Peroral Endoscopic Myotomy for Achalasia in a Thoracic Surgical Practice

Management of end - stage achalasia with laparoscopic Heller myotomy: A case report

INTRODUCTION

Achalasia is a rare esophageal motility disorder causing dysphagia and weight loss. Severe cases may present with a significantly dilated and sigmoid-shaped esophagus (sigmoid achalasia). Traditionally, esophagectomy was used for such cases. However, laparoscopic Heller myotomy (LHM) is emerging as a less invasive alternative with comparable outcomes.

CASE PRESENTATION

We present a 45-year-old male with a seven-year history of dysphagia, regurgitation, chest pain, and recent weight loss. Barium esophagogram, high-resolution esophageal manometry, and upper endoscopy confirmed severe achalasia with a sigmoid esophagus (Type I according to Chicago classification). Esophagectomy was considered, but due to the patient's age and the lack of prior treatment attempts, LHM with Dor's fundoplication was performed successfully. At 24-month follow-up, the patient reported significant symptom improvement and weight gain.

CLINICAL DISCUSSION

While esophagectomy was historically used for severe achalasia, LHM is increasingly being employed due to its minimally invasive nature and favorable outcomes. This case highlights the potential benefits of LHM in carefully selected patients with severe achalasia, even those with sigmoid esophagus. However, it's important to acknowledge that LHM may not be suitable for all end-stage cases, and esophagectomy might be necessary in some situations. CONCLUSIóN: Laparoscopic Heller myotomy with Dor's fundoplication is a promising treatment option for end-stage of achalasia, offering faster recovery and improved quality of life. However, further long-term studies are needed to confirm its long-term effectiveness.

Peroral endoscopic myotomy (POEM) vs pneumatic dilation (PD) in treatment of achalasia: A meta-analysis of studies with ≥ 12-month follow-up

Background and study aims  Peroral endoscopic myotomy (POEM) is increasingly being used as the preferred treatment option for achalasia. The aim of this systematic review and meta-analysis was to compare the efficacy and safety of POEM versus pneumatic balloon dilation (PD). Methods  We performed a comprehensive review of studies that reported clinical outcomes of POEM and PD for the treatment of achalasia. Measured outcomes included clinical success (improvement of symptoms based on a validated scale including an Eckardt score ≤ 3), adverse events, and post-treatment gastroesophageal reflux disease (GERD). Results  Sixty-six studies (6268 patients) were included in the final analysis, of which 29 studies (2919 patients) reported on POEM and 33 studies (3050 patients) reported on PD and 4 studies (299 patients) compared POEM versus PD. Clinical success with POEM was superior to PD at 12, 24, and 36 months (92.9 %, vs 76.9 % P  = 0.001; 90.6 % vs 74.8 %, P  = 0.004; 88.4 % vs 72.2 %, P  = 0.006, respectively). POEM was superior to PD in type I, II and III achalasia (92.7 % vs 61 %, P  = 0.01; 92.3 % vs 80.3 %, P  = 0.01; 92.3 %v 41.9 %, P  = 0.01 respectively) Pooled OR of clinical success at 12 and 24 months were significantly higher with POEM (8.97; P  = 0.001 & 5.64; P  = 0.006). Pooled OR of GERD was significantly higher with POEM (by symptoms: 2.95, P  = 0.02 and by endoscopic findings: 6.98, P  = 0.001). Rates of esophageal perforation (0.3 % vs 0.6 %, P  = 0.8) and significant bleeding (0.4 % vs 0.7 %, P  = 0.56) were comparable between POEM and PD groups. Conclusions  POEM is more efficacious than PD in the treatment of patients with achalasia during short-term and long-term follow-up, albeit with higher risk of abnormal esophageal acid exposure.

Determining the Safety and Effectiveness of Electrocautery Enhanced Scissors for Peroral Endoscopic Myotomy (with Video)

BACKGROUND/AIMS

Peroral endoscopic myotomy (POEM) has recently come to the forefront in the management of achalasia. We aimed to analyze the efficacy and safety of the use of electrocautery enhanced scissors (EES) for POEM.

METHODS

This retrospective cohort study prospectively collected the data of all adult patients (aged ≥18 years) with normal foregut anatomy who underwent POEM using EES. The patients' baseline characteristics and procedure details (time, tunnel length, myotomy length, depth, and location) were recorded. The primary outcome was clinical success (3-month post-procedure Eckardt score of ≤3). The secondary outcomes were technical success and adverse events. A paired Student's t-test was performed.

RESULTS

Fifteen patients were included in this study. The technical success rate of myotomy using EES was 100%. Fellows participated in the myotomy in all cases. The clinical success rate was 93.3% (14/15). The mean pre-Eckardt score was 5.4±2.5, while the mean post-Eckardt score was 1.3±1.3, which indicated a significant improvement (p≤0.0001). The most common treatment-related adverse events were post-procedure pain (4, 26.7%) and symptomatic reflux disease (4, 26.7%).

CONCLUSION

In the largest series to date on the use of EES in POEM, we demonstrated that this technique has both technical and clinical efficacy as well as an excellent safety profile.

Wirelessly Powered Endoscopically Implantable Devices into the Submucosa as the Possible Treatment of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a rather common disease with a prevalence reaching up to 10 or 20% in the western world. The most specific symptoms which point to the diagnosis of GERD are feelings of heartburn and the regurgitation of acidic stomach contents into the esophagus. However, a certain number of patients do not respond to standard therapy, and in these cases, it is necessary to resort to other treatment methods, such as laparoscopic fundoplication or electrostimulation of the lower esophageal sphincter. The aim of our work was to design and manufacture a miniature, battery-less stimulator to provide electric stimulation of the lower esophageal sphincter, which could be implanted deep into the submucosa of the distal esophagus. The main goal was to provide a battery-less system as opposed to traditional battery neurostimulators to reduce the size and weight of the device. An electronic prototype of a wirelessly powered implantable device was developed. We used animal models for the experiments. The device is designed to treat GERD via electrical stimulation of the muscularis propria. It is implanted into the submucosal pocket by the lower esophageal sphincter with an endoscope. This method of implantation is superior to esophageal stimulators used today because of very low invasiveness of the surgery. Bipolar neurostimulation via two gold-plated leads is provided. The device does not have any source of energy; it is powered wirelessly which reduces the risk of potential battery leakage and reduces the overall dimensions.

Meta-analysis of clinical outcome after treatment for achalasia based on manometric subtypes

BACKGROUND

The introduction of high-resolution manometry and the Chicago classification has made it possible to diagnose achalasia and predict treatment response accurately. The aim of this study was to compare the effect of the different treatments available on symptomatic outcomes across all achalasia subtypes.

METHODS

The study was conducted according to PRISMA and MOOSE guidelines. A literature search of PubMed and MEDLINE databases was undertaken to identify all relevant articles reporting clinical outcomes of patients with achalasia after botulinum toxin injection, pneumatic dilatation, laparoscopic Heller myotomy (LHM) and peroral endoscopic myotomy (POEM) based on manometric subtypes. Patients were grouped according to the Chicago classification and the success rate in treating symptoms was measured as the primary endpoint.

RESULTS

Twenty studies (1575 patients) were selected, and data on botulinum toxin, pneumatic dilatation, LHM and POEM were extracted. Success rates for LHM in type I, II and III achalasia were 81, 92 and 71 per cent respectively. Those for POEM were 95, 97 and 93 per cent respectively. POEM was more likely to be successful than LHM for both type I (odds ratio (OR) 2·97, 95 per cent c.i. 1·09 to 8·03; P = 0·032) and type III (OR 3·50, 1·39 to 8·77; P = 0·007) achalasia. The likelihood of success of POEM and LHM for type II achalasia was similar.

CONCLUSION

Pneumatic dilatation had a lower but still acceptable success rate compared with POEM or LHM in patients with type II achalasia. POEM is an excellent treatment modality for type I and type III achalasia, although it did not show any superiority over LHM for type II achalasia.

Laparoscopic Heller Myotomy Versus Peroral Endoscopic Myotomy (POEM) for Achalasia: A Systematic Review and Meta-analysis

OBJECTIVE

To compare the outcome of per oral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM) for the treatment of esophageal achalasia.

BACKGROUND

Over the last 2 decades, LHM has become the primary form of treatment in many centers. However, since the first description of POEM in 2010, this technique has widely disseminated, despite the absence of long-term results and randomized trials.

METHODS

A systematic Medline literature search of articles on LHM and POEM for the treatment of achalasia was performed. The main outcomes measured were improvement of dysphagia and posttreatment gastroesophageal reflux disease (GERD). Linear regression was used to model the effect of each procedure on the different outcomes.

RESULTS

Fifty-three studies reported data on LHM (5834 patients), and 21 articles examined POEM (1958 patients). Mean follow-up was significantly longer for studies of LHM (41.5 vs. 16.2 mo, P < 0.0001). Predicted probabilities for improvement in dysphagia at 12 months were 93.5% for POEM and 91.0% for LHM (P = 0.01), and at 24 months were 92.7% for POEM and 90.0% for LHM (P = 0.01). Patients undergoing POEM were more likely to develop GERD symptoms (OR 1.69, 95% CI 1.33-2.14, P < 0.0001), GERD evidenced by erosive esophagitis (OR 9.31, 95% CI 4.71-18.85, P < 0.0001), and GERD evidenced by pH monitoring (OR 4.30, 95% CI 2.96-6.27, P < 0.0001). On average, length of hospital stay was 1.03 days longer after POEM (P = 0.04).

CONCLUSIONS

Short-term results show that POEM is more effective than LHM in relieving dysphagia, but it is associated with a very high incidence of pathologic reflux.

Laparoscopic Heller Myotomy versus Per Oral Endoscopic Myotomy: Evidence-Based Approach to the Treatment of Esophageal Achalasia

Esophageal achalasia is a rare disorder characterized by a failure of the lower esophageal sphincter to relax during swallowing, combined with aperistalsis of the esophageal body. Treatment is not curative, but aims to eliminate the outflow resistance caused by the nonrelaxing lower esophageal sphincter. Current evidence suggests that both laparoscopic Heller myotomy and per oral endoscopic myotomy (POEM) are very effectiveinthe reliefof symptoms in patients with achalasia. Specifically, for type III achalasia, POEM may achieve higher success rates. However, POEM is associated to a very high incidence of pathologic reflux, with the risk of exchanging one disease–achalasia–with another–gastroesophageal reflux.

Submucosal surgery: novel interventions in the third space

Traditional surgeries involve accessing body cavities, such as the abdomen and thorax, via incisions that divide skin and muscle. These operations result in postoperative pain and convalescence, and a risk of complications such as wound infection and hernia. The development of flexible endoscopy allowed diseases as varied as gastrointestinal bleeding and colon adenomas to be treated without incisions, but this technique is restricted by its endoluminal nature. A novel category of surgical endoscopic procedures has recently been developed that uses flexible endoscopic techniques to enter and access the submucosa of the gastrointestinal tract. Through this approach, the advantages of incisionless endoscopy can be applied to areas of the body that previously could only be reached with surgery. This Review introduces this new class of interventions by describing two examples of such submucosal surgeries for the treatment of benign gastrointestinal disease: per-oral endoscopic myotomy and per-oral pyloromyotomy. The approach to pre-procedure patient evaluation, operative technique, and the published outcomes are discussed, as well as potential future applications of similar techniques and procedures in this so-called third space.

The current state of per oral endoscopic myotomy for achalasia

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).