A Decade of Investigation: Peroral Endoscopic Myotomy Versus Laparoscopic Heller Myotomy for Achalasia

Achalasia Subtype Differences Based on Respiratory Symptoms and Radiographic Findings

Three subtypes of achalasia have been defined using esophageal manometry. Several studies have reported that symptoms are experienced differently among men and women, regardless of subtype. All subtypes could have some impact on the appearance of respiratory symptoms and lung complications due to compression of the trachea or aspiration of undigested food. The aim of this research was to analyze the differences in respiratory symptoms and radiographic presentation of lung pathology depending on the diameter and achalasia types. One or more respiratory symptoms were reported in 48% of 114 patients, and all of them had two or more gastrointestinal symptoms. The symptom score (SS) is statistically significant for the prediction of subtype 1 (area under the curve = 0.318; p < 0.001, cut-off score of 6.5 had 95.2% sensitivity) and subtype 2 (area under the curve = 0.626; p = 0.020, cut-off score of 7.5 had 93.1% sensitivity). The most common type was subtype 2 (50.8%), and although only 14 patients had subtype 3, they had the largest esophageal diameter (mean 5.8 cm). The difference in esophageal diameter was significant between subtype 1 and 3 (p = 0.011), subtype 2 and subtype 3 (p = 0.011). Nine patients (6%) had mega-esophagus (four patients in type 1, three in type 2 and two in type 3). More than half of all patients (51.7%) had at least one parenchymal lung change on CT scan. Recurrent micro-aspirations led to changes in the structure of the airways and lung parenchyma such as ground glass (GGO) and nodular changes (12%) and fibrosis (14.5%), and they had higher esophageal diameters (p < 0.001). Patients with chronic lung CT changes had significantly higher esophageal diameter than with acute changes (p < 0.001). Awareness of the association of achalasia and lung disorders is important in early diagnosis and treatment. More than half (57.5%) of patients with achalasia had some clinical and/or structural pulmonary abnormalities. All three subtypes had similar respiratory symptoms, meaning they cannot be used to predict the subtype of achalasia; on the contrary, SS can predict the first two subtypes. A higher diameter of the esophagus is associated with chronic structural lung changes. Although unexpected, the pathological radiological findings and diameter were significantly different in subtype 3 patients, but those parameters cannot lead us to a specified subtype.

Gastroesophageal Reflux after Peroral Endoscopic Myotomy: Myth or Reality?

Peroral endoscopic myotomy (POEM) is an accepted treatment for achalasia cardia (AC), and results are comparable to those of laparoscopic Heller myotomy (LHM). In recent years, several reports have confirmed higher incidence of gastroesophageal reflux (GER) following POEM. This review evaluates the current evidence regarding post-POEM GER, critically examines the potential contributing factors responsible for GER, limitations of the current available functional testing, and precautions and preventive measures, and provides future directions for research. Factors conclusively contributing to increased post-POEM GER include injury to the sling fibers of the lower esophageal sphincter, length of gastric myotomy > 2 cm, and others. Historically, these same factors have been implicated for development of GER after surgical (laparoscopic) myotomy. Although less invasive, optimal technique of POEM may be important to control post-POEM GER. Most post-POEM GER occurs during the immediate post-POEM period, is mild, and is easily treatable using proton-pump inhibitors. GER incidence plateaus at 2 years and is comparable to that after LHM. Patients should therefore be prescribed proton-pump inhibitors for at least 2 years. Antireflux procedures (ARPs) are infrequently required in these patients as the incidence of refractory GER is low. Novel ARPs have been recently described and are currently under evaluation. Conclusive diagnosis of GER is a clinical challenge. Most patients are asymptomatic, and GER is diagnosed only on abnormal esophageal acid exposure (EAE). Studies have demonstrated that current measures to diagnose GER are inadequate, inaccurate, and cannot differentiate between true GER and abnormal EAE due to food fermentation in the distal esophagus. The Lyon Consensus criteria should be implemented for confirmation of diagnosis of GER. Finally, the review recommends an evidence-based clinical algorithm for evaluation and management of post-POEM GER and provides guidelines for future research in this field.

Third Space Endoscopy: Lessons Learnt From a Decade of Submucosal Endoscopy

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.