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Ramchandani M, Nabi Z, Inavolu P, Reddy DN. Recent Advancements and Future Perspectives of Per Oral Endoscopic Myotomy. Clin Gastroenterol Hepatol 2024; 22:1983-1996.e2. [PMID: 38759824 DOI: 10.1016/j.cgh.2024.02.032] [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: 09/22/2023] [Revised: 02/28/2024] [Accepted: 02/28/2024] [Indexed: 05/19/2024]
Abstract
Per oral endoscopic myotomy (POEM) has emerged as a preferred approach for the treatment of idiopathic achalasia and various esophageal motility disorders, offering a minimally invasive alternative to traditional laparoscopic Heller's myotomy. Over the past decade, POEM has solidified its status as the primary therapeutic choice in these conditions through constant improvements. Its evolution has been marked by continuous progress, driven by the integration of innovative technologies and sophisticated techniques. Notable advancements in the techniques include the advent of shorter myotomies and sling fiber-preserving gastric myotomies. The introduction of novel image-enhanced endoscopic techniques, such as red dichromatic imaging and much safer bipolar devices, promises to enhance safety and reduce the technical demands of the POEM procedure. Furthermore, significant strides have been made in understanding gastroesophageal reflux (GERD) following POEM, enabling the differentiation of "true reflux" from acidification resulting from fermentation through manual pH tracing assessment. This distinction aids in identifying cases necessitating treatment with proton pump inhibitors. Other treatment strategies of post-POEM GERD have expanded to the incorporation of NOTES fundoplication and device-assisted fundoplication if the necessity arises. This comprehensive review delves into recent developments in POEM, encompassing technical variations, the assessment and management of post-POEM reflux, outcomes in special populations, and future prospects. By exploring these facets, we aim to provide a comprehensive overview of the current state of POEM, shedding light on its evolution and the promising directions it is poised to take in the field of third-space endoscopy.
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Affiliation(s)
- Mohan Ramchandani
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India.
| | - Zaheer Nabi
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Pradev Inavolu
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - D Nageshwar Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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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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Vespa E, Barchi A, Mandarino FV, Fasulo E, Fratto MC, Passaretti S, Azzolini F, Savarino EV, Danese S. Standard length of peroral endoscopic myotomy (POEM) for achalasia: a systematic review and meta-analysis. Dis Esophagus 2024:doae069. [PMID: 39214522 DOI: 10.1093/dote/doae069] [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] [Received: 05/06/2024] [Revised: 07/11/2024] [Accepted: 08/08/2024] [Indexed: 09/04/2024]
Abstract
Peroral endoscopic myotomy (POEM) is an established treatment for achalasia, yet there is still a lack of technical standardization. No clear definition of 'long', 'standard', or 'short' POEM exists to date. We conducted a systematic review with meta-analysis to analyze current POEM length standards. We included studies reporting technical details of POEM, in which no definite or comparative myotomy length was intentionally adopted (standard myotomy). The primary outcome was the pooled mean total myotomy length. Sub-group analyses were performed to explore heterogeneity across studies. From the initial 7172 records, 31 studies with 3023 patients were included. Pooled mean of total myotomy length was 10.39 cm (95% CI 10.06-10.71; I2 99.3%). Pooled mean of esophageal and gastric myotomy length, provided by 17 studies, was 7.11 cm (95% CI 6.51-7.71; I2 99.8%) and 2.81 cm (95% CI 2.41-3-22; I2 99.8%), respectively. On subgroup analysis for achalasia subtypes, pooled mean length in non-spastic achalasia (type I and II) was 10.17 cm (95% CI 9.91-10.43; I2 94.2%), while in type III it was 14.02 cm (95% CI 10.59-17.44; I2 98.9%). Pooled mean myotomy length for studies conducted between 2014-2020 was 10.53 cm (95% CI, 10.22-10.84; I2 99.1%) and 9.74 cm (95% CI, 7.95-11.54; I2 99.7%) in 2021-2022. Myotomy length during a 'standard' POEM is 10.4 cm, remaining over 10 cm in non-spastic achalasia. The high heterogeneity across studies confirms that the POEM technique needs further standardization. We found no significant time trend towards adopting short POEM, despite recent evidence supporting its use.
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Affiliation(s)
- Edoardo Vespa
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alberto Barchi
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesco Vito Mandarino
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Ernesto Fasulo
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Maria Caterina Fratto
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Sandro Passaretti
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesco Azzolini
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Edoardo Vincenzo Savarino
- Department of Surgery, Oncology, and Gastroenterology, University of Padua, Padua, Italy
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, Azienda Ospedale Università di Padova, Padua, Italy
| | - Silvio Danese
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
- Faculty of Medicine, Department of Gastroenterology and Endoscopy, Università Vita-Salute San Raffaele, Milan, Italy
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Ďuriček M, Demeter M, Bánovčin P. POEM in the esophagus - How to deal with the post-POEM reflux. Best Pract Res Clin Gastroenterol 2024; 71:101917. [PMID: 39209415 DOI: 10.1016/j.bpg.2024.101917] [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: 02/01/2024] [Revised: 04/10/2024] [Accepted: 05/02/2024] [Indexed: 09/04/2024]
Abstract
Reflux after peroral endoscopic myotomy (POEM) is arguably one of the greatest concerns related to the procedure. The exact incidence is difficult to establish as reflux symptoms, esophagitis, and abnormal acid exposure correlate poorly, warranting thorough diagnostic investigation. The incidence is, however, higher than after Heller myotomy or pneumatic dilatation across all these three parameters. Although PPI are effective in the resolution of symptoms and healing of esophagitis, refractory patients exist. Esophageal hypersensitivity and acidic fermentation/esophageal stasis are most likely causes and could be diagnosed by manual analysis of pH metry tracings. Long-term complications like peptic stricture and Barrett's esophagus are rare and reported sporadically. Modifications of POEM procedure aiming to decrease post-POEM reflux led to no conclusive preferred technique. Modern investigations like endoluminal functional lumen imaging probe might help to personalize myotomy to the desired distensibility of the lower esophageal sphincter and decrease reflux.
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Affiliation(s)
- Martin Ďuriček
- Clinic of Internal Medicine - Gastroenterology, Jessenius Faculty of Medicine in Martin (JFM CU), Comenius University in Bratislava, Kollárova 2, 03659, Martin, Slovakia.
| | - Michal Demeter
- Clinic of Internal Medicine - Gastroenterology, Jessenius Faculty of Medicine in Martin (JFM CU), Comenius University in Bratislava, Kollárova 2, 03659, Martin, Slovakia.
| | - Peter Bánovčin
- Clinic of Internal Medicine - Gastroenterology, Jessenius Faculty of Medicine in Martin (JFM CU), Comenius University in Bratislava, Kollárova 2, 03659, Martin, Slovakia.
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de Sire R, Capogreco A, Massimi D, Alfarone L, Mastrorocco E, Pellegatta G, Hassan C, Repici A, Maselli R. Per oral endoscopic myotomy for achalasia. Best Pract Res Clin Gastroenterol 2024; 71:101930. [PMID: 39209417 DOI: 10.1016/j.bpg.2024.101930] [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: 03/03/2024] [Revised: 05/05/2024] [Accepted: 06/04/2024] [Indexed: 09/04/2024]
Abstract
Achalasia, characterized by impaired lower esophageal sphincter (LES) relaxation and failed peristalsis, stands out as the most widely recognized primary esophageal motility disorder. It manifests with dysphagia to solid and liquid foods, chest pain, regurgitation, and weight loss, leading to significant morbidity and healthcare burden. Traditionally, surgical Heller myotomy and pneumatic dilation were the primary therapeutic approaches for achalasia. However, in 2009, Inoue and colleagues introduced a groundbreaking endoscopic technique called peroral endoscopic myotomy (POEM), revolutionizing the management of this condition. This review aims to comprehensively examine the recent advancements in the POEM technique for patients diagnosed with achalasia, delving into critical aspects, such as the tailoring of the myotomy, the prevention of intraprocedural adverse events (AEs), the evaluation of long-term outcomes, and the feasibility of retreatment in cases of therapeutic failure.
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Affiliation(s)
- Roberto de Sire
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy.
| | - Antonio Capogreco
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy
| | - Davide Massimi
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy
| | - Ludovico Alfarone
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy
| | - Elisabetta Mastrorocco
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy
| | - Gaia Pellegatta
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy
| | - Cesare Hassan
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, 20072, Pieve Emanuele, Italy
| | - Alessandro Repici
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, 20072, Pieve Emanuele, Italy
| | - Roberta Maselli
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, 20072, Pieve Emanuele, Italy
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Cao T, Sun H, Yang D, Tao K, Tang Y, Fu Y, Xu H. Modified peroral endoscopic myotomy technique with retrograde on-demand myotomy for achalasia: a retrospective cohort study (with video). Surg Endosc 2024:10.1007/s00464-024-10944-2. [PMID: 38849652 DOI: 10.1007/s00464-024-10944-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 05/19/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND Although myotomy is crucial in peroral endoscopic myotomy (POEM) surgeries, its optimum length remains controversial. Herein, we propose a modified POEM with new method of tailoring myotomy length aim to evaluate the safety, efficacy, and clinical outcomes of this modified POEM compared with standard POEM in type I or II achalasia. METHODS Seventy-five patients with type I or II achalasia who underwent POEM at the First Hospital of Jilin University between January 2018 and December 2022 were retrospectively analyzed. According to the myotomy approach, these patients were divided into the retrograde on-demand myotomy (RDM, n = 34), with myotomy beginning on gastric side and length tailored by determining the degree of lower esophageal sphincter (LES) distention, and standard myotomy (SM, n = 41) groups. The baseline data, myotomy length, operation time, clinical success rate, adverse event rate, and reflux-related adverse events were compared and analyzed. RESULTS The median myotomy length in the RDM group was significantly shorter than that in the SM group (6 vs. 8 cm, respectively; p < 0.001). Moreover, the median myotomy time in the RDM group was significantly shorter than that in the SM group (10 vs. 16 min, respectively; p < 0.001). POEM was successfully performed in all the patients. At the 2-year follow-up, high clinical success rates were observed in both the RDM and SM groups (92.0% vs. 93.3%, respectively; p = 1.000). The incidence of intraoperative adverse events and postoperative reflux-related adverse events was low and comparable in both groups. CONCLUSIONS RDM POEM is a safe and effective method for patients with type I or II achalasia. Furthermore, it has a shorter myotomy length and operation time than standard POEM technique.
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Affiliation(s)
- Tingting Cao
- Department of Gastroenterology and Endoscopy Center, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Haibo Sun
- Department of Gastroenterology and Endoscopy Center, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Dong Yang
- Department of Gastroenterology and Endoscopy Center, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Ke Tao
- Department of Gastroenterology and Endoscopy Center, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Ying Tang
- Department of Gastroenterology and Endoscopy Center, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Yingli Fu
- Department of Clinical Epidemiology, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Hong Xu
- Department of Gastroenterology and Endoscopy Center, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, 130021, Jilin, China.
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Lu J, Xu BB, Zheng HL, Li P, Xie JW, Wang JB, Lin JX, Chen QY, Cao LL, Lin M, Tu RH, Huang ZN, Lin JL, Yao ZH, Zheng CH, Huang CM. Robotic versus laparoscopic distal gastrectomy for resectable gastric cancer: a randomized phase 2 trial. Nat Commun 2024; 15:4668. [PMID: 38821945 PMCID: PMC11143299 DOI: 10.1038/s41467-024-49013-6] [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: 10/24/2023] [Accepted: 05/21/2024] [Indexed: 06/02/2024] Open
Abstract
Robotic surgery may be an alternative to laparoscopic surgery for gastric cancer (GC). However, randomized controlled trials (RCTs) reporting the differences in survival between these two approaches are currently lacking. From September 2017 to January 2020, 300 patients with cT1-4a and N0/+ were enrolled and randomized to either the robotic (RDG) or laparoscopic distal gastrectomy (LDG) group (NCT03313700). The primary endpoint was 3-year disease-free survival (DFS); secondary endpoints reported here are the 3-year overall survival (OS) and recurrence patterns. The remaining secondary outcomes include intraoperative outcomes, postoperative recovery, quality of lymphadenectomy, and cost differences, which have previously been reported. There were 283 patients in the modified intention-to-treat analysis (RDG group: n = 141; LDG group: n = 142). The trial has met pre-specified endpoints. The 3-year DFS rates were 85.8% and 73.2% in the RDG and LDG groups, respectively (p = 0.011). Multivariable Cox regression model including age, tumor size, sex, ECOG PS, lymphovascular invasion, histology, pT stage, and pN stage showed that RDG was associated with better 3-year DFS (HR: 0.541; 95% CI: 0.314-0.932). The RDG also improved the 3-year cumulative recurrence rate (RDG vs. LDG: 12.1% vs. 21.1%; HR: 0.546, 95% CI: 0.302-0.990). Compared to LDG, RDG demonstrated non-inferiority in 3-year DFS rate.
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Affiliation(s)
- Jun Lu
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
- Fujian Province Minimally Invasive Medical Center, Fuzhou, China
| | - Bin-Bin Xu
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
- Fujian Province Minimally Invasive Medical Center, Fuzhou, China
| | - Hua-Long Zheng
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
- Fujian Province Minimally Invasive Medical Center, Fuzhou, China
| | - Ping Li
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
- Fujian Province Minimally Invasive Medical Center, Fuzhou, China
| | - Jian-Wei Xie
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
- Fujian Province Minimally Invasive Medical Center, Fuzhou, China
| | - Jia-Bin Wang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
- Fujian Province Minimally Invasive Medical Center, Fuzhou, China
| | - Jian-Xian Lin
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
- Fujian Province Minimally Invasive Medical Center, Fuzhou, China
| | - Qi-Yue Chen
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
- Fujian Province Minimally Invasive Medical Center, Fuzhou, China
| | - Long-Long Cao
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
- Fujian Province Minimally Invasive Medical Center, Fuzhou, China
| | - Mi Lin
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
- Fujian Province Minimally Invasive Medical Center, Fuzhou, China
| | - Ru-Hong Tu
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
- Fujian Province Minimally Invasive Medical Center, Fuzhou, China
| | - Ze-Ning Huang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
- Fujian Province Minimally Invasive Medical Center, Fuzhou, China
| | - Ju-Li Lin
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
- Fujian Province Minimally Invasive Medical Center, Fuzhou, China
| | - Zi-Hao Yao
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
- Fujian Province Minimally Invasive Medical Center, Fuzhou, China
| | - Chao-Hui Zheng
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China.
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China.
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China.
- Fujian Province Minimally Invasive Medical Center, Fuzhou, China.
| | - Chang-Ming Huang
- Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China.
- Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China.
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China.
- Fujian Province Minimally Invasive Medical Center, Fuzhou, China.
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Nabi Z, Reddy DN. Short versus long endoscopic myotomy: how short is too short and how long is too long? Gut 2024; 73:1040. [PMID: 37311617 DOI: 10.1136/gutjnl-2023-330195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 05/19/2023] [Indexed: 06/15/2023]
Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, Telangana, India
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9
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Nabi Z, Inavolu P, Duvvuru NR. Prediction, prevention and management of gastroesophageal reflux after per-oral endoscopic myotomy: An update. World J Gastroenterol 2024; 30:1096-1107. [PMID: 38577183 PMCID: PMC10989487 DOI: 10.3748/wjg.v30.i9.1096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/26/2024] [Accepted: 02/18/2024] [Indexed: 03/06/2024] Open
Abstract
Achalasia cardia, the most prevalent primary esophageal motility disorder, is predominantly characterized by symptoms of dysphagia and regurgitation. The principal therapeutic approaches for achalasia encompass pneumatic dilatation (PD), Heller's myotomy, and the more recent per-oral endoscopic myotomy (POEM). POEM has been substantiated as a safe and efficacious modality for the management of achalasia. Although POEM demonstrates superior efficacy compared to PD and an efficacy parallel to Heller's myotomy, the incidence of gastroesophageal reflux disease (GERD) following POEM is notably higher than with the aforementioned techniques. While symptomatic reflux post-POEM is relatively infrequent, the significant occurrence of erosive esophagitis and heightened esophageal acid exposure necessitates vigilant monitoring to preclude long-term GERD-related complications. Contemporary advancements in the field have enhanced our comprehension of the risk factors, diagnostic methodologies, preventative strategies, and therapeutic management of GERD subsequent to POEM. This review focuses on the limitations inherent in the 24-h pH study for evaluating post-POEM reflux, potential modifications in the POEM technique to mitigate GERD risk, and the strategies for managing reflux following POEM.
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Affiliation(s)
- Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad 500082, Telangana, India
| | - Pradev Inavolu
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad 500082, Telangana, India
| | - Nageshwar Reddy Duvvuru
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad 500032, Telangana, India
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Vespa E, Farina DA, Pandolfino JE, Kahrilas PJ, Koop AH, Carlson DA. Presence of esophageal contractility after achalasia treatment is associated with improved esophageal emptying. Neurogastroenterol Motil 2024; 36:e14732. [PMID: 38155413 PMCID: PMC10922458 DOI: 10.1111/nmo.14732] [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: 06/25/2023] [Revised: 10/19/2023] [Accepted: 12/14/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND AND AIMS Some achalasia patients exhibit esophageal contractile activity on follow-up after treatment, yet its importance remains unclear. We aimed to identify factors associated with presence of contractility after treatment and to assess its impact on timed barium esophagram (TBE) and clinical outcomes. METHODS Patients with type I or II achalasia on baseline high-resolution manometry (HRM) who completed HRM, TBE, and functional lumen imaging probe (FLIP) after treatment were retrospectively identified. Contractility was defined on post-treatment HRM as presence of at least 1 supine swallow with DCI ≥100 mmHg s cm. KEY RESULTS One hundred twenty-two patients were included (mean age 48 ± 17 years, 50% female). At follow-up evaluation after treatment (54% peroral endoscopic myotomy, 24% pneumatic dilation, 22% laparoscopic Heller myotomy), 61 (50%) patients had contractility on HRM. Patients with contractility (compared to those without) more frequently had type II achalasia (84% vs 57%, p = 0.001) and a post-treatment normal EGJ opening classification on FLIP (69% vs 49%; p < 0.001). In the subgroup of patients with post-treatment integrated relaxation pressure <15 mmHg and normal EGJ opening on FLIP (n = 53), those with contractility had a lower median column height on TBE at 1 min (4 vs 7 cm, p = 0.002) and 5 min (0 vs 5 cm, p = 0.001). In patients with "abnormal" EGJ metrics, patients with contractility showed lower symptom scores (median Eckardt score 2 vs 3, p = 0.03). CONCLUSIONS & INFERENCES Occurring more frequently in type II achalasia, and if adequate EGJ opening is achieved after treatment, esophageal contractility may contribute to improved esophageal emptying and improved symptoms in non-spastic achalasia. Preservation of esophageal body muscle could improve outcomes in these patients.
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Affiliation(s)
- Edoardo Vespa
- Division of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Domenico A. Farina
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - John E. Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Peter J. Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Andree H. Koop
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Dustin A. Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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11
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Maluf-Filho F. Acidification of the esophagus in post-peroral endoscopic myotomy achalasia patients: all that glitters is not gold. Gastrointest Endosc 2024; 99:174-176. [PMID: 38069982 DOI: 10.1016/j.gie.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 08/28/2023] [Indexed: 01/23/2024]
Affiliation(s)
- Fauze Maluf-Filho
- Gastrointestinal Endoscopy Division, Department of Gastroenterology, Sao Paulo, Brazil; Instituto do Cancer, University of Sao Paulo, Sao Paulo, Brazil; National Council for Scientific and Technological Development, Brasilia, Brazil
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12
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Zhang H, Huang Z, Tang X. Is it necessary to explore modified peroral endoscopic myotomy strategies to prevent the occurrence of gastroesophageal reflux? Gastrointest Endosc 2024; 99:131. [PMID: 38097303 DOI: 10.1016/j.gie.2023.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 08/25/2023] [Indexed: 12/18/2023]
Affiliation(s)
- Han Zhang
- Department of Gastroenterology, Zigong First People's Hospital, Zigong, China
| | - Zhong Huang
- Department of Gastroenterology, Zigong First People's Hospital, Zigong, China
| | - Xiaowei Tang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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13
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DeWitt JM, Al-Haddad M, Stainko S, Perkins A, Fatima H, Ceppa DP, Birdas TJ. Transoral incisionless fundoplication with or without hiatal hernia repair for gastroesophageal reflux disease after peroral endoscopic myotomy. Endosc Int Open 2024; 12:E43-E49. [PMID: 38188922 PMCID: PMC10769579 DOI: 10.1055/a-2215-3415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/16/2023] [Indexed: 01/09/2024] Open
Abstract
Background and study aims Gastroesophageal reflux disease (GERD) following peroral endoscopic myotomy (POEM) occurs in 40% to 60% of patients. There are limited data evaluating antireflux surgery or transoral incisionless fundoplication (TIF) for refractory post-POEM GERD. Patients and methods In a single-center prospective cohort study, consecutive patients with medically refractory post-POEM regurgitation and/or GERD treated with TIF or combined laparoscopic hernia repair and TIF (cTIF) were evaluated. Baseline evaluation: GERD-Health Related Quality of Life (GERD-HQRL) and Reflux Symptom Questionnaire 7-day recall (RESQ-7) questionnaires, EGD, high-resolution manometry (HRM), 48-hour pH test off proton pump inhibitors (PPIs) and impedance planimetry of the esophagogastric junction (EGJ) to calculate the diameter distensibility index (EGJ-DI). A PPI was taken twice daily for 2 weeks after TIF and restarted later if required. Patients returned 9 to 12 months after treatment when all preoperative studies were repeated. Quality of life, pH studies and EGJ metrics before and after antireflux surgery were compared. Results Seventeen patients underwent TIF (n=2, 12%) or cTIF (n=15, 88%) a mean 25±15 months after POEM. At follow-up a mean of 9±1 months after TIF/cTIF, patients required less frequent daily PPIs (n=0.001), were more satisfied (P=0.008), had improved GERD-HQRL (P=0.001), less intensity and frequency of GERD (P=0.001) and fewer reflux episodes (P=0.04) by pH testing. There was no change in EGJ-DI, EGJ diameter, integrated relaxation pressure, % total time pH <4, or DeMeester score. Conclusions TIF and cTIF for difficult-to-control post-POEM GERD appear safe, decrease PPI use and reflux episodes, and improve QOL without significant change in IRP, EGJ compliance, diameter or esophageal acid exposure time.
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Affiliation(s)
- John M DeWitt
- Gastroenterology and Hepatology, Indiana University Health Inc, Indianapolis, United States
| | - Mohammad Al-Haddad
- Gastroenterology and Hepatology, Indiana University Health Inc, Indianapolis, United States
| | - Sarah Stainko
- Gastroenterology and Hepatology, Indiana University Health Inc, Indianapolis, United States
| | - Anthony Perkins
- Biostatistics, Indiana University Health Inc, Indianapolis, United States
| | - Hala Fatima
- Gastroenterology and Hepatology, Indiana University Health Inc, Indianapolis, United States
| | - DuyKhanh P Ceppa
- Gastroenterology and Hepatology, Indiana University Health Inc, Indianapolis, United States
| | - Thomas J Birdas
- Department of Surgery, Division of Cardiothoracic Surgery, Indiana University Health Inc, Indianapolis, United States
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Mandarino FV, Vespa E, Barchi A, Fasulo E, Sinagra E, Azzolini F, Danese S. Precision Endoscopy in Peroral Myotomies for Motility Disorders of the Upper Gastrointestinal Tract: Current Insights and Prospective Avenues-A Comprehensive Review. Life (Basel) 2023; 13:2143. [PMID: 38004283 PMCID: PMC10672509 DOI: 10.3390/life13112143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/28/2023] [Accepted: 10/29/2023] [Indexed: 11/26/2023] Open
Abstract
Our review delves into the realm of peroral endoscopic myotomies (POEMs) in the upper gastrointestinal tract (UGT). In recent years, POEMs have brought about a revolution in the treatment of UGT motility disorders. Esophageal POEM, the first to be introduced, has now been validated as the primary treatment for achalasia. Subsequently developed, G-POEM displays promising results in addressing refractory gastroparesis. Over time, multiple endoscopic myotomy techniques have emerged for the treatment of Zenker's diverticulum, including Z-POEM, POES, and hybrid approaches. Despite the well-established efficacy outcomes, new challenges arise in the realm of POEMs in the UGT. For esophageal POEM, the future scenario lies in customizing the myotomy extent to the minimum necessary, while for G-POEM, it involves identifying patients who can optimally benefit from the treatment. For ZD, it is crucial to validate an algorithm that considers various myotomy options according to the diverticulum's size and in relation to individual patients. These challenges align with the concept of precision endoscopy, personalizing the technique for each subject. Within our text, we comprehensively examine each myotomy technique, analyzing indications, outcomes, and adverse events. Additionally, we explore the emerging challenges posed by myotomies within the context of the evolving field of precision endoscopy.
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Affiliation(s)
- Francesco Vito Mandarino
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Edoardo Vespa
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Alberto Barchi
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Ernesto Fasulo
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto San Raffaele Giglio, 90015 Cefalù, Italy
| | - Francesco Azzolini
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Silvio Danese
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
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Hollenbach M, Vu Trung K, Hoffmeister A. [Interventional endoscopy in gastroenterology]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023:10.1007/s00108-023-01565-3. [PMID: 37405423 DOI: 10.1007/s00108-023-01565-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 06/27/2023] [Indexed: 07/06/2023]
Abstract
Essential innovations in interventional endoscopy have significantly broadened the treatment armamentarium in gastroenterology. The treatment and complication management of intraepithelial neoplasms and early forms of cancer are increasingly being primarily addressed endoscopically. In cases of endoluminal lesions with no risk of lymph node or distant metastases, endoscopic mucosal resection and endoscopic submucosal dissection have become established as standards. For broad-based adenomas, coagulation of the resection margins should be performed in the case of a piecemeal resection. Submucosal lesions can be reached and resected by tunneling techniques. Peroral endoscopic myotomy in cases of achalasia is a new treatment option for hypertensive and hypercontractile motility disorders. In addition, endoscopic myotomy for gastroparesis has shown very promising results. In this article, new resection techniques and so-called third space endoscopy are presented and critically discussed.
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Affiliation(s)
- Marcus Hollenbach
- Bereich Gastroenterologie der Klinik für Onkologie, Gastroenterologie, Hepatologie und Pneumologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103, Leipzig, Deutschland.
| | - Kien Vu Trung
- Bereich Gastroenterologie der Klinik für Onkologie, Gastroenterologie, Hepatologie und Pneumologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103, Leipzig, Deutschland
| | - Albrecht Hoffmeister
- Bereich Gastroenterologie der Klinik für Onkologie, Gastroenterologie, Hepatologie und Pneumologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103, Leipzig, Deutschland
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