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Swei E, Kassir Z, Shrigiriwar AP, Schlacterman A, Chung CS, Mandarino FV, Kedia P, Messman H, Pawa R, Desai P, Saxena P, Assefa R, Arevalo-Mora M, Azzolini F, Arcidiacono PG, Nagl S, Abu-Hammour MN, Puga-Tejada M, Baquerizo-Burgos J, Egas-Izquierdo M, Cunto D, Alcivar-Vasquez J, Del Valle R, Sharaiha RZ, Irani S, Medranda CR, Khashab M. Short esophageal myotomy versus standard myotomy for treatment of sigmoid-type achalasia: results of an international multicenter study. Gastrointest Endosc 2024:S0016-5107(24)03462-X. [PMID: 39182526 DOI: 10.1016/j.gie.2024.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 08/05/2024] [Accepted: 08/18/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND AND AIMS Patients with sigmoid-type achalasia can be challenging to treat with peroral endoscopic myotomy (POEM). A short myotomy improves technical success; however, outcomes have not previously been evaluated. METHODS This was a multicenter, international, retrospective study of patients who underwent POEM with short (≤4 cm) or standard esophageal myotomy. Outcomes included clinical and technical success, procedural adverse events, and reflux rates. RESULTS A total of 109 patients with sigmoid achalasia (sigmoid, n = 74; advanced sigmoid, n = 35) underwent POEM across 13 centers (short myotomy, n = 59; standard, n = 50). Technical success was 100% across both groups. Patients who underwent short myotomy had a significantly shorter mean procedure time (57.7 ± 27.8 vs 83.1 ± 44.7 minutes, P = .0005). A total of 6 adverse events were recorded in 6 patients (5.5%; 4 mild, 2 moderate); the adverse event rate was not significantly different between short and standard groups. Ninety-eight patients had follow-up data (median, 3.6 months; interquartile range, 1-14 months). Clinical success was 94% (short, 93%; standard, 95%; P = .70) and did not differ based on achalasia subtype or sigmoid achalasia severity. Twenty-one (22%) patients reported post-POEM reflux and 44% (16 of 36) had objective evidence of pathologic reflux. Rates of pathologic reflux were significantly increased in the standard versus short group (odds ratio, 18.0; 95% confidence interval, 2.0-159.0; P = .009). CONCLUSIONS POEM with short myotomy is effective and safe for the short-term treatment of sigmoid and advanced sigmoid achalasia. Short myotomy may lead to less reflux than standard myotomy.
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Affiliation(s)
- Eric Swei
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Department of Medicine, Baltimore, Maryland, USA
| | - Zachary Kassir
- Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Apurva Pravin Shrigiriwar
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Department of Medicine, Baltimore, Maryland, USA
| | - Alex Schlacterman
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Chen-Shuan Chung
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Francesco Vito Mandarino
- Division of Gastroenterology and Gastrointestinal Endoscopy, San Raffaele Scientific Institute for Research, Vita-Salute San Raffaele University, Milan, Italy
| | - Prashant Kedia
- Department of Gastroenterology, Methodist Dallas Medical Center, Dallas, Texas, USA
| | - Helmut Messman
- Department of Internal Medicine, Augsburg Medical Center, Augsburg, Germany
| | - Rishi Pawa
- Division of Gastroenterology and Hepatology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Pankaj Desai
- Surat Institute of Digestive Sciences, Surat, India
| | - Payal Saxena
- Department of Gastroenterology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Redeat Assefa
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Department of Medicine, Baltimore, Maryland, USA
| | - Martha Arevalo-Mora
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital Omni, Guayaquil, Ecuador
| | - Francesco Azzolini
- Division of Gastroenterology and Gastrointestinal Endoscopy, San Raffaele Scientific Institute for Research, Vita-Salute San Raffaele University, Milan, Italy
| | - Paulo Giorgio Arcidiacono
- Division of Gastroenterology and Gastrointestinal Endoscopy, San Raffaele Scientific Institute for Research, Vita-Salute San Raffaele University, Milan, Italy
| | - Sandra Nagl
- Department of Internal Medicine, Augsburg Medical Center, Augsburg, Germany
| | - Mohamad-Noor Abu-Hammour
- Department of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
| | - Miguel Puga-Tejada
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital Omni, Guayaquil, Ecuador
| | - Jorge Baquerizo-Burgos
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital Omni, Guayaquil, Ecuador
| | - Maria Egas-Izquierdo
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital Omni, Guayaquil, Ecuador
| | - Domenica Cunto
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital Omni, Guayaquil, Ecuador
| | - Juan Alcivar-Vasquez
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital Omni, Guayaquil, Ecuador
| | - Raquel Del Valle
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital Omni, Guayaquil, Ecuador
| | - Reem Z Sharaiha
- Department of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
| | - Shayan Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Carlos-Robles Medranda
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital Omni, Guayaquil, Ecuador
| | - Mouen Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Department of Medicine, Baltimore, Maryland, USA.
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Shou Y, Wang X, Liu D. Factors associated with peroral endoscopic myotomy for achalasia outcomes: systematic review and meta-analysis. Surg Endosc 2024; 38:3503-3519. [PMID: 38782829 DOI: 10.1007/s00464-024-10862-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 04/14/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is an emerging effective treatment for achalasia. However, a significant proportion of patients do not respond well to the treatment. After over a decade of clinical practice, potential risk factors associated with POEM failure have been identified. This meta-analysis aimed to summarize the evidence of risk factors for POEM failure. METHODS A systematic literature search was conducted on PubMed, Embase, Web of Science, and Cochrane Library from inception to June 10th, 2022. We included English studies that reported POEM outcomes in achalasia patients and identified risk factors for POEM failure. Relevant information was extracted and analyzed using fixed- or randomized-effect models to pool the effect size. RESULTS A total of 27 studies comprising 9371 patients with achalasia were included in this review. The pooled failure rate was 8% (90% CI 7%-10%). We identified sigmoid esophagus (OR 1.90, 95% CI 1.45-2.47), type I achalasia (OR 1.30, 95% CI 1.04-1.63), and type III achalasia (OR 1.26, 95% CI 0.89-1.78) were associated with a worse clinical response. Conversely, type II achalasia was associated with a better response (OR 0.59, 95% CI 0.47-0.75). Prior treatment with Heller myotomy (OR 5.75, 95% CI 3.97-8.34) and prior balloon dilation (OR 1.18, 95% CI 1.07-1.29) were also associated with a higher risk of clinical failure. CONCLUSION Our meta-analysis results demonstrated that sigmoid esophagus, manometric achalasia subtype, and prior treatment were associated with POEM failure. This information could be used to guide treatment decisions and improve the success rate of POEM in achalasia patients.
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Affiliation(s)
- Yajun Shou
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, China
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan Province, China
- Clinical Research Center of Digestive Diseases of Hunan Province, Changsha, 410011, Hunan Province, China
| | - Xiandi Wang
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, China
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan Province, China
- Clinical Research Center of Digestive Diseases of Hunan Province, Changsha, 410011, Hunan Province, China
| | - Deliang Liu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, China.
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan Province, China.
- Clinical Research Center of Digestive Diseases of Hunan Province, Changsha, 410011, Hunan Province, China.
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Mandavdhare HS, Samanta J, Jafra A, Singh H, Gupta P, Dutta U. OUTCOME OF PER ORAL ENDOSCOPIC MYOTOMY (POEM) IN SIGMOID ACHALASIA AT A MEDIAN FOLLOW UP OF 17 MONTHS. ARQUIVOS DE GASTROENTEROLOGIA 2022; 59:478-482. [PMID: 36515342 DOI: 10.1590/s0004-2803.202204000-85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/01/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Advanced achalasia cardia (AC) represents the end stage in the natural history of AC. Role of per oral endoscopic myotomy (POEM) in this technically difficult subset is emerging. METHODS Retrospective review of the patients who had undergone POEM for advanced AC with sigmoid esophagus. We assessed the technical success, clinical success and adverse event rate. Pre and post POEM Eckardt score (ES), integrated relaxation pressure-4sec (IRP-4), lower oesophageal sphincter pressure (LESP) and height and width of barium column at 5 minutes were noted. RESULTS Of the 85 patients who underwent POEM for AC, 10 patients had advanced AC with sigmoid esophagus of which eight were sigmoid and two were advanced sigmoid. The clinical and technical success was 100% with significant reduction of ES, IRP-4, LESP and height and width of barium column at 5 minutes. One patient had a minor adverse event in the form of mucosal injury that was closed with hemoclips. At a median follow up of 17 months there was no recurrence. CONCLUSION Our study demonstrates POEM to be a safe and effective modality of treatment in this technically difficult subset of AC with sigmoid morphology.
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Affiliation(s)
- Harshal S Mandavdhare
- Post Graduate Institute of Medical Education and Research, Department of Gastroenterology, Chandigarh, India
| | - Jayanta Samanta
- Post Graduate Institute of Medical Education and Research, Department of Gastroenterology, Chandigarh, India
| | - Anudeep Jafra
- Post Graduate Institute of Medical Education and Research, Department of Anesthesiology, Chandigarh, India
| | - Harjeet Singh
- Post Graduate Institute of Medical Education and Research, Department of Surgery, Chandigarh, India
| | - Pankaj Gupta
- Post Graduate Institute of Medical Education and Research, Department of Radiodiagnosis, Chandigarh, India
| | - Usha Dutta
- Post Graduate Institute of Medical Education and Research, Department of Gastroenterology, Chandigarh, India
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Mandavdhare HS, M PK, Shukla J, Kumar A, Sharma V. Role of Peroral Endoscopic Myotomy in Advanced Achalasia Cardia With Sigmoid and/or Megaesophagus: A Systematic Review and Metanalysis. J Neurogastroenterol Motil 2022; 28:15-27. [PMID: 34980686 PMCID: PMC8748859 DOI: 10.5056/jnm21122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/01/2021] [Accepted: 10/04/2021] [Indexed: 11/20/2022] Open
Abstract
Background/Aims Sigmoid esophagus and/or megaesophagus are considered as an advanced stage in the natural history of achalasia cardia. The role of peroral endoscopic myotomy (POEM) in these subset of patients is emerging. We performed a systematic review and metanalysis to study the efficacy of POEM in advanced achalasia cardia with sigmoid and megaesophagus. Methods A literature search in PubMed and Embase was done from inception till August 3, 2021 to look for studies reporting exclusively on the role of POEM in advanced achalasia cardia with sigmoid and/or megaesophagus. The random effect method with inverse variance approach was used for the computation of pooled prevalence. For 2 groups’ analysis of continuous outcome standardized mean difference was used as the summary measure. Results Eleven studies with 428 patients were included for analysis. The pooled technical and clinical success was 98.27% (95% CI, 96.19-99.22; I2 = 0%) and 89.38% (95% CI, 84.49-92.86; I2 = 26%) and on subgroup analysis into sigmoid and megaesophagus it was (98.06% [95% CI, 95.41-99.19; I2 = 0%], 98.47% [95% CI, 92.72-99.69; I2 = 0%] and 87.92% [95% CI, 80.68-92.70; I2 = 37%], 88.36% [95% CI, 62.62-97.17; I2 = 77%]) respectively. The clinical success at < 1 year and 1-3 year follow-up was 89.37% (95% CI, 82.82-93.61; I2 = 0%) and 88.66% (95% CI, 81.65-91.22; I2 = 46%) respectively. There was a significant reduction in the post-POEM scores with standardized mean difference for Eckardt score (4.81), for integrated relaxation pressure at 4 seconds (1.93), and for lower esophageal sphincter pressure (2.06). Conclusions POEM is an effective modality of treatment even in the subset of patients of advanced achalasia cardia with sigmoid and megaesophagus.
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Affiliation(s)
- Harshal S Mandavdhare
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Praveen Kumar M
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jayendra Shukla
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Antriksh Kumar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Evensen H, Småstuen MC, Schulz A, Kristensen V, Larssen L, Skattum J, Sandstad O, Hauge T, Medhus AW. One year comprehensive prospective follow-up of achalasia patients after peroral endoscopic myotomy. Ann Med 2021; 53:2225-2233. [PMID: 34806501 PMCID: PMC8805855 DOI: 10.1080/07853890.2021.2005253] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 11/06/2021] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) is an established therapy for achalasia, but outcome evaluation has often been limited to Eckardt score (ES). The present study was aimed to improve knowledge about outcome evaluation and predictive outcome factors by performing a comprehensive objective evaluation of achalasia patients treated by POEM. METHODS This single centre prospective study reports outcome data 12 months after POEM in treatment-naive achalasia patients. A predefined follow-up protocol included ES, high resolution manometry, 24-h pH measurement, upper endoscopy and timed barium esophagogram (TBE). Univariate and multivariate regression analyses were performed to analyze association between post-POEM variables and identify predictive factors for objective outcome. RESULTS Fifty patients were included with a drop-out rate of <5%. ES, lower oesophageal sphincter pressures, TBE heights and maximal oesophageal diameter were all reduced after POEM (p < .001), and 28% (13/47) of the patients had a positive 24-h pH registration. An oesophageal diameter >3 cm after POEM was associated with treatment failure assessed by ES (p = .04) and TBE (p = .03). Advanced achalasia stage (p = .02) and long symptom duration (p = .04) were identified as independent predictive factors for poor outcome assessed by TBE. CONCLUSIONS The present study confirms that POEM is an efficient therapy for achalasia. The comprehensive objective evaluation after POEM demonstrates that long symptom duration and major changes in oesophageal anatomy at diagnosis imply poor treatment outcome, and a post-POEM dilated oesophagus is associated with treatment failure.Key messagesPeroral endoscopic myotomy (POEM) is established as a safe and effective therapy for achalasia.Timed barium esophagogram offers objective variables that are valuable in treatment response evaluation. Advanced achalasia stage and long symptom duration are predictive factors for poor objective treatment response after POEM.
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Affiliation(s)
- Helge Evensen
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Milada Cvancarova Småstuen
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Anselm Schulz
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- Department of Diagnostic Physics, Norwegian Imaging Technology Research and Innovation Center (ImTECH), Oslo University Hospital, Oslo, Norway
| | - Vendel Kristensen
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
- Unger-Vetlesen Institute, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Lene Larssen
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Jorunn Skattum
- Department of Abdominal and Pediatric Surgery, Oslo University Hospital, Oslo, Norway
| | - Olav Sandstad
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Truls Hauge
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Asle W. Medhus
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
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Xu J, Zhong C, Huang S, Zeng X, Tan S, Shi L, Peng Y, Lü M, Ma L, Tang X. Efficacy and Safety of Peroral Endoscopic Myotomy for Sigmoid-Type Achalasia: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:677694. [PMID: 34307409 PMCID: PMC8295649 DOI: 10.3389/fmed.2021.677694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/08/2021] [Indexed: 02/05/2023] Open
Abstract
Background: The efficacy and safety of peroral endoscopic myotomy (POEM) in the treatment of sigmoid-type achalasia is unknown. This meta-analysis aims to explore the clinical outcomes of POEM for sigmoid-type achalasia. Method: We searched all relevant studies published up to September 2020 in PubMed, Embase, and Cochrane library databases. Meta-analyses for clinical success, Eckardt score, angle of esophageal tortuosity, diameter of esophagus, lower esophageal sphincter (LES) pressure, integrated relaxation pressure (IRP), adverse events, and gastroesophageal reflux diseases were performed based on random or fixed-effects models as needed. Results: We found a total of eight studies that provided data on 248 patients. Overall, the pooled clinical success was achieved in 211 sigmoid-type achalasia patients [90.4%; 95% confidence interval (CI), 85.5%−93.8%]. The pre- and post-POEM Eckardt scores, angle of esophageal tortuosity, diameter of esophageal, LES pressure, and IRP were significantly improved (All p < 0.05). The pooled adverse events rate was 13.0% (95% CI, 3.6%−37.4%). The pooled objective confirmation of reflux rate was 41.5% (95% CI, 26.5%−58.3%), and symptomatic reflux rate was 12.5% (95% CI, 8.3%−18.4%). Conclusions: Our current evidence indicated that POEM is an effective and safe therapeutic modality for the treatment of sigmoid-type achalasia.
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Affiliation(s)
- Jin Xu
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Chunyu Zhong
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shu Huang
- Department of Gastroenterology, the People's Hospital of Lianshui, Huaian, China
| | - Xinyi Zeng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shali Tan
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Lei Shi
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yan Peng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Muhan Lü
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Lianjun Ma
- Department of Endoscopy Center, China-Japan Union Hospital of Jilin University, Jilin University, Changchun, China
| | - Xiaowei Tang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
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Jonica ER, Wagh MS. Length of esophageal myotomy during peroral endoscopic myotomy for achalasia: it's okay to take the shortcut. Gastrointest Endosc 2021; 93:1313-1315. [PMID: 33691980 DOI: 10.1016/j.gie.2020.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 12/03/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Emily R Jonica
- Division of Gastroenterology, University of Colorado-Denver School of Medicine, Aurora, Colorado, USA
| | - Mihir S Wagh
- Division of Gastroenterology, University of Colorado-Denver School of Medicine, Aurora, Colorado, USA
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