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Crafts TD, Seidel H, Hedberg HM, Kuchta K, Carbray J, Anderson DJ, Joseph S, Rwigema JC, Ishii S, Ujiki MB. Efficacy and outcomes of per oral plication of the (neo)esophagus (POPE) for impaired emptying in achalasia and post-esophagectomy patients. Surg Endosc 2024:10.1007/s00464-024-11062-9. [PMID: 38992281 DOI: 10.1007/s00464-024-11062-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 07/06/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Per-oral plication of the (neo)esophagus (POPE) is an endoscopic procedure used to improve emptying of the defunctionalized esophagus or gastric conduit, with the hope of improving symptoms and quality of life. As this procedure has only been performed in the United States for the past 4 years, safety and efficacy have not been well established. METHODS This is a retrospective case series for patients who underwent POPE from a single institution between 2019 and 2023. Data collected included demographics, preoperative diagnoses and treatments, imaging, endoscopic data, operative intervention, 90-day complications, and response to treatment. Quality of life and patient satisfaction data were collected by phone survey. RESULTS Seventeen cases were identified, encompassing 13 primary procedures and 4 repeat POPEs (re-POPE). Eight patients had end-stage achalasia and 5 had impaired gastric emptying after esophagectomy with gastric conduits. Median age was 65 years and median ASA was 3, with 38.5% female patients. POPE was performed with 2-6 plication sutures in an average of 75 min. The majority of patients discharged home the same day. For the 17 procedures, there were 4 complications. Two patients required antibiotics for pneumonia, while 4 required procedural intervention. There were no deaths. Preoperative symptoms improved or resolved at initial follow up in 82.3% of patients. Four patients experienced symptom recurrence and required re-POPE, 1 with achalasia and 3 with gastric conduits. Although all achalasia patients had an "end-stage esophagus," none have required esophagectomy since the introduction of POPE. CONCLUSIONS POPE is an endoscopic procedure that is efficacious in relieving emptying difficulties for the end-stage esophagus and gastric conduit. It may obviate the need for esophagectomy or conduit replacement. Also, it can be repeated in select patients. While the risk profile of complications is favorable compared to alternative operations, patients with gastric conduits are at higher risk.
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Affiliation(s)
- Trevor D Crafts
- Department of Surgery, Endeavor Health, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA.
| | - Henry Seidel
- Department of Surgery, Endeavor Health, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
- Department of Surgery, University of Chicago Medical Center, 5841 S. Maryland Ave, Chicago, IL, 60637, USA
| | - Herbert M Hedberg
- Department of Surgery, Endeavor Health, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Kristine Kuchta
- Department of Surgery, Endeavor Health, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - JoAnn Carbray
- Department of Surgery, Endeavor Health, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Derrius J Anderson
- Department of Surgery, Endeavor Health, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
- Department of Surgery, University of Chicago Medical Center, 5841 S. Maryland Ave, Chicago, IL, 60637, USA
| | - Stephanie Joseph
- Department of Surgery, Endeavor Health, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Jean-Christophe Rwigema
- Department of Surgery, Endeavor Health, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Shun Ishii
- Department of Surgery, Endeavor Health, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Michael B Ujiki
- Department of Surgery, Endeavor Health, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA
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Anil A, Netam RK, Roy A, Chandran DS, Jaryal AK, Makharia GK, Parshad R, Deepak KK. Cardiovascular Autonomic Deficits in Different Types of Achalasia. Cureus 2024; 16:e59444. [PMID: 38826939 PMCID: PMC11140828 DOI: 10.7759/cureus.59444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2024] [Indexed: 06/04/2024] Open
Abstract
Background and objective Achalasia cardia is a primary esophageal motility disorder, and the etiopathology of this disease's progression is not known. Moreover, autonomic dysfunction has not been studied in different types of achalasia. In light of this, we aimed to address this lack of data in this study. Methods The diagnosis of achalasia was done using high-resolution esophageal manometry (HRM)-based Chicago classification v4.0. Autonomic function tests (AFT) such as the head-up tilt test, deep breathing test (DBT), Valsalva maneuver (VM), handgrip test (HGT), and cold pressor test (CPT), as well as the heart rate variability (HRV) test, were performed among the cohort and the results were compared with those of 39 age- and sex-matched healthy controls. Results AFT and HRV tests were done on 62 patients (30 achalasia type I, 28 type II, and 4 type III) and compared with 39 age- and sex-matched healthy controls. The mean duration of symptoms, high Eckardt score, and dysphagia were most common in type I achalasia, followed by type II and III. The results of AFT showed a generalized loss of parasympathetic and baroreflex-independent sympathetic reactivity in all types of achalasia. However, baroreflex-dependent cardiovascular adrenergic reactivity was normal. Regarding cardiac autonomic tone, there was a loss of parasympathetic and sympathetic influence, but sympathovagal balance was maintained. The severity of the loss of autonomic functions was higher in type I, followed by type II. Conclusions In all types of achalasia, parasympathetic reactivity, baroreflex-independent sympathetic reactivity, and cardiac autonomic tone were lower compared to healthy controls, and the severity of dysfunction increased during the progression of the disease from type II to type I.
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Affiliation(s)
- Abhijith Anil
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, New Delhi, IND
| | - Ritesh K Netam
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, New Delhi, IND
| | - Atanu Roy
- Department of Physiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, IND
| | - Dinu S Chandran
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, New Delhi, IND
| | - Ashok Kumar Jaryal
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, New Delhi, IND
| | - Govind K Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, New Delhi, IND
| | - Rajinder Parshad
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, New Delhi, IND
| | - Kishore K Deepak
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, New Delhi, IND
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Vahedi F, Low EE, Kaizer AM, Fehmi SA, Hasan A, Chang MA, Kwong W, Krinsky ML, Anand G, Greytak M, Yadlapati R. Esophageal anatomy and physiology vary across spastic and non-spastic phenotypes of disorders of esophagogastric junction outflow. Neurogastroenterol Motil 2024; 36:e14709. [PMID: 38009826 PMCID: PMC10843578 DOI: 10.1111/nmo.14709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 10/06/2023] [Accepted: 10/30/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Pathophysiologic mechanisms of disorders of esophagogastric junction (EGJ) outflow are poorly understood. We aimed to compare anatomic and physiologic characteristics among patients with disorders of EGJ outflow and normal motility. METHODS We retrospectively evaluated adult patients with achalasia types 1, 2, 3, EGJ outflow obstruction (EGJOO) or normal motility on high-resolution manometry who underwent endoscopic ultrasound (EUS) from January 2019 to August 2022. Thickened circular muscle was defined as ≥1.6 mm. Characteristics from barium esophagram (BE) and functional lumen imaging probe (FLIP) were additionally assessed. KEY RESULTS Of 71 patients (mean age 56.2 years; 49% male), there were 8 (11%) normal motility, 58 (82%) had achalasia (5 (7%) type 1, 32 (45%) classic type 2, 21 (30%) type 3 [including 12 type 2 with FEPs]), and 7 (7%) had EGJOO. A significantly greater proportion of type 3 achalasia had thickened distal circular muscle (76.2%) versus normal motility (0%; p < 0.001) or type 2 achalasia (25%; p < 0.001). Type 1 achalasia had significantly wider mean maximum esophageal diameter on BE (57.8 mm) compared to type 2 achalasia (32.8 mm), type 3 achalasia (23.4 mm), EGJOO (15.9 mm), and normal motility (13.5 mm). 100% type 3 achalasia versus 0% type 1 achalasia/normal motility had tertiary contractions on BE. Mean EGJ distensibility index on FLIP was lower for type 3 achalasia (1.2 mmHg/mm2 ) and EGJOO (1.2 mmHg/mm2 ) versus type 2 (2.3 mmHg/mm2 ) and type 1 achalasia (2.9 mmHg/mm2 ). CONCLUSIONS Our findings suggest distinct pathologic pathways may exist: type 3 achalasia and EGJOO may represent a spastic outflow phenotype consisting of a thickened, spastic circular muscle, which is distinct from type 1 and 2 achalasia consisting of a thin caliber circular muscle layer with more prominent esophageal dilation.
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Affiliation(s)
- Farnoosh Vahedi
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Eric E Low
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Alexander M Kaizer
- Department of Biostatistics and Informatics, University of Colorado, Anschutz Medical Campus, Colorado School of Public Health, Aurora, Colorado, USA
| | - Syed Abbas Fehmi
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Aws Hasan
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Michael A Chang
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Wilson Kwong
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Mary L Krinsky
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Gobind Anand
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Madeline Greytak
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
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Low EE, Fehmi SA, Hasan A, Chang M, Kwong W, Krinsky ML, Anand G, Greytak M, Kaizer A, Carlson DA, Pandolfino JE, Yadlapati R. Type II achalasia with focal elevated pressures: A distinct manometric and clinical sub-group. Neurogastroenterol Motil 2022; 34:e14449. [PMID: 35972282 PMCID: PMC9722506 DOI: 10.1111/nmo.14449] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/15/2022] [Accepted: 07/27/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Type II achalasia (Ach2) is distinguished from other achalasia sub-types by the presence of panesophageal pressurization (PEP) of ≥30 mmHg in ≥20% swallows on high-resolution manometry (HRM). Variable manometric features in Ach2 have been observed, characterized by focal elevated pressures (FEPs) (focal/segmental pressures ≥70 mmHg within the PEP band) and/or high compression pressures (PEP ≥70 mmHg). This study aimed to examine clinical and physiologic variables among sub-groups of Ach2. METHODS This retrospective single center study performed over 3 years (1/2019-1/2022) included adults with Ach2 on HRM who underwent endoscopic ultrasound (EUS), functional lumen imaging probe (FLIP), and/or barium esophagram (BE) prior to therapy. Patients were categorized into two overarching sub-groups: Ach2 without FEPs and Ach2 with FEPs. Demographic, clinical, and physiologic data were compared between these sub-groups utilizing unpaired univariate analyses. KEY RESULTS Of 53 patients with Ach2, 40 (75%) were without FEPs and 13 (25%) had FEPs. Compared with the Ach2 sub-group without FEPs, the Ach2 sub-group with FEPs demonstrated a significantly thickened distal esophageal circular muscle on EUS (1.4 mm [SD 0.9] vs. 2.1 [0.7]; p = 0.02), higher prevalence of tertiary contractions on BE (46% vs. 100%; p = 0.0006), lower esophagogastric junction distensibility index (2.2mm2 /mmHg [0.9] vs 0.9 [0.4]; p = 0.0008) as well as higher distensive pressure (31.0 mmHg [9.8] vs. 55.4 [18.8]; p = 0.01) at 60 cc fill on FLIP, and higher prevalence of chest pain on Eckardt score (p = 0.03). CONCLUSIONS AND INFERENCES We identified a distinct sub-group of type II achalasia on HRM, defined as type II achalasia with focal elevated pressures. This sub-group uniquely exhibits spastic features and may benefit from personalized treatment approaches.
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Affiliation(s)
- Eric E. Low
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Syed Abbas Fehmi
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Aws Hasan
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Michael Chang
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Wilson Kwong
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Mary L. Krinsky
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Gobind Anand
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Madeline Greytak
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Alexander Kaizer
- Department of Biostatistics & Informatics, University of Colorado, Denver, Colorado, USA
| | - Dustin A. Carlson
- Division of Gastroenterology, Northwestern University, Chicago, Illinois, USA
| | - John E. Pandolfino
- Division of Gastroenterology, Northwestern University, Chicago, Illinois, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
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