate for EoE, and endoscopic evaluation within a BE segment are areas identified to have need for improvement. As the management of esophageal diseases becomes more complex and interdisciplinary, adherence to quality metrics may be a source of standardization and improvement in delivery and ultimately patient outcomes. Indeed, the development of national quality databases has resulted in a significant growth in the use of these metrics for quality improvement activities and may form the basis for future inclusion in quality reporting and payment programs.
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Affiliation(s)
| | - Joshua P Lee
- Division of Gastroenterology, Duke University, Durham, NC, USA
| | - David A Leiman
- Division of Gastroenterology, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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Fawwaz BB, Zhang Y, Farooq A, Gorrepati VS, Forde JF, Canakis A, Kim R, Ma M, Benias P, Che S, Ujiki MB, Li AA, Hwang JH, Eke C, Kedia P, Yu A, Inayat I, Khalaf M, Othman M, Jawaid S, Hasan MK, Sharma N, Pomenti S, Sethi A, Draganov PV, Yang D. Peroral endoscopic myotomy for spastic esophageal dysmotility among opioid users: a multicenter propensity score matching study. Gastrointest Endosc 2024; 99:924-930. [PMID: 38184116 DOI: 10.1016/j.gie.2023.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/30/2023] [Accepted: 12/30/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND AND AIMS Opioid-induced esophageal dysfunction (OIED) often presents as spastic esophageal disorders (SEDs) and esophagogastric junction outflow obstruction (EGJOO). The aim of this study was to evaluate and compare clinical outcomes of peroral endoscopic myotomy (POEM) for SEDs and EGJOO among opioid users and nonusers. METHODS This propensity score (PS) matching study included consecutive opioid users and nonusers who underwent POEM for SEDs and EGJOO between January 2018 and September 2022. The following covariates were used for the PS calculation: age, sex, duration of symptoms, Eckardt score, type of motility disorder, and length of myotomy during POEM. Clinical response was defined as a post-POEM Eckardt score ≤3. RESULTS A total of 277 consecutive patients underwent POEM during the study period. PS matching resulted in the selection of 64 pairs of patients strictly matched 1:1 (n = 128) with no statistically significant differences in demographic, baseline, or procedural characteristics or in the parameters considered for the PS between the 2 groups. Clinical response to POEM was significantly lower among opioid users (51 of 64 [79.7%]) versus nonusers (60 of 64 [93.8%]) (P = .03) at a median follow-up of 18 months. Among opioid users, higher opioid dose (>60 morphine milligram equivalents per day) was associated with a higher likelihood of failure to respond to POEM (odds ratio, 4.59; 95% confidence interval, 1.31-3.98; P = .02). CONCLUSIONS Clinical response to POEM for SEDs and EGJOO is significantly lower among opioid users versus nonusers. There was a dose-relationship between opioids and response to POEM, with higher daily opioid usage associated with a higher likelihood of treatment failure.
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Affiliation(s)
| | - Yiyang Zhang
- Center for Collaborative Research, AdventHealth Research Institute, Orlando, Florida, USA
| | - Aimen Farooq
- Internal Medicine, AdventHealth Medical Group, Orlando, Florida, USA
| | - Venkata S Gorrepati
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Justin F Forde
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Raymond Kim
- Division of Gastroenterology and Hepatology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Michael Ma
- Division of Gastroenterology, Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New York, New York, USA
| | - Petros Benias
- Division of Gastroenterology, Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New York, New York, USA
| | - Simon Che
- Department of Surgery, NorthShore University Health System, Evanston, Illinois, USA
| | - Michael B Ujiki
- Department of Surgery, NorthShore University Health System, Evanston, Illinois, USA
| | - Andrew A Li
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Chiemeziem Eke
- Gastroenterology, Methodist Dallas Medical Center, Dallas, Texas, USA
| | - Prashant Kedia
- Gastroenterology, Methodist Dallas Medical Center, Dallas, Texas, USA
| | - Abraham Yu
- Gastroenterology, Methodist Dallas Medical Center, Dallas, Texas, USA
| | - Irteza Inayat
- Gastroenterology and Hepatology, AdventHealth Medical Group, Orlando, Florida, USA
| | - Mai Khalaf
- Division of Gastroenterology, Baylor College of Medicine, Houston, Texas, USA
| | - Mohamed Othman
- Division of Gastroenterology, Baylor College of Medicine, Houston, Texas, USA
| | - Salmaan Jawaid
- Division of Gastroenterology, Baylor College of Medicine, Houston, Texas, USA
| | - Muhammad K Hasan
- Center for Interventional Endoscopy, AdventHealth Medical Group, Orlando, Florida, USA
| | - Neil Sharma
- Parkview Cancer Institute, Division of Interventional Oncology and Surgical Endoscopy, Parkview Health, Fort Wayne, Indiana, USA
| | - Sydney Pomenti
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, New York, USA
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, New York, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Dennis Yang
- Center for Interventional Endoscopy, AdventHealth Medical Group, Orlando, Florida, USA.
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Farina DA, Olson DA, Carlson DA, Kahrilas PJ, Vespa E, Koop AH, Arroyo Y, Goudie E, Pandolfino JE. Effect of esophageal body recoil on clinical outcomes in non-spastic achalasia. Neurogastroenterol Motil 2024; 36:e14785. [PMID: 38523321 DOI: 10.1111/nmo.14785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 01/15/2024] [Accepted: 03/11/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Despite the established efficacy of achalasia treatments on symptomatic outcomes, there are limited data evaluating the treatment effect on esophageal dilatation. This study aimed to assess the effect achalasia treatment on esophageal dilatation and the effect of esophageal width reduction ("recoil") on clinical outcomes. METHODS Patients with type I or type II achalasia that completed high-resolution manometry (HRM), functional lumen imaging probe (FLIP), and timed barium esophagram (TBE) pre and post treatment were included. Esophageal width was measured using TBE. Focused subgroup analysis was performed on patients with normal posttreatment EGJ opening on FLIP. Good clinical outcomes were defined as barium column height of <5 cm at 5 min and Eckardt Score ≤3. KEY RESULTS Sixty-nine patients (41% type I and 59% type II) were included. Esophageal width decreased from pre to post treatment mean (SD) 4.2 (1.3) cm-2.8 (1.2) cm; p < 0.01. In the normal post treatment EGJ opening subgroup, esophageal width was less in patients with good TBE outcome compared to poor outcome mean (SD) 2.2 (0.7) cm versus 3.2 (1.4) cm (p < 0.01), but did not differ in good versus poor symptomatic outcome groups. Esophageal width recoil >25% posttreatment was associated with a greater rate of good TBE outcome (71% vs. 50%, p = 0.04) and good symptomatic outcome (88% vs. 50%; p = 0.04). CONCLUSIONS AND INFERENCES Esophageal recoil was associated with good achalasia treatment outcome in patients without posttreatment EGJ obstruction. This suggests that mechanical properties of the esophageal wall, likely associated with tissue remodeling, play a role in clinical outcomes following achalasia treatment.
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Affiliation(s)
- Domenico A Farina
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dylan A Olson
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A Carlson
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Edoardo Vespa
- Division of Gastroenterology and Digestive Endoscopy, IRCCS San Raffaele Hospital, Milan, Italy
| | - Andree H Koop
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Yadis Arroyo
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Eric Goudie
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E Pandolfino
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
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Takahashi K, Sato H, Shimamura Y, Abe H, Shiwaku H, Shiota J, Sato C, Hamada K, Ominami M, Hata Y, Fukuda H, Ogawa R, Nakamura J, Tatsuta T, Ikebuchi Y, Terai S, Inoue H. Novel scale for evaluating the therapeutic efficacy of per-oral endoscopic myotomy in achalasia. J Gastroenterol 2024:10.1007/s00535-024-02119-6. [PMID: 38811423 DOI: 10.1007/s00535-024-02119-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 05/23/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Symptom scales for achalasia after per-oral endoscopic myotomy (POEM) are lacking. This study aimed to propose a new scale based on the conventional Eckardt score (c-ES) and evaluate persistent symptoms that impair patients' quality of life (QOL) post-POEM. METHODS Dysphagia, regurgitation, and chest pain frequencies were assessed using a 6-point scale modified-ES (m-ES) after POEM, with "occasional" symptoms on the c-ES further subdivided into three-period categories on m-ES. Symptom severity was further evaluated using a 5-point scale ranging from 1 to 5 points, with a score ≥ 3 points defined as persistent symptoms impairing QOL. We analyzed the correlation between the m-ES and severity score, diagnostic performance of the m-ES for persistent symptoms, and overlaps between each residual symptom. RESULTS Overall, 536 patients (median follow-up period, 2.9 years) post-POEM were included in this multicenter study. Significant correlations were observed between the m-ES and severity scores for dysphagia (r = 0.67, p < 0.01), regurgitation (r = 0.73, p < 0.01), and chest pain (r = 0.85, p < 0.01). Twenty-six patients (4.9%) had persistent symptoms post-POEM, and 23 of them had m-ES-specific symptom frequency ≥ once a month, which was determined as the optimal frequency threshold for screening persistent symptoms. The total m-ES predicted persistent symptoms more accurately than the total c-ES (area under the curve: 0.95 vs. 0.79, p < 0.01). Furthermore, dysphagia and chest pain were the major residual symptoms post-POEM covering 91.4% of regurgitation. CONCLUSIONS The new post-POEM scale successfully evaluated the QOL-based patient symptom severities. Our study implied the possibility of a simpler scale using residual dysphagia and chest pain.
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Affiliation(s)
- Kazuya Takahashi
- Division of Gastroenterology & Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 757-1, Asahimachidori, Chuo-Ku, Niigata, Niigata, 951-8510, Japan
| | - Hiroki Sato
- Division of Gastroenterology & Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 757-1, Asahimachidori, Chuo-Ku, Niigata, Niigata, 951-8510, Japan.
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hirofumi Abe
- Department of Gastroenterology, Kobe University Hospital, Kobe, Japan
| | - Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Junya Shiota
- Department of Gastroenterology & Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Chiaki Sato
- Division of Advanced Surgical Science and Technology, Tohoku University School of Medicine, Miyagi, Japan
| | - Kenta Hamada
- Department of Practical Gastrointestinal Endoscopy, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yoshitaka Hata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hisashi Fukuda
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Ryo Ogawa
- Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Tetsuya Tatsuta
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Yuichiro Ikebuchi
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine Tottori University Faculty of Medicine, Tottori, Japan
| | - Shuji Terai
- Division of Gastroenterology & Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 757-1, Asahimachidori, Chuo-Ku, Niigata, Niigata, 951-8510, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
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Montalva L, Farha E, Hervieux E, Ali L, Rousseau V, Schmitt F, Guinot A, Sassi N, Grosos C, Arnaud AP, Scalabre A, Dubois R, Bonnard A. Complications after Heller myotomy in children: a national multicenter study on the impact of prior endoscopic dilatation and identification of risk factors. Surg Endosc 2024:10.1007/s00464-024-10884-x. [PMID: 38769183 DOI: 10.1007/s00464-024-10884-x] [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: 02/08/2024] [Accepted: 04/28/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Although esophageal achalasia has been historically treated by Heller myotomy, endoscopic esophageal dilatations are nowadays often the first-line treatment in children. The aim was to assess whether performing an endoscopic dilatation before a Heller myotomy is associated with higher risks of esophageal perforation in children. METHODS A retrospective multicentric study was performed, including children that underwent a Heller myotomy (2000-2022, 10 centers). Two groups were compared based on the history of previous dilatation before myotomy. Outcomes esophageal perforation (intra-operative or secondary) and post-operative complications requiring surgery (Clavien-Dindo III). Statistics Comparisons using contingency tables or Kruskal-Wallis when appropriate. Statistical significance: p-value < 0.05. RESULTS A Heller myotomy was performed in 77 children (median age: 11.8 years), with prior endoscopic dilatation in 53% (n = 41). A laparoscopic approach was used in 90%, with associated fundoplication in 95%. Esophageal perforation occurred in 19% of children (n = 15), including 12 patients with intra-operative mucosal tear and 3 with post-operative complications related to an unnoticed esophageal perforation. Previous endoscopic dilatation did not increase the risk of esophageal perforation (22% vs 17%, OR: 1.4, 95%CI: 0.43-4.69). Post-operative complications occurred in 8% (n = 6), with similar rates regardless of prior endoscopic dilatation. Intra-operative mucosal tear was the only risk factor for post-operative complications, increasing the risk of complications from 5 to 25% (OR: 6.89, 95%CI: 1.38-31.87). CONCLUSIONS Prior endoscopic dilatations did not increase the risk of esophageal perforation or postoperative complications of Heller myotomy in this cohort of children with achalasia. Mucosal tear was identified as a risk factor for post-operative complications.
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Affiliation(s)
- Louise Montalva
- Department of Pediatric Surgery and Urology, AP-HP, Robert-Debré Children University Hospital, 48 Boulevard Sérurier, 75019, Paris, France.
- Paris-Cité University, Paris, France.
| | - Elie Farha
- Department of Pediatric Surgery and Urology, AP-HP, Robert-Debré Children University Hospital, 48 Boulevard Sérurier, 75019, Paris, France
| | - Erik Hervieux
- Department of Pediatric Surgery, Armand Trousseau University Hospital, Paris, France
| | - Liza Ali
- Department of Pediatric Surgery and Urology, AP-HP, Robert-Debré Children University Hospital, 48 Boulevard Sérurier, 75019, Paris, France
- Paris-Cité University, Paris, France
| | - Véronique Rousseau
- Department of Pediatric Surgery, AP-HP, Necker-Enfants Malades, Paris, France
| | - Françoise Schmitt
- Department of Pediatric Surgery, Angers University Hospital, Angers, France
| | - Audrey Guinot
- Department of Pediatric Surgery, Hôtel-Dieu University Hospital, Nantes, France
| | - Nizar Sassi
- Department of Pediatric Surgery, Strasbourg University Hospital, Strasbourg, France
| | - Céline Grosos
- Department of Pediatric Surgery, Limoges University Hospital, Limoges, France
| | - Alexis P Arnaud
- Department of Pediatric Surgery, Rennes University Hospital, University of Rennes, Rennes, France
| | - Aurélien Scalabre
- Department of Pediatric Surgery, University Hospital, Saint-Etienne, France
| | - Remi Dubois
- Department of Pediatric Surgery, Hospices Civils de Lyon, Hôpital Femme Mère Enfant University Hospital, Bron, France
| | - Arnaud Bonnard
- Department of Pediatric Surgery and Urology, AP-HP, Robert-Debré Children University Hospital, 48 Boulevard Sérurier, 75019, Paris, France
- Paris-Cité University, Paris, France
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8
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Vespa E, Barchi A, Passaretti S, Danese S, Savarino EV. Pneumatic dilation for achalasia in the "POEM era": Still a valuable ally. Dig Liver Dis 2024; 56:778-785. [PMID: 37932169 DOI: 10.1016/j.dld.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/18/2023] [Accepted: 10/23/2023] [Indexed: 11/08/2023]
Abstract
Endoscopic treatments such as peroral endoscopic myotomy (POEM) and pneumatic dilation (PD) are commonly used to treat achalasia. Although POEM has gained popularity due to its high efficacy, the technique is more complex and may be associated with a higher risk of long-term complications compared to PD. This narrative review will focus on efficacy and safety of PD and POEM, and their suitability for different patient populations. While evidence suggests that POEM may be preferred for type III achalasia, PD remains a valuable alternative for patients with a straight, non-dilated esophagus, who prioritize the preservation of anatomical integrity and a lower risk of post-procedural gastroesophageal reflux disease (GERD). While PD carries a non negligibile risk of perforation, it has an excellent safety profile in terms of GERD and is minimally likely to cause permanent esophageal deformation. PD can be repeated with minimal risks to maintain symptom relief, whereas reversing permanent anatomical modifications related to POEM is difficult. The choice of treatment for achalasia should be patient-tailored, considering benefits and drawbacks of each intervention. The importance of personalized approach in the "POEM era" is highlighted, emphasizing the reasons why PD should still be considered a valuable option in the therapeutic armamentarium for achalasia. Areas requiring further research will be also outlined.
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Affiliation(s)
- Edoardo Vespa
- Division of Gastroenterology and Gastrointestinal Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy.
| | - Alberto Barchi
- Division of Gastroenterology and Gastrointestinal Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy; Università Vita-Salute San Raffaele, Milan, Italy
| | - Sandro Passaretti
- Division of Gastroenterology and Gastrointestinal Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Silvio Danese
- Division of Gastroenterology and Gastrointestinal Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy; Università Vita-Salute San Raffaele, Milan, Italy
| | - Edoardo Vincenzo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy; Gastroenterology Unit, Azienda Ospedale Università of Padua, Padua, Italy
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Altfillisch C, Mok A, Hamo F, Yuquimpo K, Dunshee C, Samo S. Concomitant Achalasia and Barrett's Esophagus: A Rare Coincidence. ACG Case Rep J 2024; 11:e01341. [PMID: 38690567 PMCID: PMC11057812 DOI: 10.14309/crj.0000000000001341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/18/2024] [Indexed: 05/02/2024] Open
Abstract
The pathophysiologies of achalasia and gastroesophageal reflux disease with Barrett's esophagus are highly distinct, though the clinical signs and symptoms of both are highly overlapped. The concomitant development of both achalasia and Barrett's esophagus is rare. We describe a case of a patient with a concomitant diagnosis of both pathologies and further explain the epidemiology of carrying both diseases simultaneously.
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Affiliation(s)
- Charles Altfillisch
- Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, KS
| | - Anthony Mok
- Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, KS
| | - Falak Hamo
- Division of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine, Kansas City, KS
| | - Kyle Yuquimpo
- Division of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine, Kansas City, KS
| | - Carlyle Dunshee
- Department of Surgery, University of Kansas School of Medicine, Kansas City, KS
| | - Salih Samo
- Division of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine, Kansas City, KS
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10
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Choi JY, Jung KW, Pandolfino JE, Choi K, Park YS, Na HK, Ahn JY, Lee JH, Kim DH, Choi KD, Song HJ, Lee GH, Jung HY. Dysphagia associated with esophageal wall thickening in patients with nonspecific high-resolution manometry findings: Understanding motility beyond the Chicago classification version 4.0. Neurogastroenterol Motil 2024; 36:e14736. [PMID: 38225864 DOI: 10.1111/nmo.14736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND Previous studies have demonstrated that 50% of patients with normal high-resolution manometry (HRM) findings or ineffective esophageal motility (IEM) may have abnormal functional luminal imaging probe (FLIP) results. However, the specific HRM findings associated with abnormal FLIP results are unknown. Herein, we investigated the relationship between nonspecific manometry findings and abnormal FLIP results. METHODS We retrospectively analyzed 684 patients who underwent HRM at a tertiary care center in Seoul, Korea, based on the Chicago Classification version 4.0 protocol. KEY RESULTS Among the 684 patients, 398 had normal HRM findings or IEM. Of these 398 patients, eight showed esophageal wall thickening on endoscopic ultrasonography or computed tomography; however, no abnormalities were seen during esophagogastroduodenoscopy. Among these eight patients, seven showed repetitive simultaneous contractions (RSCs) in at least one of the two positions: 61% (±29%) in 10 swallows in the supine position and 51% (±30%) in five swallows in the upright position. Four patients who underwent FLIP had a significantly decreased esophagogastric junction distensibility index (1.0 ± 0.5m m 2 mmHg - 1 at 60 mL). Two of these patients underwent per-oral endoscopic myotomy (POEM) due to a lack of response to medication. Esophageal muscle biopsy revealed hypertrophic muscle with marginal eosinophil infiltration. CONCLUSIONS & INFERENCES A subset of patients (2%) with normal HRM findings or IEM and RSCs experienced dysphagia associated with poor distensibility of the thickened esophageal wall. FLIP assessment or combined HRM and impedance protocols may help better define these patients who may respond well to POEM.
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Affiliation(s)
- Jin Young Choi
- Department of Gastroenterology, Kyungpook National University Hospital, Daegu, South Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - John E Pandolfino
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Kyungmin Choi
- Department of Biomedical Engineering, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Young Soo Park
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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11
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Savarino EV, Salvador R, Ghisa M, Mari A, Forattini F, Costantini A, De Giorgio R, Zaninotto G. Research gap in esophageal achalasia: a narrative review. Dis Esophagus 2024:doae024. [PMID: 38525929 DOI: 10.1093/dote/doae024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 03/08/2024] [Indexed: 03/26/2024]
Abstract
In recent years, new translational evidence, diagnostic techniques, and innovative therapies have shed new light on esophageal achalasia and revamped the attention on this relatively rare motility disorder. This narrative review aims to highlight the most recent progress and the areas where further research is needed. The four senior authors identified five topics commonly discussed in achalasia management: i.e. pathogenesis, role of functional lumen imaging probe in the diagnostic flow chart of achalasia, how to define the outcome of achalasia treatments, how to manage persistent chest pain after the treatment, and if achalasia patients' may benefit from a regular follow-up. We searched the bibliographic databases to identify systematic reviews, meta-analyses, randomized control trials, and original research articles in English up to December 2023. We provide a summary with the most recent findings in each of the five topics and the critical points where to address future research, such as the immune-genetic patterns of achalasia that might explain the transition among the different phenotypes, the need for a validated clinical definition of treatment success, the use of neuromodulators to manage chest pain, and the need for identifying achalasia patients at risk for cancer and who may benefit of long-term follow-up. Although undoubtedly, progress has been made on the definition and management of achalasia, unmet needs remain. Debated aspects range from mechanistic insights, symptoms, objective measure relationships, and accurate clinical responses to therapeutic interventions. Translational research is eagerly awaited to answer these unresolved questions.
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Affiliation(s)
- Edoardo Vincenzo Savarino
- Gastroenterology Unit, Azienda Ospedale Università of Padua, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Renato Salvador
- Chirurgia Generale 1, Azienda Ospedale Università of Padua, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Matteo Ghisa
- Gastroenterology Unit, Azienda Ospedale Università of Padua, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Amir Mari
- Gastroenterology Unit, Nazareth Hospital EMMS, The Azrieli Faculty of Medicine, Bar-Ilan University, Tel Aviv, Israel
| | - Francesca Forattini
- Chirurgia Generale 1, Azienda Ospedale Università of Padua, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Andrea Costantini
- Chirurgia Generale 1, Azienda Ospedale Università of Padua, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Roberto De Giorgio
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
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12
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Fukushima N, Masuda T, Tsuboi K, Hoshino M, Takahashi K, Yuda M, Sakashita Y, Takeuchi H, Omura N, Yano F, Eto K. Role of modified Glasgow Prognostic Score in patients with achalasia who underwent laparoscopic Heller-myotomy with Dor-fundoplication. Esophagus 2024:10.1007/s10388-024-01047-x. [PMID: 38431541 DOI: 10.1007/s10388-024-01047-x] [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: 11/20/2023] [Accepted: 01/25/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Systemic inflammatory response is significant prognostic indicator in patients with various diseases. The relationship between prognostic scoring systems based on the modified Glasgow Prognostic Score (mGPS) and achalasia in patients treated with laparoscopic Heller‑myotomy with Dor‑fundoplication (LHD) remains uninvestigated. This study aimed to examine the role of mGPS in patients with achalasia. METHODS 457 patients with achalasia who underwent LHD as the primary surgery between September 2005 and December 2020 were included. We divided patients into the mGPS 0 and mGPS 1 or 2 groups and compared the patients' background, pathophysiology, symptoms, surgical outcomes, and postoperative course. RESULTS mGPS was 0 in 379 patients and 1 or 2 in 78 patients. Preoperative vomiting and pneumonia were more common in patients with mGPS of 1 or 2. There were no differences in surgical outcomes. Postoperative upper gastrointestinal endoscopy revealed that severe esophagitis was more frequently observed in patients with mGPS of 1 or 2 (P < 0.01). The clinical success was 91% and 99% in the mGPS 0 and mGPS 1 or 2 groups, respectively (P < 0.01). CONCLUSIONS Although severe reflux esophagitis was more common in patients with achalasia with a high mGPS, good clinical success was obtained regardless of the preoperative mGPS.
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Affiliation(s)
- Naoko Fukushima
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan.
| | - Takahiro Masuda
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Kazuto Tsuboi
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Masato Hoshino
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Keita Takahashi
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Masami Yuda
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Yuki Sakashita
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Hideyuki Takeuchi
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Nobuo Omura
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Fumiaki Yano
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Ken Eto
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan
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13
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Reddy CA, Ellison A, Cipher DJ, Mendoza R, Souza RF, Spechler SJ, Konda VJA, Nguyen AD. Frequent discrepancies among diagnostic tests for detecting lower esophageal sphincter-related obstruction. Neurogastroenterol Motil 2024; 36:e14729. [PMID: 38129627 DOI: 10.1111/nmo.14729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/19/2023] [Accepted: 12/02/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND There are frequent discrepancies among high-resolution manometry (HRM), functional lumen imaging probe (FLIP), and esophagram in identifying lower esophageal sphincter (LES)-related obstruction. We aimed to determine the frequency of those discrepancies and how they influenced clinical treatment/outcomes. METHODS We identified patients who had all three tests (HRM, FLIP, and esophagram) and endoscopy performed for evaluation of esophageal symptoms in our Center for Esophageal Diseases. Discrepancies among the tests for the presence of LES obstruction were noted, and the performance of individual tests was compared against a consensus opinion rendered by a panel of esophagologists. Binary logistical regression was performed, and ROC curves were generated for prediction of the consensus clinical diagnosis of LES obstruction. KEY RESULTS A total of 126 patients (mean age 57.9 ± 17.0 years; 67% female) met inclusion criteria. All three tests agreed on the presence or absence of LES obstruction in only 72 (57%) patients [no LES obstruction in 57 (45%), LES obstruction in 15 (12%)]. Thirteen patients (10%) had a change in management based on additional findings on FLIP +/- esophagram not seen on HRM with 69% having symptomatic improvement after LES-directed intervention. FLIP was the strongest predictor of a consensus diagnosis of LES obstruction by logistic regression and ROC (OR 23.36, AUC 0.796), followed by HRM (OR 15.41, AUC 0.764). CONCLUSIONS & INFERENCE High-resolution manometry, functional lumen imaging probe, and esophagram each have considerable limitations for identifying LES obstruction, and discrepancies among these tests occur frequently. Multimodal testing is often required for adequate evaluation of LES-related obstruction.
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Affiliation(s)
- Chanakyaram A Reddy
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Ashton Ellison
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Daisha J Cipher
- College of Nursing and Health Innovation, The University of Texas at Arlington, Arlington, Texas, USA
| | - Roseann Mendoza
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Rhonda F Souza
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Stuart J Spechler
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Vani J A Konda
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Anh D Nguyen
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
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14
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Vespa E, Farina DA, Pandolfino JE, Kahrilas PJ, Koop AH, Carlson DA. Presence of esophageal contractility after achalasia treatment is associated with improved esophageal emptying. Neurogastroenterol Motil 2024; 36:e14732. [PMID: 38155413 PMCID: PMC10922458 DOI: 10.1111/nmo.14732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 10/19/2023] [Accepted: 12/14/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND AND AIMS Some achalasia patients exhibit esophageal contractile activity on follow-up after treatment, yet its importance remains unclear. We aimed to identify factors associated with presence of contractility after treatment and to assess its impact on timed barium esophagram (TBE) and clinical outcomes. METHODS Patients with type I or II achalasia on baseline high-resolution manometry (HRM) who completed HRM, TBE, and functional lumen imaging probe (FLIP) after treatment were retrospectively identified. Contractility was defined on post-treatment HRM as presence of at least 1 supine swallow with DCI ≥100 mmHg s cm. KEY RESULTS One hundred twenty-two patients were included (mean age 48 ± 17 years, 50% female). At follow-up evaluation after treatment (54% peroral endoscopic myotomy, 24% pneumatic dilation, 22% laparoscopic Heller myotomy), 61 (50%) patients had contractility on HRM. Patients with contractility (compared to those without) more frequently had type II achalasia (84% vs 57%, p = 0.001) and a post-treatment normal EGJ opening classification on FLIP (69% vs 49%; p < 0.001). In the subgroup of patients with post-treatment integrated relaxation pressure <15 mmHg and normal EGJ opening on FLIP (n = 53), those with contractility had a lower median column height on TBE at 1 min (4 vs 7 cm, p = 0.002) and 5 min (0 vs 5 cm, p = 0.001). In patients with "abnormal" EGJ metrics, patients with contractility showed lower symptom scores (median Eckardt score 2 vs 3, p = 0.03). CONCLUSIONS & INFERENCES Occurring more frequently in type II achalasia, and if adequate EGJ opening is achieved after treatment, esophageal contractility may contribute to improved esophageal emptying and improved symptoms in non-spastic achalasia. Preservation of esophageal body muscle could improve outcomes in these patients.
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Affiliation(s)
- Edoardo Vespa
- Division of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Domenico A. Farina
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - John E. Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Peter J. Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Andree H. Koop
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Dustin A. Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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15
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Salem SA, Marom G, Shein GS, Fishman Y, Helou B, Brodie R, Elazary R, Pikarsky AJ, Mintz Y. Robotic Heller's myotomy using the new Hugo™ RAS system: first worldwide report. Surg Endosc 2024; 38:1180-1190. [PMID: 38082007 DOI: 10.1007/s00464-023-10618-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 11/26/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND Achalasia is a rare disorder of the esophagus characterized by motor dysfunction in the esophagus and relaxation failure of the lower esophageal sphincter (LES). Currently, surgical myotomy procedures are considered the standard of care. Robotic Heller's myotomy (RHM) with fundoplication has been gaining popularity due to documented advantages in the precision of myotomy as well as avoiding the potential reflux following per-oral endoscopic myotomy (POEM). To the best of our knowledge, RHM has thus far has been performed exclusively by the da Vinci surgical system. The new Hugo RAS™ system offers a unique modular design and an open console which offers better maneuverability and docking options. In this study, we present the first worldwide series of patients undergoing RHM using the new Hugo RAS™ platform. Our objective is to propose optimal operating configuration and setup to fully harness the advantages of the unique modular design of this system. METHODS Ten consecutive achalasia patients underwent Robotic Heller's myotomy (RHM) with the Hugo RAS™ system. We prospectively collected patient data, including demographics, comorbidities, ASA class, Eckardt scores, pre-operative manometric data, and EndoFlip parameters. Additionally, we recorded the docking and total operative times. RESULTS Between December 2022 and August 2023, 10 patients underwent RHM with the Hugo™ RAS system. Patients had a median age of 42.5 years, 60% were female, and mean BMI was 23.2. Fifty percent had achalasia type 2 and 50% type 1. The median pre-operative integrated relaxation pressure (IRP) was 24.9. Median docking time was 10 min and overall operative time was 129.5 min. All patients, except one with acute coronary syndrome, had an uneventful peri-operative course and were discharged on post-operative day 2. CONCLUSION The Hugo™ RAS system is well designed for robotic Heller myotomy. The operative and clinical results are similar to the currently used robotic system; however, the modular design of the system has some differences. These translate to better docking angles and maneuverability as well as console surgeon's ergonomics. Further experience is needed to explore the advantages of the system's modular design and function.
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Affiliation(s)
- Samer Abu Salem
- Department of General Surgery, Hadassah Hebrew- University Medical Center, Jerusalem, Israel
| | - Gad Marom
- Department of General Surgery, Hadassah Hebrew- University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gabriel Szydlo Shein
- Department of General Surgery, Hadassah Hebrew- University Medical Center, Jerusalem, Israel
| | - Yuri Fishman
- Department of General Surgery, Hadassah Hebrew- University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Brigitte Helou
- Department of General Surgery, Hadassah Hebrew- University Medical Center, Jerusalem, Israel
| | - Ronit Brodie
- Department of General Surgery, Hadassah Hebrew- University Medical Center, Jerusalem, Israel
| | - Ram Elazary
- Department of General Surgery, Hadassah Hebrew- University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Alon J Pikarsky
- Department of General Surgery, Hadassah Hebrew- University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yoav Mintz
- Department of General Surgery, Hadassah Hebrew- University Medical Center, Jerusalem, Israel.
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
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16
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Abu Suleiman A, James D, Wilkins A, Bladel AV, Lo T. Achalasia-associated megaoesophagus presenting with dyspnoea and cough. BMJ Case Rep 2024; 17:e258950. [PMID: 38367990 PMCID: PMC10875499 DOI: 10.1136/bcr-2023-258950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2024] Open
Abstract
We present an unusual case of achalasia presenting with dyspnoea and persistent cough. These symptoms persisted for months, leading to the patient undergoing a chest X-ray by her general practitioner which showed right basal consolidation and a density extending along the right mediastinum. CT scan was done which revealed megaoesophagus with a diameter of 7 cm causing tracheal compression, as well as right basal consolidation, consistent with aspiration. Further history revealed 6-month history of progressive swallowing difficulty, retrosternal chest pain and shortness of breath which worsened when eating solid foods. After thorough workup, a diagnosis of idiopathic achalasia (type II) was made. She was treated with laparoscopic Heller cardiomyotomy and Dor fundoplication with significant improvement at follow-up. Dyspnoea and respiratory symptoms are unusual presenting symptoms, suggesting a need to consider achalasia in a wider range of presentations. Successful treatment of achalasia depends on timely diagnosis and intervention prior to oesophageal failure.
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Affiliation(s)
- Amro Abu Suleiman
- Department of Upper Gastrointestinal Surgery, Hull University Teaching Hospitals NHS Trust, Cottingham, UK
| | - Daniel James
- Department of Upper Gastrointestinal Surgery, Hull University Teaching Hospitals NHS Trust, Cottingham, UK
| | - Alexander Wilkins
- Department of Upper Gastrointestinal Surgery, Hull University Teaching Hospitals NHS Trust, Cottingham, UK
| | - Adrian Van Bladel
- Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Terence Lo
- Department of Upper Gastrointestinal Surgery, Hull University Teaching Hospitals NHS Trust, Cottingham, UK
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17
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Tobón A, Cantillo Nassar GR, Hani AC, Herrera Leaño NM, Pulgarin C, Muñoz OM. Clinical and manometric results of peroral endoscopic myotomy in patients with achalasia: experience in a latin american reference center. GASTROENTEROLOGIA Y HEPATOLOGIA 2024:S0210-5705(24)00031-1. [PMID: 38316173 DOI: 10.1016/j.gastrohep.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 02/07/2024]
Abstract
INTRODUCTION Currently there is little information in Latin America on the clinical outcome and manometric evolution of patients with Achalasia undergoing peroral endoscopic myotomy (POEM). PRIMARY OUTCOME Evaluate the manometric and clinical changes in adult patients with achalasia after peroral endoscopic myotomy at a referral center in Bogotá, Colombia. METHODS Observational, analytical, longitudinal study. Adult patients with achalasia according to the Chicago 4.0 criteria were included. Sociodemographic, clinical and manometric variables were described. To compare the pre- and post-surgical variables, the Student's or Wilcoxon's t test was used for the quantitative variables according to their normality, and McNemar's chi-square for the qualitative variables. RESULTS 29 patients were included, 55.17% (n=16) women, with a mean age at the time of surgery of 48.2 years (±11.33). The mean post-procedure evaluation time was 1.88±0.81 years. After the procedure, there was a significant decrease in the proportion of patients with weight loss (37.93% vs 21.43% p 0.0063), chest pain (48.28% vs 21.43, p 0.0225) and the median Eckardt score (8 (IQR 8 -9) vs 2(IQR 1-2), p <0.0001). In addition, in fourteen patients with post-surgical manometry, significant differences were found between IRP values (23.05±14.83mmHg vs 7.69±6.06mmHg, p 0.026) and in the mean lower esophageal sphincter tone (9.63±7.2mmHg vs 28.8±18.60mmHg, p 0.0238). CONCLUSION Peroral endoscopic myotomy has a positive impact on the improvement of symptoms and of some manometric variables (IRP and LES tone) in patients with achalasia.
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Affiliation(s)
- Angélica Tobón
- Departamento de Gastroenterología, Pontificia Universidad Javeriana, Bogotá, Colombia.
| | | | - Albis Cecilia Hani
- Departamento de Gastroenterología y Endoscopia Digestiva, Hospital Universitario San Ignacio, Bogotá, Colombia
| | | | - Cristiam Pulgarin
- Departamento de Gastroenterología, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Oscar Mauricio Muñoz
- Departamento de Medicina Interna, Hospital Universitario San Ignacio, Bogotá, Colombia
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18
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Palomba G, Capuano M, Pegoraro F, Basile R, Pesce M, Rurgo S, Effice E, Sarnelli G, De Palma GD, Aprea G. Laparoscopic Heller-Dor myotomy in elderly achalasia patients: a single center experience with PSM analysis. MINIM INVASIV THER 2024; 33:13-20. [PMID: 37747454 DOI: 10.1080/13645706.2023.2261032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023]
Abstract
INTRODUCTION Achalasia is a rare esophageal motility disorder of unknown etiology. With the ageing of the general population, treatment in elderly patients has become increasingly common; however, the gold standard treatment in this population remains unclear. The aim of this study was to evaluate the outcomes of laparoscopic Heller-Dor myotomy (LHM) in geriatric patients. MATERIAL AND METHODS In this study, consecutive achalasia patients undergoing LHM at the University Hospital 'Federico II' of Naples from November 2018 to November 2022 were prospectively enrolled. Patients were divided into two groups based on their age at intervention: elderly (≥70 years) and younger (<70 years). The two study groups were compared by minimizing the different distribution of covariates through a propensity score matching analysis (PSM). RESULTS In both populations, there was a significant improvement in terms of manometric parameters and symptoms after surgery. After applying one-on-one PSM, we obtained a total population of 48 achalasia patients divided into two groups (24 patients each). No significant differences were found in terms of demographic characteristics as well as preoperative and intraoperative variables between two groups. At 12 months from surgery, integrated relaxation pressure (IRP) was significantly lower in patients ≥ 70 years (p = 0.032), while younger patients scored significantly less at the post-operative Eckardt score (p = 0.047). CONCLUSIONS Laparoscopic Heller-Dor myotomy is a safe and effective treatment even in elderly patients with rapid post-operative recovery, improvement of symptoms and manometric parameters.
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Affiliation(s)
- Giuseppe Palomba
- Division of Endoscopic Surgery, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Marianna Capuano
- Division of Endoscopic Surgery, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Francesca Pegoraro
- Division of Hepato-Biliary-Pancreatic, Minimally Invasive and Robotic Surgery and Kidney Transplantation, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Raffaele Basile
- Division of Endoscopic Surgery, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Marcella Pesce
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Sara Rurgo
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Eleonora Effice
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Giovanni Sarnelli
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Giovanni Domenico De Palma
- Division of Endoscopic Surgery, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Giovanni Aprea
- Division of Endoscopic Surgery, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
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Samejima Y, Yoshimura S, Okata Y, Sakaguchi H, Abe H, Tanaka S, Kodama Y, Bitoh Y. Peroral Endoscopic Myotomy in Pediatric Patients with Achalasia up to 12 Years of Age: A Pilot Study in a Single-Center Experience in Japan. Eur J Pediatr Surg 2024; 34:97-101. [PMID: 37595633 DOI: 10.1055/a-2156-5099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
INTRODUCTION Peroral endoscopic myotomy (POEM) is a minimally invasive endoscopic procedure for achalasia; its indication has expanded from adults to children. We aimed to evaluate the postoperative efficacy and antireflex status of POEM in young children with achalasia aged 12 years or younger. PATIENTS AND METHODS: Pediatric patients with achalasia aged 18 years or younger who underwent POEM in our hospital between 2016 and 2021 were included and divided into two age groups: group A (≤ 12 years) and group B (13-18 years). The success rate (Eckardt score ≤ 3), endoscopic reflux findings, and antiacid use at 1 year postoperatively were compared between the groups. RESULTS Ten patients (four boys and six girls; Chicago classification type I: five, type II: four, and unclassified: one) were included. Mean age and preoperative Eckardt scores in groups A (n = 4) and B (n = 6) were 9.2 ± 3.0 versus 15.6 ± 0.6 years (p = 0.001) and 5.5 ± 3.9 versus 7.2 ± 3.7 (p = 0.509), respectively, and mean operative time and myotomy length were 51.3 ± 16.6 versus 52.5 ± 13.2 minutes (p = 0.898) and 10.8 ± 4.6 versus 9.8 ± 3.2 cm (p = 0.720), respectively. The 1-year success rate was 100% in both groups. Mild esophagitis (Los Angeles classification B) was endoscopically found in one patient in each group (16.7 vs. 25.0%, p = 0.714), and antiacid use was required in three patients (group A, two; group B, one; 50.0 vs. 16.7%, p = 0.500). CONCLUSION The success rate of POEM within 1 year in young children with achalasia aged 12 years or younger was equal to that in adolescent patients. However, young children tended to require antiacids 1 year postoperatively; therefore, long-term follow-up is necessary.
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Affiliation(s)
- Yoshitomo Samejima
- Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Shohei Yoshimura
- Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yuichi Okata
- Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Hiroya Sakaguchi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Hirofumi Abe
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Shinwa Tanaka
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
- Department of Internal Medicine, Tanaka Clinic, Kobe, Japan
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yuko Bitoh
- Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
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20
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Zhang H, Pu X, Huang S, Xia H, Zou K, Zeng X, Jiang J, Ren W, Peng Y, Lü M, Tang X. Comparing clinical outcomes of peroral endoscopic myotomy for achalasia between Eastern and Western countries: a systematic review and meta-analysis. Dis Esophagus 2024; 37:doad056. [PMID: 38300629 DOI: 10.1093/dote/doad056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 07/13/2023] [Indexed: 02/02/2024]
Abstract
Peroral endoscopic myotomy (POEM) has revolutionized the therapeutic strategy for achalasia with promising results. We conducted this meta-analysis to compare clinical outcomes between Eastern and Western countries. A comprehensive literature search was conducted in PubMed, EMBASE, Web of Science and Cochrane Library databases to query for studies that assessed the efficacy of POEM for achalasia. All articles published from inception to December 31, 2021 were included. The primary outcome was the pooled clinical success rate. The secondary outcomes included the pooled technical success rate, incidence of adverse events, procedure time and hospital stay. Eighteen Eastern studies involving 5962 patients and 11 Western studies involving 1651 patients were included. The pooled clinical success rate and technical success rate for POEM was equal in the Eastern studies compared to Western studies. The pooled incidence of procedure adverse events for POEM was a little lower in the Eastern studies compared to Western studies (6.6% vs. 8.7%). Similarly, the incidence of reflux-related adverse events was lower in Eastern studies than that in Western studies. The pooled procedure time of POEM was shorter in Eastern studies compared to Western studies (61 minutes vs. 80 minutes), while the length of hospital stay was longer in Eastern studies compared to Western studies (5.8 days vs. 2.4 days). Overall, Eastern countries have the similar POEM outcomes compared to Western countries. However, Eastern countries still need to do more to reduce the length of hospital stay.
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Affiliation(s)
- Han Zhang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Xinxin Pu
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Shu Huang
- Department of Gastroenterology, Lianshui County People' Hospital, Huaian, China
- Department of Gastroenterology, Lianshui People's Hospital of Kangda College Affiliated to Nanjing Medical University, Huaian, China
| | - Huifang Xia
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Kang Zou
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Xinyi Zeng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Jiao Jiang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Wensen Ren
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Yan Peng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Muhan Lü
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Xiaowei Tang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
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21
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Low EXS, Wang YP, Ye YC, Liu PY, Sung KY, Lin HE, Lu CL. A Comparison between Chicago Classification Versions 3.0 and 4.0 and Their Impact on Manometric Diagnoses in Esophageal High-Resolution Manometry Cases. Diagnostics (Basel) 2024; 14:263. [PMID: 38337780 PMCID: PMC10854946 DOI: 10.3390/diagnostics14030263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/14/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
High-resolution manometry (HRM) facilitates the detailed evaluation of esophageal motility. In December 2020, Chicago classification (CC) version 4.0 introduced modifications to improve consistency and accuracy. We conducted this study to compare the differences in the interpretations of HRM examinations between CC 3.0 and 4.0. Consecutive HRM records at a Taiwan tertiary medical center, including wet swallows and MRS performed in both supine and sitting positions from October 2019 to May 2021, were retrospectively reviewed and analyzed using both CC versions 3.0 and 4.0. A total of 105 patients were enrolled, and 102 patients completed the exam, while three could not tolerate HRM sitting up. Refractory gastroesophageal reflux disease (GERD) symptoms (n = 65, 63.7%) and dysphagia (n = 37, 36.3%) were the main indications. A total of 18 patients (17.6%) were reclassified to new diagnoses using CC 4.0. Of the 11 patients initially diagnosed with absent contractility, 3 (27.3%) were reclassified as having Type 1 achalasia. Of the 18 patients initially diagnosed with IEM, 6 (33.3%) were reclassified as normal. The incidence of diagnosis changes was similar in both the dysphagia and refractory GERD symptoms groups (21.6% versus 15.3%, p = 0.43). The use of CC 4.0 led to changes in the diagnoses of esophageal motility disease, irrespective of examination indications. Early adoption improves the accuracy of diagnoses and affects patient management.
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Affiliation(s)
- En Xian Sarah Low
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (E.X.S.L.); (Y.-C.Y.); (P.-Y.L.); (K.-Y.S.); (H.-E.L.)
- Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- Department of Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore 609606, Singapore
| | - Yen-Po Wang
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (E.X.S.L.); (Y.-C.Y.); (P.-Y.L.); (K.-Y.S.); (H.-E.L.)
- Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- Institute of Brain Science, National Yang-Ming University, Taipei 11221, Taiwan
- Faculty of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei 11221, Taiwan
| | - Yong-Cheng Ye
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (E.X.S.L.); (Y.-C.Y.); (P.-Y.L.); (K.-Y.S.); (H.-E.L.)
- Faculty of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei 11221, Taiwan
| | - Pei-Yi Liu
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (E.X.S.L.); (Y.-C.Y.); (P.-Y.L.); (K.-Y.S.); (H.-E.L.)
| | - Kuan-Yi Sung
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (E.X.S.L.); (Y.-C.Y.); (P.-Y.L.); (K.-Y.S.); (H.-E.L.)
- Division of Gastroenterology, Department of Medicine, Fu Jen Catholic University Hospital, Taipei 24352, Taiwan
| | - Hung-En Lin
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (E.X.S.L.); (Y.-C.Y.); (P.-Y.L.); (K.-Y.S.); (H.-E.L.)
- Division of Gastroenterology, Department of Medicine, Taipei City Hospital Chongxing Branch, Taipei 10321, Taiwan
| | - Ching-Liang Lu
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (E.X.S.L.); (Y.-C.Y.); (P.-Y.L.); (K.-Y.S.); (H.-E.L.)
- Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- Institute of Brain Science, National Yang-Ming University, Taipei 11221, Taiwan
- Faculty of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei 11221, Taiwan
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22
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Suzuki Y, Ochiai Y, Hosoi A, Okamura T, Hayasaka J, Mitsunaga Y, Tanaka M, Odagiri H, Nomura K, Yamashita S, Matsui A, Kikuchi D, Ohashi K, Hoteya S. Mucosal and Submucosal Thickening of Esophageal Wall Is a Promising Factor in the Development of Symptoms in Eosinophilic Esophagitis. Gut Liver 2024; 18:50-59. [PMID: 36789578 PMCID: PMC10791495 DOI: 10.5009/gnl220490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/21/2022] [Accepted: 12/27/2022] [Indexed: 02/16/2023] Open
Abstract
Background/Aims Asymptomatic esophageal eosinophilia (aEE) is considered to be a potential precursor of eosinophilic esophagitis (EoE). However, there are few clinical parameters that can be used to evaluate the disease. Therefore, we aimed to clarify the factors involved in the symptoms of EoE by examining the clinicopathological differences between aEE and EoE. Methods We reviewed 41 patients with esophageal eosinophilia who underwent endoscopic ultrasonography and high-resolution manometry. They were divided into the aEE group (n=16) and the EoE group (n=25) using the Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease score. The patients' clinicopathological findings were collected and examined. Results The median Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease score was 3.0 in the aEE group and 10.0 in the EoE group. There was no significant difference in patient characteristics, endoscopic findings and pathological findings. The cutoff value for wall thickening was 3.13 mm for the total esophageal wall thickness and 2.30 mm for the thickness from the surface to the muscular layer (total esophageal wall thickness: 84.0% sensitivity, 75.0% specificity; thickness from the surface to the muscular layer: 84.0% sensitivity, 68.7% specificity). The high-resolution manometry study was abnormal in seven patients (43.8%) in the aEE group and in 12 (48.0%) in the EoE group. The contractile front velocity was slower in the EoE group (p=0.026). Conclusions The esophageal wall thickening in the lower portion of the esophagus is an important clinical factors related to the symptoms in patients with EoE.
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Affiliation(s)
- Yugo Suzuki
- Departments of Gastroenterology, Toranomon Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yorinari Ochiai
- Departments of Gastroenterology, Toranomon Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsuko Hosoi
- Departments of Pathology, Toranomon Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takayuki Okamura
- Departments of Gastroenterology, Toranomon Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Junnosuke Hayasaka
- Departments of Gastroenterology, Toranomon Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yutaka Mitsunaga
- Departments of Gastroenterology, Toranomon Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masami Tanaka
- Departments of Gastroenterology, Toranomon Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroyuki Odagiri
- Departments of Gastroenterology, Toranomon Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kosuke Nomura
- Departments of Gastroenterology, Toranomon Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Satoshi Yamashita
- Departments of Gastroenterology, Toranomon Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akira Matsui
- Departments of Gastroenterology, Toranomon Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Daisuke Kikuchi
- Departments of Gastroenterology, Toranomon Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kenichi Ohashi
- Department of Human Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shu Hoteya
- Departments of Gastroenterology, Toranomon Hospital, Tokyo Medical and Dental University, Tokyo, Japan
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23
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Sykes C, Banks M, Dervin H, Vales A, Sweis R. A complex case of dysphagia with dual aetiology. Clin Med (Lond) 2024; 24:100010. [PMID: 38359665 PMCID: PMC11024826 DOI: 10.1016/j.clinme.2023.100010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
A woman in her early 60s was referred with dysphagia and chest pain to a tertiary referral centre specialising in oesophageal disorders. Cardiac symptom origin and sinister oesophageal pathology had been excluded at her local hospital in NHS Scotland. Under multidisciplinary team oversight, reinvestigation of mucosal pathology and oesophageal motility ultimately uncovered both Type III achalasia and eosinophilic oesophagitis. This case demonstrates the benefit of including provocative testing during high-resolution manometry to reproduce relevant dysphagia and the importance of stopping proton-pump inhibitors long enough to uncover excessive eosinophils which could otherwise be masked. Ultimately, tailored management for both conditions separately was required to achieve symptoms resolution.
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Affiliation(s)
- Catherine Sykes
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Matthew Banks
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Humayra Dervin
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | | | - Rami Sweis
- University College London Hospitals NHS Foundation Trust, London, UK.
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24
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Leopold AR, McCarthy P, Nair A, Kim RE, Xie G. Compartmentalized pressurization is a novel prognostic factor for hypercontractile esophagus. Neurogastroenterol Motil 2024; 36:e14711. [PMID: 37983938 PMCID: PMC10842079 DOI: 10.1111/nmo.14711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/21/2023] [Accepted: 10/30/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Hypercontractile esophagus (HE) is a disorder of increased esophageal body contractile strength on high-resolution esophageal manometry (HREM). Compartmentalized pressurization (CP) is a pattern with an isobaric contour of >30 mmHg extending from the contractile front to the lower esophageal sphincter on HREM. The relevance of CP to HE has yet to be explored. METHODS A retrospective review was performed on 830 HREM studies of patients to identify HE. HE patients' CP status and symptoms by Eckardt score (ES) were reviewed. Diagnoses were made using Chicago Classification (CC) v4.0. KEY RESULTS Forty-seven patients (5.6%) were identified as having HE by CCv3, 30 (3.6%) of which had HE by CCv4. 11/30 HE patients had CP, and 19/30 did not. CP was associated with chronic opioid use (36.4% vs. 5.3% p = 0.047). Presenting ES was greater for HE patients with CP (7 vs. 4). Seven HE patients with CP and 11 without CP were managed medically. ES after medical therapy was higher in HE patients with CP compared to those without CP (9 vs. 0). No HE patients with CP responded to medical therapy. Kaplan-Meier analysis demonstrated significance of this association over time. 83% of all HE patients had all-cause symptom remission. CONCLUSIONS & INFERENCES HE patients with CP are associated with a higher presenting ES. HE patients with CP do not respond to medical therapy, while HE patients without CP frequently do respond. CP in HE may have prognostic value in determination of treatment strategy for patients with HE.
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Affiliation(s)
- Andrew R Leopold
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Patrick McCarthy
- Department of Internal Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Anupama Nair
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Raymond E Kim
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Division of Gastroenterology and Hepatology, Veterans Affairs Maryland Healthcare System, Baltimore, Maryland, USA
| | - Guofeng Xie
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Division of Gastroenterology and Hepatology, Veterans Affairs Maryland Healthcare System, Baltimore, Maryland, USA
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25
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Prado Junior FPP, Machado IFS, Prado MPLP, Leite RBC, Gurgel SM, Gomes JWF, Garcia JHP. PERORAL ENDOSCOPIC MYOTOMY FOR ACHALASIA: SAFETY PROFILE, COMPLICATIONS AND RESULTS OF 94 PATIENTS. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2023; 36:e1784. [PMID: 38088729 PMCID: PMC10712919 DOI: 10.1590/0102-672020230066e1784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 10/10/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Achalasia is an esophageal motility disorder, with clinical presentation of dysphagia and regurgitation. This is a chronic condition with no cure. Current treatment options aim to reduce lower esophageal sphincter tone by pharmacological, endoscopic or surgical means, with the aim of improving patients' symptoms. Peroral endoscopic myotomy (POEM) is an alternative endoscopic surgery to Heller cardiomyotomy, in which the procedure is performed orally, by endoscopy, offering efficacy comparable to surgical myotomy, with relative ease and minimal invasion, without external incisions. AIMS To study the safety of POEM by analyzing its results, adverse events and perioperative complications and the main ways to overcome them, in addition to evaluating the effectiveness of the procedure and the short-term postoperative quality of life. METHODS A qualitative and quantitative, observational and cross-sectional study that analyzed patients who underwent the POEM in a reference center, from December 2016 to December 2022, maintaining the technical standard of pre-, peri- and postoperative protocol. RESULTS A total of 94 patients were included in the study, and only three had postoperative complications. The average early postoperative Eckardt score was 0.93 and the late 1.40, with a mean improvement of 7.1 in early results and 6.63 in late results (p<0.05). CONCLUSIONS POEM can be reproduced with an excellent safety profile, significant relief of symptoms and improvement in esophageal emptying, and in quality of life.
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Provenzano L, Pulvirenti R, Duci M, Capovilla G, Costantini A, Forattini F, Gamba P, Costantini M, Fascetti-Leon F, Salvador E. Laparoscopic Heller-Dor Is a Persistently Effective Treatment for Achalasia Even in Pediatric Patients: A 25-Year Experience at a Single Tertiary Center. Eur J Pediatr Surg 2023; 33:493-498. [PMID: 36720247 DOI: 10.1055/s-0043-1760822] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Esophageal achalasia (EA) is a rare primary motility disorder in any age group, and particularly rare in the pediatric population, with a reported incidence of 0.18 per 100,000 children a year. EA in pediatric age is currently treated in the same way as in adults, but this approach is based on only a few studies on small case series. The aim of this retrospective study was to assess the long-term outcome of the laparoscopic Heller-Dor (LHD) procedure when performed in pediatric patients with EA at our university hospital. MATERIALS AND METHODS We considered children and adolescents younger than 16 years old diagnosed with EA and treated with LHD between 1996 and 2022. Clinical data were prospectively collected in an ongoing database. Symptoms were recorded and their severity was calculated using the Eckardt score. Barium swallow, esophageal manometry (conventional or high-resolution), and endoscopy were performed before and after the surgical procedure. RESULTS During the study period, 40 children with a median age of 14 years (interquartile range [IQR]: 11-15) underwent LHD. At a median follow-up of 10.5 years (IQR: 4.5-13.9), a good outcome was achieved in 36/40 patients (90%). Two of the four patients whose surgical procedure failed underwent complementary pneumatic dilations successfully, thus increasing the overall success rate to 95%. A previous endoscopic treatment (in five patients) did not affect the final outcome (p = 0.49). An intraoperative mucosal lesion was detected in only one patient (2.5%) and was repaired at the time without further consequences. During the follow-up, 22 patients underwent endoscopy, and 17 had pH monitoring as well: only 2 of these patients showed reflux esophagitis at endoscopy (one of them with abnormal findings on pH monitoring), amounting to a 9.1% rate of instrumentally confirmed postoperative reflux. CONCLUSION LHD is a safe and persistently effective treatment for EA in pediatric age, with a success rate comparable with what is usually obtained in adults, and better than what has been reported to date in the pediatric literature. Adding a fundoplication certainly helps ensure an optimal long-term control of any gastroesophageal reflux induced by the myotomy.
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Affiliation(s)
- Luca Provenzano
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Rebecca Pulvirenti
- Division of Pediatric Surgery, Department of Women's and Children's Health, University of Padova, Padova, Veneto, Italy
| | - Miriam Duci
- Division of Pediatric Surgery, Department of Women's and Children's Health, University of Padova, Padova, Veneto, Italy
| | - Giovanni Capovilla
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Andrea Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Francesca Forattini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Piergiorgio Gamba
- Division of Pediatric Surgery, Department of Women's and Children's Health, University of Padova, Padova, Veneto, Italy
| | - Mario Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Francesco Fascetti-Leon
- Division of Pediatric Surgery, Department of Women's and Children's Health, University of Padova, Padova, Veneto, Italy
| | - Enato Salvador
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
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Wessels EM, Masclee GMC, Bredenoord AJ. An overview of the efficacy, safety, and predictors of achalasia treatments. Expert Rev Gastroenterol Hepatol 2023; 17:1241-1254. [PMID: 37978889 DOI: 10.1080/17474124.2023.2286279] [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: 06/12/2023] [Accepted: 11/17/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Achalasia is a rare esophageal motility disorder characterized by abnormal esophageal peristalsis and the inability of the lower esophageal sphincter to relax, resulting in poor esophageal emptying. This can be relieved by endoscopic and surgical treatments; each comes with certain advantages and disadvantages. AREAS COVERED This review aims to guide the clinician in clinical decision making on the different treatment options for achalasia regarding the efficacy, safety, and important predictors. EXPERT OPINION Botulinum toxin injection is only recommended for a selective group of achalasia patients because of the short term effect. Pneumatic dilation improves achalasia symptoms, but this effect diminishes over time and requiring repeated dilations to maintain clinical effect. Heller myotomy combined with fundoplication and peroral endoscopic myotomy are highly effective on the long term but are more invasive than dilations. Gastro-esophageal reflux complaints are more often encountered after peroral endoscopic myotomy. Patient factors such as age, comorbidities, and type of achalasia must be taken into account when choosing a treatment. The preference of the patient is also of great importance and therefore shared decision making has to play a fundamental role in deciding about treatment.
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Affiliation(s)
- Elise M Wessels
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, Netherlands
| | - Gwen M C Masclee
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, Netherlands
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Evensen H, Sandstad O, Larssen L, Hagen M, Kristensen VA, Søvik TT, Schulz A, Hauge T, Medhus AW. Intraoperative distensibility measurement in POEM for achalasia: impact on patient outcome and associations with other outcome variables at 1-year follow-up. Surg Endosc 2023; 37:9283-9290. [PMID: 37880446 PMCID: PMC10709476 DOI: 10.1007/s00464-023-10494-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 09/23/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND AND AIMS The functional luminal imaging probe (FLIP) can provide measurements of lower esophageal sphincter (LES) distensibility. Studies report that use of intraoperative FLIP examination during peroral endoscopic myotomy (POEM) for achalasia is associated with treatment success, but evidence is limited and inconsistent. The main aim of the present study was to assess associations between intraoperative FLIP values and 1-year outcomes. Additionally, associations between 1-year FLIP measurements and other 1-year outcome variables were studied. METHODS We performed a single-center prospective study of consecutive achalasia patients treated with POEM with a standardized 1-year follow-up. The inclusion period was from June 2017 to January 2020. We compared 1-year outcomes (FLIP measurement values, Eckardt score (ES), reflux esophagitis, timed barium esophagogram (TBE), and lower esophageal sphincter resting pressure (LES-rp)) in patients with and without intraoperative FLIP examination. We also assessed associations between intraoperative FLIP values, 1-year FLIP values, and other 1-year outcomes. Results are given as median (IQR), and non-parametrical statistical analyses were applied. RESULTS Sixty-two patients (27 females) with median age 45 years (35-54) were included. Baseline characteristics were similar in patients with (n = 32) and without (n = 30) intraoperative FLIP examination. In patients with intraoperative FLIP, ES was 2 (1-3) and LES distensibility index (DI) 3.7 (2.6-5.4) after 1 year, compared with ES 2 (1-3) and DI 4.0 (3.1-6.8)) in patients without intraoperative FLIP (ns). Intraoperative DI was not correlated with 1-year ES or DI. One-year DI correlated significantly with 1-year ES (rs - 0.42), TBE (rs - 0.34), and LES-rp (rs - 0.29). CONCLUSIONS Use of intraoperative FLIP measurements in POEM for achalasia is not associated with improved 1-year outcome, and the clinical value of intraoperative FLIP in POEM for achalasia is questioned. Follow-up FLIP measurements are moderately associated with symptomatic outcome, and may serve as an additional diagnostic modality in post-treatment evaluation.
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Affiliation(s)
- Helge Evensen
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway.
- Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Olav Sandstad
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Lene Larssen
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Milada Hagen
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | | | - Torgeir Thorson Søvik
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway
| | - Anselm Schulz
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- Department of Diagnostic Physics, Norwegian Imaging Technology Research and Innovation Center (ImTECH), Oslo University Hospital, Oslo, Norway
| | - Truls Hauge
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Asle W Medhus
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
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DeSouza M. Surgical Options for End-Stage Achalasia. Curr Gastroenterol Rep 2023; 25:267-274. [PMID: 37646894 DOI: 10.1007/s11894-023-00889-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE OF REVIEW Achalasia is one of the most commonly described primary esophageal motility disorders worldwide, but there is significant controversy regarding ideal management of end-stage disease. This article reviews the definition of end-stage achalasia and summarizes past and present surgical treatment. RECENT FINDINGS Myotomy of the lower esophageal sphincter remains the mainstay of treatment of achalasia, even in advanced disease. Esophagectomy may have benefit as a primary treatment modality in end-stage achalasia with sigmoid esophagus, but international guidelines recommend consideration of laparoscopic or endoscopic approaches initially in most patients. Novel peroral esophageal plication techniques may provide alternative treatment options in patients with significant esophageal dilation that fail myotomy or esophagectomy. SUMMARY End-stage achalasia is characterized by progressive tortuosity and dilation of the esophagus as a failure of primary peristalsis. Up to 20% of patients with achalasia will progress to end-stage disease. In most cases, laparoscopic or endoscopic myotomy is recommended as initial approach to surgical management.
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Affiliation(s)
- Melissa DeSouza
- Foregut Surgery, Center for Advanced Surgery, 4805 NE Glisan Ave, OR, 97,213, Portland, Oregon, USA.
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30
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Xu JQ, Geng ZH, Liu ZQ, Yao L, Zhang ZC, Zhong YS, Zhang YQ, Hu JW, Cai MY, Yao LQ, Li QL, Zhou PH. Landscape of Psychological Profiles in Patients With Esophageal Achalasia. Clin Transl Gastroenterol 2023; 14:e00613. [PMID: 37440756 PMCID: PMC10684233 DOI: 10.14309/ctg.0000000000000613] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/19/2023] [Indexed: 07/15/2023] Open
Abstract
INTRODUCTION Esophageal achalasia (EA) is a chronic esophageal dysmotility disease, of which psychological distress was poorly understood. This study aims to assess the status of psychosocial characteristics in EA and to determine the relationship between psychological distress and EA. METHODS Seventy pairs of age and gender-matched patients with EA and healthy control individuals were prospectively enrolled from December 2019 to April 2020 at our hospital. Demographic, psychosocial, and clinical data were obtained. Psychosocial assessments contained psychological distress (Symptom Checklist-90 Revised), perceived stress (Perceived Stress Scale-14), and stressful life events (Life Events Scale). Comparison for psychological parameters was made between patients with EA and controls as well as for EA before/after per oral endoscopic myotomy (POEM). Spearman rank correlation coefficients were used to testify the association between psychological distress and achalasia symptoms. RESULTS The mean course and Eckardt score of patients with EA were 4.26 ± 5.11 years and 6.63 ± 2.21, respectively. There was a significant difference between patients with EA and healthy individuals in Global Severity Index ( P = 0.039) and Positive Symptoms Total ( P = 0.041) for Symptom Checklist-90 Revised as well as positive intensity ( P = 0.011) for the Life Events Scale. Somatization ( P < 0.001), anxiety ( P = 0.021), anger-hostility ( P = 0.009), and others (appetite and sleep, P = 0.010) accounted for the most difference. Somatization was positively associated with chest pain ( P = 0.045). Two patients with EA developed recurrence and showed no relationship with psychological status. Psychological status was significantly improved after POEM. DISCUSSION Psychological distress, especially somatization, was more prevalent in patients with EA than healthy controls. POEM seemed able to improve psychological distress.
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Affiliation(s)
- Jia-Qi Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zi-Han Geng
- 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
| | - Lu Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhao-Chao Zhang
- 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
| | - 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
| | - Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
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Denzer U, Müller M, Kreuser N, Thieme R, Hoffmeister A, Feisthammel J, Niebisch S, Gockel I. [Therapy of esophageal motility disorders]. Laryngorhinootologie 2023; 102:824-838. [PMID: 37263277 DOI: 10.1055/a-1949-3583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2020 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.
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Affiliation(s)
- Ulrike Denzer
- Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Germany
| | - Michaela Müller
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - Nicole Kreuser
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - René Thieme
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Juergen Feisthammel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Stefan Niebisch
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
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Pesce M, Pagliaro M, Sarnelli G, Sweis R. Modern Achalasia: Diagnosis, Classification, and Treatment. J Neurogastroenterol Motil 2023; 29:419-427. [PMID: 37814432 PMCID: PMC10577462 DOI: 10.5056/jnm23125] [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: 08/11/2023] [Accepted: 08/20/2023] [Indexed: 10/11/2023] Open
Abstract
Achalasia is a major esophageal motor disorder featured by the altered relaxation of the esophagogastric junction in the absence of effective peristaltic activity. As a consequence of the esophageal outflow obstruction, achalasia patients present with clinical symptoms of dysphagia, chest pain, weight loss, and regurgitation of indigested food. Other less specific symptoms can also present including heartburn, chronic cough, and aspiration pneumonia. The delay in diagnosis, particularly when the presenting symptoms mimic those of gastroesophageal reflux disease, may be as long as several years. The widespread use of high-resolution manometry has permitted earlier detection and uncovered achalasia phenotypes which can have prognostic and therapeutic implications. Other tools have also emerged to help define achalasia severity and which can be used as objective measures of response to therapy including the timed barium esophagogram and the functional lumen imaging probe. Such diagnostic innovations, along with the increased awareness by clinicians and patients due to the availability of alternative therapeutic approaches (laparoscopic and robotic Heller myotomy, and peroral endoscopic myotomy) have radically changed the natural history of the disorder. Herein, we report the most recent advances in the diagnosis, classification, and management of esophageal achalasia and underline the still-grey areas that needs to be addressed by future research to reach the goal of personalizing treatment.
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Affiliation(s)
- Marcella Pesce
- Department of clinical medicine and surgery, University of Naples Federico II, Naples, Italy
| | - Marta Pagliaro
- Department of clinical medicine and surgery, University of Naples Federico II, Naples, Italy
| | - Giovanni Sarnelli
- Department of clinical medicine and surgery, University of Naples Federico II, Naples, Italy
| | - Rami Sweis
- GI Physiology Unit, University College London Hospital, London, UK
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Hoshikawa Y, Momma E, Kawami N, Iwakiri K. Esophageal Dilation in Patients with Achalasia Is a Predictive Factor for the Inability to Traverse the Esophagogastric Junction with a Manometric Catheter. Digestion 2023; 105:90-98. [PMID: 37899037 DOI: 10.1159/000534448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/02/2023] [Indexed: 10/31/2023]
Abstract
INTRODUCTION The insertion of a high-resolution manometry (HRM) catheter into the stomach is essential for accurate manometric diagnoses; however, it is impossible in some cases due to the inability to traverse the esophagogastric junction (EGJ). Predictive factors for these patients have not been investigated in detail, necessitating time-consuming and burdensome procedures for investigators and patients. Therefore, the present study investigated the percentage of and risk factors for failed intubation at the EGJ. METHODS We initially reviewed the medical charts of consecutive HRM procedures performed at our hospital between September 2018 and January 2023. Patient characteristics and the findings of endoscopy and esophagography (where available) were compared between successful and failed procedures. A multivariate logistic regression analysis was conducted to identify predictive factors for the inability to traverse the EGJ. We then validated the predictive factors identified by reviewing consecutive procedures performed between February 2023 and August 2023. RESULTS Among the 781 procedures performed, 55 (7.0%) failed due to the inability to traverse the EGJ. Achalasia was the most common disorder in these procedures. An older age and dilated esophagus of >34 mm were independent predictive factors for the inability to traverse the EGJ in patients with treatment-naïve achalasia. In the validation study, 7 out of 68 procedures (10.3%) failed due to the inability to traverse the EGJ. A flowchart using the findings of endoscopy and an esophageal diameter of >34 mm predicted the inability to traverse the EGJ with a sensitivity of 71.4% and specificity of 86.9%. CONCLUSION Based on an esophageal diameter >34 mm and endoscopic findings, we predicted the inability to traverse the EGJ in more than 70% of patients. A multi-center prospective study is warranted in the future.
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Affiliation(s)
- Yoshimasa Hoshikawa
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Eri Momma
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Noriyuki Kawami
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
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Bar N, Vélez C, Pasricha TS, Thurm T, Ben-Ami Shor D, Dekel R, Ron Y, Staller K, Kuo B. Safety of Pneumatic Dilation in Older Adults with Achalasia: An International Multicenter Cross-Sectional Study. J Clin Med 2023; 12:6682. [PMID: 37892819 PMCID: PMC10607090 DOI: 10.3390/jcm12206682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 10/03/2023] [Accepted: 10/20/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Pneumatic dilation (PD) is an effective first line treatment option for many patients with achalasia. PD use may be limited in adults with achalasia who are older than 65 because of concern for adverse events (AE), and less efficacious therapies are often utilized. We explored the periprocedural safety profile of PD in older adults. METHODS An international real world cross-sectional study of patients undergoing PD between 2006-2020 in two tertiary centers. Thirty-day AEs were compared between older adults (65 and older) with achalasia and younger patients. RESULTS A total of 252 patients underwent 319 PDs. In 319 PDs, 18 (5.7%) complications occurred: 6 (1.9%) perforations and 12 (3.8%) emergency department referrals with benign (non-perforation) chest pain, of which 9 (2.8%) were hospitalized. No bleeding or death occurred within 30 days. Perforation rates were similar in both age groups and across achalasia subtypes. Advanced age was protective of benign chest pain complications in univariate analysis, and the limited number of AEs precluded multivariable analysis. CONCLUSIONS The safety of PD in older adults is at least comparable to that of younger patients and should be offered as an option for definitive therapy for older patients with achalasia. Our results may affect informed consent discussions.
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Affiliation(s)
- Nir Bar
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (T.T.); (D.B.-A.S.); (R.D.); (Y.R.)
- Center for Neurointestinal Health, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (C.V.); (T.S.P.); (K.S.); (B.K.)
| | - Christopher Vélez
- Center for Neurointestinal Health, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (C.V.); (T.S.P.); (K.S.); (B.K.)
| | - Trisha S. Pasricha
- Center for Neurointestinal Health, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (C.V.); (T.S.P.); (K.S.); (B.K.)
| | - Tamar Thurm
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (T.T.); (D.B.-A.S.); (R.D.); (Y.R.)
| | - Dana Ben-Ami Shor
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (T.T.); (D.B.-A.S.); (R.D.); (Y.R.)
| | - Roy Dekel
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (T.T.); (D.B.-A.S.); (R.D.); (Y.R.)
| | - Yishai Ron
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (T.T.); (D.B.-A.S.); (R.D.); (Y.R.)
| | - Kyle Staller
- Center for Neurointestinal Health, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (C.V.); (T.S.P.); (K.S.); (B.K.)
| | - Braden Kuo
- Center for Neurointestinal Health, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (C.V.); (T.S.P.); (K.S.); (B.K.)
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Boutros CS, Khan SZ, Benson J, Lyons J, Hashimoto DA, Marks JM. Symptom duration is not associated with per oral endoscopic myotomy (POEM) failure. Surg Endosc 2023; 37:8000-8005. [PMID: 37460816 DOI: 10.1007/s00464-023-10253-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 06/23/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION Per oral endoscopic myotomy (POEM) is a relatively novel technique to address achalasia; however, little is known about the efficacy of POEM for patients with long-standing achalasia. We hypothesize that patients with long-standing achalasia prior to intervention will be more recalcitrant to POEM than patients with symptoms for a short duration. METHODS We performed a retrospective analysis of patients with achalasia who received a POEM at a single institution from 2012 to 2022. Patients were grouped into cohorts based on the time of symptom duration: < 1 year, 1-3 years, 4-10 years, > 10 years. POEM failure was defined as need for repeat intervention, symptom recurrence, and a high postoperative Eckart score. Demographic and clinical data were compared between cohorts. Measures of failure multivariable logistic regression analyzed the association between symptom duration and response to POEM. RESULTS During the study period, 132 patients met inclusion criteria. Patient age at surgery, sex, BMI, Charleston-Deyo Comorbidity Index, and patients with diabetes with and without end organ complications, connective tissue diseases, and patients with ulcer diseases did not differ among cohorts. Patients who have had symptoms for greater than 10 years had significantly more endoscopic interventions prior to their POEM (30% vs, 60% p = 0.002). Patients in all cohorts experienced the same number of symptoms post-POEM. Manometric measurements did not vary across cohorts after POEM. Symptom recurrence, need for repeat endoscopic intervention, repeat surgical intervention, or repeat POEM also did not vary across cohorts. Having symptoms of achalasia > 10 years did not increase the odds POEM failure on multivariable logistical regression. CONCLUSIONS These data suggest that longer symptom duration is not associated with increased rates of POEM failure. This is promising as clinicians should not exclude patients for POEM eligibility based on duration of symptoms alone.
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Affiliation(s)
- Christina S Boutros
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA.
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA.
| | - Saher-Zahara Khan
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA
| | - Jamie Benson
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA
| | - Joshua Lyons
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA
| | - Daniel A Hashimoto
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA
| | - Jeffrey M Marks
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA
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Müller M, Denzer UW, Kreuser N, Thieme R, Hoffmeister A, Feisthammel J, Niebisch S, Gockel I. [Diagnosis of esophageal motility disorders - Significance of the new Chicago classification v4.0]. Laryngorhinootologie 2023; 102:742-753. [PMID: 37253378 DOI: 10.1055/a-1949-3531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2021 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.
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Affiliation(s)
- Michaela Müller
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Germany
| | - Ulrike W Denzer
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Germany
| | - Nicole Kreuser
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - René Thieme
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Juergen Feisthammel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Stefan Niebisch
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
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Kolb JM, Pessorrusso F, Pisipati S, Han S, Menard-Katcher P, Yadlapati R, Wagh MS. Role of short interval FLIP panometry in predicting long-term outcomes after per-oral endoscopic myotomy. Surg Endosc 2023; 37:7767-7773. [PMID: 37580583 PMCID: PMC10771858 DOI: 10.1007/s00464-023-10319-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/19/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND The Eckardt score (ES) is used to assess symptom response to Per-Oral Endoscopic Myotomy (POEM), but reliable methods to assess physiologic success are needed. Functional lumen imaging probe (FLIP) panometry has a potential role in post-POEM follow-up to predict long-term outcomes. The aim of this study was to assess the correlation between clinical success and FLIP parameters following POEM to determine if short interval FLIP could predict long-term outcomes. METHODS This was a prospective study of adult patients who underwent POEM with short interval follow-up FLIP between 11/2017 and 3/2020. Clinical success was defined as post-procedure ES ≤ 3. Physiologic success was based on an esophago-gastric junction distensibility index (EGJ-DI) > 2.8 mm2/mmHg on FLIP. RESULTS 47 patients (55% female, mean age 55 years) were included in the study. Clinical success after POEM was seen in 45 (96%) patients (mean ES 6.5 ± 2.2 pre and 0.83 ± 1.0 post-POEM, p < 0.001). Physiologic success was noted in 43 (91.5%) patients (mean EGJ-DI 6.1 mm2/mmHg ± 2.5). Among 4 patients not meeting criteria for physiologic success, EGJ-DI was 2.5-2.6. There was no correlation between post-POEM EGJ-DI and ES in the short term or long term. Significant reflux esophagitis was seen in 6 (12.8%) patients with no difference in mean EGJ-DI with vs without esophagitis (5.9 vs 6.1, p = 0.44). CONCLUSION Post-POEM endoscopy with FLIP is useful to both assess EGJ physiology and to examine for reflux esophagitis. Short interval FLIP has limited utility to predict long-term patient outcomes or risk of acid reflux.
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Affiliation(s)
- Jennifer M Kolb
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Greater Los Angeles VA Healthcare System, Los Angeles, CA, USA
| | - Fernanda Pessorrusso
- Division of Gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sailaja Pisipati
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - Samuel Han
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Paul Menard-Katcher
- Division of Gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, San Diego, CA, USA
| | - Mihir S Wagh
- Division of Gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Müller M, Förschler S, Wehrmann T, Marini F, Gockel I, Eckardt AJ. Atypical presentations and pitfalls of achalasia. Dis Esophagus 2023; 36:doad029. [PMID: 37158189 DOI: 10.1093/dote/doad029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 04/04/2023] [Indexed: 05/10/2023]
Abstract
Achalasia is a rare disease with significant diagnostic delay and association with false diagnoses and unnecessary interventions. It remains unclear, whether atypical presentations, misinterpreted symptoms or inconclusive diagnostics are the cause. The aim of this study was the characterization of typical and atypical features of achalasia and their impact on delays, misinterpretations or false diagnoses. A retrospective analysis of prospective database over a period of 30 years was performed. Data about symptoms, delays and false diagnoses were obtained and correlated with manometric, endoscopic and radiologic findings. Totally, 300 patients with achalasia were included. Typical symptoms (dysphagia, regurgitation, weight loss and retrosternal pain) were present in 98.7%, 88%, 58.4% and 52.4%. The mean diagnostic delay was 4.7 years. Atypical symptoms were found in 61.7% and led to a delay of 6 months. Atypical gastrointestinal symptoms were common (43%), mostly 'heartburn' (16.3%), 'vomiting' (15.3%) or belching (7.7%). A single false diagnosis occurred in 26%, multiple in 16%. Major gastrointestinal misdiagnoses were GERD in 16.7% and eosinophilic esophagitis in 4%. Other false diagnosis affected ENT-, psychiatric, neurologic, cardiologic or thyroid diseases. Pitfalls were the description of 'heartburn' or 'nausea'. Tertiary contractions at barium swallows, hiatal hernias and 'reflux-like' changes at endoscopy or eosinophils in the biopsies were misleading. Atypical symptoms are common in achalasia, but they are not the sole source for diagnostic delays. Misleading descriptions of typical symptoms or misinterpretation of diagnostic studies contribute to false diagnoses and delays.
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Affiliation(s)
- M Müller
- Department of Gastroenterology, University Hospital Giessen and Marburg, Marburg, Germany
| | - S Förschler
- Department of General and Visceral Surgery, St. Josefs-Hospital, Wiesbaden, Germany
| | - T Wehrmann
- Department of Gastroenterology, DKD Helios Klinik Wiesbaden, Wiesbaden, Germany
| | - F Marini
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), Division Biostatistics and Bioinformatics, University Medical Center Johannes Gutenberg University, Mainz, Germany
| | - I Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Medical Center of Leipzig, Leipzig, Germany
| | - A J Eckardt
- Department of Gastroenterology, DKD Helios Klinik Wiesbaden, Wiesbaden, Germany
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Lyons J, Boutros C, Khan SZ, Benson J, Hashimoto DA, Marks J. Preoperative manometric data can predict symptom improvement after per oral endoscopic myotomy for treatment of achalasia. Surg Endosc 2023; 37:7226-7229. [PMID: 37389740 DOI: 10.1007/s00464-023-10249-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 06/23/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND While per oral endoscopic myotomy (POEM) has been shown to be efficacious in the treatment of achalasia, it can be difficult to predict who will have a robust and durable response. Historically, high lower esophageal sphincter pressures have been shown to predict a worse response to endoscopic therapies such as botox therapy. This study was designed to evaluate if modern preoperative manometric data could predict a response to therapy after POEM. METHODS This was a retrospective study of 144 patients who underwent a POEM at a single institution by a single surgeon over an 8-year period (2014-2022) who had high-resolution manometry performed preoperatively and had an Eckardt symptom score performed both preoperatively and postoperatively. The achalasia type and integrated relaxation pressures (IRP) were then tested for potential correlation with need for any further achalasia interventions postoperatively as well as the degree of Eckardt score reduction using univariate analysis. RESULTS The achalasia type on preoperatively manometry was not predictive of need for further interventions or degree of Eckardt score reduction (p = 0.74 and 0.44, respectively). A higher IRP was not predictive of need for further interventions however it was predictive of a greater reduction in postoperative Eckardt scores (p = 0.03) as shown by a nonzero regression slope. CONCLUSION In this study, achalasia type was not a predictive factor in need for further interventions or degree of symptom relief. While IRP was not predictive of need for further interventions, a higher IRP did predict better symptomatic relief postoperatively. This result is opposite that of other endoscopic treatment modalities. Therefore, patients with higher IRP on high-resolution manometry would likely benefit from myotomy which provides significant symptomatic relief postoperatively.
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Affiliation(s)
- Joshua Lyons
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA.
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA.
| | - Christina Boutros
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA
| | - Saher-Zahra Khan
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA
| | - Jamie Benson
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA
| | - Daniel A Hashimoto
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA
| | - Jeffrey Marks
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA
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40
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Gagliardi M, Iovino P, Gargano D, Zulli C, Fortino L, Santonicola A. Can esophageal symptoms be associated with sleep disorders in esophageal rare diseases? A prospective case-control study across achalasia, eosinophilic esophagitis and gastroesophageal reflux disease. Minerva Gastroenterol (Torino) 2023; 69:365-373. [PMID: 37642600 DOI: 10.23736/s2724-5985.21.03002-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND The association between sleep disorders and gastroesophageal reflux disease (GERD) has been the subject of several studies; however, quality of sleep has been under investigated in adult patients with eosinophilic esophagitis (EoE) and achalasia (Ach). This study aims to evaluate the prevalence of sleep disturbances in patients with EoE and Ach compared to GERD patients and their associations with esophageal symptoms. METHODS Thirty Ach patients and 20 EoE patients were consecutively enrolled and compared to a control group of 46 GERD patients. All patients underwent a standardized questionnaire investigating the intensity-frequency scores (from 0 to 6) of esophageal symptoms, Pittsburgh Sleep Quality Index (PSQI) questionnaire to assess sleep quality, a SF-36 survey to investigate health-related quality of life (both physical (PCS) and mental (MCS) component scales), Beck Depression Inventory-II (BDI-II) and State Trait Anxiety Inventory (STAI) to assess the presence of depression and anxiety. RESULTS The prevalence of sleep disturbances was 66.7% in Ach, 50% in EoE, and 60% in GERD patients (P=0.5). PCS and MCS significantly correlated with depression and anxiety levels. Ach patients showed significantly higher intensity-frequency scores of dysphagia for solids (Scheffè P<0.001) and liquids (Scheffè P<0.001) than EoE and GERD patients. No differences were found in the intensity-frequency scores of the esophageal symptoms among the three groups. There was a significant association between worst quality of sleep and higher intensity-frequency scores of regurgitation. CONCLUSIONS Sleep disturbances are common with Ach and EoE, similar to GERD patients. Moreover, there is a significant association between regurgitation, a typical GERD symptom, and poor quality of sleep, independent from diagnosis.
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Affiliation(s)
- Mario Gagliardi
- Unit of Gastroenterology, Scuola Medica Salernitana Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy -
| | - Paola Iovino
- Unit of Gastroenterology, Scuola Medica Salernitana Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | | | - Claudio Zulli
- Division of Gastroenterology, G. Fucito Hospital, AOU Ruggi d'Aragona, Salerno, Italy
| | - Luigi Fortino
- Unit of Gastroenterology, Scuola Medica Salernitana Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | - Antonella Santonicola
- Unit of Gastroenterology, Scuola Medica Salernitana Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
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Han SY, Youn YH. Role of endoscopy in patients with achalasia. Clin Endosc 2023; 56:537-545. [PMID: 37430397 PMCID: PMC10565433 DOI: 10.5946/ce.2023.001] [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: 11/25/2022] [Revised: 02/22/2023] [Accepted: 03/31/2023] [Indexed: 07/12/2023] Open
Abstract
Achalasia is an esophageal motility disorder characterized by impaired lower esophageal sphincter relaxation and peristalsis of the esophageal body. With the increasing prevalence of achalasia, interest in the role of endoscopy in its diagnosis, treatment, and monitoring is also growing. The major diagnostic modalities for achalasia include high-resolution manometry, esophagogastroduodenoscopy, and barium esophagography. Endoscopic assessment is important for early diagnosis to rule out diseases that mimic achalasia symptoms, such as pseudo-achalasia, esophageal cancer, esophageal webs, and eosinophilic esophagitis. The major endoscopic characteristics suggestive of achalasia include a widened esophageal lumen and food residue in the esophagus. Once diagnosed, achalasia can be treated either endoscopically or surgically. The preference for endoscopic treatment is increasing owing to its minimal invasiveness. Botulinum toxins, pneumatic balloon dilation, and peroral endoscopic myotomy (POEM) are important endoscopic treatments. Previous studies have demonstrated excellent treatment outcomes for POEM, with >95% improvement in dysphagia, making POEM the mainstay treatment option for achalasia. Several studies have reported an increased risk of esophageal cancer in patients with achalasia. However, routine endoscopic surveillance remains controversial owing to the lack of sufficient data. Further studies on surveillance methods and duration are warranted to establish concordant guidelines for the endoscopic surveillance of achalasia.
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Affiliation(s)
- So Young Han
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Hoon Youn
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Srivastava A, Poddar U, Mathias A, Mandelia A, Sarma MS, Lal R, Yachha SK. Achalasia cardia sub-types in children: Does it affect the response to therapy? Indian J Gastroenterol 2023; 42:534-541. [PMID: 37300794 DOI: 10.1007/s12664-023-01344-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 01/26/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Achalasia sub-types affect treatment response in adults, but there is no similar data in children. We studied the differences in clinico-laboratory features and response to therapy between achalasia sub-types in children. METHODS Forty-eight children (boys:girls-25:23, 14 [0.9-18] years) with achalasia (clinical, barium, high-resolution manometry [HRM], gastroscopy) were evaluated. The sub-type was determined by Chicago classification at HRM. Pneumatic dilatation (PD) or surgery was the primary therapy. Success was defined as Eckhardt score of ≤ 3. RESULTS Dysphagia (95.8%) and regurgitation (93.8%) were the most common symptoms. Forty of 48 cases had an adequate HRM study: Type I (n-19), II (n-19) and III (n-2). Types I and II had similar clinical profile. Type II had higher basal lower esophageal sphincter (LES) pressure (30.5 [16.5-46] vs. 22.5 [13-43] mmHg; p = 0.007) and less dilated esophagus on timed barium esophagogram (TBE, 25 [13-57] vs. 34.5 [20-81] mm; p = 0.006) than type I. Both types had similar success (86.6% [13/15] vs. 92.8% [13/14]; p = 1) after first PD and need of post-PD myotomy (5/17 vs. 1/16; p = 0.1) in follow-up. Twenty-three cases had TBE before and after PD; 15 (65.2%) had good clearance. These subjects required myotomy (1/15 vs. 4/8; p = 0.03) and repeat PD (5/15 vs. 4/8; p = 0.08) less often than those with poor clearance on TBE. CONCLUSION Types I and II achalasia have similar frequency and clinical profile. Type II has higher LES pressure and less dilated esophagus than Type I. Both respond equally well to initial PD. Type I required post-PD myotomy more often, though not significantly. TBE is useful for assessing therapeutic response.
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Affiliation(s)
- Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India.
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Amrita Mathias
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Ankur Mandelia
- Pediatric Surgical Superspecialty, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Richa Lal
- Pediatric Surgical Superspecialty, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Surender Kumar Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
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Yeh CC, Chen CC, Chen CC, Han ML, Wu JF, Wang HP, Wu MS, Tseng PH. Characteristics of the esophageal microbiome in patients with achalasia and its changes before and after peroral endoscopic myotomy: A pilot study. J Gastroenterol Hepatol 2023; 38:1307-1315. [PMID: 37078564 DOI: 10.1111/jgh.16192] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/03/2023] [Accepted: 04/04/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND AND AIM Achalasia often presents with chronic food stasis and fermentation in the esophageal lumen, which may lead to alterations of the esophageal microbiome, with associated mucosal inflammation and dysplastic changes. The study aims to evaluate the characteristics of the esophageal microbiome in achalasia and changes of the esophageal microbiome before and after peroral endoscopic myotomy (POEM). METHODS This is a prospective case-control study. This study enrolled patients with achalasia and asymptomatic subjects as control group. Endoscopic brushing for esophageal microbiome collection was performed in all subjects, with additional follow-up endoscopy and brushing 3 months after POEM in achalasia patients. The composition of the esophageal microbiome was determined and compared between (1) achalasia patients and asymptomatic controls and (2) achalasia patients before and after POEM. RESULTS Thirty-one achalasia patients (mean age 53.5 ± 16.2 years; male 45.2%) and 15 controls were analyzed. We observed a distinct esophageal microbial community structure in achalasia patients, with increased Firmicutes and decreased Proteobacteria when compared with the control group at the phylum level. The discriminating enriched genera in achalasia patients were Lactobacillus, followed by Megasphaera and Bacteroides, and the amount of Lactobacillus was associated with the severity of achalasia. Twenty patients were re-examined after POEM, and a high prevalence of erosive esophagitis (55%) was noted, alongside an increase in genus Neisseria and decrease in Lactobacillus and Bacteroides. CONCLUSIONS The altered esophageal microenvironment in achalasia leads to dysbiosis with a high abundance of genus Lactobacillus. Increased Neisseria and decreased Lactobacillus were observed after POEM. The long-term effect of microbial changes warrants further study.
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Affiliation(s)
- Chia-Chu Yeh
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Good Liver Clinic, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chieh-Chang Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chien-Chuan Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Lun Han
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Jia-Feng Wu
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Shiang Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ping-Huei Tseng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Wang Y, Yu T, Zhu F, Xu Y, Bao Y, Zhang L, Lin L, Tang Y. Esophagogastric Junction Outflow Obstruction Is Likely to Be a Local Manifestation of Other Primary Diseases: Analysis of Single-Center 4-Year Follow-Up Data. Diagnostics (Basel) 2023; 13:2329. [PMID: 37510073 PMCID: PMC10378678 DOI: 10.3390/diagnostics13142329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/08/2023] [Accepted: 06/30/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Whether esophagogastric junction outflow obstruction (EGJOO) is a variant of achalasia cardia (AC) or an esophageal motility state of certain organic or systemic diseases remains controversial. We aimed to investigate the differences between EGJOO and AC in clinical characteristics and outcomes through a 4-year follow-up. METHODS Patients diagnosed with primary EGJOO or AC were included. Based on the presence of concomitant disease, EGJOO patients were divided into a functional and an anatomical EGJOO group; similarly, patients with AC were divided into an AC with organic disease group and a true AC group. Disease characteristics and high-resolution manometry (HRM) parameters were retrospectively compared between the groups, and the development of organic diseases that could affect esophageal motility disorders and responses to treatment were examined during the follow-up. Symptom relief was defined as an Eckardt score of ≤3 after the treatment. RESULTS The study included 79 AC patients and 70 EGJOO patients. Compared with patients with AC, EGJOO patients were older, had shorter disease duration, a lower Eckardt score, and were more likely to have concurrent adenocarcinoma of the esophagogastric junction (AEG) and autoimmune disease (p < 0.05 for all). The severity of dysphagia and Eckardt scores were higher in the anatomical EGJOO group than in the functional EGJOO group. Significant differences were seen in HRM parameters (UES residual pressure, LES basal pressure, and LES residual pressure) between AC and EGJOO patients. However, no significant differences in HRM parameters were observed between the functional EGJOO and anatomical EGJOO groups. Sixty-seven (95.71%) patients with EGJOO and sixty-nine (87.34%) patients with AC experienced symptom relief (p = 0.071). Among patients achieving symptom relief, a relatively large proportion of patients with EGJOO had symptom relief after medications (37/67, 55.22%), the resolution of potential reasons (7/67, 10.45%), and spontaneous relief (15/67, 22.39%), while more patients with AC had symptom relief after POEM (66/69, 95.65%). Among EGJOO patients achieving symptom relief, more patients (7/20, 35%) with anatomical EGJOO had symptom relief after the resolution of potential reasons for EGJOO, while more patients (32/47, 68.09%) with functional EGJOO had symptom relief with medications. CONCLUSIONS Concurrent AEG and autoimmune diseases are more likely in EGJOO than in AC. A considerable part of EGJOO may be the early manifestation of an organic disease. Anatomical EGJOO patients experience symptom improvement with the resolution of primary diseases, while most functional EGJOO patients experience symptom relief with pharmacotherapy alone or even without any treatment.
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Affiliation(s)
- Yan Wang
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Ting Yu
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Feng Zhu
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Ying Xu
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Yun Bao
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
- Department of Gastroenterology and Hepatology, South China Hospital, Health Science Center, Shenzhen University, Shenzhen 440307, China
| | - Ling Zhang
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
- Department of Gastroenterology, Southeast University Zhongda Hospital, Nanjing 210029, China
| | - Lin Lin
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Yurong Tang
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
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Chauhan V, Nekarakanti PK, Balachandra D, Choudhary D, Sachdeva S, Nag HH. The outcome of 100 patients with achalasia cardia following laparoscopic Heller myotomy with blunt dissection technique. J Minim Access Surg 2023; 19:408-413. [PMID: 37282436 PMCID: PMC10449042 DOI: 10.4103/jmas.jmas_273_22] [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: 10/07/2022] [Accepted: 12/08/2022] [Indexed: 06/08/2023] Open
Abstract
Background Laparoscopic Heller myotomy (LHM) can be performed by blunt dissection technique (BDT). Only a few studies have assessed long-term outcomes and relief of dysphagia following LHM. The study reviews our long-term experience following LHM by BDT. Methods This retrospective study was analysed from a prospectively maintained database (from 2013 to 2021) of a single unit of the Department of Gastrointestinal Surgery at G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi. The myotomy was performed by BDT in all patients. A fundoplication was added in selected patients. Post-operative Eckardt score >3 was considered treatment failure. Results A total of 100 patients underwent surgery during the study period. Of them, 66 patients underwent LHM, 27 underwent LHM with Dor fundoplication and 7 underwent LHM with Toupet fundoplication. The median length of myotomy was 7 cm. The mean operative time was 77 ± 29.27 min and the mean blood loss of 28.05 ± 16.06 ml. Five patients had intraoperative oesophageal perforation. The median length of hospital stay was 2 days. There was no hospital mortality. The post-operative integrated relaxation pressure (IRP) was significantly lower than the mean pre-operative IRP (9.78 vs. 24.77). Eleven patients developed treatment failure, of which ten patients presented with recurrence of dysphagia. There was no difference in symptom-free survival amongst various types of achalasia cardia (P = 0.816). Conclusion LHM performed by BDT has a 90% success rate. Complication using this technique is rare, and recurrence post-surgery can be managed with endoscopic dilatation.
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Affiliation(s)
- Vivek Chauhan
- Department of Gastrointestinal Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Phani Kumar Nekarakanti
- Department of Gastrointestinal Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Deepak Balachandra
- Department of Gastrointestinal Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Devendra Choudhary
- Department of Gastrointestinal Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Sanjeev Sachdeva
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Hirdaya Hulas Nag
- Department of Gastrointestinal Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
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Tassi V, Lugaresi M, Pilotti V, Bassi F, Daddi N, D'Ovidio F, Leiva-Juarez MM, Mattioli S. Outcomes of Heller Myotomy for Esophageal Achalasia: Lessons From a 48-Year Prospective Experience With 4 Different Techniques. Ann Surg 2023; 278:e27-e34. [PMID: 36082979 DOI: 10.1097/sla.0000000000005677] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To provide information on long-term outcomes of Heller myotomy for esophageal achalasia with or without an antireflux fundoplication. BACKGROUND Since the adoption of the Heller myotomy, surgeons have modified the original technique in order to balance the cure of dysphagia and the consequent cardial incontinence. METHODS Totally, 470 patients underwent primary Heller myotomy between 1955 and 2020. A long abdominal myotomy (AM) was performed in 83 patients, the Ellis limited transthoracic myotomy (TM) in 30, the laparotomic Heller-Dor (L-HD) in 202, the videolaparoscopic Heller-Dor (VL-HD) in 155. The HD was performed under intraoperative manometric assessment. Starting on 1973 these patients underwent a prospective follow-up program of timed lifelong clinical, radiological, endoscopic evaluations. RESULTS Median follow-up time was 23.06 years [interquantile range (IQR): 15.04-32.06] for AM, 29.22 years (IQR: 13.46-40.17) for TM, 14.85 years (IQR: 11.05-21.56) for L-HD and 7.51 years (IQR: 3.25-9.60) for VL-HD. In AM, relapse of dysphagia occurred in 25/71 (35.21%), in TM in 11/30 (36.66%), in LH-D in 10/201 (4.97%), in VL-HD in 3/155 (1.93%). Erosive-ulcerative esophagitis was diagnosed for AM in 28.16%, for TM in 30%, for L-HD in 8.45%, for VL-HD in 2.58%. Overall, the outcome was satisfactory in 52.11% for AM, 41.9% for TM, 89.05% for L-HD, 96.12% for VL-HD. CONCLUSIONS The Dor fundoplication drastically reduces postmyotomy gastroesophageal reflux. The Heller-Dor operation is a competitive option for the cure of esophageal achalasia if this operation is performed according to the rules of surgical physiology learned by means of intraoperative manometry.
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Affiliation(s)
| | - Marialuisa Lugaresi
- Division of Thoracic Surgery, Maria Cecilia Hospital, Cotignola
- Alma Mater Studiorum, University of Bologna, Bologna
| | | | | | - Niccolò Daddi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Frank D'Ovidio
- Division of Cardiac, Department of Surgery, Vascular, and Thoracic Surgery, New York Presbyterian Columbia University Medical Center, New York, NY
| | - Miguel M Leiva-Juarez
- Division of Cardiac, Department of Surgery, Vascular, and Thoracic Surgery, New York Presbyterian Columbia University Medical Center, New York, NY
| | - Sandro Mattioli
- Division of Thoracic Surgery, Maria Cecilia Hospital, Cotignola
- Alma Mater Studiorum, University of Bologna, Bologna
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47
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Le KHN, Low EE, Yadlapati R. Evaluation of Esophageal Dysphagia in Elderly Patients. Curr Gastroenterol Rep 2023; 25:146-159. [PMID: 37312002 PMCID: PMC10726678 DOI: 10.1007/s11894-023-00876-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 06/15/2023]
Abstract
PURPOSE OF REVIEW While guidelines exist for the evaluation and management of esophageal dysphagia in the general population, dysphagia disproportionately affects the elderly. In this article, we reviewed the literature on evaluating esophageal dysphagia in elderly patients and proposed a diagnostic algorithm based on this evidence. RECENT FINDINGS In older patients, dysphagia is often well compensated for by altered eating habits and physiologic changes, underreported by patients, and missed by healthcare providers. Once identified, dysphagia should be differentiated into oropharyngeal and esophageal dysphagia to guide diagnostic workup. For esophageal dysphagia, this review proposes starting with endoscopy with biopsies, given its relative safety even in older patients and potential for interventional therapy. If endoscopy shows a structural or mechanical cause, then further cross-sectional imaging should be considered to assess for extrinsic compression, and same session endoscopic dilation should be considered for strictures. If biopsies and endoscopy are normal, then esophageal dysmotility is more likely, and high-resolution manometry and additional workup should be performed following the updated Chicago Classification. Even after diagnosis of the root cause, complications including malnutrition and aspiration pneumonia should also be assessed and monitored, as they both result from and can further contribute to dysphagia. The successful evaluation of esophageal dysphagia in elderly patients requires a thorough, standardized approach to collecting a history, selection of appropriate diagnostic workup, and assessment of risk of potential complications, including malnutrition and aspiration.
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Affiliation(s)
| | - Eric E Low
- Department of Gastroenterology and Hepatology, University of California, San Diego, CA, USA
| | - Rena Yadlapati
- Department of Gastroenterology and Hepatology, University of California, San Diego, CA, USA.
- , La Jolla, CA, USA.
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Aoki T, Ozawa S, Hayashi K, Ando T, Uchi Y, Shimazu M, Shinozaki H, Matsumoto K, Omura N. Laparoscopic Heller myotomy and Dor fundoplication following an unsuccessful peroral endoscopic myotomy. Surg Case Rep 2023; 9:106. [PMID: 37314527 DOI: 10.1186/s40792-023-01691-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/07/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Achalasia is an esophageal motility disorder that presents as dysphagia and severely affects quality of life. An esophageal myotomy has been the golden standard for treatment. Peroral endoscopic myotomy (POEM) as a first-line therapy has an acceptable outcome. However, after the clinical failure of POEM, appropriate second-line therapy is rather controversial. Here, we present the first published case in English of a patient who was successfully treated using laparoscopic Heller myotomy (LHM) with Dor fundoplication following an unsuccessful POEM. CASE PRESENTATION A 64-year-old man with type 1 achalasia who had been previously treated with POEM visited our hospital for further treatment. After undergoing LHM with Dor fundoplication, his Eckardt score improved from 3 to 0 points. On a timed barium esophagogram (TBE), the barium height improved from 119 mm/119 mm (1 min/5 min) to 50 mm/45 mm. No significant complications have occurred postoperatively for 1 year. CONCLUSION Treating refractory achalasia is challenging, and treatment options are controversial. LHM with Dor fundoplication after POEM could be a safe and efficient option for the treatment of refractory achalasia.
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Affiliation(s)
- Takuma Aoki
- Department of Surgery, Tamakyuryo Hospital, 1491 Shimooyamada, Machida, Tokyo, 194-0297, Japan
| | - Soji Ozawa
- Department of Surgery, Tamakyuryo Hospital, 1491 Shimooyamada, Machida, Tokyo, 194-0297, Japan.
| | - Koki Hayashi
- Department of Surgery, Tamakyuryo Hospital, 1491 Shimooyamada, Machida, Tokyo, 194-0297, Japan
| | - Tomofumi Ando
- Department of Surgery, Tamakyuryo Hospital, 1491 Shimooyamada, Machida, Tokyo, 194-0297, Japan
| | - Yusuke Uchi
- Department of Surgery, Tamakyuryo Hospital, 1491 Shimooyamada, Machida, Tokyo, 194-0297, Japan
| | - Motohide Shimazu
- Department of Surgery, Tamakyuryo Hospital, 1491 Shimooyamada, Machida, Tokyo, 194-0297, Japan
| | - Hiroharu Shinozaki
- Department of Surgery, Saiseikai Utsunomiya Hospital, 911-1 Takebayashi, Utsunomiya, Tochigi, 321-0974, Japan
| | - Kenji Matsumoto
- Department of Surgery, Saiseikai Utsunomiya Hospital, 911-1 Takebayashi, Utsunomiya, Tochigi, 321-0974, Japan
| | - Nobuo Omura
- Department of Surgery, National Hospital Organization Nishisaitama-Chuo National Hospital, 2-1671 Wakasa, Tokorozawa, Saitama, 359-1151, Japan
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Lin YJ, Liu SZ, Li LS, Han K, Shao BZ, Linghu EQ, Chai NL. Repeat peroral endoscopic myotomy with simultaneous submucosal and muscle dissection as a salvage option for recurrent achalasia. World J Gastroenterol 2023; 29:2349-2358. [PMID: 37124882 PMCID: PMC10134418 DOI: 10.3748/wjg.v29.i15.2349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 02/20/2023] [Accepted: 03/29/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND For recurrent achalasia after initial peroral endoscopic myotomy (POEM) failure, repeat POEM (Re-POEM) has been reported as a treatment option. However, severe esophageal interlayer adhesions caused by previous procedures impede the successful establishment of a submucosal tunnel and lead to aborted Re-POEM procedures. Our team previously described POEM with simultaneous submucosal and muscle dissection (POEM-SSMD) as a feasible solution for achalasia with severe interlayer adhesions.
AIM To investigate the effectiveness and safety of Re-POEM with simultaneous submucosal and muscle dissection (Re-POEM-SSMD).
METHODS A total of 1049 patients with achalasia who underwent successful endoscopic myotomy at the Digestive Endoscopic Center of Chinese PLA General Hospital from December 2014 to May 2022 were reviewed. Patients with recurrent achalasia who experienced initial POEM clinical failure were retrospectively included in this study. The primary endpoint was retreatment clinical success, defined as an Eckardt score ≤ 3 during the postretreatment follow-up and no need for additional treatment. Procedure-related adverse events, changes in manometric lower esophageal sphincter (LES) pressure and reflux complications, as well as procedure-related parameters, were recorded.
RESULTS Sixteen patients underwent Re-POEM (9 patients) or Re-POEM-SSMD (7 patients) successfully at a median of 45.5 mo (range, 4-95 mo) after initial POEM. During a median follow-up period of 31 mo (range, 7-96 mo), clinical success (Eckardt score ≤ 3) was achieved in 8 (88.9%) and 6 (85.7%) patients after Re-POEM and Re-POEM-SSMD, respectively (P = 0.849). The median Eckardt score dropped from 4 (range, 3-8) at preretreatment to 1 (range, 0-5) at postretreatment in the Re-POEM group (P = 0.025) and from 5 (range, 2-8) to 2 (range, 0-4) in the Re-POEM-SSMD group (P < 0.001). The mean manometric LES pressure decreased from 23.78 ± 9.04 mmHg to 11.45 ± 5.37 mmHg after Re-POEM (P < 0.001) and from 26.80 ± 7.48 mmHg to 11.05 ± 4.38 mmHg after Re-POEM-SSMD (P < 0.001). No serious adverse events were recorded in both groups.
CONCLUSION In conclusion, Re-POEM-SSMD appears to be a safe and effective salvage therapy for recurrent achalasia with severe interlayer adhesions.
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Affiliation(s)
- Yun-Juan Lin
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital and Chinese PLA Medical School, Beijing 100853, China
| | - Sheng-Zhen Liu
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Long-Song Li
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Ke Han
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Bo-Zong Shao
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - En-Qiang Linghu
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Ning-Li Chai
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
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50
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Hata Y, Sato H, Shimamura Y, Abe H, Shiwaku A, Shiota J, Sato C, Ominami M, Fukuda H, Ogawa R, Nakamura J, Tatsuta T, Ikebuchi Y, Yokomichi H, Ihara E, Inoue H. Impact of peroral endoscopic myotomy on high-resolution manometry findings and their association with the procedure's outcomes. Gastrointest Endosc 2023; 97:673-683.e2. [PMID: 36328208 DOI: 10.1016/j.gie.2022.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/15/2022] [Accepted: 10/20/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) is conducted for patients with esophageal motility disorders based on high-resolution manometry (HRM) findings. However, the impact of POEM on HRM findings and the associations between post-POEM HRM and outcomes have not been clarified. METHODS In a multicenter, observational, cohort study, patients with achalasia treated by POEM received follow-up HRM. Associations between patient characteristics, POEM procedures, and post-POEM HRM findings, including integrated relaxation pressure (IRP) and distal contractile integral (DCI), were investigated. Furthermore, POEM procedure outcomes were compared with post-POEM HRM findings. RESULTS Of 2171 patients, 151 (7.0%) showed residual high post-POEM IRP (≥26 mm Hg; Starlet [Starmedical Ltd, Tokyo, Japan]). In a multivariate analysis, high pre-POEM IRPs (odds ratio [OR], 24.3) and gastric myotomy >2 cm (OR, .22) were found to be positive and negative predictive factors of high post-POEM IRPs, respectively. Peristalsis recovery (DCI ≥500 mm Hg/cm/s, at least 1 swallow; Starlet) was visible in 121 of 618 patients (19.6%) who had type II to III achalasia. High pre-POEM IRP (OR, 2.65) and DCI ≥500 (OR, 2.98) predicted peristalsis recovery, whereas esophageal dilation (OR, .42) predicted a risk of no recovery. Extended myotomy did not reveal a significant impact on peristalsis recovery. High or low post-POEM IRP and DCI did not increase the incidence of clinical failure, reflux esophagitis, or symptomatic GERD. CONCLUSIONS Extended gastric myotomy decreased IRP values, whereas peristalsis recovery depended on the characteristics of achalasia. A residual high post-POEM IRP does not necessarily mean clinical failure. Routine HRM follow-up is not recommended after POEM.
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Affiliation(s)
- Yoshitaka Hata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroki Sato
- Division of Gastroenterology & Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hirofumi Abe
- Department of Gastroenterology, Kobe University Hospital, Kobe, Japan
| | - Akio Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Junya Shiota
- Department of Gastroenterology & Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Chiaki Sato
- Division of Advanced Surgical Science and Technology, Tohoku University School of Medicine, Sendai, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hisashi Fukuda
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Ryo Ogawa
- Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Tetsuya Tatsuta
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Yuichiro Ikebuchi
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Tottori University Faculty of Medicine, Yonago, Japan
| | - Hiroshi Yokomichi
- Department of Health Sciences, University of Yamanashi, Yamanashi, Japan
| | - Eikichi Ihara
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Gastroenterology and Metabolism, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
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