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Farina DA, Olson DA, Carlson DA, Kahrilas PJ, Vespa E, Koop AH, Arroyo Y, Goudie E, Pandolfino JE. Effect of esophageal body recoil on clinical outcomes in non-spastic achalasia. Neurogastroenterol Motil 2024; 36:e14785. [PMID: 38523321 DOI: 10.1111/nmo.14785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 01/15/2024] [Accepted: 03/11/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Despite the established efficacy of achalasia treatments on symptomatic outcomes, there are limited data evaluating the treatment effect on esophageal dilatation. This study aimed to assess the effect achalasia treatment on esophageal dilatation and the effect of esophageal width reduction ("recoil") on clinical outcomes. METHODS Patients with type I or type II achalasia that completed high-resolution manometry (HRM), functional lumen imaging probe (FLIP), and timed barium esophagram (TBE) pre and post treatment were included. Esophageal width was measured using TBE. Focused subgroup analysis was performed on patients with normal posttreatment EGJ opening on FLIP. Good clinical outcomes were defined as barium column height of <5 cm at 5 min and Eckardt Score ≤3. KEY RESULTS Sixty-nine patients (41% type I and 59% type II) were included. Esophageal width decreased from pre to post treatment mean (SD) 4.2 (1.3) cm-2.8 (1.2) cm; p < 0.01. In the normal post treatment EGJ opening subgroup, esophageal width was less in patients with good TBE outcome compared to poor outcome mean (SD) 2.2 (0.7) cm versus 3.2 (1.4) cm (p < 0.01), but did not differ in good versus poor symptomatic outcome groups. Esophageal width recoil >25% posttreatment was associated with a greater rate of good TBE outcome (71% vs. 50%, p = 0.04) and good symptomatic outcome (88% vs. 50%; p = 0.04). CONCLUSIONS AND INFERENCES Esophageal recoil was associated with good achalasia treatment outcome in patients without posttreatment EGJ obstruction. This suggests that mechanical properties of the esophageal wall, likely associated with tissue remodeling, play a role in clinical outcomes following achalasia treatment.
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Affiliation(s)
- Domenico A Farina
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dylan A Olson
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A Carlson
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Edoardo Vespa
- Division of Gastroenterology and Digestive Endoscopy, IRCCS San Raffaele Hospital, Milan, Italy
| | - Andree H Koop
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Yadis Arroyo
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Eric Goudie
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E Pandolfino
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
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Treatment of Achalasia and Epiphrenic Diverticulum. World J Surg 2022; 46:1547-1553. [PMID: 35142875 DOI: 10.1007/s00268-022-06476-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Epiphrenic diverticulum (ED) is a pulsion pseudodiverticulum found in the distal 10 cm of the esophagus. Motility disorders are present in the majority of patients with ED explaining the pathophysiology of this rare disease. Achalasia is the most common underlying disorder. We present a review on the diagnosis and management of ED in the setting of achalasia. METHODS Literature review. RESULTS Symptoms are most related to the underlying motility disorder. The diagnostic workup should always include an upper digestive endoscopy and a barium esophagogram. Esophageal manometry identifies the motility disorder in most patients. Therapeutic options include laparoscopic, thoracoscopic and endoscopic procedures. While a myotomy must always be performed, diverticulectomy is not always necessary. CONCLUSIONS Epiphrenic diverticulum is a rare condition whose pathophysiology involves an underlying motility disorder-achalasia in most cases. Symptoms usually include dysphagia, regurgitation, heartburn, and respiratory complaints and correlate with the motility disorder rather than the diverticulum per se. Upper digestive endoscopy and barium esophagogram are needed for the diagnosis-manometry may add useful information but is not imperative for the treatment. Laparoscopic Heller myotomy with a partial fundoplication is the procedure of choice, with satisfactory symptom relief and several advantages over the thoracic approach. Diverticulectomy may be performed in selected patients. Peroral endoscopic myotomy (POEM) are novel techniques, effective and minimally invasive that can be an option for patients unfit for surgery.
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DeWitt JM, Siwiec RM, Perkins A, Baik D, Kessler WR, Nowak TV, Wo JM, James-Stevenson T, Mendez M, Dickson D, Stainko S, Akisik F, Lappas J, Al-Haddad MA. Evaluation of timed barium esophagram after per-oral endoscopic myotomy to predict clinical response. Endosc Int Open 2021; 9:E1692-E1701. [PMID: 34790532 PMCID: PMC8589564 DOI: 10.1055/a-1546-8415] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/22/2021] [Indexed: 12/02/2022] Open
Abstract
Background and study aims The aim of this study was to evaluate whether timed barium esophagram within 24 hours post-per-oral endoscopic myotomy (POEM) (TBE-PP) could predict clinical outcomes. Patients and methods This was a single-center retrospective study of prospectively collected data on consecutive patients with ≥ 6-month follow-up who underwent POEM followed by TBE-PP. Esophageal contrast retention 2 minutes after TBE-PP was assessed as Grade 1 (< 10 %), 2 (10 %-49 %), 3 (50 %-89 %) or 4 (> 90 %). Eckardt score, esophagogastroduodenoscopy (EGD), high-resolution manometry (HRM) and function lumen imaging probe (FLIP) of the esophagogastric junction (EGJ) were obtained at baseline. These tests along with pH testing of antisecretory therapy were repeated 6 and 24 months after POEM. Clinical response by Eckardt score ≤ 3, EGJ-distensibility index (EGJ-DI) > 2.8 mm 2 /mm Hg, and integrated relaxation pressure (IRP) < 15 mm Hg and incidence of gastroesophageal reflux disease (GERD) were compared by transit time. Results Of 181 patients (58 % male, mean 53 ± 17 yr), TBE-PP was classified as Grade 1 in 122 (67.4 %), Grade 2 in 41 (22.7 %), Grade 3 in 14 (7.7 %) and Grade 4 in 4 (2.2 %). At 6 months, overall clinical response by ES (91.7 %), IRP (86.6 %), EGJ-DI (95.7 %) and the diagnosis of GERD (68.6 %) was similar between Grade 1 and Grade 2-4 TBE-PP. At 24 months, Grade 1 had a higher frequency of a normal IRP compared to Grades 2-4 (95.7 % vs. 60 %, P = 0.021) but overall response by ES (91.2 %), EGJ-DI (92.3 %) and the diagnosis of GERD (74.3 %) were similar. Conclusions Contrast emptying rate by esophagram after POEM has limited utility to predict clinical response or risk of post-procedure GERD.
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Affiliation(s)
- John M. DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - Robert M. Siwiec
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - Anthony Perkins
- Department of Biostatistics, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - Daniel Baik
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - William R. Kessler
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - Thomas V. Nowak
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - John M. Wo
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - Toyia James-Stevenson
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - Martha Mendez
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - Destenee Dickson
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - Sarah Stainko
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - Fatih Akisik
- Department of Radiology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - John Lappas
- Department of Radiology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - Mohammad A. Al-Haddad
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
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Kachala SS, Rice TW, Baker ME, Rajeswaran J, Thota PN, Murthy SC, Blackstone EH, Zanoni A, Raja S. Value of routine timed barium esophagram follow-up in achalasia after myotomy. J Thorac Cardiovasc Surg 2018; 156:871-877.e2. [DOI: 10.1016/j.jtcvs.2018.03.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 02/21/2018] [Accepted: 03/03/2018] [Indexed: 12/29/2022]
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Bobanga ID, Redline RW, DeRoss AL. Oesophageal pseudodiverticulum after foregut duplication cyst excision: Case report and literature review. Afr J Paediatr Surg 2016; 13:50-3. [PMID: 27251526 PMCID: PMC4955461 DOI: 10.4103/0189-6725.181709] [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] [Indexed: 11/22/2022] Open
Abstract
Oesophageal pseudodiverticula rarely occur after excision of benign oesophageal neoplasms. While management and outcomes have been reported in the adult leiomyoma literature, sparse data exist on the occurrence and management of pseudodiverticula after foregut duplication cyst excision. We discuss our experience with a paediatric patient and review relevant literature regarding operative techniques and surgical outcomes.
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Affiliation(s)
- Iuliana D Bobanga
- Department of General Surgery, University Hospital Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Raymond W Redline
- Department of Pathology, University Hospital Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Anthony L DeRoss
- Department of Pediatric Surgery, University Hospital Case Medical Center, Rainbow Babies and Children Hospital, Cleveland, Ohio, USA
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