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Mikulski MF, Morley TJ, Debbink KP, Desilets DJ, Romanelli JR. Impedance planimetry during per-oral endoscopic myotomy is associated with decreased inadvertent capnoperitoneum. Surg Endosc 2024; 38:280-290. [PMID: 37989889 DOI: 10.1007/s00464-023-10526-8] [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: 03/12/2023] [Accepted: 10/12/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Per-oral endoscopic myotomy (POEM) has become an accepted minimally invasive alternative to Heller myotomy for the treatment of achalasia and other disorders of esophageal dysmotility. One associated adverse event is the inadvertent creation of capnoperitoneum. A proposed mechanism is that extension of the submucosal tunnel below the esophageal hiatus and onto the gastric wall leads to transmural perforation. We hypothesized that the use of impedance planimetry with the endoscopic functional luminal imaging probe (EndoFLIP) more accurately identifies the esophagogastric junction and helps to better define the myotomy's ideal limits, thus lowering the incidence of inadvertent capnoperitoneum. METHODS This is a single-center, retrospective review of consecutive POEM cases from 06/11/2011 to 08/08/2022, with EndoFLIP introduced in 2017. Patient and procedural characteristics, including the incidence of clinically significant capnoperitoneum and decompression, were analyzed using univariate and multivariable linear regression statistics. RESULTS There were 140 POEM cases identified, 74 (52.9%) of which used EndoFLIP. Clinically significant capnoperitoneum was encountered in 26 (18.6%) cases, with no differences in patient characteristics between those who had capnoperitoneum and those who did not. There was a decreased incidence of capnoperitoneum in cases using EndoFLIP compared to those without (n = 6, 23% vs n = 20, 77%, p = 0.001), with zero instances in the final 56 cases. After adjusting for potentially confounding factors, EndoFLIP use was associated with a - 15.93% (95% confidence interval - 30.68%, - 1.18%) decrease in procedure duration. CONCLUSIONS The routine use of EndoFLIP during POEM was associated with decreased incidence of clinically significant capnoperitoneum, potentially due to improved myotomy tailoring and decreased duration of insufflation with shorter procedure times.
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Affiliation(s)
- Matthew F Mikulski
- Department of Surgery, University of Massachusetts Chan Medical School - Baystate, Springfield, MA, USA.
- Baystate Medical Center, Surgery Education Office, 759 Chestnut Street, Springfield, MA, 01199, USA.
| | - Timothy J Morley
- Department of Surgery, University of Massachusetts Chan Medical School - Baystate, Springfield, MA, USA
| | - Kaitlin P Debbink
- Department of Surgery, University of Massachusetts Chan Medical School - Baystate, Springfield, MA, USA
| | - David J Desilets
- Department of Gastroenterology, University of Massachusetts Chan Medical School - Baystate, Springfield, MA, USA
| | - John R Romanelli
- Department of Surgery, University of Massachusetts Chan Medical School - Baystate, Springfield, MA, USA
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2
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Zhu Q, Zhang H, Huang S, Gan P, Wang R, Peng Y, Lü M, Tang X. Research hotspots and trend of a emerging novel endoscopic technique of peroral endoscopic myotomy from 2010 to 2022: A bibliometric analysis. Medicine (Baltimore) 2023; 102:e35009. [PMID: 37682198 PMCID: PMC10489447 DOI: 10.1097/md.0000000000035009] [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: 06/25/2023] [Accepted: 08/08/2023] [Indexed: 09/09/2023] Open
Abstract
Peroral endoscopic myotomy (POEM), which has been used to treat achalasia and other esophageal motility disorders for the past 10 years, has proven to be secure and efficient. Every year, more and more essays on this subject are published. We sought to investigate the global scientific outputs and hotspots of POEM produced by various nations, organizations, and authors. From 2010 to October 2022, there were 875 papers on POEM that were found in the Web of Science Core database. The bibliometric visualization analyses of nations/regions, institutions, authors, journals, references, and keywords were conducted by CiteSpace V.5.8.R3. Eight hundred seventy-five publications were included in this analysis. With 68 publications, Inoue H had the highest output. While Showa University in Japan was the most productive institution, the United States was the most productive nation. Among the journals, Surgical Endoscopy published the highest number of articles, followed by Gastrointestinal Endoscopy and Endoscopy. The top 10 keywords that appeared most frequently were achalasia, peroral endoscopic myotomy, POEM, myotomy, esophageal achalasia, dysphagia, heller myotomy, endoscopy, gastroparesis and peroral endoscopic myotomy. Seven frontiers, including meta-analysis, high-resolution esophageal manometry, geriatric patient, third space endoscopy, adverse event, endoscopic submucosal dissection, and gastric peroral endoscopic myotomy, had an impact on future research on POEM. The previous 10 years have seen a considerable rise in POEM research, and this trend will continue. The most recent research frontiers, which require more attention, are meta-analysis, high-resolution esophageal manometry, geriatric patient, third space endoscopy, adverse event, and gastric peroral endoscopic myotomy.
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Affiliation(s)
- Qingliang Zhu
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Han Zhang
- Department of Gastroenterology, Zigong First People’s Hospital, Zigong, China
| | - Shu Huang
- Department of Gastroenterology, Lianshui County People’ Hospital, Huaian, China
| | - Peiling Gan
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Ruiyu Wang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yan Peng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Muhan Lü
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaowei Tang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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3
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Knight W, Kandiah K, Vrakopoulou Z, White A, Barbieri L, Tewari N, Couch J, DiMaggio F, Barley M, Ragunath K, Catton J, Botha A. Early outcomes following EndoFLIP-tailored peroral endoscopic myotomy (POEM): the establishment of POEM services in two UK centers. Dis Esophagus 2023; 36:doac110. [PMID: 36572399 DOI: 10.1093/dote/doac110] [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: 08/12/2022] [Revised: 12/06/2022] [Indexed: 07/28/2023]
Abstract
Peroral endoscopic myotomy (POEM) is a safe and effective minimally invasive treatment for achalasia. Postoperative reflux rates remain high. The functional luminal imaging probe (FLIP) allows intraoperative measurement of lower esophageal distensibility during POEM. In theory, this enables a tailoring of myotomies to ensure adequate distensibility while minimizing postoperative reflux risk. Two prospectively collected POEM databases were analyzed from two UK tertiary upper GI centers. The operators in each center used FLIP measurements to ensure adequate myotomy. Outcome measures included Eckardt score (where <3 indicated clinical success) and proton-pump inhibitor use (PPI), collected at the first postoperative appointment. Length of stay was recorded as were complications. In all, 142 patients underwent POEM between 2015 and 2019. Overall, 90% (128/142) had postoperative Eckardt scores of <3 at 6 weeks. Clinical success improved to 93% (66/71) in the latter half of each series with a significantly higher rate of complete symptom resolution (53 versus 26%, P = 0.003). In all, 79% of the poor responders had previous interventions compared with 55% of responders (P = 0.09). Median post-myotomy distensibility index was 4.0 mm2/mmHg in responders and 2.9 in nonresponders (P = 0.16). Myotomy length of <7 cm was associated with 93% clinical success and 40% post op PPI use compared with 60% PPI use with longer myotomies. There were two type IIIa, two type IIIb, and one IV Clavien-Dindo complications. This is the largest series of endoluminal functional lumen imaging probe (EndoFLIP)-tailored POEM in the UK to date. The shorter myotomies, allowed through EndoFLIP tailoring, remained clinically effective at 6 weeks. Complete symptom response rates improved in the latter half of each series. More data will be needed from high-volume collaborations to decipher optimal myotomy profiles based on EndoFLIP parameters.
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Affiliation(s)
- William Knight
- Nottingham University Hospital, Nottingham, UK
- Guy's and St Thomas' Hospitals, London, UK
| | | | | | | | | | | | | | | | - Mark Barley
- Nottingham University Hospital, Nottingham, UK
| | - Krish Ragunath
- NIHR Nottingham Digestive Diseases Centre, Nottingham University Hospital NHS Trust, Nottingham, UK
| | | | - Abraham Botha
- Guy's and St Thomas' Hospitals, London, UK
- King's College London Medical School, London, UK
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Dahiya DS, Nivedita F, Perisetti A, Goyal H, Inamdar S, Gangwani MK, Aziz M, Ali H, Cheng CI, Sanaka MR, Al-Haddad M, Sharma NR. Clinical Outcomes and Complications for Achalasia Patients Admitted After Per-Oral Endoscopic Myotomy. Gastroenterology Res 2023; 16:141-148. [PMID: 37351078 PMCID: PMC10284641 DOI: 10.14740/gr1617] [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: 03/25/2023] [Accepted: 05/13/2023] [Indexed: 06/24/2023] Open
Abstract
Background Per-oral endoscopic myotomy (POEM) is a rapidly emerging minimally invasive procedure for management of achalasia. Same-day discharge after POEM is safe and feasible; however, some patients may need hospitalization. We aimed to identify characteristics and outcomes for achalasia patients requiring hospitalizations after POEM in the United States (US). Methods The US National Inpatient Sample was utilized to identify all adult achalasia patients who were admitted after POEM from 2016 to 2019. Hospitalization characteristics and clinical outcomes were highlighted. Results From 2016 to 2019, we found that 1,885 achalasia patients were admitted after POEM. There was an increase in the total number of hospitalizations after POEM from 380 in 2016 to 490 in 2019. The mean age increased from 54.2 years in 2016 to 59.3 years in 2019. Most POEM-related hospitalizations were for the 65 - 79 age group (31.8%), females (50.4%), and Whites (68.4%). A majority (56.2%) of the study population had a Charlson Comorbidity Index of 0. The Northeast hospital region had the highest number of POEM-related hospitalizations. Most of these patients (88.3%) were eventually discharged home. There was no inpatient mortality. The mean length of stay decreased from 4 days in 2016 to 3.2 days in 2019, while the mean total healthcare charge increased from $52,057 in 2016 to $65,109 in 2019. Esophageal perforation was the most common complication seen in 1.3% of patients. Conclusion The number of achalasia patients needing hospitalization after POEM increased. There was no inpatient mortality conferring an excellent safety profile of this procedure.
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Affiliation(s)
- Dushyant Singh Dahiya
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Fnu Nivedita
- Section of Endoluminal Surgery and Interventional Gastroenterology, McGovern Medical School and UT Health Sciences Center at UT Health Houston, Houston, TX, USA
| | - Abhilash Perisetti
- Division of Gastroenterology and Hepatology, Kansas Veterans Affairs Medical Centre, Kansas City, MO, USA
| | - Hemant Goyal
- Section of Endoluminal Surgery and Interventional Gastroenterology, McGovern Medical School and UT Health Sciences Center at UT Health Houston, Houston, TX, USA
| | - Sumant Inamdar
- Department of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Manesh Kumar Gangwani
- Department of Internal Medicine, The University of Toledo Medical Center, Toledo, OH, USA
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, The University of Toledo Medical Center, Toledo, OH, USA
| | - Hassam Ali
- Department of Internal Medicine, East Carolina University, Greenville, NC, USA
| | - Chin-I Cheng
- Department of Statistics, Actuarial and Data Science, Central Michigan University, Mt Pleasant, MI, USA
| | - Madhusudhan R. Sanaka
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mohammad Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Neil R. Sharma
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
- Interventional Oncology & Surgical Endoscopy Programs (IOSE), Parkview Health, Fort Wayne, IN, USA
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Jiang K, Oda M, Hayashi Y, Shiwaku H, Misawa M, Mori K. Oesophagus Achalasia Diagnosis from Esophagoscopy Based on a Serial Multi-scale Network. COMPUTER METHODS IN BIOMECHANICS AND BIOMEDICAL ENGINEERING: IMAGING & VISUALIZATION 2023. [DOI: 10.1080/21681163.2022.2159534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Affiliation(s)
- Kai Jiang
- Graduate School of Informatics, Nagoya University, Nagoya, Japan
| | - Masahiro Oda
- Graduate School of Informatics, Nagoya University, Nagoya, Japan
- Information Strategy Office, Information and Communications, Nagoya University, Nagoya, Japan
| | - Yuichiro Hayashi
- Graduate School of Informatics, Nagoya University, Nagoya, Japan
| | - Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Masashi Misawa
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Kensaku Mori
- Graduate School of Informatics, Nagoya University, Nagoya, Japan
- Information Technology Center, Nagoya University, Nagoya, Japan
- Research Center for Medical Bigdata, National Institute of Informatics, Tokyo, Japan
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6
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Vespa E, Pellegatta G, Chandrasekar VT, Spadaccini M, Patel H, Maselli R, Galtieri PA, Carlani E, Sharma P, Hassan C, Repici A. Long-term outcomes of peroral endoscopic myotomy for achalasia: a systematic review and meta-analysis. Endoscopy 2023; 55:167-175. [PMID: 35798336 DOI: 10.1055/a-1894-0147] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The long-term outcomes of esophageal peroral endoscopic myotomy (POEM) are still unknown. METHODS We searched electronic databases (MEDLINE/PubMed, EMBASE, Scopus) for studies assessing outcomes after POEM for esophageal achalasia with a minimum median follow-up duration of 36 months. Pooled rates of clinical success and postoperative reflux were calculated and compared with the same values at 12/24/36 months when available. Subgroup analyses were performed to explore the interstudy heterogeneity. RESULTS From 1528 initial records, 11 studies (2017-2021) were included. A total of 2342 patients (age 48.1 [SD 6.8] years; 50.1 % males) with a median follow-up of 48 months (interquartile range 45-60) were analyzed. The pooled clinical success rate was 87.3 % (95 %CI 83.6 %-91.0 %; I2 = 73.1 %). The symptomatic reflux pooled rate was 22.0 % (95 %CI 14.4 %-29.5 %; I2 = 92.7 %). Three cases of peptic strictures and one Barrett's esophagus were reported. The pooled rate of severe adverse events was 1.5 % (95 %CI 0.5 %-2.5 %; I2 = 52.8 %). CONCLUSIONS Long-term clinical efficacy of POEM persisted in 87 % of patients with achalasia. Post-POEM symptomatic reflux remained stable over time. The risk for Barrett's esophagus and peptic strictures appeared minimal.
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Affiliation(s)
- Edoardo Vespa
- Department of Gastroenterology and Hepatology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Gaia Pellegatta
- Department of Gastroenterology and Hepatology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | - Marco Spadaccini
- Department of Gastroenterology and Hepatology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Harsh Patel
- Department of Internal Medicine, Ochsner Clinic Foundation, New Orleans, Louisiana, United States
| | - Roberta Maselli
- Department of Gastroenterology and Hepatology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Piera A Galtieri
- Department of Gastroenterology and Hepatology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Elisa Carlani
- Department of Gastroenterology and Hepatology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Prateek Sharma
- Department of Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, Missouri, United States
| | - Cesare Hassan
- Department of Gastroenterology and Hepatology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Alessandro Repici
- Department of Gastroenterology and Hepatology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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Hayat M, Yang D, Draganov PV. Third-space endoscopy: the final frontier. Gastroenterol Rep (Oxf) 2023; 11:goac077. [PMID: 36632624 PMCID: PMC9831051 DOI: 10.1093/gastro/goac077] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 01/11/2023] Open
Abstract
Over the years, our growing experience with endoscopic submucosal dissection along with technological advances has solidified our comfort and knowledge on working in the submucosa, also referred to as the "third space." Per-oral endoscopic myotomy (POEM) was the first prototype third-space endoscopy (TSE) procedure, demonstrating the feasibility and clinical utility of endoscopic esophagogastric myotomy via submucosal tunneling. The launch of POEM accelerated the evolution of TSE from a vanguard concept to an expanding field with a wide range of clinical applications. In this review, we discuss the status and future directions of multiple TSE interventions.
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Affiliation(s)
- Maham Hayat
- Center for Interventional Endoscopy, AdventHealth, Orlando, FL, USA
| | - Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Orlando, FL, USA
| | - Peter V Draganov
- Corresponding author. Division of Gastroenterology, Hepatology and Nutrition, University of Florida, 1329 SW 16th Street, Room #5254, Gainesville, FL 32608, USA. Tel: +1-352-273-9474; Fax: +1-352-627-9002;
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8
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Slim N, Williamson JM. Achalasia: investigation and management. Br J Hosp Med (Lond) 2023; 84:1-9. [PMID: 36708337 DOI: 10.12968/hmed.2022.0437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Achalasia, characterised by the absence of peristalsis and failure of relaxation of the lower oesophageal sphincter, is an uncommon degenerative condition that results in dysphagia. If left untreated it can lead to aspiration, oesophageal perforation, oesophagitis and malnutrition. It has a range of immune, allergic, viral and genetic aetiological causes. Successful diagnosis relies on the use of oesophagogastroduodenoscopy, barium swallow and oesophageal manometry to characterise the severity of the disease and to rule out underlying malignancy. Although no treatment can reverse the degenerative process, therapeutic strategies including lifestyle modification, medication, endoscopic and operative intervention can help to reduce symptoms. This article reviews the latest methods used to investigate and manage achalasia.
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Affiliation(s)
- Naim Slim
- Department of General Surgery, The Great Western Hospital, Swindon, UK
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Gong F, Li Y, Ye S. Effectiveness and complication of achalasia treatment: A systematic review and network meta-analysis of randomized controlled trials. Asian J Surg 2023; 46:24-34. [PMID: 35484068 DOI: 10.1016/j.asjsur.2022.03.116] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 03/16/2022] [Accepted: 03/31/2022] [Indexed: 12/16/2022] Open
Abstract
Achalasia(AC) is an esophageal motility disorder characterized by decreased esophageal motility and impaired relaxation of lower esophageal sphincter(LES). The treatment of achalasia is continuously improved for the development of technology, but each treatment has its own advantages and disadvantages. This article was to compare the efficacy and complication of different treatment on AC. PUBMED/MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials were searched for eligible studies. A random-effects model within a Bayesian framework was applied to compare treatment effects as odds ratio (OR) with their corresponding 95% credible interval (CI), also OR was applied to compare complication with 95% CI. The surface under the cumulative ranking area (SUCRA) was calculated to make the ranking of the treatments for outcomes. Twenty-seven randomized controlled trials (RCTs) were eligible. According to SUCRA ranking, anterior peroral endoscopic myotomy (APOEM) (SUCRA = 84.6%) might have the highest probability to be the best treatment for dysphagia remission in AC patients, followed by POEM (SUCRA = 78.4%). For gastroesophageal reflux disease (GERD) assessment, the corresponding SUCRA values indicated that botulinum toxin(BT) (SUCRA = 18.3%) might have lowest GERD incidence rate and POEM ranked the worst (SUCRA = 69.8%).. APOEM might have the highest probability to be the best therapeutic strategy for dysphagia remission in a short-term of follow-up, but the GERD incidence rate was high. BT injection might have the lowest probability to treat dysphagia, but the risk of GERD was the lowest. In the future, more RCTs with higher qualities are needed to make head-to-head comparison between 2 or more treatments.
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Affiliation(s)
- Fangxiao Gong
- Emergency and Critical Care Center, Intensive Care Unit, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, 310014, China
| | - Yuanyuan Li
- Department of Endocrinology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Sen Ye
- Emergency and Critical Care Center, Intensive Care Unit, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, 310014, China.
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10
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Sarkis Y, Al-Haddad MA, Siwiec R, Kessler WR, Wo JM, Stainko S, Perkins A, DeWitt JM. Safety of same-day discharge after peroral endoscopic myotomy. Dis Esophagus 2022; 36:6747074. [PMID: 36190182 DOI: 10.1093/dote/doac068] [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: 06/29/2022] [Revised: 08/21/2022] [Accepted: 09/04/2022] [Indexed: 12/11/2022]
Abstract
There are limited data on the safety of same-day discharge (SDD) after peroral endoscopic myotomy (POEM). The aim of our study is to assess the frequency and relationship to POEM for emergency department (ED) visits and hospitalizations after SDD in these patients. We retrospectively identified consecutive patients between November 2019 and August 2021 who underwent POEM with SDD and at least 6 months follow-up. Criteria for SDD includes: (1) no serious procedure-related adverse event; (2) post-POEM esophagram without leak; (3) stable vital signs; (4) ability to take liquids orally; (5) pain controlled without IV analgesia; (6) adequate social support; (7) American Society of Anesthesiologists (ASA) class I-III. A causative relationship between POEM and ED visits and hospitalizations was assigned by consensus. Out of 185 POEMs performed, 78 (41.7%, 42M, mean 51±16 years) had SDD. Within 30 days of POEM, 8 ED visits occurred in 7/78 (9%) patients and 2 (25%) were considered related to POEM; hospitalization was required in 3 (38%). After 30 days, 11 ED visits occurred in 10/78 (12.8%) patients and 1 (9%) was considered related to POEM; hospitalization was required in 5 (45%). In this study of consecutive SDD patients after POEM, 3/19 (16%) ED visits and 2/8 (25%) hospitalizations within 6 months were considered related to the procedure. Therefore, eligible patients who follow and fulfill a strict protocol after POEM may be safely discharged the same day.
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Affiliation(s)
- Yara Sarkis
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - Mohammad A Al-Haddad
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - Robert Siwiec
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - William R Kessler
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - John M Wo
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - Sarah Stainko
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - Anthony Perkins
- Department of Biostatistics, Indiana University Health Medical Center, Indianapolis, IN, USA
| | - John M DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN, USA
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11
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Changes in Distensibility Index During an Incremental POEM Myotomy. J Gastrointest Surg 2022; 26:1140-1146. [PMID: 35233701 DOI: 10.1007/s11605-022-05278-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 02/05/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND A longer myotomy for the treatment of achalasia is associated with worse gastroesophageal reflux disease despite palliating dysphagia. Recently, clinical outcomes have been correlated to the distensibility of the distal esophagus, which is measured intra-operatively using an endoscopic functional luminal image probe (EndoFLIP). We aimed to determine the minimum per oral endoscopic myotomy (POEM) length to allow for adequate distensibility index (DI). METHODS A 6-cm myotomy conducted in 2-cm increments during POEM was performed for patients with achalasia I and II from 2017 to 2019. The EndoFLIP was used to measure the DI intra-operatively: (1) prior to intervention, (2) following creation of the submucosal tunnel, (3) following transection of the high-pressure zone (HPZ), (4) following the distal extension, and (5) following the proximal esophageal extension. RESULTS A total of 16 patients underwent POEM. Ages ranged from 21 to 78 years, 10 were male, and 13 had type II achalasia. The median DI was 2.7 (1.4-3.6) mm2/mmHg prior to intervention; 2.4 (1.4-3.3) mm2/mmHg following the submucosal tunnel; 3.2 (1.6-4.4) mm2/mmHg following transection of the HPZ; 3.8 (2.6-4.5) mm2/mmHg following the gastric extension; and 4.5 (3.3-7.1) mm2/mmHg following the proximal extension. Our target range DI was achieved for 50% of patients after transection of the HPZ. CONCLUSIONS Distensibility changed with each myotomy increment and fell within the target range for most patients following a 2-4-cm myotomy. This suggests that a shorter myotomy may be appropriate for select patients, and the use of the EndoFLIP intra-operatively may allow for a tailored myotomy length.
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12
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Zhang H, Zeng X, Huang S, Xia H, Shi L, Jiang J, Ren W, Peng Y, Lü M, Tang X. Safety and Efficacy of Peroral Endoscopic Shorter Myotomy versus Longer Myotomy for Patients with Achalasia: A Systematic Review and Meta-analysis. Gastroenterol Res Pract 2022; 2022:6770864. [PMID: 35401740 PMCID: PMC8986442 DOI: 10.1155/2022/6770864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/14/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND AIMS The adequate myotomy length during peroral endoscopic myotomy (POEM) is still controversial. We performed this systematic review and meta-analysis to determine the efficacy and safety of the modified POEM with shorter myotomy (SM) and compare the outcomes between SM and longer myotomy (LM) in achalasia patients. METHODS A comprehensive literature search was conducted in PubMed, EMBASE, Cochrane Library, and Web of Science databases from inception to May 28, 2021. The primary outcome was clinical success rate and incidence of reflux-relative adverse events (AEs). Fixed- or random-effect models were adopted for the analysis according to the heterogeneity. RESULTS Five studies involving 225 patients in SM group and 222 patients in LM group were included. The overall clinical success of SM was 96.6% (95% confidence interval (CI) 92.7 to 98.4%). SM showed noninferior response as compared to LM (risk ratio (RR) 1.02, 95% CI 0.98 to 1.06, P = 0.41, I 2 = 0%). Based on the abnormal acid reflux by pH monitoring, its incidence was significantly lower in the SM group than that in the LM group (RR 0.58, 95% CI 0.36 to 0.94, P = 0.03, I 2 = 0%). With respect to procedure-related parameters, the total procedure time of SM was significantly shorter than that of LM (mean difference (MD) -16.30, 95% CI -23.10 to -9.49, P < 0.001, I 2 = 68%). CONCLUSIONS SM and LM are comparable in providing treatment efficacy for achalasia patients, whereas less operation time and lower incidence of post-POEM abnormal esophageal acid exposure are observed in SM.
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Affiliation(s)
- Han Zhang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xinyi Zeng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shu Huang
- Department of Gastroenterology, The People's Hospital of Lianshui, Huaian, China
| | - Huifang Xia
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Lei Shi
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jiao Jiang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Wensen Ren
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yan Peng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Muhan Lü
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaowei Tang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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13
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Kamal AN, Kathpalia P, Otaki F, Bredenoord AJ, Castell DO, Clarke JO, Falk GW, Fass R, Gyawali CP, Kahrilas PJ, Katz PO, Katzka DA, Pandolfino JE, Penagini R, Richter JE, Roman S, Savarino E, Triadafilopoulos G, Vaezi MF, Vela MF, Leiman DA. Development of quality indicators for the diagnosis and management of achalasia. Neurogastroenterol Motil 2021; 33:e14118. [PMID: 33720448 PMCID: PMC9380030 DOI: 10.1111/nmo.14118] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/21/2021] [Accepted: 02/14/2021] [Indexed: 12/07/2022]
Abstract
BACKGROUND The management of achalasia has improved due to diagnostic and therapeutic innovations. However, variability in care delivery remains and no established measures defining quality of care for this population exist. We aimed to use formal methodology to establish quality indicators for achalasia patients. METHODS Quality indicator concepts were identified from the literature, consensus guidelines and clinical experts. Using RAND/University of California, Los Angeles (UCLA) Appropriateness Method, experts in achalasia independently ranked proposed concepts in a two-round modified Delphi process based on 1) importance, 2) scientific acceptability, 3) usability, and 4) feasibility. Highly valid measures required strict agreement (≧ 80% of panelists) in the range of 7-9 for across all four categories. KEY RESULTS There were 17 experts who rated 26 proposed quality indicator topics. In round one, 2 (8%) quality measures were rated valid. In round two, 19 measures were modified based on panel suggestions, and experts rated 10 (53%) of these measures as valid, resulting in a total of 12 quality indicators. Two measures pertained to patient education and five to diagnosis, including discussing treatment options with risk and benefits and using the most recent version of the Chicago Classification to define achalasia phenotypes, respectively. Other indicators pertained to treatment options, such as the use of botulinum toxin for those not considered surgical candidates and management of reflux following achalasia treatment. CONCLUSIONS & INFERENCES Using a robust methodology, achalasia quality indicators were identified, which can form the basis for establishing quality gaps and generating fully specified quality measures.
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Affiliation(s)
- Afrin N. Kamal
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Priya Kathpalia
- Division of Gastroenterology and Hepatology, University of California-San Francisco, San Francisco, California, USA
| | - Fouad Otaki
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon, USA
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Donald O. Castell
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - John O. Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Gary W. Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine Philadelphia, Pennsylvania, USA
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, Department of Medicine, The MetroHealth Medical Center and Case Western Reserve, Cleveland, Ohio, USA
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Peter J Kahrilas
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Philip O. Katz
- Division of Gastroenterology, Weill Cornell School of Medicine, New York, NY, USA
| | - David A. Katzka
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - John E. Pandolfino
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Roberto Penagini
- Department of Pathophysiology and Transplantation, Università degli Studi of Milan, Milan, Italy,Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Joel E. Richter
- Division of Digestive Diseases & Nutrition, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Sabine Roman
- Digestive Physiology, Hospices Civils de Lyon, Hospital E Herriot and Lyon I University, Lyon, France
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Michael F. Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marcelo F. Vela
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - David A. Leiman
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, USA
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14
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Delayed Pneumoperitoneum After Peroral Endoscopic Myotomy. ACG Case Rep J 2021; 8:e00593. [PMID: 33997093 PMCID: PMC8116019 DOI: 10.14309/crj.0000000000000593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 02/16/2021] [Indexed: 12/04/2022] Open
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15
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Zhong C, Huang S, Xia H, Tan S, Lü M, Peng Y, Tang X. Role of Peroral Endoscopic Myotomy in Geriatric Patients with Achalasia: A Systematic Review and Meta-Analysis. Dig Dis 2021; 40:106-114. [PMID: 33752208 DOI: 10.1159/000516024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 03/18/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is a particularly attractive intervention for achalasia. Presently, POEM has been reported to be effective and safe for achalasia in geriatric patients. Herein, this systematic review was conducted to explore the role of POEM in geriatric patients with achalasia. METHOD PubMed, Embase, and Cochrane Library were searched to identify studies evaluating the clinical outcome of POEM in geriatric patients with achalasia during January 2009 to October 2020. The primary outcomes were technical and clinical success. Secondary outcomes included postoperative Eckardt score, lower esophageal sphincter (LES) pressure, adverse events, and clinical reflux. RESULTS There were 7 studies with a total of 469 geriatric patients, and the pooled technical success of POEM treatment was 98.1% (95% confidence interval [CI], 95.1-99.3%), and the pooled clinical success was 92.5% (95% CI, 89.3-94.8%). After POEM, the Eckardt score significantly decreased by 6.09 points (95% CI, 5.44-6.74, p < 0.00001), and the LES pressure significantly reduced by 13.53 mm Hg (95% CI, 5.14-21.91, p = 0.002). The pooled adverse events rate was 9.0% (95% CI, 4.3-17.9%), and the post-POEM clinical reflux rate was 17.4% (95% CI, 12.9-23.2%). CONCLUSION Our current study demonstrated that POEM was an effective and safe technique for achalasia in geriatric patients.
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Affiliation(s)
- Chunyu Zhong
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shu Huang
- Department of Gastroenterology, the People's Hospital of Lianshui, Huaian, China
| | - Huifang Xia
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shali Tan
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Muhan Lü
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yan Peng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaowei Tang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
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16
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Pesce M, Sweis R. Advances and caveats in modern achalasia management. Ther Adv Chronic Dis 2021; 12:2040622321993437. [PMID: 33786159 PMCID: PMC7958157 DOI: 10.1177/2040622321993437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 01/15/2021] [Indexed: 12/18/2022] Open
Abstract
Achalasia is a rare esophageal motility disorder characterized by the incomplete
relaxation of the lower esophageal sphincter (LES) and impaired peristaltic
activity. The advent of high-resolution manometry (HRM) and the rapidly evolving
role of therapeutic endoscopy have revolutionized the approach to the diagnosis
and management of achalasia patients in the last decade. With advances in HRM
technology and methodology, fluoroscopy and EndoFlip, achalasia can be
differentiated into therapeutically meaningful phenotypes with a high degree of
accuracy. Further, the newest treatment option, per-oral endoscopic myotomy
(POEM), has become a staple therapy following the last 10 years of experience,
and recent randomized trials appear to show no difference between POEM, graded
pneumatic dilatation and surgical Heller myotomy in terms of short- and
long-term efficacy or complication rate. On the other hand, how treatment
outcomes are measured as well as the risk of reflux following therapy remain
areas of contention. This review aims to summarize the recent advancements in
achalasia testing and therapy, describes the recent randomized clinical trials
as well as their potential setbacks, and touches on the future of personalizing
achalasia treatment.
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Affiliation(s)
- Marcella Pesce
- Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Naples, Italy
| | - Rami Sweis
- University College London Hospital, GI Services, 235 Euston Rd, London, NW1 2BU, UK
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17
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Clinical utility of routine post-peroral endoscopic myotomy imaging: Does clinical decision making outweigh the protocol? Gastrointest Endosc 2021; 93:107-109. [PMID: 33353610 DOI: 10.1016/j.gie.2020.07.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/17/2020] [Indexed: 02/08/2023]
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18
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Chadalavada P, Thota PN, Raja S, Sanaka MR. Peroral Endoscopic Myotomy as a Novel Treatment for Achalasia: Patient Selection and Perspectives. Clin Exp Gastroenterol 2020; 13:485-495. [PMID: 33173323 PMCID: PMC7648548 DOI: 10.2147/ceg.s230436] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/19/2020] [Indexed: 12/12/2022] Open
Abstract
Achalasia is a rare esophageal motility disorder characterized by esophageal aperistalsis and impaired relaxation of lower esophageal sphincter. There is no cure for achalasia and all the current treatments are aimed at palliation of symptoms by reducing the lower esophageal sphincter pressure. Currently, laparoscopic Heller myotomy (LHM) with partial fundoplication is considered the most effective and durable treatment option owing to its superiority over other treatments such as pneumatic dilation. Advancements in interventional endoscopy led to a novel minimally invasive endoscopic alternative to LHM, namely peroral endoscopic myotomy (POEM). In the last decade since its inception, POEM expanded rapidly throughout the world due to excellent safety profile and its efficacy comparable to LHM. The main drawback of POEM is gastroesophageal reflux disease since it is not combined with an anti-reflux procedure. The current review focuses on the indications, contraindications, technique, outcomes of POEM in various patient populations, and complications along with its effectiveness in comparison to LHM and pneumatic dilation.
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Affiliation(s)
| | - Prashanthi N Thota
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Siva Raja
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Madhusudhan R Sanaka
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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19
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Jawaid S, Draganov PV, Yang D. Esophageal POEM: the new standard of care. Transl Gastroenterol Hepatol 2020; 5:47. [PMID: 33073042 DOI: 10.21037/tgh.2019.12.17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 12/19/2019] [Indexed: 01/06/2023] Open
Abstract
Since its introduction into clinical practice nearly a decade ago, per-oral endoscopic myotomy (POEM) has now become an accepted minimally invasive approach for the treatment of achalasia with excellent short- and mid-term clinical outcomes in both treatment naïve and those who have failed prior therapy. POEM is comparable to laparoscopic Heller myotomy (LHM) in terms of efficacy and safety, with less procedural pain and faster recovery time. Recent data also reveals that POEM may be more effective and durable than pneumatic dilation (PD) for the treatment of achalasia, with similar safety profile. Preliminary data on POEM for spastic esophageal disorders (SED) is promising yet scarce. Post-POEM gastroesophageal reflux disease (GERD) is common but asymptomatic in most patients, further highlighting the need for ongoing research in this field and the importance of long-term surveillance of these patients.
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Affiliation(s)
- Salmaan Jawaid
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida Health, Gainesville, FL, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida Health, Gainesville, FL, USA
| | - Dennis Yang
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida Health, Gainesville, FL, USA
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20
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Hathorn KE, Chan WW, Aihara H, Thompson CC. Determining the Safety and Effectiveness of Electrocautery Enhanced Scissors for Peroral Endoscopic Myotomy (with Video). Clin Endosc 2020; 53:443-451. [PMID: 32438778 PMCID: PMC7403010 DOI: 10.5946/ce.2019.214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 02/25/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/AIMS Peroral endoscopic myotomy (POEM) has recently come to the forefront in the management of achalasia. We aimed to analyze the efficacy and safety of the use of electrocautery enhanced scissors (EES) for POEM. METHODS This retrospective cohort study prospectively collected the data of all adult patients (aged ≥18 years) with normal foregut anatomy who underwent POEM using EES. The patients' baseline characteristics and procedure details (time, tunnel length, myotomy length, depth, and location) were recorded. The primary outcome was clinical success (3-month post-procedure Eckardt score of ≤3). The secondary outcomes were technical success and adverse events. A paired Student's t-test was performed. RESULTS Fifteen patients were included in this study. The technical success rate of myotomy using EES was 100%. Fellows participated in the myotomy in all cases. The clinical success rate was 93.3% (14/15). The mean pre-Eckardt score was 5.4±2.5, while the mean post-Eckardt score was 1.3±1.3, which indicated a significant improvement (p≤0.0001). The most common treatment-related adverse events were post-procedure pain (4, 26.7%) and symptomatic reflux disease (4, 26.7%). CONCLUSION In the largest series to date on the use of EES in POEM, we demonstrated that this technique has both technical and clinical efficacy as well as an excellent safety profile.
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Affiliation(s)
- Kelly E Hathorn
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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21
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Brewer Gutierrez OI, Moran RA, Familiari P, Dbouk MH, Costamagna G, Ichkhanian Y, Seewald S, Bapaye A, Cho JY, Barret M, Eleftheriadis N, Pioche M, Hayee BH, Tantau M, Ujiki M, Landi R, Invernizzi M, Yoo IK, Roman S, Haji A, Hedberg HM, Parsa N, Mion F, Fayad L, Kumbhari V, Agarwalla A, Ngamruengphong S, Sanaei O, Ponchon T, Khashab MA. Long-term outcomes of per-oral endoscopic myotomy in achalasia patients with a minimum follow-up of 4 years: a multicenter study. Endosc Int Open 2020; 8:E650-E655. [PMID: 32355884 PMCID: PMC7165007 DOI: 10.1055/a-1120-8125] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 01/27/2020] [Indexed: 12/15/2022] Open
Abstract
Background and study aims Per-oral endoscopic myotomy (POEM) is associated with a short-term clinical response of 82 % to 100 % in treatment of patients with achalasia. Data are limited on the long-term durability of the clinical response in these patients. The aim of this study was to determine the long-term outcomes of patients undergoing POEM for management of achalasia. Methods This was a retrospective multicenter cohort study of consecutive patients who underwent POEM for management of achalasia. Patients had a minimum of 4 years follow-up. Clinical response was defined by an Eckardt score ≤ 3. Results A total of 146 patients were included from 11 academic medical centers. Mean (± SD) age was 49.8 (± 16) years and 79 (54 %) were female. The most common type of achalasia was type II, seen in 70 (47.9 %) patients, followed by type I seen in 41 (28.1 %) patients. Prior treatments included: pneumatic dilation in 29 (19.9 %), botulinum toxin injection in 13 (8.9 %) and Heller myotomy in seven patients (4.8 %). Eight adverse events occurred (6 mucosotomies, 2 pneumothorax) in eight patients (5.5 %). Median follow-up duration was 55 months (IQR 49.9-60.6). Clinical response was observed in 139 (95.2 %) patients at follow-up of ≥ 48 months. Symptomatic reflux after POEM was seen in 45 (32.1 %) patients, while 35.3 % of patients were using daily PPI at 48 months post POEM. Reflux esophagitis was noted in 16.8 % of patients who underwent endoscopy. Conclusion POEM is a durable and safe procedure with an acceptably low adverse event rate and an excellent long-term clinical response.
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Affiliation(s)
| | - Robert A. Moran
- Department of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Pietro Familiari
- Digestive Endoscopy Unit – Gemelli University Hospital,Rome, Italy
| | - Mohamad H. Dbouk
- Division of gastroenterology and hepatology Johns Hopkins Hospital, Baltimore, United States
| | - Guido Costamagna
- Digestive Endoscopy Unit – Gemelli University Hospital,Rome, Italy
| | - Yervant Ichkhanian
- Division of gastroenterology and hepatology Johns Hopkins Hospital, Baltimore, United States
| | - Stefan Seewald
- Center of Gastroenterolgy Hirslanden Private Clinic Group Witellikerstrasse 40, 8032 Zürich
| | - Amol Bapaye
- Shivanand Desai Centre for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Centre, Pune, India
| | - Joo Young Cho
- Digestive Endoscopy Center, CHA Bundang Hospital, South Korea
| | | | | | - Mathieu Pioche
- Gastroenterology unit/unit of functional disease and digestive physiology, Edouard Herriot hospital, Lion, France
| | - Bu' Hussain Hayee
- Institute of Therapeutic Endoscopy, Kingʼs College Hospital NHS Foundation Trust, London, UK
| | - Marcel Tantau
- Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Michael Ujiki
- NorthShore University HealthSystem/University of Chicago Medical Center, Chicago, United States
| | - Rosario Landi
- Digestive Endoscopy Unit – Gemelli University Hospital,Rome, Italy
| | - Martina Invernizzi
- Center of Gastroenterolgy Hirslanden Private Clinic Group Witellikerstrasse 40, 8032 Zürich
| | - In Kyung Yoo
- Digestive Endoscopy Center, CHA Bundang Hospital, South Korea
| | - Sabine Roman
- Gastroenterology unit/unit of functional disease and digestive physiology, Edouard Herriot hospital, Lion, France
| | - Amyn Haji
- Institute of Therapeutic Endoscopy, Kingʼs College Hospital NHS Foundation Trust, London, UK
| | - H. Mason Hedberg
- NorthShore University HealthSystem/University of Chicago Medical Center, Chicago, United States
| | - Nasim Parsa
- Division of gastroenterology and hepatology Johns Hopkins Hospital, Baltimore, United States
| | - Francois Mion
- Gastroenterology unit/unit of functional disease and digestive physiology, Edouard Herriot hospital, Lion, France
| | - Lea Fayad
- Division of gastroenterology and hepatology Johns Hopkins Hospital, Baltimore, United States
| | - Vivek Kumbhari
- Division of gastroenterology and hepatology Johns Hopkins Hospital, Baltimore, United States
| | - Anant Agarwalla
- Division of gastroenterology and hepatology Johns Hopkins Hospital, Baltimore, United States
| | - Saowanee Ngamruengphong
- Division of gastroenterology and hepatology Johns Hopkins Hospital, Baltimore, United States
| | - Omid Sanaei
- Division of gastroenterology and hepatology Johns Hopkins Hospital, Baltimore, United States
| | - Thierry Ponchon
- Gastroenterology unit/unit of functional disease and digestive physiology, Edouard Herriot hospital, Lion, France
| | - Mouen A. Khashab
- Division of gastroenterology and hepatology Johns Hopkins Hospital, Baltimore, United States
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22
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Liu AQ, Chiu PWY. Third space endoscopy: Current evidence and future development. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii200007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Alex Qinyang Liu
- Division of Upper GI and Metabolic Surgery, Department of Surgery, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Philip Wai Yan Chiu
- Division of Upper GI and Metabolic Surgery, Department of Surgery, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
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23
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Zou BC, Zhang L, Qin B, Wang SH, Cheng Y, Zhao HL. Effects of Peroral Endoscopic Myotomy on Esophageal Function in the Treatment of Achalasia. Surg Innov 2020; 27:333-341. [PMID: 32274966 DOI: 10.1177/1553350620913133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Peroral endoscopic myotomy (POEM) is a new technique to treat achalasia, but the effects on esophageal motor function and structure are still unclear. This study aimed to examine the esophageal function and anatomical changes of patients with achalasia treated with POEM. This was a retrospective study of 43 patients with achalasia treated with POEM between January 2013 and January 2016 at the Second Affiliated Hospital of Xi'an Jiaotong University. The patients were grouped as previous treatments for achalasia (n = 19) versus no previous treatment (n = 24). Surgical success (defined as Eckardt score ≤3 points or decreased by >3 points compared with baseline), recurrence, and reintervention were analyzed. Three patients (7.0%) were Eckardt grade I, 16 (37.2%) were grade II, and 24 (55.8%) were grade III. Operation time was 35 to 150 (median = 49) minutes. Both groups showed improvements in the Eckardt score after surgery (both P < .001), without a difference between the 2 groups (P = .749). The maximal mean diameter of the esophagus was reduced, and the lower esophageal sphincter pressure was improved after surgery (both groups, all P < .001), without difference between the 2 groups (all P > .05). One case of failure was probably due to the presence of an esophageal stent. POEM has a high success rate and is possibly unaffected by previous treatments, except maybe stent implantation. Clinical symptoms of achalasia are significantly relieved by POEM; the function of the esophageal sphincter and the esophagus structure are improved. Previous esophageal stent implantation could increase failure likelihood, but this will have to be confirmed.
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Affiliation(s)
- Bai Cang Zou
- The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Li Zhang
- The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Bin Qin
- The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Shen Hao Wang
- The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yan Cheng
- The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Hong Li Zhao
- The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Farias GF, de Moura DT, de Moura ET, de Rezende DT, Hathorn KE, Nasi A, Queiroz NS, de Moura EG. Peroral endoscopic myotomy (POEM): a comparative study between Chagasic and idiopathic achalasia. Endosc Int Open 2020; 8:E506-E512. [PMID: 32258372 PMCID: PMC7089801 DOI: 10.1055/a-1035-9288] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 09/24/2019] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Achalasia can be classified as either primary (idiopathic) achalasia or secondary achalasia, which is a consequence of another systemic disease. Peroral endoscopic myotomy (POEM) is an effective and safe treatment for achalasia. We evaluated the efficacy and safety of POEM in patients with Chagasic achalasia compared to idiopathic achalasia. Patients and methods We evaluated POEM procedures performed at a single institution from November 2016 to January 2018. Demographic data, Eckardt score, lower esophageal sphincter (LES) pressure, body mass index, post-operative erosive esophagitis, adverse events, length of hospital stay, and procedure-related parameters were analyzed. Results Fifty-one patients underwent POEM as a treatment for achalasia in this period (20 patients with Chagasic and 31 with Idiopathic etiology). The overall clinical success rate was 92.1 %, with no statistical difference between groups (90 % in the Chagasic group vs. 93.5 % in the Idiopathic group, P = 0.640). Both groups had significant reduction in Eckardt score and in LES pressure, and increase in bodey mass index (BMI) at 1-year follow-up. There was no statistical difference between groups regarding Eckardt score ( P = 0.439), LES pressure (p = 0.507), BMI ( P = 0.254), post erosive esophagitis (35 % vs. 38.7 %, P = 0.789), adverse events (30 % vs. 12 %, P = 0.163,) length of hospital stay (3.75 days vs. 3.58 days, P = 0.622), and operative time (101.3 min vs. 99.1 min, P = 0.840). Conclusion POEM is an effective and safe treatment for patients with achalasia. There is no difference in POEM outcomes for those patients with Chagasic or Idiopathic achalasia.
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Affiliation(s)
- Galileu F.A. Farias
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil,Corresponding author Galileu F. A. Farias, MD University of São Paulo Medical SchoolGastrointestinal Endoscopy UnitDr. Arnaldo Av, 455São Paulo, 01246-903Brazil+30617000
| | - Diogo T.H. de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil,Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Eduardo T.H. de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Daniel T. de Rezende
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Kelly E. Hathorn
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Ary Nasi
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Natália S.F. Queiroz
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Eduardo G.H. de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Spadaccini M, Maselli R, Chandrasekar VT, Anderloni A, Carrara S, Galtieri PA, Di Leo M, Fugazza A, Pellegatta G, Colombo M, Palma R, Hassan C, Sethi A, Khashab MA, Sharma P, Repici A. Gastric peroral endoscopic pyloromyotomy for refractory gastroparesis: a systematic review of early outcomes with pooled analysis. Gastrointest Endosc 2020; 91:746-752.e5. [PMID: 31809720 DOI: 10.1016/j.gie.2019.11.039] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 11/19/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Gastroparesis (GP) is a chronic debilitating condition. Prior pyloric-targeted procedures are either invasive or have questionable efficacy. Gastric peroral pyloromyotomy (G-POEM) has been proposed as a minimally invasive approach. We performed a pooled analysis to evaluate the efficacy and safety of G-POEM for GP. METHODS Electronic databases (Medline, Scopus, EMBASE) were searched up to January 2019. Studies including patients who underwent G-POEM for GP were eligible. Procedural, clinical, and safety outcomes were assessed by pooling data with a random- or fixed-effect model according to the degree of heterogeneity to obtain a proportion with a 95% confidence interval. RESULTS Ten studies were eligible for inclusion (292 patients), and 2 of the 10 studies were prospective. Seven studies were performed in the United States, 2 in France, and 1 in China. Endoscopic pyloromyotomy was feasible in all patients. Significant symptomatic improvement was achieved after 83.9% of procedures (mean follow-up, 7.8 ± 5.5 months). When comparing the mean values of pre- and postprocedural scintigraphic evolution, there was a significant decrease of the residual percentage at 2 and 4 hours. The overall adverse events rate was 6.8%. CONCLUSIONS G-POEM appears to be a promising approach for GP in terms of safety and efficacy outcomes in the short term.
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Affiliation(s)
- Marco Spadaccini
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Roberta Maselli
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Viveksandeep Thoguluva Chandrasekar
- Division of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, Kansas, USA; Division of Gastroenterology and Hepatology, Veteran Affairs Medical Center, Kansas City, Missouri, USA
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Silvia Carrara
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Piera Alessia Galtieri
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Milena Di Leo
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Gaia Pellegatta
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Matteo Colombo
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Rossella Palma
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Amrita Sethi
- Division of Gastroenterology and Hepatology, New York-Presbyterian Medical Center/Columbia University Medical Center, New York, New York, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Prateek Sharma
- Division of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, Kansas, USA; Division of Gastroenterology and Hepatology, Veteran Affairs Medical Center, Kansas City, Missouri, USA
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
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de Heer J, Desai M, Boeckxstaens G, Zaninotto G, Fuchs KH, Sharma P, Schachschal G, Mann O, Rösch T, Werner Y. Pneumatic balloon dilatation versus laparoscopic Heller myotomy for achalasia: a failed attempt at meta-analysis. Surg Endosc 2020; 35:602-611. [PMID: 32180002 DOI: 10.1007/s00464-020-07421-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 02/10/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The advent of peroral endoscopic myotomy (POEM) shed some light on the role of the current standards in the treatment of idiopathic achalasia, namely endoscopic pneumatic dilatation (PD) and laparoscopic Heller myotomy (LHM). We analyzed the quality of the current evidence comparing LHM and PD. METHODS A systematic literature search was performed in Pubmed/Medline, Web of Science, Google Scholar and Cochrane for meta-analyses/systematic reviews comparing PD and LHM or open surgery, limited to English language full-text articles. After a detailed review of these meta-analyses, all studies included were analyzed further in depth with respect to treatment protocol, assessment of success, complications and sequelae such as gastroesophageal reflux (GER), as well as follow-up details. RESULTS Six randomized controlled trials (RCT), 5 with LHM and 1 with open surgery, were found, published in 10 papers. In contrast to a rather homogeneous LHM technique, PD regimens as well as the clinical dysphagia scores were different in every RCT; most RCTs also showed methodological limitations. There were nine meta-analyses which included a variable number of these RCTs or other cohort studies. Meta-analyses between 2009 and 2013 favored surgery, while the 4 most recent ones reached divergent conclusions. The main difference might have been whether repeated dilatation was regarded as part of the PD protocol or as failure. CONCLUSIONS The variability in PD techniques and in definition of clinical success utilized in the achalasia RCTs on PD versus LHM render the conclusions of meta-analyses unreliable. Further randomized studies should be based on uniform criteria; in the meantime, publication of even more meta-analyses should be avoided.
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Affiliation(s)
- Jocelyn de Heer
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Madhav Desai
- Department of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas, MO, USA
| | - Guy Boeckxstaens
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | | | - Karl-Hermann Fuchs
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Prateek Sharma
- Department of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas, MO, USA
| | - Guido Schachschal
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Oliver Mann
- Department of General and Abdominal Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Yuki Werner
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Zhong C, Tan S, Ren Y, Lü M, Peng Y, Fu X, Tang X. Quality of Life Following Peroral Endoscopic Myotomy for Esophageal Achalasia: A Systematic Review and Meta-Analysis. Ann Thorac Cardiovasc Surg 2020; 26:113-124. [PMID: 32132346 PMCID: PMC7303313 DOI: 10.5761/atcs.ra.19-00273] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background: Peroral endoscopic myotomy (POEM) is a novel minimally invasive intervention for treating esophageal achalasia. Previous publications have proved its excellent efficacy and safety, and even shown it could improve patients’ quality of life (QoL). So, we conducted this study to explore the changes of QoL following POEM. Methods: A comprehensive literature search was conducted on PubMed, EMBASE, and Cochrane Library covering the period from January 2009 to April 2019. The statistical analysis was carried out using Review Manager 5.3. Results: A total of 12 studies including 549 patients were identified, which assessed the QoL using validated questionnaires administered. After POEM, the SF-36 questionnaire score of each domain (physical function, role physical function, body pain, general health (GH), social function, vitality, emotional role function, mental health) was significantly increased (p < 0.05). Meanwhile, mental component scale (MCS) and physical component scale (PCS) scores were all improved in patients after POEM procedure (MCS: 12.11, 95% confidence interval [CI], 4.67–19.55, p = 0.001, I2 = 88%, PCS: 17.01, 95% CI, 2.91–31.11, p = 0.02, I2 = 97%). The gastroesophageal reflux disease health-related quality of life questionnaires (GERD-HRQL) also decreased significantly after POEM (13.01, 95% CI, 9.98–16.03, p < 0.00001, I2 = 30%). Conclusions: Our current evidence suggests there is significant improvement in QoL after POEM procedure.
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Affiliation(s)
- Chunyu Zhong
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shali Tan
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yutang Ren
- Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Muhan Lü
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yan Peng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiangsheng Fu
- Department of Gastroenterology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xiaowei Tang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
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Werner YB, Hakanson B, Martinek J, Repici A, von Rahden BHA, Bredenoord AJ, Bisschops R, Messmann H, Vollberg MC, Noder T, Kersten JF, Mann O, Izbicki J, Pazdro A, Fumagalli U, Rosati R, Germer CT, Schijven MP, Emmermann A, von Renteln D, Fockens P, Boeckxstaens G, Rösch T. Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia. N Engl J Med 2019; 381:2219-2229. [PMID: 31800987 DOI: 10.1056/nejmoa1905380] [Citation(s) in RCA: 282] [Impact Index Per Article: 56.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Pneumatic dilation and laparoscopic Heller's myotomy (LHM) are established treatments for idiopathic achalasia. Peroral endoscopic myotomy (POEM) is a less invasive therapy with promising early study results. METHODS In a multicenter, randomized trial, we compared POEM with LHM plus Dor's fundoplication in patients with symptomatic achalasia. The primary end point was clinical success, defined as an Eckardt symptom score of 3 or less (range, 0 to 12, with higher scores indicating more severe symptoms of achalasia) without the use of additional treatments, at the 2-year follow-up; a noninferiority margin of -12.5 percentage points was used in the primary analysis. Secondary end points included adverse events, esophageal function, Gastrointestinal Quality of Life Index score (range, 0 to 144, with higher scores indicating better function), and gastroesophageal reflux. RESULTS A total of 221 patients were randomly assigned to undergo either POEM (112 patients) or LHM plus Dor's fundoplication (109 patients). Clinical success at the 2-year follow-up was observed in 83.0% of patients in the POEM group and 81.7% of patients in the LHM group (difference, 1.4 percentage points; 95% confidence interval [CI], -8.7 to 11.4; P = 0.007 for noninferiority). Serious adverse events occurred in 2.7% of patients in the POEM group and 7.3% of patients in the LHM group. Improvement in esophageal function from baseline to 24 months, as assessed by measurement of the integrated relaxation pressure of the lower esophageal sphincter, did not differ significantly between the treatment groups (difference, -0.75 mm Hg; 95% CI, -2.26 to 0.76), nor did improvement in the score on the Gastrointestinal Quality of Life Index (difference, 0.14 points; 95% CI, -4.01 to 4.28). At 3 months, 57% of patients in the POEM group and 20% of patients in the LHM group had reflux esophagitis, as assessed by endoscopy; at 24 months, the corresponding percentages were 44% and 29%. CONCLUSIONS In this randomized trial, POEM was noninferior to LHM plus Dor's fundoplication in controlling symptoms of achalasia at 2 years. Gastroesophageal reflux was more common among patients who underwent POEM than among those who underwent LHM. (Funded by the European Clinical Research Infrastructure Network and others; ClinicalTrials.gov number, NCT01601678.).
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Affiliation(s)
- Yuki B Werner
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Bengt Hakanson
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Jan Martinek
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Alessandro Repici
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Burkhard H A von Rahden
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Albert J Bredenoord
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Raf Bisschops
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Helmut Messmann
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Marius C Vollberg
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Tania Noder
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Jan F Kersten
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Oliver Mann
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Jakob Izbicki
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Alexander Pazdro
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Uberto Fumagalli
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Riccardo Rosati
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Christoph-Thomas Germer
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Marlies P Schijven
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Alice Emmermann
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Daniel von Renteln
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Paul Fockens
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Guy Boeckxstaens
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Thomas Rösch
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
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Ichkhanian Y, Benias P, Khashab MA. Case of early Barrett cancer following peroral endoscopic myotomy. Gut 2019; 68:2107-2110. [PMID: 31358575 DOI: 10.1136/gutjnl-2019-318950] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/08/2019] [Accepted: 07/12/2019] [Indexed: 01/15/2023]
Affiliation(s)
- Yervant Ichkhanian
- Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Petros Benias
- Division of Gastroenterology, Department of Medicine, Hofstra Northwell School of Medicine, Northwell Health System, North Shore University Hospital, Manhasset, New York, USA
| | - Mouen A Khashab
- Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Chan MQ, Balasubramanian G. Esophageal Dysphagia in the Elderly. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2019; 17:534-553. [PMID: 31741211 DOI: 10.1007/s11938-019-00264-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW With a globally aging population, dysphagia is a growing health concern among elderly. Increasing reflux disease has contributed to an increased prevalence of dysphagia from peptic strictures and esophageal cancer. Dysphagia can lead to malnutrition and aspiration pneumonia, causing considerable morbidity and mortality. This review article focuses on recent advances in the approach and management of esophageal dysphagia. RECENT FINDINGS Endoscopic functional luminal imaging probe is a novel test that complements upper endoscopy, esophagram, and esophageal manometry for evaluation of esophageal dysphagia. Opioid induced esophageal dysfunction (OIED) is an emerging clinical entity that can mimic achalasia. Strictures refractory to dilation can be treated with intralesional steroid injections, electrosurgical incision, or esophageal stents. Peroral endoscopic myotomy (POEM) is gaining in popularity for treatment of achalasia and other spastic disorders of esophagus. Treatment of esophageal dysphagia may include proton pump inhibitors, endoscopic dilation, or surgery and requires a personalized approach based on risks and benefits. POEM is a valuable therapy for achalasia, but further studies are needed to evaluate its use, and other alternatives, for treatment of OIED and spastic esophageal disorders.
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Affiliation(s)
- Megan Q Chan
- Department of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, 2nd floor, Columbus, OH, USA
| | - Gokulakishnan Balasubramanian
- Department of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, 2nd floor, Columbus, OH, USA.
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Quitadamo P, Tambucci R, Mancini V, Cristofori F, Baldassarre M, Pensabene L, Francavilla R, Di Nardo G, Caldaro T, Rossi P, Mallardo S, Maggiora E, Staiano A, Cresi F, Salvatore S, Borrelli O. Esophageal pH-impedance monitoring in children: position paper on indications, methodology and interpretation by the SIGENP working group. Dig Liver Dis 2019; 51:1522-1536. [PMID: 31526716 DOI: 10.1016/j.dld.2019.07.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/02/2019] [Accepted: 07/20/2019] [Indexed: 12/11/2022]
Abstract
Multichannel intraluminal impedance pH (MII-pH) monitoring currently represents the gold standard diagnostic technique for the detection of gastro-esophageal reflux (GER), since it allows to quantify and characterize all reflux events and their possible relation with symptoms. Over the last ten years, thanks to its strengths and along with the publication of several clinical studies, its worldwide use has gradually increased, particularly in infants and children. Nevertheless, factors such as the limited pediatric reference values and limited therapeutic options still weaken its current clinical impact. Through an up-to-date review of the available scientific evidence, our aim was to produce a position paper on behalf of the working group on neurogastroenterology and acid-related disorders of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) on MII-pH monitoring technique, indications and interpretation in pediatric age, in order to standardise its use and to help clinicians in the diagnostic approach to children with GER symptoms.
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Affiliation(s)
- Paolo Quitadamo
- Department of Pediatrics, A.O.R.N. Santobono-Pausilipon, Naples, Italy; Department of Translational Medical Science,"Federico II", University of Naples, Italy.
| | - Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy; Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Valentina Mancini
- Department of Pediatrics and Neonatology, Saronno Hospital, Saronno, Italy
| | - Fernanda Cristofori
- Department of Pediatrics, Giovanni XXIII Hospital, Aldo MoroUniversity of Bari, Bari, Italy
| | - Mariella Baldassarre
- Department of Biomedical Science and Human Oncology-neonatology and Nicu section, University "Aldo Moro", Bari, Italy
| | - Licia Pensabene
- Department of Medical and Surgical Sciences, Pediatric Unit, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Ruggiero Francavilla
- Department of Pediatrics, Giovanni XXIII Hospital, Aldo MoroUniversity of Bari, Bari, Italy
| | - Giovanni Di Nardo
- NESMOS Department, School of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Tamara Caldaro
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Rossi
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - Saverio Mallardo
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - Elena Maggiora
- Neonatology and Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Annamaria Staiano
- Department of Translational Medical Science,"Federico II", University of Naples, Italy
| | - Francesco Cresi
- Neonatology and Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Silvia Salvatore
- Pediatric Department, Ospedale "F. Del Ponte", University of Insubria, Varese, Italy
| | - Osvaldo Borrelli
- Division of Neurogastroenterology and Motility, Department of Paediatric Gastroenterology, UCL Institute ofChild Health and Great OrmondStreet Hospital, London, UK
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Law R, Chang A. Treatment of achalasia by Performing Outpatient Endoscopic Myotomy (POEM). Gastrointest Endosc 2019; 90:579-580. [PMID: 31540629 DOI: 10.1016/j.gie.2019.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 06/18/2019] [Indexed: 02/08/2023]
Affiliation(s)
- Ryan Law
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew Chang
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Abstract
Prevalence, clinical manifestations and of modern classifications of achalasia are reviewed in the article. Diagnosis and treatment of this pathology were analyzed by using of 58 references.
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Affiliation(s)
- A M Gasanov
- Sklifosovsky Research Institute for Emergency Medicine of Moscow Healthcare Department, Moscow, Russia
| | - N A Aliev
- Sklifosovsky Research Institute for Emergency Medicine of Moscow Healthcare Department, Moscow, Russia
| | - Sh N Danielyan
- Sklifosovsky Research Institute for Emergency Medicine of Moscow Healthcare Department, Moscow, Russia
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Lee Y, Brar K, Doumouras AG, Hong D. Peroral endoscopic myotomy (POEM) for the treatment of pediatric achalasia: a systematic review and meta-analysis. Surg Endosc 2019; 33:1710-1720. [PMID: 30767141 DOI: 10.1007/s00464-019-06701-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/06/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Achalasia is a rare primary esophageal dysmotility disorder in children. Peroral endoscopic myotomy (POEM) is a novel endoscopic technique which has shown promising results for treating achalasia in adults. However, limited data on efficacy and safety in pediatric patients are available. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of POEM in pediatric achalasia. METHODS We searched MEDLINE, Embase, PubMed, and Web of Science databases through July 2018. Studies were eligible for inclusion if they conducted POEM in pediatric patients. Main outcomes were Eckardt score and lower esophageal sphincter (LES) pressure before and after POEM. Secondary outcomes were clinical success rate and adverse events associated with POEM. Two reviewers independently reviewed the studies, collected data, and assessed quality of evidence using Methodological Index for Non-Randomized Studies (MINORS). Pooled estimates were calculated using random effects meta-analyses. Heterogeneity was quantified using the inconsistency statistic, and funnel plot was used to assess publication bias. RESULTS A total of 12 studies with 146 pediatric patients (53.68% female) underwent POEM for the treatment of achalasia (mean duration of disease of 19.48 months). There was a significant reduction in Eckardt score by 6.88 points (Mean Difference (MD) 6.88, 95% confidence interval (CI), 6.28-7.48, P < .001) and LES pressure by 20.73 mmHg (MD 20.73, 95% CI, 15.76-25.70, P < .001) following POEM. At least 93% of the patients experienced improvement or resolution of achalasia symptoms both short and long terms after POEM, with small proportion of patients experiencing minor adverse effects which could be managed conservatively. CONCLUSIONS POEM is efficacious and safe for treating achalasia in pediatric populations. Large comparative or randomized trials are warranted to confirm the efficacy and safety of POEM compared to other surgical procedures for achalasia.
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Affiliation(s)
- Yung Lee
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.,Centre for Minimal Access Surgery (CMAS), Division of General Surgery, Department of Surgery, McMaster University St. Joseph's Healthcare, 50 Charlton Avenue East Hamilton, Hamilton, ON, L8N 4A6, Canada
| | - Karanbir Brar
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Aristithes G Doumouras
- Centre for Minimal Access Surgery (CMAS), Division of General Surgery, Department of Surgery, McMaster University St. Joseph's Healthcare, 50 Charlton Avenue East Hamilton, Hamilton, ON, L8N 4A6, Canada
| | - Dennis Hong
- Centre for Minimal Access Surgery (CMAS), Division of General Surgery, Department of Surgery, McMaster University St. Joseph's Healthcare, 50 Charlton Avenue East Hamilton, Hamilton, ON, L8N 4A6, Canada.
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Mari A, Patel K, Mahamid M, Khoury T, Pesce M. Achalasia: Insights into Diagnostic and Therapeutic Advances for an Ancient Disease. Rambam Maimonides Med J 2019; 10:RMMJ.10361. [PMID: 30720423 PMCID: PMC6363376 DOI: 10.5041/rmmj.10361] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Achalasia is a chronic idiopathic disease characterized by the absence of esophageal body peristalsis and by defective lower esophageal sphincter (LES) relaxation. The incidence rate ranges from 1.07 to up to 2.8 new cases per year per 100,000 population. Presenting symptoms include dysphagia, regurgitation, vomiting, and weight loss. The diagnosis of achalasia has undergone a revolution in the last decade due to the advent of high-resolution manometry (HRM) and the consequent development of the Chicago Classification. Recent progress has allowed achalasia to be more precisely diagnosed and to be categorized into three subtypes, based on the prevalent manometric features of the esophageal peristalsis. Treatment options are pharmacotherapy, endoscopic management (Botox injection or pneumatic dilation), and surgery, e.g. laparoscopic Heller myotomy (LHM). More recently, a new endoscopic technique, per oral endoscopic myotomy (POEM), has developed as a less invasive approach alternative to the traditional LHM. Since the first POEM procedure was performed in 2008, increasing evidence is accumulating regarding its efficacy and safety profiles. Currently, POEM is being introduced as a reasonable therapeutic option, though randomized controlled trails are still lacking. The current review sheds light onto the diagnosis and management of achalasia, with special focus on the recent advances of HRM and POEM.
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Affiliation(s)
- Amir Mari
- Gastroenterology Institute, Nazareth EMMS Hospital, Nazareth, Israel
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- GI Physiology Unit, University College London Hospital, London, United Kingdom
| | - Kalp Patel
- GI Physiology Unit, University College London Hospital, London, United Kingdom
| | - Mahmud Mahamid
- Gastroenterology Institute, Nazareth EMMS Hospital, Nazareth, Israel
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Tawfik Khoury
- Gastroenterology Institute, Nazareth EMMS Hospital, Nazareth, Israel
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Marcella Pesce
- GI Physiology Unit, University College London Hospital, London, United Kingdom
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Li H, Peng W, Huang S, Ren Y, Peng Y, Li Q, Wu J, Fu X, Tang X. The 2 years' long-term efficacy and safety of peroral endoscopic myotomy for the treatment of achalasia: a systematic review. J Cardiothorac Surg 2019; 14:1. [PMID: 30606216 PMCID: PMC6318943 DOI: 10.1186/s13019-018-0811-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 12/03/2018] [Indexed: 02/08/2023] Open
Abstract
AIM In this retrospective review, we aimed to investigate the long-term efficacy and safety of POEM with follow-up period over 2 years. MATERIALS AND METHODS A systematic review related to POEM for achalasia was conducted. A literature search was performed in Pubmed, Medline, Ovid, Cochrane and EBSCO databases on November 2017. The following postoperative outcomes were extracted: Eckardt score, lower esophageal sphincter pressure, complications and clinical success. RESULTS The total number of patients was 373. The mean operative time was 66.7 min and the overall rate of complications was 21.2%. The mean follow-up period was 30.0 months. The overall clinical success rate was 92.9% and the rate of gastroesophageal reflux disease was 10.2%. Rate of mortality after POEM was 0. CONCLUSIONS Our study demonstrated that POEM is effective and safe for treating achalasia during the long-term followed up over 2 years.
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Affiliation(s)
- Huan Li
- Department of Gastroenterology, Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099 Sichuan Province China
| | - Wei Peng
- Department of Gastroenterology, Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099 Sichuan Province China
| | - Shu Huang
- Department of Gastroenterology, the People’s Hospital of Lianshui, Huaian, China
| | - Yutang Ren
- Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China
| | - Yan Peng
- Department of Gastroenterology, Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099 Sichuan Province China
| | - Qing Li
- Department of Gastroenterology, Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099 Sichuan Province China
| | - Jiao Wu
- Department of Gastroenterology, Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099 Sichuan Province China
| | - Xiangsheng Fu
- Department of Gastroenterology, Affiliated Hospital of North Sichuan Medical College, Road Wenhua 63#, Region Shunqing, Sichuan, 637000 China
| | - Xiaowei Tang
- Department of Gastroenterology, Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099 Sichuan Province China
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Okada H, Shiwaku H, Yamashita K, Ohmiya T, Inoue H, Hasegawa S. Patient with mediastinitis caused by delayed mucosal damage after peroral endoscopic myotomy. Asian J Endosc Surg 2019; 12:107-110. [PMID: 29656451 DOI: 10.1111/ases.12481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 01/17/2018] [Accepted: 02/15/2018] [Indexed: 12/20/2022]
Abstract
Peroral endoscopic myotomy (POEM) is a groundbreaking procedure for treating esophageal achalasia, and many reports from various facilities have described its safety and efficacy. However, there have been few reports on adverse events. Here, we report a case of a patient with mediastinitis caused by delayed mucosal damage after POEM. This case was the most severe among all POEM cases at our hospital. A 58-year-old man had experienced dysphagia and chest tightness since he was around 50 years old. At a previous hospital, he had been diagnosed with nonerosive reflux disease and had undergone fundoplication. As his symptoms did not improve, he was referred to our department. POEM was able to be finished but a stable visual field could not be maintained throughout procedure because of strong esophageal contractions. From findings of endoscopy and esophagography after POEM, the patient was diagnosed mediastinitis caused by delayed esophageal perforation. In this case, conservative treatment (fasting, antibiotic therapy, and enteral feeding) was successful. However, the option to administer surgical treatment, such as drainage, must not be overlooked.
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Affiliation(s)
- Hiroki Okada
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Kanefumi Yamashita
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Toshihiro Ohmiya
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
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de Moura DTH, Jirapinyo P, Aihara H, Thompson CC. Endoscopic tunneled stricturotomy in the treatment of stenosis after sleeve gastrectomy. VideoGIE 2018; 4:68-71. [PMID: 30766946 PMCID: PMC6362310 DOI: 10.1016/j.vgie.2018.09.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
| | - Pichamol Jirapinyo
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hiroyuki Aihara
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Campagna RAJ, Hungness ES. Treatment of Idiopathic Achalasia with Per-Oral Esophageal Myotomy. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018; 20:114-119. [PMID: 30872910 DOI: 10.1016/j.tgie.2018.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Achalasia is a rare esophageal motility disorder that necessitates the disruption of the lower esophageal sphincter. Patients with achalasia should be evaluated in a systematic, multidisciplinary fashion. Workup should include upper endoscopy, esophagography, and high-resolution manometry. The gold standard for surgical treatment is laparoscopic Heller myotomy with partial fundoplication. Per-oral esophageal myotomy is a novel endoscopic technique that has gained considerable traction over the past decade. The procedure includes the creation of a submucosal tunnel and a selective circular myotomy of the lower esophageal sphincter. Common intra-operative hazards include bleeding within the submucosal tunnel and capnoperitoneum. Significant complications are rare. Patients experience excellent dysphagia relief that is on par with laparoscopic Heller myotomy at moderate-term follow up. Post-operative gastroesophageal reflux disease occurs in greater than one-third of patients, and the vast majority of cases are readily controlled with an anti-secretory medication. Although data is sparse, there is a growing body of literature that supports the long-term durability of per-oral esophageal myotomy.
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Affiliation(s)
- Ryan A J Campagna
- Department of Surgery, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 650, Chicago, Illinois, 60611
| | - Eric S Hungness
- Department of Surgery, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 650, Chicago, Illinois, 60611
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Ramchandani M, Nageshwar Reddy D, Nabi Z, Chavan R, Bapaye A, Bhatia S, Mehta N, Dhawan P, Chaudhary A, Ghoshal UC, Philip M, Neuhaus H, Deviere J, Inoue H. Management of achalasia cardia: Expert consensus statements. J Gastroenterol Hepatol 2018; 33:1436-1444. [PMID: 29377271 DOI: 10.1111/jgh.14097] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 01/14/2018] [Indexed: 12/14/2022]
Abstract
Achalasia cardia (AC) is a frequently encountered motility disorder of the esophagus resulting from an irreversible degeneration of neurons. Treatment modalities are palliative in nature, and there is no curative treatment available for AC as of now. Significant advancements have been made in the management of AC over last decade. The introduction of high resolution manometry and per-oral endoscopic myotomy (POEM) has strengthened the diagnostic and therapeutic armamentarium of AC. High resolution manometry allows for the characterization of the type of achalasia, which in turn has important therapeutic implications. The endoscopic management of AC has been reinforced with the introduction of POEM that has been found to be highly effective and safe in palliating the symptoms in short-term to mid-term follow-up studies. POEM is less invasive than Heller's myotomy and provides the endoscopist with the opportunity of adjusting the length and orientation of esophageal myotomy according to the type of AC. The management of achalasia needs to be tailored for each patient, and the role of pneumatic balloon dilatation, POEM, or Heller's myotomy needs to be revisited. In this review, we discuss the important aspects of diagnosis as well as management of AC. The statements presented in the manuscript reflect the cumulative efforts of an expert consensus group.
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Affiliation(s)
- Mohan Ramchandani
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - D Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Radhika Chavan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Amol Bapaye
- Department of Digestive Diseases and Endoscopy, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra, India
| | - Shobna Bhatia
- Department of Gastroenterology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Nilay Mehta
- Department of Gastroenterology, Vedanta Institute of Medical Sciences, Ahmedabad, Gujarat, India
| | - Pankaj Dhawan
- Department of Gastroenterology, Bhatia General Hospital, Mumbai, Maharashtra, India
| | - Adarsh Chaudhary
- Department of Surgical Gastroenterology, Medanta The Medicity, Gurgaon, Haryana, India
| | - Uday C Ghoshal
- Department of Gastroenterology, SGPGI, Lucknow, Uttar Pradesh, India
| | - Mathew Philip
- Gastroenterology, PVS Memorial Hospital, Ernakulam, Kerala, India
| | - Horst Neuhaus
- Department of Internal Medicine, Evangelical Hospital Düsseldorf, Dusseldorf, Nordrhein-Westfalen, Germany
| | - Jacques Deviere
- Department of Gastroenterology, Erasmus Hospital, Bruxelles, Belgium
| | - Haruhiro Inoue
- Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
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Li QL, Wu QN, Zhang XC, Xu MD, Zhang W, Chen SY, Zhong YS, Zhang YQ, Chen WF, Qin WZ, Hu JW, Cai MY, Yao LQ, Zhou PH. Outcomes of per-oral endoscopic myotomy for treatment of esophageal achalasia with a median follow-up of 49 months. Gastrointest Endosc 2018; 87:1405-1412.e3. [PMID: 29108981 DOI: 10.1016/j.gie.2017.10.031] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 10/13/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Per-oral endoscopic myotomy (POEM) has received wide acceptance as a highly effective and safe treatment for esophageal achalasia. Short-term and small-scale studies are ample, but long-term large-scale studies are few. The aim of the study was to systematically analyze our long-term results of POEM, with particular emphasis on POEM failures and associated risk factors. METHODS In this single-center study, consecutive patients treated with POEM between August 2010 and December 2012 were included. The Kaplan-Meier survival function was used to estimate clinical success rate at each year. The Cox proportional hazards model was used to analyze risk factors related to recurrence. RESULTS A total of 564 patients were included. Major perioperative adverse events occurred in 36 patients (6.4%). After a median follow-up of 49 months (range, 3-68), the Eckardt score and lower esophageal sphincter (LES) pressure were significantly decreased (median Eckardt score, 8 to 2 [P < .05]; median LES pressure, 29.7 mm Hg to 11.9 mm Hg [P < .05]). Fifteen failures occurred within 3 months, 23 between 3 months and 3 years, and 10 after 3 years. The estimated clinical success rates at 1, 2, 3, 4, and 5 years were 94.2%, 92.2%, 91.1%, 88.6%, and 87.1%, respectively. Multivariate Cox regression revealed long disease duration (≥10 years) and history of prior interventions to be risk factors for recurrence. Clinical reflux occurred in 37.3% of patients (155/ 416). CONCLUSIONS POEM is a highly safe and effective treatment for esophageal achalasia with favorable long-term outcomes.
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Affiliation(s)
- Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qiu-Ning Wu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiao-Cen Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Mei-Dong Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wei Zhang
- Department of Biostatistics, Shanghai Medical College, Fudan University, Shanghai, China
| | - Shi-Yao Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun-Shi Zhong
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi-Qun Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wei-Feng Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen-Zheng Qin
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jian-Wei Hu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ming-Yan Cai
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li-Qing Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
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Repici A, Fuccio L, Maselli R, Mazza F, Correale L, Mandolesi D, Bellisario C, Sethi A, Khashab MA, Rösch T, Hassan C. GERD after per-oral endoscopic myotomy as compared with Heller's myotomy with fundoplication: a systematic review with meta-analysis. Gastrointest Endosc 2018; 87:934-943.e18. [PMID: 29102729 DOI: 10.1016/j.gie.2017.10.022] [Citation(s) in RCA: 149] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 10/13/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Per-oral endoscopic myotomy (POEM) represents a less invasive alternative to conventional laparoscopic Heller's myotomy (LHM) for patients with achalasia. It cannot be excluded, however, that the lack of fundoplication after POEM may result in a higher incidence of reflux disease, as compared with LHM. The aim of our study was to conduct a systematic review of prospective studies reporting the incidence of reflux disease developed after POEM and LHM. METHODS A literature search with electronic databases was performed (up to February 2017) to identify full articles on the incidence of gastroesophageal reflux symptoms and endoscopic monitoring and pH monitoring findings after POEM and LHM (with fundoplication). Proportions and rates were pooled by means of random or fixed-effects models, according to the level of heterogeneity between studies. RESULTS After we applied the selection criteria, 17 and 28 studies, including 1542 and 2581 participants who underwent POEM and LHM, respectively, were included. The pooled rate of postprocedural symptoms was 19.0% (95% confidence interval [CI], 15.7%-22.8%) after POEM and 8.8% (95% CI, 5.3%-14.1%) after LHM, respectively. The pooled rate estimate of abnormal acid exposure at pH monitoring was 39.0% (95% CI, 24.5%-55.8%) after POEM and 16.8% (95% CI, 10.2%-26.4%) after LHM, respectively. The rate of esophagitis after POEM was 29.4% (95% CI, 18.5%-43.3%) after POEM and 7.6% (95% CI, 4.1%-13.7%) after LHM. At meta-regression, heterogeneity was explained partly by the POEM approach and study population. CONCLUSION The incidence of reflux disease appears to be significantly more frequent after POEM than after LHM with fundoplication. Monitoring pH and ensuring appropriate treatment after POEM should be considered in order to prevent long-term reflux-related adverse events.
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Affiliation(s)
- Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Rozzano (MI), Italy
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Roberta Maselli
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Rozzano (MI), Italy
| | - Fabrizio Mazza
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Rozzano (MI), Italy
| | | | - Daniele Mandolesi
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Cristina Bellisario
- Department of Cancer Screening, Centre for Epidemiology and Prevention in Oncology, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Thomas Rösch
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
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Nast JF, Berliner C, Rösch T, von Renteln D, Noder T, Schachschal G, Groth S, Ittrich H, Kersten JF, Adam G, Werner YB. Endoscopy versus radiology in post-procedural monitoring after peroral endoscopic myotomy (POEM). Surg Endosc 2018; 32:3956-3963. [PMID: 29546671 DOI: 10.1007/s00464-018-6137-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 02/23/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The newly developed technique of peroral endoscopic myotomy (POEM) has been shown to be effective in several short- and mid-term studies. Limited information is available about the adequacy of immediate post-POEM monitoring tests. METHODS POEM was performed under general anesthesia in 228 patients (59.6% male, mean age 45.6 ± 15.5 years). Post-procedural checks comprised clinical and laboratory examination, and, during post-procedure days 1-5, endoscopy and-in the first 114 cases-radiologic examination using water-soluble contrast (1st group); the remaining patients underwent post-procedure controls without radiology (2nd group). Main outcome was value of endoscopic compared to radiologic control for recognition of early adverse events. RESULTS In the first group, routine fluoroscopic contrast swallow suggested minor leakages at the mucosal entry site in two cases which was confirmed endoscopically in only one. Endoscopy revealed two minor entry site leakages and, in six additional cases, dislocated clips without leakage (overall 5.3%). All eight patients underwent reclipping and healed without clinical sequelae. In the 2nd group, endoscopy showed 5 clip dislocations (all reclipped) and one ischemic cardiac perforation in a patient with clinical deterioration on post-POEM day 1 who had to undergo surgery after confirmation of leakage by CT. CONCLUSIONS Radiologic monitoring (contrast swallow) after POEM is not useful and can be omitted. Even routine endoscopic monitoring for detection and closure of minor defects of the mucosal entry site yields limited information with regards to final outcome; major complications are very rare and probably associated with clinical deterioration. Clinical Trials Gov Registration number of the main study: NCT01405417.
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Affiliation(s)
- Jan Friso Nast
- Department of Gastroenterology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Berliner
- Department of Diagnostic and Interventional Radiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany. .,Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Daniel von Renteln
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany.,Department of Gastroenterology, Centre Hospitalier de l´Université de Montreal, Montreal, Canada
| | - Tania Noder
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Guido Schachschal
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Groth
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Harald Ittrich
- Department of Diagnostic and Interventional Radiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jan F Kersten
- Department of Medical Biometry and Epidemiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Yuki B Werner
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Yang D, Draganov PV. Expanding Role of Third Space Endoscopy in the Management of Esophageal Diseases. ACTA ACUST UNITED AC 2018; 16:41-57. [PMID: 29435819 DOI: 10.1007/s11938-018-0169-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OPINION STATEMENT: "Third space" endoscopy, also commonly referred as submucosal endoscopy, is founded on the principle that the deeper layers of the gastrointestinal (GI) tract can be accessed by tunneling in the submucosal space without compromising the integrity of the overlying mucosa. Peroral endoscopic myotomy (POEM), endoscopic submucosal dissection (ESD), and submucosal tunneling endoscopic resection (STER) are innovative techniques within the field of third space endoscopy in the management of esophageal disorders. POEM has become an accepted minimally invasive therapy for achalasia and related motility disorders with excellent short-term results, with early studies yielding similar efficacy to surgical myotomy and increased durability when compared to pneumatic balloon dilation (PBD). Data are needed to establish long-term outcomes with POEM, with particular interest on the incidence of gastroesophageal reflux, which appears to be higher than initially anticipated. ESD, a mature endoscopic resection technique in Asia, has recently gained traction in the West as a viable option for the management of early Barrett's esophagus (BE) neoplasia. Compared to standard endoscopic mucosal resection (EMR), ESD allows the en bloc resection of lesions irrespective of size, which may facilitate histological interpretation and reduce recurrence rates. Large prospective randomized controlled trials are needed to validate the efficacy and safety of this technique and to further define its role in the endoscopic armamentarium in early BE neoplasia. STER is an attractive technique that theoretically permits the resection of subepithelial esophageal tumors (SETs) arising from the deeper GI layers. Initial studies from highly experienced endoscopic centers support its technical feasibility and safety, although these results should be interpreted with caution due to variability arising from small numbers and heterogeneity among studies. Overall, third space endoscopy is an expanding field within endoscopic therapeutics for the treatment of esophageal diseases. While initial results have been very promising, large prospective studies, long-term data, and structured training programs with the establishment of competency parameters are needed before third space endoscopy can be advocated outside of highly specialized centers.
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Affiliation(s)
- Dennis Yang
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, 1329 SW 16th Street Suite 5262, Gainesville, FL, 32608, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, 1329 SW 16th Street Suite 5262, Gainesville, FL, 32608, USA.
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Cho YK, Kim SH. Current Status of Peroral Endoscopic Myotomy. Clin Endosc 2018; 51:13-18. [PMID: 29397656 PMCID: PMC5806926 DOI: 10.5946/ce.2017.165] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/16/2017] [Accepted: 01/10/2018] [Indexed: 12/17/2022] Open
Abstract
Peroral endoscopic myotomy (POEM) has been established as an optional treatment for achalasia. POEM is an endoluminal procedure that involves dissection of esophageal muscle fibers followed by submucosal tunneling. Inoue first attempted to use POEM for the treatment of achalasia in humans. Expanded indications of POEM include classic indications such as type I, type II, type III achalasia, failed prior treatments, including Botulinum toxin injection, endoscopic balloon dilation, laparoscopic Heller myotomy, and hypertensive motor disorders such as diffuse esophageal spasm, jackhammer esophagus. Contraindications include prior radiation therapy to the esophagus and prior extensive esophageal mucosal resection/ablation involving the POEM field. Most of the complications are minor and self-limited and can be managed conservatively. As POEM emerged as the main treatment for achalasia, various adaptations to tunnel endoscopic surgery have been attempted. Tunnel endoscopic surgery includes POEM, peroral endoscopic tumor resection, gastric peroral endoscopic pyloromyotomy. POEM has been widely accepted as a treatment for all types of achalasia, even for specific cases such as achalasia with failed prior treatments, and hypertensive motor disorders.
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Affiliation(s)
- Young Kwan Cho
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Eulji University College of Medicine, Seoul, Korea
| | - Seong Hwan Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Eulji University College of Medicine, Seoul, Korea
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Mejía M. R, Donoso D. A, Manríquez A. E, Sáez B. J, Crovari E. F, Gabrielli N. M, Norero M. E, Pimentel M. F, Ceroni V. M, Muñoz C. R, Sharp P. A. Miotomía endoscópica por vía oral (POEM) para el tratamiento de la acalasia. Experiencia clínica inicial y resultados a corto plazo. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.rchic.2017.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Repici A, Maselli R, Carrara S, Anderloni A, Enderle M, Hassan C. Standard needle versus needleless injection modality: animal study on different fluids for submucosal elevation. Gastrointest Endosc 2017; 86:553-558. [PMID: 28161450 DOI: 10.1016/j.gie.2017.01.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 01/07/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Submucosal injection is currently used in GI endoscopy to reduce resection risks and to perform submucosal dissection; it is usually performed via an injection needle or a needleless device. The aim of the study was to compare 2 submucosal injection modalities (needle-assisted vs needleless) by using substances with different viscosities. METHODS Needle and needleless injections were compared by assessing the efficacy of tissue elevation with 5 different substances in an ex vivo porcine model. The height of the submucosal elevation was measured 0(t0), 10(t1), and 30 minutes after injection (t2). Viscosity of the solution was also measured. RESULTS For both stomach and rectum, at t0, t1, and t2 no difference in the height of the elevation was found between the needle and needleless technique, irrespective of the substance. Tissue elevation in the stomach was similar between the 2 techniques at t0 (9.9 ± 1.58 vs 9.4 ± 1.3 mm, P = .3), t1 (7.2 ± 1.56 vs 6.9 ± 1.4 mm, P =. 26), and t2 (6 ± 1.6 vs 5.5 ± 1.3 mm, P = .18). No difference was found in the rectum at t1 and t2, whereas a slightly higher elevation with the needle-assisted technique was observed at t0 (t0: 12.4 ± 1.3 vs 11.2 ± 1.6 mm, P = .003; t1: 8.7 ± 1.3 vs 8.3 ± 1.5 mm; P = .32; t2: 7.0 ± 1.4 vs 7.2 ± .76 mm; P = .75). When comparing the substances with normal saline solution, more viscous solutions showed a significantly higher elevation at t0, t1, and t2 irrespective of the injection modalities and the location. CONCLUSIONS No differences were found in the height of submucosal injection or in the persistence of such elevation when comparing needleless with needle-assisted injection, with the only minor exception of the initial elevation in the rectum, which does not appear to be clinically relevant. Viscous solutions resulted in higher and more persistent elevations as compared with normal saline solution.
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Affiliation(s)
- Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Roberta Maselli
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Silvia Carrara
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Markus Enderle
- Research Department, Erbe Elektromedizin GmbH, Tubingen, Germany
| | - Cesare Hassan
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Milan, Italy
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Miranda García P, Casals Seoane F, Gonzalez JM, Barthet M, Santander Vaquero C. Per-oral endoscopic myotomy (POEM): a new endoscopic treatment for achalasia. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 109:719-726. [PMID: 28724307 DOI: 10.17235/reed.2017.4732/2016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND/AIMS Per-oral endoscopic myotomy (POEM) is a new minimally invasive technique to treat achalasia. METHODS We performed a review of the literature of POEM with a special focus on technical details and the results obtained with this technique in patients with achalasia and other esophageal motility disorders. RESULTS Thousands of POEM procedures have been performed worldwide since its introduction in 2008. The procedure is based on the creation of a mucosal entry point in the proximal esophagus to reach the cardia through a submucosal tunnel and then perform a myotomy of the muscular layers of the cardia, esophagogastric junction and distal esophagus, as performed in a Heller myotomy. The clinical remission rate ranges from 82 to 100%. Although no randomized studies exist and available data are from single-center studies, no differences have been found between laparoscopic Heller myotomy (LHM) and POEM in terms of perioperative outcomes, short-term outcomes (12 months) and long-term outcomes (up to three years). Procedure time and length of hospital stay were lower for POEM. Post-POEM reflux is a concern, and controversial data have been reported compared to LHM. The technique is safe, with no reported deaths related to the procedure and an adverse event rate comparable to surgery. Potential complications include bleeding, perforation, aspiration and insufflation-related adverse events. Thus, this is a complex technique that needs specific training even in expert hands. The indication for this procedure is widening and other motor hypercontractil esophageal disorders have been treated by POEM with promising results. POEM can be performed in complicated situations such as in pediatric patients, sigmoid achalasia or after failure of previous treatments. CONCLUSIONS POEM is an effective treatment for achalasia and is a promising tool for other motor esophageal disorders. It is a safe procedure but, due to its technical difficulty and possible associated complications, the procedure should be performed in referral centers by trained endoscopists.
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Per oral endoscopic myotomy vs. laparoscopic Heller myotomy, does gastric extension length matter? Surg Endosc 2017; 32:282-288. [DOI: 10.1007/s00464-017-5675-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 06/19/2017] [Indexed: 12/21/2022]
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Peng L, Tian S, Du C, Yuan Z, Guo M, Lu L. Outcome of Peroral Endoscopic Myotomy (POEM) for Treating Achalasia Compared With Laparoscopic Heller Myotomy (LHM). Surg Laparosc Endosc Percutan Tech 2017; 27:60-64. [PMID: 28145968 DOI: 10.1097/sle.0000000000000368] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Peroral endoscopic myotomy (POEM) is an emerging endoscopic treatment for achalasia and the long-term efficacy of POEM remains to be evaluated. This study compared the outcomes of POEM with that of the standard laparoscopic Heller myotomy (LHM) for achalasia. MATERIALS AND METHODS Achalasia patients treated by POEM or LHM were retrospectively analyzed, with a minimum postoperative follow-up of 3 years. Perioperative outcomes and long-term outcomes including treatment success (Eckardt score ≤3), occurrence of gastroesophageal reflux disease (GERD) (GerdQ score ≥9) and quality of life (36-item short form) were compared. RESULTS Thirteen patients who underwent POEM were compared with 18 patients who received LHM. These patients were similar in age, sex, symptoms duration, Eckardt score, and previous therapy (all P>0.05). Mean myotomy lengths were similar (P=0.73). Operation time was shorter in the POEM group (P=0.001). One patient (7.7%) developed pneumothorax after POEM and 1 patient (5.6%) experienced postoperative infection after LHM (P=1.00). Treatment success was achieved in 83.3% (9/12) of POEM patients and 80.0% (12/15) of LHM patients (P=1.00). Both POEM and LHM significantly reduced Eckardt score (both P=0.00). GERD rate was similar (8.3% vs. 6.7%, P=1.00). There was no difference in all aspects of quality of life between the 2 groups. CONCLUSIONS Long-term outcomes indicate that POEM is an effective treatment that is comparable with LHM. More data of randomized trials comparing POEM with LHM will enrich the existing evidence.
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Affiliation(s)
- Lijun Peng
- Departments of *Gastroenterology ‡Laparoscopic Surgery, Linyi People's Hospital affiliated to Shandong University, Linyi †Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai
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