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El Abiad R, Ashat M, Khashab M. Complications related to third space endoscopic procedures. Best Pract Res Clin Gastroenterol 2024; 71:101908. [PMID: 39209411 DOI: 10.1016/j.bpg.2024.101908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/06/2024] [Accepted: 03/19/2024] [Indexed: 09/04/2024]
Abstract
Third space endoscopy (TSE) encompasses a breadth of procedures for the treatment of a variety of GI disorders. The widespread use of per-oral endoscopic myotomy (POEM) and its diversification to include extended indications and at locations other than the oesophagus has provided an insight into the potential complications encountered. The most common adverse events associated with POEM, the epitome of TSE procedures, include insufflation related injuries, bleeding, failure of mucosal barrier, infections, pain, blown out myotomy and gastroesophageal reflux disease. The purpose of this review is to highlight the pitfalls and to identify the risk factors that may lead to adverse events, and to recommend appropriate salvage interventions in the scope of the current evidence.
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Affiliation(s)
- Rami El Abiad
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
| | - Munish Ashat
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Mouen Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD, USA
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El-Magd ESA, Elgeidie A, Elmahdy Y, Abbas A, Elyamany MA, Abulazm IL. Pre-operative endoscopic balloon dilatation and its impact on outcome of laparoscopic Heller cardiomyotomy for patients with achalasia: does the frequency and interval matter? Surg Endosc 2023; 37:7667-7675. [PMID: 37517041 PMCID: PMC10520180 DOI: 10.1007/s00464-023-10314-4] [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: 03/24/2023] [Accepted: 07/15/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Many surgeons believe that pre-operative balloon dilatation makes laparoscopic myotomy more difficult in achalasia patients. Herein, we wanted to see if prior pneumatic balloon dilatation led to worse outcomes after laparoscopic myotomy. We also assessed if the frequency of dilatations and the time interval between the last one and the surgical myotomy could affect these outcomes. METHODS The data of 460 patients was reviewed. They were divided into two groups: the balloon dilation (BD) group (102 patients) and the non-balloon dilatation (non-BD) group (358 patients). RESULTS Although pre-operative parameters and surgical experience were comparable between the two groups, the incidence of mucosal perforation, operative time, and intraoperative blood loss significantly increased in the BD group. The same group also showed a significant delay in oral intake and an increased hospitalization period. At a median follow-up of 4 years, the incidence of post-operative reflux increased in the BD group, while patient satisfaction decreased. Patients with multiple previous dilatations showed a significant increase in operative time, blood loss, perforation incidence, hospitalization period, delayed oral intake, and reflux esophogitis compared to single-dilatation patients. When compared to long-interval cases, patients with short intervals had a higher incidence of mucosal perforation and a longer hospitalization period. CONCLUSION Pre-operative balloon dilatation has a significant negative impact on laparoscopic myotomy short and long term outcomes. It is associated with a significant increase in operative time, blood loss, mucosal injury, hospitalization period, and incidence of reflux symptoms. More poor outcomes are encountered in patients with multiple previous dilatations and who have a short time interval between the last dilatation and the myotomy.
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Affiliation(s)
- El-Sayed Abou El-Magd
- Department of General Surgery, Faculty of Medicine, Gastrointestinal Surgical Center GISC, Mansoura University, Gehan Street, Mansoura, Al Dakahlia Governorate, 35511, Egypt.
| | - Ahmed Elgeidie
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | | | - Amr Abbas
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Maertens V, Lagarde S, Wijnhoven B. Surgical resection of voluminous epiphrenic diverticula. Acta Chir Belg 2021; 121:274-277. [PMID: 31718462 DOI: 10.1080/00015458.2019.1693153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A 52-year-old male and 55-year-old female underwent surgical resection of a voluminous symptomatic epiphrenic diverticulum via a right thoracotomy. A formal myotomy of the distal esophagus was not performed. The first patient had an uncomplicated recovery whilst the other patient still suffers from an esophageal-cutaneous fistula and repetitive abscesses, treated by intravenous antibiotics and percutaneous drainage. The authors discuss the indication for resection, surgical techniques and complications.
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Affiliation(s)
- Vicky Maertens
- Department of Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Sjoerd Lagarde
- Department of Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Bas Wijnhoven
- Department of Surgery, Erasmus MC, Rotterdam, The Netherlands
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Triggs JR, Krause AJ, Carlson DA, Donnan EN, Campagna RA, Jain AS, Kahrilas PJ, Hungness ES, Pandolfino JE. Blown-out myotomy: an adverse event of laparoscopic Heller myotomy and peroral endoscopic myotomy for achalasia. Gastrointest Endosc 2021; 93:861-868.e1. [PMID: 32721488 PMCID: PMC7855725 DOI: 10.1016/j.gie.2020.07.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/19/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Although laparoscopic Heller myotomy (LHM) or peroral endoscopic myotomy (POEM) is highly effective, 10% to 20% of patients with achalasia remain symptomatic after treatment. In evaluating such patients, we have observed a pattern of failure associated with a pseudodiverticulum, or blown-out myotomy (BOM), in the distal esophagus. We aimed to assess risk factors and patient-reported outcomes associated with a BOM. METHODS We reviewed our manometry database for patients with achalasia previously treated with LHM or POEM. We included patients who had a post-treatment esophagram within 1 year of their follow-up manometry. A BOM was defined radiographically as a wide-mouthed outpouching (>50% increase in esophageal diameter) in the area of the myotomy. RESULTS One hundred twenty-nine patients with achalasia who underwent treatment were included; 23 (17.8%) had a BOM. Comparing patients with a BOM with those without, post-treatment Eckardt scores were significantly greater (5 vs 2, P = .002), type III achalasia was more common (39.1% vs 14.2%, P = .005), and LHM was more common than POEM (73.9% vs 26.1%, P = .013). The integrated relaxation pressure was also significantly greater in the BOM group (15.0 mm Hg vs 11.0 mm Hg, P = .025). CONCLUSIONS BOM is a common adverse event after myotomy for achalasia but is not seen after pneumatic dilation. Pretreatment type III achalasia, LHM as opposed to POEM, and a greater post-treatment integrated relaxation pressure were risk factors for developing a BOM. We speculate that esophageal wall strain in the area weakened by myotomy, whether from residual spastic contractility or continued esophageal outflow obstruction, may be the underlying mechanism of BOM development.
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Affiliation(s)
- Joseph R. Triggs
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Amanda J. Krause
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Dustin A. Carlson
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Erica N. Donnan
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ryan A.J. Campagna
- Division of Gastrointestinal Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Anand S. Jain
- Division of Gastroenterology and Hepatology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Peter J. Kahrilas
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Eric S. Hungness
- Division of Gastrointestinal Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - John E. Pandolfino
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Yoo IK, OzgurYeniova A, Cho JY. Hybrid Peroral Endoscopic Myotomy for Achalasia with Prior Treatment Failure. Clin Endosc 2020; 54:127-130. [PMID: 32238790 PMCID: PMC7939763 DOI: 10.5946/ce.2020.013] [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: 12/27/2019] [Accepted: 03/11/2020] [Indexed: 11/21/2022] Open
Abstract
Achalasia is a neurodegenerative motility disorder caused by enteric neuron damage in the lower esophageal sphincter. Peroral endoscopic myotomy (POEM) is a standard treatment method for achalasia. Previous treatment modalities may affect the outcome of POEM as they cause submucosal fibrosis. We report a new technique called “hybrid POEM” for the treatment of patients with achalasia who had been previously treated with pneumatic balloon dilatation. We performed two techniques of POEM simultaneously, the standard POEM for the upper part of the submucosal tunnel and open POEM for the stenotic part of the esophagogastric junction. We dissected the mucosa and submucosa, and performed myotomy simultaneously. We overcame submucosal fibrosis of the esophagogastric junction, which was caused by the previous hybrid POEM treatment. The risks of mucosal incision and technical challenge of submucosal tunneling for the fibrotic area may be reduced by hybrid POEM.
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Affiliation(s)
- In Kyung Yoo
- Division of Gastroenterology, Department of Internal Medicine, Cha Bundang Medical Center, Seongnam, Korea
| | - Abdullah OzgurYeniova
- Division of Gastroenterology, Department of Internal Medicine, Tokat Gaziosmanpaşa University, Tokat, Turkey
| | - Joo Young Cho
- Division of Gastroenterology, Department of Internal Medicine, Cha Bundang Medical Center, Seongnam, Korea
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Cariati M, Chiarello MM, Cannistra' M, Lerose MA, Brisinda G. Gastrointestinal Uses of Botulinum Toxin. Handb Exp Pharmacol 2020; 263:185-226. [PMID: 32072269 DOI: 10.1007/164_2019_326] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Botulinum toxin (BT), one of the most powerful inhibitors that prevents the release of acetylcholine from nerve endings, represents an alternative therapeutic approach for "spastic" disorders of the gastrointestinal tract such as achalasia, gastroparesis, sphincter of Oddi dysfunction, chronic anal fissures, and pelvic floor dyssynergia.BT has proven to be safe and this allows it to be a valid alternative in patients at high risk of invasive procedures but long-term efficacy in many disorders has not been observed, primarily due to its relatively short duration of action. Administration of BT has a low rate of adverse reactions and complications. However, not all patients respond to BT therapy, and large randomized controlled trials are lacking for many conditions commonly treated with BT.The local injection of BT in some conditions becomes a useful tool to decide to switch to more invasive therapies. Since 1980, the toxin has rapidly transformed from lethal poison to a safe therapeutic agent, with a significant impact on the quality of life.
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Affiliation(s)
- Maria Cariati
- Department of Surgery, "San Giovanni di Dio" Hospital, Crotone, Italy
| | | | - Marco Cannistra'
- Department of Surgery, "San Giovanni di Dio" Hospital, Crotone, Italy
| | | | - Giuseppe Brisinda
- Department of Surgery, "San Giovanni di Dio" Hospital, Crotone, Italy. .,Department of Surgery, "Agostino Gemelli" Hospital, Catholic School of Medicine, Rome, Italy.
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Yeniova AO, Yoo IK, Jeong E, Cho JY. Comparison of peroral endoscopic myotomy between de-novo achalasia and achalasia with prior treatment. Surg Endosc 2020; 35:200-208. [PMID: 31953735 DOI: 10.1007/s00464-020-07380-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 01/07/2020] [Indexed: 02/07/2023]
Abstract
Peroral endoscopic myotomy has been recognized as an effective treatment for patients with achalasia. Prior treatment may affect the outcome of subsequent treatment. We aimed to compare the safety and efficacy of POEM in treatment-naive patients vs. those with prior treatment failure. We retrospectively analyzed the data of achalasia patients who underwent POEM from November 2011 to January 2018. A comparative analysis was performed between De-Novo (DN) and Prior Treatment Failure (PTF) cases. Technical and clinical success, adverse events, operative time for POEM, hospital stay were compared between the two groups Overall, 209 patients with achalasia underwent POEM during the studied period, including 113 patients (54%) in the DN group and 96 patients (45%) in the PTF group. The baseline characteristics of the DN and PTF groups were not significantly different except for duration of disease. The PTF group had longer disease duration than the DN group. (7.92 ± 9.28 vs 4.45 ± 5.67 years, respectively, p = 0.005). Both groups were technically successful. Operative time was longer in the PTF group than that in the de-novo group, but the difference was not significant. The occurrence rates of complications were similar in both groups. Changes in the Eckardt score were comparable in the DN and PTF cases. IRP and LES pressure decreased after POEM. After 6 months, more patients suffered from reflux symptoms in the PTF group, but DeMeester score and endoscopic evaluation were not significantly different POEM is safe and equally effective for patients with prior treatment failure as well as de-novo patients up to 6 months post treatment.
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Affiliation(s)
- Abdullah Ozgur Yeniova
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Tokat Gaziosmanpaşa University, Tokat, Turkey
| | - In Kyung Yoo
- Department of Gastroenterology, Cha Bundang Medical Center, Cha University College of Medicine, 59 Yatapro, Bundang-gu, Seongnam-si, Korea
| | - Eunju Jeong
- Department of Gastroenterology, Cha Bundang Medical Center, Cha University College of Medicine, 59 Yatapro, Bundang-gu, Seongnam-si, Korea
| | - Joo Young Cho
- Department of Gastroenterology, Cha Bundang Medical Center, Cha University College of Medicine, 59 Yatapro, Bundang-gu, Seongnam-si, Korea.
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Achem S. Post-POEM esophageal reflux in a Mexican population. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2020. [DOI: 10.1016/j.rgmxen.2019.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Miftahussurur M, Tandan M, Makmun D, Nabi Z. Peroral Endoscopic Myotomy in a Patient with Achalasia Cardia with Prior Heller's Myotomy. Case Rep Gastroenterol 2020; 14:48-55. [PMID: 32095124 PMCID: PMC7011739 DOI: 10.1159/000505512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 12/17/2019] [Indexed: 02/05/2023] Open
Abstract
Achalasia cardia is an esophageal myenteric plexus disorder characterized by absence of or incomplete lower esophageal sphincter relaxation and esophageal aperistalsis; Heller's myotomy is the main treatment of choice due to a lower failure rate. Recently, peroral endoscopic myotomy (POEM) has been reported as an alternative treatment for achalasia due to persistent symptoms after Heller's myotomy. An Indian male, aged 18 years, was admitted to the hospital due to dysphagia which had started more than 3 years ago. He also complained of occasional regurgitation and retrosternal pain with Eckardt score 6. Heller's myotomy was performed 2 years ago. Barium swallow showed achalasia cardia and upper gastrointestinal endoscopy found liquid residue and resistance at the gastroesophageal junction. Esophageal manometry is concluded as achalasia cardia type II with a median integrated relaxation pressure (IRP) of 25.6 mm Hg. He underwent POEM; with the help of a submucosal tunnel, an extension of up to 1 cm beyond the gastroesophageal junction could be achieved with a posterior orientation of myotomy. There were no adverse events after the POEM procedure. He was treated with a soft diet for 10 days and other supportive treatments. Following POEM, barium swallow showed a significant improvement and esophageal manometry exhibited that the basal lower esophageal sphincter pressure was normal with complete relaxation on swallowing and normal median IRP. The post-procedure Eckardt score was 0. We reported an achalasia patient who received POEM after unsuccessful Heller's myotomy and showed clinical improvement.
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Affiliation(s)
- Muhammad Miftahussurur
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Dr. Soetomo Teaching Hospital, Institute of Tropical Disease, Universitas Airlangga, Surabaya, Indonesia
| | - Manu Tandan
- Asian Institute of Gastroenterology, Hyderabad, India
| | - Dadang Makmun
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India
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Achem SR. Post-POEM esophageal reflux in a Mexican population. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2019; 85:1-3. [PMID: 31677895 DOI: 10.1016/j.rgmx.2019.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 07/23/2019] [Indexed: 11/27/2022]
Affiliation(s)
- S R Achem
- Mayo College of Medicine, Mayo Clinic Florida, Jacksonville, Florida, Estados Unidos.
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Gastric myotomy length affects severity but not rate of post-procedure reflux: 3-year follow-up of a prospective randomized controlled trial of double-scope per-oral endoscopic myotomy (POEM) for esophageal achalasia. Surg Endosc 2019; 34:2963-2968. [PMID: 31463720 DOI: 10.1007/s00464-019-07079-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Since Inoue performed the first POEM in 2008, safety and efficacy have been well-established. Early studies focused on refining the technique and avoiding incomplete myotomy. Following the discovery that many patients with abnormal acid exposure are asymptomatic, the focus shifted to post-POEM reflux, but no studies have identified any associated procedural factors. In this study, we examined the intermediate-term results of our previous randomized controlled trial, with particular attention to post-POEM reflux. METHODS Previously, 100 consecutive patients were randomized to either double- or single-scope POEM. Endoscopy was conducted 2 months post-POEM and annually thereafter. Patients were included in the present study if they completed endoscopy ≥ 6 months post-POEM, and the clinical results of both groups were analyzed with particular attention to clinical efficacy and post-POEM reflux. RESULTS Median follow-up was 3 years, and most myotomies were performed in the posterior location. The final gastric myotomy length was longer in the double-scope group (3.3 vs. 2.6 cm). Clinical efficacy (≥ 80%) and rates of post-POEM reflux (~ 60%) were similar; however, there was a higher incidence of moderate esophagitis (Los Angeles Grade B) in the double-scope group (25% vs. 4%). There were no cases of severe esophagitis (Los Angeles Grade C/D). Among patients with normal endoscopy at 2 months, > 40% developed erosive esophagitis on intermediate-term follow-up. CONCLUSIONS This is the first study to demonstrate a procedural factor that increases post-POEM esophagitis. Gastric myotomy > 2.5 cm results in increased rates of moderate esophagitis without improving clinical efficacy. Some patients developed esophagitis in a delayed fashion, emphasizing the importance of ongoing surveillance. We also believe that preserving the gastric sling fibers may help to reduce reflux rates. The double-scope method may help to control myotomy length (2.0-2.5 cm) and direction (lesser curve to avoid the gastric sling) to help maximize clinical efficacy while minimizing post-POEM reflux.
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