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Mustian M, Wong K. Surgical management of achalasia. Abdom Radiol (NY) 2024:10.1007/s00261-024-04664-3. [PMID: 39585375 DOI: 10.1007/s00261-024-04664-3] [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: 09/10/2024] [Revised: 10/25/2024] [Accepted: 10/28/2024] [Indexed: 11/26/2024]
Abstract
Achalasia is a chronic esophageal motility disorder comprised of ineffective esophageal peristalsis and incomplete relaxation of the lower esophageal sphincter. This disease had historically been managed through medical means as well as endoscopic dilations. However, surgical interventions are now considered standard of care, including minimally invasive Heller myotomy, which was popularized in 1990s, followed by per oral endoscopic myotomy in the 2010s. Both surgical approaches provide acceptable resolution of dysphagia symptoms. Classification of the achalasia as well as other patient-level factors may drive the clinical decision-making between the two approaches, as well as surgical training and surgeon preference.
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Affiliation(s)
- Margaux Mustian
- University of Alabama at Birmingham, Birmingham, USA.
- Birmingham VA Medical Center, Birmingham, USA.
| | - Kristen Wong
- University of Alabama at Birmingham, Birmingham, USA
- Birmingham VA Medical Center, Birmingham, USA
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King WW, Yang D, Draganov PV. Esophageal Per-Oral Endoscopic Myotomy (E-POEM): Future Directions and Perspectives. Curr Gastroenterol Rep 2024; 26:241-250. [PMID: 39117966 DOI: 10.1007/s11894-024-00938-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2024] [Indexed: 08/10/2024]
Abstract
PURPOSE OF REVIEW POEM is a mature procedure endorsed by societal guidelines as a first line therapy for achalasia and spastic esophageal disorders. Nonetheless, several questions remain, including expanding indications for POEM, periprocedural evaluation and management, and the optimal POEM technique to enhance clinical success while mitigating risk for reflux. RECENT FINDINGS There is uncertainty regarding several technical aspects of the POEM myotomy; though aggregating evidence supports the use of real-time impedance planimetry to guide the myotomy. While post-POEM reflux remains a concerning long term sequela, there is an increasing focus on the potential role of endoscopic anti-reflux interventions. Lastly, with the widespread adoption of POEM, we continue to witness ongoing efforts to standardize post-procedural care and training in this procedure. POEM is no longer a novel but rather established procedure. Yet, this technique has continued to evolve, with the aim of optimizing treatment success while reducing adverse events and risk for post-procedural reflux.
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Affiliation(s)
- William W King
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
| | - Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Orlando, FL, USA
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, PO Box 100214, Gainesville, FL, 32610, USA.
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Albers D, Witt M, Pandolfino JE, Rösch T, Schachschal G, Beyna T, Neuhaus H, Gerges C, Kandler J, Allescher H, Martinek J, Repici A, Ebigbo A, Messmann H, Schumacher B, Werner YB. Peroral endoscopic myotomy for hypercontractile (Jackhammer) esophagus: A retrospective multicenter series with long-term follow-up. United European Gastroenterol J 2024; 12:930-940. [PMID: 38873948 PMCID: PMC11497736 DOI: 10.1002/ueg2.12586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 03/22/2024] [Indexed: 06/15/2024] Open
Abstract
INTRODUCTION Long-term outcome data are limited for non-achalasia esophageal motility disorders treated by peroral endoscopy myotomy (POEM) as a separate group. We investigated a subset of symptomatic patients with hypercontractile esophagus (Jackhammer esophagus). METHODS Forty two patients (mean age 60.9 years; 57% female, mean Eckardt score 6.2 ± 2.1) treated by primary peroral myotomy for symptomatic Jackhammer esophagus 2012-2018 in seven European centers were retrospectively analyzed; myotomy included the lower esophageal sphincter but did not extend more than 1 cm into the cardia in contrast to POEM for achalasia. Manometry data were re-reviewed by an independent expert. The main outcome was the failure rate defined by retreatment or an Eckardt score >3 after at least two years following POEM. RESULTS Despite 100% technical success (mean intervention time 107 ± 48.9 min, mean myotomy length 16.2 ± 3.7 cm), the 2-year success rate was 64.3% in the entire group. In a subgroup analysis, POEM failure rates were significantly different between Jackhammer-patients without (n = 22), and with esophagogastric junction outflow obstruction (EGJOO, n = 20) (13.6% % vs. 60%, p = 0.003) at a follow-up of 46.5 ± 19.0 months. Adverse events occurred in nine cases (21.4%). 14 (33.3%) patients were retreated, two with surgical fundoplication due to reflux. Including retreatments, an improvement in symptom severity was found in 33 (78.6%) at the end of follow-up (Eckardt score ≤3, mean Eckardt change 4.34, p < 0.001). EGJOO (p = 0.01) and frequency of hypercontractile swallows (p = 0.02) were predictors of POEM failure. The development of a pseudodiverticulum was observed in four cases within the subgroup of EGJOO. CONCLUSIONS Patients with symptomatic Jackhammer without EGJOO benefit from POEM in long-term follow-up. Treatment of Jackhammer with EGJOO, however, remains challenging and probably requires full sphincter myotomy and future studies which should address the pathogenesis of this variant and alternative strategies.
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Affiliation(s)
- David Albers
- Department of Internal Medicine and GastroenterologyElisabeth‐Krankenhaus EssenEssenGermany
| | - Mana Witt
- Department of Interdisciplinary EndoscopyUniversity Hospital Hamburg‐EppendorfHamburgGermany
| | - John E. Pandolfino
- Division of Gastroenterology and Hepatology, Department of MedicineFeinberg School of Medicine, Northwestern UniversityChicagoIllinoisUSA
| | - Thomas Rösch
- Department of Interdisciplinary EndoscopyUniversity Hospital Hamburg‐EppendorfHamburgGermany
| | - Guido Schachschal
- Department of Interdisciplinary EndoscopyUniversity Hospital Hamburg‐EppendorfHamburgGermany
| | - Torsten Beyna
- Department of Internal Medicine and GastroenterologyEvangelisches Krankenhaus DüsseldorfDüsseldorfGermany
| | - Horst Neuhaus
- Department of Internal Medicine and GastroenterologyEvangelisches Krankenhaus DüsseldorfDüsseldorfGermany
| | - Christian Gerges
- Department of Internal Medicine and GastroenterologyEvangelisches Krankenhaus DüsseldorfDüsseldorfGermany
- Present address:
University Hospital of EssenEssenGermany
| | - Jennis Kandler
- Department of Internal Medicine and GastroenterologyEvangelisches Krankenhaus DüsseldorfDüsseldorfGermany
- Present address:
University Hospital of DüsseldorfDüsseldorfGermany
| | - Hans‐Dieter Allescher
- Center for Esophageal and Gastrointestinal Motility DisordersCenter for Internal Medicine, Gastroenterology, Hepatology and MetabolismKlinikum Garmisch‐PartenkirchenGarmisch‐PartenkirchenGermany
| | - Jan Martinek
- Department of HepatogastroenterologyInstitute for Clinical and Experimental MedicinePragueCzech Republic
| | - Alessandro Repici
- Department of Biomedical SciencesPieve EmanueleHumanitas UniversityRozzanoItaly
- Department of GastroenterologyHumanitas Research Hospital ‐IRCCS‐RozzanoItaly
| | - Alanna Ebigbo
- Department of GastroenterologyUniversity Hospital AugsburgAugsburgGermany
| | - Helmut Messmann
- Department of GastroenterologyUniversity Hospital AugsburgAugsburgGermany
| | - Brigitte Schumacher
- Department of Internal Medicine and GastroenterologyElisabeth‐Krankenhaus EssenEssenGermany
- Present address:
University Hospital of EssenEssenGermany
| | - Yuki B. Werner
- Department of Interdisciplinary EndoscopyUniversity Hospital Hamburg‐EppendorfHamburgGermany
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Familiari P, Mangiola F, Parmigiani M, Landi R. POEM for non-achalasia spastic oesophageal motility disorders. Best Pract Res Clin Gastroenterol 2024; 71:101909. [PMID: 39209412 DOI: 10.1016/j.bpg.2024.101909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/19/2024] [Indexed: 09/04/2024]
Abstract
Non-achalasia oesophageal motility disorders (NAOMD) represent a heterogeneous group of rare diseases, including oesophagogastric junction outflow obstruction, distal oesophageal spasm, and hypercontractile oesophagus. Despite the differing aetiological, manometric and pathophysiological characteristics, these disorders are unified by similar clinical presentation, including dysphagia and chest pain. The management of these disorders remain a challenge for the clinician. Pharmacotherapy, botulinum toxin injection, endoscopic dilation, and laparoscopic Heller myotomy have been employed, with limited efficacy in the majority of patients. Currently, there are no controlled studies in literature that suggest which is the best management of these diseases. Since its introduction in clinical practice, PerOral Endoscopic Myotomy (POEM) has emerged as a very promising, minimally invasive and effective treatment for oesophageal achalasia. No longer after the first uses, POEM has been successfully used also for the management of selected patients with NAOMD, However, currently available data are limited by small study sample sizes and short-term follow-up.
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Affiliation(s)
- Pietro Familiari
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Digestive Endoscopy Unit, Roma, Lazio, Italy; Università Cattolica del Sacro Cuore, Facoltà di Medicina e Chirurgia, Centre for Endoscopic Research Therapeutics and Training (CERTT), Roma, Lazio, Italy.
| | - Francesca Mangiola
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Digestive Endoscopy Unit, Roma, Lazio, Italy; Università Cattolica del Sacro Cuore, Facoltà di Medicina e Chirurgia, Centre for Endoscopic Research Therapeutics and Training (CERTT), Roma, Lazio, Italy.
| | - Maria Parmigiani
- Università Cattolica del Sacro Cuore, Facoltà di Medicina e Chirurgia, Centre for Endoscopic Research Therapeutics and Training (CERTT), Roma, Lazio, Italy; Fondazione Poliambulanza Istituto Ospedaliero, Digestive Endoscopy Unit and Gastroenterology, Brescia, Lombardia, Italy.
| | - Rosario Landi
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Digestive Endoscopy Unit, Roma, Lazio, Italy; Università Cattolica del Sacro Cuore, Facoltà di Medicina e Chirurgia, Centre for Endoscopic Research Therapeutics and Training (CERTT), Roma, Lazio, Italy.
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Chinda D, Shimoyama T, Fujiwara S, Kaizuka M, Yasuda K, Akitaya K, Arai T, Sawada Y, Hayamizu S, Tatsuta T, Kikuchi H, Yanagimachi M, Mikami T, Sakuraba H, Fukuda S. Assessment of the Physical Invasiveness of Peroral Endoscopic Myotomy during the Perioperative Period Based on Changes in Energy Metabolism. Metabolites 2023; 13:969. [PMID: 37755250 PMCID: PMC10536107 DOI: 10.3390/metabo13090969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/12/2023] [Accepted: 08/21/2023] [Indexed: 09/28/2023] Open
Abstract
A novel treatment method for achalasia of the esophagus and related disorders is known as peroral endoscopic myotomy (POEM). This study aimed to calculate the resting energy expenditure (REE) and evaluated the degree of physical invasiveness based on metabolic changes during the perioperative period of POEM. Fifty-eight patients who underwent POEM were prospectively enrolled; REE, body weight (BW), and basal energy expenditure were measured on the day of POEM, postoperative day 1 (POD 1), and three days after POEM (POD 3). The median REE/BW increased from 19.6 kcal/kg on the day of POEM to 24.5 kcal/kg on POD 1. On POD 3, it remained elevated at 20.9 kcal/kg. The stress factor on POD 1 was 1.20. Among the factors, including the Eckardt score, operation time, and the length of myotomy, the length of myotomy was associated with changes in REE/BW. During the perioperative period of POEM, the level of variation in energy expenditure was lower than that of esophageal cancer surgeries performed under general anesthesia. However, because the length of myotomy is a factor affecting changes in energy expenditure, careful perioperative management is desirable for patients with longer myotomy lengths.
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Affiliation(s)
- Daisuke Chinda
- Division of Endoscopy, Hirosaki University Hospital, Hirosaki 036-8563, Japan
| | | | - Sae Fujiwara
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan; (S.F.); (M.K.); (K.Y.); (K.A.); (T.A.); (Y.S.); (S.H.); (T.T.); (H.K.); (H.S.); (S.F.)
| | - Masatoshi Kaizuka
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan; (S.F.); (M.K.); (K.Y.); (K.A.); (T.A.); (Y.S.); (S.H.); (T.T.); (H.K.); (H.S.); (S.F.)
| | - Kohei Yasuda
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan; (S.F.); (M.K.); (K.Y.); (K.A.); (T.A.); (Y.S.); (S.H.); (T.T.); (H.K.); (H.S.); (S.F.)
| | - Kazuki Akitaya
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan; (S.F.); (M.K.); (K.Y.); (K.A.); (T.A.); (Y.S.); (S.H.); (T.T.); (H.K.); (H.S.); (S.F.)
| | - Tetsu Arai
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan; (S.F.); (M.K.); (K.Y.); (K.A.); (T.A.); (Y.S.); (S.H.); (T.T.); (H.K.); (H.S.); (S.F.)
| | - Yohei Sawada
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan; (S.F.); (M.K.); (K.Y.); (K.A.); (T.A.); (Y.S.); (S.H.); (T.T.); (H.K.); (H.S.); (S.F.)
| | - Shiro Hayamizu
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan; (S.F.); (M.K.); (K.Y.); (K.A.); (T.A.); (Y.S.); (S.H.); (T.T.); (H.K.); (H.S.); (S.F.)
| | - Tetsuya Tatsuta
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan; (S.F.); (M.K.); (K.Y.); (K.A.); (T.A.); (Y.S.); (S.H.); (T.T.); (H.K.); (H.S.); (S.F.)
| | - Hidezumi Kikuchi
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan; (S.F.); (M.K.); (K.Y.); (K.A.); (T.A.); (Y.S.); (S.H.); (T.T.); (H.K.); (H.S.); (S.F.)
| | - Miyuki Yanagimachi
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan;
| | - Tatsuya Mikami
- Center of Healthy Aging Innovation, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan;
| | - Hirotake Sakuraba
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan; (S.F.); (M.K.); (K.Y.); (K.A.); (T.A.); (Y.S.); (S.H.); (T.T.); (H.K.); (H.S.); (S.F.)
| | - Shinsaku Fukuda
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562, Japan; (S.F.); (M.K.); (K.Y.); (K.A.); (T.A.); (Y.S.); (S.H.); (T.T.); (H.K.); (H.S.); (S.F.)
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Olson D, Liu KC, Aadam A. Peroral Endoscopy Myotomy (POEM) for Esophageal Motility Disorders. Curr Gastroenterol Rep 2022; 24:105-114. [PMID: 35947337 DOI: 10.1007/s11894-022-00845-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE OF REVIEW This review aims to provide an overview of the current role of per oral endoscopic myotomy (POEM) in the management of primary esophageal motility disorders and treatment of Zenker's diverticulum. RECENT FINDINGS POEM has been shown to be an effective treatment for achalasia. Recent research has suggested that the length of myotomy may be tailored to the disease phenotype and that short myotomy may be equally effective compared to long myotomy. The role of intra-operative EndoFLIP has shown promise as a tool to assess of the adequacy of myotomy. Further research is needed to determine the role of POEM in other esophageal motility disorders and for treatment of Zenker's diverticulum. Per oral endoscopic myotomy has been shown to be an effective and durable treatment option for achalasia with additional potential roles for the treatment of other esophageal motility disorders and Zenker's diverticulum.
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Affiliation(s)
- Dylan Olson
- Department of Medicine, Feinberg School of Medicine, Northwestern University, 251 E Huron St, 60611, Chicago, IL, USA
| | - Kevin C Liu
- Division of Gastroenterology and Hepatology, Banner University Medical Center, University of Arizona, Tucson, AZ, USA
| | - Aziz Aadam
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, 676 N. Saint Clair Street, Suite 1400, 60611, Chicago, IL, USA.
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Hypercontractile Esophagus From Pathophysiology to Management: Proceedings of the Pisa Symposium. Am J Gastroenterol 2021; 116:263-273. [PMID: 33273259 DOI: 10.14309/ajg.0000000000001061] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 10/22/2020] [Indexed: 12/11/2022]
Abstract
Hypercontractile esophagus (HE) is a heterogeneous major motility disorder diagnosed when ≥20% hypercontractile peristaltic sequences (distal contractile integral >8,000 mm Hg*s*cm) are present within the context of normal lower esophageal sphincter (LES) relaxation (integrated relaxation pressure < upper limit of normal) on esophageal high-resolution manometry (HRM). HE can manifest with dysphagia and chest pain, with unclear mechanisms of symptom generation. The pathophysiology of HE may entail an excessive cholinergic drive with temporal asynchrony of circular and longitudinal muscle contractions; provocative testing during HRM has also demonstrated abnormal inhibition. Hypercontractility can be limited to the esophageal body or can include the LES; rarely, the process is limited to the LES. Hypercontractility can sometimes be associated with esophagogastric junction (EGJ) outflow obstruction and increased muscle thickness. Provocative tests during HRM can increase detection of HE, reproduce symptoms, and predict delayed esophageal emptying. Regarding therapy, an empiric trial of a proton pump inhibitor, should be first considered, given the overlap with gastroesophageal reflux disease. Calcium channel blockers, nitrates, and phosphodiesterase inhibitors have been used to reduce contraction vigor but with suboptimal symptomatic response. Endoscopic treatment with botulinum toxin injection or pneumatic dilation is associated with variable response. Per-oral endoscopic myotomy may be superior to laparoscopic Heller myotomy in relieving dysphagia, but available data are scant. The presence of EGJ outflow obstruction in HE discriminates a subset of patients who may benefit from endoscopic treatment targeting the EGJ.
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Kim JY, Min YW. Peroral Endoscopic Myotomy for Esophageal Motility Disorders. Clin Endosc 2020; 53:638-645. [PMID: 33212547 PMCID: PMC7719430 DOI: 10.5946/ce.2020.223] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/22/2020] [Indexed: 12/11/2022] Open
Abstract
Peroral endoscopic myotomy (POEM) is one of the most clinically successful tunnel-based minimally invasive endoscopic treatments. The classic indications of POEM include achalasia of all types, including failed prior treatments, and expanded indications include the non-achalasia esophageal motility disorders, such as esophagogastric junction outflow obstruction, diffuse esophageal spasm, and jackhammer esophagus. For achalasia treatment, POEM has achieved a comparable surgical efficacy and a safety outcome and, therefore, has emerged as a first-line treatment. For non-achalasia esophageal motility disorders, POEM has also shown high clinical response rates. The complication rate of POEM for esophageal motility disorders is low and most complications are managed with conservative treatment. Currently, POEM is a representative procedure of natural orifice transluminal endoscopic surgery, which has shown a good clinical efficacy with low complication rates for esophageal motility disorders including achalasia. However, further studies are needed to treat non-achalasia motility disorder via POEM.
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Affiliation(s)
- Jun Young Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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9
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Abstract
BACKGROUND Esophageal motility disorders which include achalasia, esophagogastric junction outflow obstruction (EGJ outflow obstruction), jackhammer esophagus (JE), distal esophageal spasm (DES), etc. are rare disease of unknown causes. The diagnosis is based on endoscopy, barium meal, and high-resolution manometry (HRM). With the development of endoscopy, peroral endoscopic myotomy (POEM) has emerged as a standard method for the treatment of achalasia. PURPOSE The purpose of this article is to enable gastroenterologists to have a more comprehensive understanding of the application status, technical characteristics, clinical efficacy and future prospect of POEM in the treatment of esophageal motility disorders. METHODS Through a large number of reading literature, combined with clinical practice, summary and analysis of the indications, procedure, efficacy, complications, and controversies of POEM in the treatment of esophageal motility disorders, as well as the current and future perspectives of POEM were studied. RESULTS POEM is safe and effective in the treatment of esophageal motility disorders, but the GERD reflux rate is higher. CONCLUSIONS POEM can be a new option for the treatment of esophageal movement disorders, but large sample, multi-center, long-term study reports are needed, and it promotes the development of NOTES technology.
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Choi YI, Kim KO, Park DK, Chung JW, Kim YJ, Kwon KA. Clinical outcomes and safety of high-resolution manometry guided superficial partial circular muscle myotomy in per-oral endoscopic myotomy for Jackhammer esophagus: Two cases report. World J Clin Cases 2019; 7:2322-2329. [PMID: 31531326 PMCID: PMC6718798 DOI: 10.12998/wjcc.v7.i16.2322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 07/01/2019] [Accepted: 07/20/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Jack hammer esophagus is a relatively rare disease and to date, there is no dramatic treatment option. Recently, conventional per-oral endoscopic myotomy (POEM) have expanded their area into Jackhammer esophagus. However, several complications such as post procedure motility disorders (e.g., passage disturbance) are issues after POEM. To overcome these issues, we here introduced high-resolution manometry (HRM)-guided superficial partial circular muscle myotomy, which involves cutting only the superficial layer of the esophageal circular muscle.
CASE SUMMARY We report two cases of patients with Jackhammer esophagus who were treated with HRM-guided extremely superficial partial circular muscle myotomy during POEM. Case 1 was a 53-year-old female with medication-refractory odynophagia and case 2 was a 47-year-old man who presented with chest pain. They were diagnosed with Jackhammer esophagus using HRM, and the hypercontractile segments of the esophagus were identified. HRM-guided extremely superficial partial circular muscle myotomy was performed while preserving the lower esophageal sphincter. Therefore, the circular and longitudinal muscle layers are preserved but hypercontractile movements are reduced, even after POEM. Patients’ clinical symptoms dramatically improved right after POEM, and 6-mo follow-up HRM revealed completely resolved status. During a 1-year follow-up period, patients were still in good health and remained symptom free.
CONCLUSION HRM-guided superficial partial circular muscle myotomy may be a promising alternative to conventional POEM for treating Jackhammer esophagus with improved efficacy.
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Affiliation(s)
- Youn I Choi
- Department of Gastroenterology, Gil Medical Center, Gachon University, Incheon 21565, South Korea
| | - Kyoung Oh Kim
- Department of Gastroenterology, Gil Medical Center, Gachon University, Incheon 21565, South Korea
| | - Dong Kyun Park
- Department of Gastroenterology, Gil Medical Center, Gachon University, Incheon 21565, South Korea
| | - Jun-Won Chung
- Department of Gastroenterology, Gil Medical Center, Gachon University, Incheon 21565, South Korea
| | - Yoon Jae Kim
- Department of Gastroenterology, Gil Medical Center, Gachon University, Incheon 21565, South Korea
| | - Kwang An Kwon
- Department of Gastroenterology, Gil Medical Center, Gachon University, Incheon 21565, South Korea
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Kahn A, Al-Qaisi MT, Obeid RA, Katzka DA, Ravi KM, Ramirez FC, Crowell MD, Vela MF. Clinical features and long-term outcomes of lower esophageal sphincter-dependent and lower esophageal sphincter-independent jackhammer esophagus. Neurogastroenterol Motil 2019; 31:e13507. [PMID: 30443964 DOI: 10.1111/nmo.13507] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/09/2018] [Accepted: 10/15/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND The most recent Chicago Classification expanded the criteria for diagnosis of jackhammer esophagus (JHE) to include the distal contractile integral (DCI) of the lower esophageal sphincter (LES). The clinical impact of the manometric inclusion of LES hypercontractility remains unclear. We aimed to analyze the clinical features and long-term outcomes of measured LES-dependent (LD-JHE) and LES-independent (LI-JHE) jackhammer esophagus. METHODS Patients meeting diagnostic criteria for JHE were identified at two academic medical centers. High-resolution esophageal manometry data were re-analyzed with inclusion and exclusion of the LES DCI. LD-JHE was defined by falling outside JHE diagnostic criteria with exclusion of the LES. A telephone survey was conducted for follow-up utilizing the impact dysphagia (IDQ-10) questionnaire. KEY RESULTS Eighty-one patients met study inclusion criteria, with 12 (14.8%) classified as LD-JHE. LD-JHE patients had a significantly lower mean DCI and fewer swallows with DCI >8000 mm Hg-s-cm. Basal LES pressure was higher in patients with dysphagia to solids than those with dysphagia to solids and liquids. Clinical and manometric parameters were otherwise similar between groups. Sixty-six patients had clinical or phone follow-up at a median of 46.6 months. Forty-one patients (62.1%) received therapies directed at JHE. There was no difference in symptom improvement for treated vs untreated patients or for JHE subtype. CONCLUSIONS AND INFERENCES Our findings suggest that LD-JHE and LI-JHE are clinically indistinguishable and thus support existing diagnostic criteria. Furthermore, our long-term follow-up data suggest that JHE, irrespective of LES involvement, may improve without treatment. Further study is needed to clarify which patients merit therapeutic intervention.
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Affiliation(s)
- Allon Kahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | - Mohanad T Al-Qaisi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | - Robert A Obeid
- Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Karthik M Ravi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Francisco C Ramirez
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | - Michael D Crowell
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | - Marcelo F Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
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Chang KJ. Endoscopic foregut surgery and interventions: The future is now. The state-of-the-art and my personal journey. World J Gastroenterol 2019; 25:1-41. [PMID: 30643356 PMCID: PMC6328959 DOI: 10.3748/wjg.v25.i1.1] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 02/06/2023] Open
Abstract
In this paper, I reviewed the emerging field of endoscopic surgery and present data supporting the contention that endoscopy can now be used to treat many foregut diseases that have been traditionally treated surgically. Within each topic, the content will progress as follows: "lessons learned", "technical considerations" and "future opportunities". Lessons learned will provide a brief background and update on the most current literature. Technical considerations will include my personal experience, including tips and tricks that I have learned over the years. Finally, future opportunities will address current unmet needs and potential new areas of development. The foregut is defined as "the upper part of the embryonic alimentary canal from which the pharynx, esophagus, lung, stomach, liver, pancreas, and part of the duodenum develop". Foregut surgery is well established in treating conditions such as gastroesophageal reflux disease (GERD), achalasia, esophageal diverticula, Barrett's esophagus (BE) and esophageal cancer, stomach cancer, gastric-outlet obstruction, and obesity. Over the past decade, remarkable progress in interventional endoscopy has culminated in the conceptualization and practice of endoscopic foregut surgery for various clinical conditions summarized in this paper. Regarding GERD, there are now several technologies available to effectively treat it and potentially eliminate symptoms, and the need for long-term treatment with proton pump inhibitors. For the first time, fundoplication can be performed without the need for open or laparoscopic surgery. Long-term data going out 5-10 years are now emerging showing extended durability. In respect to achalasia, per-oral endoscopic myotomy (POEM) which was developed in Japan, has become an alternative to the traditional Heller's myotomy. Recent meta-analysis show that POEM may have better results than Heller, but the issue of post-POEM GERD still needs to be addressed. There is now a resurgence of endoscopic treatment of Zenker's diverticula with improved technique (Z-POEM) and equipment; thus, patients are choosing flexible endoscopic treatment as opposed to open or rigid endoscopy options. In regard to BE, endoscopic submucosal dissection (ESD) which is well established in Asia, is now becoming more mainstream in the West for the treatment of BE with high grade dysplasia, as well as early esophageal cancer. In combination with all the ablation technologies (radiofrequency ablation, cryotherapy, hybrid argon plasma coagulation), the entire spectrum of Barrett's and related dysplasia and early cancer can be managed predominantly by endoscopy. Importantly, in regard to early gastric cancer and submucosal tumors (SMTs) of the stomach, ESD and full thickness resection (FTR) can excise these lesions en-bloc and endoscopic suturing is now used to close large defects and perforations. For treatment of patients with malignant gastric outlet obstruction (GOO), endoscopic gastro-jejunostomy is now showing better results than enteral stenting. G-POEM is also emerging as a treatment option for patients with gastroparesis. Obesity has become an epidemic in many western countries and is becoming also prevalent in Asia. Endoscopic sleeve gastroplasty (ESG) is now becoming an established treatment option, especially for obese patients with body mass index between 30 and 35. Data show an average weight loss of 16 kg after ESG with long-term data confirming sustainability. Finally, in respect to endo-hepatology, there are many new endoscopic interventions that have been developed for patients with liver disease. Endoscopic ultrasound (EUS)-guided liver biopsy and EUS-guided portal pressure measurement are exciting new frontiers for the endo-hepatologists.
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Affiliation(s)
- Kenneth J Chang
- H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, Orange, CA 92868, United States
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13
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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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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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15
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Abstract
PURPOSE OF REVIEW This review addresses the similarities and differences between the spastic esophageal disorders, including jackhammer esophagus, distal esophageal spasm (DES), and type III (spastic) achalasia. The pathophysiology, diagnosis, and treatment of each separate disorder are discussed herein, with an emphasis on overlapping and discordant features. RECENT FINDINGS The Chicago Classification is a hierarchical organizational scheme for esophageal motility disorders, currently in its third iteration, with direct impact on the definitions of these three disorders. Complementary diagnostic tools such as impedance planimetry and novel manometric parameters continue to evolve. The suite of potential treatments for these disorders is also expanding, with progressive interest in the role of peroral endoscopic myotomy alongside established pharmacologic and mechanical interventions. Although jackhammer esophagus, distal esophageal spasm, and type III achalasia frequently overlap in terms of their clinical presentation and available management approaches, the divergences in their respective diagnostic criteria suggest that additional study may reveal additional mechanistic distinctions that lead in turn to further refinements in therapeutic decision-making.
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Peroral endoscopic myotomy (POEM) for esophageal motility disorders other than achalasia. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2018.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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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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18
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Ponds FAM, Smout AJPM, Fockens P, Bredenoord AJ. Challenges of peroral endoscopic myotomy in the treatment of distal esophageal spasm. Scand J Gastroenterol 2018; 53:252-255. [PMID: 29338493 DOI: 10.1080/00365521.2018.1424933] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Distal esophageal spasm (DES) is a rare motility disorder characterized by premature and rapidly propagated contractions of the distal esophagus. Treatment options are limited and often poorly effective. Peroral endoscopic myotomy (POEM) seems an effective and attractive new treatment option for DES. In this case report we describe some of the difficulties that could arise. MATERIALS AND METHODS A 84-year old man with therapy-refractory DES and complaints of severe dysphagia and chest pain underwent a POEM procedure under general anesthesia. A longer myotomy was performed to cleave the circular muscle layer from start till end of the spastic contractions. RESULTS The length of the myotomy was 16 cm. Hyperactive spastic contractions during the procedure complicated the creation of the submucosal tunnel, extended the duration (134 vs. 60-90 min for achalasia), increased postoperative pain and prolonged hospital admission. Intravenously nitroglycerin peroperative diminished spastic contractions. Postoperative a remnant of spastic contractions was present, proximal to the myotomy, causing persistent symptoms. CONCLUSION Performing POEM for DES is challenging due to reactive hyperactive spastic contractions during the procedure causing technical difficulties and an extended procedure. A long myotomy, several centimeters above the proximal border of the spastic region, is essential to prevent remnants of spasticity.
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Affiliation(s)
- Fraukje Anna-Marie Ponds
- a Department of Gastroenterology and Hepatology , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - André J P M Smout
- a Department of Gastroenterology and Hepatology , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - Paul Fockens
- a Department of Gastroenterology and Hepatology , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
| | - Albert J Bredenoord
- a Department of Gastroenterology and Hepatology , Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
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Yang D, Draganov PV. Expanding Role of Third Space Endoscopy in the Management of Esophageal Diseases. ACTA ACUST UNITED AC 2018; 16:41-57. [PMID: 29435819 DOI: 10.1007/s11938-018-0169-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OPINION STATEMENT: "Third space" endoscopy, also commonly referred as submucosal endoscopy, is founded on the principle that the deeper layers of the gastrointestinal (GI) tract can be accessed by tunneling in the submucosal space without compromising the integrity of the overlying mucosa. Peroral endoscopic myotomy (POEM), endoscopic submucosal dissection (ESD), and submucosal tunneling endoscopic resection (STER) are innovative techniques within the field of third space endoscopy in the management of esophageal disorders. POEM has become an accepted minimally invasive therapy for achalasia and related motility disorders with excellent short-term results, with early studies yielding similar efficacy to surgical myotomy and increased durability when compared to pneumatic balloon dilation (PBD). Data are needed to establish long-term outcomes with POEM, with particular interest on the incidence of gastroesophageal reflux, which appears to be higher than initially anticipated. ESD, a mature endoscopic resection technique in Asia, has recently gained traction in the West as a viable option for the management of early Barrett's esophagus (BE) neoplasia. Compared to standard endoscopic mucosal resection (EMR), ESD allows the en bloc resection of lesions irrespective of size, which may facilitate histological interpretation and reduce recurrence rates. Large prospective randomized controlled trials are needed to validate the efficacy and safety of this technique and to further define its role in the endoscopic armamentarium in early BE neoplasia. STER is an attractive technique that theoretically permits the resection of subepithelial esophageal tumors (SETs) arising from the deeper GI layers. Initial studies from highly experienced endoscopic centers support its technical feasibility and safety, although these results should be interpreted with caution due to variability arising from small numbers and heterogeneity among studies. Overall, third space endoscopy is an expanding field within endoscopic therapeutics for the treatment of esophageal diseases. While initial results have been very promising, large prospective studies, long-term data, and structured training programs with the establishment of competency parameters are needed before third space endoscopy can be advocated outside of highly specialized centers.
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Affiliation(s)
- Dennis Yang
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, 1329 SW 16th Street Suite 5262, Gainesville, FL, 32608, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, 1329 SW 16th Street Suite 5262, Gainesville, FL, 32608, USA.
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Al-Qaisi MT, Siddiki HA, Crowell MD, Burdick GE, Fleischer DE, Ramirez FC, Vela MF. The clinical significance of hypercontractile peristalsis: comparison of high-resolution manometric features, demographics, symptom presentation, and response to therapy in patients with Jackhammer esophagus versus Nutcracker esophagus. Dis Esophagus 2017; 30:1-7. [PMID: 28881883 DOI: 10.1093/dote/dox085] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 06/06/2017] [Indexed: 12/11/2022]
Abstract
The Chicago Classification version 3.0 (CC v 3.0) defines hypercontractile peristalsis as Jackhammer esophagus (JE); Nutcracker esophagus (NE) is no longer recognized. Data regarding patient characteristics and treatment response for JE versus NE are limited. We aimed to compare demographic characteristics, high resolution manometry (HRM) features, clinical presentation, management strategies, and treatment outcomes in patients with JE versus NE. We performed a retrospective analysis of adult patients diagnosed with NE (CC v 2.0) or JE (CC v 3.0) by HRM from January 2012 to August 2015. Demographics, symptoms, treatments, and response to therapy (none or partial/complete) were ascertained by chart review, for statistical comparisons. In 45 patients with JE and 29 with NE, there was no significant difference in rate of dysphagia (73% and 59%) or chest pain (44% and 59%). Treatment data were available in 29 JE (smooth muscle relaxants in 4, pain modulators in 3, botulinum toxin injection (BTX) in 10, endoscopic dilation in 5, multimodal treatment in 7), and 20 NE patients (smooth muscle relaxants in 2, pain modulators in 2, (BTX) in 6, endoscopic dilation in 3, multimodal treatment in 7). Follow-up data on 26/29 JE and 20/20 NE patients showed similar treatment response (96.4% vs. 82.1%, p= 0.08) after mean follow-up of 11.2 and 11 months, respectively. There were no major differences for JE versus NE in demographics, symptoms, or type of and response to therapy. Larger prospective, controlled trials are needed to clarify the clinical significance and response to treatment in JE and NE.
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Affiliation(s)
- M T Al-Qaisi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - H A Siddiki
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - M D Crowell
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - G E Burdick
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - D E Fleischer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - F C Ramirez
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - M F Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
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Miranda García P, Casals Seoane F, Gonzalez JM, Barthet M, Santander Vaquero C. Per-oral endoscopic myotomy (POEM): a new endoscopic treatment for achalasia. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 109:719-726. [PMID: 28724307 DOI: 10.17235/reed.2017.4732/2016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND/AIMS Per-oral endoscopic myotomy (POEM) is a new minimally invasive technique to treat achalasia. METHODS We performed a review of the literature of POEM with a special focus on technical details and the results obtained with this technique in patients with achalasia and other esophageal motility disorders. RESULTS Thousands of POEM procedures have been performed worldwide since its introduction in 2008. The procedure is based on the creation of a mucosal entry point in the proximal esophagus to reach the cardia through a submucosal tunnel and then perform a myotomy of the muscular layers of the cardia, esophagogastric junction and distal esophagus, as performed in a Heller myotomy. The clinical remission rate ranges from 82 to 100%. Although no randomized studies exist and available data are from single-center studies, no differences have been found between laparoscopic Heller myotomy (LHM) and POEM in terms of perioperative outcomes, short-term outcomes (12 months) and long-term outcomes (up to three years). Procedure time and length of hospital stay were lower for POEM. Post-POEM reflux is a concern, and controversial data have been reported compared to LHM. The technique is safe, with no reported deaths related to the procedure and an adverse event rate comparable to surgery. Potential complications include bleeding, perforation, aspiration and insufflation-related adverse events. Thus, this is a complex technique that needs specific training even in expert hands. The indication for this procedure is widening and other motor hypercontractil esophageal disorders have been treated by POEM with promising results. POEM can be performed in complicated situations such as in pediatric patients, sigmoid achalasia or after failure of previous treatments. CONCLUSIONS POEM is an effective treatment for achalasia and is a promising tool for other motor esophageal disorders. It is a safe procedure but, due to its technical difficulty and possible associated complications, the procedure should be performed in referral centers by trained endoscopists.
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Mu D, Li YY, Zhang MM, Zhang Y, Li Z, Li YQ. POEM for special patient cohorts: A review. J Dig Dis 2017; 18:265-272. [PMID: 28374443 DOI: 10.1111/1751-2980.12473] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 03/26/2017] [Accepted: 03/31/2017] [Indexed: 12/11/2022]
Abstract
Peroral endoscopic myotomy (POEM) is a natural orifice, translumenal endoscopic surgical procedure that achieves endoscopic myotomy by conducting a submucosal tunnel as an operating space. It is conventionally performed in achalasia. Recently, several centers worldwide have reported the feasibility of this procedure not only in early achalasia but also in other particular patient cohorts. Possible indications for POEM include previously failed Heller myotomy, pneumatic balloon dilatation or POEM, sigmoid achalasia, pediatric patients, spastic esophagus disorders, Zenker's diverticulum and gastroparesis. However, its application in large numbers of special patient groups awaits knowledge of the long-term outcome and greater experience with POEM.
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Affiliation(s)
- Dan Mu
- Laboratory of Translational Gastroenterology, Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan, Shandong Province, China
| | - Yue Yue Li
- Laboratory of Translational Gastroenterology, Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan, Shandong Province, China
| | - Ming Ming Zhang
- Laboratory of Translational Gastroenterology, Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan, Shandong Province, China
| | - Yan Zhang
- Laboratory of Translational Gastroenterology, Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan, Shandong Province, China
| | - Zhen Li
- Laboratory of Translational Gastroenterology, Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan, Shandong Province, China
| | - Yan Qing Li
- Laboratory of Translational Gastroenterology, Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan, Shandong Province, China
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Herregods TVK, Smout AJPM, Ooi JLS, Sifrim D, Bredenoord AJ. Jackhammer esophagus: Observations on a European cohort. Neurogastroenterol Motil 2017; 29. [PMID: 27753176 DOI: 10.1111/nmo.12975] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 09/20/2016] [Indexed: 01/17/2023]
Abstract
BACKGROUND With the advent of high-resolution manometry (HRM), a new diagnosis, jackhammer esophagus, was introduced. Little is known about this rare condition, and the relationship between symptoms and hypercontractility is not always straightforward. The aim of our study was to describe a large cohort of patients with jackhammer esophagus and to investigate whether manometric findings are associated with the presence of symptoms. METHODS All patients from 06, 2014 until 12, 2015 seen at two tertiary centers with at least one hypercontractile swallow (distal contractile integral [DCI] >8000 mm Hg/s/cm) on HRM were analyzed. Patients with ≥20% premature swallows, or patients with another diagnosis explaining their symptoms were excluded. KEY RESULTS Of the 34 patients identified with jackhammer esophagus, most suffered from dysphagia (67.6%) and/or chest pain (47.1%). The symptom chest pain was not associated with any of the manometric findings, whereas dysphagia was associated with the DCI of the hypercontractile swallows and with intrabolus pressure. In addition, all patients who had an isolated DCI of the lower esophageal sphincter (LES) zone >2000 mm Hg/s/cm had dysphagia. The differences in HRM and clinical characteristics between subgroups based on the contraction type (single- or multi-peaked) or based on meeting criteria of the Chicago Classification v3.0 and v2.0 were limited. CONCLUSIONS & INFERENCES The symptom dysphagia is accompanied with strong contractions of the LES, signs of a possible outflow obstruction, and a very high DCI. The presence of a multipeaked contraction seems to be of limited relevance, and caution is warranted in labeling patients with one hypercontractile swallow as normal.
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Affiliation(s)
- T V K Herregods
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - A J P M Smout
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - J L S Ooi
- Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - D Sifrim
- Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - A J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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Schlottmann F, Shaheen NJ, Madanick RD, Patti MG. The role of Heller myotomy and POEM for nonachalasia motility disorders. Dis Esophagus 2017; 30:1-5. [PMID: 28375487 DOI: 10.1093/dote/dox003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 01/05/2017] [Indexed: 12/11/2022]
Abstract
The best-defined primary esophageal motor disorder is achalasia. However, symptoms such as dysphagia, regurgitation and chest pain can be caused by other esophageal motility disorders such as Diffuse Esophageal Spasm (DES), Nutcracker Esophagus (NE) and the Hypertensive Lower Esophageal Sphincter (HTN-LES). Most patients with DES and HTN-LES who complain of dysphagia improve after a myotomy. Patients with NE whose main complaint is chest pain, often do not have relief of the pain and can even develop dysphagia as a consequence of the myotomy. POEM is a relatively new procedure, and there are no studies with long-term follow-up and no prospective and randomized trials comparing it to surgical myotomy. Overall, the key to success is based on a complete evaluation and a careful patient selection. The best results, regardless of the technique, are in fact obtained in patients with outflow obstruction and impaired esophageal emptying, a picture similar to achalasia.
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Affiliation(s)
- F Schlottmann
- Departments of 1Surgery and Center for Esophageal Diseases and Swallowing
| | - N J Shaheen
- Medicine and Center for Esophageal Diseases and Swallowing, University of North Carolina, Chapel Hill, North Carolina, USA
| | - R D Madanick
- Medicine and Center for Esophageal Diseases and Swallowing, University of North Carolina, Chapel Hill, North Carolina, USA
| | - M G Patti
- Departments of 1Surgery and Center for Esophageal Diseases and Swallowing
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Nikaki K, Ooi JLS, Sifrim D. Chicago Classification of Esophageal Motility Disorders: Applications and Limits in Adults and Pediatric Patients with Esophageal Symptoms. Curr Gastroenterol Rep 2016; 18:59. [PMID: 27738966 DOI: 10.1007/s11894-016-0532-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The Chicago classification (CC) is most valued for its systematic approach to esophageal disorders and great impact in unifying practice for esophageal manometric studies. In view of the ever-growing wealth of knowledge and experience gained by the expanding use of high-resolution manometry (HRM) in various clinical scenarios, the CC is regularly updated. Its clinical impact and ability to predict clinical outcome, both in adults and pediatrics, will be further promoted by recognizing its current limitations, incorporating new metrics in its diagnostic algorithms and adjusting the HRM protocols based on the clinical question posed. Herein, we discuss the current limitations of the CC and highlight some areas of improvement for the future.
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Affiliation(s)
- Kornilia Nikaki
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, E1 2AJ, London, UK
| | - Joanne Li Shen Ooi
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, E1 2AJ, London, UK
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 26 Ashfield Street, E1 2AJ, London, UK.
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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: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 10/19/2015] [Accepted: 11/24/2015] [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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28
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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: 41] [Impact Index Per Article: 4.1] [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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Nakato R, Manabe N, Mitsuoka N, Shiwaku H, Matsumoto H, Yamashita K, Shiotani A, Hata J, Watanabe T, Hirai T, Haruma K. Clinical experience with four cases of jackhammer esophagus. Esophagus 2015. [DOI: 10.1007/s10388-015-0518-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2023]
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Abstract
Peroral endoscopic myotomy (POEM) was first performed in Japan in 2008 for uncomplicated achalasia. With excellent results, it was adopted by highly skilled endoscopists around the world and the indications for POEM were expanded to include advanced sigmoid achalasia, failed surgical myotomy, patients with previous endoscopic treatments and even other spastic oesophageal motility disorders. With increased uptake and performance of POEM, variations in technique and improved management of adverse events have been developed. Now, 6 years since the first case and with >3,000 procedures performed worldwide, long-term data has shown the efficacy of POEM to be long-lasting. A growing body of literature also exists pertaining to the learning curve, application of novel technologies, extended indications and physiologic changes with POEM. Ultimately, this once experimental procedure is evolving towards becoming the preferred treatment for achalasia and other spastic oesophageal motility disorders.
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31
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Roman S, Pioche M, Mion F. Per oral endoscopic myotomy (POEM) for all spastic esophageal disorders? Endosc Int Open 2015; 3:E202-4. [PMID: 26171431 PMCID: PMC4486033 DOI: 10.1055/s-0034-1391417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 12/28/2014] [Indexed: 11/24/2022] Open
Affiliation(s)
- Sabine Roman
- Digestive Physiology, Hospices Civils de Lyon and Lyon I University, Lyon, France ,LabTau, INSERM, U1032, Lyon, France ,Corresponding author Sabine Roman, MD Digestive PhysiologyHôpital Edouard Herriot5, Place d’Arsonval69437 Lyon Cédex 03France+33-4-72-11-01-47
| | - Mathieu Pioche
- LabTau, INSERM, U1032, Lyon, France ,Gastroenterology, Hospices Civils de Lyon and Lyon I University, Lyon, France
| | - François Mion
- Digestive Physiology, Hospices Civils de Lyon and Lyon I University, Lyon, France ,LabTau, INSERM, U1032, Lyon, France
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32
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Esophageal hypomotility and spastic motor disorders: current diagnosis and treatment. Curr Gastroenterol Rep 2015; 16:421. [PMID: 25376746 DOI: 10.1007/s11894-014-0421-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Esophageal hypomotility (EH) is characterized by abnormal esophageal peristalsis, either from a reduction or absence of contractions, whereas spastic motor disorders (SMD) are characterized by an increase in the vigor and/or propagation velocity of esophageal body contractions. Their pathophysiology is not clearly known. The reduced excitation of the smooth muscle contraction mediated by cholinergic neurons and the impairment of inhibitory ganglion neuronal function mediated by nitric oxide are likely mechanisms of the peristaltic abnormalities seen in EH and SMD, respectively. Dysphagia and chest pain are the most frequent clinical manifestations for both of these dysfunctions, and gastroesophageal reflux disease (GERD) is commonly associated with these motor disorders. The introduction of high-resolution manometry (HRM) and esophageal pressure topography (EPT) has significantly enhanced the ability to diagnose EH and SMD. Novel EPT metrics in particular the development of the Chicago Classification of esophageal motor disorders has enabled improved characterization of these abnormalities. The first step in the management of EH and SMD is to treat GERD, especially when esophageal testing shows pathologic reflux. Smooth muscle relaxants (nitrates, calcium channel blockers, 5-phosphodiesterase inhibitors) and pain modulators may be useful in the management of dysphagia or pain in SMD. Endoscopic Botox injection and pneumatic dilation are the second-line therapies. Extended myotomy of the esophageal body or peroral endoscopic myotomy (POEM) may be considered in highly selected cases but lack evidence.
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33
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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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Bechara R, Inoue H. Recent advancement of therapeutic endoscopy in the esophageal benign diseases. World J Gastrointest Endosc 2015; 7:481-495. [PMID: 25992187 PMCID: PMC4436916 DOI: 10.4253/wjge.v7.i5.481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 01/13/2015] [Accepted: 02/09/2015] [Indexed: 02/05/2023] Open
Abstract
Over the past 30 years, the field of endoscopy has witnessed several advances. With the advent of endoscopic mucosal resection, removal of large mucosal lesions have become possible. Thereafter, endoscopic submucosal resection was refined, permitting en bloc removal of large superficial neoplasms. Such techniques have facilitated the development of antireflux mucosectomy, a promising novel treatment for gastroesophageal reflux. The introduction and use of over the scope clips has allowed for endoscopic closure of defects in the gastrointestinal tract, which were traditionally treated with surgical intervention. With the development of per-oral endoscopic myotomy (POEM), the treatment of achalasia and spastic disorders of the esophagus have been revolutionized. From the submucosal tunnelling technique developed for POEM, Per oral endoscopic tumor resection of subepithelial tumors was made possible. Simultaneously, advances in biotechnology have expanded esophageal stenting capabilities with the introduction of fully covered metal and plastic stents, as well as biodegradable stents. Once deemed a primarily diagnostic tool, endoscopy has quickly transcended to a minimally invasive intervention and therapeutic tool. These techniques are reviewed with regards to their application to benign disease of the esophagus.
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Abstract
After excluding a cardiac cause, potent anti-reflux therapy should be administered to patients with non-cardiac chest pain since gastroesophageal reflux disease (GERD) is the most common underlying mechanism of this disorder. If GERD is an unlikely cause of patient's symptoms, an esophageal motor disorder should be excluded. Spastic motility disorders can be treated with a smooth muscle relaxant (such as calcium channel blocker, nitrate, or phosphodiesterase 5 inhibitors). Alternatively, spastic motility disorders may respond to anti-spasmodics, pain modulators, botulinum toxin injection into the distal esophagus, and/or surgery. Patients with functional chest pain have recently seen an expanded treatment armamentarium including medications such as trazadone, tricyclic anti-depressants, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, pregabalin, and/or ramelteon.
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Affiliation(s)
- Carla Maradey-Romero
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, Case Western Reserve University, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH, 44109-1998, USA
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Friedel D, Modayil R, Stavropoulos SN. Per-oral endoscopic myotomy: Major advance in achalasia treatment and in endoscopic surgery. World J Gastroenterol 2014; 20:17746-17755. [PMID: 25548473 PMCID: PMC4273125 DOI: 10.3748/wjg.v20.i47.17746] [Citation(s) in RCA: 16] [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: 06/13/2014] [Revised: 07/20/2014] [Accepted: 12/01/2014] [Indexed: 02/06/2023] Open
Abstract
Per-oral endoscopic myotomy (POEM) represents a natural orifice endoscopic surgery (NOTES) approach to laparoscopy Heller myotomy (LHM). POEM is arguably the most successful clinical application of NOTES. The growth of POEM from a single center in 2008 to approximately 60 centers worldwide in 2014 with several thousand procedures having been performed attests to the success of POEM. Initial efficacy, safety and acid reflux data suggest at least equivalence of POEM to LHM, the previous gold standard for achalasia therapy. Adjunctive techniques used in the West include impedance planimetry for real-time intraprocedural luminal assessment and endoscopic suturing for challenging mucosal defect closures during POEM. The impact of POEM extends beyond the realm of esophageal motility disorders as it is rapidly popularizing endoscopic submucosal dissection in the West and spawning offshoots that use the submucosal tunnel technique for a host of new indications ranging from resection of tumors to pyloromyotomy for gastroparesis.
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Maradey-Romero C, Gabbard S, Fass R. Treatment of esophageal motility disorders based on the chicago classification. ACTA ACUST UNITED AC 2014; 12:441-55. [PMID: 25263532 DOI: 10.1007/s11938-014-0032-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OPINION STATEMENT The Chicago Classification divides esophageal motor disorders based on the recorded value of the integrated relaxation pressure (IRP). The first group includes those with an elevated mean IRP that is associated with peristaltic abnormalities such as achalasia and esophagogastric junction outflow obstruction. The second group includes those with a normal mean IRP that is associated with esophageal hypermotility disorders such as distal esophageal spasm, hypercontractile esophagus (jackhammer esophagus), and hypertensive peristalsis (nutcracker esophagus). The third group includes those with a normal mean IRP that is associated with esophageal hypomotility peristaltic abnormalities such as absent peristalsis, weak peristalsis with small or large breaks, and frequent failed peristalsis. The therapeutic options vary greatly between the different groups of esophageal motor disorders. In achalasia patients, potential treatment strategies comprise medical therapy (calcium channel blockers, nitrates, and phosphodiesterase 5 inhibitors), endoscopic procedures (botulinum toxin A injection, pneumatic dilation, or peroral endoscopic myotomy) or surgery (Heller myotomy). Patients with a normal IRP and esophageal hypermotility disorder are candidates for medical therapy (nitrates, calcium channel blockers, phosphodiesterase 5 inhibitors, cimetropium/ipratropium bromide, proton pump inhibitors, benzodiazepines, tricyclic antidepressants, trazodone, selective serotonin reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors), endoscopic procedures (botulinum toxin A injection and peroral endoscopic myotomy), or surgery (Heller myotomy). Lastly, in patients with a normal IRP and esophageal hypomotility disorder, treatment is primarily focused on controlling the presence of gastroesophageal reflux with proton pump inhibitors and lifestyle modifications (soft and liquid diet and eating in the upright position) to address patient's dysphagia.
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Affiliation(s)
- Carla Maradey-Romero
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, Case Western Reserve University, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH, 44109 -1998, USA
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