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Chambo L, Pandolfino JE, Halder S, Kahrilas PJ, Konda V, Carlson DA. Discriminating "impaired" from "disordered" contractile response on FLIP panometry by utilizing pressure measurement. Neurogastroenterol Motil 2024:e14818. [PMID: 38764235 DOI: 10.1111/nmo.14818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 04/29/2024] [Accepted: 05/04/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND Functional lumen imaging probe (FLIP) panometry evaluates esophageal motility, including the contractile response to distension, that is, secondary peristalsis. Impaired/disordered contractile response (IDCR) is an abnormal, but nonspecific contractile response that can represent either hypomotility or spastic motor disorders on high-resolution manometry (HRM). We hypothesized that FLIP pressure could be incorporated to clarify IDCR and aimed to determine its utility in a cohort of symptomatic esophageal motility patients. METHODS 173 adult patients that had IDCR on FLIP panometry and HRM with a conclusive Chicago Classification v4.0 (CCv4.0) diagnosis were included and analyzed as development (n = 118) and validation (n = 55) cohorts. FLIP pressure values were assessed for prediction of either hypomotility or spasm, defined on HRM/CCv4.0. KEY RESULTS HRM/CCv4.0 diagnoses were normal motility in 48 patients (28%), "hypomotility" (ineffective esophageal motility, absent contractility, or Type I or II achalasia) in 89 (51%), and "spasm" (Type III achalasia, distal esophageal spasm, or hypercontractile esophagus) in 36 (21%). The pressure at esophagogastric junction-distensibility index (DI) (60 mL) was lower in hypomotility (median [interquartile range] 34 [28-42] mmHg) than in spasm (49 [40-62] mmHg; p < 0.001) and had an area under the receiver operating characteristic curve of 0.80 (95% CI 0.73-0.88) for hypomotility and 0.76 (0.69-0.83) for spasm. For "spasm" on HRM, a threshold FLIP pressure of >35 mmHg provided 90% sensitivity (47% specificity) while >55 mmHg provided 93% specificity (40% sensitivity). CONCLUSION & INFERENCES Pressure on FLIP panometry can help clarify the significance of IDCR, with low-pressure IDCR associated with hypomotility and high-pressure IDCR suggestive of spastic motor disorders.
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Affiliation(s)
- Leya Chambo
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sourav Halder
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Northwestern University, Chicago, Illinois, USA
| | - Vani Konda
- Division of Gastroenterology, Baylor University Medical Center, Dallas, Texas, USA
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Northwestern University, Chicago, Illinois, USA
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Vespa E, Barchi A, Passaretti S, Danese S, Savarino EV. Pneumatic dilation for achalasia in the "POEM era": Still a valuable ally. Dig Liver Dis 2024; 56:778-785. [PMID: 37932169 DOI: 10.1016/j.dld.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/18/2023] [Accepted: 10/23/2023] [Indexed: 11/08/2023]
Abstract
Endoscopic treatments such as peroral endoscopic myotomy (POEM) and pneumatic dilation (PD) are commonly used to treat achalasia. Although POEM has gained popularity due to its high efficacy, the technique is more complex and may be associated with a higher risk of long-term complications compared to PD. This narrative review will focus on efficacy and safety of PD and POEM, and their suitability for different patient populations. While evidence suggests that POEM may be preferred for type III achalasia, PD remains a valuable alternative for patients with a straight, non-dilated esophagus, who prioritize the preservation of anatomical integrity and a lower risk of post-procedural gastroesophageal reflux disease (GERD). While PD carries a non negligibile risk of perforation, it has an excellent safety profile in terms of GERD and is minimally likely to cause permanent esophageal deformation. PD can be repeated with minimal risks to maintain symptom relief, whereas reversing permanent anatomical modifications related to POEM is difficult. The choice of treatment for achalasia should be patient-tailored, considering benefits and drawbacks of each intervention. The importance of personalized approach in the "POEM era" is highlighted, emphasizing the reasons why PD should still be considered a valuable option in the therapeutic armamentarium for achalasia. Areas requiring further research will be also outlined.
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Affiliation(s)
- Edoardo Vespa
- Division of Gastroenterology and Gastrointestinal Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy.
| | - Alberto Barchi
- Division of Gastroenterology and Gastrointestinal Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy; Università Vita-Salute San Raffaele, Milan, Italy
| | - Sandro Passaretti
- Division of Gastroenterology and Gastrointestinal Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Silvio Danese
- Division of Gastroenterology and Gastrointestinal Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy; Università Vita-Salute San Raffaele, Milan, Italy
| | - Edoardo Vincenzo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy; Gastroenterology Unit, Azienda Ospedale Università of Padua, Padua, Italy
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3
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Pomenti S, Nathanson J, Phipps M, Aneke-Nash C, Katzka D, Freedberg D, Jodorkovsky D. Esophagogastroduodenoscopy findings that do no not explain dysphagia are associated with underutilization of high-resolution manometry. Dis Esophagus 2024:doae028. [PMID: 38582609 DOI: 10.1093/dote/doae028] [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] [Received: 04/24/2023] [Revised: 03/15/2024] [Accepted: 03/17/2024] [Indexed: 04/08/2024]
Abstract
In patients with dysphagia that is not explained by upper endoscopy, high-resolution esophageal manometry (HRM) is the next logical step in diagnostic testing. This study investigated predictors of failure to refer for HRM after an upper endoscopy that was performed for but did not explain dysphagia. This was a retrospective cohort study of patients >18 years of age who underwent esophagogastroduodenoscopy (EGD) for dysphagia from 2015 to 2021. Patients with EGD findings that explained dysphagia (e.g. esophageal mass, eosinophilic esophagitis, Schatzki ring, etc.) were excluded from the main analyses. The primary outcome was failure to refer for HRM within 1 year of the index non-diagnostic EGD. We also investigated delayed referral for HRM, defined as HRM performed after the median. Multivariable logistic regression modeling was used to identify risk factors that independently predicted failure to refer for HRM, conditioned on the providing endoscopist. Among 2132 patients who underwent EGD for dysphagia, 1240 (58.2%) did not have findings to explain dysphagia on the index EGD. Of these 1240 patients, 148 (11.9%) underwent HRM within 1 year of index EGD. Endoscopic findings (e.g. hiatal hernia, tortuous esophagus, Barrett's esophagus, surgically altered anatomy not involving the gastroesophageal junction, and esophageal varices) perceived to explain dysphagia were independently associated with failure to refer for HRM (adjusted odds ratio 0.45, 95% confidence interval 0.25-0.80). Of the 148 patients who underwent HRM within 1 year of index EGD, 29.7% were diagnosed with a disorder of esophagogastric junction outflow, 17.6% with a disorder of peristalsis, and 2.0% with both disorders of esophagogastric outflow and peristalsis. The diagnosis made by HRM was similar among those who had incidental EGD findings that were non-diagnostic for dysphagia compared with those who had completely normal EGD findings. Demographic factors including race/ethnicity, insurance type, and income were not associated with failure to refer for HRM or delayed HRM. Patients with dysphagia and endoscopic findings unrelated to dysphagia have a similar prevalence of esophageal motility disorders to those with normal endoscopic examinations, yet these patients are less likely to undergo HRM. Provider education is indicated to increase HRM referral in these patients.
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Affiliation(s)
- Sydney Pomenti
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - John Nathanson
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Meaghan Phipps
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Chino Aneke-Nash
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - David Katzka
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Daniel Freedberg
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Daniela Jodorkovsky
- Department of Medicine, Division of Digestive Diseases, Mount Sinai Doctors, New York, NY, USA
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4
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Xue P, Canakis A, Lee DU, Kadiyala J, Fan GH, Kim RE. Active narcotic use and post-peroral endoscopic myotomy outcomes in esophageal motility disorders. Gastrointest Endosc 2024; 99:490-498.e10. [PMID: 37871847 DOI: 10.1016/j.gie.2023.10.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 10/12/2023] [Accepted: 10/14/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) is a minimally invasive technique used to treat esophageal motility disorders. Opioid use has been demonstrated to adversely affect esophageal dysmotility and is associated with an increased prevalence of esophageal motility disorders. Our aim was to investigate the effect of narcotic use on success rates in patients undergoing POEM. METHODS This was a single-center, retrospective study of patients undergoing POEM between February 2017 and September 2021. Primary outcomes were post-POEM Eckardt score (ES), distensibility index, and length of procedure. Secondary outcomes included technical success, myotomy length, length of stay, adverse events, reintervention rates, and postprocedure GERD. RESULTS During the study period, 90 patients underwent POEM for treatment of esophageal dysmotility disorders. Age, sex, race, indications for POEM, and body mass index were not significant between those with or without narcotic use. There were no differences in procedure time, preprocedure ESs, or length of stay. Postprocedure ESs were higher in the group with active narcotic use compared to the group with no prior history (2.73 vs 1.2, P = .004). Distensibility indexes measured with EndoFLIP (Medtronic, Minneapolis, Minn, USA) were not different in patients using narcotics compared with opioid-naïve patients. CONCLUSION Active narcotic use negatively affects symptom improvement after POEM for the treatment of esophageal motility disorders.
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Affiliation(s)
- Pei Xue
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - David Uihwan Lee
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jagannath Kadiyala
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | | | - Raymond E Kim
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA.
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Boeckxstaens G, Elsen S, Belmans A, Annese V, Bredenoord AJ, Busch OR, Costantini M, Fumagalli U, Smout AJPM, Tack J, Vanuytsel T, Zaninotto G, Salvador R. 10-year follow-up results of the European Achalasia Trial: a multicentre randomised controlled trial comparing pneumatic dilation with laparoscopic Heller myotomy. Gut 2024; 73:582-589. [PMID: 38050085 DOI: 10.1136/gutjnl-2023-331374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 11/19/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVE As achalasia is a chronic disorder, long-term follow-up data comparing different treatments are essential to select optimal clinical management. Here, we report on the 10-year follow-up of the European Achalasia Trial comparing endoscopic pneumodilation (PD) with laparoscopic Heller myotomy (LHM). DESIGN A total of 201 newly diagnosed patients with achalasia were randomised to either a series of PDs (n=96) or LHM (n=105). Patients completed symptom (Eckardt score) and quality-of-life questionnaires, underwent functional tests and upper endoscopy. Primary outcome was therapeutic success defined as Eckardt score <3 at yearly follow-up. Secondary outcomes were the need for retreatment, lower oesophageal sphincter pressure, oesophageal emptying, gastro-oesophageal reflux and the rate of complications. RESULTS After 10 years of follow-up, LHM (n=40) and PD (n=36) were equally effective in both the full analysis set (74% vs 74%, p=0.84) and the per protocol set (74% vs 86%, respectively, p=0.07). Subgroup analysis revealed that PD was superior to LHM for type 2 achalasia (p=0.03) while there was a trend, although not significant (p=0.05), that LHM performed better for type 3 achalasia. Barium column height after 5 min at timed barium oesophagram was significantly higher for patients treated with PD compared with LHM, while other parameters, including gastro-oesophageal reflux, were not different. CONCLUSIONS PD and LHM are equally effective even after 10 years of follow-up with limited risk to develop gastro-oesophageal reflux. Based on these data, we conclude that PD and LHM can both be proposed as initial treatment of achalasia.
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Affiliation(s)
- Guy Boeckxstaens
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - Stefanie Elsen
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - Ann Belmans
- Interuniversity Centre for Biostatistics and Statistical Bioinformatics, KU Leuven, Leuven, Belgium
| | - Vito Annese
- Department of Gastroenterology, IRCCS San Donato Policlinic, San Donato Milanese, Vita-Salute San Raffaele University, Milano, Italy
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam UMC Locatie Meibergdreef, Amsterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC Locatie Meibergdreef, Amsterdam, The Netherlands
| | - Mario Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padova, Italy
| | - Uberto Fumagalli
- Department of Digestive Surgery, European Institute of Oncology - IRCCS, Milano, Italy
| | - André J P M Smout
- Department of Gastroenterology and Hepatology, Amsterdam UMC Locatie Meibergdreef, Amsterdam, The Netherlands
| | - Jan Tack
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - Tim Vanuytsel
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - Giovanni Zaninotto
- Department of Academic Surgery, St Mary's Hospital, Imperial College London, London, UK
| | - Renato Salvador
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padova, Italy
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6
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Qian Z, Qian H, Gao X, Yang Z, Wang Y, Li X, Zhang W, Zhang G, Li X. Long-term efficacy of peroral endoscopic myotomy for achalasia under different criteria. Surg Endosc 2024:10.1007/s00464-024-10742-w. [PMID: 38453750 DOI: 10.1007/s00464-024-10742-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/28/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) has emerged as a widely accepted treatment for achalasia, with limited studies for over 2 years. Additionally, traditional measurements of achalasia after POEM have deficiencies. The study aimed to analyze the long-term outcomes of POEM under different criteria. METHODS Patients with achalasia who received POEM between November 2012 and March 2021 were recruited. Patients and characteristics were shown, and risk factors related to two novel definitions of recurrence, symptomatic reflux, and reflux esophagitis were analyzed. RESULTS Three hundred and twenty-one patients were included. At a median follow-up of 52 months, twenty-three failures happened (7.17%) under the modified criterion, and forty-seven failures occurred (14.64%) under the normal standard. Hospitalization (P = 0.027) and esophageal myotomy length (P = 0.039) were significantly associated with long-term efficacy under the modified and normal criteria, respectively. Fifty-two patients (16.20%) reported reflux symptoms and endoscopy performed in 88 patients revealed reflux esophagitis in 22 cases (25.00%). There were no predictors in the analysis of symptomatic reflux and gender (P = 0.010), LESP (P = 0.013), IRP (P = 0.015), and the esophageal myotomy length (P = 0.032) were statistically related to reflux esophagitis. CONCLUSION POEM is an extremely safe and effective treatment for achalasia with long-term follow-up. Shorter hospitalization and shorter esophageal myotomy length may decrease the incidence of recurrence under the modified and normal criteria, respectively. Long-term outcomes of POEM are unpredictable. No risk factors were related to symptomatic reflux, and male patients with low preoperative LESP and IRP needed relatively shorter esophageal myotomy to prevent reflux esophagitis.
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Affiliation(s)
- Zhouyao Qian
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Haisheng Qian
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xin Gao
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zhen Yang
- Department of Gastroenterology, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou, Jiangsu, China
| | - Yun Wang
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xueliang Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Weifeng Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Guoxin Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.
| | - Xuan Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.
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7
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Barron JO, Tasnim S, Toth AJ, Sudarshan M, Sanaka M, Ramji S, Adhikari S, Murthy SC, Blackstone EH, Raja S. The Value of Fundoplication in the Treatment of Type I Achalasia. Ann Thorac Surg 2024; 117:594-601. [PMID: 37479126 DOI: 10.1016/j.athoracsur.2023.05.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 05/12/2023] [Accepted: 05/30/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND Type I achalasia comprises 20% of achalasia and has nearly absent esophageal motor activity. Concerns that fundoplication decreases the effectiveness of Heller myotomy in these patients has increased adoption of peroral endoscopic myotomy (POEM). Hence, we compared outcomes after Heller myotomy with Dor fundoplication vs POEM. METHODS From 2005 to 2020, 150 patients with type I achalasia underwent primary surgical myotomy (117 Heller myotomy, 33 POEM). Patient demographics, prior treatments, timed barium esophagrams, Eckardt scores, and reinterventions were assessed between the 2 groups. Median follow-up was 5 years for Heller myotomy and 2.5 years for POEM. RESULTS The Heller myotomy group was younger, had fewer comorbidities, and lower body mass index vs POEM. Risk-adjusted models demonstrated clinical success (Eckardt ≤3) in 83% of Heller myotomies and 87% of POEMs at 3 years; longitudinal complete timed barium esophagram emptying and reintervention were also similar. An abnormal pH test result was documented in 10% (6 of 60) after Heller myotomy and in 45% (10 of 22) after POEM (P < .001). CONCLUSIONS Despite nearly absent esophageal contractility, Heller myotomy with Dor fundoplication and POEM result in similar long-term symptom relief, esophageal emptying, and occurrence of reintervention in patients with type I achalasia. There is decreased esophageal acid exposure with the addition of a fundoplication, without compromised esophageal drainage, allaying fears of a detrimental effect of a fundoplication. Hence, choice of procedure may be personalized based on patient characteristics and esophageal morphology and not solely on manometric subtype.
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Affiliation(s)
- John O Barron
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sadia Tasnim
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Andrew J Toth
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Monisha Sudarshan
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Madhusudhan Sanaka
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sadhvika Ramji
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Saurav Adhikari
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sudish C Murthy
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Siva Raja
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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8
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Vauquelin B, Quénéhervé L, Pioche M, Barret M, Wallenhorst T, Chabrun E, Coron E, Roman S, Mion F, Chaussade S, Ponchon T, Olivier R, Rivière P, Zerbib F, Berger A. Factors associated with early failure of peroral endoscopic myotomy in achalasia. Gastrointest Endosc 2024; 99:349-357.e3. [PMID: 37806398 DOI: 10.1016/j.gie.2023.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/21/2023] [Accepted: 10/10/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND AND AIMS Achalasia can be treated very effectively with peroral endoscopic myotomy (POEM), but factors associated with early failure remain to be determined, especially in European cohorts. METHODS All consecutive adult patients who underwent a first POEM to treat primary achalasia were included in this multicenter retrospective study. Early failure was defined by an Eckardt score (ES) >3 at 3 months after POEM. When evaluating factors predictive of early failure, 2 cohorts were considered: one consisted of the total population, for whom only basic variables were collected, and the other a cohort built for a case-control study that included matched early-failure and early-success patients (ratio, 1:2). RESULTS Among 746 patients, the early failure rate was 9.4%. Predictive factors were age ≤45 years (P = .019), achalasia types I and III (P < .001), and the development of a severe adverse event during the procedure (P = .023). In the case-control study, the only additional independent risk factor for early failure was a high pre-POEM ES (P = .001). Only the retrosternal pain subscore was significantly associated with the early failure rate. CONCLUSION The early failure rate of POEM used to treat primary achalasia is <10%. Younger age, type I/III achalasia, and a high pre-POEM ES were significantly associated with failure.
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Affiliation(s)
- Blandine Vauquelin
- Gastroenterology and Hepatology Department, INSERM CIC 1401, Haut-Lévêque University Hospital, Bordeaux, France
| | - Lucille Quénéhervé
- Gastroenterology Department, University Hospital of Brest, Brest, France
| | - Mathieu Pioche
- Department of Gastroenterology, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon University, Inserm U1032, LabTAU, Lyon, France
| | - Maximilien Barret
- Gastroenterology Department, Cochin University Hospital, AP-HP, Paris, France
| | - Timothée Wallenhorst
- Department of Gastroenterology, Pontchaillou University Hospital, Rennes, France
| | - Edouard Chabrun
- Gastroenterology and Hepatology Department, INSERM CIC 1401, Haut-Lévêque University Hospital, Bordeaux, France
| | - Emmanuel Coron
- Department of Gastroenterology and Hepatology, University Hospital of Geneva (HUG), Geneva, Switzerland
| | - Sabine Roman
- Digestive Physiology, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon University Hospital, Inserm U1032, LabTAU, Lyon, France
| | - François Mion
- Digestive Physiology, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon University Hospital, Inserm U1032, LabTAU, Lyon, France
| | - Stanislas Chaussade
- Gastroenterology Department, Cochin University Hospital, AP-HP, Paris, France
| | - Thierry Ponchon
- Department of Gastroenterology, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon University, Inserm U1032, LabTAU, Lyon, France
| | - Raphael Olivier
- Department of Gastroenterology, Nantes University Hospital, Nantes, France
| | - Pauline Rivière
- Gastroenterology and Hepatology Department, INSERM CIC 1401, Haut-Lévêque University Hospital, Bordeaux, France
| | - Frank Zerbib
- Gastroenterology and Hepatology Department, INSERM CIC 1401, Haut-Lévêque University Hospital, Bordeaux, France
| | - Arthur Berger
- Gastroenterology and Hepatology Department, INSERM CIC 1401, Haut-Lévêque University Hospital, Bordeaux, France.
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9
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Kandler J, Essing T, Schöler D, Flügen G, Knoefel WT, Roderburg C, Luedde T, Loosen SH. Surgical and per-oral endoscopic myotomy (POEM) for the treatment of primary esophageal motility disorders: A systematic analysis of current trends in Germany between 2011 and 2019. PLoS One 2024; 19:e0297265. [PMID: 38261581 PMCID: PMC10805300 DOI: 10.1371/journal.pone.0297265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 01/02/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND/AIMS While surgery remains a standard treatment for primary esophageal motility disorders (PEMDs), per-oral endoscopic myotomy (POEM) has recently evolved as an alternative. Systematic data on current trends of invasive procedures for PEMDs in Germany are missing. METHODS Hospital discharge data were used to evaluate trends and mortality of invasive treatment options for PEMDs in Germany between 2011 and 2019. RESULTS 4543 cases of PEMDs (achalasia: n = 4349, dyskinesia of the esophagus: n = 194) receiving open surgery (n = 200), minimal invasive surgery (n = 2366), or POEM (n = 1977) were identified. The relative proportion of POEM significantly increased from 10.9% (2011) to 65.7% (2019). Hospital mortality was 0.2%. The median duration of mechanical ventilation was significantly lower in POEM patients (29.4 hours) compared to open (274.0 hours) or minimal invasive (91.9 hours) surgery. The duration of hospitalization was lowest among POEM patients (5.7 days) compared to surgical procedures (13.7 and 7.7 days). CONCLUSION While the low in-hospital mortality of all procedures combined confirms the solid safety profile of invasive procedures in general, our findings show that POEM has the lowest duration of mechanical ventilation and hospitalization compared to invasive surgical options.
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Affiliation(s)
- Jennis Kandler
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf, Germany
| | - Tobias Essing
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf, Germany
- Department of Internal Medicine II, Marien Hospital, Wesel, Germany
| | - David Schöler
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf, Germany
| | - Georg Flügen
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of General, Visceral and Pediatric Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Wolfram T. Knoefel
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of General, Visceral and Pediatric Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Christoph Roderburg
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf, Germany
| | - Tom Luedde
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf, Germany
| | - Sven H. Loosen
- Medical Faculty of Heinrich Heine University Düsseldorf, Department of Gastroenterology, Hepatology and Infectious Diseases, Düsseldorf, Germany
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Low EE, Hasan A, Fehmi SA, Chang MA, Kwong W, Krinsky ML, Anand G, Greytak M, Kaizer A, Yadlapati R. Diagnostic methods to measure spastic segment and guide tailored myotomy length in type 3 achalasia. Neurogastroenterol Motil 2023; 35:e14625. [PMID: 37288617 PMCID: PMC10726676 DOI: 10.1111/nmo.14625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/27/2023] [Accepted: 05/30/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Myotomy length in type 3 achalasia is generally tailored based on segment of spasticity on high-resolution manometry (HRM). Potential of length of tertiary contractions on barium esophagram (BE) or length of thickened circular muscle on endoscopic ultrasound (EUS) to guide tailored myotomy is less understood. This study aimed to assess agreement between spastic segments lengths on HRM, BE, and EUS among patients with type 3 achalasia. METHODS This retrospective study included adults with type 3 achalasia on HRM between November 2019 and August 2022 who underwent evaluation with EUS and/or BE. Spastic segments were defined as HRM-distance between proximal borders of lower esophageal sphincter and high-pressure area (isobaric contour ≥70 mmHg); EUS-length of thickened circular muscle (≥1.2 mm) from proximal border of esophagogastric junction (EGJ) to the transition to a non-thickened circular muscle; BE-distance between EGJ to proximal border of tertiary contractions. Pairwise comparisons assessed for correlation (Pearson's) and intraclass correlation classification (ICC) agreement. KEY RESULTS Twenty-six patients were included: mean age 66.9 years (SD 13.8), 15 (57.7%) male. Spastic segments were positively correlated on HRM and BE with good agreement (ICC 0.751, [95% CI 0.51, 0.88]). Spastic segments were negatively correlated with poor agreement on HRM and EUS (ICC -0.04, [-0.45, 0.39]) as well as BE and EUS (ICC -0.03, [-0.47, 0.42]). CONCLUSIONS & INFERENCES Length of spastic segment was positively correlated on HRM and BE while negatively correlated when compared to EUS, supporting the common use of HRM and highlighting the uncertain role for EUS in tailoring myotomy length for type 3 achalasia.
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Affiliation(s)
- Eric E. Low
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Aws Hasan
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Syed Abbas Fehmi
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Michael A. Chang
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Wilson Kwong
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Mary L. Krinsky
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Gobind Anand
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Madeline Greytak
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
| | - Alexander Kaizer
- Department of Biostatistics and Informatics, University of Colorado, Denver, Colorado, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego, San Diego, California, USA
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11
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Provenzano L, Pulvirenti R, Duci M, Capovilla G, Costantini A, Forattini F, Gamba P, Costantini M, Fascetti-Leon F, Salvador E. Laparoscopic Heller-Dor Is a Persistently Effective Treatment for Achalasia Even in Pediatric Patients: A 25-Year Experience at a Single Tertiary Center. Eur J Pediatr Surg 2023; 33:493-498. [PMID: 36720247 DOI: 10.1055/s-0043-1760822] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Esophageal achalasia (EA) is a rare primary motility disorder in any age group, and particularly rare in the pediatric population, with a reported incidence of 0.18 per 100,000 children a year. EA in pediatric age is currently treated in the same way as in adults, but this approach is based on only a few studies on small case series. The aim of this retrospective study was to assess the long-term outcome of the laparoscopic Heller-Dor (LHD) procedure when performed in pediatric patients with EA at our university hospital. MATERIALS AND METHODS We considered children and adolescents younger than 16 years old diagnosed with EA and treated with LHD between 1996 and 2022. Clinical data were prospectively collected in an ongoing database. Symptoms were recorded and their severity was calculated using the Eckardt score. Barium swallow, esophageal manometry (conventional or high-resolution), and endoscopy were performed before and after the surgical procedure. RESULTS During the study period, 40 children with a median age of 14 years (interquartile range [IQR]: 11-15) underwent LHD. At a median follow-up of 10.5 years (IQR: 4.5-13.9), a good outcome was achieved in 36/40 patients (90%). Two of the four patients whose surgical procedure failed underwent complementary pneumatic dilations successfully, thus increasing the overall success rate to 95%. A previous endoscopic treatment (in five patients) did not affect the final outcome (p = 0.49). An intraoperative mucosal lesion was detected in only one patient (2.5%) and was repaired at the time without further consequences. During the follow-up, 22 patients underwent endoscopy, and 17 had pH monitoring as well: only 2 of these patients showed reflux esophagitis at endoscopy (one of them with abnormal findings on pH monitoring), amounting to a 9.1% rate of instrumentally confirmed postoperative reflux. CONCLUSION LHD is a safe and persistently effective treatment for EA in pediatric age, with a success rate comparable with what is usually obtained in adults, and better than what has been reported to date in the pediatric literature. Adding a fundoplication certainly helps ensure an optimal long-term control of any gastroesophageal reflux induced by the myotomy.
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Affiliation(s)
- Luca Provenzano
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Rebecca Pulvirenti
- Division of Pediatric Surgery, Department of Women's and Children's Health, University of Padova, Padova, Veneto, Italy
| | - Miriam Duci
- Division of Pediatric Surgery, Department of Women's and Children's Health, University of Padova, Padova, Veneto, Italy
| | - Giovanni Capovilla
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Andrea Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Francesca Forattini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Piergiorgio Gamba
- Division of Pediatric Surgery, Department of Women's and Children's Health, University of Padova, Padova, Veneto, Italy
| | - Mario Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Francesco Fascetti-Leon
- Division of Pediatric Surgery, Department of Women's and Children's Health, University of Padova, Padova, Veneto, Italy
| | - Enato Salvador
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
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12
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Wessels EM, Masclee GMC, Bredenoord AJ. An overview of the efficacy, safety, and predictors of achalasia treatments. Expert Rev Gastroenterol Hepatol 2023; 17:1241-1254. [PMID: 37978889 DOI: 10.1080/17474124.2023.2286279] [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] [Received: 06/12/2023] [Accepted: 11/17/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Achalasia is a rare esophageal motility disorder characterized by abnormal esophageal peristalsis and the inability of the lower esophageal sphincter to relax, resulting in poor esophageal emptying. This can be relieved by endoscopic and surgical treatments; each comes with certain advantages and disadvantages. AREAS COVERED This review aims to guide the clinician in clinical decision making on the different treatment options for achalasia regarding the efficacy, safety, and important predictors. EXPERT OPINION Botulinum toxin injection is only recommended for a selective group of achalasia patients because of the short term effect. Pneumatic dilation improves achalasia symptoms, but this effect diminishes over time and requiring repeated dilations to maintain clinical effect. Heller myotomy combined with fundoplication and peroral endoscopic myotomy are highly effective on the long term but are more invasive than dilations. Gastro-esophageal reflux complaints are more often encountered after peroral endoscopic myotomy. Patient factors such as age, comorbidities, and type of achalasia must be taken into account when choosing a treatment. The preference of the patient is also of great importance and therefore shared decision making has to play a fundamental role in deciding about treatment.
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Affiliation(s)
- Elise M Wessels
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, Netherlands
| | - Gwen M C Masclee
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, University Medical Centers Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, Netherlands
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13
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Srinivasan V, Shah ED. Mini-review: Tailored per-oral endoscopic myotomy for type III achalasia. Neurogastroenterol Motil 2023; 35:e14700. [PMID: 37897117 PMCID: PMC10851349 DOI: 10.1111/nmo.14700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/09/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023]
Abstract
This mini-review summarizes the most recent literature regarding per-oral endoscopic myotomy for type III achalasia, emphasizing the poorly understood science of tailoring myotomy length during this procedure. In addition, special attention will be placed on the current subjective and objective biomarkers, such as the Eckardt score, used to evaluate treatment outcomes in this population to better contextualize the existing data on patient outcomes, as proposed by Low et al in the current issue of the Journal. Understanding the current treatment landscape for type III achalasia and identifying the key areas of research deficiencies will guide future investigation and management of this disease.
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Affiliation(s)
- Vamshek Srinivasan
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Eric D Shah
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
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14
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Mandarino FV, Vespa E, Barchi A, Fasulo E, Sinagra E, Azzolini F, Danese S. Precision Endoscopy in Peroral Myotomies for Motility Disorders of the Upper Gastrointestinal Tract: Current Insights and Prospective Avenues-A Comprehensive Review. Life (Basel) 2023; 13:2143. [PMID: 38004283 PMCID: PMC10672509 DOI: 10.3390/life13112143] [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: 09/25/2023] [Revised: 10/28/2023] [Accepted: 10/29/2023] [Indexed: 11/26/2023] Open
Abstract
Our review delves into the realm of peroral endoscopic myotomies (POEMs) in the upper gastrointestinal tract (UGT). In recent years, POEMs have brought about a revolution in the treatment of UGT motility disorders. Esophageal POEM, the first to be introduced, has now been validated as the primary treatment for achalasia. Subsequently developed, G-POEM displays promising results in addressing refractory gastroparesis. Over time, multiple endoscopic myotomy techniques have emerged for the treatment of Zenker's diverticulum, including Z-POEM, POES, and hybrid approaches. Despite the well-established efficacy outcomes, new challenges arise in the realm of POEMs in the UGT. For esophageal POEM, the future scenario lies in customizing the myotomy extent to the minimum necessary, while for G-POEM, it involves identifying patients who can optimally benefit from the treatment. For ZD, it is crucial to validate an algorithm that considers various myotomy options according to the diverticulum's size and in relation to individual patients. These challenges align with the concept of precision endoscopy, personalizing the technique for each subject. Within our text, we comprehensively examine each myotomy technique, analyzing indications, outcomes, and adverse events. Additionally, we explore the emerging challenges posed by myotomies within the context of the evolving field of precision endoscopy.
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Affiliation(s)
- Francesco Vito Mandarino
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Edoardo Vespa
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Alberto Barchi
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Ernesto Fasulo
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto San Raffaele Giglio, 90015 Cefalù, Italy
| | - Francesco Azzolini
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Silvio Danese
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
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15
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Hosaka H, Kuribayashi S, Kawamura O, Itoi Y, Sato K, Hashimoto Y, Kasuga K, Tanaka H, Kusano M, Uraoka T. The relationship between manometric subtype and symptom details in achalasia. Esophagus 2023; 20:761-768. [PMID: 37093537 DOI: 10.1007/s10388-023-01008-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 04/17/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND Although dysphagia and chest pain are the two most common symptoms in patients with achalasia, the mechanism of evoking symptoms is still unknown. The aim of this study was to reveal the relationship between symptoms and the subtypes of achalasia defined by the Chicago classification. METHODS A total of 71consecutive patients with newly diagnosed achalasia were enrolled between March 2009 and December 2017. Esophageal motility was assessed by high-resolution manometry (HRM) with the Chicago classification v 3.0. and esophagograms. Their symptoms were evaluated with structured self-reported questionnaires focused on dysphagia and chest pain. Symptom profiles and radiographic findings according to the manometric subtypes were investigated. RESULTS Among the total 71 patients, 69 patients (97%) had dysphagia and 39 patients (54%) had chest pain. Regarding dysphagia, type II patients reported dysphagia in the throat the most, while types I and III patients mostly felt it in the epigastrium. Type II patients often felt dysphagia at the time of swallowing (41%), but this was reported in only 8.7% of Type I and 33% of Type III patients (p = 0.02). Concerning chest pain, Type I patients rarely had pain during meals (14%), but more often while sleeping (43%) and in early morning (43%), while type III patients often had pain during meals (67%). Type III patients reported that solid food caused pain more often than other types (I/II/III 0/10/33%, p = 0.09). CONCLUSIONS Detailed symptoms of achalasia, such as its site and timing, varied by subtypes. The status of the esophageal body might induce those differences in symptoms.
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Affiliation(s)
- Hiroko Hosaka
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-Machi Maebashi, Gunma, 371-8511, Japan.
| | - Shiko Kuribayashi
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-Machi Maebashi, Gunma, 371-8511, Japan
| | - Osamu Kawamura
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-Machi Maebashi, Gunma, 371-8511, Japan
| | - Yuki Itoi
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-Machi Maebashi, Gunma, 371-8511, Japan
| | - Keigo Sato
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-Machi Maebashi, Gunma, 371-8511, Japan
| | - Yu Hashimoto
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-Machi Maebashi, Gunma, 371-8511, Japan
| | - Kengo Kasuga
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-Machi Maebashi, Gunma, 371-8511, Japan
| | - Hirohito Tanaka
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-Machi Maebashi, Gunma, 371-8511, Japan
| | - Motoyasu Kusano
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-Machi Maebashi, Gunma, 371-8511, Japan
| | - Toshio Uraoka
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15 Showa-Machi Maebashi, Gunma, 371-8511, Japan
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16
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Han SY, Youn YH. Role of endoscopy in patients with achalasia. Clin Endosc 2023; 56:537-545. [PMID: 37430397 PMCID: PMC10565433 DOI: 10.5946/ce.2023.001] [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] [Received: 11/25/2022] [Revised: 02/22/2023] [Accepted: 03/31/2023] [Indexed: 07/12/2023] Open
Abstract
Achalasia is an esophageal motility disorder characterized by impaired lower esophageal sphincter relaxation and peristalsis of the esophageal body. With the increasing prevalence of achalasia, interest in the role of endoscopy in its diagnosis, treatment, and monitoring is also growing. The major diagnostic modalities for achalasia include high-resolution manometry, esophagogastroduodenoscopy, and barium esophagography. Endoscopic assessment is important for early diagnosis to rule out diseases that mimic achalasia symptoms, such as pseudo-achalasia, esophageal cancer, esophageal webs, and eosinophilic esophagitis. The major endoscopic characteristics suggestive of achalasia include a widened esophageal lumen and food residue in the esophagus. Once diagnosed, achalasia can be treated either endoscopically or surgically. The preference for endoscopic treatment is increasing owing to its minimal invasiveness. Botulinum toxins, pneumatic balloon dilation, and peroral endoscopic myotomy (POEM) are important endoscopic treatments. Previous studies have demonstrated excellent treatment outcomes for POEM, with >95% improvement in dysphagia, making POEM the mainstay treatment option for achalasia. Several studies have reported an increased risk of esophageal cancer in patients with achalasia. However, routine endoscopic surveillance remains controversial owing to the lack of sufficient data. Further studies on surveillance methods and duration are warranted to establish concordant guidelines for the endoscopic surveillance of achalasia.
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Affiliation(s)
- So Young Han
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Hoon Youn
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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17
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Srivastava A, Poddar U, Mathias A, Mandelia A, Sarma MS, Lal R, Yachha SK. Achalasia cardia sub-types in children: Does it affect the response to therapy? Indian J Gastroenterol 2023; 42:534-541. [PMID: 37300794 DOI: 10.1007/s12664-023-01344-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 01/26/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Achalasia sub-types affect treatment response in adults, but there is no similar data in children. We studied the differences in clinico-laboratory features and response to therapy between achalasia sub-types in children. METHODS Forty-eight children (boys:girls-25:23, 14 [0.9-18] years) with achalasia (clinical, barium, high-resolution manometry [HRM], gastroscopy) were evaluated. The sub-type was determined by Chicago classification at HRM. Pneumatic dilatation (PD) or surgery was the primary therapy. Success was defined as Eckhardt score of ≤ 3. RESULTS Dysphagia (95.8%) and regurgitation (93.8%) were the most common symptoms. Forty of 48 cases had an adequate HRM study: Type I (n-19), II (n-19) and III (n-2). Types I and II had similar clinical profile. Type II had higher basal lower esophageal sphincter (LES) pressure (30.5 [16.5-46] vs. 22.5 [13-43] mmHg; p = 0.007) and less dilated esophagus on timed barium esophagogram (TBE, 25 [13-57] vs. 34.5 [20-81] mm; p = 0.006) than type I. Both types had similar success (86.6% [13/15] vs. 92.8% [13/14]; p = 1) after first PD and need of post-PD myotomy (5/17 vs. 1/16; p = 0.1) in follow-up. Twenty-three cases had TBE before and after PD; 15 (65.2%) had good clearance. These subjects required myotomy (1/15 vs. 4/8; p = 0.03) and repeat PD (5/15 vs. 4/8; p = 0.08) less often than those with poor clearance on TBE. CONCLUSION Types I and II achalasia have similar frequency and clinical profile. Type II has higher LES pressure and less dilated esophagus than Type I. Both respond equally well to initial PD. Type I required post-PD myotomy more often, though not significantly. TBE is useful for assessing therapeutic response.
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Affiliation(s)
- Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India.
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Amrita Mathias
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Ankur Mandelia
- Pediatric Surgical Superspecialty, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Richa Lal
- Pediatric Surgical Superspecialty, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Surender Kumar Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
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Le KHN, Low EE, Yadlapati R. Evaluation of Esophageal Dysphagia in Elderly Patients. Curr Gastroenterol Rep 2023; 25:146-159. [PMID: 37312002 PMCID: PMC10726678 DOI: 10.1007/s11894-023-00876-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 06/15/2023]
Abstract
PURPOSE OF REVIEW While guidelines exist for the evaluation and management of esophageal dysphagia in the general population, dysphagia disproportionately affects the elderly. In this article, we reviewed the literature on evaluating esophageal dysphagia in elderly patients and proposed a diagnostic algorithm based on this evidence. RECENT FINDINGS In older patients, dysphagia is often well compensated for by altered eating habits and physiologic changes, underreported by patients, and missed by healthcare providers. Once identified, dysphagia should be differentiated into oropharyngeal and esophageal dysphagia to guide diagnostic workup. For esophageal dysphagia, this review proposes starting with endoscopy with biopsies, given its relative safety even in older patients and potential for interventional therapy. If endoscopy shows a structural or mechanical cause, then further cross-sectional imaging should be considered to assess for extrinsic compression, and same session endoscopic dilation should be considered for strictures. If biopsies and endoscopy are normal, then esophageal dysmotility is more likely, and high-resolution manometry and additional workup should be performed following the updated Chicago Classification. Even after diagnosis of the root cause, complications including malnutrition and aspiration pneumonia should also be assessed and monitored, as they both result from and can further contribute to dysphagia. The successful evaluation of esophageal dysphagia in elderly patients requires a thorough, standardized approach to collecting a history, selection of appropriate diagnostic workup, and assessment of risk of potential complications, including malnutrition and aspiration.
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Affiliation(s)
| | - Eric E Low
- Department of Gastroenterology and Hepatology, University of California, San Diego, CA, USA
| | - Rena Yadlapati
- Department of Gastroenterology and Hepatology, University of California, San Diego, CA, USA.
- , La Jolla, CA, USA.
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19
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Chen S, Xing X, Hou X, Zhuang Q, Tan N, Cui Y, Wang J, Zhang M, Hu S, Xiao Y. The molecular pathogenesis of achalasia: a paired lower esophageal sphincter muscle and serum 4D label-free proteomic study. Gastroenterol Rep (Oxf) 2023; 11:goad031. [PMID: 37324545 PMCID: PMC10260389 DOI: 10.1093/gastro/goad031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/11/2023] [Accepted: 05/03/2023] [Indexed: 06/17/2023] Open
Abstract
Background Achalasia is a primary esophageal motility disorder with potential molecular pathogenesis remaining uncertain. This study aimed to identify the differentially expressed proteins and potential pathways among achalasia subtypes and controls to further reveal the molecular pathogenesis of achalasia. Methods Paired lower esophageal sphincter (LES) muscle and serum samples from 24 achalasia patients were collected. We also collected 10 normal serum samples from healthy controls and 10 normal LES muscle samples from esophageal cancer patients. The 4D label-free proteomic analysis was performed to identify the potential proteins and pathways involved in achalasia. Results Analysis of Similarities showed distinct proteomic patterns of serum and muscle samples between achalasia patients and controls (both P < 0.05). Functional enrichment analysis suggested that these differentially expressed proteins were immunity-, infection-, inflammation-, and neurodegeneration-associated. The mfuzz analysis in LES specimens showed that proteins involved in the extracellular matrix-receptor interaction increased sequentially between the control group, type III, type II, and type I achalasia. Only 26 proteins altered in the same directions in serum and muscle samples. Conclusions This first 4D label-free proteomic study of achalasia indicated that there were specific protein alterations in both the serum and muscle of achalasia, involving immunity, inflammation, infection, and neurodegeneration pathways. Distinct protein clusters between types I, II, and III revealed the potential molecular pathways associated with different disease stages. Analysis of proteins changed in both muscle and serum samples highlighted the importance of further studies on LES muscle and revealed potential autoantibodies.
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Affiliation(s)
| | | | - Xun Hou
- Gastrointestinal Surgery Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Qianjun Zhuang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Niandi Tan
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Yi Cui
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Jinhui Wang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Mengyu Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Shixian Hu
- Institute of Precision Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Yinglian Xiao
- Corresponding author. Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, No. 58 Zhongshan Road 2, Guangzhou, Guangdong 510080, P. R. China. Tel: +86-13560172116;
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20
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Familiari P, Borrelli de Andreis F, Landi R, Mangiola F, Boskoski I, Tringali A, Perri V, Costamagna G. Long versus short peroral endoscopic myotomy for the treatment of achalasia: results of a non-inferiority randomised controlled trial. Gut 2023:gutjnl-2021-325579. [PMID: 37072180 DOI: 10.1136/gutjnl-2021-325579] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 04/05/2023] [Indexed: 04/20/2023]
Abstract
OBJECTIVE Peroral endoscopic myotomy (POEM) has become standard treatment for achalasia with comparable efficacy to surgery. In most of published series, the length of myotomy is 12-13 cm. Shorter cuts could have the advantage of shorter procedure time and possibly reduced gastro-oesophageal reflux disease (GORD) rate. DESIGN This single-centre, patient-blinded, randomised, non-inferiority clinical trial included 200 patients, who were randomly allocated, to receive either a long-POEM (13 cm; 101 patients) or a short-POEM (8 cm; 99 patients). Primary outcome was defined as an Eckardt symptom score of ≤3 at 24 months after the procedure; a non-inferiority design was chosen with an accepted success range of 6% between the two treatments. Secondary outcomes included operating time, complication rate, postoperative manometry, GORD rate and quality of life. RESULTS In the intention-to-treat analysis, clinical success rates were 89.1% in the long-POEM and 98.0% in the short-POEM group, resulting in an absolute between-group difference of -8.9% (90% CI -14.5 to -3.3).Procedure time was significantly reduced in the short-POEM as compared with the long-POEM group (40 vs 50 min, p<0.0001). Severe adverse events occurred in one patient in both groups.No differences were observed in postoperative GORD: acid exposure >6% on pH monitoring study at 6 months was seen in 34.3% (long-POEM) vs 31.1% (short-POEM), while endoscopic oesophagitis was diagnosed in 37.6% vs 51.5% at 6 months and in 21% vs 24.5% at 24 months. Regular proton pump inhibitor use was not different either (36.8% vs 37.5%). CONCLUSIONS Our study demonstrates non-inferiority of a shorter cut length of POEM as compared with the standard treatment, which saved some procedural time. GORD rate was not reduced by reducing cutting length. TRIAL REGISTRATION NUMBER NCT03450928.
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Affiliation(s)
- Pietro Familiari
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Federica Borrelli de Andreis
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Rosario Landi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
| | - Francesca Mangiola
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Ivo Boskoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Vincenzo Perri
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, RM, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, RM, Italy
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21
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Blonski W, Slone S, Richter JE. Update on the Diagnosis and Treatment of Achalasia. Dysphagia 2023; 38:596-608. [PMID: 35585208 DOI: 10.1007/s00455-022-10435-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 03/04/2022] [Indexed: 12/23/2022]
Abstract
Achalasia is a rare disease of the esophagus with impaired relaxation of the lower esophageal sphincter and aperistalsis. The etiology is unknown but speculations include a viral or autoimmune etiology. All specialists dealing with swallowing and esophageal diseases should recognize the classic symptoms of dysphagia for solids/liquids, regurgitation, and choking, especially at night. High-resolution manometry is critical for the diagnosis with endoscopy and barium esophagram having a supportive role. The disease cannot be cured but most can return to near normal swallowing and a regular diet with appropriate therapy. Treatment includes smooth muscle relaxants, botulinum toxin injections to the lower sphincter, pneumatic dilation, Heller myotomy, and peroral endoscopic myotomy. One treatment does not fit all and a tailored approach through a multidiscipline team will give the best long-term outcomes.
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Affiliation(s)
- Wojciech Blonski
- Division of Gastroenterology, James A. Haley VA Hospital, Tampa, FL, USA
- Division of Gastroenterology and Nutrition, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL, 33612, USA
| | - Samuel Slone
- Division of Gastroenterology and Nutrition, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL, 33612, USA
| | - Joel E Richter
- Division of Gastroenterology and Nutrition, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL, 33612, USA.
- Joy McCann Culverhouse Center for Esophageal Diseases, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
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22
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Pham KDC, Lauritzen SS, Tjora E, Gilja OH, Hatlebakk JG, Aßmus J, Havre RF. The outcome of primary per oral endoscopic myotomy (POEM) for treatment of achalasia: Norwegian single-center experience with long-term follow-up. Scand J Surg 2023; 112:3-10. [PMID: 36484306 DOI: 10.1177/14574969221139706] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Per oral endoscopic myotomy (POEM) has become an established treatment for achalasia, but no Scandinavian studies with long-term follow-up exist. This study from a tertiary referral center in Norway investigates the short-, mid-, and long-term feasibility, safety, efficacy, and complications of POEM. METHODS Prospective data from the first 84 patients who underwent POEM from 2014 to 2019 were analyzed. The median follow-up time was 44 months. Clinical success was defined as the Eckardt score (ES) ⩽3, and reflux as pathological if the acid exposure time (pH < 4) was more than 6%. ES was used for symptom evaluation before, and at 6, 12, and up to 64 months after POEM. RESULTS A total of 50 males and 34 females were included. A total of 43 (51%) were treatment naïve, 24 (28.6%) had been previously treated with botulinum toxin, pneumatic balloon dilatation, or both, and 17 (20.2%) were previously treated with Heller's myotomy. The median post-POEM ES at 12 months was 1 (0-9), compared to pre-POEM 7 (4-12) (p < 0.01). At 12 months after POEM, clinical success persisted in 74 patients (88.1%). Clinical success was the highest for patients who were naïve to treatment, 41/43 (95%), and lower for those previously treated with Heller's myotomy 12/17 (70.6%). Long-term follow-up at 5-6 years of 42 patients showed a clinical success rate of 94%. We experienced adverse events in five patients (6%). Post-POEM pathological reflux was found in 46% (28/61). After 3-4 years, the median ES was 1, and after 5-6 years, it was 2. CONCLUSION POEM was safe and relieved the symptoms of achalasia significantly and persistently. The procedure had a better outcome in treatment naïve than previously treated patients. However, POEM is associated with significantly increased esophageal acid exposure. TWITTER SUMMARY Norwegian single-center study: POEM had a clinical success rate of 94% after 5-6 years since its introduction at the center in 2014, providing a safe and effective treatment for achalasia.
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Affiliation(s)
- Khanh Do-Cong Pham
- Department of Medicine Haukeland University Hospital Jonas Lies vei 65 5021 Bergen.,Norway Department of Clinical Medicine University of Bergen Bergen Norway.,Bergen Research Group for Advanced Gastrointestinal Endoscopy (BRAGE) Haukeland University Hospital Bergen Norway
| | - Sigurd Strumse Lauritzen
- Bergen Research Group for Advanced Gastrointestinal Endoscopy (BRAGE), Haukeland University Hospital, Bergen, Norway
| | - Erling Tjora
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Odd Helge Gilja
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway.,National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
| | - Jan Gunnar Hatlebakk
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Jörg Aßmus
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
| | - Roald Flesland Havre
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Bergen Research Group for Advanced Gastrointestinal Endoscopy (BRAGE), Haukeland University Hospital, Bergen, Norway
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23
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Abe H, Tanaka S, Sato H, Shimamura Y, Okada H, Shiota J, Sato C, Sakae H, Ominami M, Hata Y, Fukuda H, Ogawa R, Nakamura J, Tatsuta T, Ikebuchi Y, Yokomichi H, Inoue H. Risk scoring system for the preprocedural prediction of the clinical failure of peroral endoscopic myotomy: a multicenter case-control study. Endoscopy 2023; 55:217-224. [PMID: 35705149 DOI: 10.1055/a-1876-7554] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is effective for the management of achalasia and its variants; however, it can be ineffective in some patients. We aimed to develop and validate a risk scoring system to predict the clinical failure of POEM preoperatively. METHODS Consecutive patients who underwent POEM in 14 high volume centers between 2010 and 2020 were enrolled in this study. Clinical failure was defined as an Eckardt score of ≥ 4 or retreatment. A risk scoring system to predict the short-term clinical failure of POEM was developed using multivariable logistic regression and internally validated using bootstrapping and decision curve analysis. RESULTS Of the 2740 study patients, 112 (4.1 %) experienced clinical failure 6 months after POEM. Risk scores were assigned for three preoperative factors as follows: preoperative Eckardt score (1 point), manometric diagnosis (-4 points for type II achalasia), and a history of prior treatments (1 point for pneumatic dilation or 12 points for surgical/endoscopic myotomy). The discriminative capacity (concordance statistics 0.68, 95 %CI 0.62-0.72) and calibration (slope 1.15, 95 %CI 0.87-1.40) were shown. Decision curve analysis demonstrated its clinical usefulness. Patients were categorized into low (0-8 points; estimated risk of clinical failure < 5 %) and high risk (9-22 points; ≥ 5 %) groups. The proportions of clinical failure for the categories were stratified according to the mid-term outcomes (log-rank test, P < 0.001). CONCLUSIONS This risk scoring system can predict the clinical failure of POEM preoperatively and provide useful information when making treatment decisions.
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Affiliation(s)
- Hirofumi Abe
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shinwa Tanaka
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroki Sato
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hiroki Okada
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Junya Shiota
- Department of Gastroenterology & Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Chiaki Sato
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroyuki Sakae
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yoshitaka Hata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hisashi Fukuda
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Ryo Ogawa
- Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Tetsuya Tatsuta
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Yuichiro Ikebuchi
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Tottori University Faculty of Medicine, Yonago, Japan
| | - Hiroshi Yokomichi
- Department of Health Sciences, University of Yamanashi, Yamanashi, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
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24
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Vespa E, Farina DA, Kahrilas PJ, Kou W, Low EE, Yadlapati R, Pandolfino JE, Carlson DA. Identifying spastic variant of type II achalasia after treatment with high-resolution manometry and FLIP Panometry. Neurogastroenterol Motil 2023:e14552. [PMID: 36807659 DOI: 10.1111/nmo.14552] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/18/2023] [Accepted: 02/07/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Panesophageal pressurization (PEP) defines type II achalasia on high-resolution-manometry (HRM) but some patients exhibit spasm after treatment. The Chicago Classification (CC) v4.0 proposed high PEP values as predictor of embedded spasm, yet supportive evidence is lacking. METHODS Fifty seven type II achalasia patients (47 ± 18 years, 54% males) with HRM and LIP Panometry before and after treatment were retrospectively identified. Baseline HRM and FLIP studies were analyzed to identify factors associated with post-treatment spasm, defined on HRM per CC v4.0. RESULTS Seven patients (12%) had spasm following treatment (peroral endoscopic myotomy 47%; pneumatic dilation [PD] 37%; laparoscopic Heller myotomy 16%). At baseline, greater median maximum PEP pressure (MaxPEP) values on HRM (77 vs 55 mmHg, p = 0.045) and spastic-reactive contractile response pattern on FLIP (43% vs 8%, p = 0.033) were more common in patients with post-treatment spasm while absent contractile response on FLIP was more common in patients without spasm (14% vs 66%, p = 0.014). The strongest predictor of post-treatment spasm was the percentage of swallows with MaxPEP ≥70 mmHg (best cut-off: ≥30%), with AUROC of 0.78. A combination of MaxPEP <70 mmHg and FLIP 60 mL pressure < 40 mmHg identified patients with lower rates of post-treatment spasm (3% overall, 0% post-PD) compared to those with values above these thresholds (33% overall, 83% post-PD). CONCLUSIONS High maximum PEP values, high FLIP 60 mL pressures and contractile response pattern on FLIP Panometry prior to treatment identified type II achalasia patients more likely to exhibit post-treatment spasm. Evaluating these features may guide personalized patient management.
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Affiliation(s)
- Edoardo Vespa
- Division of Gastroenterology and Digestive Endoscopy, IRCCS San Raffaele Hospital, Milan, Italy.,Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Domenico A Farina
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Wenjun Kou
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Eric E Low
- Division of Gastroenterology, University of California, San Diego, California, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego, California, USA
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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25
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Kahrilas PJ, Carlson DA, Pandolfino JE. Advances in the Diagnosis and Management of Achalasia and Achalasia-Like Syndromes: Insights From HRM and FLIP. GASTRO HEP ADVANCES 2023; 2:701-710. [PMID: 37503535 PMCID: PMC10373628 DOI: 10.1016/j.gastha.2023.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
High-resolution manometry, Chicago Classification v4.0, the functional lumen imaging probe, Panometry, and peroral endoscopic myotomy (POEM) are all now integral parts of the landscape for managing achalasia or, more precisely, achalasia-like syndromes. This narrative review examines the impact of these innovations on the management of achalasia-like syndromes. High-resolution manometry was the disruptive technology that prompted the paradigm shift to thinking of motility disorders as patterns of obstructive physiology involving the esophagogastric junction and/or the distal esophagus rather than as siloed entities. An early observation was that the cardinal feature of achalasia-impaired lower esophageal sphincter relaxation-can occur in several subtypes: without peristalsis, with pan-esophageal pressurization, with premature (spastic) distal esophageal contractions, or even with preserved peristalsis (esophagogastric junction outlet obstruction). Furthermore, there being no biomarker for achalasia, no manometric pattern is perfectly sensitive or specific for 'achalasia' and there is also no 'gold standard' for the diagnosis. Consequently, complimentary physiological testing with a timed barium esophagram or functional lumen imaging probe are employed both to improve the detection of patients likely to respond to treatments for 'achalasia' and to characterize other syndromes also likely to benefit from achalasia therapies. These findings have become particularly relevant with the development of a minimally invasive technique for performing a tailored esophageal myotomy, POEM. Now and in the future, optimal achalasia management is to render treatment in a phenotype-specific manner, that is, POEM calibrated in a patient-specific manner for obstructive physiology including the distal esophagus and more conservative strategies such as a short POEM or pneumatic dilation for obstructive physiology limited to the lower esophageal sphincter.
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Affiliation(s)
- Peter J Kahrilas
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Dustin A Carlson
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - John E Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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26
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Laparoscopic Esocardiomyotomy-Risk Factors and Implications of Intraoperative Mucosal Perforation. Life (Basel) 2023; 13:life13020340. [PMID: 36836695 PMCID: PMC9963844 DOI: 10.3390/life13020340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 01/20/2023] [Accepted: 01/23/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Mucosal perforation during laparoscopic esocardiomyotomy is quite frequent, and its consequences cannot always be neglected. The purpose of the study is to investigate the risk factors for intraoperative mucosal perforation and its implications on the postoperative outcomes and the functional results three months postoperatively. MATERIAL AND METHODS We retrospectively identified the patients with laparoscopic esocardiomyotomy performed at Sf. Maria Hospital Bucharest, in the period between January 2017-January 2022 and collected the data (preoperative-clinic, manometric and imaging, intra-and postoperative). To identify the risk factors for mucosal perforations, we used logistic regression analysis. RESULTS We included 60 patients; intraoperative mucosal perforation occurred in 8.33% of patients. The risk factors were: the presence of tertiary contractions (OR = 14.00, 95%CI = [1.23, 158.84], p = 0.033206), the number of propagated waves ≤6 (OR = 14.50), 95%CI = [1.18, 153.33], p < 0.05), the length of esophageal myotomy (OR = 1.74, 95%CI = [1.04, 2.89] p < 0.05), the length of esocardiomyotomy (OR = 1.74, 95%CI = [1.04, 2.89] p < 0.05), and a protective factor-the intraoperative upper endoscopy (OR = 0.037, 95%CI = [0.003, 0.382] p < 0.05). CONCLUSIONS Identifying risk factors for this adverse intraoperative event may decrease the incidence and make this surgery safer. Although mucosal perforation resulted in prolonged hospital stays, it did not lead to significant differences in functional outcomes.
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27
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Olivier R, Brochard C, des Varannes SB, Ropert A, Wallenhorst T, Reboux N, Quénéhervé L, Coron E. Peroral endoscopic myotomy: is it better to perform it in naive patients or as second-line therapy? Results of an open-label-controlled study in 105 patients. Surg Endosc 2023; 37:3760-3768. [PMID: 36670217 PMCID: PMC10156842 DOI: 10.1007/s00464-021-08767-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 10/09/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Whether Peroral Endoscopic Myotomy (POEM) can be proposed as a second-line treatment in patients with achalasia remains to be confirmed in real-life series. OBJECTIVE This study aimed to compare the efficacy, feasibility and safety of POEM between treatment-naïve patients and patients who had prior endoscopic or surgical therapies for achalasia. METHODS All consecutive patients who underwent a POEM procedure for achalasia in our centre from June 2015 to September 2018 were included in this retrospective study. They were classified into treatment-naïve patients (POEM1) and patients who had at least one previous endoscopic and/or surgical treatment for achalasia (POEM2). RESULTS A total of 105 patients were included, 52 in the POEM1 group and 53 in the POEM2 group. Clinical success (defined as an Eckardt score ≤ 3) at 6 months was observed in 93% of POEM1 patients and 84% of POEM2 patients (p = 0.18). Technical success rate was not significantly different between the two groups (100% vs 96%, respectively; p = 0.50). No significant difference was noted in terms of adverse event rate (19% vs 19%, respectively; p = 1.00). Post-procedure pain occurred in 12% of treatment-naive and 9% of non-naïve patients (p = 0.76). The median length of hospital stay was 3 days in both groups (p = 0.17). Symptomatic gastroesophageal reflux occurred in 25% of POEM1 patients and 16% of POEM2 patients (p = 0.24). CONCLUSION Efficacy, feasibility and safety of POEM are not different between treatment-naïve and non-naïve patients. POEM is a valuable second-line approach in patients with persistent symptoms of achalasia after surgical or endoscopic treatments.
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Affiliation(s)
- Raphael Olivier
- Service de Gastroentérologie, CHU de Poitiers, Poitiers, France
- Institut des Maladies de l'Appareil Digestif, IMAD, CHU Nantes, Hôpital Hôtel-Dieu, 1 place Ricordeau, 44093, Nantes cedex, France
| | - Charlène Brochard
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennes 1, Rennes, France
- Service d'Explorations Fonctionnelles Digestives, CHU Pontchaillou, Université de Rennes 1, Rennes, France
- CIC 1414, INPHY, Université de Rennes 1, Rennes, France
| | - Stanislas Bruley des Varannes
- Institut des Maladies de l'Appareil Digestif, IMAD, CHU Nantes, Hôpital Hôtel-Dieu, 1 place Ricordeau, 44093, Nantes cedex, France
| | - Alain Ropert
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennes 1, Rennes, France
- Service d'Explorations Fonctionnelles Digestives, CHU Pontchaillou, Université de Rennes 1, Rennes, France
| | - Timothée Wallenhorst
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Université de Rennes 1, Rennes, France
| | - Noémi Reboux
- Service de Gastroentérologie, CHRU de Brest, Brest, France
| | - Lucille Quénéhervé
- Institut des Maladies de l'Appareil Digestif, IMAD, CHU Nantes, Hôpital Hôtel-Dieu, 1 place Ricordeau, 44093, Nantes cedex, France
- Service de Gastroentérologie, CHRU de Brest, Brest, France
| | - Emmanuel Coron
- Institut des Maladies de l'Appareil Digestif, IMAD, CHU Nantes, Hôpital Hôtel-Dieu, 1 place Ricordeau, 44093, Nantes cedex, France.
- Department of Gastroenterology and Hepatology, University Hospital of Geneva (HUG), rue Gabrielle Perret- Gentil 4, Genève, 1205-1211, Switzerland.
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Slim N, Williamson JM. Achalasia: investigation and management. Br J Hosp Med (Lond) 2023; 84:1-9. [PMID: 36708337 DOI: 10.12968/hmed.2022.0437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Achalasia, characterised by the absence of peristalsis and failure of relaxation of the lower oesophageal sphincter, is an uncommon degenerative condition that results in dysphagia. If left untreated it can lead to aspiration, oesophageal perforation, oesophagitis and malnutrition. It has a range of immune, allergic, viral and genetic aetiological causes. Successful diagnosis relies on the use of oesophagogastroduodenoscopy, barium swallow and oesophageal manometry to characterise the severity of the disease and to rule out underlying malignancy. Although no treatment can reverse the degenerative process, therapeutic strategies including lifestyle modification, medication, endoscopic and operative intervention can help to reduce symptoms. This article reviews the latest methods used to investigate and manage achalasia.
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Affiliation(s)
- Naim Slim
- Department of General Surgery, The Great Western Hospital, Swindon, UK
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29
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Rolland S, Paterson W, Bechara R. Achalasia: Current therapeutic options. Neurogastroenterol Motil 2023; 35:e14459. [PMID: 36153803 DOI: 10.1111/nmo.14459] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 07/13/2022] [Accepted: 08/01/2022] [Indexed: 12/31/2022]
Abstract
Achalasia is an esophageal motor disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and absent peristalsis in the smooth muscle esophageal body. As a result, patients typically experience dysphagia, regurgitation, chest pain, and weight loss. Over the past 10-15 years, there has been a resurgence of interest in the evaluation of therapies for achalasia. Unfortunately, little progress in the development of effective pharmacological treatments has been made. Botulinum toxin injection provides some relief of symptoms in many patients but requires periodic reinjection that may provide progressively less benefit over time. There are now three well-established, safe, and effective therapies for the treatment of achalasia: pneumatic dilation (PD), laparoscopic Heller myotomy (LHM), and peroral endoscopic myotomy (POEM) which can lead to marked symptom improvement in most patients. Each treatment has a specific constellation of risks, benefits, and recurrence rate. The first-line treatment used will depend on patient preference, achalasia subtype, and local expertise. The recent impressive advances in both the art and science of achalasia therapy are explored with a comprehensive review of the various treatment modalities and comparative controlled clinical trials. In addition, key technical pearls of the procedural treatments are demonstrated.
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Affiliation(s)
- Sebastien Rolland
- Division of Gastroenterology, Hôpital Maisonneuve-Rosemont and Université de Montreal, Montreal, Quebec, Canada
| | - William Paterson
- Division of Gastroenterology and GI Diseases Research Unit, Queen's University, Kingston, Ontario, Canada
| | - Robert Bechara
- Division of Gastroenterology and GI Diseases Research Unit, Queen's University, Kingston, Ontario, Canada
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Ribolsi M, Andrisani G, Di Matteo FM, Cicala M. Achalasia, from diagnosis to treatment. Expert Rev Gastroenterol Hepatol 2023; 17:21-30. [PMID: 36588469 DOI: 10.1080/17474124.2022.2163236] [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] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Achalasia is an uncommon esophageal motility disorder and is characterized by alterations of the motility of the esophageal body in conjunction with altered lower esophageal sphincter (LES) relaxation. The clinical presentation of patients with achalasia may be complex; however, the most frequent symptom is dysphagia. The management of patients with achalasia is often challenging, due to the heterogeneous clinical presentation. AREAS COVERED The diagnosis and management of achalasia has significantly improved in the last years due to the growing availability of high-resolution manometry (HRM) and the implementation in the therapeutic armamentarium of new therapeutic endoscopic procedures. Traditional therapeutic strategies include botulinum toxin injected to the LES and pneumatic balloon dilation. On the other hand, surgical treatments contemplate laparoscopic Heller myotomy and, less frequently, esophagectomy. Furthermore, in the last few years, per oral endoscopic myotomy (POEM) has been proposed as the main endoscopic therapeutic alternative to the laparoscopic Heller myotomy. EXPERT OPINION Diagnosis and treatment of achalasia still represent a challenging area. However, we believe that an accurate up-front evaluation is, nowadays, necessary in addressing patients with achalasia for a more accurate diagnosis as well as for the best treatment options.
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Affiliation(s)
- Mentore Ribolsi
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, Rome, Italy
| | | | | | - Michele Cicala
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, Rome, Italy
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31
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Gong F, Li Y, Ye S. Effectiveness and complication of achalasia treatment: A systematic review and network meta-analysis of randomized controlled trials. Asian J Surg 2023; 46:24-34. [PMID: 35484068 DOI: 10.1016/j.asjsur.2022.03.116] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 03/16/2022] [Accepted: 03/31/2022] [Indexed: 12/16/2022] Open
Abstract
Achalasia(AC) is an esophageal motility disorder characterized by decreased esophageal motility and impaired relaxation of lower esophageal sphincter(LES). The treatment of achalasia is continuously improved for the development of technology, but each treatment has its own advantages and disadvantages. This article was to compare the efficacy and complication of different treatment on AC. PUBMED/MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials were searched for eligible studies. A random-effects model within a Bayesian framework was applied to compare treatment effects as odds ratio (OR) with their corresponding 95% credible interval (CI), also OR was applied to compare complication with 95% CI. The surface under the cumulative ranking area (SUCRA) was calculated to make the ranking of the treatments for outcomes. Twenty-seven randomized controlled trials (RCTs) were eligible. According to SUCRA ranking, anterior peroral endoscopic myotomy (APOEM) (SUCRA = 84.6%) might have the highest probability to be the best treatment for dysphagia remission in AC patients, followed by POEM (SUCRA = 78.4%). For gastroesophageal reflux disease (GERD) assessment, the corresponding SUCRA values indicated that botulinum toxin(BT) (SUCRA = 18.3%) might have lowest GERD incidence rate and POEM ranked the worst (SUCRA = 69.8%).. APOEM might have the highest probability to be the best therapeutic strategy for dysphagia remission in a short-term of follow-up, but the GERD incidence rate was high. BT injection might have the lowest probability to treat dysphagia, but the risk of GERD was the lowest. In the future, more RCTs with higher qualities are needed to make head-to-head comparison between 2 or more treatments.
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Affiliation(s)
- Fangxiao Gong
- Emergency and Critical Care Center, Intensive Care Unit, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, 310014, China
| | - Yuanyuan Li
- Department of Endocrinology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Sen Ye
- Emergency and Critical Care Center, Intensive Care Unit, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, 310014, China.
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Low EE, Fehmi SA, Hasan A, Chang M, Kwong W, Krinsky ML, Anand G, Greytak M, Kaizer A, Carlson DA, Pandolfino JE, Yadlapati R. Type II achalasia with focal elevated pressures: A distinct manometric and clinical sub-group. Neurogastroenterol Motil 2022; 34:e14449. [PMID: 35972282 PMCID: PMC9722506 DOI: 10.1111/nmo.14449] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/15/2022] [Accepted: 07/27/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Type II achalasia (Ach2) is distinguished from other achalasia sub-types by the presence of panesophageal pressurization (PEP) of ≥30 mmHg in ≥20% swallows on high-resolution manometry (HRM). Variable manometric features in Ach2 have been observed, characterized by focal elevated pressures (FEPs) (focal/segmental pressures ≥70 mmHg within the PEP band) and/or high compression pressures (PEP ≥70 mmHg). This study aimed to examine clinical and physiologic variables among sub-groups of Ach2. METHODS This retrospective single center study performed over 3 years (1/2019-1/2022) included adults with Ach2 on HRM who underwent endoscopic ultrasound (EUS), functional lumen imaging probe (FLIP), and/or barium esophagram (BE) prior to therapy. Patients were categorized into two overarching sub-groups: Ach2 without FEPs and Ach2 with FEPs. Demographic, clinical, and physiologic data were compared between these sub-groups utilizing unpaired univariate analyses. KEY RESULTS Of 53 patients with Ach2, 40 (75%) were without FEPs and 13 (25%) had FEPs. Compared with the Ach2 sub-group without FEPs, the Ach2 sub-group with FEPs demonstrated a significantly thickened distal esophageal circular muscle on EUS (1.4 mm [SD 0.9] vs. 2.1 [0.7]; p = 0.02), higher prevalence of tertiary contractions on BE (46% vs. 100%; p = 0.0006), lower esophagogastric junction distensibility index (2.2mm2 /mmHg [0.9] vs 0.9 [0.4]; p = 0.0008) as well as higher distensive pressure (31.0 mmHg [9.8] vs. 55.4 [18.8]; p = 0.01) at 60 cc fill on FLIP, and higher prevalence of chest pain on Eckardt score (p = 0.03). CONCLUSIONS AND INFERENCES We identified a distinct sub-group of type II achalasia on HRM, defined as type II achalasia with focal elevated pressures. This sub-group uniquely exhibits spastic features and may benefit from personalized treatment approaches.
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Affiliation(s)
- Eric E. Low
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Syed Abbas Fehmi
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Aws Hasan
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Michael Chang
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Wilson Kwong
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Mary L. Krinsky
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Gobind Anand
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Madeline Greytak
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Alexander Kaizer
- Department of Biostatistics & Informatics, University of Colorado, Denver, Colorado, USA
| | - Dustin A. Carlson
- Division of Gastroenterology, Northwestern University, Chicago, Illinois, USA
| | - John E. Pandolfino
- Division of Gastroenterology, Northwestern University, Chicago, Illinois, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
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Nicolas A, Aumar M, Tran LC, Tiret A, Duclaux-Loras R, Bridoux-Henno L, Campeotto F, Fabre A, Breton A, Languepin J, Kyheng M, Viala J, Coopman S, Gottrand F. Comparison of Endoscopic Dilatation and Heller's Myotomy for Treating Esophageal Achalasia in Children: A Multicenter Study. J Pediatr 2022; 251:134-139.e2. [PMID: 35853483 DOI: 10.1016/j.jpeds.2022.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 07/08/2022] [Accepted: 07/13/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the efficacy of, and complications from, the 2 main treatments for achalasia: endoscopic dilatation and surgical cardiomyotomy (Heller's myotomy). STUDY DESIGN We retrospectively collected data on children treated for achalasia over an 11-year period from 8 tertiary pediatric centers. A line of treatment was defined as performing either Heller's myotomy or 1-3 sessions of endoscopy dilatation over 3 months. Treatment success was a priori defined as clinical improvement and no need for new treatment. RESULTS Ninety-seven children (median age, 12 years; 57% boys) were included. The median time to diagnosis was 10.5 months, and the median follow-up period was 27 months. Thirty-seven children were treated by Heller's myotomy and 60 by endoscopy dilatation as the first-line treatment. After adjustment for potentially confounding factors, Heller's myotomy was significantly more successful than endoscopy dilatation (hazard ratio, 3.93 [1.74; 8.88]; P = .001), with a median survival without failure of 49 and 7 months, respectively, and with no significant difference in the occurrence of complications (35.2% for Heller's myotomy, 29.7% for endoscopy dilatation, P = .56). Hydrostatic dilatation was as successful as pneumatic dilatation (hazard ratio, 1.35 [0.56; 3.23]; P = .50). CONCLUSIONS Heller's myotomy is more successful than endoscopy dilatation, with no significant difference in the occurrence of serious complications. This raises the potential role of peroral endoscopic myotomy as an alternative treatment to Heller's myotomy.
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Affiliation(s)
- Audrey Nicolas
- Department of Pediatrics, CHU Limoges, Limoges, France; Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Jeanne de Flandre Children's Hospital, CHU Lille and University Lille, Lille, France
| | - Madeleine Aumar
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Jeanne de Flandre Children's Hospital, CHU Lille and University Lille, Lille, France; University Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, France
| | - Léa Chantal Tran
- University Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, France
| | - Alice Tiret
- Department of Pediatric Gastroenterology and Nutrition, Hôpital Universitaire Robert-Debré, Assistance Publique-Hôpitaux de Paris, University Paris, Paris, France
| | - Rémi Duclaux-Loras
- Department of Pediatric Gastroenterology Hepatology and Nutrition, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
| | - Laure Bridoux-Henno
- Department of Child and Adolescent Medicine, CHU Rennes Hôpital Sud, Rennes Cedex 2, France
| | - Florence Campeotto
- Pediatric Gastroenterology Department, APHP Necker-Enfants Malades Hospital, Paris, France
| | - Alexandre Fabre
- Pediatric Multidisciplinary Pediatric APHM, Timone Enfant, Marseille, France; Aix-Marseille University, INSERM, GMGF, Marseille, France
| | - Anne Breton
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Purpan University Hospital, Toulouse, France
| | | | - Maéva Kyheng
- ULR 2694 - METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, University Lille, CHU Lille, Lille, France; Department of Biostatistics, University Lille, CHU Lille, Lille, France
| | - Jérôme Viala
- Department of Pediatric Gastroenterology and Nutrition, Hôpital Universitaire Robert-Debré, Assistance Publique-Hôpitaux de Paris, University Paris, Paris, France
| | - Stéphanie Coopman
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Jeanne de Flandre Children's Hospital, CHU Lille and University Lille, Lille, France
| | - Frédéric Gottrand
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Jeanne de Flandre Children's Hospital, CHU Lille and University Lille, Lille, France; University Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, France.
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34
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Tatsuta T, Sato H, Fujiyoshi Y, Abe H, Shiwaku A, Shiota J, Sato C, Ominami M, Hata Y, Fukuda H, Ogawa R, Nakamura J, Ikebuchi Y, Yokomichi H, Fukuda S, Inoue H. Subtype of Achalasia and Integrated Relaxation Pressure Measured Using the Starlet High-resolution Manometry System: A Multicenter Study in Japan. J Neurogastroenterol Motil 2022; 28:562-571. [PMID: 36250363 PMCID: PMC9577579 DOI: 10.5056/jnm21254] [Citation(s) in RCA: 5] [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: 12/29/2021] [Accepted: 04/25/2022] [Indexed: 11/25/2022] Open
Abstract
Background/Aims ManoScan and Sandhill high-resolution manometry (HRM) systems are used worldwide; however, the diagnosis of achalasia on the Starlet HRM system is not fully characterized. Furthermore, the impact of calcium channel blockers and nitrites in treating achalasia has not been investigated using HRM. Management of recurrent cases is a priority issue, although few studies have examined patient characteristics. Methods We conducted a multicenter, large-scale database analysis. First, the diagnosis of treatment-naive achalasia in each HRM system was investigated. Next, patient characteristics were compared between type I-III achalasia, and the impact of patient characteristics, including calcium channel blocker and nitrite use for integrated relaxation pressure (IRP) values, were analyzed. Finally, patient characteristics with recurrent achalasia were elucidated. Results The frequency of type I achalasia with Starlet was significantly higher than that with ManoScan and Sandhill HRM systems. In achalasia, multivariate analysis identified male sex, advanced age, long disease duration, obesity, type I achalasia, and sigmoid type as risk factors related to normal IRP values (< 26 mmHg). Calcium channel blockers and nitrites use had no significant impact on the IRP values, although achalasia symptoms were indicated to be alleviated. In recurrent cases, the IRP value was significantly lower, and advanced age, long disease duration, and sigmoid type were more common than in treatment-naive patients. Conclusions We should cautiously interpret the type of achalasia and IRP values in the Starlet HRM system. Symptoms of recurrent cases are related to disease progression rather than IRP values, which should be considered in decision making.
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Affiliation(s)
- Tetsuya Tatsuta
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Hiroki Sato
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.,Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, OH, USA
| | - Yusuke Fujiyoshi
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hirofumi Abe
- Department of Gastroenterology, Kobe University Hospital, Kobe, Japan
| | - Akio Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Junya Shiota
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Chiaki Sato
- Division of Advanced Surgical Science and Technology, Tohoku University School of Medicine, Sendai, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yoshitaka Hata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hisashi Fukuda
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Ryo Ogawa
- Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Yuichiro Ikebuchi
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine Tottori University Faculty of Medicine, Yonago, Japan
| | - Hiroshi Yokomichi
- Department of Health Sciences, University of Yamanashi, Yamanashi, Japan
| | - Shinsaku Fukuda
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
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35
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Safety and Efficacy of the Supine Position with the Right Shoulder Raised versus the Left Lateral Position in Peroral Endoscopic Myotomy for Achalasia: A Large-Sample Retrospective Study. Gastroenterol Res Pract 2022; 2022:3202212. [PMID: 36246456 PMCID: PMC9553715 DOI: 10.1155/2022/3202212] [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: 02/08/2022] [Revised: 03/31/2022] [Accepted: 08/24/2022] [Indexed: 11/18/2022] Open
Abstract
Background. The correct surgical position is very important in the treatment of peroral endoscopic myotomy (POEM) for achalasia, which can make the procedure safer and more efficient. Currently, there are two commonly used positions: the supine position with the right shoulder raised and the left lateral position. This study aims to evaluate the differences in the safety and efficacy of these two positions. Methods. We conducted a retrospective study of 702 patients with achalasia undergoing POEM from December 2010 to December 2020. These patients were divided into the supine position with the right shoulder raised group (
) and the left lateral position group (
). The efficacy of POEM and adverse events were analyzed. Results. The clinical characteristics were similar in both groups, and there were no significant differences between the two groups in the Eckardt score change, lower esophageal sphincter (LES) basal pressure or residual pressure after POEM (all
). The mean operative time in the supine position with the right shoulder raised group was significantly shorter than that in the left lateral position group (43.5 min vs. 54.6 min, respectively,
). In addition, the differences between the two groups in terms of gas-related complications, such as pneumoperitoneum, pneumomediastinum, and subcutaneous emphysema were statistically significant (all
). Conclusions. The efficacy of POEM was comparable between the two groups. However, the supine position with the right shoulder raised significantly reduced the operative time and the rate of procedure-related adverse events, especially gas-related complications.
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Delbaen C, Gkolfakis P, Devière J, Blero D, Louis H. Guidewire-assisted placement of water-perfused esophageal high-resolution manometry probe when gastric insertion fails: A single-center experience. Neurogastroenterol Motil 2022; 34:e14379. [PMID: 35429096 DOI: 10.1111/nmo.14379] [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] [Received: 11/01/2021] [Revised: 03/17/2022] [Accepted: 03/22/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Blind positioning of a high-resolution manometry (HRM) probe across the esophagogastric junction (EGJ) is not always possible. We report our experience using guidewire-assisted water-perfused HRM probe insertion when the EGJ could not be traversed. METHODS Retrospective study analyzing the failure rate of EGJ insertion during HRM, and reporting a series of guidewire-assisted procedures. KEY RESULTS Among 2727 HRM procedures, the failure rate for traversing the EGJ was 2.7% (73 patients). The technique of guidewire-assisted placement of the HRM probe was used in 25 patients; it was well-tolerated and successful in all patients. No motility disorder was found in 6 patients. In four patients with previously diagnosed achalasia, achalasia subtype changed to type III in one patient. While a suspected motility disorder at barium esophagram and/or initial imperfect HRM tracing was confirmed in 10 patients, a new motility disorder was diagnosed in five patients using guidewire-assisted placement of the HRM probe. CONCLUSIONS AND INFERENCES In cases of inability to traverse the EGJ, insertion of a water-perfused HRM probe using an endoscopically-placed nasogastric guidewire allows successful EGJ and esophageal peristalsis assessment. Although motility disorders are often suspected using alternative diagnostic modalities, guidewire-assisted placement of HRM may be helpful for revealing them in patients where alternative diagnostic modalities are either unavailable or inconclusive.
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Affiliation(s)
- Corinne Delbaen
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Devière
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Daniel Blero
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Hubert Louis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Abstract
Esophageal achalasia is a relatively rare disease in children that has been treated with balloon dilatation, botulinum toxin injection, and Heller myotomy. Peroral endoscopic myotomy (POEM) is another treatment that has been successfully employed to treat adults with achalasia for over a decade and has been increasingly used in children. This State of the Art Review from the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Endoscopy Committee reviews the current literature in pediatric POEM including the technique, success rate, complications as well as training guidelines. Though there is limited data, POEM in children has shown encouraging success rates and with further study may become the mainstay of pediatric achalasia treatment.
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38
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Abstract
A precise diagnosis is key to the successful treatment of achalasia. Barium swallow, upper endoscopy and high-resolution manometry provide the necessary information about a patient's anatomy, absence of other diseases, and type of achalasia (I, II, III). High-resolution manometry also has prognostic value, the best results of treatment being obtained in type II achalasia according to the Chicago classification. Abdominal CT scanning and endoscopic ultrasound might be warranted if an underlying malignancy is suspected.
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Affiliation(s)
- Federica Riccio
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, Azienda Ospedale Università di Padova, University of Padova, Padua, Italy
| | - Mario Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, Azienda Ospedale Università di Padova, University of Padova, Padua, Italy
| | - Renato Salvador
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, Azienda Ospedale Università di Padova, University of Padova, Padua, Italy.
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Misra D, Banerjee A, Das K, Das K, Dhali GK. Outcome of sequential dilatation in achalasia cardia patients: a prospective cohort study. Esophagus 2022; 19:508-515. [PMID: 35066711 DOI: 10.1007/s10388-021-00902-5] [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] [Received: 08/26/2021] [Accepted: 12/13/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Sequential increment of balloon diameter for endoscopic pneumatic dilatation is a protocol that is used for symptomatic relief in achalasia cardia. However, most of the studies evaluating its effectiveness are retrospective in nature. This study intended to look into the efficacy of the above protocol in a prospective fashion. METHODS Consecutive patients of achalasia cardia (n = 72) attending gastroenterology department were subjected to graded dilatation with 30, 35, and 40 mm pneumatic balloon and followed up (median 48 weeks; range: 4-96 weeks) with Eckardt score. Efficacy was assessed by proportion of patients achieving and maintaining clinical remission (Eckardt score ≤ 3) without requiring surgery during follow-up. RESULT Overall 91% of patients (60 out of 66 with follow-up data) remained symptom free without requirement of surgery. Proportion of type 3 achalasia patients was significantly higher in the group requiring surgery compared to those who did not (p = 0.005). Threshold of 12 mm Hg in 4-week post-dilatation integrated relaxation pressure noted to predict future requirement of surgery in type 3 achalasia patients with sensitivity and specificity of 75% and 85%, respectively. Major adverse events requiring in-patient management were 2.9% with perforation noted in 1.9%. CONCLUSION A sequential increment of balloon diameter for pneumatic dilatation in achalasia is an effective mode of therapy to achieve and maintain clinical remission in achalasia. The incidents of adverse events are low in this approach. Type 3 achalasia patients are more likely to require surgery despite sequential dilatation.
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Affiliation(s)
- Debashis Misra
- Department of Gastroenterology, Institute of Postgraduate Medical Education and Research (IPGMER), Kolkata, India.
| | - Arka Banerjee
- Department of Gastroenterology, Institute of Postgraduate Medical Education and Research (IPGMER), Kolkata, India
| | - Kausik Das
- Department of Hepatology, Institute of Postgraduate Medical Education and Research (IPGMER), Kolkata, India
| | - Kshaunish Das
- Department of Gastroenterology, Institute of Postgraduate Medical Education and Research (IPGMER), Kolkata, India
| | - Gopal Krishna Dhali
- Department of Gastroenterology, Institute of Postgraduate Medical Education and Research (IPGMER), Kolkata, India
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40
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Relationship between esophageal achalasia subtypes and esophageal clearance. Esophagus 2022; 19:500-507. [PMID: 35230586 DOI: 10.1007/s10388-022-00910-z] [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] [Received: 10/18/2021] [Accepted: 02/15/2022] [Indexed: 02/03/2023]
Abstract
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.
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41
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IAROSESKI J, GROSSI JV, MARSALA GM, CAPAVERDE LH, ROSSI LF. Obesity and achalasia: challenges in diagnosing and treating them. Chirurgia (Bucur) 2022. [DOI: 10.23736/s0394-9508.21.05301-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Cubisino A, Schlottmann F, Dreifuss NH, Baz C, Mangano A, Masrur MA, Bianco FM, Giulianotti PC. Robotic redo Heller myotomy: how I do it? Langenbecks Arch Surg 2022; 407:1721-1726. [PMID: 35583834 DOI: 10.1007/s00423-022-02553-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/10/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite the high success rate associated with Heller myotomy in the treatment of primary achalasia, symptom persistence or relapse occurs in approximately 10-20% of patients. Unfortunately, the ideal treatment after failed myotomy is not well established yet. We present a didactical video with a stepwise technique to perform a robotic revisional procedure after failed Heller myotomy. METHODS In this report, each surgical step is thoroughly described and visually represented with useful technical tips that might help in improving surgical results of revisional Heller myotomy. RESULTS In patients with previous surgical myotomy, the robotic platform with its high-definition magnified view and EndoWrist instruments allow for a safe and precise redo surgical myotomy. CONCLUSIONS Despite its improved surgical capabilities, the role of robotic redo Heller myotomy in the treatment algorithm of patients with recurrent symptoms after failed surgical myotomy should be further explored.
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Affiliation(s)
- Antonio Cubisino
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA.
| | - Francisco Schlottmann
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Nicolas H Dreifuss
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Carolina Baz
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Alberto Mangano
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Mario A Masrur
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Francesco M Bianco
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
| | - Pier Cristoforo Giulianotti
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Clinical Sciences Building, Chicago, IL, 60612, USA
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Savarino E, Bhatia S, Roman S, Sifrim D, Tack J, Thompson SK, Gyawali CP. Achalasia. Nat Rev Dis Primers 2022; 8:28. [PMID: 35513420 DOI: 10.1038/s41572-022-00356-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2022] [Indexed: 02/07/2023]
Abstract
Achalasia is a rare disorder of the oesophageal smooth muscle characterized by impaired relaxation of the lower oesophageal sphincter (LES) and absent or spastic contractions in the oesophageal body. The key pathophysiological mechanism is loss of inhibitory nerve function that probably results from an autoimmune attack targeting oesophageal myenteric nerves through cell-mediated and, possibly, antibody-mediated mechanisms. Achalasia incidence and prevalence increase with age, but the disorder can affect all ages and both sexes. Cardinal symptoms consist of dysphagia, regurgitation, chest pain and weight loss. Several years can pass between symptom onset and an achalasia diagnosis. Evaluation starts with endoscopy to rule out structural causes, followed by high-resolution manometry and/or barium radiography. Functional lumen imaging probe can provide complementary evidence. Achalasia subtypes have management and prognostic implications. Although symptom questionnaires are not useful for diagnosis, the Eckardt score is a simple symptom scoring scale that helps to quantify symptom response to therapy. Oral pharmacotherapy is not particularly effective. Botulinum toxin injection into the LES can temporize symptoms and function as a bridge to definitive therapy. Pneumatic dilation, per-oral endoscopic myotomy and laparoscopic Heller myotomy can provide durable symptom benefit. End-stage achalasia with a dilated, non-functioning oesophagus may require oesophagectomy or enteral feeding into the stomach. Long-term complications can, rarely, include oesophageal cancer, but surveillance recommendations have not been established.
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Affiliation(s)
- Edoardo Savarino
- Gastroenterology Unit, Azienda Ospedale Università di Padova (AOUP), Padua, Italy. .,Department of Surgery, Oncology and Gastroenterology (DiSCOG), University of Padua, Padua, Italy.
| | - Shobna Bhatia
- Department of Gastroenterology, Sir HN Reliance Foundation Hospital, Mumbai, India
| | - Sabine Roman
- Hospices Civils de Lyon, Digestive Physiology, Hopital E Herriot, Lyon, France.,Université Lyon 1, Villeurbanne, France.,Inserm U1032, LabTAU, Lyon, France
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Queen Mary University of London, London, UK
| | - Jan Tack
- Division of Gastroenterology, University Hospital of Leuven, Leuven, Belgium
| | - Sarah K Thompson
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
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44
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Patel DA, Yadlapati R, Vaezi MF. Esophageal Motility Disorders: Current Approach to Diagnostics and Therapeutics. Gastroenterology 2022; 162:1617-1634. [PMID: 35227779 PMCID: PMC9405585 DOI: 10.1053/j.gastro.2021.12.289] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 12/03/2021] [Accepted: 12/12/2021] [Indexed: 12/13/2022]
Abstract
Dysphagia is a common symptom with significant impact on quality of life. Our diagnostic armamentarium was primarily limited to endoscopy and barium esophagram until the advent of manometric techniques in the 1970s, which provided the first reliable tool for assessment of esophageal motor function. Since that time, significant advances have been made over the last 3 decades in our understanding of various esophageal motility disorders due to improvement in diagnostics with high-resolution esophageal manometry. High-resolution esophageal manometry has improved the sensitivity for detecting achalasia and has also enhanced our understanding of spastic and hypomotility disorders of the esophageal body. In this review, we discuss the current approach to diagnosis and therapeutics of various esophageal motility disorders.
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Affiliation(s)
- Dhyanesh A. Patel
- Division of Gastroenterology, Hepatology and Nutrition, University of California San Diego
| | - Rena Yadlapati
- Vanderbilt University Medical Center and Division of Gastroenterology, University of California San Diego
| | - Michael F. Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, University of California San Diego
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45
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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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46
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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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47
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Kandulski A, Zimmermann D, Weidlich S, Schulz C. [Beningn disesases of the esophagus]. MMW Fortschr Med 2022; 164:20-28. [PMID: 35359289 DOI: 10.1007/s15006-022-0829-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Arne Kandulski
- Klinik und Poliklinik für Innere Medizin I, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
| | | | - Simon Weidlich
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany
| | - Christian Schulz
- Medizinische Klinik und -Poliklinik II, Medizinische Klinik und -Poliklinik II, Marchioninistr. 15, 81377, München, Germany
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48
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Esophageal Achalasia: Pros and Cons of the Treatment Options. World J Surg 2022; 46:1554-1560. [PMID: 35238987 PMCID: PMC9174302 DOI: 10.1007/s00268-022-06495-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2022] [Indexed: 11/05/2022]
Abstract
Achalasia is a primary esophageal motility disorder of unknown origin. The goal of treatment is to reduce the resistance caused by a lower esophageal sphincter that fails to relax and is frequently hypertensive. Many treatment options are available to achieve this goal. In this review, we discuss the pros and cons of each therapeutic approach.
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49
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Sanagapalli S, Plumb A, Sweis R. Timed barium swallow: Esophageal stasis varies markedly across subtypes of esophagogastric junction obstruction. Neurogastroenterol Motil 2022; 34:e14322. [PMID: 35072303 DOI: 10.1111/nmo.14322] [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] [Received: 10/12/2021] [Revised: 11/26/2021] [Accepted: 01/03/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Timed barium swallow (TBS) is a recommended ancillary investigation in evaluation of esophagogastric junction (EGJ) obstruction, yet there are little data comparing esophageal stasis across subtypes. METHODS A retrospective cohort study was performed. All type III achalasia diagnosed between November 2016 and November 2020 were included, along with matched numbers of consecutive types I and II and conclusive EGJOO cases with concurrent TBS evaluation. Co-primary outcomes were TBS retention at 1 and 5 min. Secondary outcomes were symptoms and manometric metrics of EGJ function and peristaltic integrity. KEY RESULTS One hundred patients were included (25 each of types I-III and conclusive EGJOO). TBS retention measured by height and width at 1 and 5 min differed significantly across the four subtypes (p < 0.0001 all comparisons), with esophageal stasis tending to be significantly greater for types I and II achalasia (88% and 84% with >5 cm column at 5 min) compared to type III and EGJOO (24% and 8% with >5 cm column; p < 0.0001). Eckardt symptom severity was similar across subtypes (p = 0.30). Magnitude of esophageal stasis and integrated relaxation pressure (IRP) were uncorrelated (R = 0.21). In EGJOO, the number of swallows with intact peristalsis inversely correlated with barium column height (R = -0.49) and those with disordered peristalsis were more likely to have any residual barium at 5 min compared to those without disordered peristalsis (43% vs. 0%; p = 0.02). CONCLUSIONS & INFERENCES Timed barium swallow findings differed markedly with significantly less esophageal stasis in type III achalasia and EGJOO, despite similar symptom severity and no correlation between degree of emptying and IRP. Preservation of peristalsis may underlie this finding in EGJOO.
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Affiliation(s)
- Santosh Sanagapalli
- Centre for Swallowing & Oesophageal Disorders, St. Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia.,St Vincent's Clinical School, UNSW Sydney, Sydney, New South Wales, Australia
| | - Andrew Plumb
- GI Physiology Unit, University College London Hospital, London, UK
| | - Rami Sweis
- GI Physiology Unit, University College London Hospital, London, UK
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50
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Tsuboi K, Yano F, Omura N, Hoshino M, Yamamoto SR, Akimoto S, Masuda T, Sakashita Y, Fukushima N, Kashiwagi H. Risk factors for the occurrence of peptic esophagitis following laparoscopic Heller-Dor surgery for esophageal achalasia. Dis Esophagus 2022; 35:6325812. [PMID: 34296268 DOI: 10.1093/dote/doab050] [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] [Received: 03/13/2021] [Revised: 05/17/2021] [Accepted: 07/04/2021] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Kazuto Tsuboi
- Department of Surgery, Fuji City General Hospital, Shizuoka, Japan.,Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Fumiaki Yano
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Nobuo Omura
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.,Department of Surgery, Nishisaitama-Chuo National Hospital, Saitama, Japan
| | - Masato Hoshino
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Se-Ryung Yamamoto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shunsuke Akimoto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takahiro Masuda
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuki Sakashita
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Naoko Fukushima
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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