ACG clinical guideline: diagnosis and management of achalasia

Endoscopic ultrasound-measured muscular thickness of the lower esophageal sphincter and long-term prognosis after peroral endoscopic myotomy for achalasia

BACKGROUND

People with achalasia typically have a thick lower esophageal muscularis propria (LEMP), and peroral endoscopic myotomy (POEM) has been effective in treating most patients. LEMP thickness may be associated with the outcomes and prognosis after POEM. However, more evidence is needed regarding the relationship between LEMP thickness and patient prognosis after POEM.

AIM

To assess the association between LEMP thickness, measured using endoscopic ultrasound (EUS), and long-term prognosis, especially relapse, after POEM for achalasia.

METHODS

All medical records, including EUS data, of patients who underwent POEM to treat achalasia at Shengjing Hospital of China Medical University from January 2012 to September 2018 were retrospectively reviewed. LEMP thickness was measured by EUS, and a thickness of ≥ 3 mm was defined as thickened. The severity of patient symptoms was evaluated using the Eckardt score. Relapse was defined as a 3-point rise in the Eckardt score after a period of clinical remission. The relationship between patient characteristics, muscle thickness, and recurrence was analyzed.

RESULTS

Eighty-two patients (32 males and 50 females, aged 17-78 years) and 85 POEM procedures were included. In total, 76.8% (63/82 patients) of patients had a thickened muscularis propria. Older age and longer disease course were associated with muscularis propria thickening (P < 0.05). The mean postoperative follow-up time was 35.4 ± 17.2 mo (range, 8-87.5 mo) in 60 patients. Five patients with Eckardt scores > 3 refused further management after their symptoms were relieved. The relapse rate was 12.73% (7/55 cases). Five patients, four of whom had muscularis propria thickening, had disease recurrence within 12 mo after the procedure. Achalasia relapsed in one patient who had a thickened muscularis propria after 24 mo and in another patient who did not have a thickened muscularis propria after 30 mo. Patients with recurrence were typically younger and had a shorter disease course (P < 0.05). The relapse rate in patients with a non-thickened muscularis propria tended to be higher (18.2%, 2/11 patients) than that in patients with a thickened muscularis propria (11.4%, 5/44 patients), although no significant difference was found. Age (hazard ratio = 0.92; 95% confidence interval: 0.865-0.979; P < 0.05) and being male (hazard ratio = 7.173; 95% confidence interval: 1.277-40.286; P < 0.05) were identified as risk factors for symptomatic recurrence by multivariable analysis using the Cox model.

CONCLUSION

Patients with a thickened muscularis are typically older and have a longer disease course. Younger age and the male sex are associated with increased recurrence. Patients with a thin muscularis propria may be prone to relapse, although further validation is needed.

ACG Clinical Guidelines: Diagnosis and Management of Achalasia

Achalasia is an esophageal motility disorder characterized by aberrant peristalsis and insufficient relaxation of the lower esophageal sphincter. Patients most commonly present with dysphagia to solids and liquids, regurgitation, and occasional chest pain with or without weight loss. High-resolution manometry has identified 3 subtypes of achalasia distinguished by pressurization and contraction patterns. Endoscopic findings of retained saliva with puckering of the gastroesophageal junction or esophagram findings of a dilated esophagus with bird beaking are important diagnostic clues. In this American College of Gastroenterology guideline, we used the Grading of Recommendations Assessment, Development and Evaluation process to provide clinical guidance on how best to diagnose and treat patients with achalasia.

Functional Luminal Imaging Probe Panometry Identifies Achalasia-Type Esophagogastric Junction Outflow Obstruction

BACKGROUND & AIMS

The etiologies of esophagogastric junction outflow obstruction (EGJOO) vary, as do their therapeutic implications. We aimed to identify patients with EGJOO most likely to benefit from achalasia-type treatment, based on findings from functional luminal imaging probe (FLIP) panometry.

METHODS

We performed a retrospective study of 34 patients who received a diagnosis of EGJOO from January 2015 through July 2017. Our analysis included patients who had been evaluated with timed barium esophagram, FLIP, or upper endoscopy.

RESULTS

Among the 34 patients with idiopathic EGJOO, 7 (21%) had a normal esophagogastric junction distensibility index (EGJ-DI), based on FLIP panometry, and all had repetitive antegrade contractions. None of the patients had radiographic evidence of EGJOO (RAD-EGJOO), defined as liquid barium retention and/or barium tablet impaction. On the other hand, all 18 patients with RAD-EGJOO had an EGJ-DI less than 2 mm²/mm Hg. Nine of the 18 patients with RAD-EGJOO and EGJ-DI less than 2 mm²/mm Hg underwent achalasia-type treatment, and 77.8% of these (7 of 9) had improvements in Eckardt score. Of the 6 patients with a normal EGJ-DI (>3 mm²/mm Hg) who were treated conservatively and followed up, 100% had improvements in subsequent Eckardt scores.

CONCLUSIONS

We found that FLIP is useful in identifying patients with EGJOO who are most likely to benefit from achalasia-type therapy. Patients with a low EGJ-DI responded well to achalasia-type treatment, whereas patients with normal results from FLIP panometry had good outcomes from conservative management. FLIP panometry might help select management strategies for this difficult population of patients.

Endoscopic ultrasound: a powerful tool to modify treatment algorithms in opioid-induced achalasia

BACKGROUND

Opioid use in the U.S. has increased dramatically over the last 15 years, recently being declared a public health emergency. Opioid use is associated with esophageal dysmotility lending to a confusing clinical picture compared to true achalasia. Patients exhibit symptoms and elicit diagnostic results consistent with esophageal motility disorders, in particular type III achalasia. Modified therapeutic strategies and outcomes become challenging. Differentiating true achalasia from opioid-induced achalasia is critical. Conventional surgical interventions, i.e., myotomy, are ineffective in the absence of true achalasia. We assess the utility of esophageal muscle layer mapping with endoscopic ultrasound (EUS) in distinguishing primary from opioid-induced achalasia.

METHODS

From 2016 to 2019, patients with abnormal manometry and suspected achalasia underwent esophagogastroduodenoscopy and EUS mapping of esophageal round muscle layer thickness. Maximum round layer thickness and length of round muscle layer thickness > 1.8 mm were collected and compared between opioid users and non-opioid users using Wilcoxon Rank sum test.

RESULTS

45 patients were included: 12 opioid users, 33 non-opioid users. Mean age 56.8 years (range 24-93), 53.3% male patients. Mean BMI in the opioid-induced achalasia group was 30.2 kg/m², mean BMI in the primary achalasia group 26.8 kg/m² (p = 0.11). In comparing endoscopic maximum round layer thickness between groups, non-opioid patients had a thicker round muscle layer (2.7 mm vs 1.8 mm, p = 0.05). Length of abnormally thickened esophageal muscle (greater than 1.8 mm) also differed between the two groups; patients on opioids had a shorter length of thickening (4.0 cm vs 0.0 cm, p = 0.04). Intervention rate was higher in the non-opioid group (p = 0.79). Of the patients that underwent therapeutic intervention, symptom resolution was higher in the non-opioid group (p = 0.002), while re-intervention post-procedure for persistent symptomatology was elevated in the opioid subset (p = 0.06). Patients in the opioid group were less likely to undergo invasive treatment (Heller). As of 2017 all interventions in the opioid group have been endoscopic.

CONCLUSION

Endoscopic ultrasound is an essential tool that has improved our treatment algorithm for suspected achalasia in patients with chronic opioid usage. Incorporation of EUS findings into treatment approach may prevent unnecessary surgery in opioid users.

Surgery Outcomes and Quality of Life in Achalasia's Treatment

Objectives: Evaluate the quality of life (QoL) in patients diagnosed with achalasia who performed Heller's myotomy. Methods: Between January 1, 2000 and March 27, 2019, 99 patients were submitted to esophagomyotomy at the São João Hospital in Oporto, Portugal. The exclusion criteria were other diagnoses, age <18 years at the date of surgery, and death. Seventy-five patients were contacted. Pre- and postoperative evaluations were performed using the achalasia disease-specific QoL questionnaire and by the Eckardt score. QoL was assessed by the Medical Outcomes Study SF-36. Results: Forty-nine patients (65%) answered the questionnaires. The median difference in the achalasia-DSQoL questionnaire between the pre- and postoperative period was -9.0 (interquartile range [IQR]: 5-12), whereas in the Eckardt score was -5.0 (IQR: 3.25-7). Lower postoperative scores correlated with higher scores on the SF-36's mental and physical summary measures (Spearman's rho [ρ] = -0.651 and ρ = -0.577 for the achalasia-DSQoL questionnaire and ρ = -0.552 and ρ = -0.515 for the Eckardt score, P < .001). Physical and mental summary measures were correlated with each other (ρ = 0.788, P < .001). Conclusions: Heller's myotomy allows a decrease in symptoms and an increase in QoL. Patients with severe symptoms before surgery had higher postoperative scores and patients with fewer symptoms had lower postoperative scores.

Achalasia: what to do in the face of failures of Heller myotomy

Achalasia is a primary motility disorder of the esophagus, and while there are several treatment options, there is no consensus regarding them. When therapeutic intervention for achalasia fails, a careful evaluation of the cause of the persistent or recurrent symptoms using upper endoscopy, esophageal manometry, and contrast radiologic studies is required to understand the cause of therapy failure and guide plans for subsequent treatment. Options for reintervention are the same as for primary intervention and include pneumatic dilation, botulinum toxin injection, peroral endoscopic myotomy, or redo esophageal myotomy. When reintervention fails or if the esophagus is not amenable to intervention and the disease is considered end-stage, esophagectomy is the last option to manage recurrent achalasia.

A Rare Paraneoplastic Syndrome of Lung Cancer

Achalasia is a neurodegenerative motor disease of the esophagus resulting mainly from a loss of function of the lower esophageal sphincter, the pathophysiology of which is still poorly understood. Its incidence is rare—it is 1.6 per 100,000—and its occurrence in the context of paraneoplastic syndrome has been rarely described in the literature. We report a rare case of paraneoplastic achalasia associated with lung cancer.

Pseudoachalasia: a systematic review of the literature

Pseudoachalasia, also known as secondary achalasia, is a clinical condition mimicking idiopathic achalasia but most commonly caused by malignant tumors of gastroesophageal junction (GEJ). Our aim was to systematically review and present all available data on demographics, clinical features, and diagnostic modalities involved in patients with pseudoachalasia. A systematic search of literature published during the period 1978-2019 was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (end-of-search date: June 25th, 2019). Two independent reviewers extracted data with regards of study design, interventions, participants, and outcomes. Thirty-five studies met our inclusion criteria and were selected in the present review. Overall, 140 patients with pseudoachalasia were identified, of whom 83 were males. Mean patient age was 60.13 years and the mean weight loss was 13.91 kg. A total of 33 (23.6%) patients were wrongly 'treated' at first for achalasia. The most common presenting symptoms were dysphagia, food regurgitation, and weight loss. The median time from symptoms' onset to hospital admission was 5 months. Most common etiology was gastric cancer (19%). Diagnostic modalities included manometry, barium esophagram, endoscopy, and computed tomography (CT). Pseudoachalasia is a serious medical condition that is difficult to be distinguished from primary achalasia. Clinical feature assessment along with the correct interpretation of diagnostic tests is nowadays essential steps to differentiate pseudoachalasia from idiopathic achalasia.

Impedance in the evaluation of the esophagus

The aim of this paper is to review esophageal electrical impedance technologies and to discuss the use of these technologies for physiological measurements, diagnostics, and therapy of esophageal disease. In order to develop a better understanding of the pathophysiology of and improve the diagnosis of esophageal disorders, such as gastroesophageal reflux disease (GERD) and achalasia, several new diagnostic tests, including intraluminal impedance, esophageal mucosal impedance, and the functional luminal imaging probe, have been developed. These technologies have proven valuable for assessment of the esophagus in recent years. They provide information on esophageal flow properties, mucosal integrity, lumen shape, and distensibility in esophageal disorders, in particular for GERD and achalasia. Despite their promise and novel clinical studies, the potential of these technologies has been far from realized. New multidisciplinary approaches will contribute to our understanding and interpretation of esophageal impedance data and disease mechanisms.

Factors Associated With Achalasia Treatment Outcomes: Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Identification of factors associated with achalasia treatment outcome might help physicians select therapies based on patient characteristics. We performed a systematic review and meta-analysis to identify factors associated with treatment response.

METHODS

We searched MEDLINE, EMBASE, and the Cochrane Library through February 21, 2019, for randomized controlled trials and cohort, case-control, and cross-sectional studies that reported patient-specific outcomes of treatment (botulinum toxin injection, pneumatic dilation, peroral endoscopic myotomy, or laparoscopic Heller myotomy). We assessed the methodologic quality of the included studies using the quality in prognosis studies tool. We planned qualitative and quantitative analyses.

RESULTS

We analyzed data from 75 studies (8 randomized controlled trials, 27 prospective cohort studies, and 40 retrospective studies) on a total of 34 different factors associated with outcomes (3 demographic, 17 clinical, and 14 diagnostic factors). Qualitative assessment showed age, manometric subtype, and presence of a sigmoid-shaped esophagus as factors associated with outcomes of treatment for achalasia with a strong level of evidence. The cumulative evidence for the association with chest pain, symptom severity, and lower esophageal sphincter pressure was inconclusive. A meta-analysis confirmed that older age (mean difference, 7.9 y; 95% CI, 1.5-14.3 y) and manometric subtype 3 (odds ratio, 7.1; 95% CI, 4.1-12.4) were associated with clinical response.

CONCLUSIONS

In a systematic review and meta-analysis, we found age and manometric subtype to be associated with outcomes of treatment for achalasia. This information should be used to guide treatment decisions.

Treating children with achalasia using per-oral endoscopic myotomy (POEM): Twenty-one cases in review

BACKGROUND

Per-oral endoscopic myotomy (POEM), a modern treatment for achalasia, has only recently emerged as an option for pediatric patients. Here we describe and characterize the success of POEM in children with achalasia.

METHODS

A single-institution prospective cohort study was performed of patients <18 years old who underwent POEM from 2014 to 2019. Main outcomes were success at one year (Eckardt ≤3), procedure duration, complications, reintervention.

RESULTS

The median age of patients (n = 21) was 13 years (range 2-17). Median procedure duration was 92 min (range 52-259) with case duration plateau of 87.4 min and learning rate of 15.5 cases. Intraoperative complications included capnoperitoneum requiring needle decompression and mucosotomy requiring additional clips. One patient experienced chest pain with small capnoperitoneum seen on chest radiography, and three patients had extraluminal carbon dioxide found incidentally on routine radiography. All were managed with observation. Pre- versus 1-month postprocedure Eckardt scores were significantly improved (7 ± 2 versus 1 ± 2, p < 0.0001, and median ± SD) with 100% symptomatic relief at one year. To achieve this, 13 patients required further dilation(s), one required laparoscopic Heller myotomy, and two required repeat POEM.

CONCLUSIONS

POEM is a viable and safe treatment for pediatric patients with achalasia. We demonstrate improvement in symptoms and procedure proficiency with minimal intra- and postoperative complications.

TYPE OF STUDY

Prospective cohort study.

LEVEL OF EVIDENCE

Level II.

Triosephosphate isomerase, carbonic anhydrase, and creatinine kinase-brain isoform are possible antigen targets in patients with achalasia

BACKGROUND

Idiopathic achalasia is an uncommon esophageal motor disorder. The disease involves interaction between inflammatory and autoimmune responses. However, the antigens related to the disease are still unknown.

AIM

To identify the possible antigen targets in muscle biopsies from lower esophageal sphincter (LES) of achalasia patients.

METHODS

Esophageal biopsies of patients with type I and type II achalasia and esophagogastric junction outflow obstruction (EGJOO) were analyzed. Lower esophageal sphincter muscle biopsy from a Healthy organ Donor (HD) was included as control for two-dimensional gel electrophoresis. Immunoblotting of muscle from LES lysate with sera of type I, type II achalasia, or type III achalasia, sera of EGJOO and sera of healthy subjects (HS) was performed. The target proteins of the serum were identified by mass spectrometry Matrix-assited laser desorption/ionization time-of-flight (MALDI-TOF).

KEY RESULTS

The proteomic map of muscle from LES tissue lysates of type I, and type II achalasia, EGJOO, and HD were analyzed and divided into three important regions. We found a difference in the concentration of certain spots. Further, we observed the serum reactivity of type I achalasia and type II achalasia against 45 and 25 kDa bands of type I achalasia tissue. Serum of type III achalasia and EGJOO mainly recognized 25 kDa band. Bands correspond to triosephosphate isomerase (TPI) (25 kDa), carbonic anhydrase (CA) (25 kDa) and creatinine kinase-brain (CKB) isoform (45 kDa).

CONCLUSIONS AND INFERENCES

We identify three antigen targets, TPI, CA, and CKB isoform, which are recognized by sera from patients with achalasia.

Peroral endoscopic myotomy for achalasia: a prospective multicenter study in Japan

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.).

Characteristics of a Subset of Achalasia With Normal Integrated Relaxation Pressure

Background/Aims

Integrated relaxation pressure (IRP) is a critical diagnostic criterion to define achalasia. However, there are some cases with typical symptoms and signs of achalasia but with normal IRP. The aim of this study is to evaluate the clinical characteristics of patients with achalasia with normal IRP and outcomes after peroral endoscopic myotomy (POEM).

Methods

Patients with achalasia were collected in whom POEM was performed from November 2014 to April 2018 at CHA Bundang Medical Center. Achalasia with normal IRP was defined by findings compatible to achalasia in Eckardt score, endoscopy with endoscopic ultrasound, high-resolution manometry, impedance planimetry (EndoFlip), and timed esophagogram.

Results

POEM was performed in 89 patients with achalasia; among them, 24 (27%) patients were diagnosed with achalasia with normal IRP. Patients with achalasia with normal IRP were older, had longer duration of symptom, and had a more tortuous esophagus. In EndoFlip, the distensibility index and cross-sectional area were higher in patients with normal IRP. Therapeutic outcomes showed no statistically significant differences. On correlation analysis, IRP had negative correlations with age, disease duration, and distensibility index.

Conclusions

Patients with achalasia of normal IRP value were older and had longer disease duration and higher distensibility index and cross-sectional area than patients with achalasia with abnormal relaxation of lower esophageal sphincter. Therapeutic outcomes were not different between the 2 groups.

2019 Seoul Consensus on Esophageal Achalasia Guidelines

Esophageal achalasia is a primary motility disorder characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. Achalasia is a chronic disease that causes progressive irreversible loss of esophageal motor function. The recent development of high-resolution manometry has facilitated the diagnosis of achalasia, and determining the achalasia subtypes based on high-resolution manometry can be important when deciding on treatment methods. Peroral endoscopic myotomy is less invasive than surgery with comparable efficacy. The present guidelines (the "2019 Seoul Consensus on Esophageal Achalasia Guidelines") were developed based on evidence-based medicine; the Asian Neurogastroenterology and Motility Association and Korean Society of Neurogastroenterology and Motility served as the operating and development committees, respectively. The development of the guidelines began in June 2018, and a draft consensus based on the Delphi process was achieved in April 2019. The guidelines consist of 18 recommendations: 2 pertaining to the definition and epidemiology of achalasia, 6 pertaining to diagnoses, and 10 pertaining to treatments. The endoscopic treatment section is based on the latest evidence from meta-analyses. Clinicians (including gastroenterologists, upper gastrointestinal tract surgeons, general physicians, nurses, and other hospital workers) and patients could use these guidelines to make an informed decision on the management of achalasia.

Effects of Peroral Endoscopic Myotomy on Esophageal Function in the Treatment of Achalasia

Peroral endoscopic myotomy (POEM) is a new technique to treat achalasia, but the effects on esophageal motor function and structure are still unclear. This study aimed to examine the esophageal function and anatomical changes of patients with achalasia treated with POEM. This was a retrospective study of 43 patients with achalasia treated with POEM between January 2013 and January 2016 at the Second Affiliated Hospital of Xi'an Jiaotong University. The patients were grouped as previous treatments for achalasia (n = 19) versus no previous treatment (n = 24). Surgical success (defined as Eckardt score ≤3 points or decreased by >3 points compared with baseline), recurrence, and reintervention were analyzed. Three patients (7.0%) were Eckardt grade I, 16 (37.2%) were grade II, and 24 (55.8%) were grade III. Operation time was 35 to 150 (median = 49) minutes. Both groups showed improvements in the Eckardt score after surgery (both P < .001), without a difference between the 2 groups (P = .749). The maximal mean diameter of the esophagus was reduced, and the lower esophageal sphincter pressure was improved after surgery (both groups, all P < .001), without difference between the 2 groups (all P > .05). One case of failure was probably due to the presence of an esophageal stent. POEM has a high success rate and is possibly unaffected by previous treatments, except maybe stent implantation. Clinical symptoms of achalasia are significantly relieved by POEM; the function of the esophageal sphincter and the esophagus structure are improved. Previous esophageal stent implantation could increase failure likelihood, but this will have to be confirmed.

Peroral endoscopic myotomy (POEM): a comparative study between Chagasic and idiopathic achalasia

Background and study aims  Achalasia can be classified as either primary (idiopathic) achalasia or secondary achalasia, which is a consequence of another systemic disease. Peroral endoscopic myotomy (POEM) is an effective and safe treatment for achalasia. We evaluated the efficacy and safety of POEM in patients with Chagasic achalasia compared to idiopathic achalasia. Patients and methods  We evaluated POEM procedures performed at a single institution from November 2016 to January 2018. Demographic data, Eckardt score, lower esophageal sphincter (LES) pressure, body mass index, post-operative erosive esophagitis, adverse events, length of hospital stay, and procedure-related parameters were analyzed. Results  Fifty-one patients underwent POEM as a treatment for achalasia in this period (20 patients with Chagasic and 31 with Idiopathic etiology). The overall clinical success rate was 92.1 %, with no statistical difference between groups (90 % in the Chagasic group vs. 93.5 % in the Idiopathic group, P  = 0.640). Both groups had significant reduction in Eckardt score and in LES pressure, and increase in bodey mass index (BMI) at 1-year follow-up. There was no statistical difference between groups regarding Eckardt score ( P  = 0.439), LES pressure (p = 0.507), BMI ( P  = 0.254), post erosive esophagitis (35 % vs. 38.7 %, P  = 0.789), adverse events (30 % vs. 12 %, P  = 0.163,) length of hospital stay (3.75 days vs. 3.58 days, P  = 0.622), and operative time (101.3 min vs. 99.1 min, P  = 0.840). Conclusion  POEM is an effective and safe treatment for patients with achalasia. There is no difference in POEM outcomes for those patients with Chagasic or Idiopathic achalasia.

Is Peroral Endoscopic Myotomy a Potential Therapy for Esophageal Absent Contractility?

AIM

Peroral endoscopic myotomy (POEM) is recommended for the endoscopic treatment of achalasia and esophageal junction outflow obstruction (EGJOO); however, absent contractility, a subtype of peristalsis disorders classified by the Chicago Classification of esophageal motility v3.0, has no effective treatment. The purpose of this study was to assess the efficacy of POEM in absent contractility, in the part of the patients presents with dysphagia.

METHODS

We conducted a single-center retrospective study at a tertiary referral center. We included 30 patients who mainly complain with dysphagia, and they underwent POEM from January 2013 to December 2018. The data of high-resolution esophageal manometry was collected before and after POEM. They were divided into 3 groups: EGJOO, Achalasia, and Absent contractility according to the Chicago Classification of esophageal motility v3.0 before POEM. Telephone follow-up was made in February 2019 to obtain Eckardt scores and weight changes.

RESULTS

We found that both Eckardt scores and integrated relaxation pressure decreased post-POEM in the 3 groups (P<0.05). Eckardt score was significantly lower in the EGJOO group than in the Absent contractility group (P=0.004) post-POEM. The difference of Eckardt Score was higher in the EGJOO group (P=0.010) and the Achalasia group (P=0.007) than in the Absent contractility group, as was weight gain (P=0.023; P=0.002).

CONCLUSIONS

These findings suggest that POEM is an effective endoscopic procedure for patients with EGJOO and achalasia. Furthermore, POEM can significantly improve symptoms in patients with absent contractility, although less so than for the other 2 groups. POEM is a potential therapy for absent contractility patients presenting with dysphagia.

Pneumatic balloon dilatation versus laparoscopic Heller myotomy for achalasia: a failed attempt at meta-analysis

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.

The Role of Automatically Generated Chicago Classification in Delayed Achalasia Diagnosis

Achalasia is an esophageal motility disorder characterized by a lack of peristalsis and an increased lower esophageal sphincter pressure that does not relax with swallowing. High-resolution manometry (HRM), a valuable diagnostic tool for esophageal disorders, often comes with software for automated study interpretation. Although helpful, there are certain caveats in the diagnostic criteria for achalasia which the software may miss. We highlight 2 patients in whom software analysis of HRM studies resulted in misdiagnosis of achalasia as manometrically detected nonachalasia esophagogastric junction outflow obstruction and emphasize the importance of manual interpretation of HRM data by clinicians.

Respiratory infections and chronic cough due to triple A (Allgrove) syndrome

Cough and respiratory infections are common in pediatrics. Our case report illustrates the need for pediatricians to consider rare diagnoses such as genetic syndromes and primary gastrointestinal motility disorders in patients with unremitting respiratory and gastrointestinal symptoms. Early identification provides early intervention and reduces long-term morbidity for pediatric patients.

Poem Versus Laparoscopic Heller Myotomy in the Treatment of Esophageal Achalasia: A Case-Control Study from Two High Volume Centers Using the Propensity Score

BACKGROUND

POEM has recently had a widespread diffusion, aiming at being the treatment of choice for esophageal achalasia. The results of ongoing RCTs against laparoscopic myotomy are not available, yet. We, therefore, designed this propensity score (PS) case-control study with the aim of evaluating how POEM compares to the long-standing laparoscopic Heller myotomy + Dor fundoplication (LHD) and verifying if it may really replace the latter as the first-line treatment for achalasia.

METHODS

Two groups of consecutive patients undergoing treatment for primary achalasia from January 2014 to November 2017 were recruited in two high-volume centers, one with extensive experience with POEM and one with LHD. Patients with previous endoscopic treatment were included, whereas patients with previous LHD or POEM were excluded. A total of 140 patients in both centers were thus matched. LHD and POEM were performed following established techniques. The patients were followed with clinical (Eckardt score), endoscopic, and pH-manometry evaluations.

RESULTS

The procedure was successfully completed in all the patients. POEM required a shorter operation time and postoperative stay compared to LHD (p < 0.001). No mortality was recorded in either group. Seven complications were recorded in the POEM group (five mucosal perforations) and 3 in the LHD group (3 mucosal perforations)(p = 0.33). Two patients in the POEM group and one in the LHD were lost to follow-up. One patient in both groups died during the follow-up for unrelated causes. At a median follow-up of 24 months [15-30] for POEM and 31 months [15-41] for LHD (p < 0.05), 99.3% of the POEM patients and 97.7% of the LHD patients showed an Eckardt score ≤ 3 (p < 0.12). Four years after the treatment, the probability to have symptoms adequately controlled was > 90% for both groups (p = 0.2, Log-rank test). HR-Manometry showed a similar reduction in the LES pressure and 4sIRP; 24-h pH-monitoring showed however an abnormal exposure to acid in 38.4% of POEM patients, as compared to 17.1% of LHD patients (p < 0.01) and esophagitis was found in 37.4% of the POEM and 15.2% of LHD patients (p < 0.05).

CONCLUSION

POEM provides the same midterm results as LHD. This study confirms, however, a higher incidence of postoperative GERD with the former, even if its real significance needs to be further evaluated.

ASGE guideline on the management of achalasia

Achalasia is a primary esophageal motor disorder of unknown etiology characterized by degeneration of the myenteric plexus, which results in impaired relaxation of the esophagogastric junction (EGJ), along with the loss of organized peristalsis in the esophageal body. The criterion standard for diagnosing achalasia is high-resolution esophageal manometry showing incomplete relaxation of the EGJ coupled with the absence of organized peristalsis. Three achalasia subtypes have been defined based on high-resolution manometry findings in the esophageal body. Treatment of patients with achalasia has evolved in recent years with the introduction of peroral endoscopic myotomy. Other treatment options include botulinum toxin injection, pneumatic dilation, and Heller myotomy. This American Society for Gastrointestinal Endoscopy Standards of Practice Guideline provides evidence-based recommendations for the treatment of achalasia, based on an updated assessment of the individual and comparative effectiveness, adverse effects, and cost of the 4 aforementioned achalasia therapies.

Gastrointestinal Motility Issues in Cancer Patients

PURPOSE OF REVIEW

This paper seeks to highlight GI motility disorders that are frequently present in patients with a malignancy. GI dysmotility can occur due to the cancer itself or as a consequence of medical and surgical treatments. Often, symptoms are nonspecific and the diagnosis requires a high index of suspicion. The goal of the paper is to review the common motility problems seen in patients with cancer, their clinical manifestations, and options for management.

RECENT FINDINGS

Studies show that newer endoscopy techniques such as endoscopic mucosal dissection can cause esophageal dysmotility. Opioid-induced constipation is frequently encountered in patients with cancer. Motility disorders in cancer patient can lead to clinical morbidity, poor quality of life, and malnutrition. Newer diagnostic tests and medical and surgical treatments may be helpful in improving the diagnosis and management of these disorders.

Frequency and factors associated with malnutrition among patients with achalasia and effect of pneumatic dilation

Background

Although achalasia patients are undernourished, studies are scant. We studied: (i) the frequency of malnutrition among these patients and (ii) the effect of pneumatic dilatation (PD) on malnutrition.

Methods

A total of 70 adult achalasia patients and 70 healthy controls were evaluated through dietary recall, anthropometry, and biochemical parameters, and patients were reevaluated 6 months after PD.

Results

Patients had lower intake of calories (median, interquartile range [IQR]: 1835.0 [1682.5–1915.0] vs 2071.5 [1950–2276.2] kcal/day, P < 0.001), protein (40.9 [36.3–42.2] vs 52.9 [45.7–62] g/day, P < 0.001), calcium (310 [192.5–392.4] vs 477.5 [350–560] mg/day, P < 0.001), and iron (6.7 [4.7–8.8] vs 10.1 [7.5–11.50] mg/day, P < 0.001) than controls. Patients had lower body mass index (BMI: 19.6 [16.6–22] vs 22.8 [19.5,29.1], P < 0.001), midarm circumference (MAMC; 20 [17.5–23] vs 24.1 [21.4–28.5], P < 0.001), biceps (BSFT; 3.1 [1.9–3.9] vs 5.5 [3.8–9.2] mm, P < 0.001), triceps’ skin fold thickness (TSFT; 5 [2.4–7] vs 7.8 [5.1–9.4] mm, P < 0.001), serum protein (7.2 ± 0.8 vs 7.6 ± 0.8 g/dL, P = 0.005), and albumin (4.0 [3.5–4.4] vs 4.1 [3.9–4.2] g/dL, P = 0.009). PD increased calories (1803 [950–2400] vs 2050 [1470–2950] kcal/day), protein intake (41.0 [22–70] vs 45.0 [37.5–80.0] gm/day), BMI (19.6 [12.8–30.0] vs 22.2[15.9–30.0] P = 0.001 for all), and MAMC (21 [14.1–32.0] vs 24.2 [15–32.0] cm, P = 0.03). Reduced intake was a determinant of malnutrition.

Conclusions

Malnutrition is common in achalasia patients, and PD improved it.

Esophageal Dysphagia in the Elderly

PURPOSE OF REVIEW

With a globally aging population, dysphagia is a growing health concern among elderly. Increasing reflux disease has contributed to an increased prevalence of dysphagia from peptic strictures and esophageal cancer. Dysphagia can lead to malnutrition and aspiration pneumonia, causing considerable morbidity and mortality. This review article focuses on recent advances in the approach and management of esophageal dysphagia.

RECENT FINDINGS

Endoscopic functional luminal imaging probe is a novel test that complements upper endoscopy, esophagram, and esophageal manometry for evaluation of esophageal dysphagia. Opioid induced esophageal dysfunction (OIED) is an emerging clinical entity that can mimic achalasia. Strictures refractory to dilation can be treated with intralesional steroid injections, electrosurgical incision, or esophageal stents. Peroral endoscopic myotomy (POEM) is gaining in popularity for treatment of achalasia and other spastic disorders of esophagus. Treatment of esophageal dysphagia may include proton pump inhibitors, endoscopic dilation, or surgery and requires a personalized approach based on risks and benefits. POEM is a valuable therapy for achalasia, but further studies are needed to evaluate its use, and other alternatives, for treatment of OIED and spastic esophageal disorders.

Laparoscopic Approach of the Obstruction of the Lower Third of the Esophagus in Children

Objective: To review the diagnostic methodology in pediatric patients with obstruction of the lower third of the esophagus as well as minimally invasive therapeutic options. Materials and Methods: Retrospective study carried out reviewing records of children with esophageal obstruction diagnostic, from 2000 to 2018. They were divided into Group I stenosis secondary to reflux; Group II achalasia; and Group III embryonic remnants. Results: Thirty-three patients. Group I: 7; esophageal barium swallow irregular stenosis of the distal third and endoscopy irregular stenosis in 7. Treated with laparoscopic fundoplication 2, Collis Nissen 5. Group II: 22 patients, age X = 11.55 years. All with dysphagia and symmetrical stenosis of esophagogastric junction. Fifteen underwent manometry and all underwent intraoperative endoscopy. All had laparoscopic myotomy, with 2 perforations and no conversions, 2 patients had subsequent dysphagia to solids, and they did not need esophageal dilatation. Group III: 4 patients, stenosis was above esophagogastric junction. On endoscopy, inflammation was present in all 3 with irregular esophagogastric junction and difficulty passing endoscope. Three patients underwent laparoscopic resection and anastomosis. One patient leaked and developed a fistula. One patient has not been operated upon as yet. Conclusions: In those patients, the best surgical option depends upon the diagnosis. Esophageal barium studies and endoscopy allow discerning among them.

Esophageal pH-impedance monitoring in children: position paper on indications, methodology and interpretation by the SIGENP working group

Multichannel intraluminal impedance pH (MII-pH) monitoring currently represents the gold standard diagnostic technique for the detection of gastro-esophageal reflux (GER), since it allows to quantify and characterize all reflux events and their possible relation with symptoms. Over the last ten years, thanks to its strengths and along with the publication of several clinical studies, its worldwide use has gradually increased, particularly in infants and children. Nevertheless, factors such as the limited pediatric reference values and limited therapeutic options still weaken its current clinical impact. Through an up-to-date review of the available scientific evidence, our aim was to produce a position paper on behalf of the working group on neurogastroenterology and acid-related disorders of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) on MII-pH monitoring technique, indications and interpretation in pediatric age, in order to standardise its use and to help clinicians in the diagnostic approach to children with GER symptoms.

Post-POEM reflux: who's at risk?

INTRODUCTION

Per-Oral Endoscopic Myotomy (POEM) is a less invasive alternative to laparoscopic Heller myotomy for patients with achalasia. While a partial fundoplication is often performed concurrently with laparoscopic myotomy, an endoscopic approach does not offer this and leaves patients prone to post-operative reflux. The objectives of this study were to (1) identify patients with post-POEM reflux using BRAVO pH and endoscopic evaluations, and (2) investigate risk factors associated with post-POEM reflux and esophagitis to optimize patient selection for POEM and identify those who will benefit from a proactive approach to post-operative reflux management.

METHODS

A retrospective review of a prospectively collected database of patients who underwent POEM between January 2011 and July 2017 at a single institution was performed. Demographics along with pre-POEM and post-POEM variables were obtained. Univariate and multivariate analyses were performed, using p values ≤ 0.05 for statistical significance.

RESULTS

Forty-six patients were included, with a mean follow-up of 358 days. Mean age was 58 (19.2); 61% were female. Thirty-six patients underwent 48-h BRAVO pH testing after POEM, which revealed abnormal esophageal acid exposure in 15 patients (41.7%). There was a correlation between positive BRAVO results and presence of preoperative esophagitis (p = 0.02). Only 13% of patients had symptom-related reflux episodes based on the Symptom Associated Probability of the BRAVO study. Post-operative endoscopy revealed 6 patients with esophagitis, compared to 4 patients who had esophagitis on preoperative endoscopy. Only higher preoperative Eckardt score was significantly associated with endoscopic evidence of esophagitis post-POEM.

CONCLUSIONS

Reflux is common after POEM. A majority of patients with a positive BRAVO study are asymptomatic, which is concerning. Objective follow-up is of paramount importance with upper endoscopy and ambulatory pH monitoring being the gold standard. Elevated preoperative Eckardt score and esophagitis are associated with post-POEM reflux. This population warrants close surveillance.

Do we need endoscopic ultrasonography for the workup of patients with esophageal motility disorder?

INTRODUCTION

Endoscopic ultrasonography (EUS) is advised in the workup of achalasia patients to rule out secondary achalasia or pseudoachalasia, and search for a typical esophageal wall thickening. The purpose of this study was to assess the clinical contribution of EUS findings in achalasia and other esophageal motility disorders (EMD).

METHODS

We conducted a single center retrospective study at a tertiary referral centre. We included all patients with an EUS for the workup of a suspected EMD from January 2012 to December 2017.

RESULTS

Sixty-nine patients were included, 52% were men, with a median (±SD) age of 61 ± 14 years. Median (±SD) Eckardt Score was 7 ± 2. EUS was normal in 26 (38%) patients, and showed an esophageal wall thickening in 43 (62%) patients. Three cases of secondary achalasia were diagnosed at mucosal biopsies: 2 esophageal carcinomas and one eosinophilic esophagitis. Esophageal wall thickening was not significantly associated with the type of EMD or achalasia subtype and there was no statistical correlation between the presence of a wall thickening at EUS and therapeutic outcomes.

CONCLUSION

In our work, the presence of an esophageal wall thickening was not predictive of the type of EMD nor achalasia subtype or treatment outcome. The contribution of endoscopic ultrasonography in achalasia and other EMD seems limited.

Evaluation and Management of Premalignant Conditions of the Esophagus: A Systematic Survey of International Guidelines

Esophageal cancer represents one of the most lethal forms of malignancy. The growing incidence of esophageal adenocarcinoma represents an emerging public health concern. This review article summarizes current diagnostic, management, and therapeutic practices of premalignant conditions of the esophagus including Barrett's esophagus, tylosis, granular cell tumors, achalasia, and the ingestion of caustic substances. Our report provides clinicians and academics with a global clinical perspective regarding presentation, surveillance guidelines, and therapeutic management of these esophageal conditions.

Unusual cause of dysphagia

In this case, we describe a unique case of large renal hydronephrosis in a 79-year-old Indian male patient who had initially presented with 3 months of progressive dysphagia and loss of weight. His dysphagia was initially thought to be related to the atypical diagnosis of achalasia and was being considered for an elective laparoscopic Heller myotomy. On performing CT of the abdomen, a large renal mass was discovered. However, predicament remained regarding the exact aetiology of this renal mass. This case highlights a tremendously intriguing case of dysphagia with an underlying aetiology that has not been reported elsewhere previously.

How I Approach Dysphagia

PURPOSE OF REVIEW

This review presents an overview of the diagnostic approach to esophageal dysphagia and summarizes recent epidemiological trends and technical advancements.

RECENT FINDINGS

The evaluation of dysphagia begins with a detailed history followed by endoscopy to evaluate for any structural abnormalities including malignancy. This is especially true given the emergence of eosinophilic esophagitis (EoE) as a dominant cause of esophageal dysphagia. In fact, it is now standard practice to obtain esophageal biopsies during endoscopy performed to evaluate dysphagia, since EoE can present without the characteristic mucosal features of rings, furrows, and exudate. Achalasia is also more frequently encountered since the introduction of high-resolution manometry (HRM) and the Chicago Classification into clinical practice. The Chicago Classification provides a stepwise diagnostic algorithm for evaluating HRM studies and systematically diagnosing esophageal motility disorders. Lastly, the functional lumen imaging probe (FLIP) is a novel technology that has added insight into both achalasia and EoE. Measuring esophageal distensibility with FLIP has useful prognostic implications for both diseases, and FLIP can identify motility abnormalities in achalasics not detected with HRM. A careful history is key to the efficient evaluation of dysphagia, and endoscopy is usually the first diagnostic study to obtain. For patients with prominent reflux symptoms, an empiric trial with proton pump inhibitors is reasonable then because reflux disease is such a common cause of dysphagia. Thereafter, patients should undergo HRM to evaluate for a motility disorder, and FLIP can provide complementary data to guide management.

Effective treatment improves the body composition of patients with esophageal motility disorders

Although treatment for esophageal motility disorder improves dysphagia and increases body weight, the effect of the treatment on body composition is unclear. This study aimed to assess the change in body composition between before and after treatment, the preoperative predictors of muscle increase, and the association between muscle increase and quality of life. Sixty-one patients (achalasia, n = 55; spastic esophageal disorder n = 6) who underwent per-oral endoscopic myotomy were analyzed in a single-arm prospective observational study. Appendicular skeletal muscle mass was measured with dual X-ray absorptiometry before and 3 months after per-oral endoscopic myotomy. For subgroup analysis, patients with postoperative appendicular skeletal muscle mass increase were defined as the muscle-increase group and the rest as the non-muscle-increase group. Preoperative factors related to the muscle-increase group were clarified via multivariate analysis. Further, the improvement after per-oral endoscopic myotomy in health-related quality-of-life score (Short Form-36) was compared between the muscle-increase and non-muscle-increase groups. Appendicular skeletal muscle mass increased significantly 3 months after per-oral endoscopic myotomy (P = 0.0002). The patients who underwent effective treatment (postoperative Eckardt score < 3) showed a significant improvement in appendicular skeletal muscle mass compared to those who did not (P = 0.04). In the stepwise logistic regression analysis, the preoperative Eckardt score (odds ratio: 1.95, 95% confidence interval 1.30-3.26, P = 0.0005) and preoperative serum prealbumin (odds ratio: 0.83, 95% confidence interval 0.70-0.97, P = 0.02) were identified as independent factors related to postoperative muscle increase. The improvements in the Short Form-36 domains of General Health (P = 0.0007) and Vitality (P = 0.003) were significantly higher in the muscle-increase group. The findings show that effective treatment improved the body composition of patients with esophageal motility disorder and that the Eckardt score and serum prealbumin may aid the prediction of increased appendicular skeletal muscle mass after treatment, resulting in a better quality of life.

Peroral endoscopic myotomy (POEM) for achalasia

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.

A Decade of Investigation: Peroral Endoscopic Myotomy Versus Laparoscopic Heller Myotomy for Achalasia

Background: Although laparoscopic Heller myotomy (LHM) with partial fundoplication has long been considered the gold standard for treatment of patients with achalasia, peroral endoscopic myotomy (POEM) has emerged in the last decade as a viable alternative. Methods: A collective review of literature concerning investigations that have reported patient outcomes and treatment success of LHM and POEM for all achalasia subtypes. Results: While POEM has shown excellent short-term safety and efficacy in the relief of symptoms, the long-term symptomatic outcomes after the intervention are yet to be concluded. Further evaluation of patients' interpretations and answers on subjective questionnaires is warranted before determining treatment success for POEM. Use of more reliable and disease-specific health-related quality-of-life questionnaires are better justified when comparing a new endoscopic procedure to an established gold standard. The need for objective parameters to measure reflux, longer follow-up studies, and randomized trials comparing POEM to LHM is particularly important when assessing the outcome of this new technique. High incidence of post-POEM pathologic reflux and indication for daily proton pump inhibitor use is of concern, and the lack of more long-term, objective evidence leaves the clinical value of the procedure in a state of uncertainty. Conclusions: The LHM combined with partial fundoplication is still considered to be the gold standard treatment modality for achalasia, but as the POEM procedure rapidly becomes common practice, this treatment may be performed in the majority of achalasia cases. Given the number of flaws overlooked in seminal investigations, careful consideration should be given to the patients being selected for this therapy.

Pseudoachalasia secondary to metastatic bladder cancer

Pseudoachalasia, or secondary achalasia, is a clinical condition that must be distinguished from primary achalasia. Both diagnoses may present similarly, but the aetiology and management for each are drastically different. Most significantly, pseudoachalasia carries a high association with malignancy, most often with primary adenocarcinoma of the oesophagus or cardia. Our case involves a patient with signs and symptoms consistent with pseudoachalasia due to metastatic bladder cancer.

Efficacy and safety of pneumatic dilation in achalasia: A systematic review and meta-analysis

BACKGROUND AND AIMS

One of the most used treatments for achalasia is pneumatic dilation of the lower esophageal sphincter to improve esophageal emptying. Multiple treatment protocols have been described with a varying balloon size, number of dilations, inflation pressure, and duration. We aimed to identify the most efficient and safe treatment protocol.

METHODS

We performed a systematic review and meta-analysis of studies on pneumatic dilation in patients with primary achalasia. Clinical remission was defined as an Eckardt score ≤3 or adequate symptom reduction measured with a similar validated questionnaire. We compared the clinical remission rates and occurrence of complications between different treatment protocols.

RESULTS

We included 10 studies with 643 patients. After 6 months, dilation with a 30-mm or 35-mm balloon gave comparable mean success rates (81% and 79%, respectively), whereas a series of dilations up to 40 mm had a higher success rate of 90%. Elective additional dilation in patients with insufficient symptom resolution was somewhat more effective than performing a predefined series of dilations: 86% versus 75% after 12 months. Perforations occurred most often during initial dilations, and significantly more often using a 35-mm balloon than a 30-mm balloon (3.2 vs 1.0%); P = 0.027. A subsequent 35-mm dilation was safer than an initial dilation with 35 mm (0.97% vs 9.3% perforations), P = 0.0017.

CONCLUSIONS

The most efficient and safe method of dilating achalasia patients is a graded approach starting with a 30-mm dilation, followed by an elective 35-mm dilation and 40 mm when there is insufficient symptom relief.

The 100 most cited manuscripts in esophageal motility disorders: a bibliometric analysis

BACKGROUND

The use of bibliometrics can help us identify the most impactful articles on a topic or scientific discipline and their influence on clinical practice. We aimed to identify the 100 most cited articles covering esophageal motility disorders and examine their key characteristics.

METHODS

The Web of Science database was utilized to perform the search, using predefined search terms. The returned dataset was filtered to include full manuscripts written in the English language. After screening, we identified the 100 most cited articles and analyzed them for title, year of publication, names of authors, institution, country of the first author, number of citations and citation rate.

RESULTS

The initial search returned 29,521 results. The top 100 articles received a total of 20,688 citations. The most cited paper was by Inoue et al. (665 citations) who first described peroral endoscopic myotomy (POEM) for treating achalasia. The article with the highest citation rate was the third version of the Chicago Classification system, written by Kahrilas and colleagues. Gastroenterology published most papers on the list (n=32) and accrued the highest number of citations (6,675 citations). Peter Kahrilas was the most cited author (3,650 citations) and, along with Joel Richter, authored the highest number of manuscripts (n=14). Most articles were produced in the USA (n=66) between the years 1991 and 2000 (n=32).

CONCLUSIONS

By analyzing the most influential articles, this work is a reference on the articles that shaped our understanding of esophageal motility disorders, thus serving as a guide for future research.