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Iqbal U, Yodice M, Ahmed Z, Anwar H, Arif SF, Lee-Smith WM, Diehl DL. Safety and efficacy of EsoFLIP dilation in patients with esophageal dysmotility: a systematic review. Dis Esophagus 2024:doae036. [PMID: 38659256 DOI: 10.1093/dote/doae036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 02/24/2024] [Accepted: 04/08/2024] [Indexed: 04/26/2024]
Abstract
Esophageal manometry is utilized for the evaluation and classification of esophageal motility disorders. EndoFlip has been introduced as an adjunctive test to evaluate esophagogastric junction (EGJ) distensibility. Treatment options for achalasia and EGJ outflow obstruction (EGJOO) include pneumatic dilation, myotomy, and botulinum toxin. Recently, a therapeutic 30 mm hydrostatic balloon dilator (EsoFLIP, Medtronic, Minneapolis, MN, USA) has been introduced, which uses impedance planimetry technology like EndoFlip. We performed a systematic review to evaluate the safety and efficacy of EsoFLIP in the management of esophageal motility disorders. A systematic literature search was performed with Medline, Embase, Web of science, and Cochrane library databases from inception to November 2022 to identify studies utilizing EsoFLIP for management of esophageal motility disorders. Our primary outcome was clinical success, and secondary outcomes were adverse events. Eight observational studies including 222 patients met inclusion criteria. Diagnoses included achalasia (158), EGJOO (48), post-reflux surgery dysphagia (8), and achalasia-like disorder (8). All studies used 30 mm maximum balloon dilation except one which used 25 mm. The clinical success rate was 68.7%. Follow-up duration ranged from 1 week to a mean of 5.7 months. Perforation or tear occurred in four patients. EsoFLIP is a new therapeutic option for the management of achalasia and EGJOO and appears to be effective and safe. Future comparative studies with other therapeutic modalities are needed to understand its role in the management of esophageal motility disorders.
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Affiliation(s)
- Umair Iqbal
- Department of Gastroenterology and Hepatology, Wellspan York Hospital, York, PA, USA
| | - Michael Yodice
- Department of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, PA, USA
| | - Zohaib Ahmed
- Department of Gastroenterology, University of Toledo Medical Center, Toledo, OH, USA
| | - Hafsa Anwar
- Department of Medicine, Capital Health Regional Medical Center, Trenton, NJ, USA
| | | | - Wade M Lee-Smith
- Department of University Libraries, University of Toledo Medical Center, Toledo, OH, USA
| | - David L Diehl
- Department of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, PA, USA
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French MP, Busing J, Acra S, Chen H, Stafman L, Zamora I, Holzman M, Lovvorn HN. Effects of Anterior Fundoplication on Postoperative Dysphagia and Reflux After Laparoscopic Esophagocardiomyotomy for Pediatric Achalasia. J Laparoendosc Adv Surg Tech A 2024. [PMID: 38597929 DOI: 10.1089/lap.2023.0415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Abstract
Introduction: Achalasia among children often fails endoscopic management (e.g., dilation, botulinum toxin). Laparoscopic esophagocardiomyotomy (L-ECM) is a standard intervention to relieve obstruction but can induce gastroesophageal reflux (GER). Concurrent anterior fundoplication (A-fundo) has been evaluated in randomized trials among adults, demonstrating mixed results on controlling postoperative GER without exacerbating dysphagia. Furthermore, evidence for the best approach among children remains sparse. We hypothesized that, among children undergoing L-ECM without mucosal violation, routine A-fundo would not improve postoperative GER control while exacerbating dysphagia. Materials and Methods: Observational data of 47 consecutive achalasia patients ≤18 years who received L-ECM (2002-2023) at a single academic institution were collected. Patient records were culled for demographics, achalasia characteristics, and outcomes. Two L-ECM groups were identified: with or without A-fundo. Patients were screened for postoperative dysphagia (additional procedures) and GER (new antireflux medications). Univariate independence testing was conducted to identify statistically significant variables. Results: Among 47 patients undergoing L-ECM, 28 (59.6%) received concurrent A-fundo. Compared with patients undergoing L-ECM alone, patients with L-ECM/A-fundo had significantly longer hospital stays (P < .01) without statistically different rates of postoperative dysphagia (P = .81) or GER (P = .51). Five children (10.6%) experienced mucosal injury with L-ECM: 4 recognized intraoperatively received A-Fundo without subsequent leak; 1 mucosal injury was missed and did not receive A-Fundo, which subsequently leaked. Conclusion: In this largest observation of pediatric achalasia patients, A-fundo appeared clinically insignificant when determining contributors to control GER or exacerbate postoperative dysphagia. A-fundo should not be routinely adopted in children having L-ECM for achalasia without further multicenter analysis but appears beneficial in cases having inadvertent mucosal violation.
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Affiliation(s)
| | - Jordan Busing
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, USA
| | - Sari Acra
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, USA
| | - Heidi Chen
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Laura Stafman
- Department of Pediatric Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Irving Zamora
- Department of Pediatric Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Michael Holzman
- Department of Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Vanderbilt University, Nashville, Tennessee, USA
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3
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Wessels EM, Masclee GMC, Bastiaansen BAJ, Fockens P, Bredenoord AJ. Incidence and risk factors of reflux esophagitis after peroral endoscopic myotomy. Neurogastroenterol Motil 2024:e14794. [PMID: 38587128 DOI: 10.1111/nmo.14794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/21/2024] [Accepted: 04/01/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is an effective and safe treatment for achalasia, but often leads to posttreatment gastroesophageal reflux disease. The aim of this study was to examine the incidence and severity of reflux esophagitis after POEM and to identify associated predictive factors. METHODS Patients who underwent POEM between August 2011 and December 2022 were included. Multivariate logistic regression was used to assess predictive factors for reflux esophagitis after POEM. KEY RESULTS In total, 252 patients were included; of which, 46% were female and age ranged between 18 and 87 years. Reflux esophagitis within 1 year after POEM was observed in 131 patients (52%), which was severe in 29 patients (LA grade C/D, 12%). Length of full-thickness myotomy (cm; OR 1.11, 95% CI 1.02-1.21), Eckardt scores before POEM (OR 0.84, 95% CI 0.74-0.96), previous pneumatic dilation (OR 0.51, 95% CI 0.29-0.91), and previous laparoscopic Heller myotomy (LHM; OR 0.44, 95% CI 0.23-0.86) were associated with reflux esophagitis after POEM. Alcohol use (none vs > 7 units per week; OR 3.51, 95% CI 1.35-9.11) and overweight (BMI ≥25 kg/m2; OR 2.67, 95% CI 1.17-6.09) were positive predictive factors and previous LHM (OR 0.13, 95% CI 0.02-0.95) was a negative predictive factor for severe reflux esophagitis after POEM (LA grade C/D). CONCLUSION About half of the patients develop reflux esophagitis after POEM and 12% is graded as severe. Recognizing predictive factors of reflux esophagitis after POEM treatment leads to better patient selection before POEM and provides an opportunity to take preventive measures or start preemptive treatment.
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Affiliation(s)
- Elise M Wessels
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Gwen M C Masclee
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Barbara A J Bastiaansen
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
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4
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Sudarshan M, Tasnim S, Ramji S, Rappaport J, Barron JO, Bribriesco AC, Schraufnagel DP, Lapin B, Li Y, Raymond DP, Blackstone EH, Murthy SC, Raja S. Development and validation of a universal esophageal patient-reported outcome measure: The Cleveland Clinic Esophageal Questionnaire (CEQ). J Thorac Cardiovasc Surg 2024; 167:1490-1497.e17. [PMID: 37625617 DOI: 10.1016/j.jtcvs.2023.08.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/25/2023] [Accepted: 08/13/2023] [Indexed: 08/27/2023]
Abstract
OBJECTIVE Currently, there is no validated patient-reported outcome measure (PROM) applicable to all esophageal diseases. Our objective was to create a psychometrically robust, validated universal esophageal PROM that can also objectively assess patients' quality of life (QoL). METHODS The pilot PROM constructed based on expert opinions, literature review, and previous unpublished institutional research had 27 items covering 8 domains. It was completed by 30 patients in the outpatient clinic followed by a structured debriefing interview, which allowed for refining the PROM. The final PROM: Cleveland Clinic Esophageal Questionnaire (CEQ) included 34 items across 6 domains (Dysphagia, Eating, Pain, Reflux & Regurgitation, Dyspepsia, Dumping), each accompanied by a corresponding QoL component. Further psychometric assessment of the PROM was conducted by evaluating (1) acceptability, (2) construct validity, (3) reliability, and (4) responsiveness. RESULTS Five hundred forty-six unique patients (median 63.7 years [54.3-71.7], 53% male [287], 86% White) completed CEQ at >90% completion within 5 minutes. Construct validity was demonstrated by differentiating scores across esophageal cancer (n = 146), achalasia (n = 170), hiatal hernia (n = 160), and other diagnoses (n = 70). Internal reliability (Cronbach alpha 0.83-0.89), and test-retest reliability (intraclass correlation coefficients 0.63-0.85) were strong. Responsiveness was demonstrated through CEQ domains improving for 53 patients who underwent surgery for achalasia or hiatal hernia (Cohen d 0.86-2.59). CONCLUSIONS We have constructed a psychometrically robust, universal esophageal PROM that allows concise, consistent, objective quantification of symptoms and their effect on the patient. The CEQ is valuable in prognostication and tracking of longitudinal outcomes in both benign and malignant esophageal diseases.
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Affiliation(s)
- Monisha Sudarshan
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
| | - Sadia Tasnim
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Sadhvika Ramji
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Jesse Rappaport
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - John O Barron
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Dean P Schraufnagel
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Brittany Lapin
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio; Center for Outcomes Research and Evaluation, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Yadi Li
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio; Center for Outcomes Research and Evaluation, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Daniel P Raymond
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Sudish C Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Siva Raja
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
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Boeckxstaens G, Elsen S, Belmans A, Annese V, Bredenoord AJ, Busch OR, Costantini M, Fumagalli U, Smout AJPM, Tack J, Vanuytsel T, Zaninotto G, Salvador R. 10-year follow-up results of the European Achalasia Trial: a multicentre randomised controlled trial comparing pneumatic dilation with laparoscopic Heller myotomy. Gut 2024; 73:582-589. [PMID: 38050085 DOI: 10.1136/gutjnl-2023-331374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 11/19/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVE As achalasia is a chronic disorder, long-term follow-up data comparing different treatments are essential to select optimal clinical management. Here, we report on the 10-year follow-up of the European Achalasia Trial comparing endoscopic pneumodilation (PD) with laparoscopic Heller myotomy (LHM). DESIGN A total of 201 newly diagnosed patients with achalasia were randomised to either a series of PDs (n=96) or LHM (n=105). Patients completed symptom (Eckardt score) and quality-of-life questionnaires, underwent functional tests and upper endoscopy. Primary outcome was therapeutic success defined as Eckardt score <3 at yearly follow-up. Secondary outcomes were the need for retreatment, lower oesophageal sphincter pressure, oesophageal emptying, gastro-oesophageal reflux and the rate of complications. RESULTS After 10 years of follow-up, LHM (n=40) and PD (n=36) were equally effective in both the full analysis set (74% vs 74%, p=0.84) and the per protocol set (74% vs 86%, respectively, p=0.07). Subgroup analysis revealed that PD was superior to LHM for type 2 achalasia (p=0.03) while there was a trend, although not significant (p=0.05), that LHM performed better for type 3 achalasia. Barium column height after 5 min at timed barium oesophagram was significantly higher for patients treated with PD compared with LHM, while other parameters, including gastro-oesophageal reflux, were not different. CONCLUSIONS PD and LHM are equally effective even after 10 years of follow-up with limited risk to develop gastro-oesophageal reflux. Based on these data, we conclude that PD and LHM can both be proposed as initial treatment of achalasia.
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Affiliation(s)
- Guy Boeckxstaens
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - Stefanie Elsen
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - Ann Belmans
- Interuniversity Centre for Biostatistics and Statistical Bioinformatics, KU Leuven, Leuven, Belgium
| | - Vito Annese
- Department of Gastroenterology, IRCCS San Donato Policlinic, San Donato Milanese, Vita-Salute San Raffaele University, Milano, Italy
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam UMC Locatie Meibergdreef, Amsterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC Locatie Meibergdreef, Amsterdam, The Netherlands
| | - Mario Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padova, Italy
| | - Uberto Fumagalli
- Department of Digestive Surgery, European Institute of Oncology - IRCCS, Milano, Italy
| | - André J P M Smout
- Department of Gastroenterology and Hepatology, Amsterdam UMC Locatie Meibergdreef, Amsterdam, The Netherlands
| | - Jan Tack
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - Tim Vanuytsel
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - Giovanni Zaninotto
- Department of Academic Surgery, St Mary's Hospital, Imperial College London, London, UK
| | - Renato Salvador
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padova, Italy
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6
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DeWitt JM, Othman MO, Bapaye A. Do's and Don'ts in Esophageal Peroral Endoscopic Myotomy: Troubleshooting, Managing Adverse Events and Tips for Success. Gastrointest Endosc 2024:S0016-5107(24)00145-7. [PMID: 38447664 DOI: 10.1016/j.gie.2024.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/04/2024] [Accepted: 02/29/2024] [Indexed: 03/08/2024]
Affiliation(s)
- John M DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN
| | - Mohamed O Othman
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX
| | - Amol Bapaye
- Shivan and Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital & Research Center, Pune India
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Lee K, Hong SP, Yoo IK, Yeniova AÖ, Hahn JW, Kim MS, Yoon SY, Rahmati M, Lee JH, Lee M, Cho W, Yon DK. Global trends in incidence and prevalence of achalasia, 1925-2021: A systematic review and meta-analysis. United European Gastroenterol J 2024. [PMID: 38430514 DOI: 10.1002/ueg2.12555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/12/2024] [Indexed: 03/04/2024] Open
Abstract
BACKGROUND Achalasia poses a significant socioeconomic burden, yet global trends remain undocumented. This study aims to describe the worldwide trends in the incidence and prevalence of achalasia from 1925 to 2021 and explore their correlation with various factors through a comprehensive systematic review. METHODS We searched the PubMed/MEDLINE, Embase, and Cochrane databases from inception to 30 June 2023, to identify studies reporting the incidence or prevalence of achalasia in the general population. This study utilized pooled estimates with 95% confidence intervals (CI) to estimate the incidence and prevalence of achalasia, and conducted various subgroup analyses. RESULTS A total of 26 eligible studies covering approximately 269 million participants and 20,873 patients from 14 countries across five continents were included. Global pooled incidence and prevalence of achalasia were estimated to be 0.78 cases per 100,000 person-years (95% CI, 0.64-0.93; number of studies, 26; sample population, 269,315,171) and 10.82 cases per 100,000 person-years (95% CI, 8.15-13.48; number of studies, 14; sample population, 192,176,076), respectively. The incidence of achalasia was higher in Oceania (than Asia and Africa) and in adults (than children) after the introduction of the Chicago classification. Prevalence followed a similar pattern. The pooled incidence of achalasia showed an overall upward trend from 1925 to 2021 (1925-1999; 0.40 [0.32-0.49] vs. 2018-2021; 1.64 [1.33-1.95] cases per 100,000 person-years). CONCLUSIONS The incidence and prevalence of achalasia have notably increased, particularly with advancements in diagnosis, and show significant variation worldwide, despite the large heterogeneity within the sample population. Further studies are necessary to accurately assess the global incidence and prevalence of achalasia.
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Affiliation(s)
- Kwanjoo Lee
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, South Korea
| | - Sung Pyo Hong
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, South Korea
- Department of Gastroenterology and Hepatology, H plus Yangji Hospital, Seoul, South Korea
| | - In Kyung Yoo
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, South Korea
| | - Abdullah Özgür Yeniova
- Division of Gastroenterology, Department of Internal Medicine, Tokat Gaziosmanpaşa University Faculty of Medicine, Tokat, Turkey
| | - Jong Woo Hahn
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Min Seo Kim
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Soo-Young Yoon
- Division of Nephrology, Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, South Korea
| | - Masoud Rahmati
- Department of Physical Education and Sport Sciences, Faculty of Literature and Human Sciences, Lorestan University, Khoramabad, Iran
- Department of Physical Education and Sport Sciences, Faculty of Literature and Humanities, Vali-e-Asr University of Rafsanjan, Rafsanjan, Iran
| | - Jun Hyuk Lee
- Health and Human Science, University of Southern California, Los Angeles, California, USA
| | - Myeongcheol Lee
- Center for Digital Health, Medical Science Research Institute, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, South Korea
| | - Wonyoung Cho
- Center for Digital Health, Medical Science Research Institute, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, South Korea
| | - Dong Keon Yon
- Center for Digital Health, Medical Science Research Institute, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, South Korea
- Department of Pediatrics, Kyung Hee University College of Medicine, Seoul, South Korea
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8
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Reddy CA, Ellison A, Cipher DJ, Mendoza R, Souza RF, Spechler SJ, Konda VJA, Nguyen AD. Frequent discrepancies among diagnostic tests for detecting lower esophageal sphincter-related obstruction. Neurogastroenterol Motil 2024; 36:e14729. [PMID: 38129627 DOI: 10.1111/nmo.14729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/19/2023] [Accepted: 12/02/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND There are frequent discrepancies among high-resolution manometry (HRM), functional lumen imaging probe (FLIP), and esophagram in identifying lower esophageal sphincter (LES)-related obstruction. We aimed to determine the frequency of those discrepancies and how they influenced clinical treatment/outcomes. METHODS We identified patients who had all three tests (HRM, FLIP, and esophagram) and endoscopy performed for evaluation of esophageal symptoms in our Center for Esophageal Diseases. Discrepancies among the tests for the presence of LES obstruction were noted, and the performance of individual tests was compared against a consensus opinion rendered by a panel of esophagologists. Binary logistical regression was performed, and ROC curves were generated for prediction of the consensus clinical diagnosis of LES obstruction. KEY RESULTS A total of 126 patients (mean age 57.9 ± 17.0 years; 67% female) met inclusion criteria. All three tests agreed on the presence or absence of LES obstruction in only 72 (57%) patients [no LES obstruction in 57 (45%), LES obstruction in 15 (12%)]. Thirteen patients (10%) had a change in management based on additional findings on FLIP +/- esophagram not seen on HRM with 69% having symptomatic improvement after LES-directed intervention. FLIP was the strongest predictor of a consensus diagnosis of LES obstruction by logistic regression and ROC (OR 23.36, AUC 0.796), followed by HRM (OR 15.41, AUC 0.764). CONCLUSIONS & INFERENCE High-resolution manometry, functional lumen imaging probe, and esophagram each have considerable limitations for identifying LES obstruction, and discrepancies among these tests occur frequently. Multimodal testing is often required for adequate evaluation of LES-related obstruction.
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Affiliation(s)
- Chanakyaram A Reddy
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Ashton Ellison
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Daisha J Cipher
- College of Nursing and Health Innovation, The University of Texas at Arlington, Arlington, Texas, USA
| | - Roseann Mendoza
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Rhonda F Souza
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Stuart J Spechler
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Vani J A Konda
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Anh D Nguyen
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
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9
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Vespa E, Farina DA, Pandolfino JE, Kahrilas PJ, Koop AH, Carlson DA. Presence of esophageal contractility after achalasia treatment is associated with improved esophageal emptying. Neurogastroenterol Motil 2024; 36:e14732. [PMID: 38155413 PMCID: PMC10922458 DOI: 10.1111/nmo.14732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 10/19/2023] [Accepted: 12/14/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND AND AIMS Some achalasia patients exhibit esophageal contractile activity on follow-up after treatment, yet its importance remains unclear. We aimed to identify factors associated with presence of contractility after treatment and to assess its impact on timed barium esophagram (TBE) and clinical outcomes. METHODS Patients with type I or II achalasia on baseline high-resolution manometry (HRM) who completed HRM, TBE, and functional lumen imaging probe (FLIP) after treatment were retrospectively identified. Contractility was defined on post-treatment HRM as presence of at least 1 supine swallow with DCI ≥100 mmHg s cm. KEY RESULTS One hundred twenty-two patients were included (mean age 48 ± 17 years, 50% female). At follow-up evaluation after treatment (54% peroral endoscopic myotomy, 24% pneumatic dilation, 22% laparoscopic Heller myotomy), 61 (50%) patients had contractility on HRM. Patients with contractility (compared to those without) more frequently had type II achalasia (84% vs 57%, p = 0.001) and a post-treatment normal EGJ opening classification on FLIP (69% vs 49%; p < 0.001). In the subgroup of patients with post-treatment integrated relaxation pressure <15 mmHg and normal EGJ opening on FLIP (n = 53), those with contractility had a lower median column height on TBE at 1 min (4 vs 7 cm, p = 0.002) and 5 min (0 vs 5 cm, p = 0.001). In patients with "abnormal" EGJ metrics, patients with contractility showed lower symptom scores (median Eckardt score 2 vs 3, p = 0.03). CONCLUSIONS & INFERENCES Occurring more frequently in type II achalasia, and if adequate EGJ opening is achieved after treatment, esophageal contractility may contribute to improved esophageal emptying and improved symptoms in non-spastic achalasia. Preservation of esophageal body muscle could improve outcomes in these patients.
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Affiliation(s)
- Edoardo Vespa
- Division of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Domenico A. Farina
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - John E. Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Peter J. Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Andree H. Koop
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Dustin A. Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Levy A, Jimenez J, Shah S, Kayton M. Sudden-Onset Back Pain and Intermittent Dyspnea While Eating: A Case of Pediatric Achalasia. Cureus 2024; 16:e56663. [PMID: 38646200 PMCID: PMC11032682 DOI: 10.7759/cureus.56663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2024] [Indexed: 04/23/2024] Open
Abstract
A 14-year-old girl with a history of asthma was hospitalized because of sudden-onset back pain around her thoracic region that spread to her chest and abdomen. She had been experiencing dysphagia and breathing difficulties for two years, especially after overeating, which often resulted in vomiting undigested food. CT imaging revealed a severely dilated esophagus narrowing at the gastroesophageal junction, suggestive of type 1 achalasia. Further testing confirmed the diagnosis, with an esophageal manometry showing a lack of esophageal contractions and sphincter relaxation. She then underwent a laparoscopic Heller myotomy with relief to her symptoms. This case underscores the rarity of pediatric-onset achalasia with significant esophageal dilation and secondary airway compression, presenting with unusual musculoskeletal and respiratory symptoms. Timely diagnosis and treatment are crucial to prevent worsening and complications.
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Affiliation(s)
- Avrohom Levy
- Pediatrics, Jersey Shore University Medical Center, Neptune, USA
| | - Jennifer Jimenez
- Pediatric Gastroenterology, Jersey Shore University Medical Center, Neptune, USA
| | - Shefali Shah
- Gastroenterology, Jersey Shore University Medical Center, Neptune, USA
| | - Mark Kayton
- Pediatric Surgery, Jersey Shore University Medical Center, Neptune, USA
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11
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Sultan MN, Shakoo N, Razouk A, Alari Y, Aldaher B, Niazi A. A 16-year-old boy presented with triple-A syndrome associated with neuromuscular disorders: a case report. Ann Med Surg (Lond) 2024; 86:1758-1761. [PMID: 38463068 PMCID: PMC10923340 DOI: 10.1097/ms9.0000000000001779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/23/2024] [Indexed: 03/12/2024] Open
Abstract
Introduction and importance Allgrove syndrome (AS) (AAA syndrome) is a rare autosomal recessive disease caused by mutations in the AAAS gene located on chromosome 12q13. The AAAS gene encodes for the ALADIN protein (alacrima, achalasia, adrenal insufficiency, neurologic disorder). AS can manifest with a plethora of symptoms. Early recognition of the syndrome remains challenging due to its rarity and progressive nature. This report presents an unusual case of triple-A syndrome (TAS) with concurrent neuromuscular manifestations. Understanding the atypical presentation of this syndrome is vital for early diagnosis and appropriate management. Case presentation We report a 16-year-old boy with severe malnutrition presented with painful swallowing, fatigue, and bilateral congenital ptosis. Barium swallow, upper gastrointestinal endoscopy, and Shimmer test were performed, which led to the diagnosis of TAS. Treatment included laparoscopic Heller's procedure, artificial tears, hydrocortisone. Clinical discussion TAS, also known as AS, is a rare multisystem disorder characterized by achalasia, Addison's disease, and alacrima. This syndrome is occasionally referred to as 4A syndrome due to the inclusion of autonomic dysfunction. There is no treatment for AS. Management includes artificial tears for alacrima, glucocorticoid replacement therapy to treat adrenal insufficiency, and treatment of achalasia. Conclusion This case emphasizes the importance of considering atypical presentations of TAS. Early diagnosis and treatment are paramount in addressing the varied components of this rare disorder. Understanding the clinical complexities of this syndrome aids in improved patient care and underscores the necessity for comprehensive evaluation and management in similar cases.
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Affiliation(s)
| | | | | | | | | | - Ammar Niazi
- Surgery Department, Aleppo University Hospital, Aleppo, Syria
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12
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Li S, Chen X, Zhang L, Jin H, Wang B, Liu C, Ru S, Liu X, Zhao W. Early-onset esophageal squamous cell carcinoma with achalasia: A case report. Medicine (Baltimore) 2024; 103:e37140. [PMID: 38306510 PMCID: PMC10843513 DOI: 10.1097/md.0000000000037140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/11/2024] [Indexed: 02/04/2024] Open
Abstract
RATIONALE Individuals afflicted with achalasia of the cardia (AC) are more susceptible to the development of esophageal cancer (EC). However, the presence of esophageal retention obscured observation, making it difficult to detect EC early, which leads to misdiagnosis and poor prognosis in AC patients with EC. Besides, the persistence of high-risk factors may have contributed to the rapid progression of EC shortly after per-oral endoscopic myotomy (POEM). Therefore, it is imperative to alert clinicians to this extremely rare and instructive early-onset cancer. PATIENT CONCERNS The patient was a 67-year-old male who developed dysphagia 3 years ago without obvious causes, with intermittent onset and aggravating trend, accompanied by weight loss. He usually eats high-temperature foods and pickled foods, and has a family history of esophageal squamous cell carcinoma. DIAGNOSIS AND INTERVENTIONS The patient was initially diagnosed with AC 2 years ago and subsequently underwent POEM surgery. One year after surgery, he was found to have mid-upper EC during follow-up and underwent partial esophagectomy in time. OUTCOMES The patient's symptoms have significantly improved with weight gain, and he is still adhering to regular follow-up and endoscopic examination. LESSONS In rare cases, EC develops early in patients with achalasia after POEM surgery. To avoid missed diagnosis, a comprehensive examination to improve the accuracy to diagnose achalasia and identify possible early-onset cancer is very important in clinical practice. Especially for patients with AC who have a family history of EC or other high-risk factors may develop EC early after POEM surgery. Therefore, regular endoscopic follow-up after POEM surgery is essential.
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Affiliation(s)
- Shujin Li
- Department of Gastroenterology and Hepatology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Xin Chen
- Department of Gastroenterology and Hepatology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Lili Zhang
- Department of Gastroenterology and Hepatology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Hong Jin
- Department of Gastroenterology and Hepatology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Bin Wang
- Department of Gastroenterology and Hepatology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Cong Liu
- Department of Gastroenterology and Hepatology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Shiwei Ru
- Department of Gastroenterology and Hepatology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Xuechai Liu
- Department of Gastroenterology and Hepatology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Wei Zhao
- Department of Gastroenterology and Hepatology, General Hospital of Tianjin Medical University, Tianjin, China
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13
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Inoue M, Adris N, Cai R, Siah C, Kong J, Ragunath K. Incidence, prevalence and clinical management of achalasia since the introduction of high-resolution manometry in Western Australia. Intern Med J 2024; 54:312-319. [PMID: 37272918 DOI: 10.1111/imj.16150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 05/30/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Epidemiological studies in achalasia and its clinical management in Australia are limited. AIMS To determine the prevalence and trends in incidence rates and describe the types of treatment stratified by subtypes of achalasia. METHODS A retrospective observational study was conducted at a single site that offers a state-wide high-resolution manometry (HRM) service in Western Australia (WA). Patients (aged ≥ 18 years) newly diagnosed with achalasia based on HRM findings between 2012 and 2021 were extracted from the HRM database. The crude incidence rate and age-standardised incidence rate (ASIR) along with the 2021-point prevalence were calculated. Trends were assessed by the Kendall τb test. The patients' initial and subsequent treatment modalities were described. RESULTS A total of 296 new cases were identified, and the median age at diagnosis was 56 years. The patient's median age, sex and year of the first treatment did not vary significantly with the subtypes. The lowest and highest ASIR (cases/100 000 person-years) were 0.8 in 2012 and 2.1 in 2021, respectively. Only type 2 achalasia showed a significant increasing trend (P = 0.009). The 2021-point prevalence was 16.9 cases/100 000 people and increased with age. Pneumatic balloon dilatation (PBD) was the most common treatment for types 1 and 2, while laparoscopic Heller myotomy was most common for type 3. Peroral endoscopic myotomy (POEM) has become common in the past 5 years. CONCLUSION The ASIR of type 2 achalasia significantly increased in WA. PBD was most commonly performed, although peroral endoscopic myotomy has recently increased as a preferred treatment option.
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Affiliation(s)
- Madoka Inoue
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
| | - Niwansa Adris
- Department of Gastroenterology and Hepatology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Richmond Cai
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
| | - Chiang Siah
- Department of Gastroenterology and Hepatology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Jee Kong
- Department of Gastroenterology and Hepatology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Krish Ragunath
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
- Department of Gastroenterology and Hepatology, Royal Perth Hospital, Perth, Western Australia, Australia
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14
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Lee Lynch K, Chen J, Jain A, Yadlapati R. Esophagogastric Junction Outflow Obstruction: A Diagnosis in Evolution. Gastroenterol Hepatol (N Y) 2024; 20:108-114. [PMID: 38414912 PMCID: PMC10895913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
Esophagogastric junction outflow obstruction (EGJOO) is a rapidly evolving diagnosis that can represent early or variant achalasia. Since the publication of the Chicago Classification version 4.0, the criteria for this diagnosis have been more stringent. Currently, the criteria include an elevated median integrated relaxation pressure (IRP) in both the supine and upright positions, elevated intrabolus pressure in at least 20% of supine swallows, dysphagia and/or chest pain, as well as an abnormal timed barium esophagram and/or impedance planimetry testing. Additionally, other secondary causes may result in an elevated IRP and must be excluded. The management of conclusive EGJOO is targeted therapy to the lower esophageal sphincter (LES), although treatment is not straightforward. Overall, adjuvant testing and data should be scrutinized for appropriateness of LES disruption. The spectrum of treatment options includes simple monitoring as well as more invasive therapies such as endoscopic dilation and myotomy. This article explores the newest criteria and management options for clinically relevant EGJOO.
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Affiliation(s)
- Kristle Lee Lynch
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joan Chen
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Anand Jain
- Division of Digestive Diseases, Emory University, Atlanta, Georgia
| | - Rena Yadlapati
- Division of Gastroenterology and Hepatology, University of California San Diego, La Jolla, California
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Zhang H, Pu X, Huang S, Xia H, Zou K, Zeng X, Jiang J, Ren W, Peng Y, Lü M, Tang X. Comparing clinical outcomes of peroral endoscopic myotomy for achalasia between Eastern and Western countries: a systematic review and meta-analysis. Dis Esophagus 2024; 37:doad056. [PMID: 38300629 DOI: 10.1093/dote/doad056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 07/13/2023] [Indexed: 02/02/2024]
Abstract
Peroral endoscopic myotomy (POEM) has revolutionized the therapeutic strategy for achalasia with promising results. We conducted this meta-analysis to compare clinical outcomes between Eastern and Western countries. A comprehensive literature search was conducted in PubMed, EMBASE, Web of Science and Cochrane Library databases to query for studies that assessed the efficacy of POEM for achalasia. All articles published from inception to December 31, 2021 were included. The primary outcome was the pooled clinical success rate. The secondary outcomes included the pooled technical success rate, incidence of adverse events, procedure time and hospital stay. Eighteen Eastern studies involving 5962 patients and 11 Western studies involving 1651 patients were included. The pooled clinical success rate and technical success rate for POEM was equal in the Eastern studies compared to Western studies. The pooled incidence of procedure adverse events for POEM was a little lower in the Eastern studies compared to Western studies (6.6% vs. 8.7%). Similarly, the incidence of reflux-related adverse events was lower in Eastern studies than that in Western studies. The pooled procedure time of POEM was shorter in Eastern studies compared to Western studies (61 minutes vs. 80 minutes), while the length of hospital stay was longer in Eastern studies compared to Western studies (5.8 days vs. 2.4 days). Overall, Eastern countries have the similar POEM outcomes compared to Western countries. However, Eastern countries still need to do more to reduce the length of hospital stay.
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Affiliation(s)
- Han Zhang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Xinxin Pu
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Shu Huang
- Department of Gastroenterology, Lianshui County People' Hospital, Huaian, China
- Department of Gastroenterology, Lianshui People's Hospital of Kangda College Affiliated to Nanjing Medical University, Huaian, China
| | - Huifang Xia
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Kang Zou
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Xinyi Zeng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Jiao Jiang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Wensen Ren
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Yan Peng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Muhan Lü
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Xiaowei Tang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
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Wen LQ, Wei DW. A case report of cardia carcinoma: Underwent Heller myotomy for Achalasia. Medicine (Baltimore) 2024; 103:e36924. [PMID: 38277562 PMCID: PMC10817151 DOI: 10.1097/md.0000000000036924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 12/20/2023] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND One of the risk factors for esophageal adenocarcinoma is achalasia, an esophageal motility disorder that is typically treated surgically through laparotomy or laparoscopic surgery. The risk factors of gastric cardia cancer are also similar to esophageal adenocarcinoma due to the anatomical location of the gastric cardia close to the esophagus. There is currently no clinical evidence that achalching has a correlation with gastric cardia cancer. CASE SUMMARY We report the case of an 85-year-old female patient was admitted to our department with dysphagia for 6 months. She underwent a dissecting Heller myotomy for pancreatic achalasia in 2006, with occasional postoperative symptoms of reflux and heartburn. Outpatient upper gastrointestinal imaging was suggestive of cardia cancer, and gastroscopic pathological findings were suggestive of moderately-lowly-differentiated adenocarcinoma. The patient was admitted to the operating room on August 30, 2022 to undergo radical pancreatic cancer surgery plus abdominal adhesion release, and postoperative review of the upper gastrointestinal imaging showed a patent anastomosis with no spillage, filling of the residual stomach, and duodenal visualization. CONCLUSION Postoperative patients with achalasia often have symptoms of reflux, which may be one of the factors for the development of pancreatic cancer in this patient, thus requiring clinicians to pay more attention to the use of antireflux procedures in the surgical treatment of pancreatic achalasia. And the choice of which modality to perform surgery in patients with previous surgical history is also one of the points to be discussed.
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Affiliation(s)
- Lin-qi Wen
- Thoracic Surgery Department, HePing Hospital Affilated to Changzhi Medical College, Changzhi City, Shanxi Province, China
| | - Da-wei Wei
- Thoracic Surgery Department, HePing Hospital Affilated to Changzhi Medical College, Changzhi City, Shanxi Province, China
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17
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Low EXS, Wang YP, Ye YC, Liu PY, Sung KY, Lin HE, Lu CL. A Comparison between Chicago Classification Versions 3.0 and 4.0 and Their Impact on Manometric Diagnoses in Esophageal High-Resolution Manometry Cases. Diagnostics (Basel) 2024; 14:263. [PMID: 38337780 PMCID: PMC10854946 DOI: 10.3390/diagnostics14030263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/14/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
High-resolution manometry (HRM) facilitates the detailed evaluation of esophageal motility. In December 2020, Chicago classification (CC) version 4.0 introduced modifications to improve consistency and accuracy. We conducted this study to compare the differences in the interpretations of HRM examinations between CC 3.0 and 4.0. Consecutive HRM records at a Taiwan tertiary medical center, including wet swallows and MRS performed in both supine and sitting positions from October 2019 to May 2021, were retrospectively reviewed and analyzed using both CC versions 3.0 and 4.0. A total of 105 patients were enrolled, and 102 patients completed the exam, while three could not tolerate HRM sitting up. Refractory gastroesophageal reflux disease (GERD) symptoms (n = 65, 63.7%) and dysphagia (n = 37, 36.3%) were the main indications. A total of 18 patients (17.6%) were reclassified to new diagnoses using CC 4.0. Of the 11 patients initially diagnosed with absent contractility, 3 (27.3%) were reclassified as having Type 1 achalasia. Of the 18 patients initially diagnosed with IEM, 6 (33.3%) were reclassified as normal. The incidence of diagnosis changes was similar in both the dysphagia and refractory GERD symptoms groups (21.6% versus 15.3%, p = 0.43). The use of CC 4.0 led to changes in the diagnoses of esophageal motility disease, irrespective of examination indications. Early adoption improves the accuracy of diagnoses and affects patient management.
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Affiliation(s)
- En Xian Sarah Low
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (E.X.S.L.); (Y.-C.Y.); (P.-Y.L.); (K.-Y.S.); (H.-E.L.)
- Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- Department of Medicine, Ng Teng Fong General Hospital, National University Health System, Singapore 609606, Singapore
| | - Yen-Po Wang
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (E.X.S.L.); (Y.-C.Y.); (P.-Y.L.); (K.-Y.S.); (H.-E.L.)
- Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- Institute of Brain Science, National Yang-Ming University, Taipei 11221, Taiwan
- Faculty of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei 11221, Taiwan
| | - Yong-Cheng Ye
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (E.X.S.L.); (Y.-C.Y.); (P.-Y.L.); (K.-Y.S.); (H.-E.L.)
- Faculty of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei 11221, Taiwan
| | - Pei-Yi Liu
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (E.X.S.L.); (Y.-C.Y.); (P.-Y.L.); (K.-Y.S.); (H.-E.L.)
| | - Kuan-Yi Sung
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (E.X.S.L.); (Y.-C.Y.); (P.-Y.L.); (K.-Y.S.); (H.-E.L.)
- Division of Gastroenterology, Department of Medicine, Fu Jen Catholic University Hospital, Taipei 24352, Taiwan
| | - Hung-En Lin
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (E.X.S.L.); (Y.-C.Y.); (P.-Y.L.); (K.-Y.S.); (H.-E.L.)
- Division of Gastroenterology, Department of Medicine, Taipei City Hospital Chongxing Branch, Taipei 10321, Taiwan
| | - Ching-Liang Lu
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (E.X.S.L.); (Y.-C.Y.); (P.-Y.L.); (K.-Y.S.); (H.-E.L.)
- Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- Institute of Brain Science, National Yang-Ming University, Taipei 11221, Taiwan
- Faculty of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei 11221, Taiwan
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Jia X, Chen S, Hou X, Zhuang Q, Tan N, Zhang M, Wang J, Xing X, Xiao Y. Development and Validation of Serum Markers as Noninvasive Diagnostic Methods for Achalasia. Clin Transl Gastroenterol 2024; 15:e00651. [PMID: 37787436 PMCID: PMC10810595 DOI: 10.14309/ctg.0000000000000651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/25/2023] [Indexed: 10/04/2023] Open
Abstract
INTRODUCTION Currently, the diagnosis of achalasia mainly relies on invasive or radioactive examinations. This study aimed to develop a noninvasive diagnostic method for achalasia based on specific serum markers. METHODS Serum levels of profilin-1, galectin-10, immunoglobulin heavy variable 3-9, vasodilator-stimulated phosphoprotein, and transgelin-2 were measured in patients with achalasia and controls by enzyme-linked immunosorbent assay. The diagnostic values and thresholds were determined by the receiver operating characteristic curve analysis. Then, patients with dysphagia were prospectively enrolled to validate the ability of these molecules for achalasia diagnosing. RESULTS A total of 142 patients with achalasia and 50 nonachalasia controls (healthy volunteers and patients with reflux esophagitis) were retrospectively included. The serum levels of profilin-1, galectin-10, and transgelin-2 in patients with achalasia were significantly higher than those in healthy volunteers and patients with reflux esophagitis ( P all < 0.001). Profilin-1, galectin-10, and transgelin-2 were of good performance in diagnosing achalasia, with optimal thresholds of 2,171.2, 33.9, and 1,630.6 pg/mL, respectively. Second, 40 patients with dysphagia were prospectively enrolled to the validation of achalasia. For profilin-1, the positive predictive value, negative predictive value, sensitivity, and specificity were 100.0%, 64.5%, 45.0%, and 100.0%, respectively. The figures for transgelin-2 were 65.5%, 90.9%, 95.0%, and 50.0%. When both increased, the positive predictive value reached to 100.0%. When both indexes were normal, the negative predictive value was 100.0%. DISCUSSION Profilin-1 and transgelin-2 were promising biomarkers for achalasia diagnosis and performed better in combination. Further multicenter studies are necessary to verify their application as preliminary screening tools for achalasia.
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Affiliation(s)
- Xingyu Jia
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangdong, China
| | - Songfeng Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangdong, China
| | - Xun Hou
- Gastrointestinal Surgery Center, The First Affiliated Hospital of Sun Yat-sen University, Guangdong, China
| | - Qianjun Zhuang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangdong, China
| | - Niandi Tan
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangdong, China
| | - Mengyu Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangdong, China
| | - Jinhui Wang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangdong, China
| | - Xiangbin Xing
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangdong, China
| | - Yinglian Xiao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangdong, China
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North A, Tewari N. Peroral endoscopic myotomy compared to laparoscopic Heller myotomy and pneumatic dilation in the treatment of achalasia: a systematic review. Dis Esophagus 2024; 37:doad055. [PMID: 37539633 PMCID: PMC10762503 DOI: 10.1093/dote/doad055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/28/2023] [Accepted: 07/20/2023] [Indexed: 08/05/2023]
Abstract
Peroral endoscopic myotomy (POEM) is an intervention for the treatment of achalasia which has gained popularity over the last decade. It's efficacy and invasiveness are comparable to laparoscopic Heller myotomy (LHM). The purpose of this systematic review is to compare POEM to existing therapies. The systematic review was performed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. MEDLINE, EMBASE, Web of Science and Cochrane Libraries were searched using keywords: esophageal achalasia, POEM, LHM, pneumatic dilation (PD), and related terms. The studied outcomes were Eckardt score, clinical success, hospital stay, cost-utility analysis, complications, and post-treatment gastro-esophageal reflux disease. Articles were reviewed by one researcher and uncertainty was resolved by a second researcher. The search strategy retrieved 1948 citations. After removing duplicates and applying the exclusion criteria, 91 studies were selected for full-text review of which a total of 31 studies were considered eligible for further analysis, including two studies which were found through manual searching. POEM has improved efficacy compared to PD with similar cost-effectiveness. POEM results showed comparable patient outcomes when compared with laparoscopic myotomy. Overall, POEM is a feasible first-line treatment for achalasia.
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Affiliation(s)
- Adam North
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Nilanjana Tewari
- General Surgery Department, University Hospitals of Derby and Burton, Derby, UK
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Sawada A, Zhang M, Ustaoglu A, Nikaki K, Lee C, Woodland P, Yazaki E, Takashima S, Ominami M, Tanaka F, Ciafardini C, Nachman F, Ditaranto A, Agotegaray J, Bilder C, Savarino E, Gyawali CP, Penagini R, Fujiwara Y, Sifrim D. Superficial oesophageal mucosal innervation may contribute to severity of symptoms in oesophageal motility disorders. Aliment Pharmacol Ther 2024; 59:100-112. [PMID: 37845817 DOI: 10.1111/apt.17773] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 08/31/2023] [Accepted: 10/07/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Mechanisms underlying perception of dysphagia and chest pain have not been completely elucidated, although oesophageal mucosal afferent nerves might play an important role. AIMS To evaluate the relationship between oesophageal mucosal afferent nerves and the severity of dysphagia and chest pain in oesophageal motility disorders. METHODS We prospectively recruited patients with oesophageal motility disorders having dysphagia and/or chest pain from whom oesophageal biopsies were obtained. High-resolution manometry classified patients into disorders of oesophagogastric junction (OGJ) outflow and disorders of peristalsis. Symptom severity was assessed using validated questionnaires including Brief Oesophageal Dysphagia Questionnaire (BEDQ). Immunohistochemistry was performed on oesophageal biopsies to evaluate the location of calcitonin gene-related peptide (CGRP)-immunoreactive mucosal afferent nerves. Findings were compared to existing data from 10 asymptomatic healthy volunteers. RESULTS Of 79 patients, 61 patients had disorders of OGJ outflow and 18 had disorders of peristalsis. CGRP-immunoreactive mucosal nerves were more superficially located in the mucosa of patients with oesophageal motility disorders compared to healthy volunteers. Within disorders of OGJ outflow, the location of CGRP-immunoreactive nerves negatively correlated with BEDQ score both in the proximal (ρ = -0.567, p < 0.001) and distal oesophagus (ρ = -0.396, p = 0.003). In the proximal oesophagus, strong chest pain was associated with more superficially located mucosal nerves than weak chest pain (p = 0.04). Multivariate analysis showed superficial nerves in the proximal oesophagus was independently associated with severe dysphagia in disorders of OGJ outflow (p = 0.008). CONCLUSIONS Superficial location of mucosal nerves in the proximal oesophagus might contribute to symptoms, especially severe dysphagia, in disorders of OGJ outflow.
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Affiliation(s)
- Akinari Sawada
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Mengyu Zhang
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Ahsen Ustaoglu
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Kornilia Nikaki
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Chung Lee
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Philip Woodland
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Etsuro Yazaki
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Shingo Takashima
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Fumio Tanaka
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Clorinda Ciafardini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Nachman
- Fundacion Favaloro Hospital, Buenos Aires, Argentina
| | | | | | | | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Italy
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
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Srinivasan V, Shah ED. Mini-review: Tailored per-oral endoscopic myotomy for type III achalasia. Neurogastroenterol Motil 2023; 35:e14700. [PMID: 37897117 PMCID: PMC10851349 DOI: 10.1111/nmo.14700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/09/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023]
Abstract
This mini-review summarizes the most recent literature regarding per-oral endoscopic myotomy for type III achalasia, emphasizing the poorly understood science of tailoring myotomy length during this procedure. In addition, special attention will be placed on the current subjective and objective biomarkers, such as the Eckardt score, used to evaluate treatment outcomes in this population to better contextualize the existing data on patient outcomes, as proposed by Low et al in the current issue of the Journal. Understanding the current treatment landscape for type III achalasia and identifying the key areas of research deficiencies will guide future investigation and management of this disease.
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Affiliation(s)
- Vamshek Srinivasan
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Eric D Shah
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
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Wakim El-Khoury J, Pandolfino JE, Kahrilas PJ, Godo B, Farina DA, Kou W, Carlson DA. Relaxation of the lower esophageal sphincter in response to reduced volume distension during FLIP Panometry. Neurogastroenterol Motil 2023; 35:e14663. [PMID: 37691556 DOI: 10.1111/nmo.14663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/29/2023] [Accepted: 07/31/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND The esophageal response to stepwise distension during the functional lumen imaging probe (FLIP) Panometry study often parallels high-resolution manometry (HRM) motility diagnoses. This study aimed to describe the changes in FLIP metrics during FLIP emptying, that is, reduced volume distension. METHODS Adult patients who completed FLIP and HRM for esophageal motility evaluation were included. Esophagogastric junction (EGJ) opening parameters were assessed during stepwise FLIP filling to volumes of 60 mL ("filling 60 mL"), then 70 mL, and then back to 60 mL ("emptying 60 mL"). HRM studies were analyzed per Chicago classification version 4.0 (CCv4.0). KEY RESULTS Among 265 patients included, HRM/CCv4.0 diagnoses included achalasia in 80 patients (30%), normal motility in 70 (26%), and ineffective esophageal motility (IEM) in 43 (16%). EGJ-distensibility index (DI) and EGJ diameter were greater during emptying 60 mL than filling 60 mL in achalasia, normal motility, and IEM (p values <0.002). If applying the emptying 60 mL EGJ-DI (vs. filling 60 mL EGJ-DI), EGJ opening classification changed from reduced EGJ opening to borderline EGJ opening in 31% of achalasia patients and in 2% of patients with normal motility or IEM. EGJ opening classification was unchanged in 69% achalasia and 96% of normal motility/IEM. CONCLUSIONS AND INFERENCES This study suggests that isotonic or auxotonic relaxation of the lower esophageal sphincter occurs with reduced volume distension in patients with achalasia and normal motility. The study also supports the importance of utilizing a standardized FLIP motility study protocol (i.e., controlled, stepwise filling to 50 mL, 60 mL, then 70 mL) to provide reliable and generalizable FLIP metrics to facilitate diagnosis of esophageal motility disorders.
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Affiliation(s)
- Jeanine Wakim El-Khoury
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
- Division of Gastroenterology and Hepatology, Department of Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Bidemi Godo
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Domenico A Farina
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Wenjun Kou
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
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Dervin H, Endersby J, Sanagapalli S, Mills H, Sweis R. Assessing the diagnostic yield of achalasia using provocative testing in high-resolution esophageal manometry: Serial diagnostic study. Neurogastroenterol Motil 2023; 35:e14668. [PMID: 37846024 DOI: 10.1111/nmo.14668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 07/27/2023] [Accepted: 08/19/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Chicago Classification v4.0 recommends that if achalasia is demonstrated with single water swallows (SWS); provocative testing is not required. We determine whether provocative testing in patients with suspected achalasia can change manometric findings and reproduce symptoms. METHODS Between 2016 and 2022, 127 consecutive manometry studies of patients with achalasia were retrospectively analyzed. All patients underwent SWS, a solid meal (SM) and/or a rapid drink challenge (RDC). Demographic data, fluoroscopy, gastroscopy, and pre-and post-treatment Eckardt scores were collated. KEY RESULTS Of 127 achalasia patients (50.6 ± 16.6 years and 54.6% male), all completed a SM and 116 (91.3%) completed RDC; overall 83 were naïve (65.4%) to previous therapy. 15.4% patients with normal integrated relaxation pressure (IRP) on SWS demonstrated obstruction with RDC. SM gave a different achalasia phenotype in 44.9% of patients (p ⟨ 0.001). Twelve patients with normal IRP during SWS had persistent/recurrent obstruction during provocative testing; 83.3% had previous achalasia therapy. None of 13 patients with Type III (TIII) achalasia with SWS exhibited a change in manometric findings with provocative testing. Impedance bolus heights were lower in patients with TIII achalasia and those with normal IRP with SWS. During the SM, symptoms were reproduced in 56.7% of patients. Forty-six of 103 patients (44.7%) underwent therapy based upon the final achalasia subtype which was defined by the provocative test result of the high-resolution manometry (HRM) study. All treatments were effective, regardless of the achalasia subtype. CONCLUSIONS AND INFERENCES Manometric findings remain unchanged when TIII achalasia is diagnosed with SWS. In patients with normal IRP, Type I, or Type II achalasia during SWS, provocative testing can alter achalasia phenotype or uncover achalasia where diagnosis is unclear. Further, it can reproduce symptoms. Such findings can personalize and guide effective therapeutic decisions.
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Affiliation(s)
- Humayra Dervin
- GI Physiology Unit, University College London, London, UK
| | - James Endersby
- GI Physiology Unit, University College London, London, UK
| | - Santosh Sanagapalli
- GI Physiology Unit, University College London, London, UK
- St Vincent's Hospital, Sydney, Victoria, Australia
| | - Holly Mills
- GI Physiology Unit, University College London, London, UK
| | - Rami Sweis
- GI Physiology Unit, University College London, London, UK
- University College London, London, UK
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Nabi Z, Ramchandani M, Basha J, Inavolu P, Kotla R, Goud R, Darisetty S, Reddy DN. Per-oral endoscopic myotomy in cases with prior Heller's myotomy: Outcomes at a median follow-up of 5 years. J Gastroenterol Hepatol 2023; 38:2035-2039. [PMID: 37571986 DOI: 10.1111/jgh.16320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/11/2023] [Accepted: 07/23/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND AND AIM Per-oral endoscopic myotomy (POEM) is an established treatment for achalasia cardia. However, data on the long-term efficacy of POEM in patients with failed Heller's myotomy (HM) are limited. The purpose of this study was to evaluate the long-term outcomes of POEM in patients with persistent or recurrent symptoms following HM. METHODS Data of patients with recurrence of symptoms after HM who underwent POEM (September 2013 to December 2022) were analyzed, retrospectively. Primary outcome was clinical success [Eckardt score (ES) ≤ 3]. Secondary outcomes included improvement of manometry parameters, barium emptying at 5 min and gastroesophageal reflux (esophagitis and increased esophageal acid exposure) after POEM. RESULTS Seventy-two cases (45.9 ± 13.4 years, 43 men) with history of HM were included in the study. The subtypes of achalasia were type 1 (40.3%), type 2 (37.5%), and unknown (19.4%). Prior treatment included HM in 48 (66.7%), HM plus pneumatic dilatation in 20 (27.8%), and HM plus pneumatic dilatation and Botox in 4 (5.5%). Technical success was achieved in all cases. Mean length of myotomy was 10.7 ± 3.3 cm, and mean procedure duration was 59.2 ± 25.9 min. There was significant improvement in ES (pre-POEM 6.5 ± 1.8 vs post-POEM 0.7 ± 0.7), lower esophageal sphincter pressure pressures (31.7 ± 12.5 vs 13.3 ± 5.7 mmHg) and barium emptying (14.2 ± 4.2 vs 2.4 ± 3.1 cm) after POEM. At a median follow-up of 63 months (IQR 40-95), clinical success (ES ≤ 3) was documented in 58 (80.6%) patients. Reflux esophagitis and increased esophageal acid exposure were recorded in 28 of 49 (57.1%) and 11 of 20 (55%) patients, respectively. CONCLUSION POEM is a durable treatment modality in cases with relapse of symptoms after HM.
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Affiliation(s)
- Zaheer Nabi
- Interventional Endoscopy Asian Institute of Gastroenterology, Hyderabad, India
| | | | | | | | - Rama Kotla
- Asian Institute of Gastroenterology, Hyderabad, India
| | - Rajesh Goud
- Asian Institute of Gastroenterology, Hyderabad, India
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Mandarino FV, Vespa E, Barchi A, Fasulo E, Sinagra E, Azzolini F, Danese S. Precision Endoscopy in Peroral Myotomies for Motility Disorders of the Upper Gastrointestinal Tract: Current Insights and Prospective Avenues-A Comprehensive Review. Life (Basel) 2023; 13:2143. [PMID: 38004283 PMCID: PMC10672509 DOI: 10.3390/life13112143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/28/2023] [Accepted: 10/29/2023] [Indexed: 11/26/2023] Open
Abstract
Our review delves into the realm of peroral endoscopic myotomies (POEMs) in the upper gastrointestinal tract (UGT). In recent years, POEMs have brought about a revolution in the treatment of UGT motility disorders. Esophageal POEM, the first to be introduced, has now been validated as the primary treatment for achalasia. Subsequently developed, G-POEM displays promising results in addressing refractory gastroparesis. Over time, multiple endoscopic myotomy techniques have emerged for the treatment of Zenker's diverticulum, including Z-POEM, POES, and hybrid approaches. Despite the well-established efficacy outcomes, new challenges arise in the realm of POEMs in the UGT. For esophageal POEM, the future scenario lies in customizing the myotomy extent to the minimum necessary, while for G-POEM, it involves identifying patients who can optimally benefit from the treatment. For ZD, it is crucial to validate an algorithm that considers various myotomy options according to the diverticulum's size and in relation to individual patients. These challenges align with the concept of precision endoscopy, personalizing the technique for each subject. Within our text, we comprehensively examine each myotomy technique, analyzing indications, outcomes, and adverse events. Additionally, we explore the emerging challenges posed by myotomies within the context of the evolving field of precision endoscopy.
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Affiliation(s)
- Francesco Vito Mandarino
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Edoardo Vespa
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Alberto Barchi
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Ernesto Fasulo
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto San Raffaele Giglio, 90015 Cefalù, Italy
| | - Francesco Azzolini
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Silvio Danese
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
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Takahashi K, Sato H, Shimamura Y, Abe H, Shiwaku H, Shiota J, Sato C, Hamada K, Ominami M, Hata Y, Fukuda H, Ogawa R, Nakamura J, Tatsuta T, Ikebuchi Y, Yokomichi H, Terai S, Inoue H. Achalasia phenotypes and prediction of peroral endoscopic myotomy outcomes using machine learning. Dig Endosc 2023. [PMID: 37886891 DOI: 10.1111/den.14714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 10/26/2023] [Indexed: 10/28/2023]
Abstract
OBJECTIVES High-resolution manometry (HRM) and esophagography are used for achalasia diagnosis; however, achalasia phenotypes combining esophageal motility and morphology are unknown. Moreover, predicting treatment outcomes of peroral endoscopic myotomy (POEM) in treatment-naïve patients remains an unmet need. METHODS In this multicenter cohort study, we included 1824 treatment-naïve patients diagnosed with achalasia. In total, 1778 patients underwent POEM. Clustering by machine learning was conducted to identify achalasia phenotypes using patients' demographic data, including age, sex, disease duration, body mass index, and HRM/esophagography findings. Machine learning models were developed to predict persistent symptoms (Eckardt score ≥3) and reflux esophagitis (RE) (Los Angeles grades A-D) after POEM. RESULTS Machine learning identified three achalasia phenotypes: phenotype 1, type I achalasia with a dilated esophagus (n = 676; 37.0%); phenotype 2, type II achalasia with a dilated esophagus (n = 203; 11.1%); and phenotype 3, late-onset type I-III achalasia with a nondilated esophagus (n = 619, 33.9%). Types I and II achalasia in phenotypes 1 and 2 exhibited different clinical characteristics from those in phenotype 3, implying different pathophysiologies within the same HRM diagnosis. A predictive model for persistent symptoms exhibited an area under the curve of 0.70. Pre-POEM Eckardt score ≥6 was the greatest contributing factor for persistent symptoms. The area under the curve for post-POEM RE was 0.61. CONCLUSION Achalasia phenotypes combining esophageal motility and morphology indicated multiple disease pathophysiologies. Machine learning helped develop an optimal risk stratification model for persistent symptoms with novel insights into treatment resistance factors.
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Affiliation(s)
- Kazuya Takahashi
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Hiroki Sato
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hirofumi Abe
- Department of Gastroenterology, Kobe University Hospital, Kobe, Japan
| | - Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Junya Shiota
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Chiaki Sato
- Division of Advanced Surgical Science and Technology, Tohoku University School of Medicine, Miyagi, Japan
| | - Kenta Hamada
- Department of Practical Gastrointestinal Endoscopy, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yoshitaka Hata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hisashi Fukuda
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Ryo Ogawa
- Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Tetsuya Tatsuta
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Yuichiro Ikebuchi
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Tottori University Faculty of Medicine, Tottori, Japan
| | - Hiroshi Yokomichi
- Department of Health Sciences, University of Yamanashi, Yamanashi, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
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Maselli R, Fiacca M, Pellegatta G, de Sire R, De Blasio F, Capogreco A, Galtieri PA, Massimi D, Trotta M, Hassan C, Repici A. Peroral Endoscopic Myotomy for Achalasia after Bariatric Surgery: A Case Report and Review of the Literature. Diagnostics (Basel) 2023; 13:3311. [PMID: 37958207 PMCID: PMC10647658 DOI: 10.3390/diagnostics13213311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/07/2023] [Accepted: 10/18/2023] [Indexed: 11/15/2023] Open
Abstract
INTRODUCTION Achalasia following bariatric surgery is a rare phenomenon with diverse potential physiopathological origins. AIMS This article aims to explore the hypothetical physiopathological connection between bariatric surgery and the subsequent onset of achalasia. MATERIAL AND METHODS A review was conducted to identify studies reporting cases of peroral endoscopic myotomy (POEM) after bariatric procedures and detailing the outcomes in terms of the technical and clinical success. Additionally, a case of a successful POEM performed on a patient two years after undergoing laparoscopic sleeve gastrectomy (LSG) is presented. RESULTS The selection criteria yielded eight studies encompassing 40 patients treated with POEM for achalasia after bariatric surgery: 34 after Roux-en-Y gastric bypass (RYGB) and 6 after LSG. The studies reported an overall technical success rate of 97.5%, with clinical success achieved in 85% of cases. Adverse events were minimal, with only one case of esophageal leak treated endoscopically. However, a postprocedural symptomatic evaluation was notably lacking in most of the included studies. CONCLUSIONS Achalasia poses a considerable challenge within the bariatric surgery population. POEM has emerged as a technically viable and safe intervention for this patient demographic, providing an effective treatment option where surgical alternatives for achalasia are limited. Our findings highlight the promising outcomes of POEM in these patients, but the existing data remain limited. Hence, prospective studies are needed to elucidate the optimal pre-surgical assessment and timing of endoscopic procedures for optimizing outcomes.
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Affiliation(s)
- Roberta Maselli
- Humanitas Clinical and Research Center—IRCCS, 20089 Milan, Italy (C.H.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
| | - Matteo Fiacca
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
- Department of Surgery, Oncology and Gastroenterology, University of Padua, 35128 Padua, Italy
| | - Gaia Pellegatta
- Humanitas Clinical and Research Center—IRCCS, 20089 Milan, Italy (C.H.); (A.R.)
| | - Roberto de Sire
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
- Gastroenterology, Department of Clinical Medicine and Surgery, University Federico II, 80138 Naples, Italy
| | - Federico De Blasio
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
- Clinic of Gastroenterology, Hepatology and Emergency Digestive Endoscopy, University Politecnica delle Marche, 60126 Ancona, Italy
| | - Antonio Capogreco
- Humanitas Clinical and Research Center—IRCCS, 20089 Milan, Italy (C.H.); (A.R.)
| | | | - Davide Massimi
- Humanitas Clinical and Research Center—IRCCS, 20089 Milan, Italy (C.H.); (A.R.)
| | - Manuela Trotta
- Humanitas Clinical and Research Center—IRCCS, 20089 Milan, Italy (C.H.); (A.R.)
| | - Cesare Hassan
- Humanitas Clinical and Research Center—IRCCS, 20089 Milan, Italy (C.H.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
| | - Alessandro Repici
- Humanitas Clinical and Research Center—IRCCS, 20089 Milan, Italy (C.H.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
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28
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Bar N, Vélez C, Pasricha TS, Thurm T, Ben-Ami Shor D, Dekel R, Ron Y, Staller K, Kuo B. Safety of Pneumatic Dilation in Older Adults with Achalasia: An International Multicenter Cross-Sectional Study. J Clin Med 2023; 12:6682. [PMID: 37892819 PMCID: PMC10607090 DOI: 10.3390/jcm12206682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 10/03/2023] [Accepted: 10/20/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Pneumatic dilation (PD) is an effective first line treatment option for many patients with achalasia. PD use may be limited in adults with achalasia who are older than 65 because of concern for adverse events (AE), and less efficacious therapies are often utilized. We explored the periprocedural safety profile of PD in older adults. METHODS An international real world cross-sectional study of patients undergoing PD between 2006-2020 in two tertiary centers. Thirty-day AEs were compared between older adults (65 and older) with achalasia and younger patients. RESULTS A total of 252 patients underwent 319 PDs. In 319 PDs, 18 (5.7%) complications occurred: 6 (1.9%) perforations and 12 (3.8%) emergency department referrals with benign (non-perforation) chest pain, of which 9 (2.8%) were hospitalized. No bleeding or death occurred within 30 days. Perforation rates were similar in both age groups and across achalasia subtypes. Advanced age was protective of benign chest pain complications in univariate analysis, and the limited number of AEs precluded multivariable analysis. CONCLUSIONS The safety of PD in older adults is at least comparable to that of younger patients and should be offered as an option for definitive therapy for older patients with achalasia. Our results may affect informed consent discussions.
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Affiliation(s)
- Nir Bar
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (T.T.); (D.B.-A.S.); (R.D.); (Y.R.)
- Center for Neurointestinal Health, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (C.V.); (T.S.P.); (K.S.); (B.K.)
| | - Christopher Vélez
- Center for Neurointestinal Health, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (C.V.); (T.S.P.); (K.S.); (B.K.)
| | - Trisha S. Pasricha
- Center for Neurointestinal Health, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (C.V.); (T.S.P.); (K.S.); (B.K.)
| | - Tamar Thurm
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (T.T.); (D.B.-A.S.); (R.D.); (Y.R.)
| | - Dana Ben-Ami Shor
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (T.T.); (D.B.-A.S.); (R.D.); (Y.R.)
| | - Roy Dekel
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (T.T.); (D.B.-A.S.); (R.D.); (Y.R.)
| | - Yishai Ron
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (T.T.); (D.B.-A.S.); (R.D.); (Y.R.)
| | - Kyle Staller
- Center for Neurointestinal Health, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (C.V.); (T.S.P.); (K.S.); (B.K.)
| | - Braden Kuo
- Center for Neurointestinal Health, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (C.V.); (T.S.P.); (K.S.); (B.K.)
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Sanagapalli S, Plumb A, Lord RV, Sweis R. How to effectively use and interpret the barium swallow: Current role in esophageal dysphagia. Neurogastroenterol Motil 2023; 35:e14605. [PMID: 37103465 DOI: 10.1111/nmo.14605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/27/2023] [Accepted: 04/11/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND The barium swallow is a commonly performed investigation, though recent decades have seen major advances in other esophageal diagnostic modalities. PURPOSE The purpose of this review is to clarify the rationale for components of the barium swallow protocol, provide guidance on interpretation of findings, and describe the current role of the barium swallow in the diagnostic paradigm for esophageal dysphagia in relation to other esophageal investigations. The barium swallow protocol, interpretation, and reporting terminology are subjective and non-standardized. Common reporting terminology and an approach to their interpretation are provided. A timed barium swallow (TBS) protocol provides more standardized assessment of esophageal emptying but does not evaluate peristalsis. Barium swallow may have higher sensitivity than endoscopy for detecting subtle strictures. Barium swallow has lower overall accuracy than high-resolution manometry for diagnosing achalasia but can help secure the diagnosis in cases of equivocal manometry. TBS has an established role in objective assessment of therapeutic response in achalasia and helps identify the cause of symptom relapse. Barium swallow has a role in the evaluating manometric esophagogastric junction outflow obstruction, in some cases helping to identify where it represents an achalasia-like syndrome. Barium swallow should be performed in dysphagia following bariatric or anti-reflux surgery, to assess for both structural and functional postsurgical abnormality. Barium swallow remains a useful investigation in esophageal dysphagia, though its role has evolved due to advancements in other diagnostics. Current evidence-based guidance regarding its strengths, weaknesses, and current role are described in this review.
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Affiliation(s)
- Santosh Sanagapalli
- Department of Gastroenterology and Hepatology, St. Vincent's Hospital Sydney, Darlinghurst, Australia
- School of Clinical Medicine, St. Vincent's Healthcare Campus, University of New South Wales, Sydney, Australia
| | - Andrew Plumb
- Centre for Medical Imaging, University College London Hospital, London, UK
| | - Reginald V Lord
- Department of Surgery, University of Notre Dame School of Medicine, Sydney, Australia
| | - Rami Sweis
- GI Physiology Unit, University College London Hospital, London, UK
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Koop AH, Kahrilas PJ, Schauer J, Pandolfino JE, Carlson DA. The impact of primary peristalsis, contractile reserve, and secondary peristalsis on esophageal clearance measured by timed barium esophagogram. Neurogastroenterol Motil 2023; 35:e14638. [PMID: 37417394 DOI: 10.1111/nmo.14638] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/12/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Primary and secondary peristalsis facilitate esophageal bolus transport; however, their relative impact for bolus clearance remains unclear. We aimed to compare primary peristalsis and contractile reserve on high-resolution manometry (HRM) and secondary peristalsis on functional lumen imaging probe (FLIP) Panometry with emptying on timed barium esophagogram (TBE) and incorporate findings into a comprehensive model of esophageal function. METHODS Adult patients who completed HRM with multiple rapid swallows (MRS), FLIP, and TBE for esophageal motility evaluation and without abnormal esophagogastric junction outflow/opening or spasm were included. An abnormal TBE was defined as a 1-min column height >5 cm. Primary peristalsis and contractile reserve after MRS were combined into an HRM-MRS model. Secondary peristalsis was combined with primary peristalsis assessment to describe a complementary neuromyogenic model. KEY RESULTS Of 89 included patients, differences in rates of abnormal TBEs were observed with primary peristalsis classification (normal: 14.3%; ineffective esophageal motility: 20.0%; absent peristalsis: 54.5%; p = 0.009), contractile reserve (present: 12.5%; absent: 29.3%; p = 0.05), and secondary peristalsis (normal: 9.7%; borderline: 17.6%; impaired/disordered: 28.6%; absent contractile response: 50%; p = 0.039). Logistic regression analysis (akaike information criteria, area under the receiver operating curve) demonstrated that the neuromyogenic model (80.8, 0.83) had a stronger relationship predicting abnormal TBE compared to primary peristalsis (81.5, 0.82), contractile reserve (86.8, 0.75), or secondary peristalsis (89.0, 0.78). CONCLUSIONS AND INFERENCES Primary peristalsis, contractile reserve, and secondary peristalsis were associated with abnormal esophageal retention as measured by TBE. Added benefit was observed when applying comprehensive models to incorporate primary and secondary peristalsis supporting their complementary application.
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Affiliation(s)
- Andree H Koop
- Division of Gastroenterology, Department of Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jacob Schauer
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
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31
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Müller M, Förschler S, Wehrmann T, Marini F, Gockel I, Eckardt AJ. Atypical presentations and pitfalls of achalasia. Dis Esophagus 2023; 36:doad029. [PMID: 37158189 DOI: 10.1093/dote/doad029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 04/04/2023] [Indexed: 05/10/2023]
Abstract
Achalasia is a rare disease with significant diagnostic delay and association with false diagnoses and unnecessary interventions. It remains unclear, whether atypical presentations, misinterpreted symptoms or inconclusive diagnostics are the cause. The aim of this study was the characterization of typical and atypical features of achalasia and their impact on delays, misinterpretations or false diagnoses. A retrospective analysis of prospective database over a period of 30 years was performed. Data about symptoms, delays and false diagnoses were obtained and correlated with manometric, endoscopic and radiologic findings. Totally, 300 patients with achalasia were included. Typical symptoms (dysphagia, regurgitation, weight loss and retrosternal pain) were present in 98.7%, 88%, 58.4% and 52.4%. The mean diagnostic delay was 4.7 years. Atypical symptoms were found in 61.7% and led to a delay of 6 months. Atypical gastrointestinal symptoms were common (43%), mostly 'heartburn' (16.3%), 'vomiting' (15.3%) or belching (7.7%). A single false diagnosis occurred in 26%, multiple in 16%. Major gastrointestinal misdiagnoses were GERD in 16.7% and eosinophilic esophagitis in 4%. Other false diagnosis affected ENT-, psychiatric, neurologic, cardiologic or thyroid diseases. Pitfalls were the description of 'heartburn' or 'nausea'. Tertiary contractions at barium swallows, hiatal hernias and 'reflux-like' changes at endoscopy or eosinophils in the biopsies were misleading. Atypical symptoms are common in achalasia, but they are not the sole source for diagnostic delays. Misleading descriptions of typical symptoms or misinterpretation of diagnostic studies contribute to false diagnoses and delays.
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Affiliation(s)
- M Müller
- Department of Gastroenterology, University Hospital Giessen and Marburg, Marburg, Germany
| | - S Förschler
- Department of General and Visceral Surgery, St. Josefs-Hospital, Wiesbaden, Germany
| | - T Wehrmann
- Department of Gastroenterology, DKD Helios Klinik Wiesbaden, Wiesbaden, Germany
| | - F Marini
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), Division Biostatistics and Bioinformatics, University Medical Center Johannes Gutenberg University, Mainz, Germany
| | - I Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Medical Center of Leipzig, Leipzig, Germany
| | - A J Eckardt
- Department of Gastroenterology, DKD Helios Klinik Wiesbaden, Wiesbaden, Germany
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Nishikawa Y, Inoue H, Shimamura Y, Navarro MJ, Kawamata N, Azuma D, Ushikubo K, Kimoto Y, Yamamoto K, Fujiyoshi Y, Okada H, Tanaka I, Toshimori A, Tanabe M, Onimaru M. Endoscopic pressure study integrated system for the diagnosis of achalasia. Dig Endosc 2023. [PMID: 37770104 DOI: 10.1111/den.14695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/27/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVES The endoscopic pressure study integrated system (EPSIS) is a novel diagnostic tool used to evaluate lower esophageal sphincter (LES) function. EPSIS allows the measurement of intragastric pressure (IGP) during gastric insufflation through esophagogastroduodenoscopy (EGD) and records its pressure waveform. This study aimed to assess the usefulness and applicability of EPSIS as an adjunct diagnostic modality for achalasia. METHODS This case-control study was conducted using a database of patients who underwent EGD, barium swallow (BS), high-resolution manometry (HRM), and EPSIS between January 2022 and December 2022. The achalasia (experimental) group (n = 35) consisted of patients with a definitive diagnosis of achalasia. The control group (n = 34) consisted of patients with no abnormalities in EGD, BS, or HRM and no abnormal acid reflux confirmed with 24-h pH-impedance monitoring. EPSIS findings were compared between the two groups and characterized by the waveform pattern (uphill or flat), maximum IGP (IGP-Max), pressure difference, and the gradient of the waveform. RESULTS All patients in the achalasia group showed an uphill pattern, in contrast to 21 patients (61.8%) in the control group. IGP-Max demonstrated the best diagnostic accuracy for achalasia, with a cut-off value of 15.8 mmHg (100% sensitivity, 58.8% specificity, and area under the curve [AUC] 0.78). The pressure gradient also demonstrated good diagnostic accuracy, with a cut-off value of 0.40 mmHg/s (80% sensitivity, 61.8% specificity, and AUC 0.76). CONCLUSION This study demonstrated that EPSIS can be applied as a diagnostic modality in patients with achalasia.
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Affiliation(s)
- Yohei Nishikawa
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Marc Julius Navarro
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
- Institute of Digestive and Liver Diseases, St. Luke's Medical Center, Quezon City, Philippines
| | - Natsuki Kawamata
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Daisuke Azuma
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Kei Ushikubo
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yoshiaki Kimoto
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Kazuki Yamamoto
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yusuke Fujiyoshi
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Hiroki Okada
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Ippei Tanaka
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Akiko Toshimori
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Mayo Tanabe
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Hansen S, Hamo F, Samo S. Peroral Endoscopic Myotomy May Be Safe in Solid-Organ Transplant Patients With Achalasia. ACG Case Rep J 2023; 10:e01135. [PMID: 37654620 PMCID: PMC10468111 DOI: 10.14309/crj.0000000000001135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/23/2023] [Accepted: 07/27/2023] [Indexed: 09/02/2023] Open
Abstract
Peroral endoscopy myotomy (POEM) is a safe and effective therapy for achalasia among the general population. However, data regarding its safety and efficacy in organ transplant recipients are lacking. These patients present unique risks and challenges because of chronic immunosuppression. We present 3 cases of successful POEM performed safely for achalasia in patients with previous solid-organ transplantation without interruption of their immunosuppression medications. This case series suggests that POEM may be safe in solid-organ transplant recipients.
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Affiliation(s)
- Spencer Hansen
- University of Kansas School of Medicine, Kansas City, KS
| | - Falak Hamo
- University of Kansas School of Medicine, Kansas City, KS
| | - Salih Samo
- University of Kansas School of Medicine, Kansas City, KS
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Fass OZ, Regalia KA, Sweatt AJ, Nandwani MC, Zikos TA, Fernandez-Becker NQ, Nguyen LA, Sonu IS, Triadafilopoulos G, Clarke JO. The integrated relaxation pressure may not be an appropriate gold standard for deglutitive relaxation due to reliance on a single intragastric reference sensor. Neurogastroenterol Motil 2023; 35:e14635. [PMID: 37357376 PMCID: PMC10906680 DOI: 10.1111/nmo.14635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 06/09/2023] [Accepted: 06/16/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Integrated relaxation pressure (IRP) calculation depends on the selection of a single gastric reference sensor. Variable gastric pressure readings due to sensor selection can lead to diagnostic uncertainty. This study aimed to examine the effect of gastric reference sensor selection on IRP measurement and diagnosis. METHODS We identified high-resolution manometry (HRM) conducted between January and November 2017 with at least six intragastric reference sensors. IRP measurements and Chicago Classification 3.0 (CCv3) diagnoses were obtained for each of six gastric reference sensors. Studies were categorized as "stable" (no change in diagnosis) or "variable" (change in diagnosis with gastric reference selection). Variable diagnoses were further divided into "variable normal/dysmotility" (≥1 normal IRP measurement and ≥1 CCv3 diagnosis), or "variable dysmotility" (≥1 CCv3 diagnosis, only elevated IRP measurements). Bland-Altman plots were used to compare IRP measurements within HRM studies. KEY RESULTS The analysis included 100 HRM studies, among which 18% had variable normal/dysmotility, and 10% had variable dysmotility. The average IRP difference between reference sensors was 6.7 mmHg for variable normal/dysmotility and 5.9 mmHg for variable dysmotility. The average difference between the proximal-most and distal-most sensors was -1.52 mmHg (lower limit of agreement -10.03 mmHg, upper limit of agreement 7.00 mmHg). CONCLUSIONS & INFERENCES IRP values can vary greatly depending on the reference sensor used, leading to inconsistent diagnoses in 28% of HRM studies. Choosing the correct gastric reference sensor is crucial for accurate test results and avoiding misdiagnosis. Standardization of reference sensor selection or supportive testing for uncertain results should be considered.
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Affiliation(s)
- Ofer Z. Fass
- Division of Gastroenterology, Stanford University School of Medicine, Redwood City, California, USA
| | | | - Andrew J. Sweatt
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Monica C. Nandwani
- Division of Gastroenterology, Stanford University School of Medicine, Redwood City, California, USA
| | - Thomas A. Zikos
- West Los Angeles Medical Center, Kaiser Permanente, Los Angeles, California, USA
| | | | - Linda A. Nguyen
- Division of Gastroenterology, Stanford University School of Medicine, Redwood City, California, USA
| | - Irene S. Sonu
- Division of Gastroenterology, Stanford University School of Medicine, Redwood City, California, USA
| | - George Triadafilopoulos
- Division of Gastroenterology, Stanford University School of Medicine, Redwood City, California, USA
| | - John O. Clarke
- Division of Gastroenterology, Stanford University School of Medicine, Redwood City, California, USA
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Loh R, Noverati N, Goldberg I, Josloff K, Schiavone G, Halegoua-DeMarzio D, Schlachterman A. Safe Use of POEM in a Patient With Decompensated Cirrhosis and Severe Achalasia. ACG Case Rep J 2023; 10:e01144. [PMID: 37753108 PMCID: PMC10519461 DOI: 10.14309/crj.0000000000001144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 09/28/2023] Open
Abstract
Patients with both achalasia and decompensated cirrhosis can often present a therapeutic challenge because portal hypertension has generally been considered a contraindication to definitive therapies for achalasia. This case report depicts a patient who presented with progressive dysphagia, weight loss, and large-volume ascites; was diagnosed with type II achalasia and decompensated cirrhosis without esophageal varices; and underwent peroral endoscopic myotomy after preprocedural transjugular intrahepatic portosystemic shunt placement. Our case highlights the importance of multidisciplinary care and need for definitive therapies for these complex patients at high risk of malnutrition and sarcopenia.
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Affiliation(s)
- Rebecca Loh
- Thomas Jefferson University Hospital, Philadelphia, PA
| | | | | | - Kevan Josloff
- Thomas Jefferson University Hospital, Philadelphia, PA
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Nakai T, Abe H, Tanaka S, Kawara F, Toyonaga T, Sakaguchi H, Ueda C, Ikezawa N, Tsuda K, Urakami S, Kodama Y. Risk-scoring system for predicting challenging cases of peroral endoscopic myotomy. Dig Endosc 2023; 35:729-735. [PMID: 36571213 DOI: 10.1111/den.14508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 12/22/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Peroral endoscopic myotomy (POEM) is an effective treatment for esophageal motility disorders including achalasia and its variants. However, some surgeons have encountered challenging cases. This study aimed to develop a risk-scoring system to predict challenging cases of POEM. METHODS Consecutive patients who underwent POEM between April 2015 and March 2020 at our hospital were included in this single-center retrospective study. Challenging cases of POEM were defined as patients with any of the following: (i) procedure time ≥90 min; (ii) mucosal perforation; (iii) pneumothorax; and (iv) major bleeding. A risk-scoring system for predicting challenging cases was developed based on multivariate logistic regression and internal validation was performed using the bootstrap method. Clinical usefulness was evaluated using a decision curve analysis. RESULTS Of the 467 patients, 59 (12.6%) had challenging POEM. A risk-scoring system consisted of four variables: duration of symptoms ≥5 years (assigned score, 1 point), antithrombotics use (1 point), manometric diagnosis of achalasia variants (2 points), and dilation grade 3 (2 points). Our scoring system showed satisfactory discrimination (area under the receiver operating characteristic curve, 0.69; 95% confidence interval [CI] 0.61-0.77) and calibration (slope, 0.99; 95% CI 0.65-1.35). The decision curve analysis demonstrated its clinical usefulness. CONCLUSIONS We established a risk-scoring system to predict challenging cases of POEM. This scoring system may aid the selection of patients who require treatment from experienced surgeons.
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Affiliation(s)
- Tatsuya Nakai
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Hirofumi Abe
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Shinwa Tanaka
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Fumiaki Kawara
- Division of Gastroenterology, Konan Medical Center, Hyogo, Japan
| | | | - Hiroya Sakaguchi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Chise Ueda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Nobuaki Ikezawa
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Kazunori Tsuda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Satoshi Urakami
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
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Güler S, Aksoy B, Onur Öztan M, Ç. Appak Y, Çelik SK, Karabağ ŞO, Köylüoğlu G, Baran M. The Results of Pneumatic Balloon Dilatation Treatment in Children with Achalasia: A Single-Center Experience. Turk J Gastroenterol 2023; 34:968-974. [PMID: 37485561 PMCID: PMC10543740 DOI: 10.5152/tjg.2023.22328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 12/06/2022] [Indexed: 07/25/2023]
Abstract
BACKGROUND/AIMS Achalasia is a primary motility disorder characterized by a relaxation disorder of the lower esophageal sphincter. In pneumatic balloon dilatation, which is one of the treatment methods, the muscle fibers are torn with an endoscopically inflated balloon in the lower esophageal sphincter. This study aimed to evaluate the results of long-term pneumatic balloon dilatation treatment in our clinic for children diagnosed with achalasia. MATERIALS AND METHODS Pediatric patients who underwent pneumatic balloon dilatation with a diagnosis of achalasia in our pediatric gastroenterology clinic between 2016 and 2021 were included in the study. Demographic data of the patients, clinical findings at diagnosis, and follow-up results were evaluated retrospectively. RESULTS Ten patients who underwent 18 pneumatic balloon dilatation operations were included in the study. The mean follow-up period of the patients was 23.7 ± 14.1 months. It was observed that the procedure was performed once in 3 (30%) patients, twice in 2 (20%) patients, and 3 times in 3 (30%) patients. It is noteworthy that the diameter of the balloon used in the first procedure in patients who needed repeated operations was less than 30 mm. No complications were observed except for chest pain, which was detected in 1 patient. CONCLUSION When the patients who needed recurrent dilatation were evaluated, it was noted that the diameter of the balloon in which the first procedure was performed in these patients was smaller. This study is an important contribution to the literature due to the scarcity of the pediatric achalasia data, in which long-term results related to pneumatic balloon dilatation are reported in Turkey.
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Affiliation(s)
- Selen Güler
- Department of Pediatric Gastroenterology, Hepatology and Nutrition Clinic, Health Sciences University, Tepecik Training and Research Hospital, İzmir, Turkey
| | - Betül Aksoy
- Department of Pediatric Gastroenterology, Hepatology and Nutrition Clinic, Health Sciences University, Tepecik Training and Research Hospital, İzmir, Turkey
| | - M. Onur Öztan
- Pediatric Surgery Clinic, Katip Celebi University & Health Sciences University Tepecik Training and Research Hospital, İzmir, Turkey
| | - Yeliz Ç. Appak
- Department of Pediatric Gastroenterology, Hepatology and Nutrition Clinic, Katip Celebi University & Health Sciences University, Tepecik Training and Research Hospital, İzmir, Turkey
| | - Sinem Kahveci Çelik
- Department of Pediatric Gastroenterology, Hepatology and Nutrition Clinic, Health Sciences University, Tepecik Training and Research Hospital, İzmir, Turkey
| | - Şenay Onbaşı Karabağ
- Department of Pediatric Gastroenterology, Hepatology and Nutrition Clinic, Health Sciences University, Tepecik Training and Research Hospital, İzmir, Turkey
| | - Gökhan Köylüoğlu
- Pediatric Surgery Clinic, Katip Celebi University & Health Sciences University Tepecik Training and Research Hospital, İzmir, Turkey
| | - Maşallah Baran
- Department of Pediatric Gastroenterology, Hepatology and Nutrition Clinic, Katip Celebi University & Health Sciences University, Tepecik Training and Research Hospital, İzmir, Turkey
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Liu ZQ, Dai H, Yao L, Chen WF, Wang Y, Ma LY, Li XQ, Lin SL, He MJ, Gao PT, Liu XY, Xu JX, Xu XY, Wang KH, Wang L, Chen L, Zhou PH, Li QL. A single-cell transcriptional landscape of immune cells shows disease-specific changes of T cell and macrophage populations in human achalasia. Nat Commun 2023; 14:4685. [PMID: 37542039 PMCID: PMC10403544 DOI: 10.1038/s41467-023-39750-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/28/2023] [Indexed: 08/06/2023] Open
Abstract
Achalasia is a rare motility disorder of the esophagus caused by the gradual degeneration of myenteric neurons. Immune-mediated ganglionitis has been proposed to underlie the loss of myenteric neurons. Here, we measure the immune cell transcriptional profile of paired lower esophageal sphincter (LES) tissue and blood samples in achalasia and controls using single-cell RNA sequencing (scRNA-seq). In achalasia, we identify a pattern of expanded immune cells and a specific transcriptional phenotype, especially in LES tissue. We show C1QC+ macrophages and tissue-resident memory T cells (TRM), especially ZNF683+ CD8+ TRM and XCL1+ CD4+ TRM, are significantly expanded and localized surrounding the myenteric plexus in the LES tissue of achalasia. C1QC+ macrophages are transcriptionally similar to microglia of the central nervous system and have a neurodegenerative dysfunctional phenotype in achalasia. TRM also expresses transcripts of dysregulated immune responses in achalasia. Moreover, inflammation increases with disease progression since immune cells are more activated in type I compared with type II achalasia. Thus, we profile the immune cell transcriptional landscape and identify C1QC+ macrophages and TRM as disease-associated immune cell subsets in achalasia.
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Affiliation(s)
- Zu-Qiang Liu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Hao Dai
- Key Laboratory of Systems Biology, Shanghai Institute of Biochemistry and Cell Biology, Center for Excellence in Molecular Cell Science, Chinese Academy of Sciences, Shanghai, China
| | - Lu Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Wei-Feng Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Yun Wang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Li-Yun Ma
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Xiao-Qing Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Sheng-Li Lin
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Meng-Jiang He
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Ping-Ting Gao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Xin-Yang Liu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Jia-Xin Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Xiao-Yue Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Ke-Hao Wang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Li Wang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Luonan Chen
- Key Laboratory of Systems Biology, Shanghai Institute of Biochemistry and Cell Biology, Center for Excellence in Molecular Cell Science, Chinese Academy of Sciences, Shanghai, China.
- Key Laboratory of Systems Health Science of Zhejiang Province, Hangzhou Institute for Advanced Study, University of Chinese Academy of Sciences, Chinese Academy of Sciences, Hangzhou, China.
- School of Life Science and Technology, ShanghaiTech University, Shanghai, China.
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China.
| | - Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
- Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China.
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Chen JW, Khan A, Chokshi RV, Clarke JO, Fass R, Garza JM, Gupta M, Gyawali CP, Jain AS, Katz P, Konda V, Lazarescu A, Lynch KL, Schnoll-Sussman F, Spechler SJ, Vela MF, Yadlapati R, Schauer JM, Kahrilas PJ, Pandolfino JE, Carlson DA. Interrater Reliability of Functional Lumen Imaging Probe Panometry and High-Resolution Manometry for the Assessment of Esophageal Motility Disorders. Am J Gastroenterol 2023; 118:1334-1343. [PMID: 37042784 PMCID: PMC10523887 DOI: 10.14309/ajg.0000000000002285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/23/2023] [Indexed: 04/13/2023]
Abstract
INTRODUCTION High-resolution manometry (HRM) and functional lumen imaging probe (FLIP) are primary and/or complementary diagnostic tools for the evaluation of esophageal motility. We aimed to assess the interrater agreement and accuracy of HRM and FLIP interpretations. METHODS Esophageal motility specialists from multiple institutions completed the interpretation of 40 consecutive HRM and 40 FLIP studies. Interrater agreement was assessed using intraclass correlation coefficient (ICC) for continuous variables and Fleiss' κ statistics for nominal variables. Accuracies of rater interpretation were assessed using the consensus of 3 experienced raters as the reference standard. RESULTS Fifteen raters completed the HRM and FLIP studies. An excellent interrater agreement was seen in supine median integral relaxation pressure (ICC 0.96, 95% confidence interval 0.95-0.98), and a good agreement was seen with the assessment of esophagogastric junction (EGJ) outflow, peristalsis, and assignment of a Chicago Classification version 4.0 diagnosis using HRM (κ = 0.71, 0.75, and 0.70, respectively). An excellent interrater agreement for EGJ distensibility index and maximum diameter (0.91 [0.90-0.94], 0.92 [0.89-0.95]) was seen, and a moderate-to-good agreement was seen in the assignment of EGJ opening classification, contractile response pattern, and motility classification (κ = 0.68, 0.56, and 0.59, respectively) on FLIP. Rater accuracy for Chicago Classification version 4.0 diagnosis on HRM was 82% (95% confidence interval 78%-84%) and for motility diagnosis on FLIP Panometry was 78% (95% confidence interval 72%-81%). DISCUSSION Our study demonstrates high levels of interrater agreement and accuracy in the interpretation of HRM and FLIP metrics and moderate-to-high levels for motility classification in FLIP, supporting the use of these approaches for primary or complementary evaluation of esophageal motility disorders.
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Affiliation(s)
- Joan W Chen
- Division of Gastroenterology & Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Abraham Khan
- Center for Esophageal Health, Division of Gastroenterology & Hepatology, NYU Grossman School of Medicine, NYU Langone Health, New York, New York, USA
| | - Reena V Chokshi
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - John O Clarke
- Division of Gastroenterology & Hepatology, Stanford University School of Medicine, Redwood City, California, USA
| | - Ronnie Fass
- Division of Gastroenterology & Hepatology, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Jose M Garza
- GI Care for Kids, Neurogastroenterology and Motility Program Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Milli Gupta
- Division of Gastroenterology & Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Anand S Jain
- Division of Digestive Diseases, Emory University Department of Medicine, Atlanta, Georgia, USA
| | - Philip Katz
- Department of Gastroenterology Weill Cornell Medical Center, New York, New York, USA
| | - Vani Konda
- Division of Gastroenterology, Baylor University Medical Center, Dallas, Texas, USA
| | - Adriana Lazarescu
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Kristle L Lynch
- Division of Gastroenterology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Stuart J Spechler
- Division of Gastroenterology, Baylor University Medical Center, Dallas, Texas, USA
| | - Marcelo F Vela
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Jacob M Schauer
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Tustumi F, Arienzo VP, Sunye IR, Lucas PFS, Colonno BB, Quintas JG, Lisboa EN, Szor DJ. Esophageal Dysbiosis in Achalasia and Cancer Development: A Critical Review. Genes (Basel) 2023; 14:1521. [PMID: 37628573 PMCID: PMC10454429 DOI: 10.3390/genes14081521] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/18/2023] [Accepted: 07/21/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Microorganisms provide various benefits to their human hosts, including assisting with digestion, synthesizing certain vitamins, developing the gastrointestinal and immune systems, regulating metabolism, and protecting against some pathogens. However, microbial imbalances can cause tissue damage and contribute to inflammatory disorders and cancers. Microbial dysbiosis refers to an imbalance or disruption in the normal composition and function of the microbial communities that inhabit various body parts, including the gut, oral cavity, skin, and reproductive tract. Emerging research suggests that microbial dysbiosis plays a significant role in cancer development and progression. This issue is particularly relevant in achalasia, in which food stasis, changes in endoluminal pH, and poor esophageal clearance might contribute to esophageal microbial dysbiosis. This study aimed to evaluate the association between dysbiosis and esophageal cancer development, focused on esophageal dysmotility disorders. METHODS This study is a critical review, gathering the current evidence for the association between dysbiosis and the development of esophageal cancer. RESULTS Studies have shown that microbiota play a role in cancer development, although the mechanisms for how they do so are not yet fully understood. One possible explanation is that microbiota alterations can lead to chronic inflammation, promoting cancer cell growth. Additionally, some bacteria produce toxins that can damage DNA and cause genomic instability, and certain bacterial products can promote tumor growth. CONCLUSION Despite the close relationship between dysbiosis and cancer development in esophageal dysmotility disorders, further investigations are still needed to elucidate the precise mechanisms by which dysbiosis contributes to cancer development and to identify potential therapeutic interventions targeting the microbiota to prevent or treat cancer.
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Affiliation(s)
- Francisco Tustumi
- Department of Health Sciences, Hospital Israelita Albert Einstein, Sao Paulo 05652-900, Brazil (J.G.Q.)
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Jankovic J, Milenkovic B, Skrobic O, Ivanovic N, Djurdjevic N, Buha I, Jandric A, Colic N, Milin-Lazovic J. Achalasia Subtype Differences Based on Respiratory Symptoms and Radiographic Findings. Diagnostics (Basel) 2023; 13:2198. [PMID: 37443591 DOI: 10.3390/diagnostics13132198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/07/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
Three subtypes of achalasia have been defined using esophageal manometry. Several studies have reported that symptoms are experienced differently among men and women, regardless of subtype. All subtypes could have some impact on the appearance of respiratory symptoms and lung complications due to compression of the trachea or aspiration of undigested food. The aim of this research was to analyze the differences in respiratory symptoms and radiographic presentation of lung pathology depending on the diameter and achalasia types. One or more respiratory symptoms were reported in 48% of 114 patients, and all of them had two or more gastrointestinal symptoms. The symptom score (SS) is statistically significant for the prediction of subtype 1 (area under the curve = 0.318; p < 0.001, cut-off score of 6.5 had 95.2% sensitivity) and subtype 2 (area under the curve = 0.626; p = 0.020, cut-off score of 7.5 had 93.1% sensitivity). The most common type was subtype 2 (50.8%), and although only 14 patients had subtype 3, they had the largest esophageal diameter (mean 5.8 cm). The difference in esophageal diameter was significant between subtype 1 and 3 (p = 0.011), subtype 2 and subtype 3 (p = 0.011). Nine patients (6%) had mega-esophagus (four patients in type 1, three in type 2 and two in type 3). More than half of all patients (51.7%) had at least one parenchymal lung change on CT scan. Recurrent micro-aspirations led to changes in the structure of the airways and lung parenchyma such as ground glass (GGO) and nodular changes (12%) and fibrosis (14.5%), and they had higher esophageal diameters (p < 0.001). Patients with chronic lung CT changes had significantly higher esophageal diameter than with acute changes (p < 0.001). Awareness of the association of achalasia and lung disorders is important in early diagnosis and treatment. More than half (57.5%) of patients with achalasia had some clinical and/or structural pulmonary abnormalities. All three subtypes had similar respiratory symptoms, meaning they cannot be used to predict the subtype of achalasia; on the contrary, SS can predict the first two subtypes. A higher diameter of the esophagus is associated with chronic structural lung changes. Although unexpected, the pathological radiological findings and diameter were significantly different in subtype 3 patients, but those parameters cannot lead us to a specified subtype.
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Affiliation(s)
- Jelena Jankovic
- Clinic for Pulmonology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
| | - Branislava Milenkovic
- Clinic for Pulmonology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
| | - Ognjan Skrobic
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
- Clinic for Digestive Surgery, First Surgical University Hospital, Clinical Centre of Serbia, 11000 Belgrade, Serbia
| | - Nenad Ivanovic
- Clinic for Digestive Surgery, First Surgical University Hospital, Clinical Centre of Serbia, 11000 Belgrade, Serbia
| | - Natasa Djurdjevic
- Clinic for Pulmonology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Ivana Buha
- Clinic for Pulmonology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
| | - Aleksandar Jandric
- Clinic for Pulmonology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Nikola Colic
- Center for Radiology and MR, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Jelena Milin-Lazovic
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
- Institute for Medical Statistics and Informatics, University of Belgrade, 11000 Belgrade, Serbia
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Nakajima M, Masuda N, Shoda T, Wakayama S, Kono T, Ogawa A, Takita J, Haga N, Suzuki K, Yamaguchi S, Nakamura T, Kojima K. Laparoscopic Heller myotomy with Dor fundoplication for esophageal achalasia treatment after distal gastrectomy and Billroth-II reconstruction. Asian J Endosc Surg 2023. [PMID: 37308447 DOI: 10.1111/ases.13215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/25/2023] [Indexed: 06/14/2023]
Abstract
Laparoscopic Heller myotomy with Dor fundoplication is the standard surgical treatment for esophageal achalasia. However, there are few reports on the use of this method after gastric surgery. We report a case of a 78-year-old man who underwent laparoscopic Heller myotomy with Dor fundoplication for achalasia after distal gastrectomy and Billroth-II reconstruction. After the intraabdominal adhesion was sharply dissected using an ultrasonic coagulation incision device (UCID), Heller myotomy was performed 5 cm above and 2 cm below the esophagogastric junction using the UCID. To prevent postoperative gastroesophageal reflux (GER), Dor fundoplication was performed without cutting the short gastric artery and vein. The postoperative course was uneventful, and the patient is in good health without symptoms of dysphagia or GER. Although per-oral endoscopic myotomy is becoming the mainstay of treatment for achalasia after gastric surgery, laparoscopic Heller myotomy with Dor fundoplication is also an effective strategy.
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Affiliation(s)
- Masanobu Nakajima
- Department of Upper Gastrointestinal Surgery, Dokkyo Medical University, Tochigi, Japan
- Department of Surgical Oncology, Dokkyo Medical University Graduate School of Medicine, Tochigi, Japan
- Department of Surgery, National Hospital Organization Utsunomiya Hospital, Tochigi, Japan
| | - Norihiro Masuda
- Department of Surgery, National Hospital Organization Utsunomiya Hospital, Tochigi, Japan
| | - Takahiro Shoda
- Department of Surgery, National Hospital Organization Utsunomiya Hospital, Tochigi, Japan
| | - Shigeyoshi Wakayama
- Department of Upper Gastrointestinal Surgery, Dokkyo Medical University, Tochigi, Japan
- Department of Surgical Oncology, Dokkyo Medical University Graduate School of Medicine, Tochigi, Japan
- Department of Surgery, National Hospital Organization Utsunomiya Hospital, Tochigi, Japan
| | - Takahiro Kono
- Department of Upper Gastrointestinal Surgery, Dokkyo Medical University, Tochigi, Japan
- Department of Surgical Oncology, Dokkyo Medical University Graduate School of Medicine, Tochigi, Japan
- Department of Surgery, National Hospital Organization Utsunomiya Hospital, Tochigi, Japan
| | - Atsushi Ogawa
- Department of Surgery, National Hospital Organization Utsunomiya Hospital, Tochigi, Japan
| | - Junko Takita
- Department of Surgery, National Hospital Organization Utsunomiya Hospital, Tochigi, Japan
| | | | - Kan Suzuki
- Department of Surgical Oncology, Dokkyo Medical University Graduate School of Medicine, Tochigi, Japan
| | - Satoru Yamaguchi
- Department of Surgery, Dokkyo Medical University Nikko Medical Center, Tochigi, Japan
| | - Takatoshi Nakamura
- Department of Surgical Oncology, Dokkyo Medical University Graduate School of Medicine, Tochigi, Japan
| | - Kazuyuki Kojima
- Department of Upper Gastrointestinal Surgery, Dokkyo Medical University, Tochigi, Japan
- Department of Surgical Oncology, Dokkyo Medical University Graduate School of Medicine, Tochigi, Japan
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Chen S, Xing X, Hou X, Zhuang Q, Tan N, Cui Y, Wang J, Zhang M, Hu S, Xiao Y. The molecular pathogenesis of achalasia: a paired lower esophageal sphincter muscle and serum 4D label-free proteomic study. Gastroenterol Rep (Oxf) 2023; 11:goad031. [PMID: 37324545 PMCID: PMC10260389 DOI: 10.1093/gastro/goad031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/11/2023] [Accepted: 05/03/2023] [Indexed: 06/17/2023] Open
Abstract
Background Achalasia is a primary esophageal motility disorder with potential molecular pathogenesis remaining uncertain. This study aimed to identify the differentially expressed proteins and potential pathways among achalasia subtypes and controls to further reveal the molecular pathogenesis of achalasia. Methods Paired lower esophageal sphincter (LES) muscle and serum samples from 24 achalasia patients were collected. We also collected 10 normal serum samples from healthy controls and 10 normal LES muscle samples from esophageal cancer patients. The 4D label-free proteomic analysis was performed to identify the potential proteins and pathways involved in achalasia. Results Analysis of Similarities showed distinct proteomic patterns of serum and muscle samples between achalasia patients and controls (both P < 0.05). Functional enrichment analysis suggested that these differentially expressed proteins were immunity-, infection-, inflammation-, and neurodegeneration-associated. The mfuzz analysis in LES specimens showed that proteins involved in the extracellular matrix-receptor interaction increased sequentially between the control group, type III, type II, and type I achalasia. Only 26 proteins altered in the same directions in serum and muscle samples. Conclusions This first 4D label-free proteomic study of achalasia indicated that there were specific protein alterations in both the serum and muscle of achalasia, involving immunity, inflammation, infection, and neurodegeneration pathways. Distinct protein clusters between types I, II, and III revealed the potential molecular pathways associated with different disease stages. Analysis of proteins changed in both muscle and serum samples highlighted the importance of further studies on LES muscle and revealed potential autoantibodies.
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Affiliation(s)
| | | | - Xun Hou
- Gastrointestinal Surgery Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Qianjun Zhuang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Niandi Tan
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Yi Cui
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Jinhui Wang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Mengyu Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Shixian Hu
- Institute of Precision Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Yinglian Xiao
- Corresponding author. Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, No. 58 Zhongshan Road 2, Guangzhou, Guangdong 510080, P. R. China. Tel: +86-13560172116;
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Ilie VC, Manciu S, Lacatus M, Stanciulea O, Bitere O, Bancila I, Dimitriu AM, Badea L, Manuc M, Vasilescu C. Achalasia Treatment. Robotic Approach or Laparoscopy? Chirurgia (Bucur) 2023; 118:272-280. [PMID: 37480353 DOI: 10.21614/chirurgia.2023.v.118.i.3.p.272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2023] [Indexed: 07/24/2023]
Abstract
Background: Nowadays the question persists whether to choose the endoscopic or surgical method as the first treatment of choice for achalasia. Another debate topic is about the differences between the outcomes of the two approaches of minimally invasive surgical treatment and their feasibility. Material and Methods: This retrospective observational study included 193 patients with achalasia treated between 2008 and 2021. The patients were divided into 2 groups (A and B): 152 with minimally invasive heller myotomy (HM), and 41 with pneumatic dilation (PD). Patients surgically treated were then subdivided into robotic group (RG) and laparoscopic group (LG). Results: The recurrence rate was significantly higher in PD group (Ã?2 = 16.81, DF = 1, p 0.0001), with a success rate of 63,4%, comparing with 92,7% in HM group. No significant difference was obtained between the 2 groups concerning symptom relief on patients successfully treated. The success rate was comparable between the robotic and laparoscopic groups (p = 1). Significant difference was obtained in length of hospital stay between the 2 groups, with a mean of 4.78 +-1.59 days in the RG and, respectively, 5.52 +-2.1 days in the LG (t = 2.40, DF = 124.34, p = 0.0177). Postprocedural esophagitis rates were higher in patients with no fundoplication (6 out of 37 - 16.2%) and in patients treated with pneumatic dilation (4 out of 26 - 15.4%) than in patients with fundoplication (4 out of 46 - 8.5%). Conclusion: The present study indicates that surgery may be a better choice in fit patients for the treatment of achalasia. The procedure has a better success rate, even if the long-term outcomes are comparable in patients successfully treated. The success rate and long-term results were comparable between laparoscopy and robotic surgery.
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Uchima H, Muñoz-González R, Marín Í, Caballero N, Cepero C, Iborra I, Colán-Hernández J, Castillo E, Moreno V. Endocitoscopia de la muscular propia en acalasia de rápida evolución y recidiva de acalasia post-Heller. Gastroenterol Hepatol 2023:S0210-5705(23)00343-6. [PMID: 37236306 DOI: 10.1016/j.gastrohep.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/16/2023] [Accepted: 05/18/2023] [Indexed: 05/28/2023]
Affiliation(s)
- Hugo Uchima
- Unidad de Endoscopias, Servicio de Gastroenterología, Hospital Universitari Germans Trias I Pujol, Badalona, España; Unidad de Endoscopias, Centro Médico Teknon, Barcelona, España.
| | - Raquel Muñoz-González
- Unidad de Endoscopias, Servicio de Gastroenterología, Hospital Universitari Germans Trias I Pujol, Badalona, España; Unidad de Endoscopias, Centro Médico Teknon, Barcelona, España
| | - Íngrid Marín
- Unidad de Endoscopias, Servicio de Gastroenterología, Hospital Universitari Germans Trias I Pujol, Badalona, España
| | - Noemí Caballero
- Unidad de Endoscopias, Servicio de Gastroenterología, Hospital Universitari Germans Trias I Pujol, Badalona, España
| | - Claudia Cepero
- Unidad de Endoscopias, Servicio de Gastroenterología, Hospital Universitari Joan XXIII, Tarragona, España
| | - Ignacio Iborra
- Unidad de Endoscopias, Servicio de Gastroenterología, Hospital Universitari Germans Trias I Pujol, Badalona, España
| | - Juan Colán-Hernández
- Unidad de Endoscopias, Servicio de Gastroenterología, Hospital Universitari Germans Trias I Pujol, Badalona, España
| | - Edgar Castillo
- Unidad de Endoscopias, Servicio de Gastroenterología, Hospital Universitari Germans Trias I Pujol, Badalona, España
| | - Vicente Moreno
- Unidad de Endoscopias, Servicio de Gastroenterología, Hospital Universitari Germans Trias I Pujol, Badalona, España
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Shi LL, Yang T, Jiang N, Lyu Y, Guo HM, Zou XP, Yang H, Yin Q, Zhang NN. A comprehensive analysis of partial peristalsis recovery after peroral endoscopic myotomy in patients with achalasia. J Dig Dis 2023. [PMID: 37210606 DOI: 10.1111/1751-2980.13192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 05/22/2023]
Abstract
OBJECTIVE To determine whether per-oral endoscopic myotomy (POEM) improves esophageal peristalsis and investigate the association between the presence of peristalsis after POEM and clinico-physiological features. METHODS In a single center retrospective study, data were gathered from patients with achalasia who underwent POEM between January 2014 and May 2016. Parameters of high-resolution esophageal manometry, demographics data, Eckardt score and post-procedural gastroesophageal reflux disease questionnaire (GERD-Q) score were collected. Presence of weak and fragmented contraction was defined as partial recovery of esophageal peristalsis based on Chicago classification v3.0. Logistic regression analysis was used to study variables associated with partial recovery of peristalsis after POEM. RESULTS A total of 103 patients were enrolled. Esophageal contractile activity was observed in the distal two-thirds of the esophagus in 24 patients. The Eckardt score, integrated relaxation pressure (IRP) and lower esophageal sphincter (LES) resting pressure were significantly decreased after POEM. Univariate analyses revealed the correlation between preprocedural LES resting pressure as well as weight loss score, reflux score, Eckardt score and peristaltic recovery (all P < 0.05). Via multivariate analysis, preprocedural LES resting pressure (P = 0.013) and preprocedural Eckardt score (P = 0.002) were correlated with peristalsis recovery. Symptoms of gastroesophageal reflux and reflux esophagitis after POEM were less frequent in those with partial recovery of peristalsis (all P < 0.05). CONCLUSIONS Normalization of esophagogastric junction relaxation pressure achieved by POEM is associated with partial recovery of esophageal peristalsis in some patients. Preprocedural LES resting pressure and symptom score are predictive of the peristalsis recovery which prevents GERD symptoms and reflux esophagitis.
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Affiliation(s)
- Liang Liang Shi
- Department of Gastroenterology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Tian Yang
- Department of Gastroenterology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Ni Jiang
- Department of Gastroenterology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Ying Lyu
- Department of Gastroenterology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Hui Min Guo
- Department of Gastroenterology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Xiao Ping Zou
- Department of Gastroenterology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Hua Yang
- Department of Gastroenterology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Qin Yin
- Department of Gastroenterology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Ni Na Zhang
- Department of Gastroenterology, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu Province, China
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Wasim AU, Khan MW, Khan OA, Almatraf KS. Acute-Onset Achalasia Following a Recent COVID-19 Infection: A Case Report. Cureus 2023; 15:e38803. [PMID: 37303428 PMCID: PMC10250781 DOI: 10.7759/cureus.38803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Achalasia is a rare esophageal motility disorder that leads to dysphagia, regurgitation, and several other symptoms. While the etiology of achalasia is not completely understood, studies have suggested an immune reaction to viral infections, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), as a potential cause. Here, we present a case report of a previously healthy 38-year-old male who presented to the emergency room with severe shortness of breath, recurrent vomiting, and dry cough, that had progressively worsened over five days. The patient was diagnosed with coronavirus disease 2019 (COVID-19), and a chest CT also revealed prominent features of achalasia with a markedly dilated esophagus and areas of narrowing at the distal esophagus. The initial management of the patient included IV fluids, antibiotics, anticholinergics, and corticosteroid inhalers which improved his symptoms. This case report highlights the importance of considering the acute-onset of achalasia in COVID-19 patients and the need for further research on the potential association between SARS-CoV-2 and achalasia.
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Affiliation(s)
- Asad Ullah Wasim
- Internal Medicine, Air University - Fazaia Medical College, Islamabad, PAK
- Division of Clinical and Translational Research, Larkin Community Hospital, Miami, USA
| | | | - Osama A Khan
- Internal Medicine, Al Iman General Hospital, Riyadh, SAU
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Familiari P, Borrelli de Andreis F, Landi R, Mangiola F, Boskoski I, Tringali A, Perri V, Costamagna G. Long versus short peroral endoscopic myotomy for the treatment of achalasia: results of a non-inferiority randomised controlled trial. Gut 2023:gutjnl-2021-325579. [PMID: 37072180 DOI: 10.1136/gutjnl-2021-325579] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 04/05/2023] [Indexed: 04/20/2023]
Abstract
OBJECTIVE Peroral endoscopic myotomy (POEM) has become standard treatment for achalasia with comparable efficacy to surgery. In most of published series, the length of myotomy is 12-13 cm. Shorter cuts could have the advantage of shorter procedure time and possibly reduced gastro-oesophageal reflux disease (GORD) rate. DESIGN This single-centre, patient-blinded, randomised, non-inferiority clinical trial included 200 patients, who were randomly allocated, to receive either a long-POEM (13 cm; 101 patients) or a short-POEM (8 cm; 99 patients). Primary outcome was defined as an Eckardt symptom score of ≤3 at 24 months after the procedure; a non-inferiority design was chosen with an accepted success range of 6% between the two treatments. Secondary outcomes included operating time, complication rate, postoperative manometry, GORD rate and quality of life. RESULTS In the intention-to-treat analysis, clinical success rates were 89.1% in the long-POEM and 98.0% in the short-POEM group, resulting in an absolute between-group difference of -8.9% (90% CI -14.5 to -3.3).Procedure time was significantly reduced in the short-POEM as compared with the long-POEM group (40 vs 50 min, p<0.0001). Severe adverse events occurred in one patient in both groups.No differences were observed in postoperative GORD: acid exposure >6% on pH monitoring study at 6 months was seen in 34.3% (long-POEM) vs 31.1% (short-POEM), while endoscopic oesophagitis was diagnosed in 37.6% vs 51.5% at 6 months and in 21% vs 24.5% at 24 months. Regular proton pump inhibitor use was not different either (36.8% vs 37.5%). CONCLUSIONS Our study demonstrates non-inferiority of a shorter cut length of POEM as compared with the standard treatment, which saved some procedural time. GORD rate was not reduced by reducing cutting length. TRIAL REGISTRATION NUMBER NCT03450928.
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Affiliation(s)
- Pietro Familiari
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Federica Borrelli de Andreis
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Rosario Landi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
| | - Francesca Mangiola
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Ivo Boskoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Vincenzo Perri
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
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Mohajir WA, Khurana S, Singh K, Chong RW, Bhutani MS. Botulinum Toxin A Use in the Gastrointestinal Tract: A Reappraisal After Three Decades. Gastroenterol Hepatol (N Y) 2023; 19:198-212. [PMID: 37705841 PMCID: PMC10496347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
The discovery of botulinum toxin A (BTX)'s therapeutic properties has led to studies evaluating its usefulness in multiple medical disorders. Its use in the gastrointestinal (GI) tract has been studied for 30 years. Multiple databases, including PubMed, AccessMedicine, ClinicalKey, Cochrane Library, Embase, and Medline, were used to review research from case series to randomized controlled trials on BTX use in the GI tract. This article reviews the current literature on the efficacy of BTX and the strength of recommendations for or against its use in various disorders, including cricopharyngeal dysphagia, achalasia, nonachalasia motility disorders, gastroparesis, obesity, sphincter of Oddi disorders, chronic anal fissure, chronic idiopathic anal pain, and anismus. The appeal of BTX comes from its simplicity of administration, good safety profile, and reliability in decreasing muscular tone. However, there are several drawbacks that limit its use, including the lack of long-term efficacy and/or limited data in many GI disorders.
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Affiliation(s)
- Wasay A. Mohajir
- Department of Gastroenterology, Texas A&M College of Medicine and Baylor Scott & White Medical Center, Round Rock, Texas
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas
| | - Shruti Khurana
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas
| | - Khushboo Singh
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas
| | - Reubyn William Chong
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas
| | - Manoop S. Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston, Texas
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