Peroral Endoscopic Myotomy for Esophageal Motility Disorders

Diffuse Esophageal Spasm: An Alternative Treatment Approach

Diffuse esophageal spasm (DES) is a rare esophageal motility disorder characterized by abnormal contractions of the esophagus, leading to curling of the esophagus. The classic finding on barium swallow resembles that of the turns of a corkscrew. This case report presents a case of DES with impressive imaging and an alternative treatment approach. There are no well-established guidelines for the treatment of DES. Treatment options include surgical myotomy, oral medications to aid in smooth muscle relaxation, esophageal dilation, and several newer approaches such as endoscopic botulinum toxin injections. There is a need for less invasive treatment modalities that provide a solution, longer than the duration of action of an oral medication in patients who are not candidates for surgical intervention. This case report presents a complex and challenging case of DES in the context of multiple complicating comorbidities. This case is unique in demonstrating the successful management of a rare esophageal motility disorder in a high-risk patient using a more traditional, less invasive treatment approach. This case report presents a 91-year-old cachectic female with DES in the context of various comorbidities. Given her age, comorbidities, and current status, she was not a candidate for surgical intervention. After attempts at pharmacological therapy, the patient's dysphagia continued to worsen. Upper gastrointestinal endoscopy with pneumatic esophageal dilation was performed. The patient's swallowing improved in the days following endoscopic dilation.

Clinical Outcomes and Complications for Achalasia Patients Admitted After Per-Oral Endoscopic Myotomy

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.

Benefit of extending the protocol for high resolution manometry according to the version 4.0 of the Chicago criteria. A multicenter study

BACKGROUND

The last version of the Chicago Criteria for high resolution esophageal manometry proposes an expanded protocol including complementary maneuvers to improve the diagnostic yield of the exploration. Our aim was to determine the diagnostic gain of the CCv4.0 protocol compared to the CCv3.0 protocol.

METHODS

All manometry recordings performed in 4 reference centers during the first 10 months after the implementation of the new protocol were retrospectively reviewed. The time spent to complete the protocol was measured, and the changes in diagnosis resulting from the new CCv4.0 were compared to CCv3.0.

KEY RESULTS

From a total of 756 HRM performed, 606 studies could be properly analyzed. The duration of the studies was 18.3 ± 4.3 min. From these, 11.3 ± 3.4 min were spent to complete the CCv3.0 protocol, and 7.4 ± 3.6 min were spent for the remaining maneuvers. A discordant diagnosis between CCv3.0 and CCv4.0 was obtained in 12% of patients: 32% of patients with ineffective esophageal motility turned to normal motility; 24% of patients with esophagogastric junction outlet obstruction (EGJOO) turned to a non-obstructive disorder; and 1% of patients with an apparently normal EGJ relaxation, turned to an obstructive disorder. EGJOO according to CCv4.0 was more prevalent in patients referred for dysphagia (11%) than those referred for GERD (4%; p = 0.003).

CONCLUSIONS AND INFERENCES

Prolongation of the time spent to complete the CCv4.0 protocol leads to a change in the diagnosis of 12% of patients. Clinically relevant changes are mainly related to the evaluation of EGJOO.

Role of Endoscopy in Motility Disorders of Upper Gastrointestinal Tract

Gastrointestinal motility disorders have a wide range of symptoms and affect patients' quality of life. With the advancement of endoscopy, the diagnostic and therapeutic roles of endoscopy in motility disorders is becoming more significant. Endoscopy is necessary to rule out possible organic diseases in patients with suspected motility disorders and provide significant clues for their diagnosis. Moreover, interventional endoscopy may be a primary or alternative treatment option for selected patients with motility disorders, and it is becoming a promising field as new therapeutic applications are developed and utilized for various motility disorders. This review may provide suitable indications for the use of endoscopy in diagnosing and treating motility disorders of the upper gastrointestinal tract.

Clinical and financial outcomes of per-oral endoscopic myotomy compared to laparoscopic heller myotomy for treatment of achalasia

BACKGROUND

Previous studies analyzing short-term outcomes for per-oral endoscopic myotomy (POEM) have shown excellent clinical response rates and shorter operative times compared to laparoscopic Heller myotomy (LHM). Despite this, many payors have been slow to recognize POEM as a valid treatment option. Furthermore, comparative studies analyzing long-term outcomes are limited. This study compares perioperative and long-term outcomes, cost-effectiveness, and reimbursement for POEM and LHM at a single institution.

METHODS

Adult patients who underwent POEM or LHM between 2014 and 2021 and had complete preoperative data with at least one complete follow up, were retrospectively analyzed. Demographic data, success rate, operative time, myotomy length, length of stay, pre- and postoperative symptom scores, anti-reflux medication use, cost and reimbursement were compared.

RESULTS

58 patients met inclusion with 25 undergoing LHM and 33 undergoing POEM. There were no significant differences in preoperative characteristics. Treatment success (Eckardt ≤ 3) for POEM and LHM was achieved by 88% and 76% of patients, respectively (p = 0.302). POEM patients had a shorter median operative time (106 min. vs. 145 min., p = 0.003) and longer median myotomy length (11 cm vs. 8 cm, p < 0.001). All LHM patients had a length of stay (LOS) ≥ 1 day vs. 51.5% for POEM patients (p < 0.001). Both groups showed improvements in dysphagia, heartburn, regurgitation, Eckardt score, GERD HRQL, RSI, and anti-reflux medication use. The improvement in dysphagia score was greater in patients undergoing POEM (2.30 vs 1.12, p = 0.003). Median hospital reimbursement was dramatically less for POEM ($3,658 vs. $14,152, p = 0.002), despite median hospital costs being significantly lower compared to LHM ($2,420 vs. $3,132, p = 0.029).

RESULTS

POEM is associated with a shorter operative time and LOS, longer myotomy length, and greater resolution of dysphagia compared to LHM. POEM costs are significantly less than LHM but is poorly reimbursed.

Pediatric anesthesia and achalasia: 10 years' experience in peroral endoscopy myotomy management

BACKGROUND

Endoscopic treatment for achalasia (POEM) is a recently introduced technique that incorporates the concepts of natural orifice transluminal surgery. Although pediatric achalasia is rare, POEM has been episodically used in children since 2012. Despite this procedure entails many implications for airway management and mechanical ventilation, evidences about anesthesiologic management are very poor. We conducted this retrospective study to pay attention on the clinical challenge for pediatric anesthesiologists. We put special emphasis on the risk in intubation maneuvers and in ventilation settings.

RESULTS

We retrieved data on children 18 years old and younger who underwent POEM in a single tertiary referral endoscopic center between 2012 and 2021. Demographics, clinical history, fasting status, anesthesia induction, airway management, anesthesia maintenance, timing of anesthesia and procedure, PONV, and pain treatment and adverse events were retrieved from the original database. Thirty-one patients (3-18 years) undergoing POEM for achalasia were analyzed. In 30 of the 31 patients, rapid sequence induction was performed. All patients manifested consequences of endoscopic CO₂ insufflation and most of them required a new ventilator approach. No life-threatening adverse events have been detected.

CONCLUSIONS

POEM procedure seems to be characterized by a low-risk profile, but specials precaution must be taken. The inhalation risk is actually due to the high rate of full esophagus patients, even if the Rapid Sequence Induction was effective in preventing ab ingestis pneumonia. Mechanical ventilation may be difficult during the tunnelization step. Future prospective trials will be necessary to individuate the better choices in such a special setting.

[Endoscopic Management of Dysphagia]

Dysphagia is difficulty in swallowing that can be caused by a number of disorders that involve either the oropharynx or the esophagus. Specific endoscopic treatment for dysphagia depends on its etiology, whether the dysphagia is caused by mechanical narrowing or a motor disorder. Variable endoscopic treatment strategies can be used to manage dysphagia. Patient with dysfunction of the upper esophageal sphincter may benefit from esophageal dilationor injection of botulinum toxin. Pneumatic balloon dilation, injection of botulinum toxin, peroral endoscopic myotomy can be considered as treatment options for esophageal motility disorders. Endoscopic dilation is the treatment choice of esophageal stricture, while intraluminal steroid injection and temporary stent can be considered in refractory benign esophageal stricture. Self-expandable metal stent insertion can be considered for dysphagia with malignant cause.