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Vespa E, Mandarino FV, Barchi A, Azzolini F, Danese S. Is peroral endoscopic myotomy easier after previous achalasia treatment? The jury is still out. Gastrointest Endosc 2023; 98:262. [PMID: 37455052 DOI: 10.1016/j.gie.2023.03.004] [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: 03/03/2023] [Accepted: 03/03/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Edoardo Vespa
- Division of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Vito Mandarino
- Division of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Barchi
- Division of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Azzolini
- Division of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Silvio Danese
- Division of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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Kadiyala J, Canakis A, Lee DU, Xue P, Fan GH, Kim RE. Comparing clinical success and procedural difficulty between treatment-naïve and treatment-refractory patients with esophageal motility disorders during peroral endoscopic myotomy. Gastrointest Endosc 2023; 98:19-27.e11. [PMID: 36739994 DOI: 10.1016/j.gie.2023.01.052] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/18/2023] [Accepted: 01/29/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) can successfully treat patients with achalasia. Prior therapy with Botox (Allergan, Madison, NJ, USA) injections, pneumatic dilation (PD), and/or laparoscopic Heller myotomy (LHM) is believed to increase the difficulty of POEM procedures. We aimed to determine if prior treatment methods were associated with longer procedure times or lower clinical success. METHODS In this single-center retrospective study, consecutive patients who underwent POEM for achalasia between February 2017 and September 2021 were studied. Collected data were patient demographics, prior treatment, pre- and postprocedure Eckardt score (ES), distensibility indices (DIs), and procedure times. Primary outcomes were clinical success and procedure difficulty. RESULTS Of 95 patients (mean age, 55.6 years; 45% women), 25 patients underwent POEM for type I achalasia, 31 for type II achalasia, and 33 for spastic esophageal pathologies. Thirty-three patients (34.7%) were treated for achalasia before POEM with onabotulinumtoxinA injections (n = 18), PD (n = 17), and LHM (n = 3). There were no significant differences in post-treatment ESs or technical success between the 2 groups (P = .98 and P = .66, respectively). Multivariate analysis showed that prior treatment was associated with decreased case time and easier tunneling during POEM. CONCLUSIONS Prior treatment did not impact the clinical success rate of POEM and led to decreased case times and easier tunneling difficulty, likely because of persistent lower esophageal sphincter changes and differences in diagnostic indications. POEM should be considered for patients with treatment-refractory symptoms as a safe and feasible option. Further large-scale studies are needed to validate our findings.
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Affiliation(s)
- Jagannath Kadiyala
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Andrew Canakis
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - David Uihwan Lee
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Pei Xue
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gregory H Fan
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Raymond E Kim
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
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Liu XY, Geng ZH, Chen WF, Xu MD, Chen SY, Zhong YS, Zhang YQ, Ma LL, Qin WZ, Hu JW, Cai MY, Li QL, Zhou PH. A prediction model and nomogram for technical difficulty of peroral endoscopic myotomy. Surg Endosc 2022; 37:2781-2788. [PMID: 36477640 DOI: 10.1007/s00464-022-09798-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 11/27/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) is a promising endoscopic technique for achalasia. We aimed to establish a regression model and develop a simple nomogram to predict the technical difficulty of POEM in a single center with large volume cases. METHODS 3385 achalasia patients treated with POEM were included, and the technical difficulty was systemically evaluated. All of them were randomized into the training cohort (n = 1693) or internal validation cohort (n = 1692). Then, the prediction model and nomogram were proposed based on multivariate logistic regression analysis in the training cohort and assessed in the validation cohort. RESULTS Of 3385 patients, technical difficulty happened in 417 (12.32%) cases. In the training stage, six factors were weighted based on the β coefficient from the regression model, including age, disease duration, sigmoid esophagus, mucosal edema, submucosal fibrosis, and tunnel length. The patients were categorized into low-risk (< 0.1), medium-risk (0.1-0.25), and high-risk (> = 0.25) groups. Our score model performed satisfying discrimination with the areas under the receiver-operating characteristic curve (AUC) of 0.743 (95% confidence interval (CI), 0.701-0.785) and calibration with goodness of fit in the Hosmer-Lemeshow test (P = 0.088) in internal validation. CONCLUSIONS The prediction model and nomogram demonstrated good performance in predicting the technical difficulty of POEM.
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Affiliation(s)
- Xin-Yang Liu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Zi-Han Geng
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Wei-Feng Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Mei-Dong Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shi-Yao Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Yun-Shi Zhong
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Yi-Qun Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Li-Li Ma
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Wen-Zheng Qin
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Jian-Wei Hu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Ming-Yan Cai
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China.
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China.
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Nabi Z, Nageshwar Reddy D. Impact of modified techniques on outcomes of peroral endoscopic myotomy: A narrative review. Front Med (Lausanne) 2022; 9:948299. [PMID: 36059849 PMCID: PMC9433832 DOI: 10.3389/fmed.2022.948299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/08/2022] [Indexed: 12/02/2022] Open
Abstract
Peroral endoscopic myotomy (POEM) is an established frontline treatment modality for achalasia cardia. Since its initial description, several modifications have been proposed to the technique of POEM. Broadly speaking, these modifications follow the basic principles of submucosal endoscopy, but incorporate variations in the POEM technique, including the difference in the orientation of myotomy (anterior or posterior), length of myotomy (short or long), and thickness of myotomy (selective circular or full thickness). Some of these modifications have been shown to reduce procedural duration without compromising the efficacy of the POEM procedure. More recently, several alterations have been reported that intend to reduce gastroesophageal reflux after POEM. These include preservation of sling fibers during posterior POEM and addition of NOTES fundoplication to the POEM procedure. Although some of the modified techniques have been compared with the conventional techniques in quality trials, randomized studies are awaited for others. The incorporation of some of these modifications will likely make POEM a technically easy and safer modality in near future. This review aims to discuss the current evidence with regard to the impact of modified techniques on the outcome of POEM.
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Peng D, Tan Y, Li C, Lv L, Zhu H, Liang C, Li R, Liu D. Peroral Endoscopic Myotomy for Pediatric Achalasia: A Retrospective Analysis of 21 Cases With a Minimum Follow-Up of 5 Years. Front Pediatr 2022; 10:845103. [PMID: 35444970 PMCID: PMC9013798 DOI: 10.3389/fped.2022.845103] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 03/01/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) has shown promising short-term safety and efficacy in pediatric patients, while long-term outcomes are largely unknown. This study aimed to assess the clinical effects of POEM for pediatric achalasia who had a follow-up of at least 5 years. METHODS Pediatric patients from a single center who underwent a POEM between October 2011 and November 2016 were, respectively, collected and analyzed for long-term clinical outcomes. Patients were contacted to evaluate their current symptoms and encouraged repeat endoscopy and manometry. The clinical success, procedure-related parameters, adverse events, gastroesophageal reflux disease after POEM, and quality of life were evaluated. RESULTS A total of twenty-four patients who underwent POEM in our center were studied, with a mean age of 14.42 ± 2.65. Two of the 24 patients (8.3%) had previous treatment. The mean of the procedure time was 58.67 ± 19.10 min, 8.3% (2/24) of patients experienced perioperative adverse events. The current symptom scores were obtained from 21 patients at a mean follow-up of 92.57 months, the remainder were lost to follow-up after a mean of 38 months. Eckardt scores were significantly improved from preoperative baseline (preoperative 7.67 ± 1.62 vs. current 0.86 ± 1.28, P < 0.001). Long-term overall success was achieved in 95.8% of patients and none required retreatment for symptoms. 12.5% of patients were suffered from clinical reflux. 76.2% of patients expressed satisfaction with POEM. No severe adverse events were observed during the operation and the 5-years follow-up. CONCLUSION POEM resulted in successful symptomatic mitigation in a majority of pediatric patients after 5 years. A multi-center large-scale, prospective study is necessary for a confirmed conclusion.
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Affiliation(s)
- Dongzi Peng
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
| | - Yuyong Tan
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
| | - Chenjie Li
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
| | - Liang Lv
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
| | - Hongyi Zhu
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
| | - Chengbai Liang
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
| | - Rong Li
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
| | - Deliang Liu
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
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Günay S, SarıtaşYüksel E, Topal F, Paköz B, Çekiç C, Çamyar H, Vatansever S. Dissection of mucosa and muscularis mucosa instead of submucosal dissection: rapid retroflow of the injection fluid can be an indicator. Endoscopy 2021; 53:E122-E123. [PMID: 32707582 DOI: 10.1055/a-1216-0448] [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: 12/10/2022]
Affiliation(s)
- Süleyman Günay
- Department of Gastroenterology, Katip Çelebi University, Atatürk Training and Research Hospital, İzmir, Turkey
| | - Elif SarıtaşYüksel
- Department of Gastroenterology, Katip Çelebi University, Atatürk Training and Research Hospital, İzmir, Turkey
| | - Firdevs Topal
- Department of Gastroenterology, Katip Çelebi University, Atatürk Training and Research Hospital, İzmir, Turkey
| | - Betül Paköz
- Department of Gastroenterology, Katip Çelebi University, Atatürk Training and Research Hospital, İzmir, Turkey
| | - Cem Çekiç
- Department of Gastroenterology, Katip Çelebi University, Atatürk Training and Research Hospital, İzmir, Turkey
| | - Hakan Çamyar
- Department of Gastroenterology, Katip Çelebi University, Atatürk Training and Research Hospital, İzmir, Turkey
| | - Sezgin Vatansever
- Department of Gastroenterology, Katip Çelebi University, Atatürk Training and Research Hospital, İzmir, Turkey
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Mandavdhare HS, Mishra S, Kumar A, Shah J, Samanta J, Gupta P, Singh H, Dutta U. Per-oral Endoscopic Myotomy and Other Applications of Third Space Endoscopy: Current Status and Future Perspectives. Surg Laparosc Endosc Percutan Tech 2021; 31:624-636. [PMID: 33710101 DOI: 10.1097/sle.0000000000000920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 01/13/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The modification of NOTES (natural orifice transluminal endoscopic surgery) by mucosal safety flap has introduced us to the world of third space endoscopy (TSE). POEM (per-oral endoscopic myotomy) for achalasia cardia being its first vista, the realm expanded so that we can now remove en bloc a subepithelial/intramural tumor by POET (per-oral endoscopic tumor resection), perform G-POEM (gastric per-oral endoscopic myotomy) for refractory gastroparesis, restore esophageal continuity in complete obstruction by performing POETRE (per-oral endoscopic tunneling for the restoration of the esophagus), divide the septum in Zenker diverticulum completely with negligible risk of perforation by Z-POEM (Zenker per-oral endoscopic myotomy) and relieve constipation in Hirschsprung disease by PREM (per-rectal endoscopic myotomy). However, the real potential of TSE became evident with the introduction of POEM with fundoplication. TSE has opened the gates of the peritoneal cavity. Improved expertise and equipment will make the role of endoscopist complimentary to the surgeon with the dawn of a new field in therapeutic endoscopy. AREAS COVERED This review intends to comprehensively discuss the various aspects of POEM for achalasia studied so far followed by a brief discussion about other applications of TSE and the future perspectives in this exciting field.
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Affiliation(s)
| | | | | | | | | | | | - Harjeet Singh
- Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Outcomes of peroral endoscopic myotomy in challenging achalasia patients: a long-term follow-up study. Surg Endosc 2020; 35:3732-3743. [PMID: 32794046 DOI: 10.1007/s00464-020-07864-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 08/05/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) has been shown to be effective for achalasia patients. Our study aimed to analyze the clinical outcomes of POEM for challenging patients. METHODS We retrospectively enrolled 278 challenging achalasia patients who underwent POEM from January 2011 to July 2019. The outcomes of POEM such as procedure time, adverse events, and risk factors of adverse events were analyzed. RESULTS Of the 278 patients (134 males and 144 females) with a mean age of 47.0 years, 103, 223, 93, and 98 patients had prior treatment and were Ling classification IIc/III, submucosal fibrosis (SMF) classification 2/3, and esophageal mucosa in achalasia (EMIA) classification c/d/e/f, respectively. The mean procedure time was 45.9 min (range, 15-158 min). The mean length of the tunnel and myotomy were 10.1 cm (range, 7-17 cm) and 6.6 cm (range, 5-13 cm), respectively. The major adverse event rate was 14.1%, while the minor adverse event rate was 4.7%. SMF classification 2/3 was an independent risk factor for incomplete tunneling, adverse events, and procedure time ≥ 90 min. The mean follow-up time was 37.2 months (range 1-99 months). The mean Eckardt score and esophageal sphincter pressure were both significantly declined postoperatively. The clinical success rate was 95.6%. CONCLUSION POEM is safe and effective for challenging achalasia patients. SMF classification grade 2/3 was shown to be an independent risk factor for incomplete tunneling, adverse events, and procedure time ≥ 90 min. For these patients, POEM should be performed by experienced endoscopists, some cases are better served with traditional surgery, such as minimally invasive Heller with Dor fundoplication.
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Feasibility of Speedboat RS2 with bipolar radiofrequency energy for peroral endoscopic myotomy in patients with achalasia (with video). Endosc Int Open 2020; 8:E998-E1001. [PMID: 32743048 PMCID: PMC7373652 DOI: 10.1055/a-1165-0087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/01/2020] [Indexed: 10/27/2022] Open
Abstract
Background During peroral endoscopic myotomy (POEM), use of traditional instruments leads to an increase in overall time of procedure due to constant exchange of instruments. Speedboat-RS2 (Creo-Medical, UK) is a novel device which has shown promising results for endoscopic submucosal dissection of gastrointestinal lesions, but its feasibility, and safety for POEM is unexplored. Methods Data from patients who had undergone POEM for achalasia cardia utilizing Speedboat-RS2 was reviewed. Results Two patients with mean age of 46 years and mean symptom duration of 3 years were included. Both patients had type II achalasia diagnosed on esophageal manometry. One patient underwent anterior myotomy and the other posterior approach. Submucosal tunneling (~15 cm) was achieved in a mean of 20 minutes, myotomy (~ 9 cm) in 8 minutes and the entire procedure was completed in a mean of 30 minutes with 100 % technical success. Both patients were discharged the day after the procedure without any immediate adverse events. At 6 weeks, endoscopy was uneventful and the patients were asymptomatic. Conclusions Early experience shows that Speedboat-RS2 is feasible for performing POEM with good safety profile. Submucosal tunneling was relatively quick and coagulation was effective. Long term studies with a larger patient cohort are warranted.
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