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Chatha HN, Lyons J, Boutros CS, Khan SZ, Wieland P, Levine I, Benson J, Alvarado C, Katz G, Marks JM. Elevated preoperative lower esophageal sphincter pressure predicts improved clinical outcomes after per oral endoscopic myotomy (POEM). Surg Endosc 2024; 38:6105-6110. [PMID: 39271509 DOI: 10.1007/s00464-024-11229-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 08/23/2024] [Indexed: 09/15/2024]
Abstract
BACKGROUND Although per oral endoscopic myotomy (POEM) has shown to be beneficial for the treatment of achalasia, it can be difficult to predict who will have a robust and long-lasting response. Historically, it has been shown that higher lower esophageal sphincter pressures have been associated with poorer responses to alternative endoscopic therapies such as Botox therapy and pneumatic dilation. This study was designed to evaluate if modern preoperative manometric data could similarly predict response to therapy after POEM. METHODS This was a retrospective study of 237 patients who underwent POEM at a single institution over a period of 13 years (2011-2023) and who had a high-resolution manometry performed preoperatively and an Eckardt symptom score performed both preoperative and postoperatively. The achalasia type and integrated relaxation pressures (IRP) were tested for potential correlation with the need for any further achalasia interventions postoperatively as well as the degree of Eckardt score reduction using a linear regression model. RESULTS The Achalasia type on preoperative manometry was not predictive for further interventions or degree of Eckardt score reduction (p = 0.76 and 0.43, respectively). A higher IRP was not predictive of the need for further interventions, however, it was predictive of a greater reduction in postoperative Eckardt scores (p = 0.03) as shown by the non-zero regression slope. CONCLUSION In this study, achalasia type was not a predictive factor in the need for further interventions or the degree of symptom relief. Although IRP was not predictive of the need for further interventions, a higher IRP did predict better symptomatic relief postoperatively. This result is opposite that of other endoscopic treatment modalities (Botox and pneumatic dilation). Therefore, patients with higher IRP on preoperative high-resolution manometry would likely benefit from POEM which provides significant symptomatic relief postoperatively.
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Affiliation(s)
- Hamza Nasir Chatha
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
| | - Joshua Lyons
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA.
- Case Western Reserve University, Cleveland, OH, USA.
| | - Christina S Boutros
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Saher-Zahra Khan
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Patrick Wieland
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Iris Levine
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
| | - Jamie Benson
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Christine Alvarado
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Guy Katz
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Jeffrey M Marks
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Case Western Reserve University, Cleveland, OH, USA
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Vauquelin B, Quénéhervé L, Pioche M, Barret M, Wallenhorst T, Chabrun E, Coron E, Roman S, Mion F, Chaussade S, Ponchon T, Olivier R, Rivière P, Zerbib F, Berger A. Factors associated with early failure of peroral endoscopic myotomy in achalasia. Gastrointest Endosc 2024; 99:349-357.e3. [PMID: 37806398 DOI: 10.1016/j.gie.2023.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/21/2023] [Accepted: 10/10/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND AND AIMS Achalasia can be treated very effectively with peroral endoscopic myotomy (POEM), but factors associated with early failure remain to be determined, especially in European cohorts. METHODS All consecutive adult patients who underwent a first POEM to treat primary achalasia were included in this multicenter retrospective study. Early failure was defined by an Eckardt score (ES) >3 at 3 months after POEM. When evaluating factors predictive of early failure, 2 cohorts were considered: one consisted of the total population, for whom only basic variables were collected, and the other a cohort built for a case-control study that included matched early-failure and early-success patients (ratio, 1:2). RESULTS Among 746 patients, the early failure rate was 9.4%. Predictive factors were age ≤45 years (P = .019), achalasia types I and III (P < .001), and the development of a severe adverse event during the procedure (P = .023). In the case-control study, the only additional independent risk factor for early failure was a high pre-POEM ES (P = .001). Only the retrosternal pain subscore was significantly associated with the early failure rate. CONCLUSION The early failure rate of POEM used to treat primary achalasia is <10%. Younger age, type I/III achalasia, and a high pre-POEM ES were significantly associated with failure.
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Affiliation(s)
- Blandine Vauquelin
- Gastroenterology and Hepatology Department, INSERM CIC 1401, Haut-Lévêque University Hospital, Bordeaux, France
| | - Lucille Quénéhervé
- Gastroenterology Department, University Hospital of Brest, Brest, France
| | - Mathieu Pioche
- Department of Gastroenterology, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon University, Inserm U1032, LabTAU, Lyon, France
| | - Maximilien Barret
- Gastroenterology Department, Cochin University Hospital, AP-HP, Paris, France
| | - Timothée Wallenhorst
- Department of Gastroenterology, Pontchaillou University Hospital, Rennes, France
| | - Edouard Chabrun
- Gastroenterology and Hepatology Department, INSERM CIC 1401, Haut-Lévêque University Hospital, Bordeaux, France
| | - Emmanuel Coron
- Department of Gastroenterology and Hepatology, University Hospital of Geneva (HUG), Geneva, Switzerland
| | - Sabine Roman
- Digestive Physiology, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon University Hospital, Inserm U1032, LabTAU, Lyon, France
| | - François Mion
- Digestive Physiology, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon University Hospital, Inserm U1032, LabTAU, Lyon, France
| | - Stanislas Chaussade
- Gastroenterology Department, Cochin University Hospital, AP-HP, Paris, France
| | - Thierry Ponchon
- Department of Gastroenterology, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon University, Inserm U1032, LabTAU, Lyon, France
| | - Raphael Olivier
- Department of Gastroenterology, Nantes University Hospital, Nantes, France
| | - Pauline Rivière
- Gastroenterology and Hepatology Department, INSERM CIC 1401, Haut-Lévêque University Hospital, Bordeaux, France
| | - Frank Zerbib
- Gastroenterology and Hepatology Department, INSERM CIC 1401, Haut-Lévêque University Hospital, Bordeaux, France
| | - Arthur Berger
- Gastroenterology and Hepatology Department, INSERM CIC 1401, Haut-Lévêque University Hospital, Bordeaux, France.
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Denzer U, Müller M, Kreuser N, Thieme R, Hoffmeister A, Feisthammel J, Niebisch S, Gockel I. [Therapy of esophageal motility disorders]. Laryngorhinootologie 2023; 102:824-838. [PMID: 37263277 DOI: 10.1055/a-1949-3583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2020 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.
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Affiliation(s)
- Ulrike Denzer
- Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Germany
| | - Michaela Müller
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - Nicole Kreuser
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - René Thieme
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Juergen Feisthammel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Stefan Niebisch
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
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Lyons J, Boutros C, Khan SZ, Benson J, Hashimoto DA, Marks J. Preoperative manometric data can predict symptom improvement after per oral endoscopic myotomy for treatment of achalasia. Surg Endosc 2023; 37:7226-7229. [PMID: 37389740 DOI: 10.1007/s00464-023-10249-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 06/23/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND While per oral endoscopic myotomy (POEM) has been shown to be efficacious in the treatment of achalasia, it can be difficult to predict who will have a robust and durable response. Historically, high lower esophageal sphincter pressures have been shown to predict a worse response to endoscopic therapies such as botox therapy. This study was designed to evaluate if modern preoperative manometric data could predict a response to therapy after POEM. METHODS This was a retrospective study of 144 patients who underwent a POEM at a single institution by a single surgeon over an 8-year period (2014-2022) who had high-resolution manometry performed preoperatively and had an Eckardt symptom score performed both preoperatively and postoperatively. The achalasia type and integrated relaxation pressures (IRP) were then tested for potential correlation with need for any further achalasia interventions postoperatively as well as the degree of Eckardt score reduction using univariate analysis. RESULTS The achalasia type on preoperatively manometry was not predictive of need for further interventions or degree of Eckardt score reduction (p = 0.74 and 0.44, respectively). A higher IRP was not predictive of need for further interventions however it was predictive of a greater reduction in postoperative Eckardt scores (p = 0.03) as shown by a nonzero regression slope. CONCLUSION In this study, achalasia type was not a predictive factor in need for further interventions or degree of symptom relief. While IRP was not predictive of need for further interventions, a higher IRP did predict better symptomatic relief postoperatively. This result is opposite that of other endoscopic treatment modalities. Therefore, patients with higher IRP on high-resolution manometry would likely benefit from myotomy which provides significant symptomatic relief postoperatively.
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Affiliation(s)
- Joshua Lyons
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA.
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA.
| | - Christina Boutros
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA
| | - Saher-Zahra Khan
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA
| | - Jamie Benson
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA
| | - Daniel A Hashimoto
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA
| | - Jeffrey Marks
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA
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Denzer UW, Müller M, Kreuser N, Thieme R, Hoffmeister A, Feisthammel J, Niebisch S, Gockel I. [Therapy of esophageal motility disorders]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:183-197. [PMID: 35835360 DOI: 10.1055/a-1833-9299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2020 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.
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Affiliation(s)
- Ulrike W Denzer
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - Michaela Müller
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - Nicole Kreuser
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - René Thieme
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Juergen Feisthammel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Stefan Niebisch
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
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Luo J, Huang B, Zheng H, Yang Z, Xu M, Xu Z, Ma W, Lin R, Feng Z, Wu M, Cui S. Acupuncture combined with balloon dilation for post-stroke cricopharyngeal achalasia: A meta-analysis of randomized controlled trials. Front Neurosci 2023; 16:1092443. [PMID: 36711135 PMCID: PMC9879211 DOI: 10.3389/fnins.2022.1092443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/22/2022] [Indexed: 01/13/2023] Open
Abstract
Background The purpose of this study was to systematically evaluate the effectiveness of acupuncture combined with balloon dilatation in patients with post-stroke cricopharyngeal achalasia (CPA) according to the effective rate, videofluoroscopy swallowing study (VFSS) score and standardized swallowing function assessment scale (SSA) score through Meta-analysis. Methods English and Chinese language literature published before July 24,2022 were searched in ten electronic databases. The identified articles were screened, data were extracted, and the methodological quality of the included trials was assessed. Using RevMan 5.4.1 software to perform Meta-analysis. Results 10 studies with 517 patients with post-stroke CPA were included. Meta-analysis showed that the effective rate of the experience group was higher than that of the control group [OR = 0.62; 95% CI (2.32, 13.05); I 2 = 0%; p = 0.0001]. Compared to the control group, the SSA score was lower in the experience group [MD = -4.22; 95% CI (-4.57, -3.87); I 2 = 42%; p < 0.00001]. In terms of VFSS scores, the experience group showed greater efficacy differences than control group [MD = 1.53; 95% CI (1.32, 1.75); I 2 = 0%; p < 0.00001]. The subgroup analysis of VFSS score based on the average course of disease (<1 month vs. ≥1 month) showed no significant difference. The subgroup analysis based on average age (>60 years vs. ≤60 years) showed the VFSS score of the experience group was significantly higher than that of the control group, and the effect may be better in the subgroup older than 60 years. The subgroup analysis based on the treatment course (>30 days vs. ≤30 days) showed the VFSS score of the experience group was significantly higher than that of the control group, and the effect may be better in the subgroup the treatment course>30 days. Conclusion Acupuncture combined with balloon dilatation may be an effective method for treating post-stroke CPA. Compared with balloon dilatation, acupuncture combined with balloon can significantly improve the swallowing function of patients, and it is also effective for patients of different courses, ages, and treatment course, while patients over 60 years old and the treatment course over 30 days may have better clinical outcomes.
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Affiliation(s)
- Jing Luo
- Department of Rehabilitation, Shenzhen Hospital of Guangzhou University of Chinese Medicine, Shenzhen, Guangdong, China
- Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Bingjing Huang
- Department of Rehabilitation, Shenzhen Hospital of Guangzhou University of Chinese Medicine, Shenzhen, Guangdong, China
- Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Huiyan Zheng
- Clinical Medical College of Acupuncture Moxibustion and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Zeyu Yang
- Department of Rehabilitation, Shenzhen Hospital of Guangzhou University of Chinese Medicine, Shenzhen, Guangdong, China
- Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Mingzhu Xu
- Department of Rehabilitation, Shenzhen Hospital, Southern Medical University, Shenzhen, Guangdong, China
| | - Zhenhua Xu
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, Guangdong, China
| | - Wenjun Ma
- Department of Rehabilitation, Shenzhen Hospital of Guangzhou University of Chinese Medicine, Shenzhen, Guangdong, China
| | - Run Lin
- Department of Rehabilitation, Shenzhen Hospital of Guangzhou University of Chinese Medicine, Shenzhen, Guangdong, China
- Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Zitong Feng
- Clinical Medical College of Acupuncture Moxibustion and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Meng Wu
- Department of Rehabilitation, Shenzhen Hospital of Guangzhou University of Chinese Medicine, Shenzhen, Guangdong, China
| | - Shaoyang Cui
- Department of Rehabilitation, Shenzhen Hospital of Guangzhou University of Chinese Medicine, Shenzhen, Guangdong, China
- Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
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Ribolsi M, Andrisani G, Di Matteo FM, Cicala M. Achalasia, from diagnosis to treatment. Expert Rev Gastroenterol Hepatol 2023; 17:21-30. [PMID: 36588469 DOI: 10.1080/17474124.2022.2163236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Achalasia is an uncommon esophageal motility disorder and is characterized by alterations of the motility of the esophageal body in conjunction with altered lower esophageal sphincter (LES) relaxation. The clinical presentation of patients with achalasia may be complex; however, the most frequent symptom is dysphagia. The management of patients with achalasia is often challenging, due to the heterogeneous clinical presentation. AREAS COVERED The diagnosis and management of achalasia has significantly improved in the last years due to the growing availability of high-resolution manometry (HRM) and the implementation in the therapeutic armamentarium of new therapeutic endoscopic procedures. Traditional therapeutic strategies include botulinum toxin injected to the LES and pneumatic balloon dilation. On the other hand, surgical treatments contemplate laparoscopic Heller myotomy and, less frequently, esophagectomy. Furthermore, in the last few years, per oral endoscopic myotomy (POEM) has been proposed as the main endoscopic therapeutic alternative to the laparoscopic Heller myotomy. EXPERT OPINION Diagnosis and treatment of achalasia still represent a challenging area. However, we believe that an accurate up-front evaluation is, nowadays, necessary in addressing patients with achalasia for a more accurate diagnosis as well as for the best treatment options.
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Affiliation(s)
- Mentore Ribolsi
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, Rome, Italy
| | | | | | - Michele Cicala
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, Rome, Italy
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de Moura ETH, Jukemura J, Ribeiro IB, Farias GFA, de Almeida Delgado AA, Coutinho LMA, de Moura DTH, Aissar Sallum RA, Nasi A, Sánchez-Luna SA, Sakai P, de Moura EGH. Peroral endoscopic myotomy vs laparoscopic myotomy and partial fundoplication for esophageal achalasia: A single-center randomized controlled trial. World J Gastroenterol 2022; 28:4875-4889. [PMID: 36156932 PMCID: PMC9476850 DOI: 10.3748/wjg.v28.i33.4875] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/07/2022] [Accepted: 08/05/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Achalasia is a rare benign esophageal motor disorder characterized by incomplete relaxation of the lower esophageal sphincter (LES). The treatment of achalasia is not curative, but rather is aimed at reducing LES pressure. In patients who have failed noninvasive therapy, surgery should be considered. Myotomy with partial fundoplication has been considered the first-line treatment for non-advanced achalasia. Recently, peroral endoscopic myotomy (POEM), a technique that employs the principles of submucosal endoscopy to perform the equivalent of a surgical myotomy, has emerged as a promising minimally invasive technique for the management of this condition.
AIM To compare POEM and laparoscopic myotomy and partial fundoplication (LM-PF) regarding their efficacy and outcomes for the treatment of achalasia.
METHODS Forty treatment-naive adult patients who had been diagnosed with achalasia based on clinical and manometric criteria (dysphagia score ≥ II and Eckardt score > 3) were randomized to undergo either LM-PF or POEM. The outcome measures were anesthesia time, procedure time, symptom improvement, reflux esophagitis (as determined with the Gastroesophageal Reflux Disease Questionnaire), barium column height at 1 and 5 min (on a barium esophagogram), pressure at the LES, the occurrence of adverse events (AEs), length of stay (LOS), and quality of life (QoL).
RESULTS There were no statistically significant differences between the LM-PF and POEM groups regarding symptom improvement at 1, 6, and 12 mo of follow-up (P = 0.192, P = 0.242, and P = 0.242, respectively). However, the rates of reflux esophagitis at 1, 6, and 12 mo of follow-up were significantly higher in the POEM group (P = 0.014, P < 0.001, and P = 0.002, respectively). There were also no statistical differences regarding the manometry values, the occurrence of AEs, or LOS. Anesthesia time and procedure time were significantly shorter in the POEM group than in the LM-PF group (185.00 ± 56.89 and 95.70 ± 30.47 min vs 296.75 ± 56.13 and 218.75 ± 50.88 min, respectively; P = 0.001 for both). In the POEM group, there were improvements in all domains of the QoL questionnaire, whereas there were improvements in only three domains in the LM-PF group.
CONCLUSION POEM and LM-PF appear to be equally effective in controlling the symptoms of achalasia, shortening LOS, and minimizing AEs. Nevertheless, POEM has the advantage of improving all domains of QoL, and shortening anesthesia and procedure times but with a significantly higher rate of gastroesophageal reflux.
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Affiliation(s)
- Eduardo Turiani Hourneaux de Moura
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Sao Paulo 05403-010, Brazil
| | - José Jukemura
- Division of Esophageal Surgery, Hospital das Clínicas, University of São Paulo School of Medicine, Sao Paulo 05403-010, Brazil
| | - Igor Braga Ribeiro
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Sao Paulo 05403-010, Brazil
| | - Galileu Ferreira Ayala Farias
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Hospital das Clínicas, University of São Paulo School of Medicine, Sao Paulo 05403-010, Brazil
| | - Aureo Augusto de Almeida Delgado
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Hospital das Clínicas, University of São Paulo School of Medicine, Sao Paulo 05403-010, Brazil
| | - Lara Meireles Azeredo Coutinho
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Hospital das Clínicas, University of São Paulo School of Medicine, Sao Paulo 05403-010, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Hospital das Clínicas, University of São Paulo School of Medicine, Sao Paulo 05403-010, Brazil
| | - Rubens Antonio Aissar Sallum
- Division of Esophageal Surgery, Hospital das Clínicas, University of São Paulo School of Medicine, Sao Paulo 05403-010, Brazil
| | - Ary Nasi
- Division of Esophageal Surgery, Hospital das Clínicas, University of São Paulo School of Medicine, Sao Paulo 05403-010, Brazil
| | - Sergio A Sánchez-Luna
- Department of Internal Medicine, The University of Alabama at Birmingham Heersink School of Medicine, Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology and Hepatology, Birmingham, AL 35233, United States
| | - Paulo Sakai
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Sao Paulo 05403-010, Brazil
| | - Eduardo Guimarães Hourneaux de Moura
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Sao Paulo 05403-010, Brazil
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9
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Torresan F, Cortellini F, Azzaroli F, Ioannou A, Mularoni C, Shoshan D, Mandolesi D, De Giorgio R, Karamanolis G, Bazzoli F. Graded pneumatic dilation in subtype I and II achalasia: long-term experience in a single center. Ann Gastroenterol 2022; 35:28-33. [PMID: 34987285 PMCID: PMC8713348 DOI: 10.20524/aog.2021.0683] [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: 07/11/2021] [Accepted: 10/25/2021] [Indexed: 11/11/2022] Open
Abstract
Background The efficacy of pneumatic dilation (PD) in the management of achalasia has yielded variable results. The availability of high-resolution manometry led to the identification of 3 clinically relevant subtypes of achalasia, revealing the poor efficacy of PD in subtype III. Furthermore, PD showed a lower response rate in patients with subtype III compared to laparoscopic Heller myotomy and peroral endoscopic myotomy. This study aimed to investigate the short- and long-term efficacy, safety profile and side effects of PD with a "graded approach" in subtypes I and II achalasia. Methods We enrolled 141 patients (male 67, mean age=66±16.26 years) with achalasia (n=27 subtype I, n=74 subtype II and n=40 subtype III) between January 2010 and July 2020 at St. Orsola University Hospital, Bologna, Italy. We analyzed the data of patients with subtypes I and II, who underwent a graded-protocol PD. Short- and long-term clinical efficacy, complications and gastroesophageal reflux disease (GERD) were recorded. Results One month after graded protocol PD, 100% subtype I and 96.2% subtype II achalasia patients showed clinical remission. The PD procedure was completed without major complications in all patients. In the long-term follow up (median time: 56 months), 95.5% subtype I and 90% subtype II achalasia patients had an Eckardt score ≤3. GERD occurred in 27.7% of all patients. Conclusion A graded-protocol PD applied in the appropriate achalasia subtypes was shown to be a safe and highly effective approach, in both the short- and long-term.
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Affiliation(s)
- Francesco Torresan
- Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy (Francesco Torresan, Fabio Cortellini, Francesco Azzaroli, Daniele Mandolesi, Franco Bazzoli)
| | - Fabio Cortellini
- Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy (Francesco Torresan, Fabio Cortellini, Francesco Azzaroli, Daniele Mandolesi, Franco Bazzoli).,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy (Fabio Cortellini, Francesco Azzaroli, Cecilia Mularoni, Dikla Shoshan, Franco Bazzoli)
| | - Francesco Azzaroli
- Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy (Francesco Torresan, Fabio Cortellini, Francesco Azzaroli, Daniele Mandolesi, Franco Bazzoli).,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy (Fabio Cortellini, Francesco Azzaroli, Cecilia Mularoni, Dikla Shoshan, Franco Bazzoli)
| | - Alexandros Ioannou
- 2 Department of Surgery, Gastroenterology Unit, "Aretaieio" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece (Alexandros Ioannou, George Karamanolis)
| | - Cecilia Mularoni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy (Fabio Cortellini, Francesco Azzaroli, Cecilia Mularoni, Dikla Shoshan, Franco Bazzoli)
| | - Dikla Shoshan
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy (Fabio Cortellini, Francesco Azzaroli, Cecilia Mularoni, Dikla Shoshan, Franco Bazzoli)
| | - Daniele Mandolesi
- Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy (Francesco Torresan, Fabio Cortellini, Francesco Azzaroli, Daniele Mandolesi, Franco Bazzoli)
| | - Roberto De Giorgio
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy (Roberto De Giorgio)
| | - George Karamanolis
- 2 Department of Surgery, Gastroenterology Unit, "Aretaieio" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece (Alexandros Ioannou, George Karamanolis)
| | - Franco Bazzoli
- Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy (Francesco Torresan, Fabio Cortellini, Francesco Azzaroli, Daniele Mandolesi, Franco Bazzoli).,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy (Fabio Cortellini, Francesco Azzaroli, Cecilia Mularoni, Dikla Shoshan, Franco Bazzoli)
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10
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Nabi Z, Ramchandani M, Reddy DN. Optional Management of Achalasia in 2021: Dilatation or Myotomy. JOURNAL OF DIGESTIVE ENDOSCOPY 2021. [DOI: 10.1055/s-0041-1731626] [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] [Indexed: 10/20/2022] Open
Abstract
AbstractAchalasia 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.
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Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, Telangana, India
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11
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Ofosu A, Mohan BP, Ichkhanian Y, Masadeh M, Febin J, Barakat M, Ramai D, Chandan S, Haiyeva G, Khan SR, Aghaie Meybodi M, Facciorusso A, Repici A, Wani S, Thosani N, Khashab MA. Peroral endoscopic myotomy (POEM) vs pneumatic dilation (PD) in treatment of achalasia: A meta-analysis of studies with ≥ 12-month follow-up. Endosc Int Open 2021; 9:E1097-E1107. [PMID: 34222636 PMCID: PMC8216779 DOI: 10.1055/a-1483-9406] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 11/23/2020] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Peroral endoscopic myotomy (POEM) is increasingly being used as the preferred treatment option for achalasia. The aim of this systematic review and meta-analysis was to compare the efficacy and safety of POEM versus pneumatic balloon dilation (PD). Methods We performed a comprehensive review of studies that reported clinical outcomes of POEM and PD for the treatment of achalasia. Measured outcomes included clinical success (improvement of symptoms based on a validated scale including an Eckardt score ≤ 3), adverse events, and post-treatment gastroesophageal reflux disease (GERD). Results Sixty-six studies (6268 patients) were included in the final analysis, of which 29 studies (2919 patients) reported on POEM and 33 studies (3050 patients) reported on PD and 4 studies (299 patients) compared POEM versus PD. Clinical success with POEM was superior to PD at 12, 24, and 36 months (92.9 %, vs 76.9 % P = 0.001; 90.6 % vs 74.8 %, P = 0.004; 88.4 % vs 72.2 %, P = 0.006, respectively). POEM was superior to PD in type I, II and III achalasia (92.7 % vs 61 %, P = 0.01; 92.3 % vs 80.3 %, P = 0.01; 92.3 %v 41.9 %, P = 0.01 respectively) Pooled OR of clinical success at 12 and 24 months were significantly higher with POEM (8.97; P = 0.001 & 5.64; P = 0.006). Pooled OR of GERD was significantly higher with POEM (by symptoms: 2.95, P = 0.02 and by endoscopic findings: 6.98, P = 0.001). Rates of esophageal perforation (0.3 % vs 0.6 %, P = 0.8) and significant bleeding (0.4 % vs 0.7 %, P = 0.56) were comparable between POEM and PD groups. Conclusions POEM is more efficacious than PD in the treatment of patients with achalasia during short-term and long-term follow-up, albeit with higher risk of abnormal esophageal acid exposure.
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Affiliation(s)
- Andrew Ofosu
- Gastroenterology and Hepatology, Stanford University, Stanford, California, United States
| | - Babu P. Mohan
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, Utah, United States
| | - Yervant Ichkhanian
- Internal Medicine, Henry Ford University Medical Center, Detroit, Michigan, United States
| | - Maen Masadeh
- Kaiser Permanente Northern California, California, United States
| | - John Febin
- Gastroenterology and Hepatology, Stanford University, Stanford, California, United States
| | - Mohamed Barakat
- Gastroenterology and Hepatology, Stanford University, Stanford, California, United States
| | - Daryl Ramai
- Gastroenterology and Hepatology, Stanford University, Stanford, California, United States
| | - Saurabh Chandan
- Gastroenterology and Hepatology, University of Nebraska, United States
| | - Gulara Haiyeva
- Beneficts Hospital Inc., Great Falls, Montana, United States
| | - Shahab R. Khan
- Gastroenterology, Rush University Medical Center, Chicago, Illinois, United States
| | - Mohamad Aghaie Meybodi
- Gastroenterology and Hepatology, John Hopkins University Hospital, Baltimore, Maryland, United States
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Alessandro Repici
- Humanitas Research Hospital, Humanitas University, Rozzano, Milan, Italy
| | - Sachin Wani
- Gastroenterology, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Nirav Thosani
- Gastroenterology, Hepatology and Nutrition, University of Texas Health Science Center at Houston, Houston, Texas, United States
| | - Mouen A. Khashab
- Gastroenterology and Hepatology, John Hopkins University Hospital, Baltimore, Maryland, United States
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Brindise E, Khashab MA, El Abiad R. Insights into the endoscopic management of esophageal achalasia. Ther Adv Gastrointest Endosc 2021; 14:26317745211014706. [PMID: 34017943 PMCID: PMC8114742 DOI: 10.1177/26317745211014706] [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: 01/15/2021] [Accepted: 04/07/2021] [Indexed: 01/21/2023] Open
Abstract
Achalasia is a primary esophageal motility disorder characterized by the loss of inhibitory neurons in the myenteric plexus, resulting in impaired relaxation of the esophagogastric junction. Achalasia is an incurable disease, and the treatment modalities are aimed at disruption of the esophagogastric junction and vary widely from pharmacological to endoscopic to surgical. Traditional endoscopic therapy includes pneumatic dilation, botulinum toxin injection, and peroral endoscopic myotomy. This review aims to provide an overview of the endoscopic management of achalasia, while focusing on the utilization of peroral endoscopic myotomy and other novel approaches.
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Affiliation(s)
- Elizabeth Brindise
- Division of Gastroenterology and Hepatology, The University of Iowa, Iowa City, IA, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Rami El Abiad
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals & Clinics, The University of Iowa, 4612 JCP, Iowa City, IA 52241, USA
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13
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Swanström LL. Achalasia: treatment, current status and future advances. Korean J Intern Med 2019; 34:1173-1180. [PMID: 30866609 PMCID: PMC6823561 DOI: 10.3904/kjim.2018.439] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 02/10/2019] [Indexed: 12/19/2022] Open
Abstract
Achalasia was first described in the 17th century and its treatment continues to be challenging. Palliative treatment involves disruption of the lower esophageal sphincter, which can be accomplished mechanically (balloon dilation or surgical myotomy) or chemically (Botox). True surgical treatment originated some 100 years ago and remained largely unchanged until the advent of thoracoscopic and then laparoscopic myotomy beginning in the 1980s. Because these procedures provided relatively definitive treatment and were well tolerated by patients, minimal invasive surgery assumed a primary role in the treatment algorithms for achalasia. In 2008, an endoscopic (incision-less) myotomy approach, per-oral endoscopic myotomy, was described. This even less invasive approach has rapidly been adopted in the majority of high-volume achalasia centers. Newer interventions, such as stenting and cell transplant, are under active investigation.
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Affiliation(s)
- Lee L. Swanström
- Division of Surgery, Oregon Health Sciences University, Portland, OR, USA
- IHU-Strasbourg, Strasbourg, France
- Correspondence to Lee L. Swanström, M.D. Division of Surgery, Oregon Health Sciences University, 4805 Northeast Glisan, 6N60, Portland, OR 97213, USA Tel: +1-336-51080361 Fax: +1-333-88119099 E-mail:
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14
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Andolfi C, Fisichella PM. Meta-analysis of clinical outcome after treatment for achalasia based on manometric subtypes. Br J Surg 2019; 106:332-341. [PMID: 30690706 DOI: 10.1002/bjs.11049] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 08/30/2018] [Accepted: 10/11/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND The introduction of high-resolution manometry and the Chicago classification has made it possible to diagnose achalasia and predict treatment response accurately. The aim of this study was to compare the effect of the different treatments available on symptomatic outcomes across all achalasia subtypes. METHODS The study was conducted according to PRISMA and MOOSE guidelines. A literature search of PubMed and MEDLINE databases was undertaken to identify all relevant articles reporting clinical outcomes of patients with achalasia after botulinum toxin injection, pneumatic dilatation, laparoscopic Heller myotomy (LHM) and peroral endoscopic myotomy (POEM) based on manometric subtypes. Patients were grouped according to the Chicago classification and the success rate in treating symptoms was measured as the primary endpoint. RESULTS Twenty studies (1575 patients) were selected, and data on botulinum toxin, pneumatic dilatation, LHM and POEM were extracted. Success rates for LHM in type I, II and III achalasia were 81, 92 and 71 per cent respectively. Those for POEM were 95, 97 and 93 per cent respectively. POEM was more likely to be successful than LHM for both type I (odds ratio (OR) 2·97, 95 per cent c.i. 1·09 to 8·03; P = 0·032) and type III (OR 3·50, 1·39 to 8·77; P = 0·007) achalasia. The likelihood of success of POEM and LHM for type II achalasia was similar. CONCLUSION Pneumatic dilatation had a lower but still acceptable success rate compared with POEM or LHM in patients with type II achalasia. POEM is an excellent treatment modality for type I and type III achalasia, although it did not show any superiority over LHM for type II achalasia.
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Affiliation(s)
- C Andolfi
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - P M Fisichella
- Department of Surgery, Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
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Chuah SK, Lim CS, Liang CM, Lu HI, Wu KL, Changchien CS, Tai WC. Bridging the Gap between Advancements in the Evolution of Diagnosis and Treatment towards Better Outcomes in Achalasia. BIOMED RESEARCH INTERNATIONAL 2019; 2019:8549187. [PMID: 30881999 PMCID: PMC6381566 DOI: 10.1155/2019/8549187] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 01/02/2019] [Accepted: 01/20/2019] [Indexed: 02/05/2023]
Abstract
Over the past few decades, there was an encouraging breakthrough in bridging the gap between advancements in the evolution of diagnosis and treatment towards a better outcome in achalasia. The purpose of this review is to provide updated knowledge on how the current evidence has bridged the gap between advancements in the evolution of diagnosis and treatment of esophageal achalasia. The advent of high-resolution manometry and standardization based on the Chicago classification has increased early recognition of the disease. These 3 clinical subtypes of achalasia can predict the outcomes of patients, and the introduction of POEM has revolutionized the choice of treatment. Previous evidence has shown that laparoscopic Heller myotomy (LHM) and anterior fundoplication were considered the most durable treatments for achalasia. Based on the current evidence, POEM has been evolving as a promising strategy and is effective against all 3 types of achalasia, but the efficacy of POEM is based on short- and medium-term outcome studies from a limited number of centers. Types I and II achalasia respond well to POEM, LHM, and PD, while most studies have shown that type III achalasia responds better to POEM than to LHM and PD. In general, among the 3 subtypes of achalasia, type II achalasia has the most favorable outcomes after medical or surgical therapies. The long-term efficacy of POEM is still unknown. The novel ENDOFLIP measures the changes in intraoperative esophagogastric junction dispensability, which enables a quantitative assessment of luminal patency and sphincter distension; however, this technology is in its infancy with little data to date supporting its intraoperative use. In the future, identifying immunomodulatory drugs and the advent of stem cell therapeutic treatments, including theoretically transplanting neuronal stem cells, may achieve a functional cure. In summary, it is important to identify the clinical subtype of achalasia to initiate target therapy for these patients.
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Affiliation(s)
- Seng-Kee Chuah
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
| | - Chee-Sang Lim
- Department of Hepatology, Hospital Selayang, Lebuh Raya Selayang-Kepong, Batu Caves, Selangor, Malaysia
| | - Chih-Ming Liang
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
| | - Hung-I Lu
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 833 Kaohsiung, Taiwan
| | - Keng-Liang Wu
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
| | - Chi-Sin Changchien
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
| | - Wei-Chen Tai
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
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