Very late results of esophagomyotomy for patients with achalasia: clinical, endoscopic, histologic, manometric, and acid reflux studies in 67 patients for a mean follow-up of 190 months

Prediction, prevention and management of gastroesophageal reflux after per-oral endoscopic myotomy: An update

Achalasia cardia, the most prevalent primary esophageal motility disorder, is predominantly characterized by symptoms of dysphagia and regurgitation. The principal therapeutic approaches for achalasia encompass pneumatic dilatation (PD), Heller's myotomy, and the more recent per-oral endoscopic myotomy (POEM). POEM has been substantiated as a safe and efficacious modality for the management of achalasia. Although POEM demonstrates superior efficacy compared to PD and an efficacy parallel to Heller's myotomy, the incidence of gastroesophageal reflux disease (GERD) following POEM is notably higher than with the aforementioned techniques. While symptomatic reflux post-POEM is relatively infrequent, the significant occurrence of erosive esophagitis and heightened esophageal acid exposure necessitates vigilant monitoring to preclude long-term GERD-related complications. Contemporary advancements in the field have enhanced our comprehension of the risk factors, diagnostic methodologies, preventative strategies, and therapeutic management of GERD subsequent to POEM. This review focuses on the limitations inherent in the 24-h pH study for evaluating post-POEM reflux, potential modifications in the POEM technique to mitigate GERD risk, and the strategies for managing reflux following POEM.

Per-oral endoscopic myotomy in cases with prior Heller's myotomy: Outcomes at a median follow-up of 5 years

BACKGROUND AND AIM

Per-oral endoscopic myotomy (POEM) is an established treatment for achalasia cardia. However, data on the long-term efficacy of POEM in patients with failed Heller's myotomy (HM) are limited. The purpose of this study was to evaluate the long-term outcomes of POEM in patients with persistent or recurrent symptoms following HM.

METHODS

Data of patients with recurrence of symptoms after HM who underwent POEM (September 2013 to December 2022) were analyzed, retrospectively. Primary outcome was clinical success [Eckardt score (ES) ≤ 3]. Secondary outcomes included improvement of manometry parameters, barium emptying at 5 min and gastroesophageal reflux (esophagitis and increased esophageal acid exposure) after POEM.

RESULTS

Seventy-two cases (45.9 ± 13.4 years, 43 men) with history of HM were included in the study. The subtypes of achalasia were type 1 (40.3%), type 2 (37.5%), and unknown (19.4%). Prior treatment included HM in 48 (66.7%), HM plus pneumatic dilatation in 20 (27.8%), and HM plus pneumatic dilatation and Botox in 4 (5.5%). Technical success was achieved in all cases. Mean length of myotomy was 10.7 ± 3.3 cm, and mean procedure duration was 59.2 ± 25.9 min. There was significant improvement in ES (pre-POEM 6.5 ± 1.8 vs post-POEM 0.7 ± 0.7), lower esophageal sphincter pressure pressures (31.7 ± 12.5 vs 13.3 ± 5.7 mmHg) and barium emptying (14.2 ± 4.2 vs 2.4 ± 3.1 cm) after POEM. At a median follow-up of 63 months (IQR 40-95), clinical success (ES ≤ 3) was documented in 58 (80.6%) patients. Reflux esophagitis and increased esophageal acid exposure were recorded in 28 of 49 (57.1%) and 11 of 20 (55%) patients, respectively.

CONCLUSION

POEM is a durable treatment modality in cases with relapse of symptoms after HM.

Probability of additional intervention and long-term follow-up of esophagomyotomy

INTRODUCTION

Two common surgical procedures used to treat esophageal motility disorders are laparoscopic Heller myotomy (LHM) with partial fundoplication and per-oral endoscopic myotomy (POEM). The difference in frequency of follow-up interventions following these procedures is unknown. This study was designed to report differences in post-surgical interventions as one of the major long-term follow-up expectations.

METHODS

An IRB approved registry was used to identify all patients undergoing surgery with LHM or POEM. Following surgery, patients requiring additional interventions with esophageal non-pneumatic dilation, botox injection, or repeat myotomy, as well as persistent proton pump inhibitor (PPI) use were recorded. Multivariable logistic regression analysis was performed to estimate risk factors associated with return for additional post-operative intervention.

RESULTS

A total of 203 patients were identified, 139 met inclusion criteria (33 LHM and 106 POEM). There was a higher rate of non-pneumatic EGD dilation (33% vs 15%, p = 0.04), repeat myotomy (18% vs 2%, p < 0.01), and higher rate of overall post-operative intervention in LHM than POEM. With POEM, there was a higher rate of post-operative PPI use (63 vs 29%, p < 0.01). There was no difference in time to post-operative intervention for either group, but if intervention were to occur the median time was within the first year. Patients with a change in pre- to post-operative Eckardt score of 4 or greater decreased their chance of having a post-operative intervention.

CONCLUSION

Our results for both LHM and POEM emphasize the importance of long-term follow-up in patients with an esophageal motility disorder. We have found that patients undergoing LHM are more likely to have a post-operative intervention as well as a higher rate of repeat myotomy than POEM. With both interventions, a greater change in Eckardt score decreased the likelihood of reintervention.

Third-space endoscopy: the final frontier

Over the years, our growing experience with endoscopic submucosal dissection along with technological advances has solidified our comfort and knowledge on working in the submucosa, also referred to as the "third space." Per-oral endoscopic myotomy (POEM) was the first prototype third-space endoscopy (TSE) procedure, demonstrating the feasibility and clinical utility of endoscopic esophagogastric myotomy via submucosal tunneling. The launch of POEM accelerated the evolution of TSE from a vanguard concept to an expanding field with a wide range of clinical applications. In this review, we discuss the status and future directions of multiple TSE interventions.

From laparoscopic to robotic-assisted Heller myotomy for achalasia in a single high-volume visceral surgery center: postoperative outcomes and quality of life

Background

Laparoscopic (LSC) Heller myotomy (HM) is considered the standard procedure for the treatment of achalasia. Robotic platforms, established over the last years, provide important advantages to surgeons, such as binocular 3-dimensional vision and improvement of fine motor control. However, whether perioperative outcomes and long-term results of robotic-assisted laparoscopic (RAL) HM are similar or even superior to LSC technique, especially concerning long-term follow-up, is still debated. Therefore, the aim of the present study was to evaluate intra- and postoperative results as well as long-term quality of life after RAL compared to LSC surgery for achalasia in a single high-volume visceral surgery center.

Methods

Between August 2007 and April 2020, 43 patients undergoing minimally invasive HM for achalasia in a single high-volume Swiss visceral surgery center, were included in the present study. Intra- and postoperative outcome parameters were collected and evaluated, and a long-term follow-up was performed using the gastroesophageal-reflux disease health-related quality of life (GERD-Hr-QuoL) questionnaire.

Results

A total of 11 patients undergoing RAL and 32 undergoing LSC HM were analyzed. Baseline demographics and clinical characteristics were similar. A trend (p = 0.052) towards a higher number of patients with ASA III score treated with RAL was detectable. Operation time was marginally, but significantly, shorter in LSC (140 min, IQR: 136–150) than in RAL (150 min, IQR: 150–187, p = 0.047). Postoperative complications graded Clavien-Dindo ≥ 3 were only observed in one patient in each group. Length of hospital stay was similar in both groups (LSC: 11 days, IQR: 10–13 vs. RAL: 11 days, IQR: 10–14, p = 0.712). Long-term follow-up (LSC: median 89 months, vs. RAL: median 28 months, p = 0.001) showed comparable results and patients from both groups expressed similar levels of satisfaction (p = 0.181).

Conclusions

LSC and RAL HM show similar peri- and postoperative results and a high quality of life, even in long-term (> 24 months) follow-up. Prospective, randomized, controlled multicenter trials are needed to overcome difficulties associated to small sample sizes in a rare condition and to confirm the equality or demonstrate the superiority of robotic-assisted procedures for achalasia. Meanwhile, the choice of the treatment technique could be left to the operating surgeon’s preferences.

Impact of modified techniques on outcomes of peroral endoscopic myotomy: A narrative review

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.

POEM, GPOEM, and ZPOEM

Our tripartite narrative review discusses Peroral Endoscopic Myotomy (POEM), gastric POEM (GPOEM) and POEM for Zenker's diverticula (ZPOEM). POEM is the prototypical procedure that launched the novel "3rd space endoscopy" field of advanced endoscopy. It revolutionized achalasia therapy by offering a much less invasive version of the prior gold standard, the laparoscopic Heller myotomy (HM). We review in detail indications, outcomes, technique variations and comparative data between POEM and HM particularly with regard to the hotly debated issue of GERD. We then proceed to discuss two less illustrious but nevertheless important offshoots of the iconic POEM procedure: GPOEM for gastroparesis and ZPOEM for the treatment of hypopharyngeal diverticula. For GPOEM, we discuss the rationale of pylorus-directed therapies, briefly touch on GPOEM technique variations and then focus on the importance of proper patient selection and emerging data in this area. On the third and final part of our review, we discuss ZPOEM and expound on technique variations including our "ultra-short tunnel technique". Our review emphasizes that, despite the superiority of endoscopy over surgery for the treatment of hypopharyngeal diverticula, there is no clear evidence yet of the superiority of the newfangled ZPOEM technique compared to the conventional endoscopic myotomy technique practiced for over two decades prior to the advent of ZPOEM.

Esophageal Achalasia: Evaluation and Treatment of Recurrent Symptoms

BACKGROUND

Esophageal achalasia is a primary esophageal motility disorder of unknown origin. Treatment is palliative and its goal is to decrease the resistance posed by a non-relaxing and often hypertensive lower esophageal sphincter. This goal can be accomplished by different treatment modalities such as pneumatic dilatation, laparoscopic myotomy or peroral endoscopic myotomy. In some patients, however, symptoms tend to recur overtime.

METHODS

A comprehensive literature search was performed on PubMed focused on the management of recurrent achalasia.

RESULTS

The available treatment modalities can be used, alone or in combination. The goal of treatment is to resolve/improve symptoms, avoiding an esophagectomy, an operation linked to significant morbidity.

CONCLUSIONS

The treatment of these patients is often very challenging, and the best results are obtained in centers where a multidisciplinary team-radiologists, gastroenterologists, and surgeons-is present.

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.

Achalasia: Diagnosis, Management and Surveillance

Achalasia is a rare chronic esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter and abnormal peristalsis. This abnormal motor function leads to impaired bolus emptying and symptoms of dysphagia, regurgitation, chest pain, or heartburn. After an upper endoscopy to exclude structural causes of symptoms, the gold standard for diagnosis is high-resolution esophageal manometry. However, complementary diagnostic tools include barium esophagram and functional luminal impedance planimetry. Definitive treatments include pneumatic dilation, Heller myotomy with fundoplication, and peroral endoscopic myotomy.

Peroral endoscopic myotomy: 10-year outcomes from a large, single-center U.S. series with high follow-up completion and comprehensive analysis of long-term efficacy, safety, objective GERD, and endoscopic functional luminal assessment

BACKGROUND AND AIMS

Peroral endoscopic myotomy (POEM) is becoming the treatment of choice for achalasia. Data beyond 3 years are emerging but are limited. We herein report our 10-year experience, focusing on long-term efficacy and safety including the prevalence, management, and sequelae of postoperative reflux.

METHODS

This was a single-center prospective cohort study.

RESULTS

Six hundred ten consecutive patients received POEM from October 2009 to October 2019, 160 for type 1 achalasia (26.2%), 307 for type II (50.3%), 93 for type III (15.6%), 25 for untyped achalasia (4.1%), and 23 for nonachalasia disorders (3.8%). Two hundred ninety-two patients (47.9%) had prior treatment(s). There was no aborted POEM. Median operation time was 54 minutes. Accidental mucosotomies occurred in 64 patients (10.5%) and clinically significant adverse events in 21 patients (3.4%). No adverse events led to death, surgery, interventional radiology interventions/drains, or altered functional status. At a median follow-up of 30 months, 29 failures occurred, defined as postoperative Eckardt score >3 or need for additional treatment. The Kaplan-Meier clinical success estimates at years 1, 2, 3, 4, 5, 6, and 7 were 98%, 96%, 96%, 94%, 92%, 91%, and 91%, respectively. These are highly accurate estimates because only 13 patients (2%) were missing follow-up assessments. One hundred twenty-five patients (20.5%) had reflux symptoms more than once per week. At a median of 4 months, the pH study was completed in 406 patients (66.6%) and was positive in 232 (57.1%), and endoscopy was completed in 438 patients (71.8%) and showed reflux esophagitis in 218 (49.8%), mostly mild.

CONCLUSIONS

POEM is exceptionally safe and highly effective on long-term follow-up, with >90% clinical success at ≥5 years.

Optional Management of Achalasia in 2021: Dilatation or Myotomy

Achalasia cardia is a primary motility disorder of the esophagus, defined by lack of normal esophageal peristalsis along with inadequate relaxation of lower esophageal sphincter . The mainstay of management in achalasia includes pneumatic dilatation, Heller’s myotomy and peroral endoscopic myotomy (POEM). Pneumatic dilatation and Heller’s myotomy have gained maturity over several decades. The current best practice with regard to pneumatic dilatation is graded and on-demand dilatation in appropriately selected cases with type I and II achalasia. Laparoscopic Heller’s myotomy plus partial fundoplication is minimally invasive with reduced postoperative reflux and has virtually replaced open Heller’s myotomy with or without fundoplication. The subtyping of achalasia using high-resolution manometry bears prognostic significance and may help in choosing appropriate therapeutic modality in these patients. Since all the three modalities are effective for type I and II achalasia, the choice among these depends on the availability, expertise, and patient’s preferences. On the other hand, POEM is more effective than pneumatic dilatation and Heller’s myotomy and, therefore, preferred in type III achalasia. Although POEM is effective across the spectrum of esophageal motility disorders, the incidence of gastroesophageal reflux is high and needs to be considered while choosing among various options in these patients. In cases with failed POEM, redo POEM appears to be effective in alleviating symptoms.

Outcomes of 100 Patients More Than 4 Years After POEM for Achalasia

OBJECTIVE

We aim to describe the long-term follow-up data from our institution's POEM experience.

SUMMARY BACKGROUND DATA

Per-oral endoscopic myotomy (POEM) is a well-established endoscopic therapy for achalasia with excellent short-term efficacy, but long-term outcomes data are limited.

METHODS

Patients older than 4 years removed from POEM for treatment of achalasia were studied. Clinical success was defined as an Eckardt Symptom (ES) score ≤3 and freedom from reintervention for achalasia. Patients underwent esophagogastroduodenoscopy (EGD), high-resolution manometry, impedance planimetry, and timed barium esophagram (TBE) preoperatively and at least 4 years postoperatively. Objective gastroesophageal reflux disease (GERD) was defined LA Grade B or worse esophagitis on EGD.

RESULTS

One hundred and nineteen consecutive patients were included. Five patients died or had catastrophic events unrelated to achalasia or POEM. One hundred of the remaining patients (88%, 100/114) had long-term data available. Clinical follow-up for all patients was greater than 4 years postoperatively and the mean was 55 months. Mean current ES was significantly improved from preop (n = 100, 1 ± 1 vs 7 ± 2, P < 0.001). Overall clinical success was 88% and 92%. Five patients had a current ES >3 and 4 patients required procedural reintervention on the lower esophageal sphincter. Reinterventions were successful in 75% of patients (3/4), with current ES ≤3. The rate of objective GERD was 33% (15/45). Esophageal physiology was improved with a decrease in median integrated relaxation pressure (11 ± 4 vs 33 ± 15 mm Hg, P < 0.001), a decrease in median TBE column height (3 ± 3 vs 13 ± 8 cm, P < 0.001), and an increase in median distensibility index (5.1 ± 2 vs 1.1 ± 1 mm2/mm Hg, P < 0.001).

CONCLUSIONS

POEM provides durable symptom relief and improvement in physiologic esophagogastric junction relaxation parameters over 4.5 years postoperatively. Reinterventions are rare and effective.

The incidence of reintervention and reoperation following Heller myotomy across multiple indications

INTRODUCTION

Achalasia is a debilitating primary esophageal motility disorder. Heller myotomy (HM) is a first-line therapy for the treatment of achalasia patients who have failed other modalities. Other indications for HM include diverticulum, diffuse esophageal spasm, and esophageal strictures. However, long-term outcomes of HM are unclear. This study aims to assess incidence of reintervention, either endoscopically or through minimally invasive or resectional procedures, in patients who underwent HM in New York State.

METHODS

The Statewide Planning and Research Cooperative System (SPARCS) administrative longitudinal database identified 1817 adult patients who underwent HM between 2000 and 2008 for achalasia, esophageal diverticulum, diffuse esophageal spasm, and esophageal strictures, based on ICD-9 and CPT codes. Through the use of unique identifiers, patients requiring reintervention were tracked up to 2016 (for at least 8 years follow-up). Primary outcome was incidence of subsequent procedures following HM. Secondary outcomes were time to reintervention and risk factors for reintervention.

RESULTS

Of the 1817 patients who underwent HM, 320 (17.6%) required subsequent intervention. Of the 320 patients, 234 (73.1%) underwent endoscopic reinterventions, 54 (16.9%) underwent minimally invasive procedures, and 32 (10%) underwent resectional procedures as their initial revisional intervention. Of the 234 patients who underwent endoscopic reintervention as their initial revisional procedure, only 40 (16.8%) required subsequent surgical procedures. Over a mean follow-up of 7.0 years, the mean time to a subsequent procedure was 4.3 ± 3.74 years. Reintervention rates after 10 years following HM for achalasia, diverticulum ,and other indication were 24.4%, 12.6%, and 37%, respectively.

CONCLUSION

The majority of HM reinterventions were managed solely by endoscopic procedures (60.6%). Heller myotomy remains an excellent procedure to prevent surgical reintervention for achalasia and diverticulum.

Risk of Squamous Cell Carcinoma and Adenocarcinoma of the Esophagus in Patients With Achalasia: A Long-Term Prospective Cohort Study in Italy

INTRODUCTION

Epidemiological studies assessing relative risk and incidence rate of esophageal cancer in patients with achalasia are scarce. We performed a long-term prospective cohort study to evaluate the risk of both squamous cell carcinoma and adenocarcinoma of the esophagus in these patients.

METHODS

Between 1973 and 2018, patients with primary achalasia were followed by the same protocol including upper endoscopy with esophageal biopsies. Standardized incidence ratios (SIRs) with 95% confidence interval (CI) were used to estimate the relative risk of esophageal cancer in patients with achalasia compared with the sex- and age-matched general population.

RESULTS

A cohort of 566 patients with achalasia (46% men, mean age at diagnosis: 48.1 years) was followed for a mean of 15.5 years since the diagnosis of achalasia. Overall, 20 patients (15 men) developed esophageal cancer: 15 squamous cell carcinoma and 5 adenocarcinoma. The risk of esophageal cancer was significantly greater than the general population (SIR 104.2, 95% CI 63.7-161), and this for both squamous cell carcinoma (SIR 126.9, 95% CI 71.0-209.3) and adenocarcinoma (SIR 110.2, 95% CI 35.8-257.2). The excess risk was higher in men than women. Annual incidence rate of esophageal cancer was only 0.24% and was higher for squamous cell carcinoma (0.18%) than adenocarcinoma (0.06%).

DISCUSSION

Patients with achalasia have an excess risk of developing both squamous cell carcinoma and adenocarcinoma of the esophagus; however, this prospective cohort study confirms that the annual incidence of esophageal cancer is rather low. These findings may have implications for endoscopic surveillance of patients with achalasia.

Long-term (17 years) subjective and objective evaluation of the durability of laparoscopic Heller esophagomyotomy in patients with achalasia of the esophagus (90% of follow-up): a real challenge to POEM

INTRODUCTION

Laparoscopic Heller Myotomy (LHM) with partial anterior or posterior fundoplication is the standard surgical procedure for treating achalasia patients. The results reported are mainly based on symptomatic evaluations and have less than 5 years of follow-up and none more than ten.

OBJECTIVE

To determine the late results of LHM, performing endoscopic, histologic, manometric, and functional studies in addition to clinical evaluations.

MATERIALS AND METHODS

Eighty-nine consecutive patients were included in a prospective study from 1993 to 2008. Inclusion criteria corresponded to achalasia patients with Types I to III (radiological evaluation). Exclusion criteria included patients with grade IV, patients with previous procedures (surgical or endoscopic), or giant hiatal hernia. They were submitted to a radiological evaluation, over two endoscopic procedures with biopsy samples, manometric assessments, and 24-h pH monitoring late after surgery.

RESULTS

There was no operative mortality nor postoperative complications. The average hospital stay was two days. Nine patients (10.1%) were lost from follow-up. The mean late follow-up was 17 years (10-26). Visick I and II (success) corresponded to 78.7% of patients and grades III-IV (failure) to 21.3%, mainly due to gastroesophageal reflux disease (GERD). Manometric evaluations showed a significant and permanent decrease in lower esophageal sphincter pressure (LESP). 24-h pH monitoring was normal among Visick I patients and showed pathologic acid reflux in patients with GERD. Two patients (2.5%) developed Barrett's esophagus. Squamous-cell carcinoma (SCC) appeared in three patients (3.7%).

CONCLUSION

LHM controlled symptoms in 79% of achalasia patients very late (17 years) after surgery. This was corroborated by endoscopic, manometric, and functional studies. GERD symptoms developed in 18.7% and SCC in 3.7% in previously asymptomatic patients. Endoscopic surveillance at regular intervals is recommended for all patients who have had surgery. These very long-term results are a real challenge to POEM endoscopic treatment. Unique Identifying Registration Number 3743.

Long-term Symptom Control After Laparoscopic Heller Myotomy and Dor Fundoplication for Achalasia

BACKGROUND

Achalasia is a primary esophageal motility disorder in which there is incomplete relaxation of the lower esophageal sphincter and absence of peristalsis in the lower two thirds of the esophagus. A favored treatment is laparoscopic modified Heller myotomy with Dor fundoplication (LHMDor) with more than 90% immediate beneficial effect. The short-term outcomes of LHMDor are well documented, but stability and durability of postoperative symptom control over time is less understood.

METHODS

Between 2004 and 2016, 54 patients with achalasia underwent LHMDor (single center). Using validated questionnaires, patients rated their symptoms in five domains: pain, gastroesophageal reflux disease (GERD), dysphagia, regurgitation, and quality of life. Symptom ratings were done preoperatively, 4 weeks postoperatively, 6 months postoperatively, and yearly after the operation.

RESULTS

As expected, patients reported marked improvement in dysphagia, odynophagia, regurgitation, GERD, and quality of life after the operation (P < .001). From then on, the symptom control remained durable with respect to absence of pain, regurgitation, and odynophagia; however, we observed a recurrence of GERD symptoms beginning 3 to 5 years postoperatively (P = .001 and P = .04, respectively), with associated increased antireflux medication use. After initial LHMDor, 5 patients required endoscopic dilatation an average of 1.5 years postoperatively, and no patient required reoperation. Patients reported preserved improved quality of life to 11 years after the operation (P = .001).

CONCLUSIONS

These results demonstrate the durability of LHMDor in the definitive management of achalasia, offering consistent symptomatic relief and significant improvement in quality of life over the decade after surgery, despite some increase in GERD symptoms and antireflux medication use.

Achalasia: what to do in the face of failures of Heller myotomy

Achalasia is a primary motility disorder of the esophagus, and while there are several treatment options, there is no consensus regarding them. When therapeutic intervention for achalasia fails, a careful evaluation of the cause of the persistent or recurrent symptoms using upper endoscopy, esophageal manometry, and contrast radiologic studies is required to understand the cause of therapy failure and guide plans for subsequent treatment. Options for reintervention are the same as for primary intervention and include pneumatic dilation, botulinum toxin injection, peroral endoscopic myotomy, or redo esophageal myotomy. When reintervention fails or if the esophagus is not amenable to intervention and the disease is considered end-stage, esophagectomy is the last option to manage recurrent achalasia.

Surgical management of achalasia

Esophageal achalasia is a primary esophageal motility disorder characterized by lack of peristalsis and by incomplete or absent relaxation of the lower esophageal sphincter in response to swallowing. The cause of the disease is unknown. The goal of treatment is to eliminate the functional outflow obstruction at the level of the gastroesophageal junction, therefore allowing emptying of the esophagus into the stomach. They include the laparoscopic Heller myotomy with partial fundoplication, pneumatic dilatation, and peroral endoscopic myotomy. Esophagectomy is considered as a last resort for patients who have failed prior therapeutic attempts. In this evidence and experience-based review, we will illustrate the technique and results of the surgical treatment of esophageal achalasia and compare it to the other available treatment modalities.

Per oral endoscopic myotomy with fundoplication is a technically feasible NOTES for achalasia cardia

Background: Per-oral endoscopic myotomy (POEM) has become the standard of care for the endoscopic management of achalasia but its major long-term adverse effect has been the development of reflux-associated symptoms and sequelae.Aim: This study was conducted to assess the feasibility and reproducibility of the technique of POEM with fundoplication (POEM + F), a pure Natural Orifice Transluminal Endoscopic Surgery (NOTES) procedure in achalasia.Material and methods: Between November 2019 and January 2020, three patients with achalasia cardia were subjected to POEM + F. Various parameters such as technical feasibility, procedure time, adverse events and post-procedure follow-up were noted.Results: POEM + F was successfully completed in all three patients. Other than intra-operative capno-peritoneum, no major adverse events were noted. On follow-up at one month, maintenance of wrap was noted.Conclusion: POEM + F is a technically feasible and a reproducible pure NOTES procedure.

Outcomes of Laparoscopic Heller Myotomy for Achalasia: 22-Year Experience

INTRODUCTION

Laparoscopic Heller Myotomy is the most effective treatment of achalasia. We examined the durability of symptomatic relief, with and without fundoplication.

METHODS

A single institution database between 1995 and 2017 was reviewed. Achalasia symptom severity was assessed by Eckardt scores (ES) obtained at 3-time points via patient questionnaire. Primary outcome was treatment success defined as ES of < 3.

RESULTS

Completed surveys were returned by 130 patients (median follow-up of 6.6 years). A partial fundoplication was performed in 86%. At both 1-year and late follow-up, patients reported a significant improvement in ES compared to baseline (p < 0.05). Of those followed for ≥ 10 years (n = 44), 82% reported ES < 3 at 1-year (p < 0.001), and 78% at last follow-up (p < .001). Of patients who reported treatment success 1-year postoperatively (103/130), 85% continued to report symptomatic relief at last follow-up. Five-year cohort analysis did not show deterioration of dysphagia relief over time. The presence or absence of fundoplication had no impact on long-term outcome (p > 0.05).

CONCLUSIONS

LHM provides immediate and durable symptomatic relief, with very few patients requiring further therapeutic intervention. Fundoplication does not appear to influence the durability of symptom relief. Treatment success at 1-year is predictive of long-lasting symptomatic relief.

Use of a report card to evaluate outcomes of achalasia surgery: beyond the Eckardt score

BACKGROUND

Achalasia outcome is primarily defined using the Eckardt score with failure recognized as > 3. However, patients experience many changes after myotomy including new onset GERD, swallowing difficulties, and potential need for additional treatment. We aim to devise a comprehensive assessment tool to demonstrate the extent of patient-reported outcomes, objective changes, and need for re-interventions following myotomy.

METHODS

We performed a retrospective chart review of surgically treated primary achalasia patients. We identified 185 patients without prior foregut surgery who underwent either per oral endoscopic myotomy (POEM) or Heller myotomy from 2005 to 2017. Eight outcome measures in subjective, objective, and interventional categories formulated a global postoperative assessment tool. These outcomes included Eckardt score, Dakkak Dysphagia score, GERD-HRQL score, normalization of pH scores and IRP, esophagitis, timed barium clearance at 5 min, and the most invasive re-intervention performed.

RESULTS

Of 185 patients, achalasia subtypes included Type I = 42 (23%), II = 109 (59%), and III = 34 (18%). Patients underwent minimally invasive myotomy in 114 (62%), POEM in 71 (38%). Median proximal myotomy length was 4 cm (IQR 4-5) and distal 2 cm (IQR 2-2.5). Based on postoperative Eckardt score, 135/145 (93%) had successful treatment of achalasia. But, only 47/104 (45%) reported normal swallowing, and 78/108 (72%) had GERD-HRQL score ≤ 10. Objectively, IRP was normalized in 48/60 (80%), whereas timed barium clearance occurred in 51/84 (61%). No evidence of esophagitis was documented in 82/115 (71%). Postoperative normal DeMeester scores occurred in 38/76 (50%). No additional treatments were required in 110/139 (79%) of patients.

CONCLUSIONS

Use of the Eckardt score alone to assess outcomes after achalasia surgery shows outstanding results. Using patient-reported outcomes, objective measurements, re-intervention rates, organized into a report card provides a more comprehensive and informative view.

Effect of Peroral Endoscopic Myotomy vs Pneumatic Dilation on Symptom Severity and Treatment Outcomes Among Treatment-Naive Patients With Achalasia: A Randomized Clinical Trial

IMPORTANCE

Case series suggest favorable results of peroral endoscopic myotomy (POEM) for treatment of patients with achalasia. Data comparing POEM with pneumatic dilation, the standard treatment for patients with achalasia, are lacking.

OBJECTIVE

To compare the effects of POEM vs pneumatic dilation as initial treatment of treatment-naive patients with achalasia.

DESIGN, SETTING, AND PARTICIPANTS

This randomized multicenter clinical trial was conducted at 6 hospitals in the Netherlands, Germany, Italy, Hong Kong, and the United States. Adult patients with newly diagnosed achalasia and an Eckardt score greater than 3 who had not undergone previous treatment were included. The study was conducted between September 2012 and July 2015, the duration of follow-up was 2 years after the initial treatment, and the final date of follow-up was November 22, 2017.

INTERVENTIONS

Randomization to receive POEM (n = 67) or pneumatic dilation with a 30-mm and a 35-mm balloon (n = 66), with stratification according to hospital.

MAIN OUTCOMES AND MEASURES

The primary outcome was treatment success (defined as an Eckardt score ≤3 and the absence of severe complications or re-treatment) at the 2-year follow-up. A total of 14 secondary end points were examined among patients without treatment failure, including integrated relaxation pressure of the lower esophageal sphincter via high-resolution manometry, barium column height on timed barium esophagogram, and presence of reflux esophagitis.

RESULTS

Of the 133 randomized patients, 130 (mean age, 48.6 years; 73 [56%] men) underwent treatment (64 in the POEM group and 66 in the pneumatic dilation group) and 126 (95%) completed the study. The primary outcome of treatment success occurred in 58 of 63 patients (92%) in the POEM group vs 34 of 63 (54%) in the pneumatic dilation group, a difference of 38% ([95% CI, 22%-52%]; P < .001). Of the 14 prespecified secondary end points, no significant difference between groups was demonstrated in 10 end points. There was no significant between-group difference in median integrated relaxation pressure (9.9 mm Hg in the POEM group vs 12.6 mm Hg in the pneumatic dilation group; difference, 2.7 mm Hg [95% CI, -2.1 to 7.5]; P = .07) or median barium column height (2.3 cm in the POEM group vs 0 cm in the pneumatic dilation group; difference, 2.3 cm [95% CI, 1.0-3.6]; P = .05). Reflux esophagitis occurred more often in the POEM group than in the pneumatic dilation group (22 of 54 [41%] vs 2 of 29 [7%]; difference, 34% [95% CI, 12%-49%]; P = .002). Two serious adverse events, including 1 perforation, occurred after pneumatic dilation, while no serious adverse events occurred after POEM.

CONCLUSIONS AND RELEVANCE

Among treatment-naive patients with achalasia, treatment with POEM compared with pneumatic dilation resulted in a significantly higher treatment success rate at 2 years. These findings support consideration of POEM as an initial treatment option for patients with achalasia.

TRIAL REGISTRATION

Netherlands Trial Register number: NTR3593.

Massive esophageal bleeding in long-standing achalasia complicated by esophageal carcinoma and aspirin-induced stasis ulcer: Case report

RATIONALE

Esophageal hemorrhage may occasionally develop subsequent to esophagitis and stasis ulcer, but potentially fatal esophageal bleeding is very uncommon in primary achalasia.

PATIENT CONCERNS

We describe a case of a 64-year-old man with long-standing achalasia and megaesophagus who presented acute episodes of life-threatening upper gastrointestinal bleeding.

DIAGNOSES AND INTERVENTIONS

Five esophagogastroduodenoscopies (EGD) were conducted and during each large amount of static food, bloody material, and clots should be removed from the esophagus because of impaired esophageal transit. Eventually, diffuse multiple irregular ulcers were observed in the middle and lower portions of the esophagus that were presumed to have been caused by aspirin stasis based on considerations of previous drug use. EGD also revealed a 2.0 × 2.5 cm flat nodular lesion with central ulceration at the mid-to-lower esophagus and adherent blood clots suggestive of bleeding stigma. The biopsy specimen demonstrated esophageal cancer. Accordingly, a diagnosis of massive esophageal hemorrhage in long-standing achalasia complicated by squamous cell carcinoma, possibly triggered by acute mucosal irritation and ulcer caused by aspirin stasis, was made. The patient then successfully underwent the Ivor-Lewis operation. Resultantly, the tumor was diagnosed as moderately differentiated squamous cell carcinoma stage IIA (T2N0M0).

OUTCOMES

The patient's postoperative course was uneventful, and no evidence of tumor recurrence or metastasis has been found during the 6 months of follow-up examination. He was tolerating normal food with only minimal reflux symptoms.

LESSONS

Although, fortunately in the described case, esophageal cancer was diagnosed at a relatively early stage because it is the acute presentation of life-threatening upper gastrointestinal bleeding, this report cautions that when symptoms of dysphagia are aggravated, taking drugs capable of acting as local irritants, such as aspirin, could cause fatal esophageal hemorrhage in achalasia.

Gastroesophageal reflux disease after peroral endoscopic myotomy: Short-term, medium-term, and long-term results

INTRODUCTION AND AIMS

Achalasia is characterized by incomplete relaxation of the lower esophageal sphincter and esophageal aperistalsis. The efficacy of peroral endoscopic myotomy (POEM) is similar to that of the Heller myotomy, with an apparently greater prevalence of gastroesophageal reflux disease. Our aim was to determine the presence of GERD in a post-POEM cohort of Mexican patients with achalasia and follow-up of at least 12 months.

MATERIALS AND METHODS

A retrospective cohort study was conducted on post-POEM patients with a minimum of 12 months of follow-up, within the time frame of 2012 to 2017. Pregnant patients were excluded. Serial endoscopy, pH study, and GERDQ application were performed. Univariate and bivariate data analyses were carried out and statistical significance was set at a P<0.05.

RESULTS

Sixty-eight patients had post-POEM follow-up for 12 months. Of those patients, follow-up continued to 24 months for 58, 36 months for 47, 48 months for 39, and 60 months for 25. Mean patient age was 47.8±14.3 years, 57.3% of the patients were women, 77.9% were treatment-naïve, and 54.4% had type II achalasia. The pH study, endoscopy, and questionnaire were positive in 73, 28, and 18% at 3 months; 48, 35, and 13% at 6 months, and 55, 30, and 15% at 12 months, respectively. Once the proton pump inhibitor was begun, the percentages decreased to 5, 2, and 6% at 24 months; 6, 2, and 8% at 36 months; 4,1, and 6% at 48 months; and 3, 1, and 4% at 60 months, respectively. There was no relation between the efficacy of POEM and the presence or intensity of GERD. There were no secondary complications due to gastroesophageal reflux.

CONCLUSIONS

The post-POEM prevalence of GERD was 50% in the short term (12 months), with no evidence of complications at the medium term or long term (60 months). Gastroesophageal reflux was adequately controlled through proton pump inhibitors administration in over 95% of the cases.

Achalasia and associated esophageal cancer risk: What lessons can we learn from the molecular analysis of Barrett's-associated adenocarcinoma?

Idiopathic achalasia and Barrett's esophagus (BE) are preneoplastic conditions of the esophagus. BE increases the risk of esophageal adenocarcinoma (EAC), while achalasia is associated with both EAC and esophageal squamous cell carcinoma (ESCC). However, while the molecular mechanisms underlying the transformation of esophageal epithelial cells in BE are relatively well characterized, less is known regarding these processes in achalasia. Nevertheless, both conditions are associated with chronic inflammation and BE can occur in achalasia patients, and it is likely that similar processes underlie cancer risk in both diseases. The present review will discuss possible lessons that we can learn from the molecular analysis of BE for the study of achalasia-associated cancer and contrast findings in BE with those in achalasia. First, we will describe cellular fate during development of BE, EAC, and ESCC, and consider the inflammatory status of the epithelial barrier in BE and achalasia in terms of its contribution to carcinogenesis. Next, we will summarize current data on genetic alterations and molecular pathways involved in these processes. Lastly, the plausible role of the microbiota in achalasia-associated carcinogenesis and its contribution to abnormal lower esophageal sphincter (LES) functioning, the maintenance of chronic inflammatory status and influence on the esophageal mucosa through carcinogenic by-products, will be discussed.

Impact of the Myotomy Extent on Gastric Side on Surgical Outcome After Heller's Cardiomotomy for Achalasia

BACKGROUND

Laparoscopic Heller cardiomyotomy (LHM) with Dor fundoplication represents the most commonly accepted surgical management for achalasia. The ideal extent of myotomy on the gastric side remains a matter of continuous debate. The aim of this study was to compare the impact of the extent of myotomy on the gastric side on the outcome of LHM.

PATIENTS AND METHODS

Patients with achalasia who underwent LHM included in the study. The patients were classified according to the length of the gastric myotomy into 3 groups (group I: <1.5 cm, group II: 1.5 to 2.5 cm, and group III: >2.5 cm).

RESULTS

In total, 212 patients (94 males and 118 females) with achalasia treated by LHM and Dor fundoplication included in the study. No statistically significant differences were found among the 3 groups as regards preoperative data, intraoperative mucosal perforation, operative time, blood loss, and hospital stay. The incidence of persistent dysphagia was significantly higher in the group I. Postoperative GERD symptoms were significantly higher in group III (23.3%, P<0.0001). Recurrent achalasia was significantly higher in group I with 11 patients (15.9%), 8 patients in group II (7.1%), and nil in group III (P<0.02).

CONCLUSIONS

Longer myotomy on the gastric side (>2.5 cm) ensures complete division of the LES with better outcomes in term of resolution of dysphagia but may be associated with higher postoperative GERD. Therefore, a myotomy length of 1.5 to 2.5 cm on the gastric side provides a balance between relieve of dysphagia and development of postoperative GERD.

Angle of His Accentuation Is a Viable Alternative to Dor Fundoplication as an Adjunct to Laparoscopic Heller Cardiomyotomy: Results of a Randomized Clinical Study

BACKGROUND

There is no consensus regarding the type of anti-reflux procedure to be used as an adjunct to laparoscopic Heller cardiomyotomy (LHCM). The aim of this study was to compare Angle of His accentuation (AOH) with Dor Fundoplication (Dor) as an adjunct to LHCM.

METHODS

A total of 110 patients with achalasia cardia presenting for LHCM from March 2010 to July 2015 were randomized to Dor and AOH. Symptom severity, achalasia-specific quality of life (ASQOL), new onset heartburn, and patient satisfaction were assessed using standardized scores preoperatively, at 3, 6 months, and then yearly. The primary outcome was relief of esophageal symptoms while secondary outcomes were new onset heartburn and ASQOL.

RESULTS

Both groups were comparable with respect to the baseline demographic characteristics. There was no conversion to open and no mortality in either group. Median operative time was 128 min in AOH and 144 min in Dor group (p < 0.01). Mean follow-up was 36 months and was available in 98% patients. There was significant improvement in esophageal symptoms in both groups with no statistically significant difference between the two groups (p > 0.05). There was no difference in cumulative symptom scores between the two groups over the period of follow-up. New onset heartburn was seen in 11% in AOH and 9% in Dor group. Mean ASQOL score improved in both groups with no difference between the two groups (p = 0.83). Patient satisfaction was similar in both groups.

CONCLUSION

AOH is similar to Dor as an adjunct to LHCM in safety and efficacy and can be performed in shorter time.

CLINICAL REGISTRATION NUMBER

CTRI: REF/2014/06/007146.

The 2018 ISDE achalasia guidelines

Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.

What to do when Heller's myotomy fails? Pneumatic dilatation, laparoscopic remyotomy or peroral endoscopic myotomy: A systematic review

BACKGROUND

Surgical treatment of achalasia fails in 10%-20% of patients. The most frequent responsible cause is the performance of an incomplete myotomy at primary surgery. The treatment when the failure happens is not well defined. In this study, we review and evaluate the possible treatments to be carried out when surgical myotomy fails. We define its benefits and results, with the purpose of defining a therapeutic algorithm.

MATERIALS AND METHODS

The systematic review was performed following the guidelines established by the Meta-analysis of Observational Studies in Epidemiology statement. We searched several electronic databases (MEDLINE, PubMED, EMBASE and Cochrane) from January 1991 to March 2017, with the keywords 'recurrent achalasia' 'POEM remyotomy', 'esophagomyotomy failure', 'Heller myotomy failure', 'myotomy failure', 'pneumatic balloon dilatation achalasia' and combinations between them, 'redo Heller', 'redo myotomy', 'reoperative Heller'.

RESULTS

A total of 61 observational studies related to the treatment of patients with failure of Heller's myotomy were initially found. Finally, 37 articles were included in our study that provided data on 289 patients. Of these 289 patients, diagnosed of failed Heller's myotomy, 87 were treated with pneumatic dilatation (PD), 166 underwent surgical revision and finally 36 were treated with POEM. No randomised controlled trial was identified.

CONCLUSIONS

The three therapeutic options analysed in this review are effective and safe in the treatment of patients with achalasia with failure of surgical myotomy. The best results can be achieved following an algorithm similar to the one proposed here, where each procedure must be performed by well-experienced team in the selected modality.

POEM for Achalasia

In 2008, a new treatment modality for esophageal achalasia was introduced—peroral endoscopic myotomy (POEM). POEM is a procedure performed endoscopically, which allows transection of the muscular fibers of the distal esophagus and of the lower esophageal sphincter. The procedure is therefore similar to a laparoscopic Heller myotomy without a fundoplication. Short-term studies have shown that POEM is very effective in relieving dysphagia and regurgitation, but concerns have been raised about the incidence of post-POEM gastroesophageal reflux. Prospective and randomized trials will be needed to determine the role of this new procedure in the treatment algorithm of esophageal achalasia.

An Update on Current Management Strategies for Achalasia and Future Perspectives

The last decade has seen growing insight into the pathophysiology of achalasia, and current treatments decreasing the resting pressure in the lower esophageal sphincter by endoscopic (botulinum toxin injection, pneumatic dilation, peroral endoscopic myotomy) or surgical means (Heller myotomy). Manometry is considered the gold standard to confirm the diagnosis of achalasia. Pneumatic dilation and laparoscopic Heller myotomy have similar effectiveness and are both more successful in patients with type II achalasia. Laparoscopic myotomy when combined with partial fundoplication is an effective surgical technique and has been considered the operative procedure of choice until recently. Peroral endoscopic myotomy is an emerging therapy with promising results since it offers a minimally invasive and efficacious option especially in type III achalasia. However, it remains to be determined if peroral endoscopic myotomy offers long-term efficacy.

[Laparoscopic Heller myotomy after failed POEM and multiple balloon dilatations : Better late than never]

BACKGROUND

Despite the lack of long-term results, peroral endoscopic myotomy (POEM) has been increasingly propagated as a feasible alternative to pneumatic balloon dilatation (BD) and laparoscopic Heller myotomy (LHM) in patients with achalasia. After a long-term follow-up, a large percentage of patients reported recurrence of dysphagia. It is unclear which kind of procedure (redo POEM or LHM) should be utilized in these patients with failed POEM.

CASE REPORT AND RESULTS

We report the case of a 37-year-old female patient with type I achalasia who was successfully treated with LHM after a failed POEM procedure. After the manometric diagnosis of type I achalasia, the patient was treated with six balloon dilatations within a period of 5 months. Because of the persistence of symptoms a POEM procedure was performed with no relief and the patient was referred for surgical treatment. An esophagography showed a pronounced widening of the middle and the distal esophagus with a persistent narrowing of the lower esophageal sphincter (LES) and because of these indications LHM was performed. The intraoperative examination revealed extensive scarring of the submucosal layer with the muscularis mucosae of the distal esophagus; nevertheless, it was possible to carry out a 5 cm long cardiomyotomy without mucosal injury. The operation was completed with a Dor fundoplication. There were no postoperative complications. After surgery the patient reported an immediate and complete relief of dysphagia.

DISCUSSION AND CONCLUSION

The published experiences with POEM seem to show promising short-term results in terms of dysphagia relief; however, the few available mid-term analyses demonstrated no essential advantages when compared to LHM; therefore, the LHM must still be considered the gold standard procedure for definitive treatment of achalasia. According to our case report, LHM was shown to be a safe and effective although laborious treatment option due to scarring even after failed treatment by POEM.

Peroral endoscopic myotomy for the treatment of achalasia and other esophageal motor disorders: Short-term and medium-term results at a Mexican tertiary care center

INTRODUCTION AND AIMS

Achalasia is characterized by the absence of lower esophageal sphincter relaxation and esophageal aperistalsis. Diagnosis is confirmed through high-resolution esophageal manometry. Laparoscopic myotomy is the standard treatment, but peroral endoscopic myotomy (POEM) is a safe and effective alternative, with good short-term and medium-term results. Our aim was to describe the short-term and medium-term experience with POEM at a tertiary care center.

MATERIALS AND METHODS

The study was conducted within the time frame of November 2014 and February 2017. Treatment-naïve achalasia patients and previously-treated achalasia patients that were candidates for POEM were included. A protocolized 24-month follow-up was carried out.

RESULTS

Fifty procedures were included and 31 (68%) were performed on women. Forty-one (82%) of the procedures were carried out on previously untreated patients, 7 (14%) were performed on previously treated patients, and 2 (4%) of the patients had redo-POEM. The mean age of the patients was 48.8±14.1 years. The pre-POEM Eckardt score was 9 and the integrated relaxation pressure was 24.4mmHg. Sixty-eight percent of the patients had type ii achalasia. Procedure time was 80min and myotomy length was 12.6cm. Hospital stay was 3 days and subcutaneous emphysema was the most common adverse event (30%). A total of 22/50 (44%) patients reached the 24-month follow-up, maintaining the Eckardt score and the decrease in the integrated relaxation pressure. There were no deaths. A total of 47.5% of the patients had a positive pH-study at 6 months, 15% had clinical reflux, and 35% presented with mild esophagitis. All the patients were adequately controlled with proton pump inhibitors.

CONCLUSION

POEM is safe and effective in the short term and medium term for the treatment of achalasia and other esophageal motor disorders in Mexican patients.

Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: long-term symptomatic follow-up of a prospective randomized controlled trial

BACKGROUND

Our prior randomized controlled trial of Heller myotomy alone versus Heller plus Dor fundoplication for achalasia from 2000 to 2004 demonstrated comparable postoperative resolution of dysphagia but less gastroesophageal reflux after Heller plus Dor. Patient-reported outcomes are needed to determine whether the findings are sustained long-term.

METHODS

We actively engaged participants from the prior randomized cohort, making up to six contact attempts per person using telephone, mail, and electronic messaging. We collected patient-reported measures of dysphagia and gastroesophageal reflux using the Dysphagia Score and the Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) instrument. Patient-reported re-interventions for dysphagia were verified by obtaining longitudinal medical records.

RESULTS

Among living participants, 27/41 (66%) were contacted and all completed the follow-up study at a mean of 11.8 years postoperatively. Median Dysphagia Scores and GERD-HRQL scores were slightly worse for Heller than Heller plus Dor but were not statistically different (6 vs 3, p = 0.08 for dysphagia, 15 vs 13, p = 0.25 for reflux). Five patients in the Heller group and 6 in Heller plus Dor underwent re-intervention for dysphagia with most occurring more than five years postoperatively. One patient in each group underwent redo Heller myotomy and subsequent esophagectomy. Nearly all patients (96%) would undergo operation again.

CONCLUSIONS

Long-term patient-reported outcomes after Heller alone and Heller plus Dor for achalasia are comparable, providing support for either procedure.

Esophageal achalasia: a risk factor for carcinoma. A systematic review and meta-analysis

Achalasia of the cardia is associated with an increased risk of esophageal carcinoma. The real burden of achalasia at the malignancy genesis is still a controversial issue. Therefore, there are no generally accepted recommendations on follow-up evaluation for achalasia patients. This study aims to estimate the risk of esophageal adenocarcinoma and squamous cell carcinoma in achalasia patients. We searched for association between carcinoma and esophageal achalasia in databases up to January 2017 to perform a systematic review and meta-analysis. A total of 1,046 studies were identified from search strategy, of which 40 were selected for meta-analysis. A cumulative number of 11,978 esophageal achalasia patients were evaluated. The incidence of squamous cell carcinoma was 312.4 (StDev 429.16) cases per 100,000 patient-years at risk. The incidence of adenocarcinoma was 21.23 (StDev 31.6) cases per 100,000 patient-years at risk. The prevalence for esophageal carcinoma was 28 carcinoma cases in 1,000 esophageal achalasia patients (CI 95% 2, 39). The prevalence for squamous cell carcinoma was 26 cases in 1,000 achalasia patients (CI 95% 18, 39) and for adenocarcinoma was 4 cases in 1,000 achalasia patients (CI 95% 3, 6).The absolute risk increase for squamous cell carcinoma was 308.1 and for adenocarcinoma was 18.03 cases per 100,000 patients per year. To the best of our knowledge, this is the first meta-analysis estimating the burden of achalasia as an esophageal cancer risk factor. The high increased risk rate for cancer in achalasia patients points to a strict endoscopic surveillance for these patients. Also, the increased risk for developing adenocarcinoma in achalasia patients suggests fundoplication after myotomy, to avoid esophageal reflux and Barret esophagus, a known risk factor for adenocarcinoma.

Per-oral Endoscopic Myotomy (POEM) After the Learning Curve: Durable Long-term Results With a Low Complication Rate

OBJECTIVE

We aimed to report long-term outcomes for patients undergoing per-oral endoscopic myotomy (POEM) after our initial 15-case learning curve.

BACKGROUND

POEM has become an established, natural-orifice surgical approach for treating esophageal motility disorders. To date, published outcomes and comparative-effectiveness studies have included patients from the early POEM experience.

METHODS

Consecutive patients undergoing POEM after our initial 15 cases, with a minimum of 1-year postoperative follow-up, were included. Treatment success was defined as an Eckardt score ≤3 without reintervention. Gastroesophageal reflux was defined by abnormal pH-testing or reflux esophagitis >Los Angeles grade A.

RESULTS

Between January 2012 and March 2015, 115 patients underwent POEM at a single, high-volume center. Operative time was 101 ± 29 minutes, with 95% (109/115) of patients discharged on postoperative day 1. Clavien-Dindo grade III complications occurred in 2.7%, one of which required diagnostic laparoscopy to rule out Veress needle injury to the gall bladder. The rate of grade I complications was 15.2%. At an average of 2.4 years post-POEM (range 12-52 months), the overall success rate was 92%. Objective evidence of reflux was present in 40% for all patients and 33% for patients with a body mass index <35 kg/m and no hiatal hernia.

CONCLUSIONS

POEM performed by experienced surgeons provided durable symptomatic relief in 94% of patients with nonspastic achalasia and 90% of patients with type 3 achalasia/spastic esophageal motility disorders, with a low rate of complications. The rate of gastroesophageal reflux was comparable with prior studies of both POEM and laparoscopic Heller myotomy.

Per-oral endoscopic myotomy for achalasia

Symptoms in patients with achalasia are produced by outflow obstruction at the level of the lower esophageal sphincter (LES). As a consequence of neural destruction the LES does not undergo normal swallow-induced relaxation. In addition, the esophageal body loses normal peristaltic function and esophageal emptying is on the basis of gravity. All therapies for achalasia are palliative in that normal LES or esophageal body function cannot be restored. The efficacy of any therapy for achalasia is directly related to its ability to reduce the outflow obstruction at the LES. The three main treatment options are pneumatic dilatation, laparoscopic myotomy and partial fundoplication and per-oral endoscopic myotomy or per-oral esophageal myotomy (POEM). Details of the procedures and outcomes will be discussed.

Esophageal Achalasia: Predictive Value of Preoperative Resting Pressure of LES Correlated with Type of Fundoplication

OBJECTIVE

The aim of the present study is to show the predictive value of the preoperative resting pressure of the lower esophageal sphincter (LES) correlated with the type of fundoplication (Nissen or Dor) after Heller myotomy in our series.

MATERIALS AND METHODS

From January 1998 to June 2010, 88 patients affected by esophageal achalasia underwent surgery at our unit. However, our study focused on a sample of 36 patients, because many data were lost or was never recorded. Among these, 14 patients underwent laparoscopic Heller myotomy plus Nissen fundoplication (group N), whereas 22 patients underwent laparoscopic Heller myotomy plus Dor fundoplication (group D). Clinical evaluation was performed using a modified DeMeester symptom scoring system consisting of the assessment of three symptoms: dysphagia, regurgitation, and heartburn. To each symptom was assigned a score from 0 to 3, depending on its severity, and the reduction in the severity of each symptom after surgery was assessed.

RESULTS

The surgical treatment is considered to be effective (p<0.0001). The preoperative resting pressures of LES were compared by Student's t-test, and it was found that patients who reported a greater improvement in the dysphagia symptom had a preoperative average pressure of LES that was significantly higher than that in other patients in both group N (p=0.03) and group D (p=0.01; p=0.003; p=0.001). The Dor treatment was shown to be more effective than the Nissen treatment (p<0.0001).

CONCLUSION

The preoperative resting pressure of LES is a predictive factor of surgical success both before Dor fundoplication and before Nissen fundoplication, but its predictive power is influenced by the chosen type of fundoplication.

A Matched Comparison of Per Oral Endoscopic Myotomy to Laparoscopic Heller Myotomy in the Treatment of Achalasia

BACKGROUND

Per oral endoscopic myotomy (POEM) is increasingly utilized to treat patients with achalasia. Early results have demonstrated significant improvement of symptoms, but there are concerns about postoperative reflux. With only limited comparative data available, we sought to compare POEM to laparoscopic Heller myotomy (LHM) with partial fundoplication.

METHODS

This is a retrospective review of 42 POEM and 84 LHM patients undergoing primary myotomy for achalasia. Patients were matched by achalasia type, by Eckardt and dysphagia scores, and by quality of life (QOL) metrics. Analysis at 6-12-month follow-up evaluated these metrics, PPI use, pH, manometric, and endoscopic data.

RESULTS

We matched 25 patients with achalasia types I (6), II (13), and III (6). Follow-up was longer for LHM at 158.1 (36.5-272.9) weeks versus 36.2 (22.2-41.2) weeks (p = 0.001). Eckardt scores, QOL metrics, and dysphagia significantly improved in both groups. DeMeester scores and total percent time less than 4 were abnormal in both groups and comparable (p = 0.925 and p = 0.838). Esophagitis was seen in 53.4 % (POEM) and 31.6 % (LHM) (Yates' p = 0.91), and PPI use was equivalent at 36 %.

CONCLUSION

Early clinical outcomes are excellent with POEM and comparable to the standard of care LHM. Long-term follow-up is required as concerns for reflux persist.

Clinical response to peroral endoscopic myotomy in patients with idiopathic achalasia at a minimum follow-up of 2 years

BACKGROUND

The recently developed technique for peroral endoscopic myotomy (POEM) has been shown to be effective in several short-term studies. Longer term outcome data are largely non-existent.

OBJECTIVE

To systematically report clinical outcome with a minimum post-POEM follow-up of 2 years.

DESIGN

All patients treated consecutively by POEM for achalasia at three centres were retrospectively analysed, with a minimum follow-up of 2 years. The main outcome was the rate of POEM failures (Eckardt score >3) related to follow-up time.

RESULTS

Of 85 patients treated, five (5.9%) cases were excluded due to protocol violation or loss to follow-up; the remaining 80 patients (mean age 44.9 years, 54% men) were followed clinically for 29 months (range 24-41). Initial clinical response was observed in 77 cases (96.3%). Clinical recurrences (later failures) were seen in a further 14 cases (17.7%), accounting for a total failure rate of 21.5%. In a multivariate analysis, age and endoscopic reflux signs were independent predictors of treatment success. Of the 17 failures, eight were among the first 10 cases treated in the participating centres. Reflux-associated sequelae included one case of a severe reflux-associated stricture requiring dilatation, and two patients with minor transient Eckardt score elevations curable by proton pump inhibitor (PPI) treatment. Endoscopic signs of reflux oesophagitis, mostly Los Angeles grade A/B, were seen in 37.5% (37/72) at the 2-year control.

CONCLUSIONS

In this multicentre retrospective analysis, a high initial success rate of POEM is followed by a mid-term recurrence rate of 18%. Reflux oesophagitis, albeit mild, is frequent and should probably be treated by regular low-dose PPI therapy.

TRIAL REGISTRATION NUMBER

NCT 01405417 (UKE study).