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Otowa Y, Kawara F, Takiguchi G, Yamanaka K, Goto T, Nishioka C, Kuroda D, Ku Y. Treatment strategy and clinical outcomes of thoracoscopic endoscopic cooperative surgery for submucosal tumors in the esophagus. Surg Today 2025:10.1007/s00595-025-03003-3. [PMID: 40019506 DOI: 10.1007/s00595-025-03003-3] [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: 06/22/2024] [Accepted: 12/25/2024] [Indexed: 03/01/2025]
Abstract
PURPOSE Recently, submucosal tumors (SMTs) of the esophagus have been treated with peroral endoscopic tumor resection (POET) and a new procedure called thoracoscopic endoscopic cooperative surgery (TECS). This study aimed to validate the treatment strategy for SMTs and determine whether or not TECS is a viable option when POET is not feasible. METHODS POET and TECS were performed in 12 patients between February 2020 and January 2024. The clinical characteristics and perioperative outcomes were retrospectively evaluated. RESULTS Six patients were included in each group, with most of the tumors located in the middle thoracic esophagus (75%). The general anesthesia duration was significantly longer in the TECS group than in the POET group (P < 0.001), but no significant differences in endoscopic procedure time, tumor mass index, oral intake date, or length of hospital stay were observed between the two groups. En bloc and R0 resections were performed in all patients. One patient in the TECS group experienced a Clavien-Dindo grade 3a adverse event, and no tumor recurrence occurred during the median follow-up period of 33 (range, 6-53) months. CONCLUSION TECS is a safe and feasible option for SMTs when POET is difficult to perform.
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Affiliation(s)
- Yasunori Otowa
- Department of Gastrointestinal Surgery, Konan Medical Center, 1-5-16 Kamokogahara, Higashinada Ward, Kobe, 658-0064, Japan
| | - Fumiaki Kawara
- Department of Gastroenterology, Konan Medical Center, Kobe, Japan.
| | - Gosuke Takiguchi
- Department of Gastrointestinal Surgery, Konan Medical Center, 1-5-16 Kamokogahara, Higashinada Ward, Kobe, 658-0064, Japan
- Takiguchi Clinic, Kobe, Japan
| | - Kodai Yamanaka
- Department of Gastroenterology, Konan Medical Center, Kobe, Japan
| | - Tadahiro Goto
- Department of Gastrointestinal Surgery, Konan Medical Center, 1-5-16 Kamokogahara, Higashinada Ward, Kobe, 658-0064, Japan
| | - Chiharu Nishioka
- Department of Gastroenterology, Konan Medical Center, Kobe, Japan
| | - Daisuke Kuroda
- Department of Gastrointestinal Surgery, Konan Medical Center, 1-5-16 Kamokogahara, Higashinada Ward, Kobe, 658-0064, Japan
| | - Yonson Ku
- Department of Gastrointestinal Surgery, Konan Medical Center, 1-5-16 Kamokogahara, Higashinada Ward, Kobe, 658-0064, Japan
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Tawheed A, Bahcecioglu IH, Yalniz M, El-Kassas M. Gastroesophageal reflux after per-oral endoscopic myotomy: Management literature. World J Gastroenterol 2024; 30:2947-2953. [PMID: 38946871 PMCID: PMC11212704 DOI: 10.3748/wjg.v30.i23.2947] [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: 03/13/2024] [Revised: 05/06/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024] Open
Abstract
In this editorial, we respond to a review article by Nabi et al, in which the authors discussed gastroesophageal reflux (GER) following peroral endoscopic myotomy (POEM). POEM is presently the primary therapeutic option for achalasia, which is both safe and effective. A few adverse effects were documented after POEM, including GER. The diagnostic criteria were not clear enough because approximately 60% of patients have a long acid exposure time, while only 10% experience reflux symptoms. Multiple predictors of high disease incidence have been identified, including old age, female sex, obesity, and a baseline lower esophageal sphincter pressure of less than 45 mmHg. Some technical steps during the procedure, such as a lengthy or full-thickness myotomy, may further enhance the risk. Proton pump inhibitors are currently the first line of treatment. Emerging voices are increasingly advocating for the routine combining of POEM with an endoscopic fundoplication method, such as peroral endoscopic fundoplication or transoral incisionless fundoplication. However, more research is necessary to determine the safety and effectiveness of these procedures in the long term for patients who have undergone them.
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Affiliation(s)
- Ahmed Tawheed
- Department of Endemic Medicine, Faculty of Medicine, Helwan University, Cairo 11795, Egypt
| | | | - Mehmet Yalniz
- Department of Gastroenterology, Faculty of Medicine, Firat University, Elazig 23119, Türkiye
| | - Mohamed El-Kassas
- Department of Endemic Medicine, Faculty of Medicine, Helwan University, Cairo 11795, Egypt
- Liver Disease Research Center, College of Medicine, King Saud University, Riyadh 7805, Saudi Arabia
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DeWitt JM, Othman MO, Bapaye A. Do's and don'ts in esophageal peroral endoscopic myotomy: troubleshooting, managing adverse events, and tips for success. Gastrointest Endosc 2024; 99:886-894. [PMID: 38447664 DOI: 10.1016/j.gie.2024.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/04/2024] [Accepted: 02/29/2024] [Indexed: 03/08/2024]
Affiliation(s)
- John M DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, USA
| | - Mohamed O Othman
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - Amol Bapaye
- Shivan and Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
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Hernández Mondragón OV, Solórzano Pineda OM. Peroral esophageal myotomy for esophageal motility disorders. Minerva Gastroenterol (Torino) 2023; 69:193-208. [PMID: 37191670 DOI: 10.23736/s2724-5985.22.02987-4] [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: 05/17/2023]
Abstract
The concept of third space endoscopy first described in 2007, was adapted and performed in humans in 2010 by Inoue et al. in a group of patients with esophageal achalasia (EA). Since then, esophageal endoscopic myotomy (E-POEM), has been performed in more than 10,000 patients worldwide up to now. Safety and efficacy have been confirmed at early, mid and long-term evaluations, in different gastrointestinal diseases including achalasia, refractory gastroparesis, and other esophageal motility disorders (EMD). Nowadays, this treatment has shown to be not only an excellent option, but also with its excellent outcomes, the first option in certain clinical scenarios such as type III achalasia. Thus, the minimal invasive nature of POEM gives us multiple advantages compared with the classical treatments that includes pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM), including not only clinical aspects but also economical. High resolution manometry (HRM) has substantially redefined the actual approach of esophageal motility disorders with the major changes in instrumental use, diagnostic algorithms, and therapeutics. The previous Chicago's classification V 3.0 clearly improved our knowledge about pathophysiology of spastic esophageal motor disorders, however, with its recent update (Chicago V 4.0), multiple changes in diagnosis and treatment are expected. In the present article, we aimed to review and analyze the most important aspects about the results of E-POEM in the management of EMD according to the view of the new Chicago's classification V 4.0.
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Affiliation(s)
| | - Omar M Solórzano Pineda
- Department of Gastrointestinal Endoscopy, XXI Century National Medical Center, Mexico City, Mexico
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Maselli R, Spadaccini M, Pellegatta G, Repici A. Peroral Endoscopic Myotomy Technique, from Mouth to Anus. Gastrointest Endosc Clin N Am 2023; 33:127-142. [PMID: 36375877 DOI: 10.1016/j.giec.2022.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The peroral endoscopic myotomy (POEM) procedure, as described over 10 years ago, is a submucosal endoscopy procedure that allows access to the muscle layers throughout the gastrointestinal (GI) tract. With this access, and ability to cut the muscle fibers, POEM can be performed not only for motility disorders but for structural pathology as well, such as Zenker diverticulum. Regardless of the location, there are 4 steps to the procedure: mucosotomy, submucosal tunneling, myotomy, and mucostomy closure. This review outlines these key components as well as variations in techniques for POEM throughout the GI tract.
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Affiliation(s)
- Roberta Maselli
- Department of Biomedical Sciences, Pieve Emanuele, Humanitas University, Rozzano, Italy; Humanitas Clinical and Research Center -IRCCS-, Endoscopy Unit, Rozzano, Italy
| | - Marco Spadaccini
- Department of Biomedical Sciences, Pieve Emanuele, Humanitas University, Rozzano, Italy; Humanitas Clinical and Research Center -IRCCS-, Endoscopy Unit, Rozzano, Italy.
| | - Gaia Pellegatta
- Humanitas Clinical and Research Center -IRCCS-, Endoscopy Unit, Rozzano, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Pieve Emanuele, Humanitas University, Rozzano, Italy; Humanitas Clinical and Research Center -IRCCS-, Endoscopy Unit, Rozzano, Italy
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Ujiie N, Sato H, Fujiyoshi MRA, Tanaka S, Shiwaku H, Shiota J, Ogawa R, Yokomichi H, Kamei T, Inoue H. Geriatric patients with esophageal motility disorders benefit more from minimally invasive peroral endoscopic myotomy: a multicenter study in Japan. Dis Esophagus 2022; 35:6479783. [PMID: 34937083 DOI: 10.1093/dote/doab086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/23/2021] [Indexed: 12/11/2022]
Abstract
Geriatric patients with existing studies on the safety and efficacy of peroral endoscopic myotomy (POEM) for achalasia involve small sample sizes and single institutions. However, multi-center, large-scale data analyses are lacking. The study aimed to clarify the characteristics of geriatric patients with esophageal motility disorders (EMDs) and determine the procedure-related outcomes and clinical course following POEM. This cohort study included 2,735 patients with EMDs who were treated at seven Japanese facilities between 2010 and 2019. The patients' characteristics and post-POEM clinical courses were compared between the geriatric (age ≥ 75 years; n = 321) and non-geriatric (age < 75 years; n = 2,414) groups. Compared with the non-geriatric group, the geriatric group had higher American Society of Anesthesiologists physical status scores; more recurrent cases; lower incidence of chest pain; and higher incidence of type III achalasia, distal esophageal spasm, and Jackhammer esophagus. Furthermore, the incidence of sigmoid esophagus was higher, although esophageal dilation was not severe in this group. POEM was safe and effective for geriatric patients with treatment-naïve and recurrent EMDs. Furthermore, compared with the non-geriatric group, the geriatric group had lower post-POEM Eckardt scores, fewer complaints of refractory chest pain, and a lower incidence rate of post-POEM reflux esophagitis. Geriatric patients are characterized by worse clinical conditions, more spastic disorders, and greater disease progression of EMDs, which are also the indications for minimally invasive POEM. POEM is more beneficial in geriatric patients as it has lowering symptom scores and incidence rates of reflux esophagitis.
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Affiliation(s)
- Naoto Ujiie
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan.,Department of Medicine, Feinberg School of Medicine, Feinberg Cardiovascular and Renal Research Institute, Northwestern University, Chicago, IL, USA
| | - Hiroki Sato
- Division of Gastroenterology & Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Shinwa Tanaka
- Department of Gastroenterology, Kobe University Hospital, Kobe, Japan
| | - Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Junya Shiota
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Ryo Ogawa
- Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan
| | - Hiroshi Yokomichi
- Department of Health Sciences, University of Yamanashi, Yamanashi, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
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Shiwaku H, Inoue H. Recent advancement of submucosal endoscopy: Peroral endoscopic myotomy and offshoot. Dig Endosc 2022; 34 Suppl 2:36-39. [PMID: 34668246 DOI: 10.1111/den.14155] [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: 09/01/2021] [Revised: 09/21/2021] [Accepted: 09/29/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
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Lee JY, Lim CH, Kim DH, Jung HY, Youn YH, Jung DH, Park JC, Moon HS, Hong SJ. Adverse Events Associated With Peroral Endoscopic Myotomy Affecting Extended Hospital Stay: A Multi-center Retrospective Study in South Korea. J Neurogastroenterol Motil 2022; 28:247-254. [PMID: 35362451 PMCID: PMC8978124 DOI: 10.5056/jnm21081] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/17/2021] [Accepted: 11/10/2021] [Indexed: 12/16/2022] Open
Abstract
Background/Aims To analyze various adverse events (AEs) related to the peroral endoscopic myotomy (POEM) procedure and to analyze whether these AEs are related to an extended hospital stay. Methods Patients admitted for POEM for esophageal motility disorders from August 2012 to February 2020 at 5 centers were retrospectively collected. Length of hospital stay, AEs during or after the POEM procedure were analyzed. Results Of the 328 patients, 63.1% did not have any AEs, but 2.4% had major AEs, and 33.4% had minor AEs. Major AEs included mucosal injury, bleeding, and hemothorax, accounting for 1.5%, 0.6%, and 0.3%, respectively. Among the minor AEs, pneumoperitoneum was the most common gas-related AEs. Among non-gas-related minor AEs, pneumonia was the most common at 4.6%, followed by pain, fever, and pleural effusion. All major AEs had meaningful delayed discharge and significantly extended hospital stay compared to the no AEs group (median differences range 4.5-9.0 days). Among gas-related minor AEs, except for 4 cases of emphysema, the extended hospital stay was meaningless. All non-gas-related minor AEs was associated with a significant prolongation of hospital stay compared to that in the no AEs group (median differences range 2.0-4.0 days). Conclusions In conclusion, most gas-related minor AEs do not significantly affect the patient's clinical course. However, subcutaneous emphysema and minor non-gas related AEs such as pneumonia, pain, fever, and pleural effusion can prolong the hospital stay, therefore careful observation is required. Efforts will be made to reduce major AEs that significantly prolong hospitalization.
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Affiliation(s)
- Ju Yup Lee
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Chul-Hyun Lim
- Division of Gastroenterology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Young Hoon Youn
- Department of Gastroenterology, Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Da Hyun Jung
- Department of Gastroenterology, Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Chul Park
- Department of Gastroenterology, Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hee Seok Moon
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Su Jin Hong
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Gyeonggi-do, Korea
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Jo HE, Lee JE, Kim SH, Hong SJ, Choi SY, Lee MH, Lim S, Lee S, Hwang JA, Moon JE. Correlation of timed barium esophagography with Eckardt score in primary achalasia patients treated with peroral endoscopic myotomy. Abdom Radiol (NY) 2022; 47:538-546. [PMID: 34919159 DOI: 10.1007/s00261-021-03379-z] [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] [Received: 10/05/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE The purpose of our study was to evaluate the role of timed barium esophagogram (TBE) in quantitative measurement of improved esophageal emptying in primary achalasia patients treated with POEM. Also, we investigated the correlation of TBE with improvement of clinical symptoms as measured by Eckardt score. METHODS This retrospective study included 30 patients who underwent POEM due to primary achalasia. As a baseline study, all patients underwent TBE and were evaluated for clinical status by Eckardt score based on presence and frequency of dysphagia, regurgitation, substernal pain, and weight loss. Follow-up evaluation was performed within 3 months after POEM. Pre- and post-POEM TBE results were compared using a calculated value based on summation of height of the barium columns on 1-, 2- and 5-min delayed images. Also, the correlation of TBE with improvement of Eckardt score was evaluated using Pearson's correlation test. RESULTS There was a significant decrease in the calculated value of height between pre- and post-POEM TBE studies (40.5 ± 15.8-17.0 ± 11.6, p < 0.01). Also, the Eckardt score decreased significantly after POEM (6.7 ± 2.0-0.8 ± 1.0, p < 0.01). Pearson's correlation test revealed a positive correlation between improvement of TBE results and Eckardt score (correlation coefficient = 0.56, p < 0.01). CONCLUSION TBE is an objective method for quantitative measurement of improved esophageal emptying in primary achalasia patients treated with POEM and shows positive correlation with clinical symptoms evaluated by Eckardt score.
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Affiliation(s)
- Ha Eun Jo
- Department of Radiology, Soonchunhyang University College of Medicine, Bucheon Hospital, 170 Jomaru-ro, Bucheon-Si, Gyeonggi-do, 14584, Republic of Korea
| | - Ji Eun Lee
- Department of Radiology, Soonchunhyang University College of Medicine, Bucheon Hospital, 170 Jomaru-ro, Bucheon-Si, Gyeonggi-do, 14584, Republic of Korea.
| | - Shin Hee Kim
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon Hospital, 170 Jomaru-ro, Bucheon-Si, Gyeonggi-do, 14584, Republic of Korea
| | - Su Jin Hong
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon Hospital, 170 Jomaru-ro, Bucheon-Si, Gyeonggi-do, 14584, Republic of Korea
| | - Seo-Youn Choi
- Department of Radiology, Soonchunhyang University College of Medicine, Bucheon Hospital, 170 Jomaru-ro, Bucheon-Si, Gyeonggi-do, 14584, Republic of Korea
| | - Min Hee Lee
- Department of Radiology, Soonchunhyang University College of Medicine, Bucheon Hospital, 170 Jomaru-ro, Bucheon-Si, Gyeonggi-do, 14584, Republic of Korea
| | - Sanghyeok Lim
- Department of Radiology, Soonchunhyang University College of Medicine, Bucheon Hospital, 170 Jomaru-ro, Bucheon-Si, Gyeonggi-do, 14584, Republic of Korea
| | - Sunyoung Lee
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Jeong Ah Hwang
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Ilwon-Ro, Gangnam-gu, Seoul, 06351, Korea
| | - Ji Eun Moon
- Department of Biostatistics, Clinical Trial Center, Soonchunhyang University College of Medicine, Bucheon Hospital, 170 Jomaru-ro, Bucheon-Si, Gyeonggi-do, 14584, Republic of Korea
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Rehospitalization, Treatment, and Resource Use After Inpatient Admission for Achalasia in the USA. Dig Dis Sci 2021; 66:4149-4158. [PMID: 33386520 DOI: 10.1007/s10620-020-06775-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 12/08/2020] [Indexed: 12/09/2022]
Abstract
INTRODUCTION Readmission for achalasia treatment is associated with significant morbidity and cost. Factors predictive of readmission would be useful in identifying patients at risk. METHODS We performed a retrospective study using the Nationwide Readmission Database for the year 2016 and 2017. We collected data on hospital readmissions of 17,848 adults who were hospitalized for achalasia and discharged. The 30-day readmission rate as well as the primary cause, mortality rate, in-hospital adverse events, and total hospitalization charges were examined. A cox multivariate regression model was used to identify independent risk factors for 30-day readmission, including the surgical or endoscopic treatment used during the index admission. RESULTS From 2016 to 2017, the 30-day readmission rate for index admission with achalasia was 15.2%. Of these 15.2%, 34% were readmitted with persistent symptoms of achalasia or treatment-related complications. Older age, higher comorbidity index, possessing private insurance, and those with either pneumatic balloon dilation or no endoscopic/surgical treatment showed higher odds of readmission on multivariate analysis. Those treated with laparoscopic Heller myotomy (LHM) or peroral endoscopic myotomy (POEM) showed lower odds of readmission. There was no difference in rates of readmission between those undergoing POEM or LHM, but mortality rate for readmission was significantly higher for the LHM group. The in-hospital mortality rate and length of stay were significantly higher for readmissions (p < 0.01) than the index admissions. CONCLUSION Three in 20 patients admitted with achalasia are likely to be readmitted within 30 days of their initial hospitalization, a number which can be higher in untreated patients and in those with multiple comorbidities. Rehospitalizations bear a higher mortality rate than the initial admission and present a burden to the healthcare system.
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Ujiie N, Sato C, Taniyama Y, Koseki K, Takaya K, Okamoto H, Fukutomi T, Unno M, Kamei T. Characteristics of esophageal achalasia in geriatric patients over 75 years of age and outcomes after peroral endoscopic myotomy. Geriatr Gerontol Int 2021; 21:788-793. [PMID: 34250704 DOI: 10.1111/ggi.14235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/04/2021] [Accepted: 06/14/2021] [Indexed: 01/11/2023]
Abstract
AIM As the population ages, the proportion aged ≥75 years is expected to increase. Many studies on peroral endoscopic myotomy (POEM) as treatment for esophageal achalasia have already been reported; however, few studies have been designed on patients aged ≥75 years. The purpose of this study is to describe the characteristics of esophageal achalasia in patients >75 years and to evaluate the outcomes of POEM. METHODS This study included 121 patients who underwent POEM for esophageal achalasia, which was divided into the geriatric (n = 18) group aged ≥75 and the young (n = 103) group ≤74 years. The characteristics of esophageal achalasia and the short-term outcomes after POEM in the geriatric group compared with the young group were retrospectively investigated. RESULTS The median age of the geriatric group was 78 years, and two patients were initially diagnosed with refractory pneumonia, and esophageal achalasia was initially overlooked. The preoperative Eckardt score of the geriatric group was significantly lower than that of the young group (4 vs. 6, P = 0.007), particularly in the regurgitation score. The Eckardt score and integrated relaxation pressure of both groups were significantly improved after POEM (P < 0.001). There were no cases of perioperative complications in the geriatric group. CONCLUSIONS POEM for esophageal achalasia is a safe and effective treatment even in geriatric patients >75 years of age. In geriatric patients with recurrent or intractable pneumonia, it is important to rule out esophageal achalasia. Geriatr Gerontol Int 2021; 21: 788-793.
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Affiliation(s)
- Naoto Ujiie
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Chiaki Sato
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yusuke Taniyama
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ken Koseki
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kai Takaya
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroshi Okamoto
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toshiaki Fukutomi
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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12
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Fujiyoshi Y, Inoue H, Abad MRA, Rodriguez de Santiago E, Nishikawa Y, Sakaguchi T, Toshimori A, Shimamura Y, Tanabe M, Sumi K, Kimura R, Izawa S, Ikeda H, Onimaru M. Importance of second-look endoscopy after per-oral endoscopic myotomy for safe postoperative management. Dig Endosc 2021; 33:364-372. [PMID: 32544261 DOI: 10.1111/den.13770] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/07/2020] [Accepted: 06/10/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Per-oral endoscopic myotomy (POEM) is a safe and effective treatment for achalasia and esophageal motility disorders. The role of second-look endoscopy (SE) on postoperative day 1 has not been examined. This study aimed to evaluate the findings and need of SE after POEM. METHODS This is a single-center, retrospective study. All consecutive patients who underwent POEM and SE on postoperative day 1 between December 2017 and September 2019 were included. The primary endpoint was the rate of newly-detected adverse events (nAE) during SE that required endoscopic intervention or deviation from the normal postoperative course. Multivariate logistic regression was used to identify predictors of nAE. RESULTS Four-hundred-ninety-seven patients (mean age, 50.3 years; female, 49.9%) were included. SE identified abnormal findings in a total of 71 patients (14.3%). nAE which required endoscopic intervention or deviation from the normal postoperative course were identified in 12 patients (2.4%): eight (1.6%) entry site dehiscence; two (0.4%) submucosal hemorrhage or hematoma; and two (0.4%) dehiscence of an intraoperative perforation site after endoclip closure. Other findings such as mucosal thermal damage without perforation and small submucosal hematoma were found in 54 patients (10.9%) and five patients (1.0%), respectively. Multivariate analysis showed that longer operation time and intraoperative adverse events (AE) were associated with clinically significant nAE during SE. CONCLUSIONS Second-look endoscopy can detect and treat nAE that may lead to severe AE. Thus, SE should be highly considered before starting oral ingestion in all cases, and especially in those who present an intraoperative AE and longer operation time.
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Affiliation(s)
- Yusuke Fujiyoshi
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | | | - Enrique Rodriguez de Santiago
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan.,Department of Gastroenterology and Hepatology Hospital Universitario Ramon y Cajal, University of Alcala IRYCIS, Madrid, Spain
| | - Yohei Nishikawa
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Takuki Sakaguchi
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Akiko Toshimori
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Mayo Tanabe
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Kazuya Sumi
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Ryusuke Kimura
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Shinya Izawa
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Haruo Ikeda
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
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Kurumi H, Isomoto H, Ikebuchi Y. Endpoint marking during peroral endoscopic myotomy: Indocyanine green injection combined with infrared imaging. Dig Endosc 2021; 33:e12-e13. [PMID: 33226687 DOI: 10.1111/den.13869] [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: 09/20/2020] [Revised: 10/02/2020] [Accepted: 10/06/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Hiroki Kurumi
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Hajime Isomoto
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Yuichiro Ikebuchi
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori, Japan
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14
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Drexel S, Kishawi S, Marks J. Peroral Esophageal Myotomy. Surg Clin North Am 2020; 100:1183-1192. [PMID: 33128887 DOI: 10.1016/j.suc.2020.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Achalasia is a neurodegenerative disorder of the lower esophagus characterized by high lower esophageal pressures and aperistalsis of the esophageal body. It remains a difficult to treat disease with significant burden on patients due to difficulty swallowing leading to malnutrition. Peroral endoscopic myotomy (POEM) is a newer endoscopic treatment of achalasia. It involves dividing the muscular layer of the esophagus through a submucosal tunnel. Ten-year data show POEM is a safe and effective treatment of achalasia. However, postoperative gastroesophageal reflux disease remains an important consideration.
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Affiliation(s)
- Sabrina Drexel
- Northwest Minimally Invasive Surgery, 2222 Northwest Lovejoy Street, Suite 322, Portland, OR 97210, USA.
| | - Sami Kishawi
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5047, USA
| | - Jeffrey Marks
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106-5047, USA
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15
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Peroral endoscopic myotomy is a safe and effective treatment modality for geriatric patients with achalasia. Esophagus 2020; 17:484-491. [PMID: 32394115 DOI: 10.1007/s10388-020-00746-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 04/26/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is an appealing treatment for older patients, as it is minimally invasive but highly efficacious similar to surgical myotomy. However, there is a lack of systematic studies analyzing POEM outcomes in young (< 65 years) versus geriatric patients (≥ 65 years). Hence, we aimed to compare the safety and efficacy of POEM in young versus geriatric patients. METHODS Records of all achalasia patients who underwent POEM at our institution between April 2014 and May 2019 were reviewed. Patients were categorized into two groups: young (< 65 years) and old (≥ 65 years). Demographic and procedural details, timed barium esophagram (TBE), high-resolution manometry (HREM), pH study findings and Eckardt scores were compared between the two groups. Post-POEM Eckhardt score of ≤ 3 was defined as treatment success. RESULTS A total of 148 patients met the study criteria (young = 93; old = 55). Younger patients were more likely to have lower TBE height at 1 min but wider TBE width at 5 min. The rest of the pre-operative parameters and Eckardt scores were similar in the two groups. Young patients were more likely to have undergone prior Heller myotomy, while Botox injections were common in the older group. The operative details and outcomes were similar in the two groups. Treatment success rates were similar in both groups (94.9% young vs. 94.7% in old patients, p = 1.00). At 2-month follow-up, both groups showed significant improvements in Eckhardt scores and HREM parameters; however, older patients showed greater improvement in TBE height at 1 and 5 min. The rates of symptomatic GERD and abnormal esophageal pH study findings were similar in the two groups. CONCLUSION POEM was safe and highly effective treatment for geriatric patients with achalasia. These findings suggest that POEM might emerge as the preferred approach for myotomy in this patient population.
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16
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Shiwaku H, Inoue H, Sato H, Onimaru M, Minami H, Tanaka S, Sato C, Ogawa R, Okushima N, Yokomichi H. Peroral endoscopic myotomy for achalasia: a prospective multicenter study in Japan. Gastrointest Endosc 2020; 91:1037-1044.e2. [PMID: 31759035 DOI: 10.1016/j.gie.2019.11.020] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 11/04/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) is an available treatment modalities for achalasia. The reported efficacy of POEM in the only prospective multicenter study was 82%; however, a retrospective multicenter study in Japan reported a higher efficacy rate of 95%. The aim of this study was to prospectively verify treatment outcomes after POEM at multiple facilities in Japan. METHODS This was a prospective single-arm trial of POEM for achalasia at 8 facilities in Japan between April 2016 and March 2018 to evaluate its safety and efficacy. Patients were re-evaluated at 3 months and up to 1 year after POEM. RESULTS Among the 233 patients with achalasia who underwent POEM, procedure-related adverse events occurred in 24 patients (10.3%), none of whom required surgical intervention. In the 207 patients satisfying the inclusion criteria, the efficacy rate of POEM, defined by an Eckardt score ≤3 at 1 year, was 97.4% (95% CI, 95.3%-99.7%). The Eckardt score decreased significantly from 6.6 ± 2.0 preoperatively to 1.1 ± 1.1, 1 year after POEM. Postoperative reflux esophagitis, severe reflux esophagitis, and symptomatic GERD were reported in 54.2%, 5.6%, and 14.7%, respectively, and proton pump inhibitors were administered in 21.1%. CONCLUSIONS Our prospective multicenter study in Japan showed greater efficacy of POEM for achalasia compared with the results of a previous prospective multicenter study. POEM is safe and highly effective for at least 1 year. (Clinical trial registration number: UMIN 000021550.).
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Affiliation(s)
- Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hiroki Sato
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hitomi Minami
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Shinwa Tanaka
- Department of Gastroenterology, Kobe University Hospital, Hyogo, Japan
| | - Chiaki Sato
- Department of Surgery, Tohoku University School of Medicine, Miyagi, Japan
| | - Ryo Ogawa
- Department of Gastroenterology, Oita University Faculty of Medicine, Oita, Japan
| | | | - Hiroshi Yokomichi
- Division of Medicine, Graduate School Department of Interdisciplinary Research, University of Yamanashi, Yamanashi, Japan
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de Heer J, Desai M, Boeckxstaens G, Zaninotto G, Fuchs KH, Sharma P, Schachschal G, Mann O, Rösch T, Werner Y. Pneumatic balloon dilatation versus laparoscopic Heller myotomy for achalasia: a failed attempt at meta-analysis. Surg Endosc 2020; 35:602-611. [PMID: 32180002 DOI: 10.1007/s00464-020-07421-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 02/10/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The advent of peroral endoscopic myotomy (POEM) shed some light on the role of the current standards in the treatment of idiopathic achalasia, namely endoscopic pneumatic dilatation (PD) and laparoscopic Heller myotomy (LHM). We analyzed the quality of the current evidence comparing LHM and PD. METHODS A systematic literature search was performed in Pubmed/Medline, Web of Science, Google Scholar and Cochrane for meta-analyses/systematic reviews comparing PD and LHM or open surgery, limited to English language full-text articles. After a detailed review of these meta-analyses, all studies included were analyzed further in depth with respect to treatment protocol, assessment of success, complications and sequelae such as gastroesophageal reflux (GER), as well as follow-up details. RESULTS Six randomized controlled trials (RCT), 5 with LHM and 1 with open surgery, were found, published in 10 papers. In contrast to a rather homogeneous LHM technique, PD regimens as well as the clinical dysphagia scores were different in every RCT; most RCTs also showed methodological limitations. There were nine meta-analyses which included a variable number of these RCTs or other cohort studies. Meta-analyses between 2009 and 2013 favored surgery, while the 4 most recent ones reached divergent conclusions. The main difference might have been whether repeated dilatation was regarded as part of the PD protocol or as failure. CONCLUSIONS The variability in PD techniques and in definition of clinical success utilized in the achalasia RCTs on PD versus LHM render the conclusions of meta-analyses unreliable. Further randomized studies should be based on uniform criteria; in the meantime, publication of even more meta-analyses should be avoided.
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Affiliation(s)
- Jocelyn de Heer
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Madhav Desai
- Department of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas, MO, USA
| | - Guy Boeckxstaens
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | | | - Karl-Hermann Fuchs
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Prateek Sharma
- Department of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas, MO, USA
| | - Guido Schachschal
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Oliver Mann
- Department of General and Abdominal Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Yuki Werner
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Orlandini B, Barret M, Guillaumot MA, Léandri C, Leblanc S, Prat F, Chaussade S. Per-oral endoscopic myotomy for esophageal diverticula with or without esophageal motility disorders. Clin Res Hepatol Gastroenterol 2020; 44:82-89. [PMID: 31080116 DOI: 10.1016/j.clinre.2019.03.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 03/25/2019] [Accepted: 03/26/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Mid-esophageal and epiphrenic diverticula (MED) can be associated with esophageal motility disorders. Per-oral endoscopic myotomy (POEM) is an established treatment for esophageal motility disorders that has also been introduced for the treatment of MED. METHODS Data were prospectively collected from patients with MED treated with POEM at our institution. When esophageal motility disorders were present, myotomy was performed extending the myotomy to the lower esophageal sphincter (LES) to treat the motility dysfunction associated with the diverticulum. In the absence of esophageal motility disorder, POEM was performed without including the LES in the myotomy to achieve diverticulotomy. RESULTS Four patients were treated with POEM for MED between April 2017 and March 2018. The patients suffered from distal esophageal spasm, jackhammer esophagus or esophago-gastric junction outflow obstruction. One patient had no esophageal motility disorder. Diverticulum size was 3 cm in one case and 6 cm in the others. Preoperative Eckardt scores ranged from 6 to 8. No life-threatening complications were reported. Intraoperative pneumoperitoneum was described in two cases and one patient experienced aspiration pneumonia. The patients with motility disorders were asymptomatic at 6-8 months follow-up. The patient without documented underlying esophageal motility disorder had an Eckardt score of 3 at 9-months follow-up. Two cases of gastro-esophageal reflux were successfully managed with proton pump inhibitors. CONCLUSIONS In the case of MED and esophageal motility disorder, POEM permitted treatment of the underlying cause of the diverticulum, achieving favorable early clinical outcomes. In the absence of motility disorder, POEM was feasible with promising early outcomes, and could be a valid alternative to surgical diverticulectomy in selected patients.
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Affiliation(s)
- Beatrice Orlandini
- Department of gastroenterology, department of experimental and clinical biomedical sciences, Careggi hospital, University of Florence, Viale San Luca, 50134, Florence, Italy; Department of gastroenterology, Cochin hospital, assistance publique - Hôpitaux de Paris, Paris Descartes university, 27, rue du Faubourg St Jacques 75014, Paris, France
| | - Maximilien Barret
- Department of gastroenterology, Cochin hospital, assistance publique - Hôpitaux de Paris, Paris Descartes university, 27, rue du Faubourg St Jacques 75014, Paris, France.
| | - Marie-Anne Guillaumot
- Department of gastroenterology, Cochin hospital, assistance publique - Hôpitaux de Paris, Paris Descartes university, 27, rue du Faubourg St Jacques 75014, Paris, France
| | - Chloé Léandri
- Department of gastroenterology, Cochin hospital, assistance publique - Hôpitaux de Paris, Paris Descartes university, 27, rue du Faubourg St Jacques 75014, Paris, France
| | - Sarah Leblanc
- Department of gastroenterology, Cochin hospital, assistance publique - Hôpitaux de Paris, Paris Descartes university, 27, rue du Faubourg St Jacques 75014, Paris, France
| | - Frédéric Prat
- Department of gastroenterology, Cochin hospital, assistance publique - Hôpitaux de Paris, Paris Descartes university, 27, rue du Faubourg St Jacques 75014, Paris, France
| | - Stanislas Chaussade
- Department of gastroenterology, Cochin hospital, assistance publique - Hôpitaux de Paris, Paris Descartes university, 27, rue du Faubourg St Jacques 75014, Paris, France
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Abstract
The field of third space endoscopy (TSE), also called submucosal endoscopy using a mucosal flap valve, allows secure access to the submucosal and deeper layers of the gastrointestinal tract without the risk of a full-thickness perforation. Since the first description of per-oral endoscopic myotomy (POEM) for the treatment of achalasia cardia 10 years ago, this field has expanded rapidly. Several new procedures, submucosal tunneling endoscopic resection, gastric-POEM, Zenker POEM, per-rectal endoscopic myotomy, diverticular POEM, and recanalization for complete esophageal obstruction (per-oral endoscopic tunneling for restoration of the esophagus), have been performed. All TSE procedures employ a similar technique-after a mucosal incision, a submucosal tunnel is created, a myotomy is performed, or a subepithelial tumor is resected distal to the site of mucosal incision, after which the mucosal incision is closed. Potential indications for TSE include resection of subepithelial tumors in the esophagus, gastroesophageal junction, or stomach; refractory gastroparesis; Zenker diverticulum; Hirschsprung disease or other forms of megacolon; and recanalization for complete esophageal obstruction. Data are currently available for POEM, submucosal tunneling endoscopic resection, and gastric-POEM, although mainly in the form of retrospective studies, and randomized trials and long-term follow-up data are limited. Submucosal endoscopy has an excellent safety profile with very few intraoperative adverse events, the majority being related to insufflation, although bleeding, perforation, and sepsis have been reported. TSE procedures require special training and have demonstrated a learning curve.
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20
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Simple mathematical equation to predict distance to gastroesophageal junction through the submucosal tunnel during peroral endoscopic myotomy. Endosc Int Open 2019; 7:E1371-E1378. [PMID: 31673607 PMCID: PMC6805208 DOI: 10.1055/a-0977-2695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 05/13/2019] [Indexed: 02/08/2023] Open
Abstract
Background and aim Accurate estimation of the distance to the gastroesophageal junction (GEJ) through a tunnel during per oral endoscopic myotomy (POEM) is technically challenging. The methods currently employed are often insufficient, and resultant errors may lead to incomplete myotomy and/or prolonged procedure times. Our hypothesis states that the additional distance while traversing the tunnel is directly proportional to the widest esophageal diameter; and is calculated by the formula X = Y + CZ (X = distance to the GEJ through the tunnel, Y = distance to the GEJ through the lumen, Z = widest esophageal diameter, C = arithmetic constant). This study evaluates the validity and accuracy of this hypothesis. Patients and methods This was a prospective single-center study with 80 patients, 12 in the pilot group and 68 in the study group. In the pilot group, Y was recorded during esophagogastroduodenoscopy (EGD) before POEM, Z on barium swallow/contrast enhanced computed tomography (CECT), and X was measured during POEM. Using the formula, mean C (SD) was calculated. In the study group, 'C' was substituted in the equation to predict the GEJ distance through the tunnel (Xp) before POEM. The operator was blinded to Xp and recorded the true Xt during POEM. The correlation between Xp and Xt was calculated. Results In the pilot group, the mean distances (cm, SD) for X, Y, and Z were 42.58 (3.33), 39.83 (3.08), and 4.39 (1.16), respectively. The calculated mean C was 0.63 (0.11). In the study group, the mean distances (cm, SD) for Y, Z, Xp, and Xt were 40.45 (2.58), 4.99 (1.43), 43.57 (2.68), and 43.54 (2.78), respectively. The Xp and Xt values demonstrated a high correlation (r = 0.97, P = 0.000). Conclusions Formula X = Y + CZ reliably predicts the GEJ distance through a tunnel during POEM. It is user friendly and requires no additional resources.
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21
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Abstract
Achalasia is an uncommon disorder that results from the degeneration of ganglion cells of the myenteric plexus in the lower esophageal wall. It is manifested by a loss of peristalsis in the lower part of the esophagus and failure of the lower esophageal sphincter (LES) to relax. Peroral endoscopic myotomy (POEM) is a minimally invasive intervention that aims to treat achalasia. It is regarded as the endoscopic equivalent of Heller myotomy. POEM is a form of natural orifice transluminal endoscopic surgery that is completed by creating a submucosal tunnel in the lower part of esophagus to reach the inner circular muscle bundles of the LES to perform myotomy, while preserving the outer longitudinal muscle bundles. The result is decreased resting pressure of the LES, facilitating the passage of ingested material. POEM was initially introduced to treat achalasia by targeting the LES. POEM has expanded to include gastric POEM (G-POEM), myotomy of the pyloric sphincter to treat gastroparesis, and per rectal endoscopic myotomy to treat adult Hirschsprung's disease.
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Affiliation(s)
- Yahya Ahmed
- Baylor St Luke's Medical Center, Houston, TX, USA
| | - Mohamed O Othman
- Baylor St Luke's Medical Center, Houston, TX, USA.,Division of Gastroenterology, Baylor College of Medicine, Houston, TX, USA
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22
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Shiwaku H, Inoue H, Onimaru M, Minami H, Sato H, Sato C, Tanaka S, Ogawa R, Okushima N. Multicenter collaborative retrospective evaluation of peroral endoscopic myotomy for esophageal achalasia: analysis of data from more than 1300 patients at eight facilities in Japan. Surg Endosc 2019; 34:464-468. [PMID: 31183791 DOI: 10.1007/s00464-019-06833-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 05/15/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is a novel, minimally invasive treatment for esophageal achalasia. We retrospectively examined and evaluated the results following POEM to verify the technique's efficacy and safety. METHODS We retrospectively analyzed data for patients who underwent POEM at eight Japanese facilities between September 2008 and October 2015. Pre- and postoperative assessments 3 months and 1 year after POEM included patient interviews, endoscopy, and manometry. RESULTS A total of 1346 patients underwent POEM during the study period. Achalasia was the straight type in 1105 patients (82%) and the sigmoid type in 241 patients (18%). The average patient age was 47.2 years (range 3-95 years); 617 patients (46%) were men and 729 (54%) were women. Previous treatment included balloon dilatation in 381 patients (28%) and Heller-Dor operation in 43 patients (3%). The average operation time was 99.6 min. The mean length of the myotomy in the esophageal body was 10.8 cm, and the myotomy extended into the stomach a mean of 2.8 cm. The response rate (Eckardt score ≤ 3) was 95.1% 3 months postoperatively and 94.7% 1 year postoperatively. We noted 50 adverse events (3.7%) of Clavien-Dindo classification grade ≤ IIIa, and all resolved with conservative treatment. There were no Clavien-Dindo classification grade ≥ IIIb adverse events. After POEM, erosive esophagitis according to the Los Angeles classification was absent in 37% of the patients, grade A in 33%, B in 24%, C in 6%, and D in 0.2%. Symptomatic gastroesophageal reflux disease after POEM was confirmed in 14.8% of the patients; both erosive esophagitis and symptomatic gastroesophageal reflux disease responded to treatment with a proton-pump inhibitor. CONCLUSION Our results confirmed the safety and efficacy of POEM in a large patient series and support POEM as the first-line and standard treatment for esophageal achalasia.
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Affiliation(s)
- Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan.
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hitomi Minami
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Hiroki Sato
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Chiaki Sato
- Department of surgery, Tohoku University School of Medicine, Miyagi, Japan
| | - Shinwa Tanaka
- Department of Gastroenterology, Kobe University Hospital, Hyogo, Japan
| | - Ryo Ogawa
- Department of Gastroenterology, Oita University Faculty of Medicine, Oita, Japan
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2007-2019: a "Third"-Space Odyssey in the Endoscopic Management of Gastrointestinal Tract Diseases. ACTA ACUST UNITED AC 2019; 17:202-220. [PMID: 31037613 DOI: 10.1007/s11938-019-00233-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW The main scope of this review article is to introduce readers to the innovative field of third-space endoscopy and offer a closer look at its history, milestones, and procedure spectrum while discussing ongoing and future challenges arising from its increasing adoption worldwide. RECENT FINDINGS Over the past few years, third-space endoscopy has been utilized in various diagnostic and interventional procedures performed throughout the gastrointestinal tract: obliteration of Zenker's diverticulum, myotomy for achalasia, gastroparesis or Hirschsprung's disease, biopsy or removal of subepithelial tumors, stricture management, post-per-oral endoscopic myotomy endoscopic fundoplication, and mediastino-, thoraco-, and peritoneoscopy. Third-space endoscopic interventions have revolutionized the management of esophageal motility disorders, gastroparesis, and gastrointestinal tract subepithelial tumors. Despite the high efficacy and safety of such interventions, some common (e.g., the high level of necessary endoscopic skill) and unique for each procedure (e.g., post-procedure gastroesophageal reflux or poor outcomes in patient subgroups) challenges still remain. Through a dedicated endoscopic training, a rigorous pre-procedure patient evaluation and selection, and the application of modified or new techniques, challenges can be overcome thus establishing existing procedures and paving the way for additional breakthroughs in the field of third-space endoscopy.
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24
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Filicori F, Dunst CM, Sharata A, Abdelmoaty WF, Zihni AM, Reavis KM, Demeester SR, Swanström LL. Long-term outcomes following POEM for non-achalasia motility disorders of the esophagus. Surg Endosc 2018; 33:1632-1639. [PMID: 30232618 DOI: 10.1007/s00464-018-6438-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 09/05/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Optimal treatment for symptomatic patients with non-achalasia motility disorders (NAD) such as diffuse esophageal spasm, esophagogastric junction outlet obstruction, and hypercontractile disorder is not well established. POEM has been offered to these patients since it is a less invasive and less morbid procedure but long-term outcomes remain undetermined. The aim of this study was to assess long-term outcomes of POEM for patients with NAD. METHODS Records of 40 consecutive patients undergoing POEM for NAD from May 2011 to January 2016 at a single center were retrospectively reviewed. Preoperative and 6-month postoperative symptom scores, high-resolution manometry, pH testing, and timed barium swallow (TBS) data were collected. Patients were contacted by phone to obtain long-term symptom assessment. Symptoms were assessed using a standardized symptom questionnaire with scores for symptoms graded according to frequency and the Eckardt score. RESULTS Ten percent had minor complications with no postoperative sequelae. 90% of patients had significant improvement in their mean Eckardt scores (5.02 vs. 1.12, p < 0.001) at early follow-up. Improvements in chest pain (1.02-0.36, p = 0.001) and dysphagia (2.20 vs. 0.40, p = 0.001) were seen. Significant improvements in manometric pressures and esophageal emptying on TBS were observed across groups. 38% (10/26) of patients had a postoperative pH score > 14.72. Long-term (median 48 months) symptom scores were obtained from 29 (72.5%) patients. 82% of patients (24/29) had sustained symptom improvement. A small increase in the dysphagia scores was reported in the long-term follow-up compared to the immediate postoperative period (0.36-0.89, p = 0.046). CONCLUSIONS Chest pain and dysphagia are effectively palliated with POEM in patients with non-achalasia disorders of the esophagus. Significant improvements are durable in long-term follow-up. Despite earlier reports by our group suggesting possible inferior outcomes from POEM for this difficult group of patients, this study is far more encouraging. POEM should be considered in the treatment of patients with non-achalasia disorders of the esophagus.
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Affiliation(s)
- Filippo Filicori
- Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 3805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.,Foundation for Surgical Innovation and Education, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA
| | - Christy M Dunst
- Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 3805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA. .,Foundation for Surgical Innovation and Education, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.
| | - Ahmed Sharata
- Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 3805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.,Foundation for Surgical Innovation and Education, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA
| | - Walaa F Abdelmoaty
- Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 3805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.,Foundation for Surgical Innovation and Education, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA
| | - Ahmed M Zihni
- Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 3805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.,Foundation for Surgical Innovation and Education, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA
| | - Kevin M Reavis
- Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 3805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.,Foundation for Surgical Innovation and Education, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA
| | - Steven R Demeester
- Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 3805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.,Foundation for Surgical Innovation and Education, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA
| | - Lee L Swanström
- Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 3805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.,Institut Hospitalo Universitaire Strasbourg, 1, Place de l'Hôpital, 97000, Strasbourg, France.,Foundation for Surgical Innovation and Education, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA
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25
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Inoue H, Shiwaku H, Iwakiri K, Onimaru M, Kobayashi Y, Minami H, Sato H, Kitano S, Iwakiri R, Omura N, Murakami K, Fukami N, Fujimoto K, Tajiri H. Clinical practice guidelines for peroral endoscopic myotomy. Dig Endosc 2018; 30:563-579. [PMID: 30022514 DOI: 10.1111/den.13239] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 07/17/2018] [Indexed: 12/11/2022]
Abstract
Peroral endoscopic myotomy (POEM) is a novel clinical technique developed in Japan used to treat esophageal achalasia and esophageal motility disorders. This technique has been rapidly accepted and widely disseminated throughout our clinical practice because of its low invasiveness, technical novelty, and high efficacy. Since the advent of POEM, there have been no clinical guidelines that clearly indicated its standard of care, and these guidelines have been anticipated both nationally and internationally by clinicians who engage in POEM practice. In 2017, to meet these needs, the Japan Gastroenterological Endoscopy Society (JGES) launched the guideline committee for POEM. Based on the guideline development process proposed by the Medical Information Network Distribution Service (MINDS), the guideline committee initially created research questions on POEM and conducted a systematic review and meta-analysis on each topic. The clinical research extracted from databases for these clinical questions and the systematic review mainly comprised a few retrospective studies with a small number of participants and short trial periods; hence, the strength of the evidence and recommendations derived from these results was low. Throughout this process, the guideline committee met thrice: once on May 13, 2017, and again on September 17, 2017, to formulate the draft. A consensus meeting was then held on January 14, 2018, in Tokyo to establish the guideline statements and finalize the recommendations using the modified Delphi method. This manuscript presents clinical guidelines regarding current standards of practice and recommendations in terms of the nine chief topics in POEM.
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Affiliation(s)
- Haruhiro Inoue
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | | | - Manabu Onimaru
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Hitomi Minami
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Hiroki Sato
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Seigo Kitano
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Nobuo Omura
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Norio Fukami
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Hisao Tajiri
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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Shiwaku H, Yamashita K, Ohmiya T, Nimura S, Shiwaku Y, Inoue H, Hasegawa S. New endoscopic finding of esophageal achalasia with ST Hood short type: Corona appearance. PLoS One 2018; 13:e0199955. [PMID: 30063701 PMCID: PMC6067694 DOI: 10.1371/journal.pone.0199955] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 05/09/2018] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Detecting esophageal achalasia remains a challenge. We describe the diagnostic utility of corona appearance, a novel endoscopic finding specific to esophageal achalasia. Patients and methods Corona appearance and seven conventional endoscopic findings were compared for sensitivity and consistency (κ-value) among 53 untreated esophageal achalasia patients who underwent endoscopy at our hospital. The following criteria had to be met during lower esophageal sphincter examination using the attached ST Hood short-type for positive corona appearance: A) congestion inside the hood, B) ischemic change around the hood, and C) palisade vessels outside the hood. Results Corona appearance had the highest sensitivity (91%; κ-value, 0.71). Other findings in descending order of sensitivity included 1) functional stenosis of the esophagogastric junction (EGJ; 86%; κ-value, 0.58), 2) mucosal thickening and whitish change (71%; κ-value, 0.27), 3) abnormal contraction of the esophageal body (59%; κ-value, 0.32), 4) dilation of the esophageal lumen (58%; κ-value, 0.53), 5) liquid remnant (57%; κ-value, 0.51), 6) Wrapping around EGJ (49%; κ-value, 0.14), and 7) food remnant (30%; κ-value, 0.88). Even in 22 patients with poor (grade 1) intraluminal expansion, corona appearance had highest sensitivity (88%) compared to other endoscopic findings (κ-value, 0.63). Conclusions Among endoscopic findings using a ST Hood short-type to diagnose esophageal achalasia, corona appearance had the highest sensitivity and its consistency (κ-value) among endoscopists was substantial compared to other endoscopic findings. Similar results were obtained for esophageal achalasia cases with poor expansion. Endoscopic diagnosis of esophageal achalasia with hood attached is useful.
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Affiliation(s)
- Hironari Shiwaku
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
- * E-mail:
| | - Kanefumi Yamashita
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Toshihiro Ohmiya
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Satoshi Nimura
- Department of Pathology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | | | - Haruhiro Inoue
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
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27
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Kristo I, Schwameis K, Paireder M, Jomrich G, Kainz A, Schoppmann SF. Dysphagia severity is related to the amplitude of distal contractile integral in patients with Jackhammer esophagus. Neurogastroenterol Motil 2018; 30:e13276. [PMID: 29266608 DOI: 10.1111/nmo.13276] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 12/04/2017] [Indexed: 01/11/2023]
Abstract
BACKGROUND Dysphagia and non-cardiac chest pain are common symptoms associated with a novel hypercontractile disorder, namely Jackhammer esophagus (JE). The aim of this study was to explore these symptoms in patients with JE and to elucidate associations with disease defining metrics, crucial for subsequent therapies. METHODS All consecutive patients, who were referred between January 2014 and December 2016 and fulfilled the criteria for JE were included in this study. Exclusion criteria were opioid intake, previous gastrointestinal surgery, mechanical esophageal obstruction and diseases explaining their symptoms. KEY RESULTS Of 2205 examined subjects, thirty patients (females: n = 17, 56.7%) with a median age of 58 (51.6-64.9) years were finally enrolled. Dysphagia was noted in 53.3% (n = 16), whereas non-cardiac chest pain was specified within 40% (n = 12) with symptom duration of up to 10 years. Perception of dysphagia (P = .03) and presence of both symptoms (P = .008) increased to the end of the study period. Dysphagia was significantly associated with distal contractile integral (DCI) scores of all (P = .023), hypercontractile (P = .011) and maximum DCI swallows (P = .008). Symptoms duration influenced hypercontractile DCI scores (P = .015, r = .438) and significantly correlated with the intensity of perceived dysphagia (P = .01, r = .585). Presence of non-cardiac chest pain was not associated with any of these metrics. CONCLUSIONS & INTERFERENCES The DCI mediates dysphagia in patients with JE. Duration of symptoms affected hypercontractile DCI scores and aggravated perception of dysphagia indicating a progressive character of disease.
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Affiliation(s)
- I Kristo
- Department of Surgery, Upper GI Research & Service, Medical University of Vienna, Vienna, Austria
| | - K Schwameis
- Department of Surgery, Upper GI Research & Service, Medical University of Vienna, Vienna, Austria
| | - M Paireder
- Department of Surgery, Upper GI Research & Service, Medical University of Vienna, Vienna, Austria
| | - G Jomrich
- Department of Surgery, Upper GI Research & Service, Medical University of Vienna, Vienna, Austria
| | - A Kainz
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - S F Schoppmann
- Department of Surgery, Upper GI Research & Service, Medical University of Vienna, Vienna, Austria
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Systematic Review and Meta-Analysis of Perioperative Outcomes of Peroral Endoscopic Myotomy (POEM) and Laparoscopic Heller Myotomy (LHM) for Achalasia. Surg Laparosc Endosc Percutan Tech 2018; 27:123-131. [PMID: 28472017 DOI: 10.1097/sle.0000000000000402] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIMS AND OBJECTIVES Laparoscopic Heller myotomy (LHM) is the preferred surgical method for treating achalasia. However, peroral endoscopic myotomy (POEM) is providing good short-term results. The objective of this systematic review and meta-analysis was to compare the safety and efficacy of LHM and POEM. MATERIALS AND METHODS A search of PubMed, Cochrane database, Medline, Embase, Science Citation Index, and current contents for English-language articles comparing LHM and POEM between 2007 and 2016 was performed. Variables analyzed included prior endoscopic treatment, prior medical treatment, prior Heller myotomy, operative time, overall complications rate, postoperative gastroesophageal reflux disease (GERD), length of hospital stay, postoperative pain score, and long-term GERD. RESULTS Seven trials consisting of 483 (LHM=250, POEM=233) patients were analyzed. Preoperative variables, for example, prior endoscopic treatment [odds ratio (OR), 1.32; 95% confidence interval (CI), 0.23-4.61; P=0.96], prior medical treatment [weighted mean difference (WMD), 1.22; 95% CI, 0.52-2.88; P=0.65], and prior Heller myotomy (WMD, 0.47; 95% CI, 0.13-1.67; P=0.25) were comparable. Operative time was 26.28 minutes, nonsignificantly longer for LHM (WMD, 26.28; 95% CI, -11.20 to 63.70; P=0.17). There was a comparable overall complication rate (OR, 1.25; 95% CI, 0.56-2.77; P=0.59), postoperative GERD rate (OR, 1.27; 95% CI, 0.70-2.30; P=0.44), length of hospital stay (WMD, 0.30; 95% CI, -0.24 to 0.85; P=0.28), postoperative pain score (WMD, -0.26; 95% CI, -1.58 to 1.06; P=0.70), and long-term GERD (WMD, 1.06; 95% CI, 0.27-4.1; P=0.08) for both procedures. There was a significantly higher short-term clinical treatment failure rate for LHM (OR, 9.82; 95% CI, 2.06-46.80; P<0.01). CONCLUSIONS POEM compares favorably to LHM for achalasia treatment in short-term perioperative outcomes. However, there was a significantly higher clinical treatment failure rate for LHM on short-term postoperative follow-up. Presently long-term postoperative follow-up data for POEM beyond 1 year are unavailable and eagerly awaited.
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29
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Nast JF, Berliner C, Rösch T, von Renteln D, Noder T, Schachschal G, Groth S, Ittrich H, Kersten JF, Adam G, Werner YB. Endoscopy versus radiology in post-procedural monitoring after peroral endoscopic myotomy (POEM). Surg Endosc 2018; 32:3956-3963. [PMID: 29546671 DOI: 10.1007/s00464-018-6137-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 02/23/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The newly developed technique of peroral endoscopic myotomy (POEM) has been shown to be effective in several short- and mid-term studies. Limited information is available about the adequacy of immediate post-POEM monitoring tests. METHODS POEM was performed under general anesthesia in 228 patients (59.6% male, mean age 45.6 ± 15.5 years). Post-procedural checks comprised clinical and laboratory examination, and, during post-procedure days 1-5, endoscopy and-in the first 114 cases-radiologic examination using water-soluble contrast (1st group); the remaining patients underwent post-procedure controls without radiology (2nd group). Main outcome was value of endoscopic compared to radiologic control for recognition of early adverse events. RESULTS In the first group, routine fluoroscopic contrast swallow suggested minor leakages at the mucosal entry site in two cases which was confirmed endoscopically in only one. Endoscopy revealed two minor entry site leakages and, in six additional cases, dislocated clips without leakage (overall 5.3%). All eight patients underwent reclipping and healed without clinical sequelae. In the 2nd group, endoscopy showed 5 clip dislocations (all reclipped) and one ischemic cardiac perforation in a patient with clinical deterioration on post-POEM day 1 who had to undergo surgery after confirmation of leakage by CT. CONCLUSIONS Radiologic monitoring (contrast swallow) after POEM is not useful and can be omitted. Even routine endoscopic monitoring for detection and closure of minor defects of the mucosal entry site yields limited information with regards to final outcome; major complications are very rare and probably associated with clinical deterioration. Clinical Trials Gov Registration number of the main study: NCT01405417.
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Affiliation(s)
- Jan Friso Nast
- Department of Gastroenterology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Berliner
- Department of Diagnostic and Interventional Radiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany. .,Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Daniel von Renteln
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany.,Department of Gastroenterology, Centre Hospitalier de l´Université de Montreal, Montreal, Canada
| | - Tania Noder
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Guido Schachschal
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Groth
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Harald Ittrich
- Department of Diagnostic and Interventional Radiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jan F Kersten
- Department of Medical Biometry and Epidemiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Yuki B Werner
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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30
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Cho YK, Kim SH. Current Status of Peroral Endoscopic Myotomy. Clin Endosc 2018; 51:13-18. [PMID: 29397656 PMCID: PMC5806926 DOI: 10.5946/ce.2017.165] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/16/2017] [Accepted: 01/10/2018] [Indexed: 12/17/2022] Open
Abstract
Peroral endoscopic myotomy (POEM) has been established as an optional treatment for achalasia. POEM is an endoluminal procedure that involves dissection of esophageal muscle fibers followed by submucosal tunneling. Inoue first attempted to use POEM for the treatment of achalasia in humans. Expanded indications of POEM include classic indications such as type I, type II, type III achalasia, failed prior treatments, including Botulinum toxin injection, endoscopic balloon dilation, laparoscopic Heller myotomy, and hypertensive motor disorders such as diffuse esophageal spasm, jackhammer esophagus. Contraindications include prior radiation therapy to the esophagus and prior extensive esophageal mucosal resection/ablation involving the POEM field. Most of the complications are minor and self-limited and can be managed conservatively. As POEM emerged as the main treatment for achalasia, various adaptations to tunnel endoscopic surgery have been attempted. Tunnel endoscopic surgery includes POEM, peroral endoscopic tumor resection, gastric peroral endoscopic pyloromyotomy. POEM has been widely accepted as a treatment for all types of achalasia, even for specific cases such as achalasia with failed prior treatments, and hypertensive motor disorders.
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Affiliation(s)
- Young Kwan Cho
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Eulji University College of Medicine, Seoul, Korea
| | - Seong Hwan Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Eulji University College of Medicine, Seoul, Korea
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31
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Tang X, Ren Y, Gao Q, Huang S, Zhou J, Zhang X, Yang J, Wei Z, Chen Z, Jiang B, Gong W. Peroral endoscopic myotomy is safe and effective in achalasia patients aged older than 60 years compared with younger patients. Geriatr Gerontol Int 2017; 17:2407-2413. [PMID: 28707343 DOI: 10.1111/ggi.13083] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 01/26/2017] [Accepted: 03/30/2017] [Indexed: 02/05/2023]
Abstract
AIM Peroral endoscopic myotomy (POEM) has been proven to be effective for treating achalasia, but there are limited data on POEM in elderly patients. We therefore aimed to assess the role of POEM for achalasia in patients aged ≥60 years. METHODS All consecutive patients that underwent POEM between December 2011 and November 2015 at a single center were retrospectively reviewed. Patients aged ≥60 years were assigned to group A, whereas patients aged <60 years were assigned to group B. Demographic data, clinical data and treatment outcomes were compared between the two groups. RESULTS During the study period, 113 patients (18 in group A, and 95 in group B) were enrolled. The mean age of patients in group A was 63 ± 3.9 years (range 60-74 years; 55.6% women), and that for patients in group B was 37.7 ± 11.6 years (range 18-59 years; 42.2% women). The procedural time in group A was similar to group B (66.3 ± 33.3 vs 59.8 ± 24.2 min, P = 0.332). There were also no significant differences in the incidence of intraoperative complications (P = 1.000) and gastroesophageal reflux rate (P = 0.906) between the two groups. During the mean follow-up period of 25.2 months, treatment success (Eckardt score ≤3) was achieved in 92.9% of patients in group A, and 89.9% in group B (P = 1.000). CONCLUSIONS As well as in younger patients, POEM can be safely carried out in elderly patients, providing significant symptom relief. POEM might be recommended as the first therapeutic approach to elderly achalasia patients. Geriatr Gerontol Int 2017; 17: 2407-2413.
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Affiliation(s)
- Xiaowei Tang
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Department of Gastroenterology, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, China
| | - Yutang Ren
- Department of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China
| | - Qiaoping Gao
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Silin Huang
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jieqiong Zhou
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaofeng Zhang
- Department of Gastroenterology, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, China
| | - Jianfeng Yang
- Department of Gastroenterology, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, China
| | - Zhengjie Wei
- Department of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China
| | - Zhenyu Chen
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Bo Jiang
- Department of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China
| | - Wei Gong
- Department of Gastroenterology, Shenzhen Hospital of Southern Medical University, Shenzhen, China
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Wong I, Law S. Peroral endoscopic myotomy (POEM) for treating esophageal motility disorders. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:192. [PMID: 28616407 DOI: 10.21037/atm.2017.04.36] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Pneumatic dilatation and Heller myotomy have been thoroughly studied as the most viable treatment options for achalasia. The pendulum, however, is shifting to the minimally invasive approach. Since Inoue et al. published the experience of the first 17 cases of peroral endoscopic myotomy (POEM) in 2010, there have been at least 5,000 cases performed worldwide and the number is increasing exponentially. Experts across the globe have been extending the indications to various esophageal motility disorders, to patients of extremes of age, sigmoidal esophagus and re-operated patients. There are a few variations in technique across different centers in defining the gastroesophageal junction (GEJ) and adequacy of myotomy, the optimal length, site of myotomy and whether the full thickness of the muscle wall should be cut. Large case series demonstrated its promising efficacy & reasonable complication profile. Randomized controlled trial in comparison with the gold standard, Heller myotomy, is ongoing. The future application of submucosal tunnelling technique is thrilling with its extension in tumour resection, antropyloromyotomy and other natural orifice transluminal endoscopic surgery (NOTES).
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Affiliation(s)
- Ian Wong
- Division of Esophageal and Upper Gastrointestinal Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Simon Law
- Division of Esophageal and Upper Gastrointestinal Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong
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33
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Xue HB, Fan HZ, Meng XM, Cristofaro S, Mekaroonkamol P, Dacha S, Li LY, Fu XL, Zhan SH, Cai Q. Fluoroscopy-guided gastric peroral endoscopic pyloromyotomy (G-POEM): a more reliable and efficient method for treatment of refractory gastroparesis. Surg Endosc 2017; 31:4617-4624. [PMID: 28409375 DOI: 10.1007/s00464-017-5524-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 03/15/2017] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Prior studies show promising results of the gastric peroral endoscopic pyloromyotomy (G-POEM) procedure for treatment of refractory gastroparesis. One major technical challenge involved in this procedure is identifying the pyloric muscular ring (PMR). The aim of this study is to establish a reliable method for identification of the PMR during G-POEM. METHODS Fluoroscopy-guided G-POEM was performed by placing an endoclip at the 9 to 11'o clock position at the pylorus for identification of PMR. Conventional G-POEM was performed by observation of blue colored mucosa at the pylorus area as an indirect marker for PMR. The degree of the PMR identification was graded into well identified, identified, and not identified based on the appearance of the PMR. Procedure times were accurately documented. Gastroparesis cardinal symptoms index and gastric emptying scintigraphy were evaluated before and after the procedure. RESULTS Fourteen patients were studied, seven underwent fluoroscopy-guided G-POEM, and seven patients underwent conventional G-POEM. All procedures achieved technical success and no adverse events occurred. In the seven patients who underwent fluoroscopy-guided G-POEM, the PMR was well identified in four patients and identified in three patients. In the seven patients who underwent conventional G-POEM, the PMR was identified in four patients and not identified in three patients. The average time to complete the fluoroscopy-guided G-POEM was significantly shorter than that of the conventional G-POEM. CONCLUSIONS Fluoroscopy-guided G-POEM by placement of an endoclip at the pylorus was a reliable and safe method to direct the orientation of the submucosal tunnel, to facilitate the location of the PMR, and to shorten the procedure time.
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Affiliation(s)
- H B Xue
- Division of Digestive Diseases, Emory University, 1365 Clifton Road, B1262, Atlanta, GA, 30322, USA
- Department of Gastroenterology, Renji Hospital, Jiaotong University School of Medicine, Shanghai, China
| | - H Z Fan
- Division of Digestive Diseases, Emory University, 1365 Clifton Road, B1262, Atlanta, GA, 30322, USA
- Department of Gastroenterology, Yichun People's Hospital, Yichun Jiangxi, China
| | - X M Meng
- Division of Digestive Diseases, Emory University, 1365 Clifton Road, B1262, Atlanta, GA, 30322, USA
- Division of Gastroenterology, Second Affiliated Hospital of Baotou Medical School, Baotou, Inner Mongolia, China
| | - S Cristofaro
- Division of Digestive Diseases, Emory University, 1365 Clifton Road, B1262, Atlanta, GA, 30322, USA
| | - P Mekaroonkamol
- Division of Digestive Diseases, Emory University, 1365 Clifton Road, B1262, Atlanta, GA, 30322, USA
| | - S Dacha
- Division of Digestive Diseases, Emory University, 1365 Clifton Road, B1262, Atlanta, GA, 30322, USA
| | - L Y Li
- Division of Digestive Diseases, Emory University, 1365 Clifton Road, B1262, Atlanta, GA, 30322, USA
- Division of Digestive Diseases, PLA 306 Hospital, Beijing, China
| | - X L Fu
- Division of Digestive Diseases, Emory University, 1365 Clifton Road, B1262, Atlanta, GA, 30322, USA
- Division of Digestive Diseases, Anshan Hospital, Anshan, China
| | - S H Zhan
- Division of Digestive Diseases, Emory University, 1365 Clifton Road, B1262, Atlanta, GA, 30322, USA
- Department of Gastroenterology, Qingdao Municipal Hospital, Qingdao, China
| | - Q Cai
- Division of Digestive Diseases, Emory University, 1365 Clifton Road, B1262, Atlanta, GA, 30322, USA.
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Current status of achalasia management: a review on diagnosis and treatment. J Gastroenterol 2017; 52:401-406. [PMID: 28188367 DOI: 10.1007/s00535-017-1314-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 01/26/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Achalasia is a rare esophageal motility disorder that is characterized by loss of peristalsis and failure of relaxation of the lower esophageal sphincter (LES), particularly during swallowing. This review focuses on the diagnosis of esophageal motility disorders as defined by the Chicago Classification ver 3.0, and presents management options with regard to per-oral endoscopic myotomy (POEM) as the treatment of choice. METHODS A concise review of literature was performed for articles related to the management of achalasia, and this was contrasted with our institution's current practice. RESULTS Achalasia is still incompletely understood, and management is focused on establishing a proper diagnosis, and relieving the obstructive symptoms. CONCLUSIONS Achalasia should be considered when dysphagia is present, and not otherwise caused by an obstruction or inflammation, and when criteria is met as per the Chicago Classification ver 3.0. Lowering LES tone and disruption of LES can be accomplished by various methods, most notably pneumatic balloon dilatation and surgical myotomy. POEM has been gaining momentum as a first line therapy for achalasia symptoms, and can be considered an important tool for motility disorders of the esophagus.
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Zhang WG, Linghu EQ, Li HK. Fibrin sealant for closure of mucosal penetration at the cardia during peroral endoscopic myotomy: A retrospective study at a single center. World J Gastroenterol 2017; 23:1637-1644. [PMID: 28321165 PMCID: PMC5340816 DOI: 10.3748/wjg.v23.i9.1637] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 01/22/2017] [Accepted: 02/08/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the efficacy and safety of fibrin sealant for closure of mucosal penetration at the cardia during peroral endoscopic myotomy (POEM).
METHODS Twenty-four patients who underwent POEM and experienced mucosal injury of the cardia during the procedure were retrospectively identified. Of the 24 patients, 21 had mucosal penetration and 3 had only slight mucosal damage without penetration. The 21 patients with mucosal penetration received fibrin sealant for closure at the site of penetration. Penetration-related characteristics, treatment, and recovery were reviewed for all 21 patients to assess the efficacy and safety of fibrin sealant for closure of mucosal penetration at the cardia. Clinical data, including general characteristics, procedure-related parameters, Eckardt scores, lower esophageal sphincter pressures (LESP), and esophagogastroduodenoscopy (EGD) results, were analyzed to determine their influence on treatment success after mucosal penetration during POEM.
RESULTS All 21 patients had a solitary mucosal penetration in the cardia (12 in esophageal region of the cardia, 9 in the stomach region of the cardia, and 1 in both the esophageal and stomach regions). Twelve had a hole-like penetration and 9 had a linear penetration. For those with a hole-like penetration, the mean size was 0.14 cm2 (0.02-0.32 cm2). For those with a linear penetration, the median size was 0.37 cm (0.10-1.00 cm). Closure of the mucosal penetration using fibrin sealant was performed successfully in all 21 patients (two patients required 5 mL fibrin sealant, and the remaining 19 patients required 2.5 mL). Two patients had a nasogastric tube placed for five days after POEM; the remaining 19 patients were kept fasting for 3 d. All 21 patients were discharged after a median of 5 d (range: 5-7 d) postoperatively. During a median 42 mo (range: 9-62 mo) follow-up, all 21 patients with a mucosal penetration successfully healed without the occurrence of infection, ulcer, or esophagitis. Furthermore, the median LESP decreased from 31.9 mmHg (range: 21.9-67.1 mmHg) preoperatively to 20.3 mmHg (range: 6.0-41.0 mmHg) postoperatively (P < 0.05). The median preoperative and postoperative Eckardt scores were 5.0 (range; 4-10) and 1.0 (range: 0-4), respectively (P < 0.05). Of the 21 patients with mucosal penetration, symptom remission, which is defined as a postoperative Eckardt score ≤ 3, was achieved in 20 patients (95.2%) indicating that mucosal penetration did not influence the success of POEM treatment if closed successfully using fibrin sealant.
CONCLUSION Fibrin sealant is safe and effective for closure of mucosal penetration during POEM. Mucosal penetrations do not appear to influence the treatment success of POEM if closed successfully using fibrin sealant. Additional studies regarding the feasibility, efficacy, and safety of fibrin sealant for closure of larger mucosal penetrations is warranted.
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Jayan N, Jacob JS, Mathew M, Mukkada RJ. Anesthesia for peroral endoscopic myotomy: A retrospective case series. J Anaesthesiol Clin Pharmacol 2016; 32:379-81. [PMID: 27625490 PMCID: PMC5009848 DOI: 10.4103/0970-9185.188829] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) is a safe and minimally invasive modality regarded as the first-line management of all types of achalasia. POEM is performed under general anesthesia with endotracheal intubation using an orally inserted flexible fiberscope. The aim of this study is to describe the anesthetic management of POEM for achalasia. MATERIAL AND METHODS A chart review of 21 patients who underwent POEM for achalasia at our center from March 2013 to June 2015 was performed. RESULTS In the 21 patients, the end-tidal carbon dioxide was elevated following esophageal carbon dioxide insufflation and required adjustments in ventilation. POEM was successfully completed, and the patients were extubated immediately afterward. Subcutaneous emphysema occurred in five patients. Complications such as mediastinitis, pleural effusion, pneumoperitoneum, and pneumomediastinum were managed conservatively. Esophageal perforation occurred in one patient and needed surgical intervention. CONCLUSION For patients with achalasia, POEM offers the efficacy of surgery with the lower cost and morbidity of an endoscopic procedure. Prevention of aspiration and carbon dioxide insufflation-related complications are the two aspects that demand vigilance from the anesthesiologist.
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Affiliation(s)
- Nithin Jayan
- Department of Anesthesia and Critical Care, Lakeshore Hospital and Research Centre, Kochi, Kerala, India
| | - Jaya Susan Jacob
- Department of Anesthesia and Critical Care, Lakeshore Hospital and Research Centre, Kochi, Kerala, India
| | - Mohan Mathew
- Department of Anesthesia and Critical Care, Lakeshore Hospital and Research Centre, Kochi, Kerala, India
| | - Roy Joy Mukkada
- Department of Medical Gastroenterology, Lakeshore Hospital and Research Centre, Kochi, Kerala, India
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Hashimi S, Bremner RM. Complications Following Surgery for Gastroesophageal Reflux Disease and Achalasia. Thorac Surg Clin 2016; 25:485-98. [PMID: 26515948 DOI: 10.1016/j.thorsurg.2015.07.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Surgical procedures to treat reflux disease are common, but good outcomes rely on both a thorough preoperative workup and careful surgical techniques. Although complications are uncommon, surgeons should recognize these and possess the skills to overcome them in clinical practice.
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Affiliation(s)
- Samad Hashimi
- Department of Thoracic Disease and Transplantation, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Suite 500, Phoenix, AZ 85013, USA
| | - Ross M Bremner
- Department of Thoracic Disease and Transplantation, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Suite 500, Phoenix, AZ 85013, USA.
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Cheung AC, Hachem CY, Lai J. Idiopathic hypereosinophilic syndrome presenting with hepatitis and achalasia. Clin J Gastroenterol 2016; 9:238-42. [PMID: 27294613 DOI: 10.1007/s12328-016-0661-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 05/31/2016] [Indexed: 02/05/2023]
Abstract
Idiopathic hypereosinophilic syndrome (HES) is a rare diagnosis defined by the World Health Organization as a persistent eosinophilia for 6 months and resulting in end-organ dysfunction. While many patients present with nonspecific symptoms, others will present with symptoms of the affected organs, most commonly those involving the heart, skin, or nervous system. Gastrointestinal or liver involvement is estimated to affect up to one-third of patients with HES, although patients with clinically significant disease are limited to case reports. This is the first report of a patient presenting with hepatitis and achalasia related to idiopathic HES.
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Affiliation(s)
- Amanda C Cheung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, SSM Health Saint Louis University Hospital, 3635 Vista Avenue, Saint Louis, MO, 63110, USA.
| | - Christine Y Hachem
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, SSM Health Saint Louis University Hospital, 3635 Vista Avenue, Saint Louis, MO, 63110, USA
| | - Jinping Lai
- Division of Anatomic Pathology, Department of Pathology, SSM Health Saint Louis University Hospital, Saint Louis, MO, USA
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Kumbhari V, Besharati S, Abdelgelil A, Tieu AH, Saxena P, El-Zein MH, Ngamruengphong S, Aguila G, Kalloo AN, Khashab MA. Intraprocedural fluoroscopy to determine the extent of the cardiomyotomy during per-oral endoscopic myotomy (with video). Gastrointest Endosc 2016; 81:1451-6. [PMID: 25887723 DOI: 10.1016/j.gie.2015.01.052] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Accepted: 01/27/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND An adequate myotomy on the gastric side is considered essential to optimize outcomes in patients undergoing per-oral endoscopic myotomy (POEM). An objective method to measure the length of gastric myotomy has not yet been reported. OBJECTIVE To evaluate a new method of precisely determining the length of the submucosal tunnel below the esophagogastric junction (EGJ) using intraprocedural fluoroscopy. DESIGN Single-center cohort study. SETTING Academic tertiary care center. PATIENTS Twenty-four consecutive patients who underwent POEM for management of achalasia. INTERVENTIONS A radiopaque marker (endoscopic clip placed at the EGJ or fluoroscopically guided placement of a 19-gauge needle on the skin) was used to mark the EGJ. The endoscope was inserted to the most distal aspect of the submucosal tunnel and, using fluoroscopy, the distance between the radiopaque marker and the tip of the endoscope was measured. MAIN OUTCOME MEASUREMENTS Technical success, procedural impact, duration of technique, and adverse events. RESULTS Technical success was achieved in 100% of patients. The submucosal tunnel was extended in 5 patients (20.8%) with a mean extension of 1.4±.5 cm. The mean increase in procedure time was 4 minutes with the endoscopic clip and 2 minutes with the 19-gauge needle. There were no adverse events associated with this technique. LIMITATIONS Need for fluoroscopy. Absence of available criterion standard. CONCLUSIONS Intraprocedural fluoroscopy was an efficient and safe method of objectively documenting the extent of gastric myotomy during POEM. This may benefit those investigating the anatomic and physiologic changes that occur during the myotomy and those early in their experience performing POEM.
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Affiliation(s)
- Vivek Kumbhari
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Sepideh Besharati
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Ahmed Abdelgelil
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Alan H Tieu
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Payal Saxena
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mohamed H El-Zein
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Saowanee Ngamruengphong
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Gerard Aguila
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Anthony N Kalloo
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Esposito D, Maione F, D’Alessandro A, Sarnelli G, De Palma GD. Endoscopic treatment of esophageal achalasia. World J Gastrointest Endosc 2016; 8:30-39. [PMID: 26839644 PMCID: PMC4724029 DOI: 10.4253/wjge.v8.i2.30] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 09/19/2015] [Accepted: 12/15/2015] [Indexed: 02/05/2023] Open
Abstract
Achalasia is a motility disorder of the esophagus characterized by dysphagia, regurgitation of undigested food, chest pain, weight loss and respiratory symptoms. The most common form of achalasia is the idiopathic one. Diagnosis largely relies upon endoscopy, barium swallow study, and high resolution esophageal manometry (HRM). Barium swallow and manometry after treatment are also good predictors of success of treatment as it is the residue symptomatology. Short term improvement in the symptomatology of achalasia can be achieved with medical therapy with calcium channel blockers or endoscopic botulin toxin injection. Even though few patients can be cured with only one treatment and repeat procedure might be needed, long term relief from dysphagia can be obtained in about 90% of cases with either surgical interventions such as laparoscopic Heller myotomy or with endoscopic techniques such pneumatic dilatation or, more recently, with per-oral endoscopic myotomy. Age, sex, and manometric type by HRM are also predictors of responsiveness to treatment. Older patients, females and type II achalasia are better after treatment compared to younger patients, males and type III achalasia. Self-expandable metallic stents are an alternative in patients non responding to conventional therapies.
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Eleftheriadis N, Inoue H, Ikeda H, Onimaru M, Maselli R, Santi G. Submucosal tunnel endoscopy: Peroral endoscopic myotomy and peroral endoscopic tumor resection. World J Gastrointest Endosc 2016; 8:86-103. [PMID: 26839649 PMCID: PMC4724034 DOI: 10.4253/wjge.v8.i2.86] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 08/01/2015] [Accepted: 11/25/2015] [Indexed: 02/05/2023] Open
Abstract
Peroral endoscopic myotomy (POEM) is an innovative, minimally invasive, endoscopic treatment for esophageal achalasia and other esophageal motility disorders, emerged from the natural orifice transluminal endoscopic surgery procedures, and since the first human case performed by Inoue in 2008, showed exciting results in international level, with more than 4000 cases globally up to now. POEM showed superior characteristics than the standard 100-year-old surgical or laparoscopic Heller myotomy (LHM), not only for all types of esophageal achalasia [classical (I), vigorous (II), spastic (III), Chicago Classification], but also for advanced sigmoid type achalasia (S1 and S2), failed LHM, or other esophageal motility disorders (diffuse esophageal spasm, nutcracker esophagus or Jackhammer esophagus). POEM starts with a mucosal incision, followed by submucosal tunnel creation crossing the esophagogastric junction (EGJ) and myotomy. Finally the mucosal entry is closed with endoscopic clip placement. POEM permitted relatively free choice of myotomy length and localization. Although it is technically demanding procedure, POEM can be performed safely and achieves very good control of dysphagia and chest pain. Gastroesophageal reflux is the most common troublesome side effect, and is well controllable with proton pump inhibitors. Furthermore, POEM opened the era of submucosal tunnel endoscopy, with many other applications. Based on the same principles with POEM, in combination with new technological developments, such as endoscopic suturing, peroral endoscopic tumor resection (POET), is safely and effectively applied for challenging submucosal esophageal, EGJ and gastric cardia tumors (submucosal tumors), emerged from muscularis propria. POET showed up to know promising results, however, it is restricted to specialized centers. The present article reviews the recent data of POEM and POET and discussed controversial issues that need further study and future perspectives.
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George N, Abdallah J, Maradey-Romero C, Gerson L, Fass R. Review article: the current treatment of non-cardiac chest pain. Aliment Pharmacol Ther 2016; 43:213-39. [PMID: 26592490 DOI: 10.1111/apt.13458] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 10/02/2015] [Accepted: 10/14/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Non-cardiac chest pain is one of the most common functional gastrointestinal disorders. By recognising that gastro-oesophageal reflux disease (GERD), oesophageal dysmotility and oesophageal hypersensitivity are the main underlying mechanisms of NCCP, a more directed therapeutic approach has been developed. AIM To determine the value of the current therapeutic modalities for NCCP. METHODS Electronic (Pubmed/Medline/Cochrane central) and manual search. RESULTS Double-dose PPI treatment for two months is a reasonable first choice approach in patients with NCCP because GERD is the most common aetiology. Studies evaluating the role of medical therapy in NCCP patients with hypercontractile oesophageal motility suggest a limited value to muscle relaxants like calcium channel blockers (nifedipine, diltiazem), nitrates and sildenafil. While most trials evaluating pain modulators are small and many are not placebo-controlled, these type of medications appear efficacious in both patients with NCCP due to oesophageal dysmotility and those with functional chest pain. Cognitive behavioural therapy has been extensively studied in patients with functional chest pain with good results. Other psychological techniques such as hypnotherapy, group therapy or coping skills have been scarcely studied but appear to be effective in NCCP patients. CONCLUSION Medical, endoscopic and surgical therapeutic options are available for the treating physician, although some patients with non-cardiac chest pain may require a multimodal therapeutic approach.
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Affiliation(s)
- N George
- Division of Gastroenterology and Hepatology, The Esophageal and Swallowing Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - J Abdallah
- Division of Gastroenterology and Hepatology, The Esophageal and Swallowing Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - C Maradey-Romero
- Division of Gastroenterology and Hepatology, The Esophageal and Swallowing Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - L Gerson
- Division of Gastroenterology, California Pacific Medical Center, University of California, San Francisco, San Francisco, CA, USA
| | - R Fass
- Division of Gastroenterology and Hepatology, The Esophageal and Swallowing Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
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Chan SM, Wu JCY, Teoh AYB, Yip HC, Ng EKW, Lau JYW, Chiu PWY. Comparison of early outcomes and quality of life after laparoscopic Heller's cardiomyotomy to peroral endoscopic myotomy for treatment of achalasia. Dig Endosc 2016; 28:27-32. [PMID: 26108140 DOI: 10.1111/den.12507] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 06/12/2015] [Accepted: 06/17/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIM This retrospective cohort study compared clinical outcomes and quality of life after peroral endoscopic myotomy (POEM) against laparoscopic Heller myotomy (LHM) for treatment of achalasia. METHODS Patient demographics, operation time, intraoperative blood loss, hospital stay, time to resume diet and analgesic requirement were recorded. Clinical outcomes including recurrence of dysphagia, need for reintervention, and occurrence of gastroesophageal reflux disease (GERD) were recorded. RESULTS From 2001 to 2014, 33 patients underwent POEM whereas 23 patients received LHM. Patients LHM had with longer mean operative time (P = 0.02), more blood loss (P = 0.001) and higher requirement for analgesics (P = 0.009) than those treated by POEM. Hospital stay and time to resume diet were similar. Both POEM and LHM achieved similar dysphagia scores at postoperative 4 weeks, 3 months and 6 months. Twenty-six percent of LHM patients and 15.2% of POEM patients sustained gastroesophageal reflux disease (GERD) after treatment (P = 0.311). Six patients required regular proton pump inhibitor three after POEM and three after LHM (P = 0.639). Thirteen percent of LHM patients sustained recurrent dysphagia and one required reintervention. There was no recurrence in the POEM group. Follow-up duration (mean [SD]) for the LHM group was significantly longer (60 [42] months vs 6 [4] months; P = 0.001). There was also no difference in all four aspects of GERD-related quality of life outcomes. CONCLUSION Compared to LHM, POEM achieved shorter operative time, less blood loss and pain. POEM is comparable to LHM for treatment of achalasia with similar incidence of GERD after the procedure.
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Affiliation(s)
| | - Justin Che Yuen Wu
- Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
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Youn YH, Minami H, Chiu PWY, Park H. Peroral Endoscopic Myotomy for Treating Achalasia and Esophageal Motility Disorders. J Neurogastroenterol Motil 2015; 22:14-24. [PMID: 26717928 PMCID: PMC4699718 DOI: 10.5056/jnm15191] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 12/14/2015] [Accepted: 12/22/2015] [Indexed: 12/11/2022] Open
Abstract
Peroral endoscopic myotomy (POEM) is the application of esophageal myotomy to the concept of natural orifice transluminal surgery (NOTES) by utilizing a submucosal tunneling method. Since the first case of POEM was performed for treating achalasia in Japan in 2008, this procedure is being more widely used by many skillful endosopists all over the world. Currently, POEM is a spotlighted, emerging treatment option for achalasia, and the indications for POEM are expanding to include long-standing, sigmoid shaped esophagus in achalasia, even previously failed endoscopic treatment or surgical myotomy, and other spastic esophageal motility disorders. Accumulating data about POEM demonstrate excellent short-term outcomes with minimal risk of major adverse events, and some existing long-term data show the efficacy of POEM to be long lasting. In this review article, we review the technical details and clinical outcomes of POEM, and discuss some considerations of POEM in special situations.
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Affiliation(s)
- Young Hoon Youn
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hitomi Minami
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Philip Wai Yan Chiu
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Hyojin Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Abstract
Idiopathic achalasia is a primary esophageal motor disorder characterized by loss of esophageal peristalsis and insufficient lower esophageal sphincter relaxation in response to deglutition. Patients with achalasia commonly complain of dysphagia to solids and liquids, bland regurgitation often unresponsive to an adequate trial of proton pump inhibitor, and chest pain. Weight loss is present in many, but not all patients. Although the precise etiology is unknown, it is often thought to be either autoimmune, viral immune, or neurodegenerative. The diagnosis is based on history of the disease, barium esophagogram, and esophageal motility testing. Endoscopic assessment of the gastroesophageal junction and gastric cardia is necessary to rule out malignancy. Newer diagnostic modalities such as high resolution manometry help in predicting treatment response in achalasia based on esophageal pressure topography patterns identifying three phenotypes of achalasia (I-III) and outcome studies suggest better treatment response with types I and II compared to type III. Although achalasia cannot be permanently cured, excellent outcomes are achieved in over 90 % of patients. Current medical and surgical therapeutic options (pneumatic dilation, endoscopic and surgical myotomy, and pharmacologic agents) aim at reducing the LES pressure and facilitating esophageal emptying by gravity and hydrostatic pressure of retained food and liquids. Either graded pneumatic dilatation or laparoscopic surgical myotomy with a partial fundoplication are recommended as initial therapy guided by patient age, gender, preference, and local institutional expertise. The prognosis in achalasia patients is excellent. Most patients who are appropriately treated have a normal life expectancy but the disease does recur and the patient may need intermittent treatment.
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Affiliation(s)
| | - Hannah P Kim
- Department of Internal Medicine, Nashville, TN, USA
| | | | - Michael F Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA.
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Kumbhari V, Khashab MA. Peroral endoscopic myotomy. World J Gastrointest Endosc 2015; 7:496-509. [PMID: 25992188 PMCID: PMC4436917 DOI: 10.4253/wjge.v7.i5.496] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 11/15/2014] [Accepted: 01/20/2015] [Indexed: 02/05/2023] Open
Abstract
Peroral endoscopic myotomy (POEM) incorporates concepts of natural orifice translumenal endoscopic surgery and achieves endoscopic myotomy by utilizing a submucosal tunnel as an operating space. Although intended for the palliation of symptoms of achalasia, there is mounting data to suggest it is also efficacious in the management of spastic esophageal disorders. The technique requires an understanding of the pathophysiology of esophageal motility disorders as well as knowledge of surgical anatomy of the foregut. POEM achieves short term response in 82% to 100% of patients with minimal risk of adverse events. In addition, it appears to be effective and safe even at the extremes of age and regardless of prior therapy undertaken. Although infrequent, the ability of the endoscopist to manage an intraprocedural adverse event is critical as failure to do so could result in significant morbidity. The major late adverse event is gastroesophageal reflux which appears to occur in 20% to 46% of patients. Research is being conducted to clarify the optimal technique for POEM and a personalized approach by measuring intraprocedural esophagogastric junction distensibility appears promising. In addition to esophageal disorders, POEM is being studied in the management of gastroparesis (gastric pyloromyotomy) with initial reports demonstrating technical feasibility. Although POEM represents a paradigm shift the management of esophageal motility disorders, the results of prospective randomized controlled trials with long-term follow up are eagerly awaited.
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Murata H, Tanaka E, Minami H. In reply: Preventing aspiration during peroral endoscopic myotomy. J Anesth 2014; 28:960. [PMID: 25351641 DOI: 10.1007/s00540-014-1913-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 08/25/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Hiroaki Murata
- Department of Anesthesiology, Nagasaki University School of Medicine, Nagasaki, Japan,
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