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Daza Castro EM, Fuentes CF, Córdoba Guzmán AC, Aponte D, Rocha JN, González C, Sabbagh LC. Multimodal Endoscopic Management of Esophageal Perforations as a Complication of Peroral Endoscopic Myotomy for a Zenker's Diverticulum. ACG Case Rep J 2023; 10:e01059. [PMID: 37312755 PMCID: PMC10259639 DOI: 10.14309/crj.0000000000001059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 04/24/2023] [Indexed: 06/15/2023] Open
Abstract
Zenker's diverticulum develops because of a weakness in Killian's triangle, leading to a mucosal and submucosal herniation. Its treatment has evolved from morbid surgical interventions to safer endoscopic techniques such as peroral endoscopic myotomy (Z-POEM). Despite being a safe technique, Z-POEM is not free of complications such as perforations, bleeding, pneumoperitoneum, and pneumothorax, for which new endoscopic techniques have been developed. We present the case of a 53-year-old man taken to a Z-POEM who postoperatively presented dehiscence of the mucosotomy and a mediastinal collection, managed with a vacuum-assisted endoscopic closure device.
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Affiliation(s)
| | - Carlos Fernando Fuentes
- Department of Gastroenterology, Sanitas Foundation University, Colombia University Clinic, Keralty Group, Bogotá, Colombia
| | | | - Diego Aponte
- Department of Gastroenterology, Sanitas Foundation University, Colombia University Clinic, Keralty Group, Bogotá, Colombia
- Department of Gastroenterology, Sanitas Foundation University, Reina Sofía Clinic, Colsanitas Clinic, Keralty Group, Bogotá, Colombia
| | - José Nicolás Rocha
- Department of Gastroenterology, Sanitas Foundation University, Colombia University Clinic, Keralty Group, Bogotá, Colombia
| | - Carlos González
- Department of Gastroenterology, Sanitas Foundation University, Colombia University Clinic, Keralty Group, Bogotá, Colombia
- Department of Gastroenterology, Sanitas Foundation University, Reina Sofía Clinic, Colsanitas Clinic, Keralty Group, Bogotá, Colombia
| | - Luis Carlos Sabbagh
- Department of Gastroenterology, Sanitas Foundation University, Colombia University Clinic, Keralty Group, Bogotá, Colombia
- Department of Gastroenterology, Sanitas Foundation University, Reina Sofía Clinic, Colsanitas Clinic, Keralty Group, Bogotá, Colombia
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Dahiya DS, Nivedita F, Perisetti A, Goyal H, Inamdar S, Gangwani MK, Aziz M, Ali H, Cheng CI, Sanaka MR, Al-Haddad M, Sharma NR. Clinical Outcomes and Complications for Achalasia Patients Admitted After Per-Oral Endoscopic Myotomy. Gastroenterology Res 2023; 16:141-148. [PMID: 37351078 PMCID: PMC10284641 DOI: 10.14740/gr1617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 05/13/2023] [Indexed: 06/24/2023] Open
Abstract
Background Per-oral endoscopic myotomy (POEM) is a rapidly emerging minimally invasive procedure for management of achalasia. Same-day discharge after POEM is safe and feasible; however, some patients may need hospitalization. We aimed to identify characteristics and outcomes for achalasia patients requiring hospitalizations after POEM in the United States (US). Methods The US National Inpatient Sample was utilized to identify all adult achalasia patients who were admitted after POEM from 2016 to 2019. Hospitalization characteristics and clinical outcomes were highlighted. Results From 2016 to 2019, we found that 1,885 achalasia patients were admitted after POEM. There was an increase in the total number of hospitalizations after POEM from 380 in 2016 to 490 in 2019. The mean age increased from 54.2 years in 2016 to 59.3 years in 2019. Most POEM-related hospitalizations were for the 65 - 79 age group (31.8%), females (50.4%), and Whites (68.4%). A majority (56.2%) of the study population had a Charlson Comorbidity Index of 0. The Northeast hospital region had the highest number of POEM-related hospitalizations. Most of these patients (88.3%) were eventually discharged home. There was no inpatient mortality. The mean length of stay decreased from 4 days in 2016 to 3.2 days in 2019, while the mean total healthcare charge increased from $52,057 in 2016 to $65,109 in 2019. Esophageal perforation was the most common complication seen in 1.3% of patients. Conclusion The number of achalasia patients needing hospitalization after POEM increased. There was no inpatient mortality conferring an excellent safety profile of this procedure.
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Affiliation(s)
- Dushyant Singh Dahiya
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Fnu Nivedita
- Section of Endoluminal Surgery and Interventional Gastroenterology, McGovern Medical School and UT Health Sciences Center at UT Health Houston, Houston, TX, USA
| | - Abhilash Perisetti
- Division of Gastroenterology and Hepatology, Kansas Veterans Affairs Medical Centre, Kansas City, MO, USA
| | - Hemant Goyal
- Section of Endoluminal Surgery and Interventional Gastroenterology, McGovern Medical School and UT Health Sciences Center at UT Health Houston, Houston, TX, USA
| | - Sumant Inamdar
- Department of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Manesh Kumar Gangwani
- Department of Internal Medicine, The University of Toledo Medical Center, Toledo, OH, USA
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, The University of Toledo Medical Center, Toledo, OH, USA
| | - Hassam Ali
- Department of Internal Medicine, East Carolina University, Greenville, NC, USA
| | - Chin-I Cheng
- Department of Statistics, Actuarial and Data Science, Central Michigan University, Mt Pleasant, MI, USA
| | - Madhusudhan R. Sanaka
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mohammad Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Neil R. Sharma
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
- Interventional Oncology & Surgical Endoscopy Programs (IOSE), Parkview Health, Fort Wayne, IN, USA
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Wessels EM, Schuitenmaker JM, Bastiaansen BAJ, Fockens P, Masclee GMC, Bredenoord AJ. Efficacy and safety of peroral endoscopic myotomy for esophageal diverticula. Endosc Int Open 2023; 11:E546-E552. [PMID: 37251790 PMCID: PMC10219786 DOI: 10.1055/a-2071-6744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/03/2023] [Indexed: 05/31/2023] Open
Abstract
Background and study aims Epiphrenic diverticula are rare and mainly occur in patients with underlying esophageal motility disorders. The current standard treatment is surgical diverticulectomy often combined by myotomy and is associated with significant adverse event (AE) rates. The aim of this study was to examine the efficacy and safety of peroral endoscopic myotomy in reducing esophageal symptoms in patients with esophageal diverticula. Patients and methods We performed a retrospective cohort study including patients with an esophageal diverticulum who underwent POEM between October 2014 and December 2022. After informed consent, data were extracted from medical records and patients completed a survey by telephone. The primary outcome was treatment success, defined as Eckardt score below 4 with a minimal reduction of 2 points. Results Seventeen patients (mean age 71 years, 41.2 % female) were included. Achalasia was confirmed in 13 patients (13 /17, 76.5 %), Jackhammer esophagus in two patients (2 /17, 11.8 %), diffuse esophageal spasm in one patient (1 /17, 5.9 %) and in one patient no esophageal motility disorder was found (1 /17, 5.9 %). Treatment success was 68.8 % and only one patient (6.3 %) underwent retreatment (pneumatic dilatation). Median Eckardt scores decreased from 7 to 1 after POEM (p < 0.001). Mean size of the diverticula decreased from 3.6 cm to 2.9 cm after POEM (p < 0.001). Clinical admission was one night for all patients. AEs occurred in two patients (11.8 %) which were classified as grade II and IIIa (AGREE classification). Conclusions POEM is effective and safe to treat patients with esophageal diverticula and an underlying esophageal motility disorder.
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Affiliation(s)
- Elise M Wessels
- Amsterdam University Medical Centres, Gastroenterology & Hepatology, Amsterdam, Netherlands
| | - Jeroen M Schuitenmaker
- Amsterdam University Medical Centres, Gastroenterology & Hepatology, Amsterdam, Netherlands
| | | | - Paul Fockens
- Amsterdam University Medical Centres, Gastroenterology & Hepatology, Amsterdam, Netherlands
| | - Gwen M C Masclee
- Amsterdam University Medical Centres, Gastroenterology & Hepatology, Amsterdam, Netherlands
| | - Albert J Bredenoord
- Amsterdam University Medical Centres, Gastroenterology & Hepatology, Duivendrecht, Netherlands
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Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is an effective intervention for achalasia, but GERD is a major postoperative adverse event. This study aimed to characterize post-POEM GERD and identify preoperative or technical factors impacting development or severity of GERD. STUDY DESIGN This is a retrospective review of patients who underwent POEM at our institution. Favorable outcome was defined as postoperative Eckardt score of 3 or less. Subjective GERD was defined as symptoms consistent with reflux. Objective GERD was based on a DeMeester score greater than 14.7 or Los Angeles grade C or D esophagitis. Severe GERD was defined as a DeMeester score greater than 50.0 or Los Angeles grade D esophagitis Preoperative clinical and objective data and technical surgical elements were compared between those with and without GERD. Multivariate logistic analysis was performed to identify factors associated with each GERD definition. RESULTS A total of 183 patients underwent POEM. At a mean ± SD follow-up of 21.7 ± 20.7 months, 93.4% achieved favorable outcome. Subjective, objective, and severe objective GERD were found in 38.8%, 50.5%, and 19.2% of patients, respectively. Of those with objective GERD, 24.0% had no reflux symptoms. Women were more likely to report GERD symptoms (p = 0.007), but objective GERD rates were similar between sexes (p = 0.606). The independent predictors for objective GERD were normal preoperative diameter of esophagus (odds ratio [OR] 3.4; p = 0.008) and lower esophageal sphincter (LES) pressure less than 45 mmHg (OR 1.86; p = 0.027). The independent predictors for severe objective GERD were LES pressure less than 45 mmHg (OR 6.57; p = 0.007) and obesity (OR 5.03; p = 0.005). The length of esophageal or gastric myotomy or indication of procedure had no impact on the incidence or severity of GERD. CONCLUSION The rate of pathologic GERD after POEM is higher than symptomatic GERD. A nonhypertensive preoperative LES is a predictor for post-POEM GERD. No modifiable factors impact GERD after POEM.
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Zimmermann C, Torell N, Lidor A, Funk L, Shada A. Recurrent dysphagia after myotomy for achalasia: pneumatic dilation or POEM? : Which modality offers superior outcomes? Surg Endosc 2022:10.1007/s00464-022-09556-5. [PMID: 36121502 DOI: 10.1007/s00464-022-09556-5] [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: 03/30/2022] [Accepted: 08/08/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Myotomy is the gold standard treatment for achalasia, yet long-term failure rates approach 15%. Treatment options for recurrent dysphagia include pneumatic dilation (PD), laparoscopic redo myotomy, per oral endoscopic myotomy (POEM), or esophagectomy. We employ both PD and POEM as first-line treatment for these patients. We evaluated operative success and patient reported outcomes for patients who underwent PD or POEM for recurrent dysphagia after myotomy. METHODS We identified patients with achalasia who underwent PD or POEM for recurrent dysphagia after previous myotomy within a foregut database at our institution between 2013 and 2021. Gastroesophageal Reflux Disease-Health-Related quality of Life (GERD-HRQL) and Eckardt scores, and overall change in each were compared across PD and POEM groups. Successful treatment of dysphagia was defined by Eckardt scores ≤ 3. RESULTS 103 patients underwent myotomy for achalasia. Of these, 19 (18%) had either PD or POEM for recurrent dysphagia. Nine were treated with PD and 10 with POEM. The mean change in Eckardt and GERD-HRQL scores did not differ between groups. 50% of the PD group and 67% of the POEM group had resolution of their dysphagia symptoms (p = 0.65). Mean procedure length was greater in the POEM group (267 vs 72 min, p < 0.01) as was mean length of stay (1.56 vs 0.3 days, p < 0.01). There was one adverse event after PD and three adverse events after POEM. After PD, 7 patients (70%) required additional procedures compared to four patients (44%) in the POEM group, consisting mostly of repeat PD. CONCLUSION Patients undergoing PD or POEM for recurrent dysphagia after myotomy have similar rates of dysphagia resolution and reflux symptoms. Patients undergoing PD enjoy a shorter length of stay and shorter procedure time but may require more subsequent procedures.
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Affiliation(s)
- Christopher Zimmermann
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Nate Torell
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Anne Lidor
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Luke Funk
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Amber Shada
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
- Division of Minimally Invasive Surgery, Department of Surgery, University of Wisconsin-Madison, 4602 Eastpark Blvd, Suite 3525, Madison, WI, 53718, USA.
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Parsa N, Friedel D, Stavropoulos SN. POEM, GPOEM, and ZPOEM. Dig Dis Sci 2022; 67:1500-1520. [PMID: 35366120 DOI: 10.1007/s10620-022-07398-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 12/09/2022]
Abstract
Our tripartite narrative review discusses Peroral Endoscopic Myotomy (POEM), gastric POEM (GPOEM) and POEM for Zenker's diverticula (ZPOEM). POEM is the prototypical procedure that launched the novel "3rd space endoscopy" field of advanced endoscopy. It revolutionized achalasia therapy by offering a much less invasive version of the prior gold standard, the laparoscopic Heller myotomy (HM). We review in detail indications, outcomes, technique variations and comparative data between POEM and HM particularly with regard to the hotly debated issue of GERD. We then proceed to discuss two less illustrious but nevertheless important offshoots of the iconic POEM procedure: GPOEM for gastroparesis and ZPOEM for the treatment of hypopharyngeal diverticula. For GPOEM, we discuss the rationale of pylorus-directed therapies, briefly touch on GPOEM technique variations and then focus on the importance of proper patient selection and emerging data in this area. On the third and final part of our review, we discuss ZPOEM and expound on technique variations including our "ultra-short tunnel technique". Our review emphasizes that, despite the superiority of endoscopy over surgery for the treatment of hypopharyngeal diverticula, there is no clear evidence yet of the superiority of the newfangled ZPOEM technique compared to the conventional endoscopic myotomy technique practiced for over two decades prior to the advent of ZPOEM.
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Affiliation(s)
- Nasim Parsa
- Division of Gastroenterology and Hepatology, University of Missouri Health System, Columbia, MO, USA
| | - David Friedel
- Division of Gastroenterology, Hepatology and Nutrition, NYU-Winthrop Hospital, 222 Station Plaza N Suite 429, Mineola, NY, 11501, USA
| | - Stavros N Stavropoulos
- Division of Gastroenterology, Hepatology and Nutrition, NYU-Winthrop Hospital, 222 Station Plaza N Suite 429, Mineola, NY, 11501, USA.
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Maydeo A. Achalasia Cardia: Balloon, Tunnel, or Knife? JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0041-1740490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractAchalasia cardia is a rare esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter during swallowing and aperistalsis of the esophageal smooth muscles. The treatment approaches to achalasia include nonsurgical treatment with medications (nitrates, calcium channel blockers), endoscopic treatment (balloon pneumatic dilation [PD], botulinum toxin injection [BTI], peroral endoscopic myotomy [POEM]), and surgery (laparoscopic Heller's myotomy [LHM]). The subtype of achalasia (the Chicago Classification) governs the ideal treatment. For the commonly encountered achalasia subtype I and II, PD, LHM, and POEM all have similar efficacy. However, for type III achalasia, POEM seems to be the best line of treatment. Among high-risk elderly patients or those with comorbidities, BTI is preferred. The choice of treatment should be minimally invasive therapy with good short-term and sustained long-term effects with negligible adverse events. POEM seems to be evolving as a first-line therapy among the available therapies. Here, we review the treatment options among achalasia cardia patients with special attention to post-POEM gastroesophageal reflux disease and its management.
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Affiliation(s)
- Amit Maydeo
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, Maharashtra, India
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Abstract
For more than a decade, per-oral endoscopic myotomy (POEM) has been performed for the treatment of achalasia and other dysmotilities of the esophagus. POEM has become an accepted alternative to Heller myotomy, a salvation technique for patients not responding to Heller myotomy and the favorite intervention for diffuse esophageal spasm and jackhammer esophagus. POEM paved the way for endoscopic pyloromyotomy, Zenker's diverticulum myotomy, and submucosal tunneling with endoscopic resection. This review will cover the technique and the most current literature of this revolutionary third space technique.
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Chandan S, Facciorusso A, Khan SR, Ramai D, Mohan BP, Bilal M, Dhindsa B, Kassab LL, Goyal H, Perisetti A, Bhat I, Singh S, McDonough S, Adler DG. Short versus standard esophageal myotomy in achalasia patients: a systematic review and meta-analysis of comparative studies. Endosc Int Open 2021; 9:E1246-E1254. [PMID: 34447872 PMCID: PMC8383091 DOI: 10.1055/a-1490-8493] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/17/2021] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Despite the clinical efficacy of peroral endoscopic myotomy (POEM), postoperative symptomatic gastroesophageal reflux disease (GERD) remains a major concern. While it is known that length of the gastric myotomy affects postoperative GERD, the clinical relevance of variation in esophageal myotomy length is not well known. We performed a systematic review and meta-analysis of studies comparing outcomes of short versus standard myotomy length in patients with achalasia. Patients and methods We searched multiple databases from inception through November 2020 to identify studies that reported on outcomes of achalasia patients who underwent short compared with standard esophageal myotomy. Meta-analysis was performed to determine pooled odds ratio (OR) of clinical success, GERD outcomes, and adverse events with the two techniques. Results 5 studies with 474 patients were included in the final analysis (short myotomy group 214, standard myotomy group 260). There was no difference in clinical success (OR 1.17, 95 % confidence interval [CI] 0.54-2.52; I2 0 %; P = 0.69), postoperative symptomatic GERD (OR 0.87, 95 %CI 0.44-1.74; I2 29 %; P = 0.70), and overall adverse events (OR 0.52, 95 %CI 0.19-1.38; I2 40 %; P = 0.19), between the two groups. Incidence of postoperative erosive esophagitis as determined by endoscopy was lower in the short myotomy group (OR 0.50, 95 %CI 0.24-1.03; I2 0 %; P = 0.06). Conclusion Our analysis showed that performing POEM with short esophageal myotomy in achalasia was as safe and effective as standard myotomy, with lower incidence of postoperative erosive esophagitis.
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Affiliation(s)
- Saurabh Chandan
- Division of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, Nebraska, United States
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | - Shahab R. Khan
- Section of Gastroenterology, Rush University Medical Center, Chicago, Illinois, United States
| | - Daryl Ramai
- Internal Medicine, Brooklyn Hospital Center, Brooklyn, New York, United States
| | - Babu P. Mohan
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Mohammad Bilal
- Division of Gastroenterology, University of Minnesota and Minneapolis VA Health Care System, Minneapolis, Minnesota, United States
| | - Banreet Dhindsa
- Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, United States
| | - Lena L. Kassab
- Internal Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Hemant Goyal
- Gastroenterology, Wright Center for Graduate Medical Education, Scranton, Philadelphia, United States
| | - Abhilash Perisetti
- Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
| | - Ishfaq Bhat
- Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, United States
| | - Shailender Singh
- Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, United States
| | - Stephanie McDonough
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Douglas G. Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
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Same-day discharge is safe and feasible following POEM surgery for esophageal motility disorders. Surg Endosc 2020; 35:3398-3404. [DOI: 10.1007/s00464-020-07781-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 07/01/2020] [Indexed: 02/08/2023]
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Benias PC, Korrapati P, Raphael KL, D'Souza LS, Inamdar S, Trindade AJ, Lee C, Kumbhari V, Sejpal DV, Okolo P, Khashab MA, Miller L, Carr-Locke D. Safety and feasibility of performing peroral endoscopic myotomy as an outpatient procedure with same-day discharge. Gastrointest Endosc 2019; 90:570-578. [PMID: 31078571 DOI: 10.1016/j.gie.2019.04.247] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/26/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) has emerged as a promising treatment option for achalasia and other foregut dysmotility disorders. However, much of the current postprocedural care, such as mandatory admission and routine esophagrams, has been adapted from current surgical practices and may not in fact be necessary. Here, we describe our algorithm and outcomes for same-day discharge. METHODS Outcomes of 103 consecutive patients who underwent POEM for achalasia and other foregut dysmotility disorders from January 2015 to December 2018 were analyzed. Patients were discharged on the same day without esophagrams following a predetermined algorithm based on procedural adverse events and postprocedural pain. Patients were closely monitored after discharge for adverse events at 24 and 48 hours and then routinely in the office setting. RESULTS Of the 103 POEMs, 101 were completed successfully. A total of 62.4% of patients were discharged safely on the same day, 29.7% were admitted for mild pain, and 7.9% were admitted for observation for other reasons. Overall, there were no serious adverse events at any time point. Univariate analysis identified duration of disease greater than 3 years, longer length of procedure (50.9 vs 68.5 min, P < .0001), and longer length of myotomy (7.2 vs 8.5 cm, P < .0068) as significant factors associated with postprocedural pain requiring admission. CONCLUSIONS Although same-day discharge and foregoing routine esophagram have been suggested by many, this routine has not been systematically implemented. This series suggests that an algorithm for same-day discharge based on postprocedure chest pain and procedural complexity is both safe and feasible.
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Affiliation(s)
- Petros C Benias
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, New York, USA
| | - Praneet Korrapati
- Division of Gastroenterology, Icahn School of Medicine at Beth Israel, New York, New York, USA
| | - Kara L Raphael
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, New York, USA
| | - Lionel Santos D'Souza
- Division of Gastroenterology and hepatology, Stony Brook School of Medicine, East Setauket, New York, USA
| | - Sumant Inamdar
- Division of Gastroenterology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Arvind J Trindade
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, New York, USA
| | - Calvin Lee
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, New York, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Divyesh V Sejpal
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, New York, USA
| | - Patrick Okolo
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, New York, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Larry Miller
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, New York, USA
| | - David Carr-Locke
- Division of Gastroenterology and Hepatology, Weil Cornell School of Medicine, New York Hospital, New York, NY, USA
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Shimizu T, Fortinsky KJ, Chang KJ. Early experience with use of an endoscopic "hot" scissor-type knife for myotomy during per-oral endoscopic myotomy procedure. VideoGIE 2019; 4:182-184. [PMID: 31016278 PMCID: PMC6470349 DOI: 10.1016/j.vgie.2018.12.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Background and Aims Current devices used for per-oral endoscopic myotomy (POEM) function predominantly to either cut tissue or coagulate vessels. When bleeding vessels are encountered within the submucosa or muscle, dedicated coagulation grasping devices are often necessary. An endoscopic “hot” scissor-type knife is available that combines coagulation and cutting functions. Scissor-type knives may therefore be helpful during the POEM procedure. Methods We report 4 cases of achalasia that were treated by the POEM procedure using the Stag Beetle scissor-type knife for myotomy. Patients were identified from a prospectively maintained database of patients undergoing POEM at our center between September and October 2017. A single operator (K.J.C.) performed all of the procedures using both a hybrid knife and an SB knife. Demographic and clinical data were collected for all patients. Results All 4 POEM procedures were performed successfully without any adverse events. Only 3 spontaneous bleeding episodes occurred among the 4 procedures, and no perforation occurred. The patients were all doing very well at clinic follow-up at 4 weeks. Conclusions The technique of using the SB knife during myotomy during the POEM procedure is feasible and appears safe. Muscle tissue and blood vessels can be coagulated and cut simultaneously, reducing bleeding and improving control. Further comparative studies are warranted to evaluate the efficacy, safety, and cost effectiveness against existing techniques.
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Affiliation(s)
- Toshitaka Shimizu
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, Irvine, Orange, California, USA
| | - Kyle J Fortinsky
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, Irvine, Orange, California, USA
| | - Kenneth J Chang
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, Irvine, Orange, California, USA
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Abstract
PURPOSE OF REVIEW Peroral endoscopic myotomy (POEM) was developed in Japan as a less invasive treatment for esophageal achalasia requiring general anesthesia under positive pressure ventilation. In 2018, the Japan Gastroenterological Endoscopy Society published the first guidelines describing the standard care for POEM. Based on these guidelines, we discuss the typical approach to anesthesia during POEM for the management of esophageal achalasia in Japan. RECENT FINDINGS Prior cleansing of the esophagus is essential to prevent both aspiration during induction of anesthesia and contamination of the mediastinum and thoracic/abdominal cavity by esophageal remnants after endoscopic resection of the esophageal mucosa. Although rare, adverse events related to intraoperative carbon dioxide insufflation occur. These are treated through percutaneous needle decompression and insertion of a chest drainage tube for pneumoperitoneum and pneumothorax, respectively. Caution should be exercised regarding the development of subcutaneous emphysema and its involvement in airway obstruction. SUMMARY Prevention of aspiration pneumonia and adverse events related to the insufflation of carbon dioxide is essential in the management of esophageal achalasia through POEM. Close cooperation between gastrointestinal endoscopic surgeons and anesthesiologists is indispensable in POEM.
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Abstract
Transluminal surgery, also known as natural orifices endoluminal surgery, can be considered the most minimally invasive approach of gaining access to an organ. Although some approaches, such as transgastric or transvaginal cholecystectomy, have remained experimental, peroral endoscopic myotomy to treat achalasia and transanal total mesorectal excision to treat low rectal cancer have become accepted, safe, and feasible approaches by trained surgeons for selected patients. This article recapitulates the development of transluminal surgery from its experimental beginnings to the validated procedure it has become today.
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Affiliation(s)
- Antonio M Lacy
- Department of Gastrointestinal Surgery, ICMDM, IDIBAPS, CIBEREHD, AIS Channel, Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036 Barcelona, Spain.
| | - Fransisco Borja De Lacy
- Department of Gastrointestinal Surgery, ICMDM, IDIBAPS, CIBEREHD, AIS Channel, Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Silvia Valverde
- Department of Gastrointestinal Surgery, ICMDM, IDIBAPS, CIBEREHD, AIS Channel, Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036 Barcelona, Spain
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15
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Tang X, Ren Y, Huang S, Gao Q, Zhou J, Wei Z, Jiang B, Gong W. Endoscopic Submucosal Tunnel Dissection for Upper Gastrointestinal Submucosal Tumors Originating from the Muscularis Propria Layer: A Single-Center Study. Gut Liver 2018; 11:620-627. [PMID: 28335098 PMCID: PMC5593323 DOI: 10.5009/gnl15424] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 10/12/2016] [Accepted: 10/18/2016] [Indexed: 02/05/2023] Open
Abstract
Background/Aims In recent years, endoscopic submucosal tunnel dissection (ESTD) has gained popularity worldwide. The aim of this study was to evaluate the safety and efficacy of ESTD in treating upper gastrointestinal submucosal tumors (SMTs) in a large-volume endoscopic center. Methods Patients with SMTs were enrolled in this study between January 2012 and January 2015. Demographic data, clinical data, and treatment outcome were collected and analyzed. Results Seventy SMTs originating from the muscularis propria (MP) layer were identified in 69 patients. All patients successfully underwent the ESTD procedure. The mean procedure time was 49.0±29.5 minutes, and the mean tumor size was 18.7±7.2 mm. Among all lesions, the majority (70.0%) were located in the esophagus, 12.9% in the cardia, and 17.1% in the stomach. Complete resection was achieved in 67 lesions (95.7%). Perforation occurred in three patients (4.3%), who were treated by endoclips. Pneumothorax occurred in two patients (2.9%) and was successfully managed by thoracic drainage. During a median follow-up of 18.1 months, patients were free of local recurrence or distant metastasis. Conclusions Our results demonstrated the feasibility and safety of ESTD in treating upper gastrointestinal SMTs originating from the MP layer. Large-scale comparative studies with other treatment methods should be conducted in the future.
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Affiliation(s)
- Xiaowei Tang
- Department of Gastroenterology, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, China
| | - Yutang Ren
- Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China
| | - Silin Huang
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qiaoping Gao
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jieqiong Zhou
- Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China.,Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhengjie Wei
- Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China
| | - Bo Jiang
- Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China
| | - Wei Gong
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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16
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Outcomes and quality of life assessment after per oral endoscopic myotomy (POEM) performed in the endoscopy unit with trainees. Surg Endosc 2018; 32:3046-3054. [DOI: 10.1007/s00464-017-6015-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 12/19/2017] [Indexed: 12/21/2022]
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17
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Ko WJ, Cho JY. Introduction to Endoscopic Submucosal Surgery. Clin Endosc 2018; 51:8-12. [PMID: 29357614 PMCID: PMC5806918 DOI: 10.5946/ce.2017.154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 11/30/2017] [Accepted: 12/04/2017] [Indexed: 12/21/2022] Open
Abstract
The concept of using natural orifices to reduce the complications of surgery, Natural Orifices Transluminal Endoscopic Surgery, has also been applied to therapeutic endoscopy. Endoscopic submucosal surgery (ESS) provides more treatment options for various gastrointestinal diseases than traditional therapeutic endoscopy by using the submucosal layer as a working space. ESS has been performed in various fields ranging from transluminal peritoneoscopy to peroral endoscopic myotomy. With further advances in technology, ESS will be increasingly useful for diagnosis and treatment of gastrointestinal diseases.
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Affiliation(s)
- Weon Jin Ko
- Department of Gastroenterology, Cha Kumi Medical Center, Cha University College of Medicine, Gumi, Korea
| | - Joo Young Cho
- Department of Gastroenterology, Cha Bundang Medical Center, Cha University College of Medicine, Seongnam, Korea
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18
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Arshava EV, Marchigiani RJ, Gerke H, El Abiad R, Weigel RJ, Parekh KR, Keech J. Per oral endoscopic myotomy: early experience and safety of a multispecialty approach. Surg Endosc 2018; 32:3357-3363. [DOI: 10.1007/s00464-018-6056-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 01/11/2018] [Indexed: 12/20/2022]
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19
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Abstract
PURPOSE OF REVIEW To review new advances in gastric interventional endoscopy. RECENT FINDINGS Implementation of gastric endoscopy as a therapeutic option in obesity, gastric cancer, and gastroparesis. SUMMARY Less invasive new gastric endoscopic procedures can potentially replace currently offered laparoscopic approaches in many fields. In this article, we will review the use of endoscopic sleeve gastroplasty as a weight loss procedure, endoscopic submucosal dissection in treatment of early gastric cancer, and gastric per-oral endoscopic myotomy in treatment of refractory gastroparesis. These procedures can increase access to bariatric weigh loss procedures, provide an organ-saving curative option for early gastric cancer, and offer a new modality to improve refractory gastroparesis.
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20
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Smith SP, Louie BE. The current state of per oral endoscopic myotomy for achalasia. J Vis Surg 2017; 3:122. [PMID: 29078682 DOI: 10.21037/jovs.2017.07.11] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 07/21/2017] [Indexed: 12/19/2022]
Abstract
Achalasia is an acquired neuromuscular disorder that has been treated using a variety of modalities throughout medical history. Recently, the technique of per oral endoscopic myotomy (POEM) was introduced to treat the disease using a truly minimally invasive, natural orifice technique that is rapidly being adopted across the world. This review outlines the development of POEM, the technique itself, and gives a comparison to other procedures, specifically laparoscopic Heller myotomy (LHM).
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Affiliation(s)
- Shane P Smith
- Swedish Medical Center and Cancer Institute, Seattle, WA, USA
| | - Brian E Louie
- Swedish Medical Center and Cancer Institute, Seattle, WA, USA
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21
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Peroral endoscopic myotomy compared with pneumatic dilation for newly diagnosed achalasia. Surg Endosc 2017; 31:4665-4672. [PMID: 28411346 DOI: 10.1007/s00464-017-5530-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 03/15/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND This study retrospectively compared the safety and efficacy of two endoscopic techniques for treating newly diagnosed achalasia, pneumatic dilation (PD), and peroral endoscopic myotomy (POEM). METHODS Demographics, clinical and manometric data, and outcomes were collected from the medical records of patients who received POEM or PD as the primary therapy for achalasia at our hospital from January 2012 to August 2015. RESULTS Of 72 patients, 32 and 40 received POEM and PD, respectively. The two groups had similar preoperative features. On short-term follow-up, improvements in high-resolution esophageal manometry and barium esophagogram parameters were similar. For PD, the success rates at 3, 6, 12, 24, and 36 months were 95, 88, 75, 72, and 60%, respectively. For POEM, these were 96, 96, 96, 93, and 93% (P = 0.013, log-rank test). On subgroup analysis, the success rate was higher with POEM than that with PD in all 3 manometric subtypes, but only that of type III was statistically significant. POEM required significantly longer operative time and hospitalization than did PD (P < 0.001). Four POEM patients experienced subcutaneous emphysema. The rate of gastroesophageal reflux was higher in patients treated by POEM (18.8%) than that in PD (10%; P = 0.286). CONCLUSIONS In the intermediate term, the remission rate of symptoms associated with POEM therapy was better than that with PD for newly diagnosed achalasia, especially in patients with type III achalasia. The short-term outcomes of the two therapies were similar.
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22
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Khashab MA, Kumbhari V, Tieu AH, El Zein MH, Ismail A, Ngamruengphong S, Singh VK, Kalloo AN, Clarke JO, Stein EM. Peroral endoscopic myotomy achieves similar clinical response but incurs lesser charges compared to robotic heller myotomy. Saudi J Gastroenterol 2017; 23:91-96. [PMID: 28361839 PMCID: PMC5385723 DOI: 10.4103/1319-3767.203360] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND/AIM Several uncontrolled studies comparing peroral endoscopic myotomy (POEM) and Heller myotomy have demonstrated equivalent short-term efficacy and safety. However, no data exists rergarding the cost of POEM and how it compares to that of robotic Heller myotomy (RHM). The primary aim of this study was to compare the inpatient charges incurred in patients who underwent POEM or RHM for the treatment of achalasia. PATIENTS AND METHODS A retrospective single center review was conducted among 52 consecutive POEM patients (2012-2014) and 52 consecutive RHM patients (2009-2014). All RHM procedures included a Toupet fundoplication and were performed via a transabdominal approach. All POEM procedures were performed by a gastroenterologist in the endoscopy unit. Clinical response was defined by improvement of symptoms and decrease in Eckardt stage to ≤I. All procedural and facility charges were obtained from review of the hospital finance records. RESULTS There was no difference between POEM and RHM with regards to age, gender, symptom duration, achalasia subtype, manometry findings, or Eckardt symptom stage. There was no significant difference in the rate of adverse events (19.2% vs 9.6%, P = 0.26) or the length of stay (1.9 vs. 2.3, P = 0.18) between both groups. Clinical response rate of patients in the POEM groups was similar to that in the RHM group (94.3% vs. 88.5%, P = 0.48). POEM incurred significantly less total charges compared to LHM ($14481 vs. $17782, P = 0.02). CONCLUSIONS POEM when performed in an endoscopy unit was similar in efficacy and safety to RHM. However, POEM was associated with significant cost savings ($3301/procedure).
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Affiliation(s)
- Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA,Address for correspondence: Dr. Mouen A. Khashab, Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA. E-mail:
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Alan H. Tieu
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mohamad H. El Zein
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Amr Ismail
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vikesh K. Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Anthony N. Kalloo
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - John O. Clarke
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Ellen M. Stein
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Management of achalasia in the UK, do we need new guidelines? Ann Med Surg (Lond) 2016; 12:32-36. [PMID: 28050248 PMCID: PMC5187602 DOI: 10.1016/j.amsu.2016.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 10/27/2016] [Accepted: 10/27/2016] [Indexed: 01/17/2023] Open
Abstract
Aim It is recommended that management of complex benign upper gastrointestinal pathology is discussed at multi disciplinary team (MDT) meetings. American College of Gastroenterology (ACG) guidelines further recommend that treatment delivery is provided by high volume centres, with objective post-procedural investigations, in order to improve patient outcomes. We aimed to survey the current UK practice in the management of achalasia. Methods 443 Upper gastrointestinal (UGI) specialist surgeons throughout the UK were sent a surveymonkey.com questionnaire about the management of achalasia. Results 100 responses were received. The majority of patients with achalasia are referred directly to surgeons (80%) and only 15% of units have a MDT meeting for discussing such patients. Diagnosis was mainly with oesophagogastroduodenoscopy (OGD) and contrast swallow, and only 61% of units have access to high resolution manometry (HRM). 89% of younger patients were offered surgery initially, whilst in the elderly surgery was offered as first line treatment in 55%. Partial fundoplication was carried out by 91% of responders as part of the operation, and 58% responders carry out an intraoperative OGD. The average number of operations carried out per annum is 4 per responder. Most responders (66%) did not perform routine post-intervention investigations and follow-up varied from none to lifelong. Conclusion Diagnosis and management of achalasia within the UK is relatively standardised, although there remains limited access to HRM. Discussion at benign MDTs however is poor and follow-up differs widely. UK guidelines may help to make these more uniform. Questionnaire to UK Upper GI specialists on achalasia management. No current UK guidelines. NICE guidelines refer to 2011 SAGES guidelines. Only 15% have benign MDT to discuss complex achalasia cases. Disparities in management with deviations from current US guidelines.
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24
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Schneider AM, Louie BE, Warren HF, Farivar AS, Schembre DB, Aye RW. A Matched Comparison of Per Oral Endoscopic Myotomy to Laparoscopic Heller Myotomy in the Treatment of Achalasia. J Gastrointest Surg 2016; 20:1789-1796. [PMID: 27514392 DOI: 10.1007/s11605-016-3232-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 08/02/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Per oral endoscopic myotomy (POEM) is increasingly utilized to treat patients with achalasia. Early results have demonstrated significant improvement of symptoms, but there are concerns about postoperative reflux. With only limited comparative data available, we sought to compare POEM to laparoscopic Heller myotomy (LHM) with partial fundoplication. METHODS This is a retrospective review of 42 POEM and 84 LHM patients undergoing primary myotomy for achalasia. Patients were matched by achalasia type, by Eckardt and dysphagia scores, and by quality of life (QOL) metrics. Analysis at 6-12-month follow-up evaluated these metrics, PPI use, pH, manometric, and endoscopic data. RESULTS We matched 25 patients with achalasia types I (6), II (13), and III (6). Follow-up was longer for LHM at 158.1 (36.5-272.9) weeks versus 36.2 (22.2-41.2) weeks (p = 0.001). Eckardt scores, QOL metrics, and dysphagia significantly improved in both groups. DeMeester scores and total percent time less than 4 were abnormal in both groups and comparable (p = 0.925 and p = 0.838). Esophagitis was seen in 53.4 % (POEM) and 31.6 % (LHM) (Yates' p = 0.91), and PPI use was equivalent at 36 %. CONCLUSION Early clinical outcomes are excellent with POEM and comparable to the standard of care LHM. Long-term follow-up is required as concerns for reflux persist.
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Affiliation(s)
- Andreas M Schneider
- Division of Thoracic Surgery, Swedish Cancer Institute, 1101 Madison Street, Suite 900, Seattle, WA, 98104, USA
| | - Brian E Louie
- Division of Thoracic Surgery, Swedish Cancer Institute, 1101 Madison Street, Suite 900, Seattle, WA, 98104, USA.
| | - Heather F Warren
- Division of Thoracic Surgery, Swedish Cancer Institute, 1101 Madison Street, Suite 900, Seattle, WA, 98104, USA
| | - Alexander S Farivar
- Division of Thoracic Surgery, Swedish Cancer Institute, 1101 Madison Street, Suite 900, Seattle, WA, 98104, USA
| | - Drew B Schembre
- Division of Gastroenterology, Swedish Medical Center, Seattle, WA, USA
| | - Ralph W Aye
- Division of Thoracic Surgery, Swedish Cancer Institute, 1101 Madison Street, Suite 900, Seattle, WA, 98104, USA
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Gunasingam N, Perczuk A, Talbot M, Kaffes A, Saxena P. Update on therapeutic interventions for the management of achalasia. J Gastroenterol Hepatol 2016; 31:1422-8. [PMID: 27060999 DOI: 10.1111/jgh.13408] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 03/30/2016] [Indexed: 12/17/2022]
Abstract
Achalasia is a primary esophageal motility disorder. It is the absence of peristalsis in the esophageal body and inability of the lower esophageal sphincter to relax, which characterizes this rare condition. Its features typically include dysphagia, regurgitation, chest pain, and weight loss. The ultimate goal in treating achalasia is to relieve the patient's symptoms, improve esophageal emptying, and prevent further dilatation of the esophagus. Current treatment modalities targeted at achalasia include pharmacological therapy, endoscopic therapy, and surgery. This review focuses on the current therapeutic options and explores the role of peroral endoscopic myotomy in the management armamentarium.
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Affiliation(s)
- Nishmi Gunasingam
- Department of Gastroenterology and Hepatology, St Vincent's Hospital, Australia
| | - Adam Perczuk
- Department of Gastroenterology and Hepatology, Prince of Wales Hospital, New South Wales, Australia
| | - Michael Talbot
- Department of Gastroenterology and Hepatology, St George Hospital, Sydney, Australia
| | - Arthur Kaffes
- Department of Gastroenterology and Hepatology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Payal Saxena
- Department of Gastroenterology and Hepatology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Lo SK, Fujii-Lau LL, Enestvedt BK, Hwang JH, Konda V, Manfredi MA, Maple JT, Murad FM, Pannala R, Woods KL, Banerjee S. The use of carbon dioxide in gastrointestinal endoscopy. Gastrointest Endosc 2016; 83:857-65. [PMID: 26946413 DOI: 10.1016/j.gie.2016.01.046] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 01/20/2016] [Indexed: 02/08/2023]
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Optical coherence tomography (OCT) prior to peroral endoscopic myotomy (POEM) reduces procedural time and bleeding: a multicenter international collaborative study. Surg Endosc 2016; 30:5126-5133. [DOI: 10.1007/s00464-016-4859-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 03/03/2016] [Indexed: 12/20/2022]
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Abstract
Achalasia is a primary disorder of esophageal motility. It classically presents with dysphagia to both solids and liquids but may be accompanied by regurgitation and chest pain. The gold standard for the diagnosis of achalasia is esophageal motility testing with manometry, which often reveals aperistalsis of the esophageal body and incomplete lower esophageal sphincter relaxation. The diagnosis is aided by complimentary tests, such as esophagogastroduodenoscopy and contrast radiography. Esophagogastroduodenoscopy is indicated to rule out mimickers of the disease known as “pseudoachalasia” (eg, malignancy). Endoscopic appearance of a dilated esophagus with retained food or saliva and a puckered lower esophageal sphincter should raise suspicion for achalasia. Additionally, barium esophagography may reveal a dilated esophagus with a distal tapering giving it a “bird’s beak” appearance. Multiple therapeutic modalities aid in the management of achalasia, the decision of which depends on operative risk factors. Conventional treatments include medical therapy, botulinum toxin injection, pneumatic dilation, and Heller myotomy. The last two are defined as the most definitive treatment options. New emerging therapies include peroral endoscopic myotomy, placement of self-expanding metallic stents, and endoscopic sclerotherapy.
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Affiliation(s)
- Joseph T Krill
- Division of Gastroenterology, Hepatology, and Nutrition, Center for Swallowing and Esophageal Disorders, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rishi D Naik
- Division of Gastroenterology, Hepatology, and Nutrition, Center for Swallowing and Esophageal Disorders, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Center for Swallowing and Esophageal Disorders, Vanderbilt University Medical Center, Nashville, TN, USA
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29
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Hong D, Pescarus R, Khan R, Ambrosini L, Anvari M, Cadeddu M. Early clinical experience with the POEM procedure for achalasia. Can J Surg 2016; 58:389-93. [PMID: 26574830 DOI: 10.1503/cjs.017214] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Per oral endoscopic myotomy (POEM) is a viable alternative to standard Heller myotomy for surgical treatment of achalasia. Outcomes from the United States, Europe and Asia have been reported. We sought to report data after the initiation of POEM in a Canadian centre. METHODS We enrolled patients with achalasia in a research ethics board-approved pilot study. Surgeons learned the POEM procedure in a systematic manner that included visiting experts in POEM, practice in an animal laboratory and mentoring from POEM experts. Preoperative evaluation included manometry, 24-hour pH, barium swallow, endoscopy and Eckhardt Symptom Score. All patients underwent gastrograffin swallow on postoperative day 1. Patients were re-evaluated using the Eckhardt score on postoperative day 14. RESULTS Ten patients underwent POEM. Seven patients had previous endoscopic treatments: 6 had balloon dilatation and 1 had botulinum toxin injection. Mean preoperative Eckhardt score was 8.1 ± 2.4. Mean preoperative lower esophageal sphincter resting and residual pressure was 32.3 ± 9.2 and 20.8 ± 5.3, respectively. Mean duration of surgery was 141.3 ± 43.7 minutes. Mean length of hospital stay was 1 day. No major perioperative complications occurred. On postoperative day 14, the mean Eckhardt score was 1 ± 1.2. CONCLUSION Our approach to POEM introduction was systematic and deliberate. The procedure is safe, feasible and has good perioperative outcomes. Our early results are consistent with current literature.
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Affiliation(s)
- Dennis Hong
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
| | - Radu Pescarus
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
| | - Rana Khan
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
| | - Luciano Ambrosini
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
| | - Mehran Anvari
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
| | - Margherita Cadeddu
- All authors are from the Department of Surgery, McMaster University, Hamilton, Ont
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30
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Grimes KL, Inoue H. Per Oral Endoscopic Myotomy for Achalasia: A Detailed Description of the Technique and Review of the Literature. Thorac Surg Clin 2016; 26:147-62. [PMID: 27112254 DOI: 10.1016/j.thorsurg.2015.12.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Historically, the most robust outcomes in treatment of achalasia were seen with surgical myotomy. Per oral endoscopic myotomy (POEM) introduced an endoscopic method for creating a surgical myotomy. Thousands of cases of POEM have been performed; however, there is no standard technique, and the rates of clinical success and adverse events vary widely among centers. This article presents a detailed description of the POEM technique, including the rationale and potential pitfalls of the main variations, in the context of the international literature.
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Affiliation(s)
- Kevin L Grimes
- Department of Surgery, MetroHealth Medical Center, H924 2500 MetroHealth Drive, Cleveland, OH 44109-1998, USA.
| | - Haruhiro Inoue
- Digestive Disease Center, Showa University Koto-Toyosu Hospital, Toyosu 5-1-38, Koto-ku, Tokyo 135-8577, Japan
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31
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Abstract
The ethical debate regarding the introduction of new technologies in the surgical health care environment is discussed in this manuscript, with a special emphasis on minimally invasive and NOTES procedures for the treatment of esophageal achalasia. It offers an overview of the ethical principles and considerations about the implementation of new techniques and technologies.
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32
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Pandian TK, Naik ND, Fahy AS, Arghami A, Farley DR, Ishitani MB, Moir CR. Laparoscopic esophagomyotomy for achalasia in children: A review. World J Gastrointest Endosc 2016; 8:56-66. [PMID: 26839646 PMCID: PMC4724031 DOI: 10.4253/wjge.v8.i2.56] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 09/28/2015] [Accepted: 11/17/2015] [Indexed: 02/05/2023] Open
Abstract
Esophageal achalasia in children is rare but ultimately requires endoscopic or surgical treatment. Historically, Heller esophagomyotomy has been recommended as the treatment of choice. The refinement of minimally invasive techniques has shifted the trend of treatment toward laparoscopic Heller myotomy (LHM) in adults and children with achalasia. A review of the available literature on LHM performed in patients < 18 years of age was conducted. The pediatric LHM experience is limited to one multi-institutional and several single-institutional retrospective studies. Available data suggest that LHM is safe and effective. There is a paucity of evidence on the need for and superiority of concurrent antireflux procedures. In addition, a more complete portrayal of complications and long-term (> 5 years) outcomes is needed. Due to the infrequency of achalasia in children, these characteristics are unlikely to be defined without collaboration between multiple pediatric surgery centers. The introduction of peroral endoscopic myotomy and single-incision techniques, continue the trend of innovative approaches that may eventually become the standard of care.
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Khashab MA, El Zein M, Kumbhari V, Besharati S, Ngamruengphong S, Messallam A, Abdelgalil A, Saxena P, Tieu AH, Raja S, Stein E, Dhalla S, Garcia P, Singh VK, Pasricha PJ, Kalloo AN, Clarke JO. Comprehensive analysis of efficacy and safety of peroral endoscopic myotomy performed by a gastroenterologist in the endoscopy unit: a single-center experience. Gastrointest Endosc 2016. [PMID: 26212369 DOI: 10.1016/j.gie.2015.06.013] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The safety and efficacy of peroral endoscopic myotomy (POEM) when performed by gastroenterologists in the endoscopy unit are currently unknown. The aims of this study were to assess (1) the safety and efficacy of POEM in which all procedures were performed by 1 gastroenterologist in the endoscopy unit, and (2) the predictors of adverse events and nonresponse. METHODS All consecutive patients who underwent POEM at 1 tertiary center were included. Clinical response was defined by a decrease in the Eckardt score to 3 or lower. Adverse events were graded according to the American Society for Gastrointestinal Endoscopy lexicon's severity grading system. RESULTS A total of 60 consecutive patients underwent POEM in the endoscopy suite with a mean procedure length of 99 minutes. The mean length of submucosal tunnel was 14 cm and the mean myotomy length was 11 cm. The median length of hospital stay was 1 day. Among 52 patients with a mean follow-up period of 118 days (range 30-750), clinical response was observed in 48 patients (92.3%). There was a significant decrease in Eckardt score after POEM (8 vs 1.19, P < .0001). The mean lower esophageal sphincter pressure decreased significantly after POEM (29 mm Hg vs 11 mm Hg, P < .0001). A total of 10 adverse events occurred in 10 patients (16.7%): 7 rated as mild, 3 as moderate, and none as severe. Procedure length was the only predictor of adverse events (P = .01). pH impedance testing was completed in 25 patients, and 22 (88%) had abnormal acid exposure, but positive symptom correlation was present in only 6 patients. All patients with symptomatic reflux were successfully treated with proton pump inhibitors. CONCLUSIONS POEM can be effectively and safely performed by experienced gastroenterologists at a tertiary care endoscopy unit. Adverse events are infrequent, and most can be managed intraprocedurally. Post-POEM reflux is frequent but can be successfully managed medically.
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Affiliation(s)
- Mouen A Khashab
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mohamad El Zein
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Sepideh Besharati
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Ahmed Messallam
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Ahmed Abdelgalil
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Payal Saxena
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Alan H Tieu
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Shreya Raja
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Ellen Stein
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Sameer Dhalla
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Patricia Garcia
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Pankaj J Pasricha
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Anthony N Kalloo
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Vigneswaran Y, Ujiki MB. Peroral endoscopic myotomy: An emerging minimally invasive procedure for achalasia. World J Gastrointest Endosc 2015; 7:1129-1134. [PMID: 26468336 PMCID: PMC4600178 DOI: 10.4253/wjge.v7.i14.1129] [Citation(s) in RCA: 3] [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: 05/28/2015] [Revised: 08/25/2015] [Accepted: 09/08/2015] [Indexed: 02/05/2023] Open
Abstract
Peroral endoscopic myotomy (POEM) is an emerging minimally invasive procedure for the treatment of achalasia. Due to the improvements in endoscopic technology and techniques, this procedure allows for submucosal tunneling to safely endoscopically create a myotomy across the hypertensive lower esophageal sphincter. In the hands of skilled operators and experienced centers, the most common complications of this procedure are related to insufflation and accumulation of gas in the chest and abdominal cavities with relatively low risks of devastating complications such as perforation or delayed bleeding. Several centers worldwide have demonstrated the feasibility of this procedure in not only early achalasia but also other indications such as redo myotomy, sigmoid esophagus and spastic esophagus. Short-term outcomes have showed great clinical efficacy comparable to laparoscopic Heller myotomy (LHM). Concerns related to postoperative gastroesophageal reflux remain, however several groups have demonstrated comparable clinical and objective measures of reflux to LHM. Although long-term outcomes are necessary to better understand durability of the procedure, POEM appears to be a promising new procedure.
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Double-scope per oral endoscopic myotomy (POEM): a prospective randomized controlled trial. Surg Endosc 2015; 30:1344-51. [PMID: 26173548 DOI: 10.1007/s00464-015-4396-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 06/27/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Since its introduction in 2010, per oral endoscopic myotomy (POEM) has offered an alternative to laparoscopic Heller myotomy for the treatment of achalasia. A gastric myotomy length of 3 cm has been recommended; however, it can be difficult to ensure that adequate submucosal dissection has been performed during the procedure. Commonly accepted endoscopic markers of the gastric side can be inaccurate, particularly in patients with prior endoscopic treatments, such as balloon dilation or Botox injection of the lower esophageal sphincter. We hypothesized that the use of a second endoscope would result in a more complete gastric myotomy. METHODS One hundred consecutive achalasia patients were randomized into single- and double-scope POEM groups. In the treatment group, a second endoscope was used to obtain a retroflexed view of the gastric cardia, while the dissecting scope transilluminated from the end of the submucosal tunnel. Prospectively collected data were analyzed, including myotomy lengths, procedure times, adverse events, and clinical outcomes. RESULTS POEM was completed with high rates of technical (98-100%) and clinical success (93-97%) in both groups, with a low rate of serious adverse events (2%). The second endoscope resulted in a 17 min increase in procedure time (94 vs. 77 min), myotomy extension in 34% of cases, and an increase in the average gastric myotomy length from 2.6 to 3.2 cm (p = 0.01). CONCLUSION A second endoscope is useful for ensuring a complete gastric myotomy during POEM. With minimal increase in procedure time and no increase in morbidity, it may be particularly useful in cases of sigmoid esophagus or otherwise altered anatomy that makes identification of the gastroesophageal junction difficult.
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Kumbhari V, Tieu AH, Onimaru M, El Zein MH, Teitelbaum EN, Ujiki MB, Gitelis ME, Modayil RJ, Hungness ES, Stavropoulos SN, Shiwaku H, Kunda R, Chiu P, Saxena P, Messallam AA, Inoue H, Khashab MA. Peroral endoscopic myotomy (POEM) vs laparoscopic Heller myotomy (LHM) for the treatment of Type III achalasia in 75 patients: a multicenter comparative study. Endosc Int Open 2015; 3:E195-201. [PMID: 26171430 PMCID: PMC4486039 DOI: 10.1055/s-0034-1391668] [Citation(s) in RCA: 183] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 12/08/2014] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Type III achalasia is characterized by rapidly propagating pressurization attributable to spastic contractions. Although laparoscopic Heller myotomy (LHM) is the current gold standard management for type III achalasia, peroral endoscopic myotomy (POEM) is conceivably superior because it allows for a longer myotomy. Our aims were to compare the efficacy and safety of POEM with LHM for type III achalasia patients. PATIENTS AND METHODS A retrospective study of 49 patients who underwent POEM for type III achalasia across eight centers were compared to 26 patients who underwent LHM at a single institution. Procedural data were abstracted and pre- and post-procedural symptoms were recorded. Clinical response was defined by improvement of symptoms and decrease in Eckardt stage to ≤ 1. Secondary outcomes included length of myotomy, procedure duration, length of hospital stay, and rate of adverse events. RESULTS Clinical response was significantly more frequent in the POEM cohort (98.0 % vs 80.8 %; P = 0.01). POEM patients had significantly shorter mean procedure time than LHM patients (102 min vs 264 min; P < 0.01) despite longer length of myotomy (16 cm vs 8 cm; P < 0.01). There was no significant difference between POEM and LHM in the length of hospital stay (3.3 days vs 3.2 days; P = 0.68), respectively. Rate of adverse events was significantly less in the POEM group (6 % vs 27 %; P < 0.01). CONCLUSIONS POEM allows for a longer myotomy than LHM, which may result in improved clinical outcomes. POEM appears to be an effective and safe alternative to LHM in patients with type III achalasia.
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Affiliation(s)
- Vivek Kumbhari
- Johns Hopkins Medical Institutions, Gastroenterology and Hepatology, Baltimore, Maryland, United States,Corresponding author Mouen A. Khashab, M.D Associate Professor of MedicineDirector of Therapeutic EndoscopyJohns Hopkins Hospital1800 Orleans St, Suite 7125BBaltimore, MD 21287(443) 287-1960(443) 683 8335
| | - Alan H Tieu
- Johns Hopkins Medical Institutions, Gastroenterology and Hepatology, Baltimore, Maryland, United States
| | - Manabu Onimaru
- Showa University Northern Yokohama Hospital, Digestive Disease Center, Yokohama, Japan
| | - Mohammad H. El Zein
- Johns Hopkins Medical Institutions, Gastroenterology and Hepatology, Baltimore, Maryland, United States
| | - Ezra N. Teitelbaum
- Northwestern University Feinberg School of Medicine, Department of Surgery, Chicago, Illinois, United States
| | - Michael B. Ujiki
- NorthShore University Health Systems, NorthShore Center for Simulation and Innovation, Evanston, Illinois, United States
| | - Matthew E. Gitelis
- NorthShore University Health Systems, NorthShore Center for Simulation and Innovation, Evanston, Illinois, United States
| | - Rani J. Modayil
- Winthrop University Hospital, Gastroenterology and Hepatology, Mineola, New York, United States
| | - Eric S. Hungness
- Northwestern University Feinberg School of Medicine, Department of Surgery, Chicago, Illinois, United States
| | - Stavros N. Stavropoulos
- Winthrop University Hospital, Gastroenterology and Hepatology, Mineola, New York, United States
| | - Hiro Shiwaku
- Fukuoka University Faculty of Medicine, Gastroenterology and Hepatology, Fukuoka, Japan
| | - Rastislav Kunda
- Aarhus University Hospital, Department of Surgery, Aarhus, Denmark
| | - Philip Chiu
- Institute of Digestive Disease, Gastroenterology and Hepatology, Shatin, Hong Kong
| | - Payal Saxena
- Johns Hopkins Medical Institutions, Gastroenterology and Hepatology, Baltimore, Maryland, United States
| | - Ahmed A. Messallam
- Johns Hopkins Medical Institutions, Gastroenterology and Hepatology, Baltimore, Maryland, United States
| | - Haruhiro Inoue
- Showa University Northern Yokohama Hospital, Digestive Disease Center, Yokohama, Japan
| | - Mouen A. Khashab
- Johns Hopkins Medical Institutions, Gastroenterology and Hepatology, Baltimore, Maryland, United States
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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: 1.1] [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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Patel KS, Calixte R, Modayil RJ, Friedel D, Brathwaite CE, Stavropoulos SN. The light at the end of the tunnel: a single-operator learning curve analysis for per oral endoscopic myotomy. Gastrointest Endosc 2015; 81:1181-7. [PMID: 25597422 DOI: 10.1016/j.gie.2014.10.002] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 10/02/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Per oral endoscopic myotomy (POEM) represents a natural orifice transluminal endoscopic surgery approach to Heller myotomy. Our center was the first to offer POEM outside of Japan, allowing us to accumulate what is likely the highest single-operator POEM volume in the United States. OBJECTIVE To define the POEM learning curve of a gastroenterologist by using a larger data set and more detailed statistical analysis than used in 2 other reports of POEM performed by surgeons. DESIGN Prospective cohort study. SETTING Tertiary-care academic medical center. PATIENTS We analyzed the first 93 consecutive POEMs on patients with achalasia aged >18 years without contraindications to POEM performed by a single operator from October 2009 to November 2013. INTERVENTIONS (1) Efficiency estimation via cumulative sum (CUSUM) analysis, (2) mastery estimation via penalized basis-spline regression and CUSUM analysis, (3) correlation of operator experience with clinical outcomes (Eckardt score improvement, lower esophageal sphincter pressure reduction) and technical errors (accidental mucosotomy rate), and (4) unadjusted and adjusted regression analysis to assess how patient characteristics affected procedure time by using a generalized linear model. MAIN OUTCOME MEASUREMENTS Clinical outcomes, procedure time, technical errors. RESULTS Efficiency was attained after 40 POEMs and mastery after 60 POEMs. When we used the adjusted regression analysis, only case number (operator experience) significantly affected procedure time (P < .0001). Improvements in clinical outcomes were excellent but not significantly affected by operator experience, as was the case with accidental mucosotomies. Procedure time was not significantly affected by age, sex, achalasia stage, baseline lower esophageal sphincter pressure, baseline Eckardt score, prior treatment of achalasia, prior botulinum toxin injection, incidence of accidental mucosotomies, length of myotomy, or type of knife used (all P > .05). LIMITATIONS Our analysis may underestimate the number of POEMs required to achieve mastery for operators with limited or no endoscopic submucosal dissection experience. CONCLUSION These results offer thresholds for efficiency and mastery of a single gastroenterologist operator that may guide the efforts of novice POEM operators.
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Affiliation(s)
- Kumkum Sarkar Patel
- Department of Internal Medicine, Winthrop University Hospital, Mineola, New York, USA
| | - Rose Calixte
- Department of Biostatistics, Winthrop University Hospital, Mineola, New York, USA
| | - Rani J Modayil
- Division of Gastroenterology, Winthrop University Hospital, Mineola, New York, USA
| | - David Friedel
- Division of Gastroenterology, Winthrop University Hospital, Mineola, New York, USA
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Sternbach JM, Hungness ES. Surgical intervention for esophageal dysmotility. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2015. [DOI: 10.1016/j.tgie.2015.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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