Per-oral endoscopic myotomy short-term outcomes are good-but the long-term results are what count

The Endoscopic Management of Achalasia: Less May Lead to More

Achalasia is a rare motor disorder of the lower esophageal sphincter. Currently, both endoscopic and surgical techniques are used to treat achalasia. Herein, we detail our institutional experience of surgical re-intervention following the endoscopic management of achalasia.

Antireflux Surgery for Gastroesophageal Reflux Refractory to Medical Treatment After Peroral Endoscopic Myotomy

Background: Between 1995 and 2010, the laparoscopic Heller myotomy (LHM) was considered in most centers the treatment of choice for esophageal achalasia. The technique evolved over time, and the initial thoracoscopic approach was abandoned in favor of LHM with the addition of a fundoplication, due to the high incidence of postoperative reflux. Recently, a new endoscopic technique has been adopted in the treatment of achalasia-peroral endoscopic myotomy (POEM), which has slowly become the preferred treatment modality in many centers. While POEM is as effective as LHM in relieving symptoms, it has been associated with a very high rate of pathological reflux, development of strictures, Barrett's esophagus, and adenocarcinoma. In addition, many patients still complain of heartburn and regurgitation even when treated with high doses of proton pump inhibitors. Methods: We described 3 cases of achalasia patients with reflux symptoms refractory to medical treatment after POEM who underwent laparoscopic antireflux surgery. Results: The operations were completed laparoscopically despite presence of mediastinal adhesions, probably secondary to micro-leaks during POEM. All patients had resolution of their symptoms. Conclusions: This is the first report that describes patients who developed severe heartburn and regurgitation refractory to medical treatment following POEM, who eventually underwent a laparoscopic partial fundoplication with resolution of their symptoms. Our experience shows that post-POEM reflux is a serious concern, especially when refractory to medical treatment. We feel that this is a worrisome problem that will require frequent surgical interventions in the future.

The Treatment of Esophageal Achalasia: At the Intersection Between Innovation and Patient's Care

Innovation is of critical importance for the progress of medicine in general, and of surgery in particular. The introduction of minimally invasive surgery 30 years ago determined a revolution in the way we treat surgical diseases today, as most operations are now performed avoiding large incisions, with a consequent decrease in postoperative pain, shorter hospital stay, and a faster return to daily activities. However, for any innovation to become standard of care, the following criteria must be met: (1) Is it feasible? (2) Is it safe? (3) Does it offer clinical advantages to patients and the health care system? The treatment of esophageal achalasia represents an example of an innovation-per oral endoscopic myotomy-that although feasible and safe has become the standard of care without clear proof that it improves patients' outcome and provides an advantage for the health care system. The review of the treatment of esophageal achalasia during the past 30 years will shed light on this controversial dichotomy-innovation versus patient's care.