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Katsumi A, Mori H, Matsuura N, Masaoka T, Takatori Y, Tomida H, Akimoto T, Ando H, Kato M, Kanai T. Concurrent Diagnosis of Superficial Esophageal Cancer and Esophageal Achalasia: A Case Report and Literature Review. DEN OPEN 2026; 6:e70164. [PMID: 40529107 PMCID: PMC12171625 DOI: 10.1002/deo2.70164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2025] [Revised: 06/06/2025] [Accepted: 06/07/2025] [Indexed: 06/20/2025]
Abstract
We report a case of a 70-year-old woman with esophageal achalasia and concurrent superficial esophageal squamous cell carcinoma. Three adjacent superficial lesions were resected en bloc by endoscopic submucosal dissection (ESD), with no lymphovascular invasion. Given that the patient's dysphagia was effectively controlled with medication and dietary modifications, peroral endoscopic myotomy (POEM) was deferred following a careful assessment of the risk-benefit balance. As both ESD and POEM involve submucosal intervention, this case highlights the importance of individualized treatment based on symptom severity and lesion characteristics.
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Affiliation(s)
- Ai Katsumi
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineKeio University School of MedicineTokyoJapan
| | - Hideki Mori
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineKeio University School of MedicineTokyoJapan
| | - Noriko Matsuura
- Division of Research and Development for Minimally Invasive TreatmentCancer CenterKeio University School of MedicineTokyoJapan
| | - Tatsuhiro Masaoka
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineKeio University School of MedicineTokyoJapan
- Center for EndoscopyKawasaki Municipal HospitalKanagawaJapan
| | - Yusaku Takatori
- Division of Research and Development for Minimally Invasive TreatmentCancer CenterKeio University School of MedicineTokyoJapan
| | - Hideomi Tomida
- Division of Research and Development for Minimally Invasive TreatmentCancer CenterKeio University School of MedicineTokyoJapan
| | - Teppei Akimoto
- Division of Research and Development for Minimally Invasive TreatmentCancer CenterKeio University School of MedicineTokyoJapan
| | - Hiroko Ando
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineKeio University School of MedicineTokyoJapan
| | - Motohiko Kato
- Center for Diagnostic and Therapeutic EndoscopyKeio University School of MedicineTokyoJapan
| | - Takanori Kanai
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineKeio University School of MedicineTokyoJapan
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Rengarajan A, Aadam A. Peroral Endoscopic Myotomy and Functional Lumen Imaging Probe. Gastrointest Endosc Clin N Am 2025; 35:665-675. [PMID: 40412997 DOI: 10.1016/j.giec.2025.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2025]
Abstract
Esophageal motor disorders (EMDs) encompass a spectrum of conditions characterized by abnormal motility patterns leading to impaired bolus transit through the esophagus. These disorders can generally be categorized as dysfunction of the esophagogastric junction, dysfunction of peristalsis, or a combination of both. A thorough clinical history focusing on classic symptoms is imperative to guide the diagnostic approach and interpretation of testing appropriately. High-resolution manometry is the cornerstone diagnostic modality for EMDs as it allows for interrogation of esophageal pressure dynamics in real time by measuring peristaltic activity of the esophageal body and the relaxation of the lower esophageal sphincter.
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Affiliation(s)
- Arvind Rengarajan
- Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Avenue, Saint Louis, MO 63110, USA
| | - Aziz Aadam
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, 675 North St. Clair St, Chicago, IL 60611, USA.
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Ahmed K, Rauf SA, Hussain T, Siddiqui A, Ahmed R, Khan NA, Shah HH, Haque MA. Evolving therapeutic approaches in achalasia: a comprehensive review of peroral endoscopic myotomy (POEM) vs. Heller's myotomy. Ann Med Surg (Lond) 2025; 87:2855-2867. [PMID: 40337384 PMCID: PMC12055194 DOI: 10.1097/ms9.0000000000003271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2025] [Accepted: 03/28/2025] [Indexed: 05/09/2025] Open
Abstract
This comprehensive narrative review thoroughly explores the treatment landscape for achalasia, a rare esophageal motility disorder. Beginning with an introduction outlining the anatomical and clinical aspects of achalasia, the review delves into its historical perspective, tracing the evolution of treatment options from early nonsurgical methods to advanced surgical techniques such as Heller's myotomy and peroral endoscopic myotomy (POEM). Technical perspectives on surgical interventions, including key steps, clinical practice guidelines, and modifications to POEM techniques, are extensively discussed. A comparative analysis between POEM and Heller's myotomy elucidates their indications, contraindications, efficacy, outcomes, and interventions for persistent symptoms or complications. Furthermore, the review explores the adverse events associated with both procedures, highlighting their safety profiles and management strategies. Finally, from a financial perspective, considerations such as operative time, hospital stay length, readmission rates, and quality-adjusted life years are examined, emphasizing the implications for patient decision-making. This review underscores the importance of a multidimensional approach to understanding and managing achalasia, advocating for further research to enhance treatment efficacy and reduce adverse effects.
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Affiliation(s)
- Khadija Ahmed
- Dow University of Health Sciences, Karachi, Pakistan
| | | | - Tooba Hussain
- Dow University of Health Sciences, Karachi, Pakistan
| | | | | | | | | | - Md Ariful Haque
- Department of Public Health, Atish Dipankar University of Science and Technology, Dhaka, Bangladesh
- Voice of Doctors Research School, Dhaka, Bangladesh
- Department of Orthopaedic Surgery, Yan’an Hospital Affiliated to Kunming Medical University, Kunming, Yunnan, China
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Diab ARF, Sujka JA, Mitra C, Hamza A, Ananthan YD, Docimo S, DuCoin CG. Short Versus Long Myotomy Length in Peroral Endoscopic Myotomy for Achalasia: Comparable Efficacy with Potential Reduction in Incidence of Reflux-A Meta-Analysis of 10 Comparative Studies. J Laparoendosc Adv Surg Tech A 2025; 35:300-312. [PMID: 40173097 DOI: 10.1089/lap.2024.0397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2025] Open
Abstract
Background: Shortening the myotomy length during peroral endoscopic myotomy (POEM) for achalasia has been hypothesized to reduce gastroesophageal reflux disease (GERD) incidence while maintaining procedural efficacy. This meta-analysis compares the outcomes of short POEM (S-POEM) and long POEM (L-POEM). Methods: A systematic review adhering to PRISMA guidelines identified studies directly comparing S-POEM and L-POEM. Study quality was assessed using the Risk of Bias in Non-randomized Studies of Interventions and Revised Cochrane Risk of Bias for Randomized Trials tools. A pairwise meta-analysis was conducted using the random-effects model. Results: In perioperative outcomes, S-POEM significantly reduced operative time and required fewer clips compared with L-POEM, with no significant differences in adverse events or length of stay. Regarding GERD-related outcomes, S-POEM demonstrated a statistically significant reduction in abnormal esophageal acid exposure on 24-hour pH-impedance testing, with a number needed to treat of 10. While the reduction in symptomatic GERD did not reach statistical significance (P = .06), the P value was very close to the threshold for significance (.05), and all seven included studies reported decreased symptomatic GERD with S-POEM. This is therefore considered a noteworthy finding. The rates of esophagitis and lower esophageal sphincter pressure did not differ significantly between the groups. Efficacy-related outcomes, including clinical success, Eckardt score, and barium height at 5 minutes, were comparable between S-POEM and L-POEM. However, integrated relaxation pressure was significantly higher in the S-POEM group. Conclusions: This study suggests that shortening the myotomy length may reduce GERD incidence following POEM without compromising its efficacy in achalasia treatment. In addition, a shorter myotomy length decreases operative time, potentially reducing time-related costs and improving workflow.
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Affiliation(s)
- Abdul-Rahman Fadi Diab
- University of Central Florida College of Medicine/HCA Healthcare GME Consortium, Ocala, Florida, USA
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Joseph Adam Sujka
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Chandan Mitra
- University of Central Florida College of Medicine/HCA Healthcare GME Consortium, Ocala, Florida, USA
| | - Alan Hamza
- University of Central Florida College of Medicine/HCA Healthcare GME Consortium, Ocala, Florida, USA
| | - Yasotha Diana Ananthan
- University of Central Florida College of Medicine/HCA Healthcare GME Consortium, Ocala, Florida, USA
- Heart of Florida Health Center, Ocala, Florida, USA
| | - Salvatore Docimo
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Christopher Garnet DuCoin
- Division of Gastrointestinal Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
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Abe H, Tanaka S, Sakaguchi H, Ueda C, Kinoshita M, Hori H, Nakai T, Yoshizaki T, Hoki S, Tanabe H, Urakami S, Toyonaga T, Kodama Y. Efficacy of a novel small-caliber therapeutic endoscope in peroral endoscopic myotomy for esophageal motility disorders: a propensity score matching analysis. Esophagus 2025; 22:264-271. [PMID: 39903431 PMCID: PMC11929706 DOI: 10.1007/s10388-025-01107-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Accepted: 01/14/2025] [Indexed: 02/06/2025]
Abstract
BACKGROUND EG-840TP is a novel small-caliber therapeutic endoscope with a large working channel. We aimed to evaluate the treatment outcomes of peroral endoscopic myotomy using EG-840TP compared to those using a conventional therapeutic endoscope (GIF-H290T). METHODS Patients who underwent peroral endoscopic myotomy for achalasia and non-achalasia esophageal motility disorders were enrolled between March 2021 and March 2023. Procedure times and other treatment outcomes were compared between patients treated with EG-840TP and GIF-H290T using propensity score matching analysis. In the subgroup analysis, patients were divided into subsets based on myotomy length, morphology, esophageal dilation, and operator skill, and the procedure time was compared between the matched groups. RESULTS A total of 154 patients were enrolled in this study, and 39 patients treated using each type of scope were matched. The EG-840TP group tended to have a shorter procedure time than the GIF-H290T group. There were no significant differences between the groups in terms of short-term clinical success or perioperative adverse events. In the subgroup analysis, the procedure time of the EG-840TP group was significantly shorter than that of the GIF-H290T group when patients had a straight esophagus (44 min vs. 54 min, p = 0.0015) and the operator was a non-expert (49 min vs. 64 min, p = 0.031). CONCLUSIONS POEM using EG-840TP showed procedure time, clinical success, and adverse events equivalent to those of a conventional therapeutic endoscope. However, EG-840TP potentially contributed to a shorter procedure time in patients with a straight esophagus or in non-expert operators than GIF-H290T.
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Affiliation(s)
- Hirofumi Abe
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
| | - Shinwa Tanaka
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Hiroya Sakaguchi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Chise Ueda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Masato Kinoshita
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Hitomi Hori
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Tatsuya Nakai
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Tetsuya Yoshizaki
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Shinya Hoki
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Hiroshi Tanabe
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Satoshi Urakami
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | | | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
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Wang J, Zhang H. Does Short Myotomy Really Not Reduce the Risk of Reflux Esophagitis and Pathologic Acid Exposure After Peroral Endoscopic Myotomy? Dig Dis Sci 2025:10.1007/s10620-025-08995-z. [PMID: 40111707 DOI: 10.1007/s10620-025-08995-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2025] [Accepted: 03/12/2025] [Indexed: 03/22/2025]
Affiliation(s)
- Jiali Wang
- Department of Gastroenterology, Zigong First People's Hospital, 42 Shangyihao Road, Zigong, 643000, Sichuan Province, China
| | - Han Zhang
- Department of Gastroenterology, Zigong First People's Hospital, 42 Shangyihao Road, Zigong, 643000, Sichuan Province, China.
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Hazrah P. Reflux after peroral endoscopic myotomy: The dilemma and the options. World J Gastroenterol 2025; 31:100510. [PMID: 39958445 PMCID: PMC11752699 DOI: 10.3748/wjg.v31.i6.100510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2024] [Revised: 12/07/2024] [Accepted: 12/23/2024] [Indexed: 01/10/2025] Open
Abstract
Per oral endoscopic myotomy (POEM) is rapidly emerging as the treatment of choice for achalasia cardia, but its success is marred by problematic reflux. Although symptomatic reflux rates are low and often comparable to that after laparoscopic Hellers myotomy (LHM), a high incidence of pathologic reflux has been noted after POEM. This poses a dilemma as to what is true reflux, and in determining the indications and optimal endpoints for managing post-POEM reflux. The two pertinent reasons for the difference in reflux rates between LHM and POEM are the variation in length and location of myotomy and the absence of an anti-reflux procedure in POEM. Proton pump inhibitor remains the most sought-after treatment of POEM derived reflux. Nevertheless, modifications in the procedural technique of POEM and the addition of endoscopic fundoplication can probably emerge as a game changer. This article briefly reviews the incidence, causes, controversies, predictive factors, and management strategies related to post-POEM reflux.
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Affiliation(s)
- Priya Hazrah
- Department of Surgery, Lady Hardinge Medical College, New Delhi 110001, Delhi, India
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Albunni H, Beran A, Hadaki N, DeWitt JM, Al-Haddad M. Short Versus Standard Peroral Endoscopic Myotomy for Esophageal Achalasia: A Meta-Analysis of Randomized Controlled Trials. Dig Dis Sci 2025; 70:685-695. [PMID: 39806083 DOI: 10.1007/s10620-024-08825-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2024] [Accepted: 12/22/2024] [Indexed: 01/16/2025]
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) has become the treatment of choice for achalasia. However, the impact of myotomy length on POEM outcomes remains unclear. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the outcomes of short versus standard-length myotomy in achalasia patients. METHODS We conducted a comprehensive search in PubMed, Embase, and Web of Science databases to identify all RCTs that compared POEM using short myotomy with standard myotomy. The primary outcomes were clinical success and post-operative gastroesophageal reflux disease (GERD). The secondary outcomes were procedural time, length of hospital stay, and intraprocedural complications. Pooled odds ratio (OR) and mean difference (MD) with the corresponding 95% confidence intervals (CIs) were calculated. RESULTS Three RCTs with 365 achalasia patients treated with short (n = 179) or standard (n = 186) myotomy were included. Short and standard myotomies showed similar clinical success (OR 1.95, 95% CI 0.61-6.23, p = 0.26; I2 = 41%), reflux symptoms (OR 0.97, 95% CI 0.49-1.89, p = 0.92; I2 = 20%), pathologic acid exposure on pH monitoring (OR 0.70, 95% CI 0.33-1.50, p = 0.36; I2 = 58%), reflux esophagitis on upper endoscopy (OR 0.82, 95% CI 0.40-1.70, p = 0.59; I2 = 42%), intraprocedural complications (OR 1.22, 95% CI 0.53-2.79, p = 0.65; I2 = 0%), and length of hospital stay (MD - 0.01, 95% CI - 0.72 to 0.69, p = 0.97, I2 = 73%). Procedural time was shorter in short myotomy (MD - 16.11 min, 95% CI - 26.04 to - 6.19, p = 0.001; I2 = 84%). CONCLUSIONS POEM using short myotomy for achalasia is non-inferior to standard myotomy for efficacy, safety, and post-operative GERD but is associated with a shorter procedural time.
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Affiliation(s)
- Hashem Albunni
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Azizullah Beran
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nwal Hadaki
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John M DeWitt
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mohammad Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
- School of Medicine, University of Jordan, Amman, Jordan
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Swei E, Kassir Z, Shrigiriwar AP, Schlacterman A, Chung CS, Mandarino FV, Kedia P, Messman H, Pawa R, Desai P, Saxena P, Assefa R, Arevalo-Mora M, Azzolini F, Arcidiacono PG, Nagl S, Abu-Hammour MN, Puga-Tejada M, Baquerizo-Burgos J, Egas-Izquierdo M, Cunto D, Alcivar-Vasquez J, Del Valle R, Sharaiha RZ, Irani S, Medranda CR, Khashab M. Short esophageal myotomy versus standard myotomy for treatment of sigmoid-type achalasia: results of an international multicenter study. Gastrointest Endosc 2025; 101:377-384.e2. [PMID: 39182526 DOI: 10.1016/j.gie.2024.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 08/05/2024] [Accepted: 08/18/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND AND AIMS Patients with sigmoid-type achalasia can be challenging to treat with peroral endoscopic myotomy (POEM). A short myotomy improves technical success; however, outcomes have not previously been evaluated. METHODS This was a multicenter, international, retrospective study of patients who underwent POEM with short (≤4 cm) or standard esophageal myotomy. Outcomes included clinical and technical success, procedural adverse events, and reflux rates. RESULTS A total of 109 patients with sigmoid achalasia (sigmoid, n = 74; advanced sigmoid, n = 35) underwent POEM across 13 centers (short myotomy, n = 59; standard, n = 50). Technical success was 100% across both groups. Patients who underwent short myotomy had a significantly shorter mean procedure time (57.7 ± 27.8 vs 83.1 ± 44.7 minutes, P = .0005). A total of 6 adverse events were recorded in 6 patients (5.5%; 4 mild, 2 moderate); the adverse event rate was not significantly different between short and standard groups. Ninety-eight patients had follow-up data (median, 3.6 months; interquartile range, 1-14 months). Clinical success was 94% (short, 93%; standard, 95%; P = .70) and did not differ based on achalasia subtype or sigmoid achalasia severity. Twenty-one (22%) patients reported post-POEM reflux and 44% (16 of 36) had objective evidence of pathologic reflux. Rates of pathologic reflux were significantly increased in the standard versus short group (odds ratio, 18.0; 95% confidence interval, 2.0-159.0; P = .009). CONCLUSIONS POEM with short myotomy is effective and safe for the short-term treatment of sigmoid and advanced sigmoid achalasia. Short myotomy may lead to less reflux than standard myotomy.
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Affiliation(s)
- Eric Swei
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Department of Medicine, Baltimore, Maryland, USA
| | - Zachary Kassir
- Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Apurva Pravin Shrigiriwar
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Department of Medicine, Baltimore, Maryland, USA
| | - Alex Schlacterman
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Chen-Shuan Chung
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Francesco Vito Mandarino
- Division of Gastroenterology and Gastrointestinal Endoscopy, San Raffaele Scientific Institute for Research, Vita-Salute San Raffaele University, Milan, Italy
| | - Prashant Kedia
- Department of Gastroenterology, Methodist Dallas Medical Center, Dallas, Texas, USA
| | - Helmut Messman
- Department of Internal Medicine, Augsburg Medical Center, Augsburg, Germany
| | - Rishi Pawa
- Division of Gastroenterology and Hepatology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Pankaj Desai
- Surat Institute of Digestive Sciences, Surat, India
| | - Payal Saxena
- Department of Gastroenterology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Redeat Assefa
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Department of Medicine, Baltimore, Maryland, USA
| | - Martha Arevalo-Mora
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital Omni, Guayaquil, Ecuador
| | - Francesco Azzolini
- Division of Gastroenterology and Gastrointestinal Endoscopy, San Raffaele Scientific Institute for Research, Vita-Salute San Raffaele University, Milan, Italy
| | - Paulo Giorgio Arcidiacono
- Division of Gastroenterology and Gastrointestinal Endoscopy, San Raffaele Scientific Institute for Research, Vita-Salute San Raffaele University, Milan, Italy
| | - Sandra Nagl
- Department of Internal Medicine, Augsburg Medical Center, Augsburg, Germany
| | - Mohamad-Noor Abu-Hammour
- Department of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
| | - Miguel Puga-Tejada
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital Omni, Guayaquil, Ecuador
| | - Jorge Baquerizo-Burgos
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital Omni, Guayaquil, Ecuador
| | - Maria Egas-Izquierdo
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital Omni, Guayaquil, Ecuador
| | - Domenica Cunto
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital Omni, Guayaquil, Ecuador
| | - Juan Alcivar-Vasquez
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital Omni, Guayaquil, Ecuador
| | - Raquel Del Valle
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital Omni, Guayaquil, Ecuador
| | - Reem Z Sharaiha
- Department of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
| | - Shayan Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Carlos-Robles Medranda
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, University Hospital Omni, Guayaquil, Ecuador
| | - Mouen Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Department of Medicine, Baltimore, Maryland, USA.
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Mari A, Khoury T, Sweis R. Achalasia: beyond the basics. Frontline Gastroenterol 2025; 16:59-71. [DOI: 10.1136/flgastro-2024-102822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2025] Open
Abstract
Achalasia is a rare oesophageal disease characterised by an unrelaxing lower oesophageal sphincter and abnormal peristalsis of the oesophageal body. Achalasia symptoms include dysphagia to solid and liquid, chest pain, regurgitation and weight loss. Achalasia diagnosis might be delayed for many years when atypical symptoms dominate. Significant progress has been made over the last two decades regarding our understanding of pathophysiology, methods of evaluation and management. The development of high-resolution manometry in particular has improved the diagnosis of achalasia, as well as other major motility disorders. Subtyping achalasia into manometric patterns has pathophysiological and therapeutic implications. Furthermore, complementary tests such as timed barium swallow and the functional lumen imaging probe (EndoFLIP; Crospon Medical Devices, Galway, Ireland) have significantly added to achalasia diagnosis algorithm and management decision-making. Progression in management has helped optimise established therapy (pneumatic dilatation and Heller myotomy) and introduced new endoscopic treatments (peroral endoscopic myotomy) and surgical techniques (surgical robotic Heller myotomy). This review will aim to shed light on the most recent advances in achalasia diagnosis, classification and management.
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Abstract
This article offers a detailed overview of recent advancements in third space endoscopy (TSE), highlighting key procedures and their clinical applications and outcomes. Clinical TSE started as a treatment for achalasia and was named peroral endoscopic myotomy (POEM). Outcome data and comparative data of POEM with other treatments were detailed and discussed. This article also explores the indications and outcomes of other TSE procedures, such as G-POEM, Z-POEM, D-POEM, per-rectal endoscopic myotomy, and STER/POET. This article serves as a valuable resource for endoscopists looking to enhance their understanding and stay updated on these advanced TSE procedures.
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Affiliation(s)
- Sonmoon Mohapatra
- Department of Gastroenterology and Hepatology, Sai Institute of Gastroenterology and Liver Sciences, Plot 145, Ganganagar, Unit-6, Bhubaneswar, Odisha 751030, India. https://twitter.com/Sonmoon20
| | - Mitsuru Esaki
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
| | - Norio Fukami
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA.
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Vespa E, Barchi A, Mandarino FV, Fasulo E, Fratto MC, Passaretti S, Azzolini F, Savarino EV, Danese S. Standard length of peroral endoscopic myotomy (POEM) for achalasia: a systematic review and meta-analysis. Dis Esophagus 2024; 37:doae069. [PMID: 39214522 PMCID: PMC11605639 DOI: 10.1093/dote/doae069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 07/11/2024] [Accepted: 08/08/2024] [Indexed: 09/04/2024]
Abstract
Peroral endoscopic myotomy (POEM) is an established treatment for achalasia, yet there is still a lack of technical standardization. No clear definition of 'long', 'standard', or 'short' POEM exists to date. We conducted a systematic review with meta-analysis to analyze current POEM length standards. We included studies reporting technical details of POEM, in which no definite or comparative myotomy length was intentionally adopted (standard myotomy). The primary outcome was the pooled mean total myotomy length. Sub-group analyses were performed to explore heterogeneity across studies. From the initial 7172 records, 31 studies with 3023 patients were included. Pooled mean of total myotomy length was 10.39 cm (95% CI 10.06-10.71; I2 99.3%). Pooled mean of esophageal and gastric myotomy length, provided by 17 studies, was 7.11 cm (95% CI 6.51-7.71; I2 99.8%) and 2.81 cm (95% CI 2.41-3-22; I2 99.8%), respectively. On subgroup analysis for achalasia subtypes, pooled mean length in non-spastic achalasia (type I and II) was 10.17 cm (95% CI 9.91-10.43; I2 94.2%), while in type III it was 14.02 cm (95% CI 10.59-17.44; I2 98.9%). Pooled mean myotomy length for studies conducted between 2014-2020 was 10.53 cm (95% CI, 10.22-10.84; I2 99.1%) and 9.74 cm (95% CI, 7.95-11.54; I2 99.7%) in 2021-2022. Myotomy length during a 'standard' POEM is 10.4 cm, remaining over 10 cm in non-spastic achalasia. The high heterogeneity across studies confirms that the POEM technique needs further standardization. We found no significant time trend towards adopting short POEM, despite recent evidence supporting its use.
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Affiliation(s)
- Edoardo Vespa
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alberto Barchi
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesco Vito Mandarino
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Ernesto Fasulo
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Maria Caterina Fratto
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Sandro Passaretti
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesco Azzolini
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Edoardo Vincenzo Savarino
- Department of Surgery, Oncology, and Gastroenterology, University of Padua, Padua, Italy
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, Azienda Ospedale Università di Padova, Padua, Italy
| | - Silvio Danese
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
- Faculty of Medicine, Department of Gastroenterology and Endoscopy, Università Vita-Salute San Raffaele, Milan, Italy
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13
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Eke C, Greenberg I, Bushe B, Joelson A, Acharya P, Lee D, Sethi A, Kedia P. Utility of Intraprocedural Luminal Diameter and Distensibility Measurements During the Esophageal Peroral Endoscopic Myotomy Procedure. J Clin Gastroenterol 2024; 58:970-974. [PMID: 38227843 DOI: 10.1097/mcg.0000000000001960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 11/30/2023] [Indexed: 01/18/2024]
Abstract
GOALS Through evaluation of the lower esophageal sphincter immediately before and after myotomy using an endoluminal functional lumen imaging probe (EFLIP), our study aimed to determine the clinical response to peroral endoscopic myotomy (POEM) and the incidence of postprocedure reflux. BACKGROUND Achalasia is a rare esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and diminished peristalsis. POEM is a therapeutic option for durable management of achalasia. However, symptomatic acid reflux and esophagitis are well-known adverse effects of the procedure. STUDY Electronic medical records of 168 patients who underwent POEM for achalasia at 2 tertiary care referral centers from May 2014 to May 2021 were reviewed. EFLIP was used at a range of catheter fill volumes to assess LES dynamics. Preprocedure and postprocedure Eckardt Symptom Scores were recorded. RESULTS Significant clinical improvement from POEM was sustained in over 94% of patients after 1 year. EFLIP changed intraprocedural management 5% of the time by means of myotomy extension. In patients with reflux>1 year following POEM, there was no significant difference in post-POEM LES diameter or change in LES diameter compared with those without reflux. However, post-POEM LES distensibility index (DI) was significantly higher in patients with reflux after 1 year compared with those without reflux. CONCLUSIONS POEM is a safe and increasingly effective therapy for patients with symptomatic achalasia. Intraprocedural EFLIP measurements suggest that post-POEM reflux may be correlated more with DI than LES diameter. Yet, more data is needed to substantiate these outcomes.
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Affiliation(s)
- Chiemeziem Eke
- Methodist Digestive Institute, Methodist Dallas Medical Center
| | - Ian Greenberg
- Methodist Digestive Institute, Methodist Dallas Medical Center
| | | | | | | | - David Lee
- Methodist Digestive Institute, Methodist Dallas Medical Center
- Digestive Health Associates of Texas, GI Alliance, Fort Worth, TX
| | - Amrita Sethi
- Columbia University Irving Medical Center, New York, NY
| | - Prashant Kedia
- Methodist Digestive Institute, Methodist Dallas Medical Center
- Digestive Health Associates of Texas, GI Alliance, Fort Worth, TX
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14
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Khazoom F, Louie BE. Management of Complications After Per Oral Endoscopic Myotomy. Thorac Surg Clin 2024; 34:341-353. [PMID: 39332859 DOI: 10.1016/j.thorsurg.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2024]
Abstract
This is a comprehensive review of intraoperative, early postoperative, and late postoperative complications of Per Oral Endoscopic Myotomy with a focus on prevention, intraoperative management, and postoperative management.
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Affiliation(s)
- Francois Khazoom
- Division of Thoracic Surgery, Swedish Cancer Institute and Medical Center, 1101 Madison Street, Suite 900, Seattle, WA 90814, USA
| | - Brian E Louie
- Division of Thoracic Surgery, Swedish Cancer Institute and Medical Center, 1101 Madison Street, Suite 900, Seattle, WA 90814, USA.
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15
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Rai P, Kumar P, Goel A, Singh TP, Mishra P, Verma P, Kumar A, Kumar V. Peroral Endoscopic Myotomy: Short Versus Long Esophageal Myotomy for Achalasia Cardia: A Randomized Controlled Noninferiority Trial. Surg Laparosc Endosc Percutan Tech 2024; 34:445-451. [PMID: 38989656 DOI: 10.1097/sle.0000000000001303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 06/04/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND AND AIMS The appropriate length of esophageal myotomy in peroral endoscopic myotomy (POEM) for achalasia cardia remains unclear. This study aimed to compare the outcome of short (≤3 cm) and long (≥6 cm) esophageal myotomy in patients with type I and II achalasia cardia. METHODS This single-blinded, randomized controlled noninferiority trial was conducted at a tertiary center between July 2021 and December 2021. Patients with achalasia types I and II were randomized into short (≤3 cm) and long (≥6 cm) esophageal myotomy groups. The primary outcome of the study was clinical success (Eckardt score ≤3) 1 year after the procedure. The secondary outcomes included a comparison of technical success, operating duration, occurrence of intraoperative adverse events, alterations in integrated relaxation pressure (IRP), change in barium column height after 5 minutes (1 mo), and gastroesophageal reflux disease (3 mo) between the groups. RESULTS Fifty-four patients were randomized into the short (n=27) or long (n=27) esophageal myotomy groups. Technical success rates were 100% (27/27) and 96.3% (26/27) in short myotomy (SM) and long myotomy (LM) groups, respectively. The clinical success rates were 96.3% (26/27) and 96.2% (25/26) in the SM and LM groups, respectively ( P =0.998). The mean (±SD) length of the esophageal myotomy was 2.75±0.36 cm in the SM and 6.69±1.35 cm in the LM groups ( P <0.001). The mean (±SD) procedure time for the SM and LM groups was 61.22±8.44 and 82.42±14.70 minutes ( P <0.001), respectively. The mean integrated relaxation pressure (IRP), Eckardt score, adverse events, reflux esophagitis, symptomatic gastroesophageal reflux disease, and esophageal acid exposure (>6%) did not differ significantly between the 2 groups following POEM treatment. CONCLUSIONS Short myotomy is noninferior to long myotomy in terms of clinical success, gastroesophageal reflux disease, and intraoperative adverse events at the short-term follow-up ( P >0.05). Short myotomy resulted in a reduced operative time ( P <0.05).
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Affiliation(s)
| | | | | | | | - Prabhaker Mishra
- Biostatistics & Health Informatics, Sanjay Gandhi Post Graduate Institute of Medical Sciences
| | - Prashant Verma
- Department of Gastroenterology, Dr Ram Manohar Lohia Institute of Medical Sciences
| | - Ajay Kumar
- Department of General Medicine, King George Medical University, Lucknow
| | - Vinod Kumar
- Department of Gastroenterology, IMS-BHU, Varanasi, Uttar Pradesh, India
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16
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Kasapoglu M, Noor Us Saba S, Hashemi A, Panchal M, Khan S. Comparative Effectiveness of Peroral Endoscopic Myotomy (POEM) Versus Traditional Treatment Modalities for Achalasia: A Systematic Review. Cureus 2024; 16:e71917. [PMID: 39564071 PMCID: PMC11574915 DOI: 10.7759/cureus.71917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2024] [Accepted: 10/20/2024] [Indexed: 11/21/2024] Open
Abstract
Achalasia is a rare esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and absence of peristalsis, leading to significant swallowing difficulties and other symptoms. Traditional treatment options, including Heller myotomy (HM) and pneumatic dilation (PD), have been effective but are associated with risks such as perforation and gastroesophageal reflux disease (GERD). Peroral endoscopic myotomy (POEM) has emerged as a minimally invasive alternative, potentially offering several advantages over conventional methods. This systematic review aims to compare the efficacy, safety, and long-term outcomes of POEM versus HM in the treatment of achalasia. We systematically reviewed studies that compared POEM with HM in achalasia patients, focusing on key outcomes such as myotomy length, operative time, treatment success rates, and complication rates. The review included 15 studies comprising four randomized controlled trials, 10 cohort studies, and one case-control study. The results consistently showed that POEM achieved longer myotomy lengths and shorter operative times compared to HM. POEM also demonstrated higher or comparable treatment success rates, with a uniform definition of success based on achieving an Eckardt score of ≤3. However, the complication rates, particularly the incidence of GERD, varied between the two procedures, highlighting the need for careful patient selection and long-term follow-up. POEM offers a promising alternative to HM for the treatment of achalasia, with advantages in terms of reduced invasiveness, shorter operative times, and potentially higher treatment success rates. However, further high-quality research is necessary to fully establish its long-term efficacy and safety compared to conventional treatments.
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Affiliation(s)
- Malik Kasapoglu
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
- Medicine, Bahçeşehir University, Istanbul, TUR
| | - Syeda Noor Us Saba
- Ophthalmology, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Ava Hashemi
- College of Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Malaika Panchal
- Medical Oncology, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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17
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Ramchandani M, Nabi Z, Inavolu P, Reddy DN. Recent Advancements and Future Perspectives of Per Oral Endoscopic Myotomy. Clin Gastroenterol Hepatol 2024; 22:1983-1996.e2. [PMID: 38759824 DOI: 10.1016/j.cgh.2024.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 02/28/2024] [Accepted: 02/28/2024] [Indexed: 05/19/2024]
Abstract
Per oral endoscopic myotomy (POEM) has emerged as a preferred approach for the treatment of idiopathic achalasia and various esophageal motility disorders, offering a minimally invasive alternative to traditional laparoscopic Heller's myotomy. Over the past decade, POEM has solidified its status as the primary therapeutic choice in these conditions through constant improvements. Its evolution has been marked by continuous progress, driven by the integration of innovative technologies and sophisticated techniques. Notable advancements in the techniques include the advent of shorter myotomies and sling fiber-preserving gastric myotomies. The introduction of novel image-enhanced endoscopic techniques, such as red dichromatic imaging and much safer bipolar devices, promises to enhance safety and reduce the technical demands of the POEM procedure. Furthermore, significant strides have been made in understanding gastroesophageal reflux (GERD) following POEM, enabling the differentiation of "true reflux" from acidification resulting from fermentation through manual pH tracing assessment. This distinction aids in identifying cases necessitating treatment with proton pump inhibitors. Other treatment strategies of post-POEM GERD have expanded to the incorporation of NOTES fundoplication and device-assisted fundoplication if the necessity arises. This comprehensive review delves into recent developments in POEM, encompassing technical variations, the assessment and management of post-POEM reflux, outcomes in special populations, and future prospects. By exploring these facets, we aim to provide a comprehensive overview of the current state of POEM, shedding light on its evolution and the promising directions it is poised to take in the field of third-space endoscopy.
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Affiliation(s)
- Mohan Ramchandani
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India.
| | - Zaheer Nabi
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Pradev Inavolu
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - D Nageshwar Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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18
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King WW, Yang D, Draganov PV. Esophageal Per-Oral Endoscopic Myotomy (E-POEM): Future Directions and Perspectives. Curr Gastroenterol Rep 2024; 26:241-250. [PMID: 39117966 DOI: 10.1007/s11894-024-00938-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2024] [Indexed: 08/10/2024]
Abstract
PURPOSE OF REVIEW POEM is a mature procedure endorsed by societal guidelines as a first line therapy for achalasia and spastic esophageal disorders. Nonetheless, several questions remain, including expanding indications for POEM, periprocedural evaluation and management, and the optimal POEM technique to enhance clinical success while mitigating risk for reflux. RECENT FINDINGS There is uncertainty regarding several technical aspects of the POEM myotomy; though aggregating evidence supports the use of real-time impedance planimetry to guide the myotomy. While post-POEM reflux remains a concerning long term sequela, there is an increasing focus on the potential role of endoscopic anti-reflux interventions. Lastly, with the widespread adoption of POEM, we continue to witness ongoing efforts to standardize post-procedural care and training in this procedure. POEM is no longer a novel but rather established procedure. Yet, this technique has continued to evolve, with the aim of optimizing treatment success while reducing adverse events and risk for post-procedural reflux.
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Affiliation(s)
- William W King
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
| | - Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Orlando, FL, USA
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, PO Box 100214, Gainesville, FL, 32610, USA.
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19
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Ren XF, Yu ZH, Song WX, Meng QG, Chen X. Diagnostic and therapeutic strategies for achalasia of the cardia. Shijie Huaren Xiaohua Zazhi 2024; 32:545-555. [DOI: 10.11569/wcjd.v32.i8.545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 07/12/2024] [Accepted: 07/19/2024] [Indexed: 09/01/2024] Open
Abstract
The diagnosis of achalasia of the cardidia (AC) is primarily based on clinical symptoms, esophagographic findings, esophagodynamic examination, and upper gastrointestinal endoscopic findings. High resolution manometry is considered the gold standard for diagnosis. With the advan-cement of new technologies, the diagnostic methods for AC have become more diverse, and three-dimensional modeling may facilitate early detection of AC. The use of endoscopic functional intracavity imaging probe can enhance diagnostic accuracy. Common treatment options include endoscopic balloon dilation, laparoscopic Heller myotomy, and peroral endoscopic myotomy (POEM). POEM has emerged as the most widely utilized therapeutic approach currently, significantly improving the clinical success rate in treating AC. This article provides a comprehensive review on recent research progress in the diagnosis and treatment of AC.
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Affiliation(s)
- Xiang-Feng Ren
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Zi-Han Yu
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Wen-Xuan Song
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Qing-Guo Meng
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Xin Chen
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin 300052, China
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20
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Itskoviz D, Malnick SDH. Gastroesophageal reflux following peroral endoscopic myotomy for achalasia: Bumps in the road to success. World J Gastroenterol 2024; 30:3461-3464. [PMID: 39156501 PMCID: PMC11326092 DOI: 10.3748/wjg.v30.i29.3461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 05/16/2024] [Accepted: 07/10/2024] [Indexed: 07/29/2024] Open
Abstract
Achalasia can significantly impair the quality of life. The clinical presentation typically includes dysphagia to both solids and liquids, chest pain, and regurgitation. Diagnosis can be delayed in patients with atypical presentations, and they might receive a wrong diagnosis, such as gastroesophageal reflux disease (GERD), owing to overlapping symptoms of both disorders. Although the cause of achalasia is poorly understood, its impact on the motility of the esophagus and gastroesophageal junction is well established. Several treatment modalities have been utilized, with the most common being surgical Heller myotomy with concomitant fundoplication and pneumatic balloon dilatation. Recently, peroral endoscopic myotomy (POEM) has gained popularity as an effective treatment for achalasia, despite a relatively high incidence of GERD occurring after treatment compared to other modalities. The magnitude of post-POEM GERD depends on its definition and is influenced by patient and procedure-related factors. The long-term sequelae of post-POEM GERD are yet to be determined, but it appears to have a benign course and is usually manageable with clinically available modalities. Identifying risk factors for post-POEM GERD and modifying the POEM procedure in selected patients may improve the overall success of this technique.
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Affiliation(s)
- David Itskoviz
- Kaplan Medical Center, Institute of Gastroenterology and Hepatology, Hebrew University Medical School of Jerusalem, Rehovot 76100, Israel
| | - Stephen David Howard Malnick
- Kaplan Medical Center, Department of Internal Medicine C, Hebrew University Medical School of Jerusalem, Rehovot 76100, Israel
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21
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Sanavio M, Vauquelin B, Picot MC, Altwegg R, Bozon A, Charpy F, Caillo L, Berger A, Zerbib F, Debourdeau A. Selective inner muscle layer myotomy is associated with lower pain and same clinical efficacy that full-thickness myotomy in patients treated by POEM for achalasia: A multicenter retrospective comparative analysis of 158 patients. Clin Res Hepatol Gastroenterol 2024; 48:102401. [PMID: 38897558 DOI: 10.1016/j.clinre.2024.102401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 05/24/2024] [Accepted: 06/15/2024] [Indexed: 06/21/2024]
Abstract
INTRODUCTION The aim of this study was to compare the impact of the depth of myotomy (selective inner layer myotomy (SIM) vs. full-thickness myotomy (FTM)) on the outcome of patients treated with POEM for achalasia. METHODS This was a retrospective, observational, conducted in two tertiary centers between October 2018 and September 2022. Patients were divided into two groups: SIM and FTM. The primary endpoint was clinical efficacy at 6 months, while secondary endpoints were postoperative criteria (such as pain, length of hospital stay, complications) and occurrence of gastroesophageal reflux disease (GERD) (esophagitis at 6 months, heartburn, and pH-metry). RESULTS 158 patients were included in the study (33 in the FTM group and 125 in the SIM group). The success rates at 6 and 12 months were similar in both groups, with 84 % and 70 % in the SIM group versus 90 % and 80 % in the FTM group, respectively (p = 0.57 and p = 0.74). However, more opioid analgesics were consumed in the FTM group compared to the SIM group (41% vs 21 %, p < 0.01). The length of hospitalization was longer in the FTM group than in the SIM group (2.17 ± 2.62 vs 2.94 ± 2.33, p < 0.001). The rate of esophagitis at 6 months was comparable (16 % in the SIM group vs 12 % in the FTM group, p = 0.73). There was no significant difference in terms of heartburn at 6 or 12 months between the SIM and FTM groups (18.5% vs 3.8 %, p = 0.07 and 27% vs 12.5 %, p = 0.35, respectively). CONCLUSION There was no significant difference in terms of clinical efficacy and GERD occurrence between FTM and SIM. However, full-thickness myotomy was associated with more postoperative pain and a longer length of hospital stay. Therefore, selective internal myotomy should be preferred over full-thickness myotomy.
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Affiliation(s)
- Mathilde Sanavio
- CHU de Montpellier, Gastroenterology, Hepatology and Transplantation Department, Montpellier, Montpellier Univ, France.
| | - Blandine Vauquelin
- Gastroenterology and Hepatology Department, INSERM CIC 1401, Haut-Lévêque University Hospital, Bordeaux, France
| | - Marie-Christine Picot
- Department of Medical Information, University Hospital of Montpellier, Montpellier Univ, France
| | - Romain Altwegg
- CHU de Montpellier, Gastroenterology, Hepatology and Transplantation Department, Montpellier, Montpellier Univ, France
| | - Anne Bozon
- CHU de Montpellier, Gastroenterology, Hepatology and Transplantation Department, Montpellier, Montpellier Univ, France
| | - Flora Charpy
- CHU de Montpellier, Gastroenterology, Hepatology and Transplantation Department, Montpellier, Montpellier Univ, France
| | - Ludovic Caillo
- CHU de Nimes, Gastroenterology and Hepatology Department, Nimes, Montpellier Univ France
| | - Arthur Berger
- Gastroenterology and Hepatology Department, INSERM CIC 1401, Haut-Lévêque University Hospital, Bordeaux, France
| | - Frank Zerbib
- Gastroenterology and Hepatology Department, INSERM CIC 1401, Haut-Lévêque University Hospital, Bordeaux, France
| | - Antoine Debourdeau
- CHU de Montpellier, Gastroenterology, Hepatology and Transplantation Department, Montpellier, Montpellier Univ, France; CHU de Nimes, Gastroenterology and Hepatology Department, Nimes, Montpellier Univ France
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22
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de Sire R, Capogreco A, Massimi D, Alfarone L, Mastrorocco E, Pellegatta G, Hassan C, Repici A, Maselli R. Per oral endoscopic myotomy for achalasia. Best Pract Res Clin Gastroenterol 2024; 71:101930. [PMID: 39209417 DOI: 10.1016/j.bpg.2024.101930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 05/05/2024] [Accepted: 06/04/2024] [Indexed: 09/04/2024]
Abstract
Achalasia, characterized by impaired lower esophageal sphincter (LES) relaxation and failed peristalsis, stands out as the most widely recognized primary esophageal motility disorder. It manifests with dysphagia to solid and liquid foods, chest pain, regurgitation, and weight loss, leading to significant morbidity and healthcare burden. Traditionally, surgical Heller myotomy and pneumatic dilation were the primary therapeutic approaches for achalasia. However, in 2009, Inoue and colleagues introduced a groundbreaking endoscopic technique called peroral endoscopic myotomy (POEM), revolutionizing the management of this condition. This review aims to comprehensively examine the recent advancements in the POEM technique for patients diagnosed with achalasia, delving into critical aspects, such as the tailoring of the myotomy, the prevention of intraprocedural adverse events (AEs), the evaluation of long-term outcomes, and the feasibility of retreatment in cases of therapeutic failure.
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Affiliation(s)
- Roberto de Sire
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy.
| | - Antonio Capogreco
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy
| | - Davide Massimi
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy
| | - Ludovico Alfarone
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy
| | - Elisabetta Mastrorocco
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy
| | - Gaia Pellegatta
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy
| | - Cesare Hassan
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, 20072, Pieve Emanuele, Italy
| | - Alessandro Repici
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, 20072, Pieve Emanuele, Italy
| | - Roberta Maselli
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, 20072, Pieve Emanuele, Italy
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23
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Cao T, Sun H, Yang D, Tao K, Tang Y, Fu Y, Xu H. Modified peroral endoscopic myotomy technique with retrograde on-demand myotomy for achalasia: a retrospective cohort study (with video). Surg Endosc 2024:10.1007/s00464-024-10944-2. [PMID: 38849652 DOI: 10.1007/s00464-024-10944-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 05/19/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND Although myotomy is crucial in peroral endoscopic myotomy (POEM) surgeries, its optimum length remains controversial. Herein, we propose a modified POEM with new method of tailoring myotomy length aim to evaluate the safety, efficacy, and clinical outcomes of this modified POEM compared with standard POEM in type I or II achalasia. METHODS Seventy-five patients with type I or II achalasia who underwent POEM at the First Hospital of Jilin University between January 2018 and December 2022 were retrospectively analyzed. According to the myotomy approach, these patients were divided into the retrograde on-demand myotomy (RDM, n = 34), with myotomy beginning on gastric side and length tailored by determining the degree of lower esophageal sphincter (LES) distention, and standard myotomy (SM, n = 41) groups. The baseline data, myotomy length, operation time, clinical success rate, adverse event rate, and reflux-related adverse events were compared and analyzed. RESULTS The median myotomy length in the RDM group was significantly shorter than that in the SM group (6 vs. 8 cm, respectively; p < 0.001). Moreover, the median myotomy time in the RDM group was significantly shorter than that in the SM group (10 vs. 16 min, respectively; p < 0.001). POEM was successfully performed in all the patients. At the 2-year follow-up, high clinical success rates were observed in both the RDM and SM groups (92.0% vs. 93.3%, respectively; p = 1.000). The incidence of intraoperative adverse events and postoperative reflux-related adverse events was low and comparable in both groups. CONCLUSIONS RDM POEM is a safe and effective method for patients with type I or II achalasia. Furthermore, it has a shorter myotomy length and operation time than standard POEM technique.
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Affiliation(s)
- Tingting Cao
- Department of Gastroenterology and Endoscopy Center, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Haibo Sun
- Department of Gastroenterology and Endoscopy Center, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Dong Yang
- Department of Gastroenterology and Endoscopy Center, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Ke Tao
- Department of Gastroenterology and Endoscopy Center, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Ying Tang
- Department of Gastroenterology and Endoscopy Center, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Yingli Fu
- Department of Clinical Epidemiology, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Hong Xu
- Department of Gastroenterology and Endoscopy Center, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, 130021, Jilin, China.
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24
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Nabi Z, Reddy DN. Short versus long endoscopic myotomy: how short is too short and how long is too long? Gut 2024; 73:1040. [PMID: 37311617 DOI: 10.1136/gutjnl-2023-330195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 05/19/2023] [Indexed: 06/15/2023]
Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, Telangana, India
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25
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Nabi Z, Inavolu P, Duvvuru NR. Prediction, prevention and management of gastroesophageal reflux after per-oral endoscopic myotomy: An update. World J Gastroenterol 2024; 30:1096-1107. [PMID: 38577183 PMCID: PMC10989487 DOI: 10.3748/wjg.v30.i9.1096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/26/2024] [Accepted: 02/18/2024] [Indexed: 03/06/2024] Open
Abstract
Achalasia cardia, the most prevalent primary esophageal motility disorder, is predominantly characterized by symptoms of dysphagia and regurgitation. The principal therapeutic approaches for achalasia encompass pneumatic dilatation (PD), Heller's myotomy, and the more recent per-oral endoscopic myotomy (POEM). POEM has been substantiated as a safe and efficacious modality for the management of achalasia. Although POEM demonstrates superior efficacy compared to PD and an efficacy parallel to Heller's myotomy, the incidence of gastroesophageal reflux disease (GERD) following POEM is notably higher than with the aforementioned techniques. While symptomatic reflux post-POEM is relatively infrequent, the significant occurrence of erosive esophagitis and heightened esophageal acid exposure necessitates vigilant monitoring to preclude long-term GERD-related complications. Contemporary advancements in the field have enhanced our comprehension of the risk factors, diagnostic methodologies, preventative strategies, and therapeutic management of GERD subsequent to POEM. This review focuses on the limitations inherent in the 24-h pH study for evaluating post-POEM reflux, potential modifications in the POEM technique to mitigate GERD risk, and the strategies for managing reflux following POEM.
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Affiliation(s)
- Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad 500082, Telangana, India
| | - Pradev Inavolu
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad 500082, Telangana, India
| | - Nageshwar Reddy Duvvuru
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad 500032, Telangana, India
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26
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Chuah KH, Ramasami N, Mahendran HA, Shanmuganathan G, Koleth GG, Voon K, Gew LT, Jahit MS, Lau PC, Muthukaruppan R, Said RHM, Mahadeva S, Ho SH, Lim SY, Tee SC, Siow SL, Ooi WK, Lee YY. Malaysian joint societies' consensus recommendations on diagnosis and management of disorders of esophagogastric junction outflow. J Gastroenterol Hepatol 2024; 39:431-445. [PMID: 38087846 DOI: 10.1111/jgh.16403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 09/13/2023] [Accepted: 10/18/2023] [Indexed: 03/05/2024]
Abstract
Disorders of esophagogastric junction (EGJ) outflow, including achalasia and EGJ outflow obstruction, are motility disorders characterized by inadequate relaxation of lower esophageal sphincter with or without impaired esophageal peristalsis. Current guidelines are technical and less practical in the Asia-Pacific region, and there are still massive challenges in timely diagnosis and managing these disorders effectively. Therefore, a Malaysian joint societies' task force has developed a consensus on disorders of EGJ outflow based on the latest evidence, while taking into consideration the practical relevance of local and regional context and resources. Twenty-one statements were established after a series of meetings and extensive review of literatures. The Delphi method was used in the consensus voting process. This consensus focuses on the definition, diagnostic investigations, the aims of treatment outcome, non-surgical or surgical treatment options, management of treatment failure or relapse, and the management of complications. This consensus advocates the use of high-resolution esophageal manometry for diagnosis of disorders of EGJ outflow. Myotomy, via either endoscopy or laparoscopy, is the preferred treatment option, while pneumatic dilatation can serve as a secondary option. Evaluation and management of complications including post-procedural reflux and cancer surveillance are recommended.
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Affiliation(s)
- Kee Huat Chuah
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Naveen Ramasami
- Gastroenterology and Hepatology Unit, Department of Medicine, Sultanah Bahiyah Hospital, Alor Setar, Kedah, Malaysia
| | | | | | - Glenn George Koleth
- Gastroenterology and Hepatology Unit, Department of Medicine, Sultan Ismail Hospital, Johor Bahru, Johor, Malaysia
| | - Kelvin Voon
- Department of General Surgery, Penang General Hospital, George Town, Penang, Malaysia
| | - Lai Teck Gew
- Gastroenterology and Hepatology Unit, Department of Medicine, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia
| | | | - Peng Choong Lau
- Pantai Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
- Department of Surgery, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Raman Muthukaruppan
- Gastroenterology and Hepatology Unit, Department of Medicine, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Rosaida Hj Md Said
- Gastroenterology and Hepatology Unit, Department of Medicine, Serdang Hospital, Serdang, Selangor, Malaysia
| | - Sanjiv Mahadeva
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Shiaw-Hooi Ho
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Shyang Yee Lim
- Department of General Surgery, Penang General Hospital, George Town, Penang, Malaysia
| | - Sze Chee Tee
- Department of Surgery, National Cancer Institute, Putrajaya, Malaysia
| | - Sze Li Siow
- Department of General Surgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Wei Keat Ooi
- Department of Surgery, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia
- GI Function and Motility Unit, Universiti Sains Malaysia Hospital, Kota Bharu, Kelantan, Malaysia
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27
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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] [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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28
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Zhang H, Huang Z, Tang X. Is it necessary to explore modified peroral endoscopic myotomy strategies to prevent the occurrence of gastroesophageal reflux? Gastrointest Endosc 2024; 99:131. [PMID: 38097303 DOI: 10.1016/j.gie.2023.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 08/25/2023] [Indexed: 12/18/2023]
Affiliation(s)
- Han Zhang
- Department of Gastroenterology, Zigong First People's Hospital, Zigong, China
| | - Zhong Huang
- Department of Gastroenterology, Zigong First People's Hospital, Zigong, China
| | - Xiaowei Tang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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29
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Dilsaver DB, Walters RW, Nandipati KC. Laparoscopic Heller Myotomy vs. Peroral Endoscopic Myotomy: an Analysis of the National Inpatient Sample Database. J Gastrointest Surg 2023; 27:2608-2610. [PMID: 37580486 DOI: 10.1007/s11605-023-05801-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/29/2023] [Indexed: 08/16/2023]
Affiliation(s)
- Danielle B Dilsaver
- Department of Clinical Research and Public Health, School of Medicine, Creighton University, Omaha, NE, USA
| | - Ryan W Walters
- Department of Clinical Research and Public Health, School of Medicine, Creighton University, Omaha, NE, USA
| | - Kalyana C Nandipati
- Department of Surgery, School of Medicine, Creighton University, 7710 Mercy Road, Suite 501, Creighton University Education Bldg, Omaha, NE, 68124, USA.
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30
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Denzer U, Müller M, Kreuser N, Thieme R, Hoffmeister A, Feisthammel J, Niebisch S, Gockel I. [Therapy of esophageal motility disorders]. Laryngorhinootologie 2023; 102:824-838. [PMID: 37263277 DOI: 10.1055/a-1949-3583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2020 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.
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Affiliation(s)
- Ulrike Denzer
- Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Germany
| | - Michaela Müller
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - Nicole Kreuser
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - René Thieme
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Juergen Feisthammel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Stefan Niebisch
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
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31
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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] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [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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32
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Denzer UW, Müller M, Kreuser N, Thieme R, Hoffmeister A, Feisthammel J, Niebisch S, Gockel I. [Therapy of esophageal motility disorders]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:183-197. [PMID: 35835360 DOI: 10.1055/a-1833-9299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2020 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.
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Affiliation(s)
- Ulrike W Denzer
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - Michaela Müller
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - Nicole Kreuser
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - René Thieme
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Juergen Feisthammel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Stefan Niebisch
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
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33
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Xiang J, Chai N, Wang S, Li L, Wang X, Linghu E. Long-term outcomes of peroral endoscopic myotomy for Chicago classification type I vs type III achalasia in treatment-naive patients. Dis Esophagus 2023; 36:doac055. [PMID: 35975660 DOI: 10.1093/dote/doac055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/14/2022] [Accepted: 07/30/2022] [Indexed: 02/01/2023]
Abstract
The efficacy of peroral endoscopic myotomy (POEM) for achalasia has potential associations with Chicago classification by high-resolution manometry (HRM). Type II achalasia demonstrates the best response to POEM of all subtypes, while there remain controversies between type I and type III. Moreover, previous treatment history might cause discrepancy in direct comparison. We aimed to compare the clinical outcome of POEM for type I vs type III in treatment-naive patients. In total, 82 patients with type I or type III achalasia (45 type I, 37 type III) from February 2015 to December 2018 were enrolled and POEM was carried out as the initial treatment. Clinical success, change of Eckardt scores and HRM parameters were analyzed and compared between type I and type III group. About, 43 (95.6%) patients and 34 (91.9%) patients in type I and type III group acquired the clinical success (P = 0.821). Eckardt score and HRM results after POEM treatment decreased significantly in either group (P<0.01). Compared to type III group, higher reduction rates of Eckardt score (type I vs type III, 78.6 vs 66.9%, P = 0.034) and basal LES pressure (type I vs type III, 58.9 vs 40.4%, P = 0.040) were observed in type I group. Type I achalasia patients showed better response to POEM with more favorable clinical remission in Eckardt score and HRM outcomes than type III.
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Affiliation(s)
- Jingyuan Xiang
- Department of Gastroenterology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Ningli Chai
- Department of Gastroenterology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Shasha Wang
- Department of Gastroenterology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Longsong Li
- Department of Gastroenterology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiangyao Wang
- Department of Gastroenterology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Enqiang Linghu
- Department of Gastroenterology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
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Sharma P, Stavropoulos SN. Is peroral endoscopic myotomy the new gold standard for achalasia therapy? Dig Endosc 2023; 35:173-183. [PMID: 36385512 DOI: 10.1111/den.14477] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/15/2022] [Indexed: 11/18/2022]
Abstract
Our review focuses on critical analysis of the literature to determine whether peroral endoscopic myotomy (POEM) is poised to replace laparoscopic Heller myotomy (LHM) as the new "gold standard" for achalasia therapy. POEM matches or exceeds the efficacy of LHM. The difference in objective gastroesophageal reflux disease (GERD) between POEM and LHM is modest at best and dissipates with time. Post-POEM GERD can be easily managed medically in most patients without long-term GERD sequelae or the need for surgical fundoplication. Emerging POEM technique modifications can further decrease GERD. Endoscopic antireflux procedures such as transoral incisionless fundoplication (TIF) or POEM + F (POEM + fundoplication) can be used in the rare cases of medication-refractory GERD, but their long-term efficacy remains in question. In this comprehensive review, we summarize the current status of POEM with emphasis on GERD evaluation, prevention, treatment, and comparative data vs. LHM. Based on this analysis, it appears that POEM is indeed the new gold standard in the therapy of achalasia.
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Affiliation(s)
- Prabin Sharma
- Department of Gastroenterology, Hartford Health Care-St. Vincent's Medical Center, Bridgeport, USA
| | - Stavros N Stavropoulos
- Division of Gastroenterology, John D. Archbold Memorial Hospital, Digestive Disease Center, Thomasville, USA
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Nabi Z, Reddy DN. Submucosal endoscopy: the present and future. Clin Endosc 2023; 56:23-37. [PMID: 36617645 PMCID: PMC9902679 DOI: 10.5946/ce.2022.139] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/17/2022] [Accepted: 07/22/2022] [Indexed: 01/10/2023] Open
Abstract
Submucosal endoscopy or third-space endoscopy utilizes the potential space between the mucosal and muscularis layers of the gastrointestinal tract to execute therapeutic interventions for various diseases. Over the last decade, endoscopic access to the submucosal space has revolutionized the field of therapeutic endoscopy. Submucosal endoscopy was originally used to perform endoscopic myotomy in patients with achalasia cardia, and its use has grown exponentially since. Currently, submucosal endoscopy is widely used to resect subepithelial tumors and to manage refractory gastroparesis and Zenker's diverticulum. While the utility of submucosal endoscopy has stood the test of time in esophageal motility disorders and subepithelial tumors, its durability remains to be established in conditions such as Zenker's diverticulum and refractory gastroparesis. Other emerging indications for submucosal endoscopy include esophageal epiphrenic diverticulum, Hirschsprung's disease, and esophageal strictures not amenable to conventional endoscopic treatment. The potential of submucosal endoscopy to provide easy and safe access to the mediastinum and peritoneal spaces may open doors to novel indications and rejuvenate the interest of endoscopists in natural orifice transluminal endoscopic surgery in the future. This review focuses on the current spectrum, recent updates, and future direction of submucosal endoscopy in the gastrointestinal tract.
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Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India
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Low EE, Fehmi SA, Hasan A, Chang M, Kwong W, Krinsky ML, Anand G, Greytak M, Kaizer A, Carlson DA, Pandolfino JE, Yadlapati R. Type II achalasia with focal elevated pressures: A distinct manometric and clinical sub-group. Neurogastroenterol Motil 2022; 34:e14449. [PMID: 35972282 PMCID: PMC9722506 DOI: 10.1111/nmo.14449] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/15/2022] [Accepted: 07/27/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Type II achalasia (Ach2) is distinguished from other achalasia sub-types by the presence of panesophageal pressurization (PEP) of ≥30 mmHg in ≥20% swallows on high-resolution manometry (HRM). Variable manometric features in Ach2 have been observed, characterized by focal elevated pressures (FEPs) (focal/segmental pressures ≥70 mmHg within the PEP band) and/or high compression pressures (PEP ≥70 mmHg). This study aimed to examine clinical and physiologic variables among sub-groups of Ach2. METHODS This retrospective single center study performed over 3 years (1/2019-1/2022) included adults with Ach2 on HRM who underwent endoscopic ultrasound (EUS), functional lumen imaging probe (FLIP), and/or barium esophagram (BE) prior to therapy. Patients were categorized into two overarching sub-groups: Ach2 without FEPs and Ach2 with FEPs. Demographic, clinical, and physiologic data were compared between these sub-groups utilizing unpaired univariate analyses. KEY RESULTS Of 53 patients with Ach2, 40 (75%) were without FEPs and 13 (25%) had FEPs. Compared with the Ach2 sub-group without FEPs, the Ach2 sub-group with FEPs demonstrated a significantly thickened distal esophageal circular muscle on EUS (1.4 mm [SD 0.9] vs. 2.1 [0.7]; p = 0.02), higher prevalence of tertiary contractions on BE (46% vs. 100%; p = 0.0006), lower esophagogastric junction distensibility index (2.2mm2 /mmHg [0.9] vs 0.9 [0.4]; p = 0.0008) as well as higher distensive pressure (31.0 mmHg [9.8] vs. 55.4 [18.8]; p = 0.01) at 60 cc fill on FLIP, and higher prevalence of chest pain on Eckardt score (p = 0.03). CONCLUSIONS AND INFERENCES We identified a distinct sub-group of type II achalasia on HRM, defined as type II achalasia with focal elevated pressures. This sub-group uniquely exhibits spastic features and may benefit from personalized treatment approaches.
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Affiliation(s)
- Eric E. Low
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Syed Abbas Fehmi
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Aws Hasan
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Michael Chang
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Wilson Kwong
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Mary L. Krinsky
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Gobind Anand
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Madeline Greytak
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Alexander Kaizer
- Department of Biostatistics & Informatics, University of Colorado, Denver, Colorado, USA
| | - Dustin A. Carlson
- Division of Gastroenterology, Northwestern University, Chicago, Illinois, USA
| | - John E. Pandolfino
- Division of Gastroenterology, Northwestern University, Chicago, Illinois, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
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Risks of refractory chest pain after peroral endoscopic myotomy in achalasia-related esophageal motility disorders: short-term results from a multicenter study in Japan. Gastrointest Endosc 2022; 96:620-629.e4. [PMID: 35568241 DOI: 10.1016/j.gie.2022.04.1347] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/30/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The etiology of chest pain in achalasia-related esophageal motility disorders and the frequency and risk factors of persistent chest pain after peroral endoscopic myotomy (POEM) remain unclear. METHODS A multicenter cohort study including 14 hospitals was conducted to elucidate the characteristics of patients with chest pain and the efficacy of POEM. RESULTS Consecutive cases of achalasia-related esophageal motility disorders included 2294 (64.2%) and 1280 (35.8%) patients with and without chest pain, respectively. Among the 2107 patients with chest pain who underwent POEM, we observed complete remission in 1464 patients (69.5%) and nonremission in 643 patients (30.5%), including a partial response in 619 patients (29.4%) and resistance in 24 patients (1.1%). Multivariate analysis revealed that advanced age (odds ratio [OR], .28), male sex (OR, .70), prior treatment (OR, 1.39), and sigmoid type (OR, .65) were related to the prevalence of chest pain. Long disease duration (OR, .69) and esophageal dilation (OR, .79) were related to decreased severity. POEM improved patients' quality of life that was hindered by chest pain. Early onset (OR, 1.45), advanced age (OR, .58), male sex (OR, .79), prior treatment (OR, 1.37), and posterior myotomy (OR, 1.42) were associated with nonremission after POEM; high-resolution manometry (HRM) findings and myotomy length showed no statistical significance on pain etiology and persistence after POEM. CONCLUSIONS The prevalence and severity of chest pain were dependent on age, sex, disease duration, prior treatment, and esophageal morphology rather than HRM findings. The efficacy of POEM is satisfactory; however, residual pain was often observed. Excessively long myotomy can be avoided, and anterior myotomy may be recommended.
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de Moura ETH, Jukemura J, Ribeiro IB, Farias GFA, de Almeida Delgado AA, Coutinho LMA, de Moura DTH, Aissar Sallum RA, Nasi A, Sánchez-Luna SA, Sakai P, de Moura EGH. Peroral endoscopic myotomy vs laparoscopic myotomy and partial fundoplication for esophageal achalasia: A single-center randomized controlled trial. World J Gastroenterol 2022; 28:4875-4889. [PMID: 36156932 PMCID: PMC9476850 DOI: 10.3748/wjg.v28.i33.4875] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/07/2022] [Accepted: 08/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Achalasia is a rare benign esophageal motor disorder characterized by incomplete relaxation of the lower esophageal sphincter (LES). The treatment of achalasia is not curative, but rather is aimed at reducing LES pressure. In patients who have failed noninvasive therapy, surgery should be considered. Myotomy with partial fundoplication has been considered the first-line treatment for non-advanced achalasia. Recently, peroral endoscopic myotomy (POEM), a technique that employs the principles of submucosal endoscopy to perform the equivalent of a surgical myotomy, has emerged as a promising minimally invasive technique for the management of this condition. AIM To compare POEM and laparoscopic myotomy and partial fundoplication (LM-PF) regarding their efficacy and outcomes for the treatment of achalasia. METHODS Forty treatment-naive adult patients who had been diagnosed with achalasia based on clinical and manometric criteria (dysphagia score ≥ II and Eckardt score > 3) were randomized to undergo either LM-PF or POEM. The outcome measures were anesthesia time, procedure time, symptom improvement, reflux esophagitis (as determined with the Gastroesophageal Reflux Disease Questionnaire), barium column height at 1 and 5 min (on a barium esophagogram), pressure at the LES, the occurrence of adverse events (AEs), length of stay (LOS), and quality of life (QoL). RESULTS There were no statistically significant differences between the LM-PF and POEM groups regarding symptom improvement at 1, 6, and 12 mo of follow-up (P = 0.192, P = 0.242, and P = 0.242, respectively). However, the rates of reflux esophagitis at 1, 6, and 12 mo of follow-up were significantly higher in the POEM group (P = 0.014, P < 0.001, and P = 0.002, respectively). There were also no statistical differences regarding the manometry values, the occurrence of AEs, or LOS. Anesthesia time and procedure time were significantly shorter in the POEM group than in the LM-PF group (185.00 ± 56.89 and 95.70 ± 30.47 min vs 296.75 ± 56.13 and 218.75 ± 50.88 min, respectively; P = 0.001 for both). In the POEM group, there were improvements in all domains of the QoL questionnaire, whereas there were improvements in only three domains in the LM-PF group. CONCLUSION POEM and LM-PF appear to be equally effective in controlling the symptoms of achalasia, shortening LOS, and minimizing AEs. Nevertheless, POEM has the advantage of improving all domains of QoL, and shortening anesthesia and procedure times but with a significantly higher rate of gastroesophageal reflux.
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Affiliation(s)
- Eduardo Turiani Hourneaux de Moura
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Sao Paulo 05403-010, Brazil
| | - José Jukemura
- Division of Esophageal Surgery, Hospital das Clínicas, University of São Paulo School of Medicine, Sao Paulo 05403-010, Brazil
| | - Igor Braga Ribeiro
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Sao Paulo 05403-010, Brazil
| | - Galileu Ferreira Ayala Farias
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Hospital das Clínicas, University of São Paulo School of Medicine, Sao Paulo 05403-010, Brazil
| | - Aureo Augusto de Almeida Delgado
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Hospital das Clínicas, University of São Paulo School of Medicine, Sao Paulo 05403-010, Brazil
| | - Lara Meireles Azeredo Coutinho
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Hospital das Clínicas, University of São Paulo School of Medicine, Sao Paulo 05403-010, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Hospital das Clínicas, University of São Paulo School of Medicine, Sao Paulo 05403-010, Brazil
| | - Rubens Antonio Aissar Sallum
- Division of Esophageal Surgery, Hospital das Clínicas, University of São Paulo School of Medicine, Sao Paulo 05403-010, Brazil
| | - Ary Nasi
- Division of Esophageal Surgery, Hospital das Clínicas, University of São Paulo School of Medicine, Sao Paulo 05403-010, Brazil
| | - Sergio A Sánchez-Luna
- Department of Internal Medicine, The University of Alabama at Birmingham Heersink School of Medicine, Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology and Hepatology, Birmingham, AL 35233, United States
| | - Paulo Sakai
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Sao Paulo 05403-010, Brazil
| | - Eduardo Guimarães Hourneaux de Moura
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de Sao Paulo, Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas HCFMUSP, Sao Paulo 05403-010, Brazil
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Nabi Z, Nageshwar Reddy D. Impact of modified techniques on outcomes of peroral endoscopic myotomy: A narrative review. Front Med (Lausanne) 2022; 9:948299. [PMID: 36059849 PMCID: PMC9433832 DOI: 10.3389/fmed.2022.948299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/08/2022] [Indexed: 12/02/2022] Open
Abstract
Peroral endoscopic myotomy (POEM) is an established frontline treatment modality for achalasia cardia. Since its initial description, several modifications have been proposed to the technique of POEM. Broadly speaking, these modifications follow the basic principles of submucosal endoscopy, but incorporate variations in the POEM technique, including the difference in the orientation of myotomy (anterior or posterior), length of myotomy (short or long), and thickness of myotomy (selective circular or full thickness). Some of these modifications have been shown to reduce procedural duration without compromising the efficacy of the POEM procedure. More recently, several alterations have been reported that intend to reduce gastroesophageal reflux after POEM. These include preservation of sling fibers during posterior POEM and addition of NOTES fundoplication to the POEM procedure. Although some of the modified techniques have been compared with the conventional techniques in quality trials, randomized studies are awaited for others. The incorporation of some of these modifications will likely make POEM a technically easy and safer modality in near future. This review aims to discuss the current evidence with regard to the impact of modified techniques on the outcome of POEM.
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Hasan A, Low EE, Fehmi SA, Yadlapati R. Evolution and evidence-based adaptations in techniques for peroral endoscopic myotomy for achalasia. Gastrointest Endosc 2022; 96:189-196. [PMID: 35278427 PMCID: PMC9838104 DOI: 10.1016/j.gie.2022.03.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/03/2022] [Indexed: 02/08/2023]
Abstract
Achalasia is an esophageal motility disorder characterized by impaired lower esophageal sphincter (LES) relaxation and failed peristalsis. Common clinical manifestations include dysphagia to solid and liquid foods, chest pain, regurgitation, and weight loss, resulting in significant morbidity and healthcare burden. Historically, surgical Heller myotomy and pneumatic dilation were the first-line therapeutic options for achalasia. This convention was shaken in 2009 when Inoue and colleagues introduced an endoscopic approach to dissect the muscle fibers of the LES, known as peroral endoscopic myotomy (POEM). Since incorporation of POEM into standard practice, the overall myotomy technique has remained unchanged; however, adaptations in the thickness and length of myotomy have evolved. Full-thickness myotomy is recognized to have similar clinical success and faster procedure times compared with selective circular muscle myotomy. Although myotomy length for type 1 and type 2 achalasia has classically been >6 cm, recent studies demonstrated similar outcomes with reduction of myotomy length to <3 cm. Length of myotomy for type 3 achalasia has been tailored to treat the entire length of spastic muscle segment, and the modality to gauge the optimal thickness and length of myotomy in this group has yet to be established. In addition to changes in POEM technique, the postoperative management of POEM has also changed, favoring reduced postprocedure imaging, antibiotic use, and hospitalizations.
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Affiliation(s)
- Aws Hasan
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Eric E. Low
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Syed Abbas Fehmi
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
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Nabi Z, Talukdar R, Mandavdhare H, Reddy DN. Short versus long esophageal myotomy during peroral endoscopic myotomy: A systematic review and meta-analysis of comparative trials. Saudi J Gastroenterol 2022; 28:261-267. [PMID: 34806659 PMCID: PMC9408737 DOI: 10.4103/sjg.sjg_438_21] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/05/2021] [Accepted: 09/07/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND : Peroral endoscopic myotomy (POEM) is an established modality of treatment for achalasia cardia. Considerable variations exist in the technique of POEM with respect to the length and orientation of the myotomy. In this systematic review and meta-analysis, we compared the outcomes of short versus long myotomy during POEM. METHODS : We searched multiple databases from January 2010 to March 2021 to identify studies reporting on POEM. We selected studies that reported on comparative outcomes of POEM using short versus long myotomy. We performed a comparative analysis of clinical success, procedural duration, gastroesophageal reflux disease (GERD), and adverse events with short and long myotomy in POEM by meta-analysis. RESULTS : A total of 521 patients from five studies in which 241 patients were treated with short and 280 patients with long myotomy approaches were analyzed. The pooled rate for clinical success gave an odds ratio (OR) of 1.27 (95% confidence interval [CI] 0.50-3.26; I2 = 0; P = 0.62); for hospital stay OR 0.22 (95% CI - 0.03 to 0.46; I2 = 0; P = 0.08); for GERD by esophagogastroduodenoscopy (EGD) OR 0.58 (95% CI 0.31-1.07; I2 = 0; P = 0.08), and for adverse events OR 0.67 (95% CI 0.29-1.53; I2 = 51; P = 0.34). Abnormal esophageal acid exposure was less frequent with OR 0.45 (95% CI 0.22-0.90; P = 0.02; I2 = 0) and the procedure duration was significantly shorter in the short myotomy group with OR - 0.76 (95% CI - 1.00 to - 0.52; I2 = 43; P =0.001). CONCLUSION : Short myotomy and long myotomy in POEM seem comparable with each other in terms of clinical success and adverse events. Short myotomy is associated with significantly shorter procedural duration and possibly reduced esophageal acid exposure compared with long myotomy.
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Affiliation(s)
- Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Rupjyoti Talukdar
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | | | - D. Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
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Changes in Distensibility Index During an Incremental POEM Myotomy. J Gastrointest Surg 2022; 26:1140-1146. [PMID: 35233701 DOI: 10.1007/s11605-022-05278-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 02/05/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND A longer myotomy for the treatment of achalasia is associated with worse gastroesophageal reflux disease despite palliating dysphagia. Recently, clinical outcomes have been correlated to the distensibility of the distal esophagus, which is measured intra-operatively using an endoscopic functional luminal image probe (EndoFLIP). We aimed to determine the minimum per oral endoscopic myotomy (POEM) length to allow for adequate distensibility index (DI). METHODS A 6-cm myotomy conducted in 2-cm increments during POEM was performed for patients with achalasia I and II from 2017 to 2019. The EndoFLIP was used to measure the DI intra-operatively: (1) prior to intervention, (2) following creation of the submucosal tunnel, (3) following transection of the high-pressure zone (HPZ), (4) following the distal extension, and (5) following the proximal esophageal extension. RESULTS A total of 16 patients underwent POEM. Ages ranged from 21 to 78 years, 10 were male, and 13 had type II achalasia. The median DI was 2.7 (1.4-3.6) mm2/mmHg prior to intervention; 2.4 (1.4-3.3) mm2/mmHg following the submucosal tunnel; 3.2 (1.6-4.4) mm2/mmHg following transection of the HPZ; 3.8 (2.6-4.5) mm2/mmHg following the gastric extension; and 4.5 (3.3-7.1) mm2/mmHg following the proximal extension. Our target range DI was achieved for 50% of patients after transection of the HPZ. CONCLUSIONS Distensibility changed with each myotomy increment and fell within the target range for most patients following a 2-4-cm myotomy. This suggests that a shorter myotomy may be appropriate for select patients, and the use of the EndoFLIP intra-operatively may allow for a tailored myotomy length.
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Zhang H, Zeng X, Huang S, Xia H, Shi L, Jiang J, Ren W, Peng Y, Lü M, Tang X. Safety and Efficacy of Peroral Endoscopic Shorter Myotomy versus Longer Myotomy for Patients with Achalasia: A Systematic Review and Meta-analysis. Gastroenterol Res Pract 2022; 2022:6770864. [PMID: 35401740 PMCID: PMC8986442 DOI: 10.1155/2022/6770864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/14/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND AIMS The adequate myotomy length during peroral endoscopic myotomy (POEM) is still controversial. We performed this systematic review and meta-analysis to determine the efficacy and safety of the modified POEM with shorter myotomy (SM) and compare the outcomes between SM and longer myotomy (LM) in achalasia patients. METHODS A comprehensive literature search was conducted in PubMed, EMBASE, Cochrane Library, and Web of Science databases from inception to May 28, 2021. The primary outcome was clinical success rate and incidence of reflux-relative adverse events (AEs). Fixed- or random-effect models were adopted for the analysis according to the heterogeneity. RESULTS Five studies involving 225 patients in SM group and 222 patients in LM group were included. The overall clinical success of SM was 96.6% (95% confidence interval (CI) 92.7 to 98.4%). SM showed noninferior response as compared to LM (risk ratio (RR) 1.02, 95% CI 0.98 to 1.06, P = 0.41, I 2 = 0%). Based on the abnormal acid reflux by pH monitoring, its incidence was significantly lower in the SM group than that in the LM group (RR 0.58, 95% CI 0.36 to 0.94, P = 0.03, I 2 = 0%). With respect to procedure-related parameters, the total procedure time of SM was significantly shorter than that of LM (mean difference (MD) -16.30, 95% CI -23.10 to -9.49, P < 0.001, I 2 = 68%). CONCLUSIONS SM and LM are comparable in providing treatment efficacy for achalasia patients, whereas less operation time and lower incidence of post-POEM abnormal esophageal acid exposure are observed in SM.
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Affiliation(s)
- Han Zhang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xinyi Zeng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shu Huang
- Department of Gastroenterology, The People's Hospital of Lianshui, Huaian, China
| | - Huifang Xia
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Lei Shi
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jiao Jiang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Wensen Ren
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yan Peng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Muhan Lü
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaowei Tang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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Weng CY, He CH, Zhuang MY, Xu JL, Lyu B. Peroral endoscopic longer vs shorter esophageal myotomy for achalasia treatment: A systematic review and meta-analysis. World J Gastrointest Surg 2022; 14:247-259. [PMID: 35432766 PMCID: PMC8984519 DOI: 10.4240/wjgs.v14.i3.247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/09/2021] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) has been demonstrated to be safe and effective in the treatment of achalasia. Longer myotomy is the standard POEM procedure for achalasia but when compared with shorter myotomy, its effectiveness is not as well known.
AIM To compare the clinical effectiveness of longer and shorter myotomy.
METHODS PubMed, EmBase, Cochrane Library, web of science and clinicaltrials.gov were queried for studies comparing shorter and longer POEM for achalasia treatment. The primary outcome was clinical success rate. Secondary outcomes comprised of operative time, adverse events (AEs) rate, gastroesophageal reflux disease (GERD) and procedure-related parameters. The Mantel-Haenszel fixed-effects model was primarily used for the analysis. Publication bias was assessed.
RESULTS Six studies were included in this analysis with a total of 514 participants. During the follow-up period of 1-28.7 mo, longer and shorter myotomy in treating achalasia showed similar excellent effectiveness [overall clinical success (OR = 1, 95%CI: 0.46-2.17, P = 1, I2: 0%; subgroup of abstract (OR = 1.19, 95%CI: 0.38 to 3.73; P = 0.76; I2: 0%); subgroup of full text (OR = 0.86 95%CI: 0.30 to 2.49; P = 0.78; I2: 0%)]. Shorter myotomy had significantly reduced mean operative time compared with the longer procedure. There were no statistically significant differences in AEs rates, including GERD (overall OR = 1.21, 95%CI: 0.76-1.91; P = 0.42; I2: 9%; subgroup of abstract OR = 0.77, 95%CI: 0.40-1.47; P = 0.43; I2: 0%; subgroup of full text OR = 1.91, 95%CI: 0.98-3.75; P = 0.06; I2: 0%), hospital stay (overall MD = -0.07, 95%CI: -0.30 to 0.16; P = 0.55; I2: 24%; subgroup of abstract MD = 0.20, 95%CI: -0.25 to 0.65; P = 0.39; I2: 0; subgroup of full text MD = -0.16, 95%CI: -0.42 to 0.10; P = 0.23; I2: 42%), and major bleeding (overall OR = 1.25, 95%CI: 0.58-2.71; P = 0.56; I2: 0%) between the two procedures. These differences remained statistically non-significant in all sensitivity analyses.
CONCLUSION POEM was effective in treating achalasia. Shorter and longer myotomy procedures provided similar therapeutic effects in terms of long-term effectiveness. In addition, shorter myotomy reduced the operative time.
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Affiliation(s)
- Chun-Yan Weng
- Department of Gastroenterology, The First Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang Province, China
| | - Cheng-Hai He
- Department of Gastroenterology, The Affiliated Hospital of Hangzhou Normal University, Hangzhou 310006, Zhejiang Province, China
| | - Ming-Yang Zhuang
- Internal Medicine of Chinese Medicine, The First Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang Province, China
| | - Jing-Li Xu
- Department of Surgery, The First Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang Province, China
| | - Bin Lyu
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang Chinese Medicine University, Hangzhou 310006, Zhejiang Province, China
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Modified Peroral Endoscopic Myotomy Technique for Type II Achalasia: A Multicenter Retrospective Study. Gastroenterol Res Pract 2022; 2022:3424470. [PMID: 35368617 PMCID: PMC8975685 DOI: 10.1155/2022/3424470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/11/2022] [Accepted: 03/15/2022] [Indexed: 11/17/2022] Open
Abstract
Aim This retrospective study is aimed at evaluating the outcomes of a modified peroral endoscopic myotomy (POEM) technique in patients with type II achalasia. Methods We performed a modified POEM procedure, which involved a shorter (total myotomy length = 4 cm), full-thickness myotomy, on 31 patients with type II achalasia. Clinical success rates, technical success rates, pre- and postoperative esophageal manometry results, complications, and reflux-related adverse events were evaluated. Results The clinical success (Eckardt score ≤ 3) rates were 100% and 88.9% within 2 years and beyond 2 years postoperatively, respectively. The median lower esophageal sphincter pressures (LESP) decreased from 31.6 (26.7-49.7) mmHg preoperatively to 13.4 (10.5-21.6) and 11.8 (7.4-16.7) mmHg (P < 0.001) at 6 and 12 months postoperatively, respectively. The median integrated relaxation pressure (IRP) decreased from 27.8 (20.6-37.5) mmHg preoperatively to 12.9 (11.3-23.4) and 11.6 (9.6-16.8) mmHg (P < 0.001) at 6 and 12 months after POEM, respectively. Only one case (3.2%) of mucosal injury, four (12.9%) cases of reflux esophagitis, and two (6.5%) cases of gastroesophageal reflux symptoms were reported. Conclusions The modified POEM technique showed excellent outcomes in patients with type II achalasia.
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Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) utilizes the principles of natural orifice transluminal surgery to create an operative tunnel within the submucosal space, perform an endoluminal esophagogastromyotomy, and ultimately mitigate the progressive symptoms of achalasia. POEM is an innovative minimally invasive technique increasing in popularity and clinical significance as an effective treatment for achalasia and other disorders of spastic esophageal motility. METHODS A comprehensive literature review was performed regarding the procedure, outcomes, and technical advancements in POEM. RESULTS A growing number of studies world-wide have shown that POEM is a safe and effective for all types of achalasia, sigmoid and non-sigmoid type. CONCLUSIONS POEM continues to gain traction as a highly effective therapeutic modality for achalasia. As natural orifice transluminal surgery advances, further research is necessary to optimize utilization of endoluminal functional imaging, to tailor endoscopic technique, and to address the adverse effect of post-operative reflux and esophagitis.
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Abstract
AbstractThird space or submucosal space is a potential space which on expansion allows the endoscopist to execute a multitude of therapeutic procedures for various gastrointestinal diseases like achalasia, subepithelial tumors, Zenker’s diverticulum, and refractory gastroparesis. Third space was first utilized for performing endoscopic myotomy in cases with achalasia cardia about a decade ago. Since then, the field of submucosal endoscopy has witnessed an exponential growth. The present review focuses on recent advances in the field of third-space endoscopy. With regard to per-oral endoscopic myotomy (POEM) in achalasia cardia, several recent studies have evaluated the long-term outcomes of POEM, compared endoscopic myotomy with pneumatic dilatation (PD) and surgical myotomy, and evaluated the outcomes of short- versus long-esophageal myotomy. In addition, the utility of multiple dose antibiotic prophylaxis to prevent infections after POEM has been questioned. Overall, the results from these studies indicate that POEM is a durable treatment modality, equally effective to Heller’s myotomy and superior to PD. With regard to gastric-POEM (G-POEM), recent studies suggest only modest efficacy in cases with refractory gastroparesis. Therefore, quality studies are required to identify predictors of response to optimize the outcomes of G-POEM in these cases. Another third-space endoscopy procedure that has gained popularity is endoscopic division of septum in cases with esophageal diverticula including Zenker’s POEM and epiphrenic diverticula POEM (Z-POEM and D-POEM, respectively). The technique of diverticulotomy using the principles of submucosal endoscopy appears safe and effective in short term. Data on term outcomes are awaited and comparative trials with flexible endoscopic myotomy required. Per-rectal endoscopic myotomy (PREM) is the most recent addition to third space endoscopy procedures for the management of short-segment Hirschsprung’s disease. Limited data suggest that PREM may be a promising alternative surgery in these cases. However, quality studies with long-term follow-up are required to validate the outcomes of PREM.
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Affiliation(s)
- Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - D Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
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Ghazaleh S, Beran A, Khader Y, Nehme C, Chuang J, Sharma S, Aziz M, Khan Z, Elzanaty AM, Burlen J, Nawras A. Short versus standard peroral endoscopic myotomy for esophageal achalasia: a systematic review and meta-analysis. Ann Gastroenterol 2021; 34:634-642. [PMID: 34475733 PMCID: PMC8375650 DOI: 10.20524/aog.2021.0644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/07/2021] [Indexed: 12/13/2022] Open
Abstract
Background Peroral endoscopic myotomy (POEM) is increasingly used to treat esophageal achalasia, but is associated with a high rate of gastroesophageal reflux disease (GERD). The aim of our meta-analysis was to compare short and standard POEM in terms of clinical success and postoperative GERD. Methods We conducted a systematic review and meta-analysis of studies that compared POEM using short myotomy with standard myotomy. The primary outcome was clinical success. Secondary outcomes were postoperative GERD, perioperative complications, operation time, and length of hospital stay. A random-effects model was used to calculate the risk ratios (RR), mean differences (MD), and confidence intervals (CI). A P-value <0.05 was considered statistically significant. Results We included 5 studies involving 474 esophageal achalasia patients. Short and standard myotomies were similar in terms of clinical success (RR 1.02, 95%CI 0.97-1.09), perioperative complications (RR 0.68, 95%CI 0.26-1.75), and length of hospital stay (MD 0.25 days, 95%CI -0.14-0.63). Operation time was shorter for short myotomy (MD -15.01 mins, 95%CI -20.34 - -9.67). Although reflux symptoms were similar (RR 0.94, 95%CI 0.51-1.74), short myotomy had a lower risk of reflux esophagitis on endoscopy (RR 0.61, 95%CI 0.39-0.98), and pathologic acid exposure on pH monitoring (RR 0.58, 95%CI 0.36-0.94). Conclusions POEM using a shorter myotomy is comparable with standard myotomy in terms of efficacy and safety in the short-term setting. A short myotomy requires a shorter operation time and might reduce the occurrence of postoperative GERD.
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Affiliation(s)
- Sami Ghazaleh
- Department of Internal Medicine, University of Toledo, Toledo, OH (Sami Ghazaleh, Azizullah Beran, Yasmin Khader, Christian Nehme, Justin Chuang, Sachit Sharma, Ahmed M. Elzanaty)
| | - Azizullah Beran
- Department of Internal Medicine, University of Toledo, Toledo, OH (Sami Ghazaleh, Azizullah Beran, Yasmin Khader, Christian Nehme, Justin Chuang, Sachit Sharma, Ahmed M. Elzanaty)
| | - Yasmin Khader
- Department of Internal Medicine, University of Toledo, Toledo, OH (Sami Ghazaleh, Azizullah Beran, Yasmin Khader, Christian Nehme, Justin Chuang, Sachit Sharma, Ahmed M. Elzanaty)
| | - Christian Nehme
- Department of Internal Medicine, University of Toledo, Toledo, OH (Sami Ghazaleh, Azizullah Beran, Yasmin Khader, Christian Nehme, Justin Chuang, Sachit Sharma, Ahmed M. Elzanaty)
| | - Justin Chuang
- Department of Internal Medicine, University of Toledo, Toledo, OH (Sami Ghazaleh, Azizullah Beran, Yasmin Khader, Christian Nehme, Justin Chuang, Sachit Sharma, Ahmed M. Elzanaty)
| | - Sachit Sharma
- Department of Internal Medicine, University of Toledo, Toledo, OH (Sami Ghazaleh, Azizullah Beran, Yasmin Khader, Christian Nehme, Justin Chuang, Sachit Sharma, Ahmed M. Elzanaty)
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH (Muhammad Aziz, Jordan Burlen, Ali Nawras)
| | - Zubair Khan
- Division of Gastroenterology and Hepatology, University of Texas, Houston, TX (Zubair Khan), USA
| | - Ahmed M Elzanaty
- Department of Internal Medicine, University of Toledo, Toledo, OH (Sami Ghazaleh, Azizullah Beran, Yasmin Khader, Christian Nehme, Justin Chuang, Sachit Sharma, Ahmed M. Elzanaty)
| | - Jordan Burlen
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH (Muhammad Aziz, Jordan Burlen, Ali Nawras)
| | - Ali Nawras
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH (Muhammad Aziz, Jordan Burlen, Ali Nawras)
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Abstract
PURPOSE OF REVIEW Third space endoscopy (TSE) or submucosal endoscopy provides with the opportunity for minimally invasive management of various gastrointestinal disorders. TSE is a relatively new field and the knowledge on its utility continues to advance. The purpose of this review is to provide with updated evidence on the efficacy and utility of TSE in gastrointestinal motility disorders including achalasia and refractory gastroparesis. RECENT FINDINGS Peroral endoscopic myotomy (POEM) is a safe procedure with emerging evidence on its durability as well. Major technical variations do not appear to impact the outcomes of POEM. Recent randomized trials suggest superiority of POEM over pneumatic dilatation and noninferiority over Heller's myotomy in idiopathic achalasia. With regard to gastric POEM (G-POEM), recent evidence confirms its efficacy in refractory gastroparesis. Although effective, the long-term outcomes of G-POEM are not well known. In addition, the criteria for patient selection remain elusive. SUMMARY TSE has emerged as a new frontier in the endoscopic management of gastrointestinal motility disorders. While short-term outcomes are encouraging, the durability of TSE remains to be seen in achalasia as well as refractory gastroparesis. Insights regarding patient selection and predictors of outcomes may help optimizing the results of gastric POEM in refractory gastroparesis.
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50
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Nabi Z, Ramchandani M, Chavan R, Basha J, Reddy M, Darisetty S, Reddy ND. Double tunnel technique reduces technical failure during POEM in cases with severe submucosal fibrosis. Endosc Int Open 2021; 9:E1335-E1341. [PMID: 34466356 PMCID: PMC8367433 DOI: 10.1055/a-1499-6817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/02/2021] [Indexed: 11/19/2022] Open
Abstract
Background and study aims Submucosal fibrosis (SMF) is one of the major reasons for technical failure during per-oral endoscopic myotomy (POEM). In this study, we aimed to evaluate the impact of double tunnel technique (DT-POEM) on the technical success of POEM in cases with severe SMF. Patients and methods Data from patients with achalasia in whom SMF was encountered during POEM from Jan 2013 to Jan 2020 at our center were retrospectively evaluated. The technical success and adverse events (AEs) were analyzed and compared between cases with SMF who underwent POEM via single tunnel versus DT-POEM technique. Results A total of 1,150 patients underwent POEM during the study period. There were 14 technical failures (1.2 %). SMF and severe SMF was found in 104 (9 %) and 21 (1.8 %) patients, respectively. The majority of patients (17, 80.9 %) with severe SMF had type I achalasia. Overall, technical failures occurred in 14 cases (1.2 %) and severe SMF resulted in the majority of the technical failures (10, 71.4 %). DT-POEM was utilized in 11 cases (52.4 %) with severe SMF. The median procedure time with DT-POEM was 150 minutes (85-210). There were no major AEs and DT-POEM was technically successful in all the patients. The technical success of POEM in cases with SMF improved after the adoption of the double tunnel technique (98.4 % vs 68.3 %, P = 0.0001). Conclusions Severe SMF is the most common reason for technical failure during POEM. DT-POEM improves the technical success rates of POEM in patients with severe SMF.
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Affiliation(s)
- Zaheer Nabi
- Asian institute of Gastroenterology, Hyderabad, India
| | | | | | | | - Manohar Reddy
- Asian institute of Gastroenterology, Hyderabad, India
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