Advances in the treatment of achalasia

Evaluation of the need for routine esophagram after peroral endoscopic myotomy (POEM)

BACKGROUND

Peroral endoscopic myotomy (POEM) is a novel surgical option for the treatment of achalasia. Most centers perform a routine esophagram on postoperative day (POD) #1 to rule esophageal perforation and leaks. In this study, we sought to determine the clinical utility of routine contrast studies post-POEM.

METHODS

POEM was performed using an anterior submucosal tunnel and selective myotomy of the circular muscle layer. A routine contrast esophagram was obtained on POD #1. We conducted a retrospective review of the radiologists' interpretations of these studies and compared them to patient's clinical course.

RESULTS

Seventy-eight patients were included. Among these, two complications occurred. One patient was non-compliant with postoperative nil per os orders and developed epigastric pain suspicious for a leak that was demonstrated on esophagram. Another patient had subcutaneous emphysema on POD #1 esophagram, a finding that was also present on physical examination, without esophageal leakage. Another esophagram in an asymptomatic patient was suspicious for submucosal tunnel hematoma which prompted a return to the operating room with negative results. Overall, 56 patients had abnormal studies. POD #1 esophagram demonstrated a sensitivity of 100 % and specificity of 45 % in identifying clinically significant complications.

CONCLUSIONS

In this series, we found routine esophagram to have a high sensitivity but a very low specificity in detecting clinically significant complications. Routine esophagram after POEM may not be necessary.

Self-medication of achalasia with cannabis, complicated by a cannabis use disorder

Achalasia is a rare esophagus motility disorder. Medical, endoscopic and surgical treatments are available, but all endorse high relapse rates. No data has been published to date reporting a therapeutic effect of cannabis use neither in achalasia nor on its influence on manometric measurements. We report the case of a patient diagnosed with achalasia. He could benefit from a large panel of therapeutic interventions, but none of them was effective over the time. He first used cannabis at age 20 and identified benefits regarding achalasia symptoms. He maintained regular moderate cannabis use for 9 years, with minimal digestive inconvenience. A manometry performed without cannabis premedication was realized at age 26 and still found a cardiospasm. Cannabis use could explain the gap between functional symptoms assessment and manometry measurement. Further investigations are warranted to explore a therapeutic effect of cannabis in achalasia and possible influence on outcome measurements.

Timing of Pharyngeal Swallow Events in Chagas' Disease

Background

Esophageal involvement by Chagas’ disease causes a significative decrease in the number of neurons of the esophageal myenteric plexus, causing an impairment of esophageal motility with the same alterations described in primary esophageal achalasia. There is also a longer duration of pharyngeal transit, which might be consequent of the involvement of the central control of swallowing by the disease, or an adaptation of the pharynx to the difficult bolus transit through the esophagus, which could contribute to the complaint of dysphagia.

Methods

We studied, by videofluoroscopy, the sequence and timings of pharyngeal bolus transit in 16 patients with esophageal involvement by Chagas’ disease and 12 healthy volunteers. Each subject swallowed in duplicate 5 mL and 10 mL of liquid and paste boluses.

Results

There was no difference between Chagas’ disease patients and normal volunteers in the sequence and timing of events associated with pharyngeal bolus flow, for liquid and paste boluses, and for 5 mL and 10 mL.

Conclusion

The timing and sequence of swallow pharyngeal events of patients with Chagas’ disease do not differ from that of control subjects, which suggested that the central control of swallowing is not impaired by the disease.

Peroral endoscopic myotomy for achalasia: Analysis of 58 cases

AIM: To assess the safety, feasibility and clinical efficacy of peroral endoscopic myotomy (POEM) in the treatment of achalasia.

METHODS: Clinical data of 58 patients with AC who underwent POEM in our department from May 2011 to June 2013 were analyzed retrospectively. Intraoperative and postoperative complications, symptoms of dysphagia (subjective symptom score and Eckardt score), height of barium (cm) at 1, 2 and 5 min, and recurrence rate and the incidence of reflux evaluated by gastrointestinal endoscopy at 3, 6, 12, and 24 mo follow-ups were analyzed.

RESULTS: All the 58 patients underwent POEM successfully. A small amount of subcutaneous emphysema was observed in only 1 case, and there were no mediastinal emphysema, pneumothorax, pneumoperitoneum or other complications. The estimated average blood loss was < 10 mL, and no serious postoperative complications such as delayed bleeding, perforation and empyema occurred. Mean comprehensive subjective symptom score decreased from 10 to 0.8 following the procedure, and there were significant differences (P < 0.01) between pre and postoperative barium height and Eckardt score. During postoperative follow-up, there appeared an improvement in the life quality of patients. Approximately 75% (43/58) of patients gained weight by an average of 3.7 kg (1-7 kg). Two patients had reflux symptoms, and endoscopy suggested esophagitis (modified Los classification LA-A in one case LA-B in the other). Esophageal 24-h pH monitoring showed that prompt esophageal acid exposure time (more than 4.5% of the time pH value < 4) was 13.4%, of which 5.7% occurred in the standing position and 26.1% in the supine position, and the symptoms in all such patients were easily controlled by the usual dosage of proton pump inhibitors (PPI). During the follow-up, two patients experienced eating choking symptoms at 3 and 6 mo, respectively, and after single endoscopic balloon dilatation (EPD), Eckardt scores became 0, and the dysphagia relieved with no reflux.

CONCLUSION: POEM is safe, minimally invasive and effective in the management of achalasia.

Retrograde myotomy: a variation in per oral endoscopic myotomy (POEM) technique

BACKGROUND

Per oral endoscopic myotomy (POEM) has evolved as a novel therapeutic option for the treatment of esophageal motility disorders such as achalasia. The originally described dissection technique involves cutting the inner circular esophageal muscle fibers in an antegrade fashion. We have modified this technique by commencing the muscular division at the most distal aspect of the submucosal tunnel and continuing the dissection in a retrograde fashion. We present our initial series of patients performed using this modified technique.

METHODS

We retrospectively reviewed our prospectively collected database. Peri- and postoperative data were collected and analyzed. POEM procedures were performed in a near-identical manner as previously published.

RESULTS

Retrograde myotomy was performed on five patients with a diagnosis of achalasia. Four had a history of prior treatment including balloon dilation, with one of these having a prior surgical myotomy. Retrograde POEM procedures were performed with trace blood loss and without any complications. Mean operative time was 85 min. All patients had normal esophagram studies, and diets were advanced as per protocol.

CONCLUSION

POEM was developed as a minimally invasive method for the treatment of achalasia. Our retrograde dissection modification allows the most critical portion of the case, namely division of the lower esophageal and upper gastric circular muscle fibers, to be performed earlier in the case. This ensures adequate dissection of the primary site of esophageal dysfunction should problems arise during the procedure. The modification is straightforward, without the need for additional training or equipment, and appears to provide a more rapid myotomy with less charring in this small cohort of patients.