Jackhammer esophagus treated by a peroral endoscopic myotomy

Peroral endoscopic myotomy for hypercontractile (Jackhammer) esophagus: A retrospective multicenter series with long-term follow-up

INTRODUCTION

Long-term outcome data are limited for non-achalasia esophageal motility disorders treated by peroral endoscopy myotomy (POEM) as a separate group. We investigated a subset of symptomatic patients with hypercontractile esophagus (Jackhammer esophagus).

METHODS

Forty two patients (mean age 60.9 years; 57% female, mean Eckardt score 6.2 ± 2.1) treated by primary peroral myotomy for symptomatic Jackhammer esophagus 2012-2018 in seven European centers were retrospectively analyzed; myotomy included the lower esophageal sphincter but did not extend more than 1 cm into the cardia in contrast to POEM for achalasia. Manometry data were re-reviewed by an independent expert. The main outcome was the failure rate defined by retreatment or an Eckardt score >3 after at least two years following POEM.

RESULTS

Despite 100% technical success (mean intervention time 107 ± 48.9 min, mean myotomy length 16.2 ± 3.7 cm), the 2-year success rate was 64.3% in the entire group. In a subgroup analysis, POEM failure rates were significantly different between Jackhammer-patients without (n = 22), and with esophagogastric junction outflow obstruction (EGJOO, n = 20) (13.6% % vs. 60%, p = 0.003) at a follow-up of 46.5 ± 19.0 months. Adverse events occurred in nine cases (21.4%). 14 (33.3%) patients were retreated, two with surgical fundoplication due to reflux. Including retreatments, an improvement in symptom severity was found in 33 (78.6%) at the end of follow-up (Eckardt score ≤3, mean Eckardt change 4.34, p < 0.001). EGJOO (p = 0.01) and frequency of hypercontractile swallows (p = 0.02) were predictors of POEM failure. The development of a pseudodiverticulum was observed in four cases within the subgroup of EGJOO.

CONCLUSIONS

Patients with symptomatic Jackhammer without EGJOO benefit from POEM in long-term follow-up. Treatment of Jackhammer with EGJOO, however, remains challenging and probably requires full sphincter myotomy and future studies which should address the pathogenesis of this variant and alternative strategies.

Peroral esophageal myotomy for esophageal motility disorders

The concept of third space endoscopy first described in 2007, was adapted and performed in humans in 2010 by Inoue et al. in a group of patients with esophageal achalasia (EA). Since then, esophageal endoscopic myotomy (E-POEM), has been performed in more than 10,000 patients worldwide up to now. Safety and efficacy have been confirmed at early, mid and long-term evaluations, in different gastrointestinal diseases including achalasia, refractory gastroparesis, and other esophageal motility disorders (EMD). Nowadays, this treatment has shown to be not only an excellent option, but also with its excellent outcomes, the first option in certain clinical scenarios such as type III achalasia. Thus, the minimal invasive nature of POEM gives us multiple advantages compared with the classical treatments that includes pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM), including not only clinical aspects but also economical. High resolution manometry (HRM) has substantially redefined the actual approach of esophageal motility disorders with the major changes in instrumental use, diagnostic algorithms, and therapeutics. The previous Chicago's classification V 3.0 clearly improved our knowledge about pathophysiology of spastic esophageal motor disorders, however, with its recent update (Chicago V 4.0), multiple changes in diagnosis and treatment are expected. In the present article, we aimed to review and analyze the most important aspects about the results of E-POEM in the management of EMD according to the view of the new Chicago's classification V 4.0.

Peroral endoscopic myotomy: techniques and outcomes

Achalasia is progressive neurodegenerative disorder of the esophagus, resulting in uncoordinated esophageal motility and failure of lower esophageal sphincter relaxation, leading to impaired swallowing. Surgical myotomy of the lower esophageal sphincter, either open or minimally invasive, has been a standard of care for the past several decades. Recently, new procedure-peroral endoscopic myotomy (POEM) has been introduced into clinical practice. This procedure accomplishes the same objective of controlled myotomy only via endoscopic approach. In the current chapter authors review the present state, clinical applications, outcomes and future directions of the POEM procedure.

Experience with Peroral Endoscopic Myotomy for Achalasia and Spastic Esophageal Motility Disorders at a Tertiary U.S. Center

Background/Aims

Peroral endoscopic myotomy (POEM) is a novel procedure for the treatment of achalasia and spastic esophageal disorders. Experience with POEM is limited, but its reported outcomes are excellent. It is deemed safe even for patients with prior interventions.

Methods

This retrospective review included patients who underwent POEM at a tertiary US center. POEM was performed in a multidisciplinary approach by advanced endoscopists and foregut surgeons. Clinical success was defined as a post-POEM Eckardt score ≤3.

Results

A total of 125 patients were included. Median follow-up period was 18 months (interquartile range, 10–22 months). Clinical success was achieved in 92% of patients and persisted at 12 months in 88% of patients. Mucosal barrier failure (MBF) occurred in 7 patients, 2 of whom required surgical intervention. MBF was more common in patients with prior laparoscopic Heller myotomy (19% vs. 3%, p=0.015). MBF requiring surgical intervention occurred early in the learning curve.

Conclusions

POEM is safe and effective in the treatment of achalasia and spastic esophageal disorders even after failed prior interventions.

Botulinum toxin for the treatment of hypercontractile esophagus: Results of a double-blind randomized sham-controlled study

INTRODUCTION

Botulinum toxin injection is known to be efficient to treat achalasia. We conducted a randomized trial in order to evaluate its efficacy to treat symptomatic hypercontractile esophageal disorders as characterized by esophageal high-resolution manometry.

METHODS

Patients with significant dysphagia and/or thoracic pain related to an hypercontractile esophageal motility disorder as defined by the Chicago Classification were randomized to receive an injection of botulinum toxin (100 U in 10 points in the distal part of the esophageal wall) or a sham procedure. Symptoms were assessed at 3 months with the Eckardt score. Patients could receive a first or second botulinum toxin injection 1 month later if symptoms persisted.

RESULTS

Twenty-three patients (13 women, mean age 60 years) were included: 13 received botulinum toxin injection, and 10 a sham procedure. The improvement of symptoms at 3 months was significant compared to baseline, but similar in the active treatment and sham procedure arms. However, there was no change in quality of life scores. Seventeen patients received a second injection at 4 months. There was a significant trend toward improvement of symptoms up to the end of follow-up at 12 months, without a significant relationship with the administration of botulinum toxin.

DISCUSSION

Botulinum toxin injection is not superior to a sham procedure to improve symptoms related to hypercontractile esophageal disorders, suggesting an important placebo effect in for this type of disease. This observation must be taken into account when evaluating more aggressive therapies such as endoscopic myotomy (clinicaltrials.gov: NCT01955174).

Clinical practice guidelines for peroral endoscopic myotomy

Peroral endoscopic myotomy (POEM) is a novel clinical technique developed in Japan used to treat esophageal achalasia and esophageal motility disorders. This technique has been rapidly accepted and widely disseminated throughout our clinical practice because of its low invasiveness, technical novelty, and high efficacy. Since the advent of POEM, there have been no clinical guidelines that clearly indicated its standard of care, and these guidelines have been anticipated both nationally and internationally by clinicians who engage in POEM practice. In 2017, to meet these needs, the Japan Gastroenterological Endoscopy Society (JGES) launched the guideline committee for POEM. Based on the guideline development process proposed by the Medical Information Network Distribution Service (MINDS), the guideline committee initially created research questions on POEM and conducted a systematic review and meta-analysis on each topic. The clinical research extracted from databases for these clinical questions and the systematic review mainly comprised a few retrospective studies with a small number of participants and short trial periods; hence, the strength of the evidence and recommendations derived from these results was low. Throughout this process, the guideline committee met thrice: once on May 13, 2017, and again on September 17, 2017, to formulate the draft. A consensus meeting was then held on January 14, 2018, in Tokyo to establish the guideline statements and finalize the recommendations using the modified Delphi method. This manuscript presents clinical guidelines regarding current standards of practice and recommendations in terms of the nine chief topics in POEM.

Current Status of Peroral Endoscopic Myotomy

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.

Peroral Endoscopic Myotomy for Treating Achalasia and Esophageal Motility Disorders

Peroral endoscopic myotomy (POEM) is the application of esophageal myotomy to the concept of natural orifice transluminal surgery (NOTES) by utilizing a submucosal tunneling method. Since the first case of POEM was performed for treating achalasia in Japan in 2008, this procedure is being more widely used by many skillful endosopists all over the world. Currently, POEM is a spotlighted, emerging treatment option for achalasia, and the indications for POEM are expanding to include long-standing, sigmoid shaped esophagus in achalasia, even previously failed endoscopic treatment or surgical myotomy, and other spastic esophageal motility disorders. Accumulating data about POEM demonstrate excellent short-term outcomes with minimal risk of major adverse events, and some existing long-term data show the efficacy of POEM to be long lasting. In this review article, we review the technical details and clinical outcomes of POEM, and discuss some considerations of POEM in special situations.

A jackhammer in the gullet: high amplitude oesophageal contractions as a cause of atypical chest pain

Chest pain is a common cause for referral to emergency departments. A proportion of these patients have non-cardiac chest pains with normal investigations. Such patients should be considered for oesophageal studies as these may reveal an underlying dysmotility disorder. We report the case of a 51-year-old man who presented with chest pain and underwent oesophageal studies. He was diagnosed with acid reflux and high amplitude oesophageal contractions, otherwise known as a jackhammer oesophagus. Treatment was successful with omeprazole and glyceryl trinitrate relieving his symptoms.

Peroral endoscopic myotomy: an evolving treatment for achalasia

Peroral endoscopic myotomy (POEM) was first performed in Japan in 2008 for uncomplicated achalasia. With excellent results, it was adopted by highly skilled endoscopists around the world and the indications for POEM were expanded to include advanced sigmoid achalasia, failed surgical myotomy, patients with previous endoscopic treatments and even other spastic oesophageal motility disorders. With increased uptake and performance of POEM, variations in technique and improved management of adverse events have been developed. Now, 6 years since the first case and with >3,000 procedures performed worldwide, long-term data has shown the efficacy of POEM to be long-lasting. A growing body of literature also exists pertaining to the learning curve, application of novel technologies, extended indications and physiologic changes with POEM. Ultimately, this once experimental procedure is evolving towards becoming the preferred treatment for achalasia and other spastic oesophageal motility disorders.