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Itskoviz D, Malnick SDH. Gastroesophageal reflux following peroral endoscopic myotomy for achalasia: Bumps in the road to success. World J Gastroenterol 2024; 30:3461-3464. [PMID: 39156501 PMCID: PMC11326092 DOI: 10.3748/wjg.v30.i29.3461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 05/16/2024] [Accepted: 07/10/2024] [Indexed: 07/29/2024] Open
Abstract
Achalasia can significantly impair the quality of life. The clinical presentation typically includes dysphagia to both solids and liquids, chest pain, and regurgitation. Diagnosis can be delayed in patients with atypical presentations, and they might receive a wrong diagnosis, such as gastroesophageal reflux disease (GERD), owing to overlapping symptoms of both disorders. Although the cause of achalasia is poorly understood, its impact on the motility of the esophagus and gastroesophageal junction is well established. Several treatment modalities have been utilized, with the most common being surgical Heller myotomy with concomitant fundoplication and pneumatic balloon dilatation. Recently, peroral endoscopic myotomy (POEM) has gained popularity as an effective treatment for achalasia, despite a relatively high incidence of GERD occurring after treatment compared to other modalities. The magnitude of post-POEM GERD depends on its definition and is influenced by patient and procedure-related factors. The long-term sequelae of post-POEM GERD are yet to be determined, but it appears to have a benign course and is usually manageable with clinically available modalities. Identifying risk factors for post-POEM GERD and modifying the POEM procedure in selected patients may improve the overall success of this technique.
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Affiliation(s)
- David Itskoviz
- Kaplan Medical Center, Institute of Gastroenterology and Hepatology, Hebrew University Medical School of Jerusalem, Rehovot 76100, Israel
| | - Stephen David Howard Malnick
- Kaplan Medical Center, Department of Internal Medicine C, Hebrew University Medical School of Jerusalem, Rehovot 76100, Israel
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Capogreco A, de Sire R, Massimi D, Alfarone L, Maselli R, Hassan C, Repici A. Underwater coagulation using hybrid knife in peroral endoscopic myotomy for achalasia. Endoscopy 2024; 56:547-548. [PMID: 38936349 PMCID: PMC11211000 DOI: 10.1055/a-2292-8460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Antonio Capogreco
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Roberto de Sire
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Davide Massimi
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Ludovico Alfarone
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Roberta Maselli
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Cesare Hassan
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
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Wessels EM, Masclee GMC, Bastiaansen BAJ, Fockens P, Bredenoord AJ. Incidence and risk factors of reflux esophagitis after peroral endoscopic myotomy. Neurogastroenterol Motil 2024; 36:e14794. [PMID: 38587128 DOI: 10.1111/nmo.14794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/21/2024] [Accepted: 04/01/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is an effective and safe treatment for achalasia, but often leads to posttreatment gastroesophageal reflux disease. The aim of this study was to examine the incidence and severity of reflux esophagitis after POEM and to identify associated predictive factors. METHODS Patients who underwent POEM between August 2011 and December 2022 were included. Multivariate logistic regression was used to assess predictive factors for reflux esophagitis after POEM. KEY RESULTS In total, 252 patients were included; of which, 46% were female and age ranged between 18 and 87 years. Reflux esophagitis within 1 year after POEM was observed in 131 patients (52%), which was severe in 29 patients (LA grade C/D, 12%). Length of full-thickness myotomy (cm; OR 1.11, 95% CI 1.02-1.21), Eckardt scores before POEM (OR 0.84, 95% CI 0.74-0.96), previous pneumatic dilation (OR 0.51, 95% CI 0.29-0.91), and previous laparoscopic Heller myotomy (LHM; OR 0.44, 95% CI 0.23-0.86) were associated with reflux esophagitis after POEM. Alcohol use (none vs > 7 units per week; OR 3.51, 95% CI 1.35-9.11) and overweight (BMI ≥25 kg/m2; OR 2.67, 95% CI 1.17-6.09) were positive predictive factors and previous LHM (OR 0.13, 95% CI 0.02-0.95) was a negative predictive factor for severe reflux esophagitis after POEM (LA grade C/D). CONCLUSION About half of the patients develop reflux esophagitis after POEM and 12% is graded as severe. Recognizing predictive factors of reflux esophagitis after POEM treatment leads to better patient selection before POEM and provides an opportunity to take preventive measures or start preemptive treatment.
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Affiliation(s)
- Elise M Wessels
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Gwen M C Masclee
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Barbara A J Bastiaansen
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
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Maluf-Filho F. Acidification of the esophagus in post-peroral endoscopic myotomy achalasia patients: all that glitters is not gold. Gastrointest Endosc 2024; 99:174-176. [PMID: 38069982 DOI: 10.1016/j.gie.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 08/28/2023] [Indexed: 01/23/2024]
Affiliation(s)
- Fauze Maluf-Filho
- Gastrointestinal Endoscopy Division, Department of Gastroenterology, Sao Paulo, Brazil; Instituto do Cancer, University of Sao Paulo, Sao Paulo, Brazil; National Council for Scientific and Technological Development, Brasilia, Brazil
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Singh AP, Singla N, Budhwani E, Januszewicz W, Memon SF, Inavolu P, Nabi Z, Jagtap N, Kalapala R, Lakhtakia S, Darisetty S, Reddy DN, Ramchandani M. Defining "true acid reflux" after peroral endoscopic myotomy for achalasia: a prospective cohort study. Gastrointest Endosc 2024; 99:166-173.e3. [PMID: 37598862 DOI: 10.1016/j.gie.2023.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND AND AIMS The symptoms of reflux in achalasia patients undergoing peroral endoscopic myotomy (POEM) are believed to result from gastroesophageal reflux, and the current treatment primarily focuses on acid suppression. Nevertheless, other factors such as nonreflux acidification caused by fermentation or stasis might play a role. This study aimed to identify patients with "true acid reflux" who actually require acid suppression and fundoplication. METHODS In this prospective large cohort study, the primary objective was to assess the incidence and risk factors for true acid reflux in achalasia patients undergoing POEM. Acid reflux with normal and delayed clearance defined true acid reflux, whereas other patterns were labeled as nonreflux acidification patterns on manual analysis of pH tracings. These findings were corroborated with a symptom questionnaire, esophagogastroscopy, esophageal manometry, and timed barium esophagogram at 3 months after the POEM procedure. RESULTS Fifty-four achalasia patients aged 18 to 80 years (mean age, 41.1 ± 12.8 years; 59.3% men; 90.7% with type II achalasia) underwent POEM, which resulted in a significant mean Eckardt score improvement (6.7 to 1.6, P < .05). True acid reflux was noted in 29.6% of patients as compared with 64.8% on automated analysis. Acid fermentation was the predominant acidification pattern seen in 42.7% of patients. On multivariable logistic regression analysis, increasing age (odds ratio, 1.12; 95% confidence interval, 1.02-1.27; P = .04) and preprocedural integrated relaxation pressure (IRP; odds ratio, 1.13; 95% confidence interval, 1.04-1.30; P = .02) were significantly associated with true acid reflux in patients after undergoing POEM. CONCLUSIONS A manual review of pH tracings helps to identify true acid reflux in patients with achalasia after undergoing POEM. Preprocedural IRP can be a predictive factor in determining patients at risk for this outcome. (Clinical trial registration number: NCT04951739.).
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Affiliation(s)
| | - Neeraj Singla
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Ekant Budhwani
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Wladyslaw Januszewicz
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Sana Fatima Memon
- Department of Medical Gastroenterology AIG Hospitals, Hyderabad, India
| | - Pradev Inavolu
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Zaheer Nabi
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Nitin Jagtap
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Rakesh Kalapala
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Sundeep Lakhtakia
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | | | | | - Mohan Ramchandani
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
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Zhang H, Huang Z, Tang X. Is it necessary to explore modified peroral endoscopic myotomy strategies to prevent the occurrence of gastroesophageal reflux? Gastrointest Endosc 2024; 99:131. [PMID: 38097303 DOI: 10.1016/j.gie.2023.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 08/25/2023] [Indexed: 12/18/2023]
Affiliation(s)
- Han Zhang
- Department of Gastroenterology, Zigong First People's Hospital, Zigong, China
| | - Zhong Huang
- Department of Gastroenterology, Zigong First People's Hospital, Zigong, China
| | - Xiaowei Tang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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Nabi Z, Reddy N. Response. Gastrointest Endosc 2024; 99:131. [PMID: 38097304 DOI: 10.1016/j.gie.2023.08.023] [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: 08/29/2023] [Revised: 08/30/2023] [Accepted: 08/30/2023] [Indexed: 12/18/2023]
Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India
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Wessels EM, Masclee GMC, Bredenoord AJ. An overview of the efficacy, safety, and predictors of achalasia treatments. Expert Rev Gastroenterol Hepatol 2023; 17:1241-1254. [PMID: 37978889 DOI: 10.1080/17474124.2023.2286279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 11/17/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Achalasia is a rare esophageal motility disorder characterized by abnormal esophageal peristalsis and the inability of the lower esophageal sphincter to relax, resulting in poor esophageal emptying. This can be relieved by endoscopic and surgical treatments; each comes with certain advantages and disadvantages. AREAS COVERED This review aims to guide the clinician in clinical decision making on the different treatment options for achalasia regarding the efficacy, safety, and important predictors. EXPERT OPINION Botulinum toxin injection is only recommended for a selective group of achalasia patients because of the short term effect. Pneumatic dilation improves achalasia symptoms, but this effect diminishes over time and requiring repeated dilations to maintain clinical effect. Heller myotomy combined with fundoplication and peroral endoscopic myotomy are highly effective on the long term but are more invasive than dilations. Gastro-esophageal reflux complaints are more often encountered after peroral endoscopic myotomy. Patient factors such as age, comorbidities, and type of achalasia must be taken into account when choosing a treatment. The preference of the patient is also of great importance and therefore shared decision making has to play a fundamental role in deciding about treatment.
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Affiliation(s)
- Elise M Wessels
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, Netherlands
| | - Gwen M C Masclee
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, Netherlands
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Mandarino FV, Vespa E, Barchi A, Fasulo E, Sinagra E, Azzolini F, Danese S. Precision Endoscopy in Peroral Myotomies for Motility Disorders of the Upper Gastrointestinal Tract: Current Insights and Prospective Avenues-A Comprehensive Review. Life (Basel) 2023; 13:2143. [PMID: 38004283 PMCID: PMC10672509 DOI: 10.3390/life13112143] [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: 09/25/2023] [Revised: 10/28/2023] [Accepted: 10/29/2023] [Indexed: 11/26/2023] Open
Abstract
Our review delves into the realm of peroral endoscopic myotomies (POEMs) in the upper gastrointestinal tract (UGT). In recent years, POEMs have brought about a revolution in the treatment of UGT motility disorders. Esophageal POEM, the first to be introduced, has now been validated as the primary treatment for achalasia. Subsequently developed, G-POEM displays promising results in addressing refractory gastroparesis. Over time, multiple endoscopic myotomy techniques have emerged for the treatment of Zenker's diverticulum, including Z-POEM, POES, and hybrid approaches. Despite the well-established efficacy outcomes, new challenges arise in the realm of POEMs in the UGT. For esophageal POEM, the future scenario lies in customizing the myotomy extent to the minimum necessary, while for G-POEM, it involves identifying patients who can optimally benefit from the treatment. For ZD, it is crucial to validate an algorithm that considers various myotomy options according to the diverticulum's size and in relation to individual patients. These challenges align with the concept of precision endoscopy, personalizing the technique for each subject. Within our text, we comprehensively examine each myotomy technique, analyzing indications, outcomes, and adverse events. Additionally, we explore the emerging challenges posed by myotomies within the context of the evolving field of precision endoscopy.
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Affiliation(s)
- Francesco Vito Mandarino
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Edoardo Vespa
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Alberto Barchi
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Ernesto Fasulo
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto San Raffaele Giglio, 90015 Cefalù, Italy
| | - Francesco Azzolini
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Silvio Danese
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
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Bar N, Vélez C, Pasricha TS, Thurm T, Ben-Ami Shor D, Dekel R, Ron Y, Staller K, Kuo B. Safety of Pneumatic Dilation in Older Adults with Achalasia: An International Multicenter Cross-Sectional Study. J Clin Med 2023; 12:6682. [PMID: 37892819 PMCID: PMC10607090 DOI: 10.3390/jcm12206682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 10/03/2023] [Accepted: 10/20/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Pneumatic dilation (PD) is an effective first line treatment option for many patients with achalasia. PD use may be limited in adults with achalasia who are older than 65 because of concern for adverse events (AE), and less efficacious therapies are often utilized. We explored the periprocedural safety profile of PD in older adults. METHODS An international real world cross-sectional study of patients undergoing PD between 2006-2020 in two tertiary centers. Thirty-day AEs were compared between older adults (65 and older) with achalasia and younger patients. RESULTS A total of 252 patients underwent 319 PDs. In 319 PDs, 18 (5.7%) complications occurred: 6 (1.9%) perforations and 12 (3.8%) emergency department referrals with benign (non-perforation) chest pain, of which 9 (2.8%) were hospitalized. No bleeding or death occurred within 30 days. Perforation rates were similar in both age groups and across achalasia subtypes. Advanced age was protective of benign chest pain complications in univariate analysis, and the limited number of AEs precluded multivariable analysis. CONCLUSIONS The safety of PD in older adults is at least comparable to that of younger patients and should be offered as an option for definitive therapy for older patients with achalasia. Our results may affect informed consent discussions.
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Affiliation(s)
- Nir Bar
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (T.T.); (D.B.-A.S.); (R.D.); (Y.R.)
- Center for Neurointestinal Health, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (C.V.); (T.S.P.); (K.S.); (B.K.)
| | - Christopher Vélez
- Center for Neurointestinal Health, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (C.V.); (T.S.P.); (K.S.); (B.K.)
| | - Trisha S. Pasricha
- Center for Neurointestinal Health, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (C.V.); (T.S.P.); (K.S.); (B.K.)
| | - Tamar Thurm
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (T.T.); (D.B.-A.S.); (R.D.); (Y.R.)
| | - Dana Ben-Ami Shor
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (T.T.); (D.B.-A.S.); (R.D.); (Y.R.)
| | - Roy Dekel
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (T.T.); (D.B.-A.S.); (R.D.); (Y.R.)
| | - Yishai Ron
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (T.T.); (D.B.-A.S.); (R.D.); (Y.R.)
| | - Kyle Staller
- Center for Neurointestinal Health, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (C.V.); (T.S.P.); (K.S.); (B.K.)
| | - Braden Kuo
- Center for Neurointestinal Health, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (C.V.); (T.S.P.); (K.S.); (B.K.)
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Keller J. [Esophageal Motility Disorders - What's New?]. Dtsch Med Wochenschr 2023; 148:1187-1200. [PMID: 37657457 DOI: 10.1055/a-1664-7458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
Esophageal motor disorders are an important cause of dysphagia but can also be associated with retrosternal pain and heartburn as well as regurgitation. In extreme cases, patients are not able to eat appropriately and lose weight. Repetitive aspiration can occur and may cause pulmonological complications. Achalasia represents the most important and best-defined esophageal motor disorder and is characterized by insufficient relaxation of the lower esophageal sphincter in combination with typical disturbances of esophageal peristalsis. Additional defined motor disorders are distal esophageal spasm, hypercontractile esophagus, absent contractility and ineffective peristalsis. Patients with appropriate symptoms should primarily undergo esophagogastroduodenoscopy for exclusion of e.g., tumors and esophagitis. Esophageal high-resolution manometry is the reference method for diagnosis and characterization of motor disorders in non-obstructive dysphagia. An esophagogram with barium swallow may deliver complementary information or may be used if manometry is not available. Balloon dilatation and Heller myotomy are long established and more or less equally effective therapeutic options for patients with achalasia. Peroral endoscopic myotomy (POEM) enhances the therapeutic armamentarium for achalasia and hypertensive/spastic motor disorders since 2010. For hypotensive motor disorders, which may occur as a complication of e.g., rheumatological diseases or idiopathically, therapeutic options are still limited.
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Albéniz E, Marra-López Valenciano C, Estremera-Arévalo F, Sánchez-Yagüe A, Montori S, Rodríguez de Santiago E. POEM from A to Z: current perspectives. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023. [PMID: 37073708 DOI: 10.17235/reed.2023.9602/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
The "third space endoscopy" or also called "submucosal endoscopy" is a reality we can transfer to our patients since 2010. Various modifications of the submucosal tunneling technique allow access to the submucosa or deeper layers of the gastrointestinal tract. In addition to peroral endoscopic myotomy for the treatment of achalasia, also called esophageal POEM, other variants have emerged that make it possible to treat different esophageal motility disorders, esophageal diverticula, subepithelial tumors of various locations, gastroparesis, reconnection of complete esophageal strictures or even thanks to exceptional endoscopists, pediatric disorders such as Hirschsprung's disease. Although some technical aspects are yet to be standardized, these procedures are becoming widespread worldwide and will likely become the standard treatment of these pathologies soon.
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Affiliation(s)
- Eduardo Albéniz
- Endoscopy Unit. Gastroenterology, Hospital Universitario de Navarra (HUN). Navarrabiomed. UPNA, IdiSNA, España
| | | | | | | | - Sheyla Montori
- Gastrointestinal Endoscopy Research Unit, Hospital Universitario de Navarra (HUN). Navarrabiomed. UPNA, IdiSNA, Spain
| | - Enrique Rodríguez de Santiago
- Gastroenterology and Hepatology , Hospital Universitario Ramón y Cajal. Universidad de Alcalá. IRYCIS. CIBERehd. ISCIII, Spain
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13
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Vespa E, Repici A. Reply to Zhang et al. Endoscopy 2023; 55:298. [PMID: 36854300 DOI: 10.1055/a-1931-4364] [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: 03/02/2023]
Affiliation(s)
- Edoardo Vespa
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy.,Department of Gastroenterology and Hepatology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy.,Department of Gastroenterology and Hepatology, IRCCS Humanitas Research Hospital, Rozzano, Italy
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14
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Zhang H, Peng Y, Tang X. Comments on: "Long-term outcomes of peroral endoscopic myotomy for achalasia: a systematic review and meta-analysis". Endoscopy 2023; 55:297. [PMID: 36854299 DOI: 10.1055/a-1929-1522] [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: 03/02/2023]
Affiliation(s)
- Han Zhang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yan Peng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaowei Tang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
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15
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Quénéhervé L, Vauquelin B, Berger A, Coron E, Olivier R. Risk factors for clinical failure of peroral endoscopic myotomy in achalasia. Front Med (Lausanne) 2022; 9:1099533. [PMID: 36569161 PMCID: PMC9773253 DOI: 10.3389/fmed.2022.1099533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022] Open
Abstract
The recent development of per oral endoscopic myotomy (POEM) has been a game changer in the management of patients with achalasia. However, approximately 1 in 10 patients will not experience clinical success. The aim of this mini-review is to describe the current state of knowledge about the risk factors associated with POEM failure for the treatment of achalasia. Suspected risk factors are detailed into pre-, intra-, and post-procedural factors and put into perspective. Pre-procedural factors have been described, such as pre-treatment Eckardt score, previous treatments for achalasia, sigmoid type esophagus, significant esophageal dilatation, non-type II achalasia, young age and long duration of symptoms. An intra-procedural factor, mucosal injury during POEM, has also been associated with POEM failure. The occurrence of post-POEM GERD was identified as a controversial post-procedural factor associated with failure. The presumed mechanisms of POEM failure are incomplete myotomy or ineffective LES disruption, as confirmed by high-resolution manometry. However, when manometry confirms a significant decrease in LES pressure, it is likely that either impaired peristalsis or a morphologic abnormality such as extreme esophageal dilatation or severe tortuosity, which are not treated by POEM, should be suspected. Notably, a recently described adverse effect of POEM is the formation of a pseudo-diverticulum at the site of the myotomy (blown out myotomy). We finally stress the importance of performing a complete workup in case of POEM failure as different mechanisms of POEM failure should lead to different management.
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Affiliation(s)
- Lucille Quénéhervé
- Gastroenterology Department, University Hospital of Brest, Brest, France,*Correspondence: Lucille Quénéhervé,
| | - Blandine Vauquelin
- Gastroenterology Department, Centre Medico-Chirurgical Magellan, INSERM CIC 1401, CHU de Bordeaux, Hôpital Haut-Lévêque, Université de Bordeaux, Bordeaux, France
| | - Arthur Berger
- Gastroenterology Department, Centre Medico-Chirurgical Magellan, INSERM CIC 1401, CHU de Bordeaux, Hôpital Haut-Lévêque, Université de Bordeaux, Bordeaux, France
| | - Emmanuel Coron
- Service de Gastro-Entérologie et Hépatologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Raphael Olivier
- Gastroenterology Department, University Hospital of Poitiers, Poitiers, France
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