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Kimoto Y, Inoue H, Shimamura Y, Azuma D, Ushikubo K, Yamamoto K, Okada H, Nishikawa Y, Tanaka I, Jandee S, Navarro MJ, Onimaru M. Hood-attached versus conventional triangular tip-jet knife in peroral endoscopic myotomy: a propensity score matching cohort study. Gastrointest Endosc 2024; 99:688-693. [PMID: 38065514 DOI: 10.1016/j.gie.2023.12.001] [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] [Received: 09/02/2023] [Revised: 11/30/2023] [Accepted: 12/03/2023] [Indexed: 04/24/2024]
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) is a safe and effective endoscopic treatment for achalasia and other esophageal motility disorders, and a versatile knife (TriangleTipKnife J [TTJ]; Olympus, Tokyo, Japan) is currently widely used in POEM. Recently, we reported a novel modification of TTJ, which was adjusted to a knife length of 2 mm by attaching a disposable clip (QuickClip Pro; Olympus) sheath to the tip as a hood attachment. This study compares the safety and effectiveness of TTJ and TTJ with a hood attachment (TTJ-H) in POEM. METHODS This 1:1 propensity score-matched retrospective cohort study compared the procedure time, myotomy efficiency, number of coagulation forceps usage, adverse events, length of hospital stay after POEM, procedural success, and clinical success between the TTJ and TTJ-H groups. RESULTS A total of 682 consecutive patients who underwent POEM between January 2021 and June 2023 were examined. We excluded 134 patients who had already undergone POEM or laparoscopic Heller myotomy as prior myotomy. Finally, 98 propensity score-matched pairs (n = 196) were identified. The mean procedure time was shortened from 93.5 minutes to 80.2 minutes (14% reduction, P = .012) when comparing the TTJ-H group versus the TTJ group. The mean myotomy efficiency was improved from 2.76 min/cm to 2.32 min/cm (16% improvement, P ≤ .001), and usage of coagulation forceps for hemostasis was decreased from 3.87 to .55 (86% reduction, P ≤ .001). CONCLUSIONS This study showed that use of TTJ-H could reduce total procedure time, improve myotomy efficiency, and reduce costs compared with TTJ.
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Affiliation(s)
- Yoshiaki Kimoto
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan.
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Daisuke Azuma
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Kei Ushikubo
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Kazuki Yamamoto
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Hiroki Okada
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yohei Nishikawa
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Ippei Tanaka
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Sawangpong Jandee
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan; Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hatyai, Thailand
| | - Marc Julius Navarro
- Institute of Digestive and Liver Diseases, St. Luke's Medical Center, Quezon City, Philippines
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
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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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Dervin H, Endersby J, Sanagapalli S, Mills H, Sweis R. Assessing the diagnostic yield of achalasia using provocative testing in high-resolution esophageal manometry: Serial diagnostic study. Neurogastroenterol Motil 2023; 35:e14668. [PMID: 37846024 DOI: 10.1111/nmo.14668] [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: 03/17/2023] [Revised: 07/27/2023] [Accepted: 08/19/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Chicago Classification v4.0 recommends that if achalasia is demonstrated with single water swallows (SWS); provocative testing is not required. We determine whether provocative testing in patients with suspected achalasia can change manometric findings and reproduce symptoms. METHODS Between 2016 and 2022, 127 consecutive manometry studies of patients with achalasia were retrospectively analyzed. All patients underwent SWS, a solid meal (SM) and/or a rapid drink challenge (RDC). Demographic data, fluoroscopy, gastroscopy, and pre-and post-treatment Eckardt scores were collated. KEY RESULTS Of 127 achalasia patients (50.6 ± 16.6 years and 54.6% male), all completed a SM and 116 (91.3%) completed RDC; overall 83 were naïve (65.4%) to previous therapy. 15.4% patients with normal integrated relaxation pressure (IRP) on SWS demonstrated obstruction with RDC. SM gave a different achalasia phenotype in 44.9% of patients (p ⟨ 0.001). Twelve patients with normal IRP during SWS had persistent/recurrent obstruction during provocative testing; 83.3% had previous achalasia therapy. None of 13 patients with Type III (TIII) achalasia with SWS exhibited a change in manometric findings with provocative testing. Impedance bolus heights were lower in patients with TIII achalasia and those with normal IRP with SWS. During the SM, symptoms were reproduced in 56.7% of patients. Forty-six of 103 patients (44.7%) underwent therapy based upon the final achalasia subtype which was defined by the provocative test result of the high-resolution manometry (HRM) study. All treatments were effective, regardless of the achalasia subtype. CONCLUSIONS AND INFERENCES Manometric findings remain unchanged when TIII achalasia is diagnosed with SWS. In patients with normal IRP, Type I, or Type II achalasia during SWS, provocative testing can alter achalasia phenotype or uncover achalasia where diagnosis is unclear. Further, it can reproduce symptoms. Such findings can personalize and guide effective therapeutic decisions.
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Affiliation(s)
- Humayra Dervin
- GI Physiology Unit, University College London, London, UK
| | - James Endersby
- GI Physiology Unit, University College London, London, UK
| | - Santosh Sanagapalli
- GI Physiology Unit, University College London, London, UK
- St Vincent's Hospital, Sydney, Victoria, Australia
| | - Holly Mills
- GI Physiology Unit, University College London, London, UK
| | - Rami Sweis
- GI Physiology Unit, University College London, London, UK
- University College London, London, UK
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Jankovic J, Milenkovic B, Skrobic O, Ivanovic N, Djurdjevic N, Buha I, Jandric A, Colic N, Milin-Lazovic J. Achalasia Subtype Differences Based on Respiratory Symptoms and Radiographic Findings. Diagnostics (Basel) 2023; 13:2198. [PMID: 37443591 DOI: 10.3390/diagnostics13132198] [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: 04/28/2023] [Revised: 06/07/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
Three subtypes of achalasia have been defined using esophageal manometry. Several studies have reported that symptoms are experienced differently among men and women, regardless of subtype. All subtypes could have some impact on the appearance of respiratory symptoms and lung complications due to compression of the trachea or aspiration of undigested food. The aim of this research was to analyze the differences in respiratory symptoms and radiographic presentation of lung pathology depending on the diameter and achalasia types. One or more respiratory symptoms were reported in 48% of 114 patients, and all of them had two or more gastrointestinal symptoms. The symptom score (SS) is statistically significant for the prediction of subtype 1 (area under the curve = 0.318; p < 0.001, cut-off score of 6.5 had 95.2% sensitivity) and subtype 2 (area under the curve = 0.626; p = 0.020, cut-off score of 7.5 had 93.1% sensitivity). The most common type was subtype 2 (50.8%), and although only 14 patients had subtype 3, they had the largest esophageal diameter (mean 5.8 cm). The difference in esophageal diameter was significant between subtype 1 and 3 (p = 0.011), subtype 2 and subtype 3 (p = 0.011). Nine patients (6%) had mega-esophagus (four patients in type 1, three in type 2 and two in type 3). More than half of all patients (51.7%) had at least one parenchymal lung change on CT scan. Recurrent micro-aspirations led to changes in the structure of the airways and lung parenchyma such as ground glass (GGO) and nodular changes (12%) and fibrosis (14.5%), and they had higher esophageal diameters (p < 0.001). Patients with chronic lung CT changes had significantly higher esophageal diameter than with acute changes (p < 0.001). Awareness of the association of achalasia and lung disorders is important in early diagnosis and treatment. More than half (57.5%) of patients with achalasia had some clinical and/or structural pulmonary abnormalities. All three subtypes had similar respiratory symptoms, meaning they cannot be used to predict the subtype of achalasia; on the contrary, SS can predict the first two subtypes. A higher diameter of the esophagus is associated with chronic structural lung changes. Although unexpected, the pathological radiological findings and diameter were significantly different in subtype 3 patients, but those parameters cannot lead us to a specified subtype.
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Affiliation(s)
- Jelena Jankovic
- Clinic for Pulmonology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
| | - Branislava Milenkovic
- Clinic for Pulmonology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
| | - Ognjan Skrobic
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
- Clinic for Digestive Surgery, First Surgical University Hospital, Clinical Centre of Serbia, 11000 Belgrade, Serbia
| | - Nenad Ivanovic
- Clinic for Digestive Surgery, First Surgical University Hospital, Clinical Centre of Serbia, 11000 Belgrade, Serbia
| | - Natasa Djurdjevic
- Clinic for Pulmonology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Ivana Buha
- Clinic for Pulmonology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
| | - Aleksandar Jandric
- Clinic for Pulmonology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Nikola Colic
- Center for Radiology and MR, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Jelena Milin-Lazovic
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
- Institute for Medical Statistics and Informatics, University of Belgrade, 11000 Belgrade, Serbia
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Winston JM, Mann FAT, Dean L. Management and outcomes of 13 dogs treated with a modified Heller myotomy and Dor fundoplication for lower esophageal sphincter achalasia-like syndrome. Vet Surg 2023; 52:315-329. [PMID: 36458673 DOI: 10.1111/vsu.13912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 09/30/2022] [Accepted: 10/17/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To report the management and outcomes of dogs treated for lower esophageal sphincter achalasia-like syndrome (LES-AS) with modified Heller myotomy, Dor fundoplication, and with the use of a temporary gastrostomy tube. STUDY DESIGN Retrospective. SAMPLE POPULATION Thirteen client-owned dogs. METHODS Medical records and a client survey were used to assess frequency of vomiting/regurgitation, quality of life (QoL), bodyweight, and feeding modifications at the following time points: prior to referral, postoperatively from discharge to first recheck (4-6 weeks), and from first recheck to survey (48 months). Postoperative and gastrostomy tube complications were surveyed and recorded. Pretreatment and 4-6 weeks postoperative videofluoroscopic swallow studies (VFSS) were compared. Two-sided t-tests were used to compare outcomes between survey time points. RESULTS Postoperative VFSS scores (available in 9 dogs) improved over preoperative scores in 6 dogs, and 12/13 dogs survived to discharge. One dog was euthanized 3 days postoperatively due to aspiration pneumonia. Postoperative gastrostomy tube complications occurred in half of the dogs that survived to discharge. According to the owners, scores assigned to vomiting/regurgitation improved by 180% (P = .004), QoL by 100% (P = .004), and bodyweight by 63% (P = .035). CONCLUSION Modified Heller myotomy with Dor fundoplication and the use of a temporary gastrostomy tube improved clinical signs and owners' perceived quality of life in half of the dogs treated for LES-AS in our clinical setting. Oral sildenafil therapy discontinued postoperatively suggests that surgery was equally efficacious. CLINICAL SIGNIFICANCE Modified Heller myotomy with Dor fundoplication and temporary gastrostomy tube is a treatment option with potentially sustained benefits for dogs that have LES-AS.
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Affiliation(s)
- John M Winston
- University of Missouri Veterinary Health Center, Columbia, Missouri, USA
| | - F A Tony Mann
- University of Missouri Veterinary Health Center, Columbia, Missouri, USA
| | - Lauren Dean
- University of Missouri Veterinary Health Center, Columbia, Missouri, USA
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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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Salvador R, Costantini M, Tolone S, Familiari P, Galliani E, Germanà B, Savarino E, Merigliano S, Valmasoni M. Manometric pattern progression in esophageal achalasia in the era of high-resolution manometry. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:906. [PMID: 34164540 PMCID: PMC8184468 DOI: 10.21037/atm.2020.03.149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Esophageal manometry represents the gold standard technique for the diagnosis of esophageal achalasia because it can detect both the lack of lower esophageal sphincter (LES) relaxation and abnormal peristalsis. From the manometric standpoint, cases of achalasia can be segregated on the grounds of three clinically relevant patterns according to the Chicago Classification v3.0. It is currently unclear whether they represent distinct entities or are part of a disease continuum with the possibility of transition from a pattern to another one. The four cases described in the present report could provide further insights on this topic because the manometric pattern changed from type III to type II in all patients—without any invasive treatment. The cases described here support the hypothesis that the different manometric patterns of achalasia represent different stages in the evolution of the same disease, type III being the early stage, type II an intermediate stage, and type I probably the end stage of achalasia.
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Affiliation(s)
- Renato Salvador
- Department of Surgery, Oncology and Gastroenterology, School of Medicine, University of Padova, Padova, Italy
| | - Mario Costantini
- Department of Surgery, Oncology and Gastroenterology, School of Medicine, University of Padova, Padova, Italy
| | - Salvatore Tolone
- Division of General, Mininvasive and Bariatric Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Pietro Familiari
- Digestive Endoscopy Unit, Catholic University of Sacred Heart, Rome, Italy
| | | | | | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, School of Medicine, University of Padova, Padova, Italy
| | - Stefano Merigliano
- Department of Surgery, Oncology and Gastroenterology, School of Medicine, University of Padova, Padova, Italy
| | - Michele Valmasoni
- Department of Surgery, Oncology and Gastroenterology, School of Medicine, University of Padova, Padova, Italy
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Pesce M, Sweis R. Advances and caveats in modern achalasia management. Ther Adv Chronic Dis 2021; 12:2040622321993437. [PMID: 33786159 PMCID: PMC7958157 DOI: 10.1177/2040622321993437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 01/15/2021] [Indexed: 12/18/2022] Open
Abstract
Achalasia is a rare esophageal motility disorder characterized by the incomplete
relaxation of the lower esophageal sphincter (LES) and impaired peristaltic
activity. The advent of high-resolution manometry (HRM) and the rapidly evolving
role of therapeutic endoscopy have revolutionized the approach to the diagnosis
and management of achalasia patients in the last decade. With advances in HRM
technology and methodology, fluoroscopy and EndoFlip, achalasia can be
differentiated into therapeutically meaningful phenotypes with a high degree of
accuracy. Further, the newest treatment option, per-oral endoscopic myotomy
(POEM), has become a staple therapy following the last 10 years of experience,
and recent randomized trials appear to show no difference between POEM, graded
pneumatic dilatation and surgical Heller myotomy in terms of short- and
long-term efficacy or complication rate. On the other hand, how treatment
outcomes are measured as well as the risk of reflux following therapy remain
areas of contention. This review aims to summarize the recent advancements in
achalasia testing and therapy, describes the recent randomized clinical trials
as well as their potential setbacks, and touches on the future of personalizing
achalasia treatment.
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Affiliation(s)
- Marcella Pesce
- Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Naples, Italy
| | - Rami Sweis
- University College London Hospital, GI Services, 235 Euston Rd, London, NW1 2BU, UK
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Scoping Review and Bibliometric Analysis of the Most Influential Publications in Achalasia Research from 1995 to 2020. BIOMED RESEARCH INTERNATIONAL 2021; 2021:8836395. [PMID: 33628819 PMCID: PMC7884120 DOI: 10.1155/2021/8836395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 01/08/2021] [Accepted: 01/15/2021] [Indexed: 02/05/2023]
Abstract
Objective To identify and evaluate characteristics of the most influential articles in achalasia research during the period 1995-2020. Methods Articles in Scopus, Web of Science Core Collection (WoSCC), and PubMed were scanned from 1995 to 2020 with achalasia as the keyword. We retrieved the articles that met all criteria by descending order after using EndNote to remove the duplicated references. Our bibliometric analysis highlighted publication year, country, journals, and networks of keywords. Results Fifteen percent of the top 100 most-cited articles were published in Annals of Surgery. They were performed in 15 countries, and most (n = 55) were from the USA. The number of citations of the 482 articles ranged from 30 to 953, 38 of which had been published in American Journal of Gastroenterology. Those articles were from 31 countries, and most of the studies (n = 217) had been performed in the USA. Most of articles (n = 335) were clinical research. Treatments were hotspots in the field of achalasia in the past years. The most influential title words were “achalasia,” “esophagomyotomy,” “pneumatic dilation,” and “lower esophageal sphincter.” Conclusion Our study offers a historical perspective on the progress of achalasia research and identified the most significant evolution in this field. Results showed treatment was the most influence aspect in achalasia.
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Trudgill NJ, Sifrim D, Sweis R, Fullard M, Basu K, McCord M, Booth M, Hayman J, Boeckxstaens G, Johnston BT, Ager N, De Caestecker J. British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring. Gut 2019; 68:1731-1750. [PMID: 31366456 PMCID: PMC6839728 DOI: 10.1136/gutjnl-2018-318115] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 06/13/2019] [Accepted: 06/16/2019] [Indexed: 12/11/2022]
Abstract
These guidelines on oesophageal manometry and gastro-oesophageal reflux monitoring supersede those produced in 2006. Since 2006 there have been significant technological advances, in particular, the development of high resolution manometry (HRM) and oesophageal impedance monitoring. The guidelines were developed by a guideline development group of patients and representatives of all the relevant professional groups using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. A systematic literature search was performed and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) tool was used to evaluate the quality of evidence and decide on the strength of the recommendations made. Key strong recommendations are made regarding the benefit of: (i) HRM over standard manometry in the investigation of dysphagia and, in particular, in characterising achalasia, (ii) adjunctive testing with larger volumes of water or solids during HRM, (iii) oesophageal manometry prior to antireflux surgery, (iv) pH/impedance monitoring in patients with reflux symptoms not responding to high dose proton pump inhibitors and (v) pH monitoring in all patients with reflux symptoms responsive to proton pump inhibitors in whom surgery is planned, but combined pH/impedance monitoring in those not responsive to proton pump inhibitors in whom surgery is planned. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG.
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Affiliation(s)
- Nigel J Trudgill
- Sandwell and West Birmingham Hospitals NHS Trust, West Bomwich, UK
| | - Daniel Sifrim
- Centre of Gastroenterology Research, Queen Mary University London, London, UK
| | - Rami Sweis
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Mark Fullard
- West Hertfordshire Hospitals NHS Trust, Watford, Hertfordshire, UK
| | - Kumar Basu
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | - John Hayman
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Guy Boeckxstaens
- Gastroenterology, University Hospital, KU Leuven, Leuven, Belgium
| | - Brian T Johnston
- Department of Gastroenterology, Belfast Health and Social Care Trust, Belfast, UK
| | - Nicola Ager
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
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Grobman ME, Schachtel J, Gyawali CP, Lever TE, Reinero CR. Videofluoroscopic swallow study features of lower esophageal sphincter achalasia-like syndrome in dogs. J Vet Intern Med 2019; 33:1954-1963. [PMID: 31381208 PMCID: PMC6766503 DOI: 10.1111/jvim.15578] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 07/11/2019] [Indexed: 12/20/2022] Open
Abstract
Background Megaesophagus (ME) carries a poor long‐term prognosis in dogs. In people, lower esophageal sphincter (LES) disorders causing functional obstruction are rare causes of ME that may respond to targeted treatment. Functional LES disorders are reported rarely in dogs because of challenges in diagnostic methodologies. Hypothesis/Objectives To identify dogs with videofluoroscopic swallow study (VFSS) features of LES achalasia‐like syndrome (LES‐AS). We hypothesized that dogs with LES‐AS could be distinguished from normal dogs using standardized VFSS criteria. Animals Dogs with LES‐AS by VFSS (n = 19), healthy normal dogs (n = 20). Methods Retrospective study. One‐hundred thirty dogs presented to the University of Missouri Veterinary Health Center (MU‐VHC) between April 2015 and December 2017 for a free‐feeding VFSS; 20 healthy dogs were included as controls. Swallow studies were evaluated for failure of the LES to relax during pharyngeal swallow (LES‐AS). Affected dogs subsequently were evaluated using standardized criteria to identify metrics important for identifying and characterizing dogs with LES‐AS. Results Nineteen dogs with LES‐AS were identified out of 130 VFSS. Megaesophagus was present in 14 of 19 (73.7%) dogs with LES‐AS. A baseline esophageal fluid‐line and “bird beak” were present in 68.4% (95% confidence interval [CI], 47.5%‐89.3%) and 63.2% (95% CI, 41.5%‐84.8%) of affected dogs, respectively. The esophagus was graded as acontractile (8/19), hypomotile (8/19), or hypermotile (3/19). Conclusions and Clinical Importance Dogs with LES‐AS may successfully be identified by VFSS using a free‐feeding protocol. These data are of critical clinical importance because a subpopulation of dogs with functional LES obstruction may be candidates for targeted intervention.
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Affiliation(s)
- Megan E Grobman
- Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, Columbia, Missouri
| | | | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - Teresa E Lever
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Missouri, Columbia, Missouri
| | - Carol R Reinero
- Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, Columbia, Missouri
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Grobman ME, Hutcheson KD, Lever TE, Mann FA, Reinero CR. Mechanical dilation, botulinum toxin A injection, and surgical myotomy with fundoplication for treatment of lower esophageal sphincter achalasia-like syndrome in dogs. J Vet Intern Med 2019; 33:1423-1433. [PMID: 30968469 PMCID: PMC6524387 DOI: 10.1111/jvim.15476] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 02/26/2019] [Indexed: 12/17/2022] Open
Abstract
Background Megaesophagus (ME) carries a poor long‐term prognosis in dogs. In people, lower esophageal sphincter (LES) achalasia is a rare cause of ME that may respond to targeted intervention. Dogs with lower esophageal sphincter achalasia‐like syndrome (LES‐AS) have been described recently, warranting investigation of analogous targeted treatment. Hypothesis/Objectives Evaluate response of dogs with LES‐AS to LES mechanical dilation and botulinum toxin A (BTA) injections, with or without surgical myotomy and fundoplication. We hypothesized that clinical and videofluoroscopic swallow study (VFSS) features of LES‐AS would improve after treatment targeting functional LES obstruction. Animals Fourteen client‐owned dogs with LES‐AS diagnosed by VFSS. Methods Retrospective study. Dogs diagnosed with LES‐AS underwent treatment between April 2015 and December 2017. Outcome measures included client perception of clinical severity, body weight (BW), body condition score (BCS), regurgitation frequency, and VFSS parameters (ME, esophageal motility, gastric filling). Dogs with positive responses were considered candidates for LES myotomy with fundoplication. Results By a median IQR of 21 (IQR, 14‐25) days after mechanical dilation and BTA, clients reported clinical improvement in 100% of dogs, BW increased 20.4% (IQR, 12.7%‐25%), pre‐ and post‐treatment BCS was 3 (IQR, 3‐4) and 5 (IQR, 4‐5), respectively, and frequency of regurgitation decreased by 80% (IQR, 50%‐85%). Duration of effect was 40 (IQR, 17‐53) days. Despite clinical improvement, ME and abnormal esophageal motility persisted in 14 dogs. Six dogs subsequently underwent myotomy and fundoplication and maintained improvement observed after mechanical dilation and BTA. Conclusions and Clinical Importance Dogs with LES‐AS experienced significant, temporary, clinical improvement after mechanical dilation and BTA. Preliminary results suggest myotomy with fundoplication provide lasting clinical benefit despite persistence of ME.
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Affiliation(s)
- M E Grobman
- Department of Veterinary Medicine and Surgery, University of Missouri College of Veterinary Medicine, Columbia, Missouri
| | - K D Hutcheson
- Department of Veterinary Medicine and Surgery, University of Missouri Columbia College of Veterinary Medicine Ringgold Standard Institution, Columbia, Missouri
| | - T E Lever
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri Columbia School of Medicine Ringgold Standard Institution, Columbia, Missouri
| | - F A Mann
- Department of Veterinary Medicine and Surgery, University of Missouri Columbia College of Veterinary Medicine Ringgold Standard Institution, Columbia, Missouri
| | - C R Reinero
- Department of Veterinary Medicine and Surgery, University of Missouri, Columbia, Missouri
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Salvador R, Provenzano L, Capovilla G, Briscolini D, Nicoletti L, Valmasoni M, Moletta L, Merigliano S, Costantini M. Extending Myotomy Both Downward and Upward Improves the Final Outcome in Manometric Pattern III Achalasia Patients. J Laparoendosc Adv Surg Tech A 2019; 30:97-102. [PMID: 30892984 DOI: 10.1089/lap.2019.0035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Achalasia is currently classified in three manometric patterns. Pattern III is the least common pattern, and reportedly correlated with the worst outcome after all available treatments. We aimed to investigate the final outcome in pattern III achalasia patients after classic laparoscopic myotomy (CLM) as compared with a myotomy lengthened both downward and upward (long laparoscopic myotomy [LLM]). Materials and Methods: The study population consisted of 61 consecutive patients with a diagnosis of pattern III achalasia who underwent laparoscopic myotomy between 1997 and 2017. In CLM the total length of the myotomy was ≤9 cm, whereas myotomies extending both downward and upward to a length >9 cm were defined as LLM. Results: Of the 61 patients considered, 24 had CLM and 37 had LLM. The postoperative improvement in symptom score differed between the two groups: it dropped from 22 (17-26) to 4 (0-8) in the CLM group and from 20 (17-24) to 3 (0-6) in the LLM group (P < .001). There were 8 of 24 failures (33.3%) in the former group and 4 of 37 (10.8%) in the latter group (P < .05). An abnormal acid exposure was detected after the treatment of CLM in 4 patients and after the treatment of LLM in 3 patients (P = n.s.). Conclusions: Although with the intrinsic limitations of this study (retrospective, different time windows of the two procedures, and different lengths of follow-up), the results indicate that extending the myotomy both downward and upward improves the final outcome of laparoscopic Heller-Dor surgery in pattern III achalasia patients. A longer myotomy does not affect any onset of postoperative gastroesophageal reflux.
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Affiliation(s)
- Renato Salvador
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, University of Padova, Padova, Italy
| | - Luca Provenzano
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, University of Padova, Padova, Italy
| | - Giovanni Capovilla
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, University of Padova, Padova, Italy
| | - Dario Briscolini
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, University of Padova, Padova, Italy
| | - Loredana Nicoletti
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, University of Padova, Padova, Italy
| | - Michele Valmasoni
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, University of Padova, Padova, Italy
| | - Lucia Moletta
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, University of Padova, Padova, Italy
| | - Stefano Merigliano
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, University of Padova, Padova, Italy
| | - Mario Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, University of Padova, Padova, Italy
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Bechara R, Woo M, Hookey L, Chung W, Grimes K, Ikeda H, Onimaru M, Sumi K, Nakamura J, Hata Y, Maruyama S, Gomi K, Shimamura Y, Inoue H. Peroral endoscopic myotomy (POEM) for complex achalasia and the POEM difficulty score. Dig Endosc 2019; 31:148-155. [PMID: 30417948 DOI: 10.1111/den.13294] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/31/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) for achalasia is technically challenging to carry out in patients with type III, multiple prior treatments, prior myotomy, and sigmoid type. Herein, we present a series of consecutive patients with complex achalasia and introduce the POEM difficulty score (PDS). AIM To demonstrate the application and discuss the utility of PDS and present the feasibility, safety, and efficacy of POEM in complex achalasia patients. METHODS Forty consecutive POEM were carried out with 28 meeting the criteria for complex achalasia. Primary outcome was clinical success (Eckardt score ≤3) at a minimum of 3 months follow-up. Secondary outcomes included adverse events, procedural velocity and PDS. RESULTS Twenty-eight complex and 12 non-complex POEM procedures were carried out with 100% and 92% clinical success, respectively, without any major adverse events with a median follow up of 15 months (complex) and 8 months (non-complex). Mean velocities for non-complex, type III, prior myotomy, ≥4 procedures and sigmoid type were as follows: 4.4 ± 1.6, 4.8 ± 1.5, 5.9 ± 2.2, 6.9 ± 2.2 and 8.2 ± 3.2 min/cm, respectively. Median PDS for non-complex, type III, prior myotomy, ≥4 treatments and sigmoid type were 1 (0-3), 2 (0-4), 2.5 (1-6), 3 (2-6) and 3.5 (1-6), respectively. PDS was shown to correlate well with procedural velocity with a correlation coefficient of 0.772 (Spearman's P < 0.001). CONCLUSIONS PDS identifies the factors that contribute to challenging POEM procedures and correlates well with procedural velocity. The order of increasing difficulty of POEM in complex achalasia appears to be type III, prior myotomy, ≥4 treatments and sigmoid type.
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Affiliation(s)
- Robert Bechara
- Division of Gastroenterology, Kingston Health Sciences Center, Queens University, Kingston General Hospital, Ontario, Canada
| | - Matthew Woo
- Division of Gastroenterology, Kingston Health Sciences Center, Queens University, Kingston General Hospital, Ontario, Canada
| | - Lawrence Hookey
- Division of Gastroenterology, Kingston Health Sciences Center, Queens University, Kingston General Hospital, Ontario, Canada
| | - Wiley Chung
- Division of Thoracic Surgery, Kingston Health Sciences Center, Queens University, Kingston General Hospital, Ontario, Canada
| | - Kevin Grimes
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Haruo Ikeda
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Tokyo, Japan
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Tokyo, Japan
| | - Kazuya Sumi
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Tokyo, Japan
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Yoshitaka Hata
- Department of Medicine and Bioregulatory Science, Kyushu University, Fukuoka, Japan
| | - Shota Maruyama
- Department of Surgery, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Kuniyo Gomi
- Division of Gastroenterology, Showa University, Fujigaoka Hospital, Kanagawa, Japan
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Tokyo, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Tokyo, Japan
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15
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Abstract
The last decade has seen growing insight into the pathophysiology of achalasia, and current treatments decreasing the resting pressure in the lower esophageal sphincter by endoscopic (botulinum toxin injection, pneumatic dilation, peroral endoscopic myotomy) or surgical means (Heller myotomy). Manometry is considered the gold standard to confirm the diagnosis of achalasia. Pneumatic dilation and laparoscopic Heller myotomy have similar effectiveness and are both more successful in patients with type II achalasia. Laparoscopic myotomy when combined with partial fundoplication is an effective surgical technique and has been considered the operative procedure of choice until recently. Peroral endoscopic myotomy is an emerging therapy with promising results since it offers a minimally invasive and efficacious option especially in type III achalasia. However, it remains to be determined if peroral endoscopic myotomy offers long-term efficacy.
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16
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Koshel AP, Klokov SS, Alekseev VA, Dibina TV, Rudaya NS, Popov KM. [Outcomes of cardiac achalasia grade II-III management]. Khirurgiia (Mosk) 2018:57-62. [PMID: 29460880 DOI: 10.17116/hirurgia2018257-62] [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: 11/17/2022]
Abstract
AIM To analyze early and remote results of the new method of cardiac achalasia grade II-III management. MATERIAL AND METHODS Original surgical approach was applied in 21 patients with cardiac achalasia grade II-III. RESULTS There were no any specific postoperative complications and deaths. Exacerbation of chronic pancreatitis, acute stomach ulcer and biliary peritonitis were observed in 3 cases respectively. All patients were followed-up within the period from 1.5 months to 5 years after surgery. Recurrent disease was absent. All employable patients have backed to work. CONCLUSION According to clinical and instrumental data original surgical repair completely cures the symptoms of cardiac achalasia and restores normal esophageal dimensions and structure early after intervention.
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Affiliation(s)
- A P Koshel
- Zherlov Medical Center, Seversk; Siberian State Medical University, Healthcare Ministry of the Russian Federation, Tomsk, Russia
| | - S S Klokov
- Zherlov Medical Center, Seversk; Siberian State Medical University, Healthcare Ministry of the Russian Federation, Tomsk, Russia
| | - V A Alekseev
- Siberian State Medical University, Healthcare Ministry of the Russian Federation, Tomsk, Russia
| | | | - N S Rudaya
- Zherlov Medical Center, Seversk; Siberian State Medical University, Healthcare Ministry of the Russian Federation, Tomsk, Russia
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17
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Hu XJ, Wang GW, Zhang LL, Qian BB, Gu YL, Li F, Yang SH. Efficacy and safety of peroral esophageal myotomy vs laparoscopic Heller's myotomy for treatment of achalasia: A meta-analysis. Shijie Huaren Xiaohua Zazhi 2017; 25:792-802. [DOI: 10.11569/wcjd.v25.i9.792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM to add convincing evidence to the best treatment of achalasia by comparing peroral esophageal myotomy (POEM) with laparoscopic Heller's myotomy (LHM) with regard to clinical efficacy and safety.
METHODS The databases including PubMed, EMBASE, the Cochrane Library, Web of Science, CNKI and China Science and Technology Journal Database were fully searched for relevant articles published in Chinese and English form database inception to February 20, 2016. The data were analyzed using Review Manager version 5.3 software. To assess the variation across studies, heterogeneity was measured with the I2 index and Q test.
RESULTS Eight non-randomized comparative studies that included a total of 574 patients (245 in the POEM group and 329 in the LHM group) met our research criteria and were assessed. Meta-analysis results were showed as follows: (1) clinical effect: the POEM group had a better result than the LHM group (RR = 1.14, 95%CI: 1.02-1.27, P = 0.02) with high between-study homogeneity (P = 0.60, I2 = 0%); (2) major complications: There was no difference between the POEM group and LHM group (RR = 1.16, 95%CI: 0.76-1.78, P = 0.49) with high between-study homogeneity (P = 0.43, I2 = 0%); (3) all complications: No significant difference was detected between the POEM group and LHM group (RR = 0.99, 95%CI: 0.72-1.36, P = 0.94). Moderate heterogeneity existed among the included studies (P = 0.12, I2 = 39%); (4) length of hospital stay: There was no statistical difference between the two groups (MD = -0.46, 95%CI: -1.09-0.16, P = 0.14) with high between-study heterogeneity (P = 0.0007, I2 = 76%); (5) operative time: The outcome showed no significant difference between the POEM group and LHM group (MD = -35.45, 95%CI: -87.01-16.10, P = 0.18) with high heterogeneity (P < 0.00001, I2 = 98%).
CONCLUSION POEM is superior to LHM in terms of short-term clinical efficacy. It is still inconclusive on whether POEM is the best therapy for achalasia or not. Long-time follow-up studies are needed to solve this issue in the future.
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18
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Asthana AK, Lubel JS, Kohn GP. Novel association of achalasia with hereditary sensory and motor neuropathy with sensorineural deafness. Dis Esophagus 2016; 29:691-4. [PMID: 23890250 DOI: 10.1111/dote.12111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Achalasia is a primary esophageal motility disorder. Unlike diffuse esophageal spasm, it has not previously been described in association with hereditary sensory and motor neuropathy (HSMN). An 18-year-old-male with HSMN with sensorineural deafness presented with a 2-day history of dysphagia to solids and liquids. Achalasia was diagnosed after extensive investigations, and his symptoms resolved with endoscopic and definitive surgical management. His monozygotic twin brother had also been diagnosed with HSMN and suffered from chronic dysphagia, which was also subsequently diagnosed with achalasia. This is the first case to illustrate an association between HSMN with sensorineural deafness and achalasia.
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Affiliation(s)
- A K Asthana
- Department of Gastroenterology and Hepatology, Eastern Health, Melbourne, Victoria, Australia
| | - J S Lubel
- Department of Gastroenterology and Hepatology, Eastern Health, Melbourne, Victoria, Australia.,Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - G P Kohn
- Department of Surgery, Eastern Health, Melbourne, Victoria, Australia.,Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
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19
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Function of high-resolution manometry in the analysis of peroral endoscopic myotomy for achalasia. Surg Endosc 2015; 30:1094-9. [PMID: 26099621 DOI: 10.1007/s00464-015-4304-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 05/11/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) was introduced as a new effective therapeutic option for esophageal achalasia. METHOD A total of 112 achalasia patients categorized into three subtypes by HRM who underwent POEM were enrolled in our study. Eckardt score and HRM were performed preoperation, 6 months, and 1 year after POEM to evaluate the effectiveness, safety, and feasibility of POEM and to investigate the treatment response to POEM for the three subtypes of achalasia, classified by high-resolution manometry (HRM). RESULTS POEM was successfully performed in all patients. Compared with pre-POEM scores, the Eckardt scores were significantly reduced from 7.3 ± 1.4 to 1.0 ± 0.8 6 months after POEM and to 1.2 ± 0.6 1 year after POEM (p < 0.05). The LESP before treatment was 41.8 ± 15.3 mmHg, compared with a LESP of 18.4 ± 7.1 mmHg 6 months after POEM and 20.7 ± 7.5 mmHg 1 year after POEM (p < 0.05). In addition, POEM decreased the 4-s IRP from 33.4 ± 9.0 to 14.6 ± 3.8 mmHg 6 months after POEM and to 16.4 ± 3.9 mmHg 1 year after POEM (p < 0.05). The 4-s IRP was reduced to <15 mmHg in 64 of 112 patients. Type II had the best response to POEM, while type III exhibited the worst response. CONCLUSIONS POEM appears to be an effective and less invasive treatment for achalasia. HRM can be useful in the classification of achalasia, while these subclassifications help to predict the responsiveness to POEM.
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20
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Kumbhari V, Tieu AH, Onimaru M, El Zein MH, Teitelbaum EN, Ujiki MB, Gitelis ME, Modayil RJ, Hungness ES, Stavropoulos SN, Shiwaku H, Kunda R, Chiu P, Saxena P, Messallam AA, Inoue H, Khashab MA. Peroral endoscopic myotomy (POEM) vs laparoscopic Heller myotomy (LHM) for the treatment of Type III achalasia in 75 patients: a multicenter comparative study. Endosc Int Open 2015; 3:E195-201. [PMID: 26171430 PMCID: PMC4486039 DOI: 10.1055/s-0034-1391668] [Citation(s) in RCA: 171] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 12/08/2014] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Type III achalasia is characterized by rapidly propagating pressurization attributable to spastic contractions. Although laparoscopic Heller myotomy (LHM) is the current gold standard management for type III achalasia, peroral endoscopic myotomy (POEM) is conceivably superior because it allows for a longer myotomy. Our aims were to compare the efficacy and safety of POEM with LHM for type III achalasia patients. PATIENTS AND METHODS A retrospective study of 49 patients who underwent POEM for type III achalasia across eight centers were compared to 26 patients who underwent LHM at a single institution. Procedural data were abstracted and pre- and post-procedural symptoms were recorded. Clinical response was defined by improvement of symptoms and decrease in Eckardt stage to ≤ 1. Secondary outcomes included length of myotomy, procedure duration, length of hospital stay, and rate of adverse events. RESULTS Clinical response was significantly more frequent in the POEM cohort (98.0 % vs 80.8 %; P = 0.01). POEM patients had significantly shorter mean procedure time than LHM patients (102 min vs 264 min; P < 0.01) despite longer length of myotomy (16 cm vs 8 cm; P < 0.01). There was no significant difference between POEM and LHM in the length of hospital stay (3.3 days vs 3.2 days; P = 0.68), respectively. Rate of adverse events was significantly less in the POEM group (6 % vs 27 %; P < 0.01). CONCLUSIONS POEM allows for a longer myotomy than LHM, which may result in improved clinical outcomes. POEM appears to be an effective and safe alternative to LHM in patients with type III achalasia.
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Affiliation(s)
- Vivek Kumbhari
- Johns Hopkins Medical Institutions, Gastroenterology and Hepatology, Baltimore, Maryland, United States,Corresponding author Mouen A. Khashab, M.D Associate Professor of MedicineDirector of Therapeutic EndoscopyJohns Hopkins Hospital1800 Orleans St, Suite 7125BBaltimore, MD 21287(443) 287-1960(443) 683 8335
| | - Alan H Tieu
- Johns Hopkins Medical Institutions, Gastroenterology and Hepatology, Baltimore, Maryland, United States
| | - Manabu Onimaru
- Showa University Northern Yokohama Hospital, Digestive Disease Center, Yokohama, Japan
| | - Mohammad H. El Zein
- Johns Hopkins Medical Institutions, Gastroenterology and Hepatology, Baltimore, Maryland, United States
| | - Ezra N. Teitelbaum
- Northwestern University Feinberg School of Medicine, Department of Surgery, Chicago, Illinois, United States
| | - Michael B. Ujiki
- NorthShore University Health Systems, NorthShore Center for Simulation and Innovation, Evanston, Illinois, United States
| | - Matthew E. Gitelis
- NorthShore University Health Systems, NorthShore Center for Simulation and Innovation, Evanston, Illinois, United States
| | - Rani J. Modayil
- Winthrop University Hospital, Gastroenterology and Hepatology, Mineola, New York, United States
| | - Eric S. Hungness
- Northwestern University Feinberg School of Medicine, Department of Surgery, Chicago, Illinois, United States
| | - Stavros N. Stavropoulos
- Winthrop University Hospital, Gastroenterology and Hepatology, Mineola, New York, United States
| | - Hiro Shiwaku
- Fukuoka University Faculty of Medicine, Gastroenterology and Hepatology, Fukuoka, Japan
| | - Rastislav Kunda
- Aarhus University Hospital, Department of Surgery, Aarhus, Denmark
| | - Philip Chiu
- Institute of Digestive Disease, Gastroenterology and Hepatology, Shatin, Hong Kong
| | - Payal Saxena
- Johns Hopkins Medical Institutions, Gastroenterology and Hepatology, Baltimore, Maryland, United States
| | - Ahmed A. Messallam
- Johns Hopkins Medical Institutions, Gastroenterology and Hepatology, Baltimore, Maryland, United States
| | - Haruhiro Inoue
- Showa University Northern Yokohama Hospital, Digestive Disease Center, Yokohama, Japan
| | - Mouen A. Khashab
- Johns Hopkins Medical Institutions, Gastroenterology and Hepatology, Baltimore, Maryland, United States
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21
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Endoscopic botulinum toxin injection: Benefit and limitation. GASTROINTESTINAL INTERVENTION 2014. [DOI: 10.1016/j.gii.2014.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Kempf J, Beckmann K, Kook PH. Achalasia-like disease with esophageal pressurization in a myasthenic dog. J Vet Intern Med 2014; 28:661-5. [PMID: 24612067 PMCID: PMC4857995 DOI: 10.1111/jvim.12329] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 01/02/2014] [Accepted: 01/14/2014] [Indexed: 12/03/2022] Open
Affiliation(s)
- J Kempf
- Clinic for Small Animal Internal Medicine, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
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23
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Abstract
Achalasia is a rare motility disorder of the oesophagus characterised by loss of enteric neurons leading to absence of peristalsis and impaired relaxation of the lower oesophageal sphincter. Although its cause remains largely unknown, ganglionitis resulting from an aberrant immune response triggered by a viral infection has been proposed to underlie the loss of oesophageal neurons, particularly in genetically susceptible individuals. The subsequent stasis of ingested food not only leads to symptoms of dysphagia, regurgitation, chest pain, and weight loss, but also results in an increased risk of oesophageal carcinoma. At present, pneumatic dilatation and Heller myotomy combined with an anti-reflux procedure are the treatments of choice and have comparable success rates. Per-oral endoscopic myotomy has recently been introduced as a new minimally invasive treatment for achalasia, but there have not yet been any randomised clinical trials comparing this option with pneumatic dilatation and Heller myotomy.
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Affiliation(s)
- Guy E Boeckxstaens
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), University Hospital Leuven, Catholic University of Leuven, Leuven, Belgium.
| | - Giovanni Zaninotto
- Department of Surgical and Gastroenterological Sciences, University of Padova, UOC General Surgery, Sts Giovanni e Paolo Hospital, Venice, Italy
| | - Joel E Richter
- Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Esophageal and Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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24
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Abstract
We describe a patient with dysphagia. The results of endoscopy, CT scan and echoendoscopy were normal. High-resolution manometry (HRM) showed esogastric junction dysfunction and hypercontractile peristaltic disorder. These HRM abnormalities completely disappeared after pneumatic esophageal dilatation. We discuss the treatment options and recovery of peristalsis after balloon dilatation.
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Affiliation(s)
- A L Pelletier
- Service d'Hépato-Gastroentérologie, Hôpital Bichat-Claude Bernard, Paris, Colombes, France
| | - D Pospai
- Service d'Hépato-Gastroentérologie, Hôpital Bichat-Claude Bernard, Paris, Colombes, France
| | - M Merrouche
- Service d'Hépato-Gastroentérologie, Hôpital Louis Mourrier, Colombes, France
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25
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Abstract
Achalasia is a rare motility disorder of the esophagus characterized by the absence of peristalsis and defective relaxation of the lower esophageal sphincter. Patients present at all ages with dysphagia and regurgitation as main symptoms. The diagnosis is suggested by barium swallow and endoscopy and confirmed by manometry. Because there is no curative treatment for achalasia, treatment is confined to disruption of the lower esophageal sphincter to improve bolus passage. The most successful therapies are pneumodilation and laparoscopic Heller myotomy, with comparable short-term clinical rates of success. The prognosis of achalasia patients is good, but re-treatment is often necessary.
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Min M, Peng LH, Yang YS, Hou XH, Guo RB, Wang WF, Sun G, Wang XX. Characteristics of achalasia subtypes in untreated Chinese patients: a high-resolution manometry study. J Dig Dis 2012; 13:504-9. [PMID: 22988923 DOI: 10.1111/j.1751-2980.2012.00622.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate and compare the clinical characteristics, manometric results and treatment outcomes of different subtypes of achalasia in untreated Chinese patients using high-resolution esophageal manometry. METHODS A total of 75 achalasia patients and 34 healthy controls were enrolled in the study, and three achalasia subtypes were determined based on the Chicago classification. Clinical characteristics, manometric and treatment outcomes were compared. RESULTS In all, 25 patients were classified as type I, 46 as type II and 4 as type III. The mean overall length of lower esophageal sphincter (LES) in type III was significantly longer than those in the controls and type I patients (P < 0.05), and abdominal LES length was significantly longer in type III than those in controls, type I and type II patients. All subtypes of achalasia had higher resting and residual LES pressures than those found in healthy controls (P < 0.05). Resting upper esophageal sphincter (UES) pressure in type III patients was significantly lower than those in healthy controls and type I patients, whereas types I and II patients had higher residual UES pressures compared with healthy controls (P < 0.05). Type II patients had a better response to the treatment than type I and III patients. CONCLUSIONS Type II is more common in untreated Chinese achalasia patients, and type II patients had better treatment outcomes than other types of patients. Large-sample multicenter trials are necessary in the future.
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Affiliation(s)
- Min Min
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
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