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Ramchandani M, Nabi Z, Inavolu P, Reddy DN. Recent Advancement and Future Perspective of Per Oral Endoscopic Myotomy. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00451-8. [PMID: 38759824 DOI: 10.1016/j.cgh.2024.02.032] [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: 09/22/2023] [Revised: 02/28/2024] [Accepted: 02/28/2024] [Indexed: 05/19/2024]
Abstract
Per oral endoscopic myotomy (POEM) has emerged as a preferred approach for the treatment of idiopathic achalasia and various esophageal motility disorders, offering a minimally invasive alternative to traditional laparoscopic Heller's myotomy. Over the past decade, POEM has solidified its status as the primary therapeutic choice in these conditions through constant improvements. Its evolution has been marked by continuous progress, driven by the integration of innovative technologies and sophisticated techniques. Notable advancements in the techniques include the advent of shorter myotomies and sling fiber-preserving gastric myotomies. The introduction of novel image-enhanced endoscopic techniques, such as red dichromatic imaging and much safer bipolar devices, promises to enhance safety and reduce the technical demands of the POEM procedure. Furthermore, significant strides have been made in understanding gastroesophageal reflux (GERD) following POEM, enabling the differentiation of "true reflux" from acidification resulting from fermentation through manual pH tracing assessment. This distinction aids in identifying cases necessitating treatment with proton pump inhibitors. Other treatment strategies of post-POEM GERD have expanded to the incorporation of NOTES fundoplication and device-assisted fundoplication if the necessity arises. This comprehensive review delves into recent developments in POEM, encompassing technical variations, the assessment and management of post-POEM reflux, outcomes in special populations, and future prospects. By exploring these facets, we aim to provide a comprehensive overview of the current state of POEM, shedding light on its evolution and the promising directions it is poised to take in the field of third-space endoscopy.
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Affiliation(s)
- Mohan Ramchandani
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India.
| | - Zaheer Nabi
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Pradev Inavolu
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - D Nageshwar Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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Zhang H, Pu X, Huang S, Xia H, Zou K, Zeng X, Jiang J, Ren W, Peng Y, Lü M, Tang X. Comparing clinical outcomes of peroral endoscopic myotomy for achalasia between Eastern and Western countries: a systematic review and meta-analysis. Dis Esophagus 2024; 37:doad056. [PMID: 38300629 DOI: 10.1093/dote/doad056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 07/13/2023] [Indexed: 02/02/2024]
Abstract
Peroral endoscopic myotomy (POEM) has revolutionized the therapeutic strategy for achalasia with promising results. We conducted this meta-analysis to compare clinical outcomes between Eastern and Western countries. A comprehensive literature search was conducted in PubMed, EMBASE, Web of Science and Cochrane Library databases to query for studies that assessed the efficacy of POEM for achalasia. All articles published from inception to December 31, 2021 were included. The primary outcome was the pooled clinical success rate. The secondary outcomes included the pooled technical success rate, incidence of adverse events, procedure time and hospital stay. Eighteen Eastern studies involving 5962 patients and 11 Western studies involving 1651 patients were included. The pooled clinical success rate and technical success rate for POEM was equal in the Eastern studies compared to Western studies. The pooled incidence of procedure adverse events for POEM was a little lower in the Eastern studies compared to Western studies (6.6% vs. 8.7%). Similarly, the incidence of reflux-related adverse events was lower in Eastern studies than that in Western studies. The pooled procedure time of POEM was shorter in Eastern studies compared to Western studies (61 minutes vs. 80 minutes), while the length of hospital stay was longer in Eastern studies compared to Western studies (5.8 days vs. 2.4 days). Overall, Eastern countries have the similar POEM outcomes compared to Western countries. However, Eastern countries still need to do more to reduce the length of hospital stay.
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Affiliation(s)
- Han Zhang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Xinxin Pu
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Shu Huang
- Department of Gastroenterology, Lianshui County People' Hospital, Huaian, China
- Department of Gastroenterology, Lianshui People's Hospital of Kangda College Affiliated to Nanjing Medical University, Huaian, China
| | - Huifang Xia
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Kang Zou
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Xinyi Zeng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Jiao Jiang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Wensen Ren
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Yan Peng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Muhan Lü
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Xiaowei Tang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
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Kandler J, Essing T, Schöler D, Flügen G, Knoefel WT, Roderburg C, Luedde T, Loosen SH. Surgical and per-oral endoscopic myotomy (POEM) for the treatment of primary esophageal motility disorders: A systematic analysis of current trends in Germany between 2011 and 2019. PLoS One 2024; 19:e0297265. [PMID: 38261581 PMCID: PMC10805300 DOI: 10.1371/journal.pone.0297265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 01/02/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND/AIMS While surgery remains a standard treatment for primary esophageal motility disorders (PEMDs), per-oral endoscopic myotomy (POEM) has recently evolved as an alternative. Systematic data on current trends of invasive procedures for PEMDs in Germany are missing. METHODS Hospital discharge data were used to evaluate trends and mortality of invasive treatment options for PEMDs in Germany between 2011 and 2019. RESULTS 4543 cases of PEMDs (achalasia: n = 4349, dyskinesia of the esophagus: n = 194) receiving open surgery (n = 200), minimal invasive surgery (n = 2366), or POEM (n = 1977) were identified. The relative proportion of POEM significantly increased from 10.9% (2011) to 65.7% (2019). Hospital mortality was 0.2%. The median duration of mechanical ventilation was significantly lower in POEM patients (29.4 hours) compared to open (274.0 hours) or minimal invasive (91.9 hours) surgery. The duration of hospitalization was lowest among POEM patients (5.7 days) compared to surgical procedures (13.7 and 7.7 days). CONCLUSION While the low in-hospital mortality of all procedures combined confirms the solid safety profile of invasive procedures in general, our findings show that POEM has the lowest duration of mechanical ventilation and hospitalization compared to invasive surgical options.
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Affiliation(s)
- Jennis Kandler
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf, Germany
| | - Tobias Essing
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf, Germany
- Department of Internal Medicine II, Marien Hospital, Wesel, Germany
| | - David Schöler
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf, Germany
| | - Georg Flügen
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of General, Visceral and Pediatric Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Wolfram T. Knoefel
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of General, Visceral and Pediatric Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Christoph Roderburg
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf, Germany
| | - Tom Luedde
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf, Germany
| | - Sven H. Loosen
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf, Germany
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Dilsaver DB, Walters RW, Nandipati KC. Laparoscopic Heller Myotomy vs. Peroral Endoscopic Myotomy: an Analysis of the National Inpatient Sample Database. J Gastrointest Surg 2023; 27:2608-2610. [PMID: 37580486 DOI: 10.1007/s11605-023-05801-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/29/2023] [Indexed: 08/16/2023]
Affiliation(s)
- Danielle B Dilsaver
- Department of Clinical Research and Public Health, School of Medicine, Creighton University, Omaha, NE, USA
| | - Ryan W Walters
- Department of Clinical Research and Public Health, School of Medicine, Creighton University, Omaha, NE, USA
| | - Kalyana C Nandipati
- Department of Surgery, School of Medicine, Creighton University, 7710 Mercy Road, Suite 501, Creighton University Education Bldg, Omaha, NE, 68124, USA.
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Dahiya DS, Nivedita F, Perisetti A, Goyal H, Inamdar S, Gangwani MK, Aziz M, Ali H, Cheng CI, Sanaka MR, Al-Haddad M, Sharma NR. Clinical Outcomes and Complications for Achalasia Patients Admitted After Per-Oral Endoscopic Myotomy. Gastroenterology Res 2023; 16:141-148. [PMID: 37351078 PMCID: PMC10284641 DOI: 10.14740/gr1617] [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: 03/25/2023] [Accepted: 05/13/2023] [Indexed: 06/24/2023] Open
Abstract
Background Per-oral endoscopic myotomy (POEM) is a rapidly emerging minimally invasive procedure for management of achalasia. Same-day discharge after POEM is safe and feasible; however, some patients may need hospitalization. We aimed to identify characteristics and outcomes for achalasia patients requiring hospitalizations after POEM in the United States (US). Methods The US National Inpatient Sample was utilized to identify all adult achalasia patients who were admitted after POEM from 2016 to 2019. Hospitalization characteristics and clinical outcomes were highlighted. Results From 2016 to 2019, we found that 1,885 achalasia patients were admitted after POEM. There was an increase in the total number of hospitalizations after POEM from 380 in 2016 to 490 in 2019. The mean age increased from 54.2 years in 2016 to 59.3 years in 2019. Most POEM-related hospitalizations were for the 65 - 79 age group (31.8%), females (50.4%), and Whites (68.4%). A majority (56.2%) of the study population had a Charlson Comorbidity Index of 0. The Northeast hospital region had the highest number of POEM-related hospitalizations. Most of these patients (88.3%) were eventually discharged home. There was no inpatient mortality. The mean length of stay decreased from 4 days in 2016 to 3.2 days in 2019, while the mean total healthcare charge increased from $52,057 in 2016 to $65,109 in 2019. Esophageal perforation was the most common complication seen in 1.3% of patients. Conclusion The number of achalasia patients needing hospitalization after POEM increased. There was no inpatient mortality conferring an excellent safety profile of this procedure.
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Affiliation(s)
- Dushyant Singh Dahiya
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Fnu Nivedita
- Section of Endoluminal Surgery and Interventional Gastroenterology, McGovern Medical School and UT Health Sciences Center at UT Health Houston, Houston, TX, USA
| | - Abhilash Perisetti
- Division of Gastroenterology and Hepatology, Kansas Veterans Affairs Medical Centre, Kansas City, MO, USA
| | - Hemant Goyal
- Section of Endoluminal Surgery and Interventional Gastroenterology, McGovern Medical School and UT Health Sciences Center at UT Health Houston, Houston, TX, USA
| | - Sumant Inamdar
- Department of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Manesh Kumar Gangwani
- Department of Internal Medicine, The University of Toledo Medical Center, Toledo, OH, USA
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, The University of Toledo Medical Center, Toledo, OH, USA
| | - Hassam Ali
- Department of Internal Medicine, East Carolina University, Greenville, NC, USA
| | - Chin-I Cheng
- Department of Statistics, Actuarial and Data Science, Central Michigan University, Mt Pleasant, MI, USA
| | - Madhusudhan R. Sanaka
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mohammad Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Neil R. Sharma
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
- Interventional Oncology & Surgical Endoscopy Programs (IOSE), Parkview Health, Fort Wayne, IN, USA
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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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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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Simkova D, Mares J, Vackova Z, Hucl T, Stirand P, Kieslichova E, Ryska O, Spicak J, Drazilova S, Veseliny E, Martinek J. Periprocedural safety profile of peroral endoscopic myotomy (POEM)-a retrospective analysis of adverse events according to two different classifications. Surg Endosc 2023; 37:1242-1251. [PMID: 36171448 DOI: 10.1007/s00464-022-09621-z] [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: 12/06/2021] [Accepted: 09/11/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is nowadays a standard method for treatment of achalasia; nevertheless, it remains an invasive intervention with corresponding risk of adverse events (AEs). The classification and grading of AEs are still a matter of discussion. The aim of our retrospective study was to assess the occurrence of all "undesirable" events and "true" adverse events in patients undergoing POEM and to compare the outcomes when either Clavien-Dindo classification (CDC) or American Society of Gastrointestinal Endoscopy (ASGE) lexicon classification applied. METHODS This was a retrospective analysis of prospectively managed database of all patients who had undergone POEM between December 2012 and August 2018. We assessed the pre-, peri-, and early-postoperative (up to patient's discharge) undesirable events (including those not fulfilling criteria for AEs) and "true" AEs according the definition in either of the classifications. RESULTS A total of 231 patients have successfully undergone 244 POEM procedures (13 × re-POEM). Twenty-nine procedures (11.9%) passed uneventfully, while in 215 procedures (88.1%), a total of 440 undesirable events occurred. The CDC identified 27 AEs (17 minor, 10 major) occurring in 23/244 (9.4%) procedures. The ASGE lexicon identified identical 27 AEs (21 mild or moderate, 6 severe or fatal) resulting in the severity distribution of AEs being the only difference between the two classifications. Only the absence of previous treatment was found to be a risk factor [p = 0.047, OR with 95% CI: 4.55 (1.02; 20.25)] in the combined logistic regression model. CONCLUSION Undesirable events are common in patients undergoing POEM but the incidence of true AEs is low according to both classifications. Severe adverse events are infrequent irrespective of the classification applied. CDC may be more appropriate than ASGE lexicon for classifying POEM-related AEs given a surgical nature of this procedure.
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Affiliation(s)
- Dagmar Simkova
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine IKEM, Videnska 1921, 140 21, Prague 4, Czech Republic
| | - Jan Mares
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine IKEM, Videnska 1921, 140 21, Prague 4, Czech Republic
| | - Zuzana Vackova
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine IKEM, Videnska 1921, 140 21, Prague 4, Czech Republic
| | - Tomas Hucl
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine IKEM, Videnska 1921, 140 21, Prague 4, Czech Republic
| | - Petr Stirand
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine IKEM, Videnska 1921, 140 21, Prague 4, Czech Republic
| | - Eva Kieslichova
- Department of Anesthesiology and Intensive Care, Institute for Clinical and Experimental Medicine IKEM, Videnska 1921, 140 21, Prague, Czech Republic
| | - Ondrej Ryska
- Royal Lancaster Infirmary, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, UK
| | - Julius Spicak
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine IKEM, Videnska 1921, 140 21, Prague 4, Czech Republic
| | - Sylvia Drazilova
- 2Nd Department of Internal Medicine, PJ Safarik University and L. Pasteur University Hospital, Trieda SNP 1, 040 11, Kosice, Slovakia
| | - Eduard Veseliny
- 2Nd Department of Internal Medicine, PJ Safarik University and L. Pasteur University Hospital, Trieda SNP 1, 040 11, Kosice, Slovakia
| | - Jan Martinek
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine IKEM, Videnska 1921, 140 21, Prague 4, Czech Republic. .,Institute of Physiology, 1St Faculty of Medicine, Charles University, Prague, Czech Republic. .,Faculty of Medicine, Ostrava University, Ostrava, Czech Republic.
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10
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Sarkis Y, Al-Haddad MA, Siwiec R, Kessler WR, Wo JM, Stainko S, Perkins A, DeWitt JM. Safety of same-day discharge after peroral endoscopic myotomy. Dis Esophagus 2022; 36:6747074. [PMID: 36190182 DOI: 10.1093/dote/doac068] [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: 06/29/2022] [Revised: 08/21/2022] [Accepted: 09/04/2022] [Indexed: 12/11/2022]
Abstract
There are limited data on the safety of same-day discharge (SDD) after peroral endoscopic myotomy (POEM). The aim of our study is to assess the frequency and relationship to POEM for emergency department (ED) visits and hospitalizations after SDD in these patients. We retrospectively identified consecutive patients between November 2019 and August 2021 who underwent POEM with SDD and at least 6 months follow-up. Criteria for SDD includes: (1) no serious procedure-related adverse event; (2) post-POEM esophagram without leak; (3) stable vital signs; (4) ability to take liquids orally; (5) pain controlled without IV analgesia; (6) adequate social support; (7) American Society of Anesthesiologists (ASA) class I-III. A causative relationship between POEM and ED visits and hospitalizations was assigned by consensus. Out of 185 POEMs performed, 78 (41.7%, 42M, mean 51±16 years) had SDD. Within 30 days of POEM, 8 ED visits occurred in 7/78 (9%) patients and 2 (25%) were considered related to POEM; hospitalization was required in 3 (38%). After 30 days, 11 ED visits occurred in 10/78 (12.8%) patients and 1 (9%) was considered related to POEM; hospitalization was required in 5 (45%). In this study of consecutive SDD patients after POEM, 3/19 (16%) ED visits and 2/8 (25%) hospitalizations within 6 months were considered related to the procedure. Therefore, eligible patients who follow and fulfill a strict protocol after POEM may be safely discharged the same day.
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Affiliation(s)
- Yara Sarkis
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - Mohammad A Al-Haddad
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - Robert Siwiec
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - William R Kessler
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - John M Wo
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - Sarah Stainko
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - Anthony Perkins
- Department of Biostatistics, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - John M DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
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Olson D, Liu KC, Aadam A. Peroral Endoscopy Myotomy (POEM) for Esophageal Motility Disorders. Curr Gastroenterol Rep 2022; 24:105-114. [PMID: 35947337 DOI: 10.1007/s11894-022-00845-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE OF REVIEW This review aims to provide an overview of the current role of per oral endoscopic myotomy (POEM) in the management of primary esophageal motility disorders and treatment of Zenker's diverticulum. RECENT FINDINGS POEM has been shown to be an effective treatment for achalasia. Recent research has suggested that the length of myotomy may be tailored to the disease phenotype and that short myotomy may be equally effective compared to long myotomy. The role of intra-operative EndoFLIP has shown promise as a tool to assess of the adequacy of myotomy. Further research is needed to determine the role of POEM in other esophageal motility disorders and for treatment of Zenker's diverticulum. Per oral endoscopic myotomy has been shown to be an effective and durable treatment option for achalasia with additional potential roles for the treatment of other esophageal motility disorders and Zenker's diverticulum.
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Affiliation(s)
- Dylan Olson
- Department of Medicine, Feinberg School of Medicine, Northwestern University, 251 E Huron St, 60611, Chicago, IL, USA
| | - Kevin C Liu
- Division of Gastroenterology and Hepatology, Banner University Medical Center, University of Arizona, Tucson, AZ, USA
| | - Aziz Aadam
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, 676 N. Saint Clair Street, Suite 1400, 60611, Chicago, IL, USA.
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12
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Lee JY, Lim CH, Kim DH, Jung HY, Youn YH, Jung DH, Park JC, Moon HS, Hong SJ. Adverse Events Associated With Peroral Endoscopic Myotomy Affecting Extended Hospital Stay: A Multi-center Retrospective Study in South Korea. J Neurogastroenterol Motil 2022; 28:247-254. [PMID: 35362451 PMCID: PMC8978124 DOI: 10.5056/jnm21081] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/17/2021] [Accepted: 11/10/2021] [Indexed: 12/16/2022] Open
Abstract
Background/Aims To analyze various adverse events (AEs) related to the peroral endoscopic myotomy (POEM) procedure and to analyze whether these AEs are related to an extended hospital stay. Methods Patients admitted for POEM for esophageal motility disorders from August 2012 to February 2020 at 5 centers were retrospectively collected. Length of hospital stay, AEs during or after the POEM procedure were analyzed. Results Of the 328 patients, 63.1% did not have any AEs, but 2.4% had major AEs, and 33.4% had minor AEs. Major AEs included mucosal injury, bleeding, and hemothorax, accounting for 1.5%, 0.6%, and 0.3%, respectively. Among the minor AEs, pneumoperitoneum was the most common gas-related AEs. Among non-gas-related minor AEs, pneumonia was the most common at 4.6%, followed by pain, fever, and pleural effusion. All major AEs had meaningful delayed discharge and significantly extended hospital stay compared to the no AEs group (median differences range 4.5-9.0 days). Among gas-related minor AEs, except for 4 cases of emphysema, the extended hospital stay was meaningless. All non-gas-related minor AEs was associated with a significant prolongation of hospital stay compared to that in the no AEs group (median differences range 2.0-4.0 days). Conclusions In conclusion, most gas-related minor AEs do not significantly affect the patient's clinical course. However, subcutaneous emphysema and minor non-gas related AEs such as pneumonia, pain, fever, and pleural effusion can prolong the hospital stay, therefore careful observation is required. Efforts will be made to reduce major AEs that significantly prolong hospitalization.
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Affiliation(s)
- Ju Yup Lee
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Chul-Hyun Lim
- Division of Gastroenterology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Young Hoon Youn
- Department of Gastroenterology, Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Da Hyun Jung
- Department of Gastroenterology, Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Chul Park
- Department of Gastroenterology, Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hee Seok Moon
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Su Jin Hong
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Gyeonggi-do, Korea
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13
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Rai M, Nazarin A, Taylor C, McMullen M, Hookey L, Chung W, Bechara R. OUP accepted manuscript. J Can Assoc Gastroenterol 2022; 5:221-225. [PMID: 36196273 PMCID: PMC9527655 DOI: 10.1093/jcag/gwac007] [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] [Indexed: 11/29/2022] Open
Abstract
Background and Aims Although usually mild to moderate in severity, postoperative pain after peroral endoscopic myotomy (POEM) is common. There are no studies that have addressed minimizing postoperative pain in patients undergoing POEM for achalasia. We hypothesized that intraoperative topical intra-tunnel irrigation with ropivacaine would result in a significant reduction in pain scores in the postoperative period. Methods A double-blind, randomized, placebo-controlled trial was conducted at the Kingston Health Sciences Center. Patients received either 30 mL of 0.2% ropivacaine or 30 mL of placebo irrigated topically into the POEM tunnel after completing the myotomy and prior to closing the mucosal incision. The primary outcome was pain post-POEM at 6 h assessed by the Numeric Rating Scale (NRS). Secondary objectives included assessing pain score at 0.5, 1, 2, 4 h post-POEM and on discharge, Quality of Recovery (QoR-15) scores at discharge, narcotic requirement, adverse events, and patients’ willingness to have the procedure done on an outpatient basis. Results A total of 20 patients were enrolled. For the primary outcome of pain post-POEM at 6 h, the NRS was 1.1 in the placebo group and 2.4 in the ropivacaine group (95% CI of the difference: −3.2 to 0.6, P = 0.171). No statistical difference was seen in the pain scores. Overall usage of post-procedural narcotics was low with no differences between the two groups. Fifty percent of patients in both groups were willing to have the procedure done as an outpatient. Conclusion The addition of intra-procedural tunnel irrigation with 30 mL 0.2% ropivacaine did not lead to reduced post-POEM pain.
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Affiliation(s)
- Mandip Rai
- Division of Gastroenterology, Queen’s University, Ontario, Canada
| | - Amir Nazarin
- Department of Medicine, Queen’s University, Ontario, Canada
| | - Connie Taylor
- Division of Gastroenterology, Queen’s University, Ontario, Canada
| | - Michael McMullen
- Department of Anesthesiology and Perioperative Medicine, Queen’s University, Ontario, Canada
| | - Lawrence Hookey
- Division of Gastroenterology, Queen’s University, Ontario, Canada
| | - Wiley Chung
- Division of General Surgery and Thoracic Surgery, Queen’s University, Ontario, Canada
| | - Robert Bechara
- Correspondence: Robert Bechara, Division of Gastroenterology, Queen’s University, Hotel Dieu Hospital, 166 Brock Street, Kingston, Ontario, K7L 5G2, Canada, e-mail:
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14
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Khoraki J, Campos GM, Alwatari Y, Mazzini GS, Mangino MJ, Wolfe LG. Perioperative outcomes of inpatient laparoscopic Heller myotomy and per-oral endoscopic myotomy in the United States. Surgery 2021; 171:1263-1272. [PMID: 34774290 DOI: 10.1016/j.surg.2021.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/03/2021] [Accepted: 10/11/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Per-oral endoscopic myotomy is an alternative to pneumatic dilation and laparoscopic Heller myotomy to treat lower esophageal sphincter diseases. Laparoscopic Heller myotomy and per-oral endoscopic myotomy perioperative outcomes data come from relatively small retrospective series and 1 randomized trial. We aimed to estimate the number of inpatient procedures performed in the United States and compare perioperative outcomes and costs of laparoscopic Heller myotomy and per-oral endoscopic myotomy using a nationally representative database. METHODS Cross-sectional retrospective analysis of hospital admissions for laparoscopic Heller myotomy or per-oral endoscopic myotomy from October 2015 through December 2018 in the National Inpatient Sample. Patient and hospital characteristics, concurrent antireflux procedures, perioperative adverse events (any adverse event and those associated with extended length of stay ≥3 days), mortality, length of stay, and costs were compared. Logistic regression evaluated factors independently associated with adverse events. RESULTS An estimated 11,270 patients had laparoscopic Heller myotomy (n = 9,555) or per-oral endoscopic myotomy (n = 1,715) without significant differences in demographics and comorbidities. A concurrent anti-reflux procedure was more frequent with laparoscopic Heller myotomy (72.8% vs 15.5%, P < .001). Overall adverse event rate was higher with per-oral endoscopic myotomy (13.3% vs 24.8%, P < .001), and mortality was similar. Per-oral endoscopic myotomy had higher rates of adverse events associated with extended length of stay (9.3% vs 16.6%, P < .001), infectious adverse events (3.5% vs 8.2%, P < .001), gastrointestinal bleeding (3.4% vs 5.8%, P = .04), accidental injuries (3% vs 5.5%, P = .03), and thoracic adverse events (4.5% vs 9%, P < .01). Rates of adverse events of both procedures remained similar during the years of the study. Per-oral endoscopic myotomy was independently associated with adverse events. Length of stay (laparoscopic Heller myotomy: 3.2 ± 0.1 vs per-oral endoscopic myotomy: 3.7 ± 0.3 days, P = .17) and costs (laparoscopic Heller myotomy: $15,471 ± 406 vs per-oral endoscopic myotomy: $15,146 ± 1,308, P = .82) were similar. CONCLUSION In this national database review, laparoscopic Heller myotomy had a lower rate of perioperative adverse events at similar length of stay and costs than per-oral endoscopic myotomy. Laparoscopic Heller myotomy remains a safer procedure than per-oral endoscopic myotomy for a myotomy of the distal esophagus and lower esophageal sphincter in the United States.
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Affiliation(s)
- Jad Khoraki
- Department of Surgery, Division of Bariatric and Gastrointestinal Surgery, Virginia Commonwealth University, Richmond, VA
| | - Guilherme M Campos
- Department of Surgery, Division of Bariatric and Gastrointestinal Surgery, Virginia Commonwealth University, Richmond, VA.
| | - Yahya Alwatari
- Department of Surgery, Division of Bariatric and Gastrointestinal Surgery, Virginia Commonwealth University, Richmond, VA
| | - Guilherme S Mazzini
- Department of Surgery, Division of Bariatric and Gastrointestinal Surgery, Virginia Commonwealth University, Richmond, VA
| | - Martin J Mangino
- Department of Surgery, Division of Bariatric and Gastrointestinal Surgery, Virginia Commonwealth University, Richmond, VA
| | - Luke G Wolfe
- Department of Surgery, Division of Bariatric and Gastrointestinal Surgery, Virginia Commonwealth University, Richmond, VA
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Abstract
PURPOSE OF REVIEW Third space endoscopy (TSE) or submucosal endoscopy provides with the opportunity for minimally invasive management of various gastrointestinal disorders. TSE is a relatively new field and the knowledge on its utility continues to advance. The purpose of this review is to provide with updated evidence on the efficacy and utility of TSE in gastrointestinal motility disorders including achalasia and refractory gastroparesis. RECENT FINDINGS Peroral endoscopic myotomy (POEM) is a safe procedure with emerging evidence on its durability as well. Major technical variations do not appear to impact the outcomes of POEM. Recent randomized trials suggest superiority of POEM over pneumatic dilatation and noninferiority over Heller's myotomy in idiopathic achalasia. With regard to gastric POEM (G-POEM), recent evidence confirms its efficacy in refractory gastroparesis. Although effective, the long-term outcomes of G-POEM are not well known. In addition, the criteria for patient selection remain elusive. SUMMARY TSE has emerged as a new frontier in the endoscopic management of gastrointestinal motility disorders. While short-term outcomes are encouraging, the durability of TSE remains to be seen in achalasia as well as refractory gastroparesis. Insights regarding patient selection and predictors of outcomes may help optimizing the results of gastric POEM in refractory gastroparesis.
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16
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Zhang LY, Bejjani M, Ghandour B, Khashab MA. Rethinking the need for overnight admission after peroral endoscopic myotomy (POEM): a pandemic-driven approach to the future. Endosc Int Open 2021; 9:E1381-E1385. [PMID: 34466362 PMCID: PMC8367444 DOI: 10.1055/a-1490-9385] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/31/2021] [Indexed: 01/09/2023] Open
Abstract
Background and study aims COVID-19 has significantly impacted endoscopic assessment and management of multiple conditions. Our group recommenced treatment of highly symptomatic achalasia patients (Eckardt score ≥ 6) adopting a same-day discharge (SDD) algorithm and present early outcomes of its utilization. Patients and methods We enrolled all outpatients undergoing POEM at a single tertiary referral center. Patients qualified for SDD if all of the following a priori criteria were met: 1) ASA grade I-III; 2) No intraprocedural adverse events (AEs); 3) Secure mucosal closure; 4) Post-procedure pain/nausea responsive to oral medications; and 5) Patients tolerating clear fluids. Results In 17 potential SDD candidates (female 82.4 %, median age 51 years [IQR 48-64]) undergoing POEM, SDD was achieved in 14 (82.4 %). The remaining were admitted due to post-procedure pain/nausea (n = 2) and intraprocedural concerns (capnoperitoneum requiring needle decompression, n = 1). There were no post-procedure AEs or unexpected readmissions. Conclusions This study demonstrates the safety and feasibility of a SDD algorithm for POEM patients and challenges the necessity of routine post-POEM hospital admission. Critically important during the COVID-19 pandemic, this may in fact constitute a changing standard for POEM post-procedure care.
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Affiliation(s)
- Linda Y. Zhang
- Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Michael Bejjani
- Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Bachir Ghandour
- Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Mouen A. Khashab
- Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
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17
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Delayed Pneumoperitoneum After Peroral Endoscopic Myotomy. ACG Case Rep J 2021; 8:e00593. [PMID: 33997093 PMCID: PMC8116019 DOI: 10.14309/crj.0000000000000593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 02/16/2021] [Indexed: 12/04/2022] Open
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18
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Fujiyoshi Y, Inoue H, Abad MRA, Rodriguez de Santiago E, Nishikawa Y, Sakaguchi T, Toshimori A, Shimamura Y, Tanabe M, Sumi K, Kimura R, Izawa S, Ikeda H, Onimaru M. Importance of second-look endoscopy after per-oral endoscopic myotomy for safe postoperative management. Dig Endosc 2021; 33:364-372. [PMID: 32544261 DOI: 10.1111/den.13770] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/07/2020] [Accepted: 06/10/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Per-oral endoscopic myotomy (POEM) is a safe and effective treatment for achalasia and esophageal motility disorders. The role of second-look endoscopy (SE) on postoperative day 1 has not been examined. This study aimed to evaluate the findings and need of SE after POEM. METHODS This is a single-center, retrospective study. All consecutive patients who underwent POEM and SE on postoperative day 1 between December 2017 and September 2019 were included. The primary endpoint was the rate of newly-detected adverse events (nAE) during SE that required endoscopic intervention or deviation from the normal postoperative course. Multivariate logistic regression was used to identify predictors of nAE. RESULTS Four-hundred-ninety-seven patients (mean age, 50.3 years; female, 49.9%) were included. SE identified abnormal findings in a total of 71 patients (14.3%). nAE which required endoscopic intervention or deviation from the normal postoperative course were identified in 12 patients (2.4%): eight (1.6%) entry site dehiscence; two (0.4%) submucosal hemorrhage or hematoma; and two (0.4%) dehiscence of an intraoperative perforation site after endoclip closure. Other findings such as mucosal thermal damage without perforation and small submucosal hematoma were found in 54 patients (10.9%) and five patients (1.0%), respectively. Multivariate analysis showed that longer operation time and intraoperative adverse events (AE) were associated with clinically significant nAE during SE. CONCLUSIONS Second-look endoscopy can detect and treat nAE that may lead to severe AE. Thus, SE should be highly considered before starting oral ingestion in all cases, and especially in those who present an intraoperative AE and longer operation time.
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Affiliation(s)
- Yusuke Fujiyoshi
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | | | - Enrique Rodriguez de Santiago
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan.,Department of Gastroenterology and Hepatology Hospital Universitario Ramon y Cajal, University of Alcala IRYCIS, Madrid, Spain
| | - Yohei Nishikawa
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Takuki Sakaguchi
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Akiko Toshimori
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Mayo Tanabe
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Kazuya Sumi
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Ryusuke Kimura
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Shinya Izawa
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Haruo Ikeda
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
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Nabi Z, Ramchandani M, Nageshwar Reddy D. Second-look endoscopy after POEM for all, some or none… More you see, the more you find! Dig Endosc 2021; 33:465. [PMID: 32816353 DOI: 10.1111/den.13816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Zaheer Nabi
- Asian institute of Gastroenterology, Hyderabad, India
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20
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Dacha S, Aihara H, Anand GS, Byrne KR, Chahal P, James T, Kowalski TE, Qayed E, Repaka A, Saadi M, Sheth SG, Taylor JR, Walsh CM, Williams RL, Wagh MS. Core curriculum for peroral endoscopic myotomy (POEM). Gastrointest Endosc 2021; 93:539-543. [PMID: 33422284 DOI: 10.1016/j.gie.2020.10.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 10/26/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Sunil Dacha
- Division of Gastroenterology, Underwood Center for Digestive Disorders, Houston Methodist Hospital, Houston, Texas, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gobind S Anand
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Kathryn R Byrne
- Division of Gastroenterology, University of Utah, Salt Lake City, Utah, USA
| | - Prabhleen Chahal
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Theodore James
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Thomas E Kowalski
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Emad Qayed
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Aparna Repaka
- Division of Gastroenterology, VA Boston Healthcare system, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Mohammed Saadi
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Jason R Taylor
- Division of Gastroenterology and Hepatology, St Louis University, St Louis, Missouri, USA
| | - Catharine M Walsh
- Division of Gastroenterology, Hepatology and Nutrition and the Research and Learning Institutes, Hospital for Sick Children, Department of Paediatrics and the Wilson Centre, University of Toronto, Toronto, Ontario, Canada
| | - Renee L Williams
- Division of Gastroenterology and Hepatology, NYU Langone Health, New York, New York, USA
| | - Mihir S Wagh
- Division of Gastroenterology, University of Colorado-Denver School of Medicine, Aurora, Colorado, USA
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21
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Delayed Tension Symptomatic Pneumoperitoneum After POEM Requiring Needle Decompression. Am J Gastroenterol 2021; 116:407-410. [PMID: 33136569 DOI: 10.14309/ajg.0000000000000998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 09/09/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Per-oral endoscopic myotomy (POEM) is an effective modality for the management of achalasia. Tension pneumoperitoneum is a significant complication that causes hemodynamic instability, generally within the periprocedural period. METHODS Here, we report 2 cases of delayed tension pneumoperitoneum that was recognized and treated several hours after uncomplicated POEM. RESULTS These cases illustrate the importance of continued vigilance for this complication outside of the immediate periprocedural period as well as the utility of computed tomography-guided aspiration in managing it. DISCUSSION When discharging patients after POEM, caregivers should be aware of this rare complication and alert patients to return for immediate care when it happens.
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22
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Reddy CA, Tavakkoli A, Abdul-Hussein M, Almazan E, Vosoughi K, Ichkhanian Y, Al-Hawary M, Chang AC, Chen JW, Korsnes S, Elmunzer BJ, Khashab MA, Law R. Clinical impact of routine esophagram after peroral endoscopic myotomy. Gastrointest Endosc 2021; 93:102-106. [PMID: 32504702 PMCID: PMC8783294 DOI: 10.1016/j.gie.2020.05.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/08/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS It is unclear whether the common practice of postoperative day (POD) 1 esophagram impacts clinical care or reliably identifies significant adverse events (AEs) related to peroral endoscopic myotomy (POEM). Therefore, we aimed to correlate the most clinically relevant esophagram findings with postoperative outcomes after POEM. METHODS Patients were retrospectively reviewed and included if they underwent POEM at 1 of the 3 study institutions between 2014 and 2018. Patient outcomes were assessed in relation to relevant POD 1 esophagram findings such as esophageal dissection or leak. RESULTS One hundred seventy post-POEM contrast esophagrams (139 fluoroscopy-based vs 31 CT-based) performed on POD 1 were included. Most esophagrams (n = 98) contained abnormal findings but only 5 showed esophageal leak or dissection. Confirmed postoperative AEs of leak or dissection occurred in 4 patients. In 2 patients, POD 1 esophagram appropriately identified the leak or dissection, but in the other 2 patients the initial esophagram was negative, and the AEs were not recognized before clinical deterioration. One patient had a false-positive leak and dissection noted on esophagram leading to an unremarkable endoscopy. CONCLUSIONS Despite the low AE rate after POEM, follow-up esophagram on POD 1 frequently shows expected, unremarkable postprocedural findings and occasionally fails to diagnose serious AEs. This results in pitfalls in accuracy regarding agreement between esophagram versus clinical and endoscopic findings. Relying exclusively on esophagram for post-POEM clinical decision-making can lead to unnecessary additional testing or missed AEs.
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Affiliation(s)
| | - Anna Tavakkoli
- Division of Gastroenterology, UT Southwestern, Dallas, Texas, USA
| | - Mustafa Abdul-Hussein
- Division of Gastroenterology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Erik Almazan
- Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kia Vosoughi
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Mahmoud Al-Hawary
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew C. Chang
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Joan W. Chen
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Sheryl Korsnes
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - B. Joseph Elmunzer
- Division of Gastroenterology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mouen A. Khashab
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ryan Law
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
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23
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Allen J, Dewan K, Herbert H, Randall DR, Starmer H, Stein E. Aspects of the assessment and management of pharyngoesophageal dysphagia. Ann N Y Acad Sci 2020; 1482:5-15. [PMID: 32794195 DOI: 10.1111/nyas.14456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/26/2020] [Accepted: 07/08/2020] [Indexed: 02/06/2023]
Abstract
Swallowing complaints are common and may have significant consequences for nutrition and pulmonary health. Etiology varies and different aspects of the deglutitive system may be affected. A thorough assessment from the oral cavity to the stomach will provide physiologic information that enables specific targeted management plans to be devised. Although the swallow trajectory bridges anatomic areas, there has previously been a tendency to compartmentalize assessment and treatment by arbitrary anatomic boundaries. It is now clear that this approach fails to appreciate the complexity of swallow mechanics and that systems (oral, pharyngeal, esophageal, and pulmonary) are intertwined and codependent. Swallowing specialists from different backgrounds and with complementary skill sets form a multidisciplinary team that can provide insight and address multiple areas of management. With the advent of new tools for instrumental evaluation, such as manometry, targeted rehabilitative strategies can be informed by physiology, increased in precision and breadth, and assessed quantitatively. Surgical approaches have evolved toward endoscopic techniques, and food technology is expanding options in dietary management. The multidisciplinary team is core to managing this varied and often neglected patient population. This review is for clinicians treating swallowing disorders and will explore the selected aspects of the assessment and management of pharyngoesophageal swallowing disorders.
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Affiliation(s)
- Jacqueline Allen
- Department of Surgery, the University of Auckland, Auckland, New Zealand
| | - Karuna Dewan
- Division of Otolaryngology, Stanford University, Stanford, California
| | - Hayley Herbert
- Department of Otolaryngology, University of Western Australia, Perth, Western Australia, Australia
| | - Derrick R Randall
- Division of Otolaryngology, the University of Calgary, Calgary, Alberta, Canada
| | - Heather Starmer
- Division of Otolaryngology, Stanford University, Stanford, California
| | - Ellen Stein
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical School, Baltimore, Maryland
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Attaar M, Su B, Wong HJ, Kuchta K, Denham W, Haggerty SP, Linn J, Ujiki MB. Factors associated with admission after implementation of a same-day discharge pathway in patients undergoing peroral endoscopic myotomy (POEM). Surg Endosc 2020; 35:3971-3980. [DOI: 10.1007/s00464-020-07866-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 08/05/2020] [Indexed: 12/18/2022]
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Hwang JH, Jamidar P, Kyanam Kabir Baig KR, Leung FW, Lightdale JR, Maranki JL, Okolo PI, Swanstrom LL, Chak A. GIE Editorial Board top 10 topics: advances in GI endoscopy in 2019. Gastrointest Endosc 2020; 92:241-251. [PMID: 32470427 DOI: 10.1016/j.gie.2020.05.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/14/2020] [Indexed: 02/06/2023]
Abstract
The American Society for Gastrointestinal Endoscopy's GIE Editorial Board reviewed original endoscopy-related articles published during 2019 in Gastrointestinal Endoscopy and 10 other leading medical and gastroenterology journals. Votes from each individual member were tallied to identify a consensus list of 10 topic areas of major advances in GI endoscopy. Individual board members summarized important findings published in these 10 areas of disinfection, artificial intelligence, bariatric endoscopy, adenoma detection, polypectomy, novel imaging, Barrett's esophagus, third space endoscopy, interventional EUS, and training. This document summarizes these "top 10" endoscopic advances of 2019.
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Affiliation(s)
- Joo Ha Hwang
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, California
| | - Priya Jamidar
- Professor of Medicine, Yale University, New Haven, Connecticut
| | | | - Felix W Leung
- Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA
| | - Jennifer R Lightdale
- University of Massachusetts Medical School, Umass Memorial Childrens Medical Center, Worcester, Massachusetts
| | | | - Patrick I Okolo
- Executive Medical Director, Rochester Regional Health Systems, Rochester, NY
| | - Lee L Swanstrom
- Professor of Surgery, Oregon Health and Sciences University: Scientific Director and Chief Innovations Officer, Institutes Hospitalos Universitaires (IHU-Strasbourg) University of Strasbourg
| | - Amitabh Chak
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Same-day discharge is safe and feasible following POEM surgery for esophageal motility disorders. Surg Endosc 2020; 35:3398-3404. [DOI: 10.1007/s00464-020-07781-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 07/01/2020] [Indexed: 02/08/2023]
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Li DF, Xiong F, Yu ZC, Zhang HY, Liu TT, Tian YH, Shi RY, Lai MG, Song Y, Xu ZL, Zhang DG, Yao J, Wang LS. Effect and safety of mark-guided vs standard peroral endoscopic myotomy: A retrospective case control study. World J Gastroenterol 2020; 26:973-983. [PMID: 32206007 PMCID: PMC7081014 DOI: 10.3748/wjg.v26.i9.973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/09/2020] [Accepted: 01/18/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is a promising therapeutic modality for esophageal achalasia worldwide. However, clinical failure and adverse events of POEM have still been concerned.
AIM To compare the efficacy and safety of a novel mark-guided POEM with standard POEM.
METHODS A total of 133 patients with esophageal achalasia who underwent POEM from May 2013 to May 2019 were enrolled in this retrospective study. Of the 133 patients, there were 64 patients in the mark-guided POEM group and 69 patients in the standard POEM group. The clinical success, procedural duration and adverse events were compared between the two groups at 3 mo, 12 mo and 24 mo postoperatively.
RESULTS Characteristic baseline was similar in the mark-guided POEM group and standard POEM group. The clinical success was comparable between the two groups, ranging from 92% to 98%, at 3 mo, 12 mo and 24 mo postoperatively (all P > 0.5). Eckart score, Gastroesophageal Reflux Disease Questionnaire score and SF-36 score were not different between the two groups after treatment (all P > 0.05). No severe adverse events occurred in the two groups. However, mark-guided POEM required shorter procedural duration, and less use of proton pump inhibitors and lower incidence of reflux symptoms than the standard POEM (all P < 0.001).
CONCLUSION Mark-guided POEM and standard POEM were both effective and safe for the treatment of esophageal achalasia. However, the mark-guided POEM was characterized by shorter procedural duration, less use of proton pump inhibitors and lower incidence of reflux symptoms.
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Affiliation(s)
- De-Feng Li
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Feng Xiong
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Zhi-Chao Yu
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Hai-Yang Zhang
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Ting-Ting Liu
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Yan-Hui Tian
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Rui-Yue Shi
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Ming-Guang Lai
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Yang Song
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Zheng-Lei Xu
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Ding-Guo Zhang
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Jun Yao
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Li-Sheng Wang
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
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Abstract
The field of third space endoscopy (TSE), also called submucosal endoscopy using a mucosal flap valve, allows secure access to the submucosal and deeper layers of the gastrointestinal tract without the risk of a full-thickness perforation. Since the first description of per-oral endoscopic myotomy (POEM) for the treatment of achalasia cardia 10 years ago, this field has expanded rapidly. Several new procedures, submucosal tunneling endoscopic resection, gastric-POEM, Zenker POEM, per-rectal endoscopic myotomy, diverticular POEM, and recanalization for complete esophageal obstruction (per-oral endoscopic tunneling for restoration of the esophagus), have been performed. All TSE procedures employ a similar technique-after a mucosal incision, a submucosal tunnel is created, a myotomy is performed, or a subepithelial tumor is resected distal to the site of mucosal incision, after which the mucosal incision is closed. Potential indications for TSE include resection of subepithelial tumors in the esophagus, gastroesophageal junction, or stomach; refractory gastroparesis; Zenker diverticulum; Hirschsprung disease or other forms of megacolon; and recanalization for complete esophageal obstruction. Data are currently available for POEM, submucosal tunneling endoscopic resection, and gastric-POEM, although mainly in the form of retrospective studies, and randomized trials and long-term follow-up data are limited. Submucosal endoscopy has an excellent safety profile with very few intraoperative adverse events, the majority being related to insufflation, although bleeding, perforation, and sepsis have been reported. TSE procedures require special training and have demonstrated a learning curve.
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Achem S. Post-POEM esophageal reflux in a Mexican population. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2020. [DOI: 10.1016/j.rgmxen.2019.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Achem SR. Post-POEM esophageal reflux in a Mexican population. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2019; 85:1-3. [PMID: 31677895 DOI: 10.1016/j.rgmx.2019.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 07/23/2019] [Indexed: 11/27/2022]
Affiliation(s)
- S R Achem
- Mayo College of Medicine, Mayo Clinic Florida, Jacksonville, Florida, Estados Unidos.
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Law R, Chang A. Treatment of achalasia by Performing Outpatient Endoscopic Myotomy (POEM). Gastrointest Endosc 2019; 90:579-580. [PMID: 31540629 DOI: 10.1016/j.gie.2019.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 06/18/2019] [Indexed: 02/08/2023]
Affiliation(s)
- Ryan Law
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew Chang
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Per-oral endoscopic myotomy and gastroesophageal reflux: Where do we stand after a decade of "POETRY"? Indian J Gastroenterol 2019; 38:287-294. [PMID: 31478146 DOI: 10.1007/s12664-019-00980-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 07/18/2019] [Indexed: 02/04/2023]
Abstract
Per-oral endoscopic myotomy (POEM) was introduced nearly a decade ago. Since then, the literature on its safety and efficacy has been ever increasing. Initial studies focused solely on the feasibility and efficacy of this procedure in patients with idiopathic achalasia. Subsequent studies analyzed the incidence of gastroesophageal reflux disease (GERD) in addition to the efficacy of POEM. These studies depict a high incidence of GERD after POEM. However, vast majority of these studies lacked a comprehensive evaluation of GERD after POEM. Consequently, it is difficult to provide a true estimate of the incidence of GERD in these patients. Majority of the patients with post-POEM GERD are asymptomatic and those with symptoms usually respond well to proton pump inhibitors. However, the long-term consequences of asymptomatic GERD with increased esophageal acid exposure are not well known. These patients should probably undergo regular surveillance due to theoretical risks of complications like Barrett's esophagus and esophageal adenocarcinoma. It should be acknowledged that there is no well-controlled study to support the strategy of surveillance in this group of patients. Given the high incidence of GERD after POEM, it is time to devise minimally invasive novel strategies to prevent and manage post-POEM GERD. The current literature suggests that the technique of POEM and other factors like type of achalasia do not influence the occurrence of GERD after POEM. Therefore, the endoscopists will need to think out of the box to prevent post-POEM GERD.
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