Impact of esophageal flexion level on the surgical outcome in patients with sigmoid esophageal achalasia

Esophageal tortuosity in achalasia: increased length-to-height ratio predicts inferior symptom relief and esophageal emptying following myotomy

BACKGROUND

Current classification of achalasia does not account for variability in esophageal tortuosity. The esophageal length-to-height ratio (LHR) was developed to objectively quantify tortuosity, based on the premise that the esophagus must elongate to become tortuous. Hence, we assess the relationship of esophageal tortuosity, measured by LHR, to preoperative patient characteristics and post-myotomy outcomes, including longitudinal symptom relief and esophageal emptying.

METHODS

From 01/2014 to 01/2020, 420 eligible adult patients underwent myotomy for achalasia at our institution, 216 (51%) Heller myotomy and 204 (49%) per-oral endoscopic myotomy. LHR was measured on pre- and first postoperative timed barium esophagram (TBE), with larger values signifying greater tortuosity. Variable predictiveness and risk-adjusted longitudinal estimates of symptom relief (Eckardt score ≤ 3) and complete emptying, in relation to LHR and manometric subtype, were estimated.

RESULTS

Median [15th, 85th percentile] preoperative LHR was 1.04 [1.01, 1.10]. Preoperative esophageal width > 3 cm and age > 68 years were most predictive of increased LHR. Increased LHR corresponded with decreases in longitudinal postoperative symptom relief and complete esophageal emptying, with a 4% difference in symptom relief and 20% difference in complete emptying, as LHR increased from 1.0 to 1.16. After adjusting for patient factors, including LHR, manometric subtype was less predictive of symptom relief, with estimated symptom relief occurring in 4% fewer patients with Type III achalasia, compared to Types I and II. Overall, LHR decreased following myotomy in patients with an initially tortuous esophagus.

CONCLUSION

Length-to-height ratio was the only variable highly predictive of both longitudinal post-myotomy symptom relief and complete esophageal emptying, whereas manometric subtype was less predictive. These findings highlight the importance of tortuosity in the treatment of patients with achalasia, suggesting that inclusion of esophageal morphology in future iterations of achalasia classification is warranted.

Novel scale for evaluating the therapeutic efficacy of per-oral endoscopic myotomy in achalasia

BACKGROUND

Symptom scales for achalasia after per-oral endoscopic myotomy (POEM) are lacking. This study aimed to propose a new scale based on the conventional Eckardt score (c-ES) and evaluate persistent symptoms that impair patients' quality of life (QOL) post-POEM.

METHODS

Dysphagia, regurgitation, and chest pain frequencies were assessed using a 6-point scale modified-ES (m-ES) after POEM, with "occasional" symptoms on the c-ES further subdivided into three-period categories on m-ES. Symptom severity was further evaluated using a 5-point scale ranging from 1 to 5 points, with a score ≥ 3 points defined as persistent symptoms impairing QOL. We analyzed the correlation between the m-ES and severity score, diagnostic performance of the m-ES for persistent symptoms, and overlaps between each residual symptom.

RESULTS

Overall, 536 patients (median follow-up period, 2.9 years) post-POEM were included in this multicenter study. Significant correlations were observed between the m-ES and severity scores for dysphagia (r = 0.67, p < 0.01), regurgitation (r = 0.73, p < 0.01), and chest pain (r = 0.85, p < 0.01). Twenty-six patients (4.9%) had persistent symptoms post-POEM, and 23 of them had m-ES-specific symptom frequency ≥ once a month, which was determined as the optimal frequency threshold for screening persistent symptoms. The total m-ES predicted persistent symptoms more accurately than the total c-ES (area under the curve: 0.95 vs. 0.79, p < 0.01). Furthermore, dysphagia and chest pain were the major residual symptoms post-POEM covering 91.4% of regurgitation.

CONCLUSIONS

The new post-POEM scale successfully evaluated the QOL-based patient symptom severities. Our study implied the possibility of a simpler scale using residual dysphagia and chest pain.

Role of modified Glasgow Prognostic Score in patients with achalasia who underwent laparoscopic Heller-myotomy with Dor-fundoplication

BACKGROUND

Systemic inflammatory response is significant prognostic indicator in patients with various diseases. The relationship between prognostic scoring systems based on the modified Glasgow Prognostic Score (mGPS) and achalasia in patients treated with laparoscopic Heller‑myotomy with Dor‑fundoplication (LHD) remains uninvestigated. This study aimed to examine the role of mGPS in patients with achalasia.

METHODS

457 patients with achalasia who underwent LHD as the primary surgery between September 2005 and December 2020 were included. We divided patients into the mGPS 0 and mGPS 1 or 2 groups and compared the patients' background, pathophysiology, symptoms, surgical outcomes, and postoperative course.

RESULTS

mGPS was 0 in 379 patients and 1 or 2 in 78 patients. Preoperative vomiting and pneumonia were more common in patients with mGPS of 1 or 2. There were no differences in surgical outcomes. Postoperative upper gastrointestinal endoscopy revealed that severe esophagitis was more frequently observed in patients with mGPS of 1 or 2 (P < 0.01). The clinical success was 91% and 99% in the mGPS 0 and mGPS 1 or 2 groups, respectively (P < 0.01).

CONCLUSIONS

Although severe reflux esophagitis was more common in patients with achalasia with a high mGPS, good clinical success was obtained regardless of the preoperative mGPS.

Quantifying the subjective: length-to-height ratio characterizes achalasia esophageal tortuosity

BACKGROUND

Esophageal morphology in achalasia is thought to affect outcomes, with "end-stage" sigmoidal morphology faring poorly; however, evaluation of morphology's role in outcomes has been limited by lack of objective characterization. Hence, the goals of this study were twofold: characterize the variability of timed barium esophagram (TBE) interpretation and evaluate an objective classification of TBE tortuosity: length-to-height ratio (LHR). We hypothesized that the esophagus must elongate to become sigmoidal such that sigmoidal morphology would demonstrate a larger LHR.

METHODS

Ninety pre-operative TBEs were selected from an institutional database. Esophageal morphology was categorized as straight, intermediate, or sigmoidal. Esophageal length was measured by a mid-lumen line from the aortic knob to the esophagogastric junction on TBE; height was measured vertically from the aortic knob to the level of the esophagogastric junction. The length divided by the height generated the LHR. Descriptive statistics and frequency of expert agreement were calculated. Median LHR was compared between consensus morphologies. A receiver operating characteristic (ROC) determined the optimal LHR for sigmoidal vs non-sigmoidal characterization.

RESULTS

From a total of 90 pre-operative TBEs, expert consensus morphology was reached in 56 (62.2%) cases. Pairs of experts agreed on morphology in 62-74% of TBEs, with all three experts agreeing on 46.7-48.9% of cases. Median LHR between expert consensus morphologies was 1.03, 1.09, and 1.24 for straight, intermediate, and sigmoidal morphologies, respectively (p < 0.001). ROC demonstrated that an LHR cutoff of 1.13 was 100% sensitive and 95% specific (AUC 0.99) for ruling out sigmoidal morphology.

CONCLUSION

These findings confirm our anecdotal experience that subjective morphology interpretation is variable, even between experts at a high-volume center. LHR provides an objective method for classification, allowing us to overcome the limitations of inter-observer variability, thus paving the way for future study of the role of morphology in achalasia outcomes.

Relationship between esophageal achalasia subtypes and esophageal clearance

BACKGROUND

The diagnosis and pathological evaluation of esophageal achalasia have been improved dramatically by the development of high-resolution manometry. It is currently known to be divided into three subtypes. However, the differences between subtypes in terms of esophageal clearance remain unclear.

AIMS

To compare the pathology of subtypes in patients with esophageal achalasia from the perspective of esophageal clearance.

METHODS

We classified the patients diagnosed with esophageal achalasia into three subtypes based on the high-resolution manometry findings and compared the patient background, esophagography findings, esophageal manometry findings, timed barium esophagogram (TBE) findings, and their symptoms. We also calculated the esophageal clearance rate from TBE to investigate the relationship with the subtypes.

RESULTS

There were 71 cases of Type I, 140 cases of Type II, and 10 cases of Type III. No differences by subtype were found in patient background or symptoms. Regarding the esophageal manometry findings, the integrated relaxation pressure was high in Type II (p = 0.0006). The esophagography revealed a mild degree of esophageal flexion in Type III (p = 0.0022) and a high degree of esophageal dilation in Type I and II (p = 0.0227). The esophageal clearance rate in descending order was: Type III, II, and I (height: p = 0.0302, width: p = 0.0008).

CONCLUSIONS

The subtypes by high-resolution manometry diagnosis had an association with the esophagography findings and best reflected the esophageal clearance, with no correlation to the patient backgrounds and symptoms.

Is an objective evaluation essential for determining the therapeutic effect of laparoscopic surgery among patients with esophageal achalasia?

BACKGROUND

Despite a high degree of satisfaction with laparoscopic Heller-Dor surgery (LHD) for esophageal achalasia, some cases show no improvement in postoperative esophageal clearance. We investigated whether an objective evaluation is essential for determining the therapeutic effect of LHD.

METHODS

We investigated the difference in symptoms, regarding esophageal clearance, using timed barium esophagogram (TBE), in 306 esophageal achalasia patients with high postoperative satisfaction who underwent LHD. Furthermore, these patients were divided into two groups, in accordance with the difference in postoperative esophageal clearance, in order to compare the preoperative pathophysiology, symptoms, and surgical results.

RESULTS

Although the poor postoperative esophageal clearance group (117 cases, 38%) was mostly male and the ratio of Sigmoid type was high compared to the good postoperative esophageal clearance group (p = 0.046, p = 0.001, respectively); in patients with high surgical satisfaction, there was no difference in terms of preoperative symptom scores and surgical results. However, although the satisfaction level was high in the poor esophageal clearance group, the scores in terms of the postoperative dysphagia and vomiting were high (p = 0.0018 and p = 0.004, respectively). The AUC was 0.9842 upon ROC analysis regarding the presence or absence of clearance at 2 min following postoperative TBE and the postoperative feeling of difficulty swallowing score, with a cut-off value of 2 points (sensitivity: 88%, specificity: 100%) in cases with a high degree of surgical satisfaction.

CONCLUSION

The esophageal clearance ability can be predicted by subjective evaluation, based on the postoperative symptom scores; so, an objective evaluation is not essential in cases with high surgical satisfaction.

Risk factors for the occurrence of peptic esophagitis following laparoscopic Heller-Dor surgery for esophageal achalasia

Peptic esophagitis can occur as a complication of laparoscopic Heller-Dor surgery (LHD) among patients with esophageal achalasia. The goal of this study was to identify the characteristics of patients who have developed peptic esophagitis following LHD surgery along with the risk factors associated with the occurrence of peptic esophagitis. Among the 447 cases consisting of esophageal achalasia patients who underwent LHD as the primary surgery, we compared the patient background, pathophysiology, symptoms, and surgical outcomes according to whether or not peptic esophagitis occurred following surgery. We also attempted to use univariate and multivariate analyses to identify the risk factors for peptic esophagitis occurring following surgery. Esophagitis following surgery was confirmed in 67 cases (15.0%). With respect to the patient backgrounds for cases in which peptic esophagitis had occurred, a significantly higher number were male patients, with a significantly high occurrence of mucosal perforation during surgery in terms of surgical outcomes, along with a high occurrence of esophageal hiatal hernias in terms of postoperative course (P = 0.045, 0.041, and 0.022, respectively). However, there were no significant differences in terms of age, BMI, disease duration, preoperative symptoms, esophageal manometric findings, esophageal barium findings, and esophageal clearance. A multivariate analysis indicated independent risk factors for the occurrence of peptic esophagitis following LHD as being male, the occurrence of mucosal perforation during surgery, and the occurrence of esophageal hiatal hernias. Peptic esophagitis occurred following LHD in 15% of cases. Independent risk factors for the occurrence of peptic esophagitis following LHD included being male, the occurrence of mucosal perforation during surgery, and the occurrence of esophageal hiatal hernias following surgery.

Per-oral endoscopic myotomy (POEM) for a sigmoid type of achalasia: short-term outcomes and changes in the esophageal angle

BACKGROUND

Per-oral endoscopic myotomy (POEM) is an endoscopic procedure whereby the esophageal muscle is incised in order to lower the lower esophageal sphincter (LES) pressure. Since the time it was first performed in 2008 and subsequently reported on in 2010 by Inoue et al., POEM has been shown to be safe and effective for straight type of achalasia. On the other hand, the efficacy of POEM had been controversial for patients with achalasia of the sigmoid type, in which a high LES pressure is accompanied by morphological changes, including dilation, acute angulation, and rotation. The aim of this study is to evaluate the safety and efficacy of POEM in patients with sigmoid type of achalasia.

METHODS

Between May 2015 and December 2017, 16 patients with a sigmoid type of achalasia underwent POEM in our institute. The POEM procedure was the same as that for the straight type of achalasia. The double-scope technique was used to check the distal end of the submucosal tunnel from the gastric side. The primary endpoint was improvement of Eckardt score at 2 months after POEM. The secondary endpoints comprised operating time, change in the esophageal angulation, and adverse events.

RESULTS

All patients underwent POEM without severe adverse events. The respective parameters before and after POEM significantly differed in terms of mean (SD) Eckardt score [4.9 (2.0) vs. 0.4 (0.6), p < 0.01], LES pressure [19.4 (10.2) vs. 9.2 (6.4), p < 0.01], and integrated relaxation pressure [17.6 (9.2) vs. 7.9 (5.5), p < 0.01]. The average operation time was 94.7 ± 31.4 min. The average esophageal angulation was 88.4° ± 23.1° before POEM and 109.5° ± 16.7° after POEM (p < 0.01). Four patients had postoperative complications that were treated conservatively.

CONCLUSIONS

POEM can improve both LES pressure and esophageal angulation in patients with sigmoid achalasia.