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Kim JY, Min YW. Peroral Endoscopic Myotomy for Esophageal Motility Disorders. Clin Endosc 2020; 53:638-645. [PMID: 33212547 PMCID: PMC7719430 DOI: 10.5946/ce.2020.223] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/22/2020] [Indexed: 12/11/2022] Open
Abstract
Peroral endoscopic myotomy (POEM) is one of the most clinically successful tunnel-based minimally invasive endoscopic treatments. The classic indications of POEM include achalasia of all types, including failed prior treatments, and expanded indications include the non-achalasia esophageal motility disorders, such as esophagogastric junction outflow obstruction, diffuse esophageal spasm, and jackhammer esophagus. For achalasia treatment, POEM has achieved a comparable surgical efficacy and a safety outcome and, therefore, has emerged as a first-line treatment. For non-achalasia esophageal motility disorders, POEM has also shown high clinical response rates. The complication rate of POEM for esophageal motility disorders is low and most complications are managed with conservative treatment. Currently, POEM is a representative procedure of natural orifice transluminal endoscopic surgery, which has shown a good clinical efficacy with low complication rates for esophageal motility disorders including achalasia. However, further studies are needed to treat non-achalasia motility disorder via POEM.
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Affiliation(s)
- Jun Young Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
Surgeons have been involved, since the beginning, in the development and evolution of endoscopy. They have been instrumental in developing new methods and have been actively involved in most of the therapeutic applications. The continued evolution of endoscopic technique is inevitable and will involve the integration of new technology with innovative thinking.
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Affiliation(s)
- Jeffrey L Ponsky
- Department of General Surgery, Cleveland Clinic, Desk A100, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| | - Andrew T Strong
- Department of General Surgery, Cleveland Clinic, Desk A100, 9500 Euclid Avenue, Cleveland, OH 44195, 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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Rai M, Woo M, Bechara R. The Canadian POEM Experience: The First 50 Patients. J Can Assoc Gastroenterol 2020; 4:110-114. [PMID: 34056528 PMCID: PMC8158644 DOI: 10.1093/jcag/gwaa018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Indexed: 02/07/2023] Open
Abstract
Background and Aims Peroral endoscopic myotomy (POEM) has emerged as a less invasive technique for performing myotomy in patients with achalasia. This study aims to assess the safety and efficacy of POEM in a Canadian tertiary care center. Methods All consecutive patients who underwent POEM between March 2016 and May 2018 at a tertiary center were included. The primary outcome of the study was clinical success rate of POEM defined as a post-POEM Eckardt score ≤3 at ≥3 months. Adverse events were recorded according to the Clavien-Dindo grading system. Results A total of 50 consecutive patients underwent 51 POEM procedures with a mean procedure length of 85.6 ± 29.6 min. Post-POEM Eckardt scores of ≤3 at ≥3 months was achieved in 98% of patients. The incidence of pathologic reflux post-poem was 23%. The median length of hospital stay was 1 day. No major adverse events occurred. Interpretation POEM is a safe and effective procedure for the treatment of achalasia. At a median follow-up of 19.5 months, 98% of patients had sustained clinical response (Eckardt score ≤3).
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Affiliation(s)
- Mandip Rai
- Division of Gastroenterology, Queen’s University, Ontario, Canada
| | - Matthew Woo
- Division of Gastroenterology, University of Calgary, Alberta, Canada; Division of Gastroenterology, Queen’s University, Ontario, Canada
| | - Robert Bechara
- Division of Gastroenterology, Queen’s University, Ontario, Canada
- Correspondence: Robert Bechara, HonBSc, MD, FRCPC, Department of Gastroenterology, Hotel Dieu Hospital, Queen’s University, 166 Brock Street Kingston, Ontario K7L 5G2, Canada, e-mail:
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Choi YI, Kim KO, Park DK, Chung JW, Kim YJ, Kwon KA. Clinical outcomes and safety of high-resolution manometry guided superficial partial circular muscle myotomy in per-oral endoscopic myotomy for Jackhammer esophagus: Two cases report. World J Clin Cases 2019; 7:2322-2329. [PMID: 31531326 PMCID: PMC6718798 DOI: 10.12998/wjcc.v7.i16.2322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 07/01/2019] [Accepted: 07/20/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Jack hammer esophagus is a relatively rare disease and to date, there is no dramatic treatment option. Recently, conventional per-oral endoscopic myotomy (POEM) have expanded their area into Jackhammer esophagus. However, several complications such as post procedure motility disorders (e.g., passage disturbance) are issues after POEM. To overcome these issues, we here introduced high-resolution manometry (HRM)-guided superficial partial circular muscle myotomy, which involves cutting only the superficial layer of the esophageal circular muscle.
CASE SUMMARY We report two cases of patients with Jackhammer esophagus who were treated with HRM-guided extremely superficial partial circular muscle myotomy during POEM. Case 1 was a 53-year-old female with medication-refractory odynophagia and case 2 was a 47-year-old man who presented with chest pain. They were diagnosed with Jackhammer esophagus using HRM, and the hypercontractile segments of the esophagus were identified. HRM-guided extremely superficial partial circular muscle myotomy was performed while preserving the lower esophageal sphincter. Therefore, the circular and longitudinal muscle layers are preserved but hypercontractile movements are reduced, even after POEM. Patients’ clinical symptoms dramatically improved right after POEM, and 6-mo follow-up HRM revealed completely resolved status. During a 1-year follow-up period, patients were still in good health and remained symptom free.
CONCLUSION HRM-guided superficial partial circular muscle myotomy may be a promising alternative to conventional POEM for treating Jackhammer esophagus with improved efficacy.
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Affiliation(s)
- Youn I Choi
- Department of Gastroenterology, Gil Medical Center, Gachon University, Incheon 21565, South Korea
| | - Kyoung Oh Kim
- Department of Gastroenterology, Gil Medical Center, Gachon University, Incheon 21565, South Korea
| | - Dong Kyun Park
- Department of Gastroenterology, Gil Medical Center, Gachon University, Incheon 21565, South Korea
| | - Jun-Won Chung
- Department of Gastroenterology, Gil Medical Center, Gachon University, Incheon 21565, South Korea
| | - Yoon Jae Kim
- Department of Gastroenterology, Gil Medical Center, Gachon University, Incheon 21565, South Korea
| | - Kwang An Kwon
- Department of Gastroenterology, Gil Medical Center, Gachon University, Incheon 21565, South Korea
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Olson MT, Triantafyllou T, Singhal S. A Decade of Investigation: Peroral Endoscopic Myotomy Versus Laparoscopic Heller Myotomy for Achalasia. J Laparoendosc Adv Surg Tech A 2019; 29:1093-1104. [PMID: 31313957 DOI: 10.1089/lap.2019.0242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Although laparoscopic Heller myotomy (LHM) with partial fundoplication has long been considered the gold standard for treatment of patients with achalasia, peroral endoscopic myotomy (POEM) has emerged in the last decade as a viable alternative. Methods: A collective review of literature concerning investigations that have reported patient outcomes and treatment success of LHM and POEM for all achalasia subtypes. Results: While POEM has shown excellent short-term safety and efficacy in the relief of symptoms, the long-term symptomatic outcomes after the intervention are yet to be concluded. Further evaluation of patients' interpretations and answers on subjective questionnaires is warranted before determining treatment success for POEM. Use of more reliable and disease-specific health-related quality-of-life questionnaires are better justified when comparing a new endoscopic procedure to an established gold standard. The need for objective parameters to measure reflux, longer follow-up studies, and randomized trials comparing POEM to LHM is particularly important when assessing the outcome of this new technique. High incidence of post-POEM pathologic reflux and indication for daily proton pump inhibitor use is of concern, and the lack of more long-term, objective evidence leaves the clinical value of the procedure in a state of uncertainty. Conclusions: The LHM combined with partial fundoplication is still considered to be the gold standard treatment modality for achalasia, but as the POEM procedure rapidly becomes common practice, this treatment may be performed in the majority of achalasia cases. Given the number of flaws overlooked in seminal investigations, careful consideration should be given to the patients being selected for this therapy.
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Affiliation(s)
- Michael T Olson
- University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Tania Triantafyllou
- Hippocration General Hospital of Athens, University of Athens, Athens, Greece
| | - Saurabh Singhal
- Department of GI Surgery and Liver Transplantation, Indraprastha Apollo Hospital, New Delhi, India
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Bechara R, Woo M, Hookey L, Chung W, Grimes K, Ikeda H, Onimaru M, Sumi K, Nakamura J, Hata Y, Maruyama S, Gomi K, Shimamura Y, Inoue H. Peroral endoscopic myotomy (POEM) for complex achalasia and the POEM difficulty score. Dig Endosc 2019; 31:148-155. [PMID: 30417948 DOI: 10.1111/den.13294] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/31/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) for achalasia is technically challenging to carry out in patients with type III, multiple prior treatments, prior myotomy, and sigmoid type. Herein, we present a series of consecutive patients with complex achalasia and introduce the POEM difficulty score (PDS). AIM To demonstrate the application and discuss the utility of PDS and present the feasibility, safety, and efficacy of POEM in complex achalasia patients. METHODS Forty consecutive POEM were carried out with 28 meeting the criteria for complex achalasia. Primary outcome was clinical success (Eckardt score ≤3) at a minimum of 3 months follow-up. Secondary outcomes included adverse events, procedural velocity and PDS. RESULTS Twenty-eight complex and 12 non-complex POEM procedures were carried out with 100% and 92% clinical success, respectively, without any major adverse events with a median follow up of 15 months (complex) and 8 months (non-complex). Mean velocities for non-complex, type III, prior myotomy, ≥4 procedures and sigmoid type were as follows: 4.4 ± 1.6, 4.8 ± 1.5, 5.9 ± 2.2, 6.9 ± 2.2 and 8.2 ± 3.2 min/cm, respectively. Median PDS for non-complex, type III, prior myotomy, ≥4 treatments and sigmoid type were 1 (0-3), 2 (0-4), 2.5 (1-6), 3 (2-6) and 3.5 (1-6), respectively. PDS was shown to correlate well with procedural velocity with a correlation coefficient of 0.772 (Spearman's P < 0.001). CONCLUSIONS PDS identifies the factors that contribute to challenging POEM procedures and correlates well with procedural velocity. The order of increasing difficulty of POEM in complex achalasia appears to be type III, prior myotomy, ≥4 treatments and sigmoid type.
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Affiliation(s)
- Robert Bechara
- Division of Gastroenterology, Kingston Health Sciences Center, Queens University, Kingston General Hospital, Ontario, Canada
| | - Matthew Woo
- Division of Gastroenterology, Kingston Health Sciences Center, Queens University, Kingston General Hospital, Ontario, Canada
| | - Lawrence Hookey
- Division of Gastroenterology, Kingston Health Sciences Center, Queens University, Kingston General Hospital, Ontario, Canada
| | - Wiley Chung
- Division of Thoracic Surgery, Kingston Health Sciences Center, Queens University, Kingston General Hospital, Ontario, Canada
| | - Kevin Grimes
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Haruo Ikeda
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Tokyo, Japan
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Tokyo, Japan
| | - Kazuya Sumi
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Tokyo, Japan
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Yoshitaka Hata
- Department of Medicine and Bioregulatory Science, Kyushu University, Fukuoka, Japan
| | - Shota Maruyama
- Department of Surgery, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Kuniyo Gomi
- Division of Gastroenterology, Showa University, Fujigaoka Hospital, Kanagawa, Japan
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Tokyo, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Tokyo, Japan
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Chuah SK, Lim CS, Liang CM, Lu HI, Wu KL, Changchien CS, Tai WC. Bridging the Gap between Advancements in the Evolution of Diagnosis and Treatment towards Better Outcomes in Achalasia. BIOMED RESEARCH INTERNATIONAL 2019; 2019:8549187. [PMID: 30881999 PMCID: PMC6381566 DOI: 10.1155/2019/8549187] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 01/02/2019] [Accepted: 01/20/2019] [Indexed: 02/05/2023]
Abstract
Over the past few decades, there was an encouraging breakthrough in bridging the gap between advancements in the evolution of diagnosis and treatment towards a better outcome in achalasia. The purpose of this review is to provide updated knowledge on how the current evidence has bridged the gap between advancements in the evolution of diagnosis and treatment of esophageal achalasia. The advent of high-resolution manometry and standardization based on the Chicago classification has increased early recognition of the disease. These 3 clinical subtypes of achalasia can predict the outcomes of patients, and the introduction of POEM has revolutionized the choice of treatment. Previous evidence has shown that laparoscopic Heller myotomy (LHM) and anterior fundoplication were considered the most durable treatments for achalasia. Based on the current evidence, POEM has been evolving as a promising strategy and is effective against all 3 types of achalasia, but the efficacy of POEM is based on short- and medium-term outcome studies from a limited number of centers. Types I and II achalasia respond well to POEM, LHM, and PD, while most studies have shown that type III achalasia responds better to POEM than to LHM and PD. In general, among the 3 subtypes of achalasia, type II achalasia has the most favorable outcomes after medical or surgical therapies. The long-term efficacy of POEM is still unknown. The novel ENDOFLIP measures the changes in intraoperative esophagogastric junction dispensability, which enables a quantitative assessment of luminal patency and sphincter distension; however, this technology is in its infancy with little data to date supporting its intraoperative use. In the future, identifying immunomodulatory drugs and the advent of stem cell therapeutic treatments, including theoretically transplanting neuronal stem cells, may achieve a functional cure. In summary, it is important to identify the clinical subtype of achalasia to initiate target therapy for these patients.
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Affiliation(s)
- Seng-Kee Chuah
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
| | - Chee-Sang Lim
- Department of Hepatology, Hospital Selayang, Lebuh Raya Selayang-Kepong, Batu Caves, Selangor, Malaysia
| | - Chih-Ming Liang
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
| | - Hung-I Lu
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 833 Kaohsiung, Taiwan
| | - Keng-Liang Wu
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
| | - Chi-Sin Changchien
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
| | - Wei-Chen Tai
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
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Mejía M. R, Donoso D. A, Manríquez A. E, Sáez B. J, Crovari E. F, Gabrielli N. M, Norero M. E, Pimentel M. F, Ceroni V. M, Muñoz C. R, Sharp P. A. Miotomía endoscópica por vía oral (POEM) para el tratamiento de la acalasia. Experiencia clínica inicial y resultados a corto plazo. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.rchic.2017.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
PURPOSE OF REVIEW The recent developments and clinical applications of natural orifice translumenal endoscopic surgery (NOTES)-procedures and technologies are going to be presented. RECENT FINDINGS In experimental as well as clinical settings, NOTES-procedures are predominantly performed in hybrid technique. Current experimental studies focus on the implementation of new surgical approaches as well as on the training of procedures. One emphasis in the clinical application is transrectal and transanal interventions. Transanal total mesorectal excision is equivalent to laparoscopic procedures but with the benefit of an even less invasive access. Transvaginal cholecystectomy can achieve results that are comparable to surgeries that are performed with laparoscopic techniques alone. An analysis of the German NOTES-Register concerning appendectomies as well as the national performance of NOTES-interventions in Switzerland is presented. Apart from intraabdominal approaches, several centers proclaim transoral thyroidectomies and transoral mediastinoscopies. SUMMARY NOTES-procedures are performed in animal experiments as well as in clinical setting although with less frequency. At this time, hybrid techniques using rigid instruments are mainly applied.
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Twenty-year trends in the utilization of Heller myotomy for achalasia in the United States. Am J Surg 2017; 214:299-302. [DOI: 10.1016/j.amjsurg.2017.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 02/21/2017] [Accepted: 03/02/2017] [Indexed: 12/13/2022]
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Intramural Surgery: A New Vista in Minimally Invasive Therapy. J Am Coll Surg 2017; 225:339-342. [PMID: 28483605 DOI: 10.1016/j.jamcollsurg.2017.04.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 04/20/2017] [Accepted: 04/24/2017] [Indexed: 12/21/2022]
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