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Peng D, Tan Y, Chen X, Lv L, Zhu H, Li R, Liu D. Prognostic factors analysis of symptoms recurrence after peroral endoscopic myotomy for the treatment of achalasia in older adults. J Gastrointest Surg 2024:S1091-255X(24)00465-7. [PMID: 38796138 DOI: 10.1016/j.gassur.2024.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/19/2024] [Accepted: 05/21/2024] [Indexed: 05/28/2024]
Affiliation(s)
- Dongzi Peng
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China; Research Center of Digestive Disease, Central South University, Changsha, China; Clinical Research Center for Disease in Hunan Province, Changsha, China
| | - Yuyong Tan
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China; Research Center of Digestive Disease, Central South University, Changsha, China; Clinical Research Center for Disease in Hunan Province, Changsha, China
| | - Xingcen Chen
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China; Research Center of Digestive Disease, Central South University, Changsha, China; Clinical Research Center for Disease in Hunan Province, Changsha, China
| | - Liang Lv
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China; Research Center of Digestive Disease, Central South University, Changsha, China; Clinical Research Center for Disease in Hunan Province, Changsha, China
| | - Hongyi Zhu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China; Research Center of Digestive Disease, Central South University, Changsha, China; Clinical Research Center for Disease in Hunan Province, Changsha, China
| | - Rong Li
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China; Research Center of Digestive Disease, Central South University, Changsha, China; Clinical Research Center for Disease in Hunan Province, Changsha, China
| | - Deliang Liu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, China; Research Center of Digestive Disease, Central South University, Changsha, China; Clinical Research Center for Disease in Hunan Province, Changsha, China.
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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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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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Takahashi K, Sato H, Shimamura Y, Abe H, Shiwaku H, Shiota J, Sato C, Hamada K, Ominami M, Hata Y, Fukuda H, Ogawa R, Nakamura J, Tatsuta T, Ikebuchi Y, Yokomichi H, Terai S, Inoue H. Achalasia phenotypes and prediction of peroral endoscopic myotomy outcomes using machine learning. Dig Endosc 2023. [PMID: 37886891 DOI: 10.1111/den.14714] [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: 06/03/2023] [Accepted: 10/26/2023] [Indexed: 10/28/2023]
Abstract
OBJECTIVES High-resolution manometry (HRM) and esophagography are used for achalasia diagnosis; however, achalasia phenotypes combining esophageal motility and morphology are unknown. Moreover, predicting treatment outcomes of peroral endoscopic myotomy (POEM) in treatment-naïve patients remains an unmet need. METHODS In this multicenter cohort study, we included 1824 treatment-naïve patients diagnosed with achalasia. In total, 1778 patients underwent POEM. Clustering by machine learning was conducted to identify achalasia phenotypes using patients' demographic data, including age, sex, disease duration, body mass index, and HRM/esophagography findings. Machine learning models were developed to predict persistent symptoms (Eckardt score ≥3) and reflux esophagitis (RE) (Los Angeles grades A-D) after POEM. RESULTS Machine learning identified three achalasia phenotypes: phenotype 1, type I achalasia with a dilated esophagus (n = 676; 37.0%); phenotype 2, type II achalasia with a dilated esophagus (n = 203; 11.1%); and phenotype 3, late-onset type I-III achalasia with a nondilated esophagus (n = 619, 33.9%). Types I and II achalasia in phenotypes 1 and 2 exhibited different clinical characteristics from those in phenotype 3, implying different pathophysiologies within the same HRM diagnosis. A predictive model for persistent symptoms exhibited an area under the curve of 0.70. Pre-POEM Eckardt score ≥6 was the greatest contributing factor for persistent symptoms. The area under the curve for post-POEM RE was 0.61. CONCLUSION Achalasia phenotypes combining esophageal motility and morphology indicated multiple disease pathophysiologies. Machine learning helped develop an optimal risk stratification model for persistent symptoms with novel insights into treatment resistance factors.
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Affiliation(s)
- Kazuya Takahashi
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Hiroki Sato
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hirofumi Abe
- Department of Gastroenterology, Kobe University Hospital, Kobe, Japan
| | - Hironari 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, Miyagi, Japan
| | - Kenta Hamada
- Department of Practical Gastrointestinal Endoscopy, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka Metropolitan 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, Tochigi, 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, Tottori, Japan
| | - Hiroshi Yokomichi
- Department of Health Sciences, University of Yamanashi, Yamanashi, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
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Khan SZ, Benson J, Boutros C, Lyons J, Hashimoto DA, Marks JM. Do preoperative endoscopic interventions predict symptom recurrence or reintervention after peroral endoscopic myotomy? Surg Endosc 2023; 37:7153-7158. [PMID: 37328594 DOI: 10.1007/s00464-023-10196-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/02/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Studies assessing outcomes of patients undergoing peroral endoscopic myotomy (POEM) after botulinum injection or dilation have had various results with respect to failure, although this has not been differentiated between lack of clinical response and recurrence. We hypothesize that patients with previous endoscopic intervention(s) are more likely to recur than treatment-naïve patients. METHODS This is a retrospective cohort study of patients that underwent POEM for achalasia at a single tertiary care center between 2011 and 2022. Patients were excluded if they had previous myotomy (POEM or Heller). The remaining patients were stratified into treatment-naïve patients (TN), those with previous botulinum injection (BTX), those with previous dilatation (BD), and those with both previous endoscopic interventions (BOTH). Primary outcome was recurrence indicated by clinical symptoms or need for repeat endoscopic intervention or surgery after originally having clinical resolution (Eckardt ≤ 3). Multivariate logistic regression using preoperative and intraoperative factors was completed to assess odds of recurrence. RESULTS A total of 164 patients were included in the analysis, 90 TN, 34 BD, 28 BTX, and 12 BOTH. There were no other significant differences in demographics or in preoperative Eckardt score (p = 0.53). There was no difference in the proportion of patients that had postoperative manometry (p = 0.74), symptom recurrence (p = 0.59), surgical intervention (p = 0.16). BTX (14.3%) and BOTH (16.7%) patients had a higher rate of repeat endoscopic intervention than BD and TN patients (5.9% and 1.1%). In the logistic regression analysis, there was no association among the BTX, BD, or BOTH groups compared to the TN group. No odds ratios achieved statistical significance. CONCLUSIONS There were no increased likelihood of recurrence with botulinum injection or dilatation prior to POEM, implying that they are similarly good candidates compared to treatment-naïve patients.
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Affiliation(s)
- Saher-Zahra Khan
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Jamie Benson
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Christina Boutros
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Joshua Lyons
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Daniel A Hashimoto
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA
| | - Jeffrey M Marks
- Department of Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 7, Cleveland, OH, 44106, USA.
- Case Western Reserve University, Cleveland, OH, USA.
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Quénéhervé L, Vauquelin B, Berger A, Coron E, Olivier R. Risk factors for clinical failure of peroral endoscopic myotomy in achalasia. Front Med (Lausanne) 2022; 9:1099533. [PMID: 36569161 PMCID: PMC9773253 DOI: 10.3389/fmed.2022.1099533] [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: 11/15/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022] Open
Abstract
The recent development of per oral endoscopic myotomy (POEM) has been a game changer in the management of patients with achalasia. However, approximately 1 in 10 patients will not experience clinical success. The aim of this mini-review is to describe the current state of knowledge about the risk factors associated with POEM failure for the treatment of achalasia. Suspected risk factors are detailed into pre-, intra-, and post-procedural factors and put into perspective. Pre-procedural factors have been described, such as pre-treatment Eckardt score, previous treatments for achalasia, sigmoid type esophagus, significant esophageal dilatation, non-type II achalasia, young age and long duration of symptoms. An intra-procedural factor, mucosal injury during POEM, has also been associated with POEM failure. The occurrence of post-POEM GERD was identified as a controversial post-procedural factor associated with failure. The presumed mechanisms of POEM failure are incomplete myotomy or ineffective LES disruption, as confirmed by high-resolution manometry. However, when manometry confirms a significant decrease in LES pressure, it is likely that either impaired peristalsis or a morphologic abnormality such as extreme esophageal dilatation or severe tortuosity, which are not treated by POEM, should be suspected. Notably, a recently described adverse effect of POEM is the formation of a pseudo-diverticulum at the site of the myotomy (blown out myotomy). We finally stress the importance of performing a complete workup in case of POEM failure as different mechanisms of POEM failure should lead to different management.
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Affiliation(s)
- Lucille Quénéhervé
- Gastroenterology Department, University Hospital of Brest, Brest, France,*Correspondence: Lucille Quénéhervé,
| | - Blandine Vauquelin
- Gastroenterology Department, Centre Medico-Chirurgical Magellan, INSERM CIC 1401, CHU de Bordeaux, Hôpital Haut-Lévêque, Université de Bordeaux, Bordeaux, France
| | - Arthur Berger
- Gastroenterology Department, Centre Medico-Chirurgical Magellan, INSERM CIC 1401, CHU de Bordeaux, Hôpital Haut-Lévêque, Université de Bordeaux, Bordeaux, France
| | - Emmanuel Coron
- Service de Gastro-Entérologie et Hépatologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Raphael Olivier
- Gastroenterology Department, University Hospital of Poitiers, Poitiers, France
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