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King WW, Yang D, Draganov PV. Esophageal Per-Oral Endoscopic Myotomy (E-POEM): Future Directions and Perspectives. Curr Gastroenterol Rep 2024; 26:241-250. [PMID: 39117966 DOI: 10.1007/s11894-024-00938-4] [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: 07/02/2024] [Indexed: 08/10/2024]
Abstract
PURPOSE OF REVIEW POEM is a mature procedure endorsed by societal guidelines as a first line therapy for achalasia and spastic esophageal disorders. Nonetheless, several questions remain, including expanding indications for POEM, periprocedural evaluation and management, and the optimal POEM technique to enhance clinical success while mitigating risk for reflux. RECENT FINDINGS There is uncertainty regarding several technical aspects of the POEM myotomy; though aggregating evidence supports the use of real-time impedance planimetry to guide the myotomy. While post-POEM reflux remains a concerning long term sequela, there is an increasing focus on the potential role of endoscopic anti-reflux interventions. Lastly, with the widespread adoption of POEM, we continue to witness ongoing efforts to standardize post-procedural care and training in this procedure. POEM is no longer a novel but rather established procedure. Yet, this technique has continued to evolve, with the aim of optimizing treatment success while reducing adverse events and risk for post-procedural reflux.
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Affiliation(s)
- William W King
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
| | - Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Orlando, FL, USA
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, PO Box 100214, Gainesville, FL, 32610, USA.
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Ren XF, Yu ZH, Song WX, Meng QG, Chen X. Diagnostic and therapeutic strategies for achalasia of the cardia. Shijie Huaren Xiaohua Zazhi 2024; 32:545-555. [DOI: 10.11569/wcjd.v32.i8.545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 07/12/2024] [Accepted: 07/19/2024] [Indexed: 09/01/2024] Open
Abstract
The diagnosis of achalasia of the cardidia (AC) is primarily based on clinical symptoms, esophagographic findings, esophagodynamic examination, and upper gastrointestinal endoscopic findings. High resolution manometry is considered the gold standard for diagnosis. With the advan-cement of new technologies, the diagnostic methods for AC have become more diverse, and three-dimensional modeling may facilitate early detection of AC. The use of endoscopic functional intracavity imaging probe can enhance diagnostic accuracy. Common treatment options include endoscopic balloon dilation, laparoscopic Heller myotomy, and peroral endoscopic myotomy (POEM). POEM has emerged as the most widely utilized therapeutic approach currently, significantly improving the clinical success rate in treating AC. This article provides a comprehensive review on recent research progress in the diagnosis and treatment of AC.
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Affiliation(s)
- Xiang-Feng Ren
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Zi-Han Yu
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Wen-Xuan Song
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Qing-Guo Meng
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Xin Chen
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin 300052, China
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Yang D, Mohammed A, Yadlapati R, Wang AY, Jeyalingam T, Draganov PV, Gonzaga ER, Hasan MK, Schlachterman A, Xu MM, Saeed A, Aadam A, Sharaiha RZ, Law R, Wong Kee Song LM, Saumoy M, Pandolfino JE, Nishimura M, Kahaleh M, Hwang JH, Bechara R, Konda VJ, DeWitt JM, Kedia P, Kumta NA, Inayat I, Stavropoulos SN, Kumbhari V, Siddiqui UD, Jawaid S, Andrawes S, Khashab M, Triggs JR, Sharma N, Othman M, Sethi A, Baumann AJ, Priraka C, Dunst CM, Wagh MS, Al-Haddad M, Gayawali CP, Kantsevoy S, Elmunzer BJ. North American Expert Consensus on the Post-procedural Care of Patients After Per-oral Endoscopic Myotomy Using a Delphi Process. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00792-4. [PMID: 39214390 DOI: 10.1016/j.cgh.2024.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 08/02/2024] [Accepted: 08/18/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND & AIMS There is significant variability in the immediate post-operative and long-term management of patients undergoing per-oral endoscopic myotomy (POEM), largely stemming from the lack of high-quality evidence. We aimed to establish a consensus on several important questions on the after care of post-POEM patients through a modified Delphi process. METHODS A steering committee developed an initial questionnaire consisting of 5 domains (33 statements): post-POEM admission/discharge, indication for immediate post-POEM esophagram, peri-procedural medications and diet resumption, clinic follow-up recommendations, and post-POEM reflux surveillance and management. A total of 34 experts participated in the 2 rounds of the Delphi process, with quantitative and qualitative data analyzed for each round to achieve consensus. RESULTS A total of 23 statements achieved a high degree of consensus. Overall, the expert panel agreed on the following: (1) same-day discharge after POEM can be considered in select patients; (2) a single dose of prophylactic antibiotics may be as effective as a short course; (3) a modified diet can be advanced as tolerated; and (4) all patients should be followed in clinic and undergo objective testing for surveillance and management of reflux. Consensus could not be achieved on the indication of post-POEM esophagram to evaluate for leak. CONCLUSIONS The results of this Delphi process established expert agreement on several important issues and provides practical guidance on key aspects in the care of patients following POEM.
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Affiliation(s)
- Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida.
| | - Abdul Mohammed
- Department of Gastroenterology, AdventHealth Medical Group, Orlando, Florida
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, San Diego, California
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia
| | - Thurarshen Jeyalingam
- Division of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida
| | | | - Muhammad K Hasan
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida
| | - Alexander Schlachterman
- Division of Gastroenterology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ming-Ming Xu
- Department of Gastroenterology, Kaiser Permanente West LA, Los Angeles, California
| | - Ahmed Saeed
- Kansas City Gastroenterology and Hepatology Physicians Group, Kansas City, Missouri
| | - Aziz Aadam
- Department of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Ryan Law
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Monica Saumoy
- Center for Digestive Health, Penn Medicine Princeton Health, Plainsboro, New Jersey
| | - John E Pandolfino
- Department of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Makoto Nishimura
- Gastroenterology, Hepatology, and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michel Kahaleh
- Department of Gastroenterology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Joo Ha Hwang
- Department of Gastroenterology, Stanford University School of Medicine, Stanford, California
| | - Robert Bechara
- Queen's University, Division of Gastroenterology, Kingston Health Science Center, Kingston, Ontario, Canada
| | - Vani Ja Konda
- Division of Gastroenterology, Baylor University Medical Center, Dallas, Texas
| | - John M DeWitt
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Nikhil A Kumta
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York
| | - Irteza Inayat
- Department of Gastroenterology, AdventHealth Medical Group, Orlando, Florida
| | | | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Jacksonville, Florida
| | - Uzma D Siddiqui
- Center for Endoscopic Research and Therapeutics, University of Chicago, Chicago, Illinois
| | - Salmaan Jawaid
- Division of Gastroenterology, Baylor University Medical Center, Dallas, Texas
| | - Sherif Andrawes
- Division of Gastroenterology and Hepatology, Department of Medicine, Staten Island University Hospital - Northwell Health, Staten Island, New York
| | - Mouen Khashab
- Department of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Joseph R Triggs
- Division of Gastroenterology, Fox Chase Cancer Center, Temple Health, Philadelphia, Pennsylvania
| | - Neil Sharma
- Division of Interventional Oncology and Surgical Endoscopy (IOSE), Parkview Cancer Institute, Fort Wayne, Indiana
| | - Mohamed Othman
- Division of Gastroenterology, Baylor University Medical Center, Dallas, Texas
| | - Amrita Sethi
- Division of Digestive and Liver Disease, Columbia University Irving Medical Center, New York, New York
| | - Alexandra J Baumann
- Department of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Cyrus Priraka
- Department of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan
| | - Christy M Dunst
- Division of Gastrointestinal and Minimally Invasive Surgery, The Oregon Clinic Center for Advanced Surgery, Portland, Oregon
| | - Mihir S Wagh
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Jacksonville, Florida
| | - Mohammad Al-Haddad
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - C Prakash Gayawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri
| | - Sergey Kantsevoy
- Institute for Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, Maryland
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
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Itskoviz D, Malnick SDH. Gastroesophageal reflux following peroral endoscopic myotomy for achalasia: Bumps in the road to success. World J Gastroenterol 2024; 30:3461-3464. [PMID: 39156501 PMCID: PMC11326092 DOI: 10.3748/wjg.v30.i29.3461] [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: 03/10/2024] [Revised: 05/16/2024] [Accepted: 07/10/2024] [Indexed: 07/29/2024] Open
Abstract
Achalasia can significantly impair the quality of life. The clinical presentation typically includes dysphagia to both solids and liquids, chest pain, and regurgitation. Diagnosis can be delayed in patients with atypical presentations, and they might receive a wrong diagnosis, such as gastroesophageal reflux disease (GERD), owing to overlapping symptoms of both disorders. Although the cause of achalasia is poorly understood, its impact on the motility of the esophagus and gastroesophageal junction is well established. Several treatment modalities have been utilized, with the most common being surgical Heller myotomy with concomitant fundoplication and pneumatic balloon dilatation. Recently, peroral endoscopic myotomy (POEM) has gained popularity as an effective treatment for achalasia, despite a relatively high incidence of GERD occurring after treatment compared to other modalities. The magnitude of post-POEM GERD depends on its definition and is influenced by patient and procedure-related factors. The long-term sequelae of post-POEM GERD are yet to be determined, but it appears to have a benign course and is usually manageable with clinically available modalities. Identifying risk factors for post-POEM GERD and modifying the POEM procedure in selected patients may improve the overall success of this technique.
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Affiliation(s)
- David Itskoviz
- Kaplan Medical Center, Institute of Gastroenterology and Hepatology, Hebrew University Medical School of Jerusalem, Rehovot 76100, Israel
| | - Stephen David Howard Malnick
- Kaplan Medical Center, Department of Internal Medicine C, Hebrew University Medical School of Jerusalem, Rehovot 76100, Israel
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El Abiad R, Ashat M, Khashab M. Complications related to third space endoscopic procedures. Best Pract Res Clin Gastroenterol 2024; 71:101908. [PMID: 39209411 DOI: 10.1016/j.bpg.2024.101908] [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: 01/04/2024] [Revised: 02/06/2024] [Accepted: 03/19/2024] [Indexed: 09/04/2024]
Abstract
Third space endoscopy (TSE) encompasses a breadth of procedures for the treatment of a variety of GI disorders. The widespread use of per-oral endoscopic myotomy (POEM) and its diversification to include extended indications and at locations other than the oesophagus has provided an insight into the potential complications encountered. The most common adverse events associated with POEM, the epitome of TSE procedures, include insufflation related injuries, bleeding, failure of mucosal barrier, infections, pain, blown out myotomy and gastroesophageal reflux disease. The purpose of this review is to highlight the pitfalls and to identify the risk factors that may lead to adverse events, and to recommend appropriate salvage interventions in the scope of the current evidence.
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Affiliation(s)
- Rami El Abiad
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
| | - Munish Ashat
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Mouen Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD, USA
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de Sire R, Capogreco A, Massimi D, Alfarone L, Mastrorocco E, Pellegatta G, Hassan C, Repici A, Maselli R. Per oral endoscopic myotomy for achalasia. Best Pract Res Clin Gastroenterol 2024; 71:101930. [PMID: 39209417 DOI: 10.1016/j.bpg.2024.101930] [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: 03/03/2024] [Revised: 05/05/2024] [Accepted: 06/04/2024] [Indexed: 09/04/2024]
Abstract
Achalasia, characterized by impaired lower esophageal sphincter (LES) relaxation and failed peristalsis, stands out as the most widely recognized primary esophageal motility disorder. It manifests with dysphagia to solid and liquid foods, chest pain, regurgitation, and weight loss, leading to significant morbidity and healthcare burden. Traditionally, surgical Heller myotomy and pneumatic dilation were the primary therapeutic approaches for achalasia. However, in 2009, Inoue and colleagues introduced a groundbreaking endoscopic technique called peroral endoscopic myotomy (POEM), revolutionizing the management of this condition. This review aims to comprehensively examine the recent advancements in the POEM technique for patients diagnosed with achalasia, delving into critical aspects, such as the tailoring of the myotomy, the prevention of intraprocedural adverse events (AEs), the evaluation of long-term outcomes, and the feasibility of retreatment in cases of therapeutic failure.
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Affiliation(s)
- Roberto de Sire
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy.
| | - Antonio Capogreco
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy
| | - Davide Massimi
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy
| | - Ludovico Alfarone
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy
| | - Elisabetta Mastrorocco
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy
| | - Gaia Pellegatta
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy
| | - Cesare Hassan
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, 20072, Pieve Emanuele, Italy
| | - Alessandro Repici
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, 20072, Pieve Emanuele, Italy
| | - Roberta Maselli
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, 20072, Pieve Emanuele, Italy
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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; 37:doae024. [PMID: 38525929 DOI: 10.1093/dote/doae024] [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: 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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Iqbal U, Yodice M, Ahmed Z, Anwar H, Arif SF, Lee-Smith WM, Diehl DL. Safety and efficacy of EsoFLIP dilation in patients with esophageal dysmotility: a systematic review. Dis Esophagus 2024; 37:doae036. [PMID: 38659256 DOI: 10.1093/dote/doae036] [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: 06/06/2023] [Revised: 02/24/2024] [Accepted: 04/08/2024] [Indexed: 04/26/2024]
Abstract
Esophageal manometry is utilized for the evaluation and classification of esophageal motility disorders. EndoFlip has been introduced as an adjunctive test to evaluate esophagogastric junction (EGJ) distensibility. Treatment options for achalasia and EGJ outflow obstruction (EGJOO) include pneumatic dilation, myotomy, and botulinum toxin. Recently, a therapeutic 30 mm hydrostatic balloon dilator (EsoFLIP, Medtronic, Minneapolis, MN, USA) has been introduced, which uses impedance planimetry technology like EndoFlip. We performed a systematic review to evaluate the safety and efficacy of EsoFLIP in the management of esophageal motility disorders. A systematic literature search was performed with Medline, Embase, Web of science, and Cochrane library databases from inception to November 2022 to identify studies utilizing EsoFLIP for management of esophageal motility disorders. Our primary outcome was clinical success, and secondary outcomes were adverse events. Eight observational studies including 222 patients met inclusion criteria. Diagnoses included achalasia (158), EGJOO (48), post-reflux surgery dysphagia (8), and achalasia-like disorder (8). All studies used 30 mm maximum balloon dilation except one which used 25 mm. The clinical success rate was 68.7%. Follow-up duration ranged from 1 week to a mean of 5.7 months. Perforation or tear occurred in four patients. EsoFLIP is a new therapeutic option for the management of achalasia and EGJOO and appears to be effective and safe. Future comparative studies with other therapeutic modalities are needed to understand its role in the management of esophageal motility disorders.
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Affiliation(s)
- Umair Iqbal
- Department of Gastroenterology and Hepatology, Wellspan York Hospital, York, PA, USA
| | - Michael Yodice
- Department of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, PA, USA
| | - Zohaib Ahmed
- Department of Gastroenterology, University of Toledo Medical Center, Toledo, OH, USA
| | - Hafsa Anwar
- Department of Medicine, Capital Health Regional Medical Center, Trenton, NJ, USA
| | | | - Wade M Lee-Smith
- Department of University Libraries, University of Toledo Medical Center, Toledo, OH, USA
| | - David L Diehl
- Department of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, PA, USA
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Tawfik M, Chain S, Elfiky A, Abureesh M, Gurala D, Andrawes S, El Douaihy Y. Novel Use of AXIOS Stent for Concurrent Management of Achalasia and Esophageal Varices in a Cirrhotic Patient. ACG Case Rep J 2024; 11:e01426. [PMID: 38994195 PMCID: PMC11239152 DOI: 10.14309/crj.0000000000001426] [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: 03/05/2024] [Accepted: 06/03/2024] [Indexed: 07/13/2024] Open
Abstract
AXIOS stents create an anastomotic connection between 2 lumens, facilitating bypass of blockages and strictures as well as drainage of large fluid collections. Historically, AXIOS stents have primarily been used for draining pancreatic fluid collections, with no documented cases of their use within the esophagus until now. In this article, we present a case of a 65-year-old man with cirrhosis admitted for dysphagia. On evaluation, he was diagnosed with type 1 achalasia and concurrent esophageal varices. A novel approach was used, utilizing an AXIOS stent, to provide both symptomatic relief and targeted treatment for his varices.
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Affiliation(s)
- Mark Tawfik
- Department of Internal Medicine, Staten Island University Hospital-Northwell Health, Staten Island, NY
| | - Stephanie Chain
- City University of New York School of Medicine, New York, NY
| | - Ahmed Elfiky
- Department of Gastroenterology and Hepatology, Staten Island University Hospital-Northwell Health, Staten Island, NY
| | - Mohammad Abureesh
- Department of Gastroenterology and Hepatology, Staten Island University Hospital-Northwell Health, Staten Island, NY
| | - Dhineshreddy Gurala
- Department of Gastroenterology and Hepatology, Staten Island University Hospital-Northwell Health, Staten Island, NY
| | - Sherif Andrawes
- Department of Gastroenterology and Hepatology, Staten Island University Hospital-Northwell Health, Staten Island, NY
| | - Youssef El Douaihy
- Department of Gastroenterology and Hepatology, Staten Island University Hospital-Northwell Health, Staten Island, NY
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Pan H, Ren M, Zhou X, Ji F. Bypassing large submucosal vessels during peroral endoscopic myotomy reduces operative time and intraoperative blood loss in patients with achalasia. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:258-263. [PMID: 38095216 DOI: 10.17235/reed.2023.9974/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
OBJECTIVE peroral endoscopic myotomy (POEM), a relatively minimally invasive endoscopic procedure, is the first-line treatment for achalasia. The aim of this study was to compare procedure-related parameters and clinical outcomes between bypassing and performing prophylactic electrocoagulation of large submucosal vessels during POEM. METHODS one hundred and twelve patients with achalasia who had undergone POEM at our hospital between April 2017 and March 2023 were retrospectively enrolled. Large submucosal vessels were bypassed to avoid injury during submucosal tunneling in the bypass group, whereas large submucosal vessels were prophylactically treated by electrocoagulation in the prophylactic electrocoagulation group. Procedure-related parameters, Eckardt score and complications were compared between the two groups. RESULTS the bypass group showed a significant reduction in operative time and amount of intraoperative blood loss than the prophylactic electrocoagulation group (37.11 ± 9.96 min vs 58.80 ± 17.90 min, and 1 [interquartile range: 1-2] ml vs 5 [interquartile range: 3-8] ml; p < 0.001). Eleven (17.5 %) and 44 (89.8 %) patients in the bypass and prophylactic electrocoagulation groups, respectively, required hemostatic forceps (p < 0.001). Furthermore, lower operative and hospitalization costs were recorded in the bypass group than in the prophylactic electrocoagulation group (p < 0.05). No statistically significant difference was found between the two groups in terms of submucosal tunnel length, myotomy length, clinical efficacy, or complications. CONCLUSIONS bypassing large submucosal vessels during POEM can reduce the operative duration and intraoperative blood loss, with no difference in clinical outcomes than prophylactic electrocoagulation treatment.
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Affiliation(s)
- Hanghai Pan
- Gastroenterology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, China
| | - Mengting Ren
- Gastroenterology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College
| | - Xinxin Zhou
- Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine
| | - Feng Ji
- Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine
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Canakis A, Lee DU, Grossman JL, Hwang DG, Wellington J, Yang AH, Fan GH, Kim GE, Kim RE. Anesthesia choice and its potential impact on endoluminal functional lumen imaging probe measurements in esophageal motility disorders. Gastrointest Endosc 2024; 99:702-711.e6. [PMID: 38052328 DOI: 10.1016/j.gie.2023.11.052] [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: 05/01/2023] [Revised: 11/20/2023] [Accepted: 10/10/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND AND AIMS The widespread use of peroral endoscopic myotomy (POEM) has revolutionized the management of esophageal motility disorders (EMDs). The introduction of an endoluminal functional lumen imaging probe (EndoFLIP, Medtronic, Dublin, Ireland) can serve as a complementary diagnostic tool to assess the mechanical properties (ie, pressure, diameter, distensibility, topography) of the esophagus. During EndoFLIP measurements, different anesthesia techniques may induce variable degrees of neuromuscular blockade, potentially affecting esophageal motility and altering the results of EndoFLIP metrics. The aim of this study was to compare the impact of using total intravenous anesthesia (TIVA) versus general anesthesia with inhalational anesthetics (GAIA) on diagnostic EndoFLIP measurements. METHODS This retrospective study included all adult patients (≥18 years) undergoing EndoFlip during the POEM procedure at our institution between February 2017 and February 2022. Differences in pressure, diameter, and distensibility index were obtained by using propofol-based TIVA versus sevoflurane-based GAIA with a 30 mL and a 60 mL balloon. The differences were divided into terciles and compared between diagnoses by using univariate comparisons and logistic regression models. RESULTS A total of 49 patients were included (39% type I achalasia, 43% type II or III achalasia, and 18% jackhammer esophagus [JE]). Compared with spastic disorders (types II and III achalasia and JE), type I had lower values of pressure differences at 60 mL in univariate (3.75 vs 15.20, P = .001) and multivariate (adjusted odds ratio, .89; 95% confidence interval, .82-.978) analyses. Compared with type I, types II and III achalasia had higher rates of pressure differences at 60 mL in the univariate (9.85 vs 3.75, P = .04) analysis and nearly reached significance in the multivariate analysis (1.09; 95% confidence interval, 1-1.20). Compared with type I achalasia, JE exhibited higher values in pressure differences at 60 mL (27.7 vs 3.75, P < .001). CONCLUSIONS Esophageal pressure, as measured by EndoFLIP, was significantly reduced when patients were sedated with sevoflurane-based GAIA. The use of sevoflurane-based GAIA for diagnostic EndoFLIP may potentially lead to the misclassification of spastic disorders as type I achalasia. Propofol-based TIVA should therefore be considered over sevoflurane-based GAIA for sedation during the diagnostic test.
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Affiliation(s)
- Andrew Canakis
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - David U Lee
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jennifer L Grossman
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Daniel G Hwang
- Division of Gastroenterology, Kaiser Permanente, Bellevue, Washington, USA
| | - Jennifer Wellington
- Atrium Health Gastroenterology and Hepatology, Charlotte, North Carolina, USA
| | - Alexander H Yang
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Grace E Kim
- Division of Gastroenterology & Hepatology, University of Chicago, Chicago, Illinois, USA
| | - Raymond E Kim
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA.
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Malik A, Qureshi S, Nadir A, Malik MI, Adler DG. Efficacy and safety of laparoscopic Heller's myotomy versus pneumatic dilatation for achalasia: A systematic review and meta-analysis of randomized controlled trials. Indian J Gastroenterol 2024:10.1007/s12664-023-01497-8. [PMID: 38564157 DOI: 10.1007/s12664-023-01497-8] [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: 09/12/2023] [Accepted: 12/01/2023] [Indexed: 04/04/2024]
Abstract
BACKGROUND AND OBJECTIVES: Achalasia has several treatment modalities. We aim to compare the efficacy and safety of laparoscopic Heller myotomy (LHM) with those of pneumatic dilatation (PD) in adult patients suffering from achalasia. METHODS We searched Cochrane CENTRAL, PubMed, Web of Science, SCOPUS and Embase for related clinical trials about patients suffering from achalasia. The quality appraisal and assessment of risk of bias were conducted with GRADE and Cochrane's risk of bias tool, respectively. Homogeneous and heterogeneous data was analyzed under fixed and random-effects models, respectively. RESULTS The pooled analysis of 10 studies showed that PD was associated with a higher rate of remission at three months, one year, three years and five years (RR = 1.25 [1.09, 1.42] (p = 0.001); RR = 1.13 [1.05, 1.20] (p = 0.0004); RR = 1.48 [1.19, 1.82] (p = 0.0003); RR = 1.49 [1.18, 1.89] (p = 0.001)), respectively. LHM was associated with lower number of cases suffering from adverse events, dysphagia and relapses (RR = 0.50 [0.25, 0.98] (p = 0.04); RR = 0.33 [0.16, 0.71] (p = 0.004); RR = 0.38 [0.15, 0.97] (p = 0.04)), respectively. There is no significant difference between both groups regarding the lower esophageal pressure, perforations, remission rate at two years, Eckardt score after one year and reflux. CONCLUSION PD had higher remission rates than LHM at three months, one year and three years, but not at two years or five years. More research is needed to determine whether PD has a significant advantage over LHM in terms of long-term remission rates.
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Affiliation(s)
- Adnan Malik
- Division of Gastroenterology, Mountain Vista Medical Center, Mesa, AZ, USA
| | - Shahbaz Qureshi
- Division of Gastroenterology, Mountain Vista Medical Center, Mesa, AZ, USA
| | - Abdul Nadir
- Division of Gastroenterology, Mountain Vista Medical Center, Mesa, AZ, USA
| | | | - Douglas G Adler
- Center for Advanced Therapeutic Endoscopy Centura Health, Porter Adventist Hospital, Denver, CO, USA.
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Xue P, Canakis A, Lee DU, Kadiyala J, Fan GH, Kim RE. Active narcotic use and post-peroral endoscopic myotomy outcomes in esophageal motility disorders. Gastrointest Endosc 2024; 99:490-498.e10. [PMID: 37871847 DOI: 10.1016/j.gie.2023.10.046] [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: 10/20/2022] [Revised: 10/12/2023] [Accepted: 10/14/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) is a minimally invasive technique used to treat esophageal motility disorders. Opioid use has been demonstrated to adversely affect esophageal dysmotility and is associated with an increased prevalence of esophageal motility disorders. Our aim was to investigate the effect of narcotic use on success rates in patients undergoing POEM. METHODS This was a single-center, retrospective study of patients undergoing POEM between February 2017 and September 2021. Primary outcomes were post-POEM Eckardt score (ES), distensibility index, and length of procedure. Secondary outcomes included technical success, myotomy length, length of stay, adverse events, reintervention rates, and postprocedure GERD. RESULTS During the study period, 90 patients underwent POEM for treatment of esophageal dysmotility disorders. Age, sex, race, indications for POEM, and body mass index were not significant between those with or without narcotic use. There were no differences in procedure time, preprocedure ESs, or length of stay. Postprocedure ESs were higher in the group with active narcotic use compared to the group with no prior history (2.73 vs 1.2, P = .004). Distensibility indexes measured with EndoFLIP (Medtronic, Minneapolis, Minn, USA) were not different in patients using narcotics compared with opioid-naïve patients. CONCLUSION Active narcotic use negatively affects symptom improvement after POEM for the treatment of esophageal motility disorders.
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Affiliation(s)
- Pei Xue
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - David Uihwan Lee
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jagannath Kadiyala
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | | | - Raymond E Kim
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA.
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14
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Nabi Z, Inavolu P, Duvvuru NR. Prediction, prevention and management of gastroesophageal reflux after per-oral endoscopic myotomy: An update. World J Gastroenterol 2024; 30:1096-1107. [PMID: 38577183 PMCID: PMC10989487 DOI: 10.3748/wjg.v30.i9.1096] [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: 12/17/2023] [Revised: 01/26/2024] [Accepted: 02/18/2024] [Indexed: 03/06/2024] Open
Abstract
Achalasia cardia, the most prevalent primary esophageal motility disorder, is predominantly characterized by symptoms of dysphagia and regurgitation. The principal therapeutic approaches for achalasia encompass pneumatic dilatation (PD), Heller's myotomy, and the more recent per-oral endoscopic myotomy (POEM). POEM has been substantiated as a safe and efficacious modality for the management of achalasia. Although POEM demonstrates superior efficacy compared to PD and an efficacy parallel to Heller's myotomy, the incidence of gastroesophageal reflux disease (GERD) following POEM is notably higher than with the aforementioned techniques. While symptomatic reflux post-POEM is relatively infrequent, the significant occurrence of erosive esophagitis and heightened esophageal acid exposure necessitates vigilant monitoring to preclude long-term GERD-related complications. Contemporary advancements in the field have enhanced our comprehension of the risk factors, diagnostic methodologies, preventative strategies, and therapeutic management of GERD subsequent to POEM. This review focuses on the limitations inherent in the 24-h pH study for evaluating post-POEM reflux, potential modifications in the POEM technique to mitigate GERD risk, and the strategies for managing reflux following POEM.
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Affiliation(s)
- Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad 500082, Telangana, India
| | - Pradev Inavolu
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad 500082, Telangana, India
| | - Nageshwar Reddy Duvvuru
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad 500032, Telangana, India
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15
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Babayev R, Taylor S, Franklin EV. Case of Nocturnal Emesis, Weight Loss, and Aspiration Pneumonia. Clin Pediatr (Phila) 2024; 63:401-404. [PMID: 37119024 PMCID: PMC10893766 DOI: 10.1177/00099228231171065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Affiliation(s)
- Roman Babayev
- Department of Adolescent Medicine, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
| | - Sharonda Taylor
- Department of Adolescent Medicine, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
| | - Elizabeth V. Franklin
- Department of Adolescent Medicine, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
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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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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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Nabi Z, Chandran V, Basha J, Ramchandani M, Inavolu P, Kalpala R, Goud R, Jagtap N, Darisetty S, Gupta R, Tandan M, Lakhtakia S, Kotla R, Devarasetty R, Rao GV, Reddy DN. Conventional versus oblique fiber-sparing endoscopic myotomy for achalasia cardia: a randomized controlled trial (with videos). Gastrointest Endosc 2024; 99:1-9. [PMID: 37598863 DOI: 10.1016/j.gie.2023.08.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/23/2023] [Accepted: 08/06/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND AND AIMS GERD is common after peroral endoscopic myotomy (POEM). Selective sparing of oblique fibers may reduce the incidence of reflux esophagitis after POEM. In this study, we compared the incidence of GERD between conventional myotomy (CM) versus oblique fiber-sparing (OFS) myotomy in patients with achalasia. METHODS Eligible patients with type I and II achalasia who underwent POEM from January 2020 to October 2020 were randomized into 2 groups (CM and OFS myotomy). Exclusion criteria were type III achalasia, sigmoid esophagus, and history of Heller's myotomy. The primary study outcome was incidence of reflux esophagitis (at least grade B) in the 2 groups. Secondary outcomes were reflux symptoms, esophageal acid exposure, clinical success, and adverse events. RESULTS One hundred fifteen patients were randomized into CM (n = 58) and OFS myotomy (n = 57) groups. POEM was technically successful in all patients. Overall, reflux esophagitis was found in 56 patients (48.7%). The incidence of at least grade B esophagitis was similar in both groups (CM vs OFS myotomy: 25.9% vs 31.6%, P = .541). The mean number of reflux episodes (48.2 ± 36.6 vs 48.9 ± 40.3, P = .933), increased esophageal acid exposure >6% (45.5% vs 31.7%, P = .266), and high DeMeester scores (38.6% vs 41.5%, P = .827) were similar in both groups. There was no difference in the rate of symptomatic reflux (GERD questionnaire score >7) or use of proton pump inhibitors at 1 year. CONCLUSIONS Sparing of sling fibers has no significant impact on the incidence of significant reflux esophagitis after POEM. Novel strategies need to be explored to prevent reflux after POEM. (Clinical trial registration number: NCT04229342.).
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Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India
| | | | | | | | | | | | - Rajesh Goud
- Asian Institute of Gastroenterology, Hyderabad, India
| | - Nitin Jagtap
- Asian Institute of Gastroenterology, Hyderabad, India
| | | | - Rajesh Gupta
- Asian Institute of Gastroenterology, Hyderabad, India
| | - Manu Tandan
- Asian Institute of Gastroenterology, Hyderabad, India
| | | | - Rama Kotla
- Asian Institute of Gastroenterology, Hyderabad, India
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Mubashir M, Andrus V, Okuampa D, Neice M, Armstrong E, Canezaro H, Dies R, Deville A, Kawji L, Rashid S, Raza SM, Hafiz N, Faisal ASM, Bhuiyan MAN, Cai Q. Short-term Outcome of Peroral Endoscopic Myotomy Performed by the Same Endoscopist on Achalasia and Nonachalasia Esophageal Motility Disorders. Surg Laparosc Endosc Percutan Tech 2023; 33:577-582. [PMID: 37852237 DOI: 10.1097/sle.0000000000001240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 07/31/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is a relatively new but increasingly therapeutic option for achalasia. In recent years, POEM has been used for nonachalasia esophageal motility disorders (NAEMDs), such as diffuse esophageal spasm, esophagogastric junction outlet obstruction, and hypercontractile disorder, with some clinical success. No studies thus far compare the outcomes of these two groups. We perform the first head-to-head comparison of outcomes after POEM in patients with achalasia and NAEMD. PATIENTS AND METHODS A retrospective analysis of all patients undergoing POEM at one university hospital by a single expert endoscopist from July 2021 to December 2022 was performed. All patients were symptomatic, and the presence of esophageal motility disorders was confirmed using multiple diagnostic modalities. These patients were then divided into 2 groups, achalasia and NAEMD, based on the underlying diagnosis. Statistical analysis of different clinical outcomes, including effectiveness and safety, was performed. RESULTS Thirty-seven patients (mean age: 59.55, females: 22) underwent POEM in the study period. Twenty patients had achalasia and 17 patients had NAEMD. The median myotomy length was 5.5 cm for the achalasia group and 10 cm for the NAEMD group. This excluded patients with esophagogastric junction outlet obstruction in which the median myotomy length was 3 cm. The procedure time, the duration of hospital stays, the rates of same-day discharge, and complications were similar between the two. Short-term outcomes of POEM for the two groups were similar with improvement in 94% of patients in the achalasia group and 93.75% in the NAEMD group. CONCLUSION Contrary to prior observations, our study highlights that POEM is equally effective in achieving clinical improvement in patients with NAEMD as achalasia over 6 months of follow-up. In addition, POEM has a comparable safety profile in both patient groups making it a feasible therapeutic option for these debilitating and challenging disorders.
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Affiliation(s)
- Maryam Mubashir
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Victoria Andrus
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - David Okuampa
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Michelle Neice
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Elizabeth Armstrong
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Hailey Canezaro
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Ross Dies
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Ashely Deville
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Lena Kawji
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Shazia Rashid
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Syed Musa Raza
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Nazar Hafiz
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
| | - Abu Saleh Mosa Faisal
- Department of Internal Medicine, Division of Clinical Informatics, Louisiana State University Health Science Center at Shreveport, Shreveport, LA
| | - Mohammad Alfrad Nobel Bhuiyan
- Department of Internal Medicine, Division of Clinical Informatics, Louisiana State University Health Science Center at Shreveport, Shreveport, LA
| | - Qiang Cai
- Department of Internal Medicine, Division of Gastroenterology and Hepatology
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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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Nabi Z, Ramchandani M, Basha J, Inavolu P, Kotla R, Goud R, Darisetty S, Reddy DN. Per-oral endoscopic myotomy in cases with prior Heller's myotomy: Outcomes at a median follow-up of 5 years. J Gastroenterol Hepatol 2023; 38:2035-2039. [PMID: 37571986 DOI: 10.1111/jgh.16320] [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: 06/12/2023] [Revised: 07/11/2023] [Accepted: 07/23/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND AND AIM Per-oral endoscopic myotomy (POEM) is an established treatment for achalasia cardia. However, data on the long-term efficacy of POEM in patients with failed Heller's myotomy (HM) are limited. The purpose of this study was to evaluate the long-term outcomes of POEM in patients with persistent or recurrent symptoms following HM. METHODS Data of patients with recurrence of symptoms after HM who underwent POEM (September 2013 to December 2022) were analyzed, retrospectively. Primary outcome was clinical success [Eckardt score (ES) ≤ 3]. Secondary outcomes included improvement of manometry parameters, barium emptying at 5 min and gastroesophageal reflux (esophagitis and increased esophageal acid exposure) after POEM. RESULTS Seventy-two cases (45.9 ± 13.4 years, 43 men) with history of HM were included in the study. The subtypes of achalasia were type 1 (40.3%), type 2 (37.5%), and unknown (19.4%). Prior treatment included HM in 48 (66.7%), HM plus pneumatic dilatation in 20 (27.8%), and HM plus pneumatic dilatation and Botox in 4 (5.5%). Technical success was achieved in all cases. Mean length of myotomy was 10.7 ± 3.3 cm, and mean procedure duration was 59.2 ± 25.9 min. There was significant improvement in ES (pre-POEM 6.5 ± 1.8 vs post-POEM 0.7 ± 0.7), lower esophageal sphincter pressure pressures (31.7 ± 12.5 vs 13.3 ± 5.7 mmHg) and barium emptying (14.2 ± 4.2 vs 2.4 ± 3.1 cm) after POEM. At a median follow-up of 63 months (IQR 40-95), clinical success (ES ≤ 3) was documented in 58 (80.6%) patients. Reflux esophagitis and increased esophageal acid exposure were recorded in 28 of 49 (57.1%) and 11 of 20 (55%) patients, respectively. CONCLUSION POEM is a durable treatment modality in cases with relapse of symptoms after HM.
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Affiliation(s)
- Zaheer Nabi
- Interventional Endoscopy Asian Institute of Gastroenterology, Hyderabad, India
| | | | | | | | - Rama Kotla
- Asian Institute of Gastroenterology, Hyderabad, India
| | - Rajesh Goud
- Asian Institute of Gastroenterology, Hyderabad, India
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22
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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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23
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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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24
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Peng D, Tan Y, Yang S, Zhou M, Lv L, Liang C, Zhu H, Li R, Liu D. Peroral Endoscopic Myotomy for Achalasia in Older Adults: A Retrospective Analysis of 39 Cases with a Minimum Follow-Up of 5 Years. Dysphagia 2023; 38:1286-1294. [PMID: 36725760 DOI: 10.1007/s00455-023-10554-5] [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: 09/03/2022] [Accepted: 01/09/2023] [Indexed: 02/03/2023]
Abstract
Peroral endoscopic myotomy (POEM) has demonstrated favorable short-term safety and efficacy in older adults, while a comprehensive understanding of the long-term outcomes were vague. We aimed to evaluate clinical outcomes in older adults' 5-year postop after undergoing POEM to treatment achalasia. Older adults from a single hospital who received POEM between January 2010 and January 2017 were analyzed. Older persons were reached to evaluate their symptoms at present and encouraged repeat examinations for objective follow-up. The clinical success, POEM-related indicators, POEM-related adverse events, and quality of life were assessed. Thirty-nine older adults with a mean age of 70.82 ± 4.72 who underwent POEM were studied at a mean 84.23 ± 25.06 month follow-up. The preoperative diagnosis was achalasia type I in 7 older adults, achalasia type II in 26 older adults, and achalasia type III in 2 older adults. Sixteen older adults had prior treatment and 21 older adults suffered from comorbidities. The median operative time was 50 (25-120) minutes, and perioperative adverse events were recorded in four older adults. The current Eckardt scores were significantly lower than that before POEM (2.08 ± 2.12 vs. 6.58 ± 1.78, P < 0.001). Besides, long-term clinical success was gained in 66.7% of older adults. Three older adults received postop treatment for symptom recurrence. Ultimately, 80.6% of old adults expressed satisfaction with POEM, while 27.8% of older adults suffered from symptomatic reflux. In conclusion, POEM can provide symptomatic improvement in a large proportion of older adults with achalasia at 5-year postop.
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Affiliation(s)
- Dongzi Peng
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China
- Research Center of Digestive Disease, Central South University, Changsha, China
| | - Yuyong Tan
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China
- Research Center of Digestive Disease, Central South University, Changsha, China
| | - Si Yang
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China
- Research Center of Digestive Disease, Central South University, Changsha, China
| | - Mei Zhou
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China
- Research Center of Digestive Disease, Central South University, Changsha, China
| | - Liang Lv
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China
- Research Center of Digestive Disease, Central South University, Changsha, China
| | - Chengbai Liang
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China
- Research Center of Digestive Disease, Central South University, Changsha, China
| | - Hongyi Zhu
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China
- Research Center of Digestive Disease, Central South University, Changsha, China
| | - Rong Li
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China.
- Research Center of Digestive Disease, Central South University, Changsha, China.
| | - Deliang Liu
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China
- Research Center of Digestive Disease, Central South University, Changsha, China
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25
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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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26
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Zhu Q, Zhang H, Huang S, Gan P, Wang R, Peng Y, Lü M, Tang X. Research hotspots and trend of a emerging novel endoscopic technique of peroral endoscopic myotomy from 2010 to 2022: A bibliometric analysis. Medicine (Baltimore) 2023; 102:e35009. [PMID: 37682198 PMCID: PMC10489447 DOI: 10.1097/md.0000000000035009] [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: 06/25/2023] [Accepted: 08/08/2023] [Indexed: 09/09/2023] Open
Abstract
Peroral endoscopic myotomy (POEM), which has been used to treat achalasia and other esophageal motility disorders for the past 10 years, has proven to be secure and efficient. Every year, more and more essays on this subject are published. We sought to investigate the global scientific outputs and hotspots of POEM produced by various nations, organizations, and authors. From 2010 to October 2022, there were 875 papers on POEM that were found in the Web of Science Core database. The bibliometric visualization analyses of nations/regions, institutions, authors, journals, references, and keywords were conducted by CiteSpace V.5.8.R3. Eight hundred seventy-five publications were included in this analysis. With 68 publications, Inoue H had the highest output. While Showa University in Japan was the most productive institution, the United States was the most productive nation. Among the journals, Surgical Endoscopy published the highest number of articles, followed by Gastrointestinal Endoscopy and Endoscopy. The top 10 keywords that appeared most frequently were achalasia, peroral endoscopic myotomy, POEM, myotomy, esophageal achalasia, dysphagia, heller myotomy, endoscopy, gastroparesis and peroral endoscopic myotomy. Seven frontiers, including meta-analysis, high-resolution esophageal manometry, geriatric patient, third space endoscopy, adverse event, endoscopic submucosal dissection, and gastric peroral endoscopic myotomy, had an impact on future research on POEM. The previous 10 years have seen a considerable rise in POEM research, and this trend will continue. The most recent research frontiers, which require more attention, are meta-analysis, high-resolution esophageal manometry, geriatric patient, third space endoscopy, adverse event, and gastric peroral endoscopic myotomy.
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Affiliation(s)
- Qingliang Zhu
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Han Zhang
- Department of Gastroenterology, Zigong First People’s Hospital, Zigong, China
| | - Shu Huang
- Department of Gastroenterology, Lianshui County People’ Hospital, Huaian, China
| | - Peiling Gan
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Ruiyu Wang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yan Peng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Muhan Lü
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaowei Tang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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27
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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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28
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Draganov PV. Peroral endoscopic myotomy: A lifelong solution or another temporizing measure for achalasia and nonachalasia spastic esophageal motility disorders? Gastrointest Endosc 2023; 98:249-251. [PMID: 37004814 DOI: 10.1016/j.gie.2023.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/08/2023] [Accepted: 03/14/2023] [Indexed: 04/04/2023]
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29
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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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30
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Dawley N. Peroral Endoscopic Myotomy: What Nurses Need to Know to Provide Preeminent Perioperative Care. Gastroenterol Nurs 2023; 46:197-207. [PMID: 37261923 DOI: 10.1097/sga.0000000000000711] [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: 06/27/2022] [Accepted: 09/20/2022] [Indexed: 06/03/2023] Open
Abstract
This article aims to explore details of research, evidence, and key concepts intended for nurses and other healthcare clinicians surrounding the paradigm shift in therapeutic endoscopy relating to the third-space endoscopic procedure, peroral endoscopic myotomy. Although many medical publications detail the procedure, there are no specific guidelines for nurses to reference when caring for the patient undergoing peroral endoscopic myotomy. With scant published resources available to direct nurses distinctly in the delivery of exceptional care to patients undergoing peroral endoscopic myotomy, there is an identified need for collated information to be accessible to all nurses providing perioperative teaching and care. As peroral endoscopic myotomy continues to transpire as a mainstream or preferred standard treatment for patients who suffer from achalasia, relevant education remains to be fully understood and assessed in the nursing arena. By examining nursing considerations for patient care, indications, techniques, and advancements regarding this ever-emergent breakthrough, readers will discover guidance in comprehensive care encompassing patients undergoing the peroral endoscopic myotomy procedure.
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Affiliation(s)
- Natalie Dawley
- Natalie Dawley, BSN-RN, CGRN, is Registered Nurse, Department of Endoscopy, Baylor St. Luke's Medical Center, Houston, Texas
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31
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Szydlo Shein G, Elazary R, Marom G, Fishman Y, Abu Gazala M, Brodie R, Jacob H, Benson AA, Rivkind A, Pikarsky AJ, Mintz Y. Post-POEM Contrast-Enhanced Swallow Study: Is It Always Necessary? J Gastrointest Surg 2023; 27:878-886. [PMID: 36720757 DOI: 10.1007/s11605-023-05605-z] [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: 10/27/2022] [Accepted: 01/09/2023] [Indexed: 02/02/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is rapidly becoming the procedure of choice for treating esophageal achalasia. In most centers, contrast-enhanced swallow studies (CESS) are routinely performed postoperatively to confirm mucosal integrity. The aim of this study was to determine the necessity of performing these studies routinely after POEM. METHODS A retrospective review of a prospectively maintained database of patients who underwent POEM between December 2012 and November 2020 was performed. All patients underwent a CESS on the first postoperative day. Medical records including vital signs, complete blood count, and POD-1 CESS were evaluated. RESULTS One hundred thirty-four consecutive patients were included in the study. Sixty-nine (51.49%) CESS showed abnormal findings; while most findings did not change the postoperative course, five (7.2%) demonstrated tunnel leaks, which did alter the overall management. Screening patients for fever, tachycardia, or leukocytosis on POD-1 had a 100% sensitivity and a 62% specificity for finding a clinically significant complication on CESS. CONCLUSIONS The study findings suggest that performing routine contrast-enhanced swallow studies on all patients is not necessary following POEM, as leaks can be screened for by clinical or laboratory abnormalities. Herein, we propose an algorithm based on objective measurable findings for the selection of patients who should undergo CESS.
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Affiliation(s)
- Gabriel Szydlo Shein
- 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
| | - Gad Marom
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yuri Fishman
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Mahmud Abu Gazala
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ronit Brodie
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Harold Jacob
- Department of Gastroenterology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Ariel A Benson
- Department of Gastroenterology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Avraham Rivkind
- Department of General Surgery, Hadassah Hebrew University Medical Center, 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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32
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Albéniz E, Marra-López Valenciano C, Estremera-Arévalo F, Sánchez-Yagüe A, Montori S, Rodríguez de Santiago E. POEM from A to Z: current perspectives. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023. [PMID: 37073708 DOI: 10.17235/reed.2023.9602/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
The "third space endoscopy" or also called "submucosal endoscopy" is a reality we can transfer to our patients since 2010. Various modifications of the submucosal tunneling technique allow access to the submucosa or deeper layers of the gastrointestinal tract. In addition to peroral endoscopic myotomy for the treatment of achalasia, also called esophageal POEM, other variants have emerged that make it possible to treat different esophageal motility disorders, esophageal diverticula, subepithelial tumors of various locations, gastroparesis, reconnection of complete esophageal strictures or even thanks to exceptional endoscopists, pediatric disorders such as Hirschsprung's disease. Although some technical aspects are yet to be standardized, these procedures are becoming widespread worldwide and will likely become the standard treatment of these pathologies soon.
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Affiliation(s)
- Eduardo Albéniz
- Endoscopy Unit. Gastroenterology, Hospital Universitario de Navarra (HUN). Navarrabiomed. UPNA, IdiSNA, España
| | | | | | | | - Sheyla Montori
- Gastrointestinal Endoscopy Research Unit, Hospital Universitario de Navarra (HUN). Navarrabiomed. UPNA, IdiSNA, Spain
| | - Enrique Rodríguez de Santiago
- Gastroenterology and Hepatology , Hospital Universitario Ramón y Cajal. Universidad de Alcalá. IRYCIS. CIBERehd. ISCIII, Spain
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33
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Nabi Z, Mandavdhare H, Akbar W, Talukdar R, Reddy DN. Long-term Outcome of Peroral Endoscopic Myotomy in Esophageal Motility Disorders: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2023; 57:227-238. [PMID: 36227028 DOI: 10.1097/mcg.0000000000001776] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIM Peroral endoscopic myotomy (POEM) is an established treatment for achalasia. In this systematic review and meta-analysis, we aimed to analyze the mid and long-term outcomes of POEM in esophageal motility disorders. METHODS Literature search was performed in databases including PubMed, Embase, Cochrane databases, and Google scholar from January 2010 to May 2021. The primary objective of the study was the clinical success (Eckardt score ≤3 or <4) at mid-term (30 to 60 mo) and long-term (>60 mo) follow-up after POEM. Secondary objectives included post-POEM gastroesophageal reflux (GER) as evaluated by symptoms, increased esophageal acid exposure, and reflux esophagitis. RESULTS Seventeen studies with 3591 patients were included in the review. Subtypes of motility disorders were type I (27%), type II (54.5%), type III (10.7%), distal esophageal spasm/Jackhammer esophagus (2%), and esophagogastric junction outflow obstruction (17.5%). Pooled mean follow-up duration was 48.9 months (95% CI, 40.02-57.75). Pooled rate of clinical success at mid-term follow-up was 87% (95% CI, 81-91; I2 , 86%) and long-term was 84% (95% CI, 76-89; I2 , 47%). In nonachalasia motility disorders (esophagogastric junction outflow obstruction, distal esophageal spasm, and Jackhammer esophagus), pooled rate of clinical success was 77% (95% CI, 65-85; I2 , 0%). GER as estimated by symptoms was 23% (95% CI, 19-27; I2 , 74%), erosive esophagitis was 27% (95% CI, 18-38%; I2 , 91%), and increased esophageal acid exposure was 41% (95% CI, 30-52; I2 , 88%). CONCLUSION POEM is a durable treatment option in cases with achalasia. One-fourth of patients suffer from erosive GER in the long-term and success rates are lower in nonachalasia esophageal motility disorders.
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Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India
| | | | - Wahid Akbar
- Asian Institute of Gastroenterology, Hyderabad, India
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Romanoff E, Zhuo J, Huang AC, Amador D, Otaki F, Kamal AN, Kathpalia P, Leiman DA. Achalasia Quality Indicator Adherence. Dig Dis Sci 2023; 68:389-395. [PMID: 36459295 DOI: 10.1007/s10620-022-07658-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 08/02/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Quality indicators (QIs) are formal ways to track health care performance and outcomes, guide quality improvement, and identify gaps in care delivery. We developed twelve quality indicators for achalasia management which cover the domains of patient education, diagnosis, and treatment of achalasia. AIM To determine adherence to established quality indicators for achalasia management. METHODS We performed a retrospective, multicenter evaluation of care patterns for adult patients greater than 18 years old with newly diagnosed achalasia from January 2018 to May 2020. A balanced random patient sample was obtained at four large academic medical centers. Independent electronic health record chart abstraction was performed using a standardized form to determine adherence to applicable QIs. Pooled and de-identified data were analyzed to identify gaps in care. RESULTS A total of 120 patients were included and the overall adherence to applicable quality indicators across all centers was 86%. The median follow-up for all patients from time of diagnosis to end of study was 511 days. Clinicians adhered to all applicable quality indicators in 49 patients (39%). The quality indicator domain with the poorest adherence was patient education (67%), with 50% of patients having had a documented discussion of the risks of gastroesophageal reflux disease following surgical or endoscopic myotomy. CONCLUSIONS Gaps in the quality of achalasia care delivery were identified, the largest of which relates to patient education about treatment risks. These findings highlight a potential area for future quality improvement studies and form the basis for developing fully specified quality measures.
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Affiliation(s)
- Emily Romanoff
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC, 27708, USA
| | - Justin Zhuo
- Department of Medicine, Stanford University, Stanford, CA, 94305, USA
| | - Annsa C Huang
- Division of Gastroenterology, UCSF, San Francisco, CA, 94143, USA
| | - Deron Amador
- Division of Gastroenterology, OHSU, Portland, OR, 97239, USA
| | - Fouad Otaki
- Division of Gastroenterology, OHSU, Portland, OR, 97239, USA
| | - Afrin N Kamal
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford, CA, 94305, USA
| | - Priya Kathpalia
- Division of Gastroenterology, UCSF, San Francisco, CA, 94143, USA
| | - David A Leiman
- Division of Gastroenterology, Duke University, Durham, NC, 27708, USA.
- Duke Clinical Research Institute, Durham, NC, 27708, USA.
- Division of Gastroenterology, Duke University School of Medicine, 200 Morris Street, Suite 6524, Durham, NC, 27701, USA.
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Zhang LY, Bejjani M, Ghandour B, Khashab MA. Through-the-scope suture closure of peroral endoscopic myotomy mucosal incision sites. Endoscopy 2023; 55:186-191. [PMID: 35926541 DOI: 10.1055/a-1890-4917] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND : Peroral endoscopic myotomy (POEM) is now widely used for esophageal motility disorders including achalasia. Closure of the mucosal incision site is a critical step of the procedure. We evaluated the use of a novel through-the-scope (TTS) suture system for closure of POEM mucosal incision sites. METHODS : We retrospectively reviewed consecutive patients who underwent POEM with TTS suture closure at our institution between February and July 2021. Technical success was defined as complete mucosal incision site closure using TTS suturing, without the need for adjunctive devices. Continuous variables are presented as median (interquartile range [IQR]) or mean (SD). RESULTS : 35 consecutive patients (median age 58 years [IQR 46.5-72]; 54.3 % female) underwent POEM with attempted mucosal closure by TTS suturing. Technical success was achieved in 32 patients (91.4 %) with a mean closure time of 12.4 (SD 6.9) minutes. The median mucosal incision length at time of closure was 2.5 cm (IQR 2-2.5). Overall, 17 patients (53.1 %) required ≥ 2 TTS suture systems and 3 patients (8.6 %) required additional TTS clips to achieve secure mucosal closure. No adverse events were encountered. CONCLUSIONS : TTS suturing was effective and safe for POEM mucosotomy closure. However, prospective comparative trials and cost-effectiveness analyses are warranted before routine adoption.
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Affiliation(s)
- Linda Yun Zhang
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore Maryland, United States
| | - Michael Bejjani
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore Maryland, United States
| | - Bachir Ghandour
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore Maryland, United States
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore Maryland, United States
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Leung LJ, Ma GK, Lee JK, Fukami N, Chang H, Svahn J, Xu MM, Lam S, Risbud A, Jue TL. Successful Design and Implementation of a POEM Program for Achalasia in an Integrated Healthcare System. Dig Dis Sci 2023; 68:2276-2284. [PMID: 36725765 PMCID: PMC9891752 DOI: 10.1007/s10620-023-07839-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 01/15/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND Per Oral Endoscopic Myotomy (POEM) is a minimally invasive treatment for achalasia with results comparable to laparoscopic Heller myotomy (LHM). Studies have described the development of proficiency for endoscopists learning to perform POEM, and societies have defined educational and technical objectives for advanced endoscopy fellows in training. However, there is limited guidance on the organizational strategy and educational plan necessary to develop an achalasia service with POEM expertise. AIMS We aim to outline the steps for design and implementation of a successful POEM program. METHODS We reported our experience developing a multi-disciplinary clinical program for POEM and the steps taken to achieve procedural proficiency. We also reported our technical success (successful tunneling into the gastric cardia and myotomy of LES muscle fibers) and clinical success (post-procedure Eckardt score ≤ 3) at 3-6 months and 12 months post-procedure. Adverse events were classified per the ASGE lexicon for endoscopic adverse events. RESULTS After creating a multi-disciplinary clinical program for achalasia and completing procedural proficiency for POEM, our technical success rate was 100% and clinical success rate 90% for the first 41 patients. One adverse event (2.4%) occurred, moderate in severity per the American Society of Gastrointestinal Endoscopy (ASGE) lexicon for adverse endoscopic events. CONCLUSION In this study, we outlined the steps involved to establish a POEM service in a large integrated healthcare system. Prior competency in interventional endoscopy, procedural training models, POEM observation and education, proctorship, and interdisciplinary patient care are recommended.
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Affiliation(s)
- Lawrence Jun Leung
- grid.414890.00000 0004 0461 9476Department of Internal Medicine, Kaiser Permanente San Francisco, San Francisco, CA USA
| | - Gene K. Ma
- grid.492756.b0000 0004 0444 0628Department of Gastroenterology, Kaiser Permanente San Jose, San Jose, CA USA
| | - Jeffrey K. Lee
- grid.414890.00000 0004 0461 9476Department of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, CA USA
| | - Norio Fukami
- grid.417468.80000 0000 8875 6339Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ USA
| | - Howard Chang
- grid.414886.70000 0004 0445 0201Department of Gastroenterology, Kaiser Permanente Oakland, Oakland, CA USA
| | - Jonathan Svahn
- grid.414886.70000 0004 0445 0201Department of Surgery, Kaiser Permanente Oakland, Oakland, CA USA
| | - Ming-Ming Xu
- grid.280062.e0000 0000 9957 7758Department of Gastroenterology, Kaiser Permanente West LA, Los Angeles, CA USA
| | - Steven Lam
- grid.414890.00000 0004 0461 9476Department of Internal Medicine, Kaiser Permanente San Francisco, San Francisco, CA USA
| | - Amita Risbud
- grid.414890.00000 0004 0461 9476Department of Internal Medicine, Kaiser Permanente San Francisco, San Francisco, CA USA
| | - Terry L. Jue
- grid.414890.00000 0004 0461 9476Department of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, CA USA ,grid.417468.80000 0000 8875 6339Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ USA
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Cai JX, Low EE, Yadlapati R. Narrowing the Quality Chasm in Achalasia. Dig Dis Sci 2023; 68:341-343. [PMID: 36242687 PMCID: PMC10766075 DOI: 10.1007/s10620-022-07662-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2022] [Indexed: 12/09/2022]
Affiliation(s)
- Jennifer X Cai
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| | - Eric E Low
- Division of Gastroenterology, University of California, San Diego, 9500 Gilman Drive, MC 0956, La Jolla, CA, 92093, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego, 9500 Gilman Drive, MC 0956, La Jolla, CA, 92093, USA
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Olivier R, Brochard C, des Varannes SB, Ropert A, Wallenhorst T, Reboux N, Quénéhervé L, Coron E. Peroral endoscopic myotomy: is it better to perform it in naive patients or as second-line therapy? Results of an open-label-controlled study in 105 patients. Surg Endosc 2023; 37:3760-3768. [PMID: 36670217 PMCID: PMC10156842 DOI: 10.1007/s00464-021-08767-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 10/09/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Whether Peroral Endoscopic Myotomy (POEM) can be proposed as a second-line treatment in patients with achalasia remains to be confirmed in real-life series. OBJECTIVE This study aimed to compare the efficacy, feasibility and safety of POEM between treatment-naïve patients and patients who had prior endoscopic or surgical therapies for achalasia. METHODS All consecutive patients who underwent a POEM procedure for achalasia in our centre from June 2015 to September 2018 were included in this retrospective study. They were classified into treatment-naïve patients (POEM1) and patients who had at least one previous endoscopic and/or surgical treatment for achalasia (POEM2). RESULTS A total of 105 patients were included, 52 in the POEM1 group and 53 in the POEM2 group. Clinical success (defined as an Eckardt score ≤ 3) at 6 months was observed in 93% of POEM1 patients and 84% of POEM2 patients (p = 0.18). Technical success rate was not significantly different between the two groups (100% vs 96%, respectively; p = 0.50). No significant difference was noted in terms of adverse event rate (19% vs 19%, respectively; p = 1.00). Post-procedure pain occurred in 12% of treatment-naive and 9% of non-naïve patients (p = 0.76). The median length of hospital stay was 3 days in both groups (p = 0.17). Symptomatic gastroesophageal reflux occurred in 25% of POEM1 patients and 16% of POEM2 patients (p = 0.24). CONCLUSION Efficacy, feasibility and safety of POEM are not different between treatment-naïve and non-naïve patients. POEM is a valuable second-line approach in patients with persistent symptoms of achalasia after surgical or endoscopic treatments.
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Affiliation(s)
- Raphael Olivier
- Service de Gastroentérologie, CHU de Poitiers, Poitiers, France
- Institut des Maladies de l'Appareil Digestif, IMAD, CHU Nantes, Hôpital Hôtel-Dieu, 1 place Ricordeau, 44093, Nantes cedex, France
| | - Charlène Brochard
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennes 1, Rennes, France
- Service d'Explorations Fonctionnelles Digestives, CHU Pontchaillou, Université de Rennes 1, Rennes, France
- CIC 1414, INPHY, Université de Rennes 1, Rennes, France
| | - Stanislas Bruley des Varannes
- Institut des Maladies de l'Appareil Digestif, IMAD, CHU Nantes, Hôpital Hôtel-Dieu, 1 place Ricordeau, 44093, Nantes cedex, France
| | - Alain Ropert
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennes 1, Rennes, France
- Service d'Explorations Fonctionnelles Digestives, CHU Pontchaillou, Université de Rennes 1, Rennes, France
| | - Timothée Wallenhorst
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennes 1, Rennes, France
| | - Noémi Reboux
- Service de Gastroentérologie, CHRU de Brest, Brest, France
| | - Lucille Quénéhervé
- Institut des Maladies de l'Appareil Digestif, IMAD, CHU Nantes, Hôpital Hôtel-Dieu, 1 place Ricordeau, 44093, Nantes cedex, France
- Service de Gastroentérologie, CHRU de Brest, Brest, France
| | - Emmanuel Coron
- Institut des Maladies de l'Appareil Digestif, IMAD, CHU Nantes, Hôpital Hôtel-Dieu, 1 place Ricordeau, 44093, Nantes cedex, France.
- Department of Gastroenterology and Hepatology, University Hospital of Geneva (HUG), rue Gabrielle Perret- Gentil 4, Genève, 1205-1211, Switzerland.
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Hayat M, Yang D, Draganov PV. Third-space endoscopy: the final frontier. Gastroenterol Rep (Oxf) 2023; 11:goac077. [PMID: 36632624 PMCID: PMC9831051 DOI: 10.1093/gastro/goac077] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 01/11/2023] Open
Abstract
Over the years, our growing experience with endoscopic submucosal dissection along with technological advances has solidified our comfort and knowledge on working in the submucosa, also referred to as the "third space." Per-oral endoscopic myotomy (POEM) was the first prototype third-space endoscopy (TSE) procedure, demonstrating the feasibility and clinical utility of endoscopic esophagogastric myotomy via submucosal tunneling. The launch of POEM accelerated the evolution of TSE from a vanguard concept to an expanding field with a wide range of clinical applications. In this review, we discuss the status and future directions of multiple TSE interventions.
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Affiliation(s)
- Maham Hayat
- Center for Interventional Endoscopy, AdventHealth, Orlando, FL, USA
| | - Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Orlando, FL, USA
| | - Peter V Draganov
- Corresponding author. Division of Gastroenterology, Hepatology and Nutrition, University of Florida, 1329 SW 16th Street, Room #5254, Gainesville, FL 32608, USA. Tel: +1-352-273-9474; Fax: +1-352-627-9002;
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Rolland S, Paterson W, Bechara R. Achalasia: Current therapeutic options. Neurogastroenterol Motil 2023; 35:e14459. [PMID: 36153803 DOI: 10.1111/nmo.14459] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 07/13/2022] [Accepted: 08/01/2022] [Indexed: 12/31/2022]
Abstract
Achalasia is an esophageal motor disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and absent peristalsis in the smooth muscle esophageal body. As a result, patients typically experience dysphagia, regurgitation, chest pain, and weight loss. Over the past 10-15 years, there has been a resurgence of interest in the evaluation of therapies for achalasia. Unfortunately, little progress in the development of effective pharmacological treatments has been made. Botulinum toxin injection provides some relief of symptoms in many patients but requires periodic reinjection that may provide progressively less benefit over time. There are now three well-established, safe, and effective therapies for the treatment of achalasia: pneumatic dilation (PD), laparoscopic Heller myotomy (LHM), and peroral endoscopic myotomy (POEM) which can lead to marked symptom improvement in most patients. Each treatment has a specific constellation of risks, benefits, and recurrence rate. The first-line treatment used will depend on patient preference, achalasia subtype, and local expertise. The recent impressive advances in both the art and science of achalasia therapy are explored with a comprehensive review of the various treatment modalities and comparative controlled clinical trials. In addition, key technical pearls of the procedural treatments are demonstrated.
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Affiliation(s)
- Sebastien Rolland
- Division of Gastroenterology, Hôpital Maisonneuve-Rosemont and Université de Montreal, Montreal, Quebec, Canada
| | - William Paterson
- Division of Gastroenterology and GI Diseases Research Unit, Queen's University, Kingston, Ontario, Canada
| | - Robert Bechara
- Division of Gastroenterology and GI Diseases Research Unit, Queen's University, Kingston, Ontario, Canada
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Nabi Z, Reddy DN. Submucosal endoscopy: the present and future. Clin Endosc 2023; 56:23-37. [PMID: 36617645 PMCID: PMC9902679 DOI: 10.5946/ce.2022.139] [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: 04/26/2022] [Accepted: 07/22/2022] [Indexed: 01/10/2023] Open
Abstract
Submucosal endoscopy or third-space endoscopy utilizes the potential space between the mucosal and muscularis layers of the gastrointestinal tract to execute therapeutic interventions for various diseases. Over the last decade, endoscopic access to the submucosal space has revolutionized the field of therapeutic endoscopy. Submucosal endoscopy was originally used to perform endoscopic myotomy in patients with achalasia cardia, and its use has grown exponentially since. Currently, submucosal endoscopy is widely used to resect subepithelial tumors and to manage refractory gastroparesis and Zenker's diverticulum. While the utility of submucosal endoscopy has stood the test of time in esophageal motility disorders and subepithelial tumors, its durability remains to be established in conditions such as Zenker's diverticulum and refractory gastroparesis. Other emerging indications for submucosal endoscopy include esophageal epiphrenic diverticulum, Hirschsprung's disease, and esophageal strictures not amenable to conventional endoscopic treatment. The potential of submucosal endoscopy to provide easy and safe access to the mediastinum and peritoneal spaces may open doors to novel indications and rejuvenate the interest of endoscopists in natural orifice transluminal endoscopic surgery in the future. This review focuses on the current spectrum, recent updates, and future direction of submucosal endoscopy in the gastrointestinal tract.
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Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India
| | - Duvvur Nageshwar Reddy
- Asian Institute of Gastroenterology, Hyderabad, India,Correspondence: Duvvur Nageshwar Reddy Asian Institute of Gastroenterology, 6-3-661 Somajiguda, Hyderabad 500 082, India E-mail:
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Forero-Vásquez BN, Yopasa-Romero JJ. Diagnóstico y manejo actual de la acalasia. REVISTA COLOMBIANA DE CIRUGÍA 2022. [DOI: 10.30944/20117582.2187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Introducción. La acalasia es un trastorno motor del esófago poco común, de etiología no clara, caracterizado por la pérdida de relajación del esfínter esofágico inferior, pérdida del peristaltismo normal, regurgitación y disfagia.
Métodos. Se realizó una revisión narrativa de la literatura en revistas científicas y bases de datos en español e inglés, con el fin de presentar información actualizada en lo referente al diagnóstico y tratamiento de esta patología.
Resultado. Se presenta la actualización de los criterios de los trastornos motores esofágicos según la clasificación de Chicago (CCv4.0) para el diagnóstico de acalasia y sus subtipos de acuerdo con los nuevos criterios, así como los tratamientos actuales.
Conclusión. La acalasia es un trastorno esofágico multimodal, con manifestaciones de predominio gastrointestinal, por lo que su diagnóstico y abordaje terapéutico oportuno es esencial para mejorar la calidad de vida de los pacientes.
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Hastier-De Chelle A, Onana-Ndong P, Olivier R, Bentellis I, Pioche M, Rivory J, Gonzalez JM, Bailly L, Piche T, Ponchon T, Brochard C, Coron E, Barthet M, Vanbiervliet G. Impact of antibiotic prophylaxis and conditioning modalities in per-oral endoscopic myotomy for esophageal motor disorders. Scand J Gastroenterol 2022; 57:1522-1530. [PMID: 35850618 DOI: 10.1080/00365521.2022.2097892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS No recommendation regarding antibiotic prophylaxis and preparation modalities are available for patients with esophageal motor disorders who benefit from Per-Oral Endoscopic Myotomy (POEM). The aim of our study was to evaluate their impact on the POEM's safety. PATIENTS AND METHODS This study was a comparative and multicentric retrospective analysis of a database prospectively collected. Patients over 18 years old with esophageal motor disorders confirmed by prior manometry, who underwent POEM were included. The primary endpoint was the occurrence of adverse events, as classified by Cotton, based on whether or not antibiotic prophylaxis was administered. RESULTS A total of 226 patients (median age 52.9 ± 19.12 years [18-105], 116 women [51.3%]) were included. The indication for POEM was mainly type 2 achalasia (n = 135, 60.3%). Antibiotic prophylaxis was administered to 170 patients (75.2%) during 3.93 ± 3.46 days [1-21]. The overall adverse events rate was 9.3% (n = 21). Antibiotic prophylaxis was associated with the occurrence of adverse events (p = .003), but had no impact on their severity (p = .238). Antibiotic prophylaxis didn't influence the effectiveness of POEM (1 [0-4] vs 1 [0-9], p = .231). The use of a liquid diet in the 48 h prior to the procedure was significantly associated with a lower adverse events rate (3.1% vs 6.19%, p = .0002). CONCLUSION The antibiotic prophylaxis during POEM does not prevent adverse events, had no impact on their severity and the efficacy of the procedure. A liquid diet before the procedure should be systematically proposed.
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Affiliation(s)
| | - Philippe Onana-Ndong
- Gastro-entérologie, Hôpital L'Archet 2, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Raphaël Olivier
- Institut des maladies de l'appareil digestif, Hôpital Hôtel-Dieu, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Imad Bentellis
- Gastro-entérologie, Hôpital L'Archet 2, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Mathieu Pioche
- Gastro-entérologie, Hôpital Édouard Herriot, Hospices civils de Lyon, Lyon, France
| | - Jérôme Rivory
- Gastro-entérologie, Hôpital Édouard Herriot, Hospices civils de Lyon, Lyon, France
| | - Jean Michel Gonzalez
- Gastro-entérologie, Hôpital Nord, Assistance Publique des hôpitaux de Marseille, Marseille, France
| | - Laurent Bailly
- Direction de L'Information Médicale, Hôpital L'Archet 2, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Thierry Piche
- Gastro-entérologie, Hôpital L'Archet 2, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Thierry Ponchon
- Gastro-entérologie, Hôpital Édouard Herriot, Hospices civils de Lyon, Lyon, France
| | - Charlène Brochard
- Gastro-entérologie, Hôpital Pontchaillou, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Emmanuel Coron
- Institut des maladies de l'appareil digestif, Hôpital Hôtel-Dieu, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Marc Barthet
- Gastro-entérologie, Hôpital Nord, Assistance Publique des hôpitaux de Marseille, Marseille, France
| | - Geoffroy Vanbiervliet
- Gastro-entérologie, Hôpital L'Archet 2, Centre Hospitalier Universitaire de Nice, Nice, France
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Storm AC, AbiMansour JP, Bofill-Garcia A, Mahmoud T, Rapaka B, Lescalleet KE, Dayyeh BKA. Use of an intragastric trocar to perform a novel stapling procedure for reflux disease. Endosc Int Open 2022; 10:E1508-E1513. [PMID: 36397862 PMCID: PMC9666069 DOI: 10.1055/a-1933-6573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/25/2022] [Indexed: 10/14/2022] Open
Abstract
Background and study aims A percutaneous intragastric trocar (PIT) enables intraluminal use of laparoscopic tools and helps overcome traditional limitations of endoscopy. The aim of this study was to determine the efficacy of using a PIT to perform an anti-reflux stapling procedure. Materials and methods Trocars were placed in four animals and an articulating stapler was used to perform fundoplication under endoscopic guidance. Animals were monitored for 14 days post-procedure. Functional lumen imaging of the esophagogastric junction (EGJ) was performed at baseline, immediately post-intervention, and at 14 days. Results The procedure was successful in all animals who survived to day 14 without distress or significant adverse events. Baseline EGJ distensibility was 5.0 ± 1.2 mm 2 /mmHg, 2.7 ± 0.7 mm 2 /mmHg post-procedurally, and 3.0 ± 0.8mm 2 /mmHg on day 14. Average change in distensibility pre- and post-procedure was -2.3 ± 1.8 mm 2 /mmHg (95 % confidence interval [CI] -0.5 to 5.1, P = 0.08) while change in pre- and day 14 distensibility was -2.0 ± 1.4 mm 2 /mmHg (95 % CI -0.1 to 4.2, P = 0.06). Conclusions An intragastric trocar allows for use of large-diameter laparoscopic instruments to safely and effectively perform endoluminal fundoplication with anti-reflux properties that persist for at least 14 days.
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Affiliation(s)
- Andrew C. Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States,Developmental Endoscopy Unit, Mayo Clinic, Rochester, Minnesota, United States
| | - Jad P. AbiMansour
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Aliana Bofill-Garcia
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Tala Mahmoud
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Babusai Rapaka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Kristin E. Lescalleet
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Barham K. Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
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DeSantis AJ, Janjua HM, Moiño D, Davis G, Sands V, Weche M, Kuo PC, Sujka J, DuCoin C. Association of individual surgeon volume and postoperative outcome in esophagomyotomy for achalasia. Surg Endosc 2022; 36:8498-8502. [PMID: 35257214 DOI: 10.1007/s00464-022-09169-y] [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: 09/20/2021] [Accepted: 02/21/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Many surgical disciplines have demonstrated superior outcomes when procedures are performed at "high-volume". Esophagomyotomy is commonly performed for achalasia, however it's unclear what constitutes "high-volume" for this procedure, and if individual procedure volume and outcome are related. We identified physicians performing esophagomyotomy, stratified them by individual case volume, and examined their outcomes with the hypothesis that high-volume surgeons will be associated with improved outcomes as compared to low-volume surgeons. METHODS The 2015-2019 Florida Agency for Health Care Administration (AHCA) inpatient dataset was queried for esophagomyotomy. Surgeons who performed ≥ 10 procedures during the study period were placed into the high-volume cohort, and those performing < 10 into the low-volume cohort. Groups were compared by length of stay, discharge disposition, and postoperative complications. Patient demographics were evaluated using student's t test and chi square test, p < 0.05 considered significant. RESULTS Six hundred and sixty-two procedures performed by 135 surgeons were identified. The mean number of esophagomyotomies per surgeon was 4.9 (Range 1-147). The high-volume group (n = 12) performed 362 of the 662 procedures (55%), while the low-volume group (n = 123) performed the remaining 300 (45%). Patients of high-volume physicians had decreased length of stay (1.4 ± 0.8 days vs 4.9 ± 6.7 days, p = 0.01) and were more likely to be discharged to home following surgery (92.8% vs 86.0, p = 0.04). High volume physicians also had statistically significant differences in rates of urinary tract infection (1.4% vs 4.0%, p = 0.034), postoperative malnutrition (5.8% vs 11.0%, p = 0.015), and postoperative fluid and electrolyte disorders (5.5% vs 13.3%, p < 0.0001). CONCLUSION Surgeons who perform higher volumes of esophagomyotomies are associated with decreased length of stay, higher likelihood of patient discharge to home, and decreased rates of some postoperative complications. This research should prompt further inquiry into defining what constitutes a high-volume center in foregut surgery and their role in improving patient outcomes.
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Affiliation(s)
- Anthony J DeSantis
- Department of Surgery, University of South Florida, Harborside Medical Tower, 5 Tampa General Circle, Suite 410, Tampa, FL, 33606, USA.
| | - Haroon M Janjua
- OnetoMap Analytics, University of South Florida, Tampa, FL, USA
| | - Daniela Moiño
- Department of Surgery, University of South Florida, Harborside Medical Tower, 5 Tampa General Circle, Suite 410, Tampa, FL, 33606, USA
| | - Graham Davis
- Department of Surgery, University of South Florida, Harborside Medical Tower, 5 Tampa General Circle, Suite 410, Tampa, FL, 33606, USA
| | - Victoria Sands
- Department of Surgery, University of South Florida, Harborside Medical Tower, 5 Tampa General Circle, Suite 410, Tampa, FL, 33606, USA
| | - McWayne Weche
- Department of Surgery, University of South Florida, Harborside Medical Tower, 5 Tampa General Circle, Suite 410, Tampa, FL, 33606, USA
| | - Paul C Kuo
- OnetoMap Analytics, University of South Florida, Tampa, FL, USA
| | - Joseph Sujka
- Department of Surgery, University of South Florida, Harborside Medical Tower, 5 Tampa General Circle, Suite 410, Tampa, FL, 33606, USA
| | - Christopher DuCoin
- Department of Surgery, University of South Florida, Harborside Medical Tower, 5 Tampa General Circle, Suite 410, Tampa, FL, 33606, USA
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46
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Minakari M, Sedaghat N. Endoscopic clipping of a complicated esophageal perforation following pneumatic dilation for achalasia: A case study and literature review. Clin Case Rep 2022; 10:e6620. [PMID: 36447673 PMCID: PMC9701890 DOI: 10.1002/ccr3.6620] [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: 04/22/2022] [Revised: 10/18/2022] [Accepted: 11/04/2022] [Indexed: 11/29/2022] Open
Abstract
A transmural esophageal tear complicated by large size and unusual location was diagnosed in a 59-year-old man after undergoing pneumatic balloon dilation for achalasia. It was closed with six endo-clips. The patient recovered and was discharged with ordinary diet 8 days later, after receiving supportive care for a week.
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Affiliation(s)
- Mohammad Minakari
- Division of Gastroenterology, Department of Internal Medicine, School of MedicineIsfahan University of Medical SciencesIsfahanIran
| | - Nahad Sedaghat
- School of MedicineIsfahan University of Medical SciencesIsfahanIran
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Shally L, Saeed K, Berglund D, Dudash M, Frank K, Obradovic VN, Petrick AT, Diehl DL, Gabrielsen JD, Parker DM. Clinical and financial outcomes of per-oral endoscopic myotomy compared to laparoscopic heller myotomy for treatment of achalasia. Surg Endosc 2022:10.1007/s00464-022-09652-6. [PMID: 36220985 DOI: 10.1007/s00464-022-09652-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 09/13/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Previous studies analyzing short-term outcomes for per-oral endoscopic myotomy (POEM) have shown excellent clinical response rates and shorter operative times compared to laparoscopic Heller myotomy (LHM). Despite this, many payors have been slow to recognize POEM as a valid treatment option. Furthermore, comparative studies analyzing long-term outcomes are limited. This study compares perioperative and long-term outcomes, cost-effectiveness, and reimbursement for POEM and LHM at a single institution. METHODS Adult patients who underwent POEM or LHM between 2014 and 2021 and had complete preoperative data with at least one complete follow up, were retrospectively analyzed. Demographic data, success rate, operative time, myotomy length, length of stay, pre- and postoperative symptom scores, anti-reflux medication use, cost and reimbursement were compared. RESULTS 58 patients met inclusion with 25 undergoing LHM and 33 undergoing POEM. There were no significant differences in preoperative characteristics. Treatment success (Eckardt ≤ 3) for POEM and LHM was achieved by 88% and 76% of patients, respectively (p = 0.302). POEM patients had a shorter median operative time (106 min. vs. 145 min., p = 0.003) and longer median myotomy length (11 cm vs. 8 cm, p < 0.001). All LHM patients had a length of stay (LOS) ≥ 1 day vs. 51.5% for POEM patients (p < 0.001). Both groups showed improvements in dysphagia, heartburn, regurgitation, Eckardt score, GERD HRQL, RSI, and anti-reflux medication use. The improvement in dysphagia score was greater in patients undergoing POEM (2.30 vs 1.12, p = 0.003). Median hospital reimbursement was dramatically less for POEM ($3,658 vs. $14,152, p = 0.002), despite median hospital costs being significantly lower compared to LHM ($2,420 vs. $3,132, p = 0.029). RESULTS POEM is associated with a shorter operative time and LOS, longer myotomy length, and greater resolution of dysphagia compared to LHM. POEM costs are significantly less than LHM but is poorly reimbursed.
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Affiliation(s)
- Lena Shally
- Geisinger Commonwealth School of Medicine, 525 Pine St, Scranton, PA, 18510, USA.
| | - Kashif Saeed
- Department of Bariatric and Foregut Surgery, Geisinger Medical Center, 100 N Academy Ave, Danville, PA, 17822, USA
| | - Derek Berglund
- Department of Bariatric and Foregut Surgery, Geisinger Medical Center, 100 N Academy Ave, Danville, PA, 17822, USA
| | - Mark Dudash
- Department of Bariatric and Foregut Surgery, Geisinger Medical Center, 100 N Academy Ave, Danville, PA, 17822, USA
| | - Katie Frank
- Department of Population Health and Sciences, Geisinger Medical Center, 100 N Academy Ave, Danville, PA, 17822, USA
| | - Vladan N Obradovic
- Department of Bariatric and Foregut Surgery, Geisinger Medical Center, 100 N Academy Ave, Danville, PA, 17822, USA
| | - Anthony T Petrick
- Department of Bariatric and Foregut Surgery, Geisinger Medical Center, 100 N Academy Ave, Danville, PA, 17822, USA
| | - David L Diehl
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, 100 N Academy Ave, Danville, PA, 17822, USA
| | - Jon D Gabrielsen
- Department of Bariatric and Foregut Surgery, Geisinger Medical Center, 100 N Academy Ave, Danville, PA, 17822, USA
| | - David M Parker
- Department of Bariatric and Foregut Surgery, Geisinger Medical Center, 100 N Academy Ave, Danville, PA, 17822, USA
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Xia H, Peng Y, Tang X. Is it necessary for endoscopic surveillance for achalasia patients? J Gastroenterol 2022; 57:812. [PMID: 36001160 DOI: 10.1007/s00535-022-01916-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 08/16/2022] [Indexed: 02/05/2023]
Affiliation(s)
- Huifang Xia
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China
| | - Yan Peng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China
| | - Xiaowei Tang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China.
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49
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Adverse events associated with EGD and EGD-related techniques. Gastrointest Endosc 2022; 96:389-401.e1. [PMID: 35843754 DOI: 10.1016/j.gie.2022.04.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 04/21/2022] [Indexed: 01/10/2023]
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50
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Nabi Z, Nageshwar Reddy D. Impact of modified techniques on outcomes of peroral endoscopic myotomy: A narrative review. Front Med (Lausanne) 2022; 9:948299. [PMID: 36059849 PMCID: PMC9433832 DOI: 10.3389/fmed.2022.948299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/08/2022] [Indexed: 12/02/2022] Open
Abstract
Peroral endoscopic myotomy (POEM) is an established frontline treatment modality for achalasia cardia. Since its initial description, several modifications have been proposed to the technique of POEM. Broadly speaking, these modifications follow the basic principles of submucosal endoscopy, but incorporate variations in the POEM technique, including the difference in the orientation of myotomy (anterior or posterior), length of myotomy (short or long), and thickness of myotomy (selective circular or full thickness). Some of these modifications have been shown to reduce procedural duration without compromising the efficacy of the POEM procedure. More recently, several alterations have been reported that intend to reduce gastroesophageal reflux after POEM. These include preservation of sling fibers during posterior POEM and addition of NOTES fundoplication to the POEM procedure. Although some of the modified techniques have been compared with the conventional techniques in quality trials, randomized studies are awaited for others. The incorporation of some of these modifications will likely make POEM a technically easy and safer modality in near future. This review aims to discuss the current evidence with regard to the impact of modified techniques on the outcome of POEM.
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