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Bard V, Solomon D, Raveh G, Menasherov N, Kashtan H. Long‐term Outcomes After Esophagectomy for
End‐Stage
Achalasia: a Bridge to a Better Quality of Life? SURGICAL PRACTICE 2022. [DOI: 10.1111/1744-1633.12565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Vyacheslav Bard
- Department of General Surgery, Rabin Medical Center, Campus Beilinson, affiliated with Sackler Faculty of Medicine Tel Aviv University Israel
| | - Daniel Solomon
- Department of General Surgery, Rabin Medical Center, Campus Beilinson, affiliated with Sackler Faculty of Medicine Tel Aviv University Israel
| | - Guy Raveh
- Department of General Surgery, Rabin Medical Center, Campus Beilinson, affiliated with Sackler Faculty of Medicine Tel Aviv University Israel
| | - Nikolai Menasherov
- Department of General Surgery, Rabin Medical Center, Campus Beilinson, affiliated with Sackler Faculty of Medicine Tel Aviv University Israel
| | - Hanoch Kashtan
- Department of General Surgery, Rabin Medical Center, Campus Beilinson, affiliated with Sackler Faculty of Medicine Tel Aviv University Israel
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Gallyamov EA, Erin SA, Gololobov GY, Burmistrov AI, Chicherina MA, Rikunova AA. [Features and results of minimally invasive treatment of recurrent achalasia]. Khirurgiia (Mosk) 2022:16-22. [PMID: 35289544 DOI: 10.17116/hirurgia202203116] [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] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To evaluate the early and long-term postoperative outcomes in patients with recurrent achalasia, as well as the main features of surgical treatment. MATERIAL AND METHODS There were 7 patients (4 men and 3 women) with recurrent achalasia. Mean age of patients was 42.3±13.5 years, body mass index - 22.7±3.3 kg/m2. Physiological status ASA grade 1-3 was observed in all patients. Concomitant diseases were diagnosed in 5 (71.4%) cases. Six (85.7%) patients underwent laparoscopic Heller cardiomyotomy with Dor fundoplication. Peroral endoscopic myotomy (POEM) was performed in 1 (14.3%) patient. Mean preoperative Eckardt score was 10.7±1.4 points, mean GERD-HRQL score - 42.7±6.4 points. According to preoperative radiography, 5 (71.4%) patients had achalasia stage III, 2 (28.6%) ones - stage IV. RESULTS All patients underwent laparoscopic Heller esophagocardiomyotomy with anterior Dor fundoplication and posterior partial fundoplication with posterior cruroraphy. Intraoperative complications (perforation of esophageal mucosa) occurred in 3 (42.9%) patients. Mean surgery time was 130±56 min, mean blood loss - 37 ml (35-205 ml), mean hospital-stay - 11.3±7.7 days. Postoperative complications Clavien-Dindo grade 3-4 were detected in 1 (14.3%) patient. One patient was diagnosed with bilateral pneumonia (SARS-Cov-2 infection) in 4 postoperative days. Median postoperative follow-up period was 22 months. Mean BMI in 6 months after surgery was 25.3±3.1 kg/m2, mean Eckardt score - 2.1±0.7 points, mean GERD-HRQL score - 3.3±0.9 points. CONCLUSION Our data confirm the effectiveness and safety of the modified laparoscopic Heller procedure with Dor fundoplication as the main method for recurrent achalasia.
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Affiliation(s)
- E A Gallyamov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - S A Erin
- Spasokukotsky Moscow City Clinical Hospital, Moscow, Russia
| | - G Yu Gololobov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A I Burmistrov
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - M A Chicherina
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A A Rikunova
- Sechenov First Moscow State Medical University, Moscow, Russia
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Samo S, Hamo F, Jain AS, Shah RH, Patel V, Calderon LF, Xie M, Mekaroonkamol P, Keilin SA, Cai Q. Gas Leak and Mucosal Injury During Endoscopic Esophageal Myotomy After Previous Myotomy: A Single-Center Experience. Clin Exp Gastroenterol 2021; 14:173-179. [PMID: 34295172 PMCID: PMC8290189 DOI: 10.2147/ceg.s297338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 05/10/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Peroral endoscopic myotomy (POEM) after prior myotomy (PM-POEM) can be technically challenging with possible increased adverse events. We aimed to assess gas leak and mucosal injury incidence during PM-POEM, compared to an index POEM (iPOEM), and post-procedure extubation time. Patients and Methods A retrospective study comparing PM-POEM to iPOEM from March 2016 to August 2018. Results There were 21 subjects in the PM-POEM and 56 subjects in the iPOEM. The PM-POEM group was younger (average age 44.33 vs 57.57 years, p=0.0082). Gas leak incidence did not differ between groups (28.6% in PM-POEM vs 14.3% in iPOEM, p=0.148). For cases with imaging available postoperatively, there was a trend towards higher incidence of gas leak in the PM-POEM, but it was not statistically significant (60% vs 42.1%, p=0.359). The post-procedure extubation time was not different between PM-POEM and iPOEM (11.38 vs 9.46 minutes, p=0.93), but it was longer when gas leak occurred (15.92 vs 8.67 minutes, p=0.027). The odds of mucosal injury were four-fold higher (OR, 4.31; 95% CI, 1.32–14.08), and more clips were used to close mucosal injuries (0.62 vs 0.14 clips, p=0.0053) in the PM-POEM group. More procedures were deemed difficult or challenging in the PM-POEM (33.3% vs 7.1%, p=0.007). The number of clips used to close the mucosotomy was not different between groups (4.05 vs 3.84 clips, p=0.498). Although the myotomy was shorter in PM-POEM, it was not statistically significant (6.38 vs 7.14 cm, p=0.074). However, the procedure was longer in PM-POEM (61.28 vs 45.39 minutes, p=0.0017). There was no intervention or ICU admission required pertinent to the procedure. Conclusion Performing PM-POEM can be more difficult with more mucosal injuries. Gas leak was associated with a slightly longer post-procedure extubation time, but clinical relevance is unclear given incidence of gas leak was unknown at time of extubation.
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Affiliation(s)
- Salih Samo
- Division of Digestive Diseases-Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.,Division of Gastroenterology, Hepatology and Motility-Department of Medicine, The University of Kansas School of Medicine, Kansas City, KS, USA
| | - Falak Hamo
- Division of Gastroenterology, Hepatology and Motility-Department of Medicine, The University of Kansas School of Medicine, Kansas City, KS, USA
| | - Anand S Jain
- Division of Digestive Diseases-Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Rushikesh H Shah
- Division of Digestive Diseases-Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Vaishali Patel
- Division of Digestive Diseases-Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Lucie F Calderon
- Division of Digestive Diseases-Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Mengdan Xie
- Division of Digestive Diseases-Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Parit Mekaroonkamol
- Division of Digestive Diseases-Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Steven A Keilin
- Division of Digestive Diseases-Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Qiang Cai
- Division of Digestive Diseases-Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Tan S, Zhong C, Ren Y, Luo X, Xu J, Fu X, Peng Y, Tang X. Efficacy and Safety of Peroral Endoscopic Myotomy in Achalasia Patients with Failed Previous Intervention: A Systematic Review and Meta-Analysis. Gut Liver 2021; 15:153-167. [PMID: 32616678 PMCID: PMC7960968 DOI: 10.5009/gnl19234] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 10/04/2019] [Accepted: 11/04/2019] [Indexed: 02/05/2023] Open
Abstract
Peroral endoscopic myotomy (POEM) has emerged as a rescue treatment for recurrent or persistent achalasia after failed initial management. Therefore, we aimed to investigate the efficacy and safety of POEM in achalasia patients with failed previous intervention. We searched the MEDLINE, Embase, Cochrane, and PubMed databases using the queries “achalasia,” “peroral endoscopic myotomy,” and related terms in March 2019. Data on technical and clinical success, adverse events, Eckardt score and lower esophageal sphincter (LES) pressure were collected. The pooled event rates, mean differences (MDs) and risk ratios (RR) were calculated. A total of 15 studies with 2,276 achalasia patients were included. Overall, the pooled technical success, clinical success and adverse events rate of rescue POEM were 98.0% (95% confidence interval [CI], 96.6% to 98.8%), 90.8% (95% CI, 88.8% to 92.4%) and 10.3% (95% CI, 6.6% to 15.8%), respectively. Seven studies compared the clinical outcomes of POEM between previous failed treatment and the treatment naïve patients. The RR for technical success, clinical success, and adverse events were 1.00 (95% CI, 0.98 to 1.01), 0.98 (95% CI, 0.92 to 1.04), and 1.17 (95% CI, 0.78 to 1.76), respectively. Overall, there was significant reduction in the pre- and post-Eckardt score (MD, 5.77; p<0.001) and LES pressure (MD, 18.3 mm Hg; p<0.001) for achalasia patients with failed previous intervention after POEM. POEM appears to be a safe, effective and feasible treatment for individuals who have undergone previous failed intervention. It has similar outcomes in previously treated and treatment-naïve achalasia patients.
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Affiliation(s)
- Shali Tan
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Chunyu Zhong
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yutang Ren
- Department of Gastroenterology, Beijing Tsinghua Changgung Hospital, Tsinghua University School of Clinical Medicine, Beijing, China
| | - Xujuan Luo
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jin Xu
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiangsheng Fu
- Department of Gastroenterology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Yan Peng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaowei Tang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
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Kamal F, Ismail MK, Khan MA, Lee-Smith W, Sharaiha RZ, Sharma S, McDonough S, Tariq R, Marella HK, Khan Z, Heda RP, Tombazzi C, Howden CW, Adler DG. Efficacy and safety of peroral endoscopic myotomy in the management of recurrent achalasia after failed Heller myotomy: a systematic review and meta-analysis. Ann Gastroenterol 2021; 34:155-163. [PMID: 33654353 PMCID: PMC7903572 DOI: 10.20524/aog.2020.0563] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 08/27/2020] [Indexed: 12/21/2022] Open
Abstract
Background Heller myotomy (HM) is an established treatment for achalasia but can fail in up to 10-20% of patients. Peroral endoscopic myotomy (POEM) may be an appropriate treatment for patients with failed HM. Methods We searched several databases to identify non-comparative studies evaluating the efficacy and/or safety of POEM after failed HM and comparative studies comparing the efficacy and/or safety of POEM in patients with and without prior HM. Outcomes assessed included clinical success, technical success, adverse events, post-treatment gastroesophageal reflux disease (GERD), and presence of esophagitis on endoscopy. We calculated weighted pooled rates with 95% confidence intervals (CI) for all outcomes in patients undergoing POEM with prior HM. We calculated pooled odds ratios with 95%CI to compare the outcomes between patients with and without previous HM who underwent POEM. Results We included 11 observational studies with 1205 patients. Weighted pooled rates (95%CI) for overall clinical success and technical success in patients with failed HM were 87% (81-91%) and 97% (94-99%), respectively. Weighted pooled rates (95%CI) for major adverse events, new-onset GERD and presence of esophagitis on endoscopy were 5% (2-10%), 33% (26-41%), and 38% (22-58%), respectively. There were no differences in clinical success, adverse events, post-treatment GERD and esophagitis between patients with and without previous HM. Conclusions POEM is safe and effective in patients with failed HM and should be considered in patients with recurrent achalasia after HM. Outcomes of POEM are comparable in patients with and without prior HM.
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Affiliation(s)
- Faisal Kamal
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, TN (Faisal Kamal, Mohammad K. Ismail, Claudio Tombazzi, Colin W. Howden)
| | - Mohammad K Ismail
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, TN (Faisal Kamal, Mohammad K. Ismail, Claudio Tombazzi, Colin W. Howden)
| | - Muhammad A Khan
- Division of Gastroenterology, University of Alabama at Birmingham, Birmingham, AL (Muhammad A. Khan)
| | - Wade Lee-Smith
- Mulford Medical Sciences Library, University of Toledo, Toledo, OH (Wade Lee-Smith)
| | - Reem Z Sharaiha
- Division of Gastroenterology, Weill Cornell Medical College, NY (Reem Z. Sharaiha)
| | - Sachit Sharma
- Department of Medicine, University of Toledo, Toledo, OH (Sachit Sharma)
| | - Stephanie McDonough
- Division of Gastroenterology, University of Utah, Salt Lake City, UT (Stephanie McDonough, Douglas G. Adler)
| | - Raseen Tariq
- Department of Medicine, Rochester General Hospital, Rochester, NY (Raseen Tariq)
| | - Hemnishil K Marella
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN (Hemnishil K. Marella)
| | - Zubair Khan
- Division of Gastroenterology, University of Texas-Houston, Houston, TX (Zubair Khan)
| | - Rajiv P Heda
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN (Rajiv P Heda), USA
| | - Claudio Tombazzi
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, TN (Faisal Kamal, Mohammad K. Ismail, Claudio Tombazzi, Colin W. Howden)
| | - Colin W Howden
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, TN (Faisal Kamal, Mohammad K. Ismail, Claudio Tombazzi, Colin W. Howden)
| | - Douglas G Adler
- Division of Gastroenterology, University of Utah, Salt Lake City, UT (Stephanie McDonough, Douglas G. Adler)
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Peroral endoscopic myotomy after failed Heller-Dor: try again, fail again, fail better. Gastrointest Endosc 2021; 93:57-58. [PMID: 33353641 DOI: 10.1016/j.gie.2020.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/13/2020] [Indexed: 12/11/2022]
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Over ten-year outcomes of laparoscopic Heller-myotomy with Dor-fundoplication with achalasia: single-center experience with annual endoscopic surveillance. Surg Endosc 2020; 35:6513-6523. [DOI: 10.1007/s00464-020-08148-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 11/03/2020] [Indexed: 12/25/2022]
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Hashimoto R, Inoue H, Shimamura Y, Sakuraba A, Tomizawa Y. Per oral endoscopic myotomy as salvage therapy in patients with achalasia refractory to endoscopic or surgical therapy is technically feasible and safe: Systematic review and meta-analysis. Dig Endosc 2020; 32:1042-1049. [PMID: 32012360 DOI: 10.1111/den.13643] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 01/31/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUNDS AND AIMS Per oral endoscopic myotomy (POEM) has been reported as an effective and safe salvage therapy for achalasia but there is limited composite data. We performed a systematic review and meta-analysis of studies that reported the rates of clinical success and adverse events among patients who underwent POEM after failed conventional endoscopic or surgical therapy. METHODS Electronic literature search was conducted from inception through December 2018 for articles reporting the efficacy and safety of POEM in patients with achalasia who failed endoscopic or surgical therapy. Primary outcome was the pooled estimated rates of clinical success, defined as Eckardt score ≤ 3 after POEM. Secondary outcomes were procedural time, the rates of POEM-related gastroesophageal reflux disease (GERD) and procedure-related adverse events. RESULTS Seven studies reporting outcomes on 487 patients met our criteria. Pooled estimated rate of clinical success of POEM was 88% (95% confidence interval (CI) 79-94%). Mean procedural time was 64 minutes (95% CI 44-85 minutes). POEM-related GERD was found in 20% (95% CI 16-24%) of patients. Estimated incidence of overall adverse events was 10% (95% CI 5-18%) with individual risk of bleeding, mucosotomy, pneumothorax, pneumoperitoneum hydrothorax/mediastinitis, and subcutaneous emphysema ranging from 1 to 4%. CONCLUSIONS Per oral endoscopic myotomy after failed endoscopic or surgical therapy in patients with achalasia is an effective and safe treatment. Further long-term follow-up studies in a larger number of patients are warranted to validate the sustainable efficacy of POEM for achalasia.
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Affiliation(s)
- Rintaro Hashimoto
- Division of Gastroenterology, University of California Irvine Medical Center, Orange, USA
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Atsushi Sakuraba
- Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, USA
| | - Yutaka Tomizawa
- Division of Gastroenterology, Harborview Medical Center, University of Washington, Seattle, USA
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Jawaid S, Draganov PV, Yang D. Esophageal POEM: the new standard of care. Transl Gastroenterol Hepatol 2020; 5:47. [PMID: 33073042 DOI: 10.21037/tgh.2019.12.17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 12/19/2019] [Indexed: 01/06/2023] Open
Abstract
Since its introduction into clinical practice nearly a decade ago, per-oral endoscopic myotomy (POEM) has now become an accepted minimally invasive approach for the treatment of achalasia with excellent short- and mid-term clinical outcomes in both treatment naïve and those who have failed prior therapy. POEM is comparable to laparoscopic Heller myotomy (LHM) in terms of efficacy and safety, with less procedural pain and faster recovery time. Recent data also reveals that POEM may be more effective and durable than pneumatic dilation (PD) for the treatment of achalasia, with similar safety profile. Preliminary data on POEM for spastic esophageal disorders (SED) is promising yet scarce. Post-POEM gastroesophageal reflux disease (GERD) is common but asymptomatic in most patients, further highlighting the need for ongoing research in this field and the importance of long-term surveillance of these patients.
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Affiliation(s)
- Salmaan Jawaid
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida Health, Gainesville, FL, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida Health, Gainesville, FL, USA
| | - Dennis Yang
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida Health, Gainesville, FL, USA
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Rahmati M, Mahmoudi M, Mohammad K, Mikaeli J, Zeraati H. Bayesian modelling of zero‐inflated recurrent events and dependent termination with compound Poisson frailty model. Stat (Int Stat Inst) 2020. [DOI: 10.1002/sta4.292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Maryam Rahmati
- Department of Epidemiology and Biostatistics, School of Public Health Tehran University of Medical Sciences Tehran Iran
| | - Mahmood Mahmoudi
- Department of Epidemiology and Biostatistics, School of Public Health Tehran University of Medical Sciences Tehran Iran
| | - Kazem Mohammad
- Department of Epidemiology and Biostatistics, School of Public Health Tehran University of Medical Sciences Tehran Iran
| | - Javad Mikaeli
- Autoimmune and Motility Disorders Research Center, Digestive Diseases Research Institute Tehran University of Medical Sciences Tehran Iran
| | - Hojjat Zeraati
- Department of Epidemiology and Biostatistics, School of Public Health Tehran University of Medical Sciences Tehran Iran
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Khashab MA, Vela MF, Thosani N, Agrawal D, Buxbaum JL, Abbas Fehmi SM, Fishman DS, Gurudu SR, Jamil LH, Jue TL, Kannadath BS, Law JK, Lee JK, Naveed M, Qumseya BJ, Sawhney MS, Yang J, Wani S. ASGE guideline on the management of achalasia. Gastrointest Endosc 2020; 91:213-227.e6. [PMID: 31839408 DOI: 10.1016/j.gie.2019.04.231] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 04/22/2019] [Indexed: 12/11/2022]
Abstract
Achalasia is a primary esophageal motor disorder of unknown etiology characterized by degeneration of the myenteric plexus, which results in impaired relaxation of the esophagogastric junction (EGJ), along with the loss of organized peristalsis in the esophageal body. The criterion standard for diagnosing achalasia is high-resolution esophageal manometry showing incomplete relaxation of the EGJ coupled with the absence of organized peristalsis. Three achalasia subtypes have been defined based on high-resolution manometry findings in the esophageal body. Treatment of patients with achalasia has evolved in recent years with the introduction of peroral endoscopic myotomy. Other treatment options include botulinum toxin injection, pneumatic dilation, and Heller myotomy. This American Society for Gastrointestinal Endoscopy Standards of Practice Guideline provides evidence-based recommendations for the treatment of achalasia, based on an updated assessment of the individual and comparative effectiveness, adverse effects, and cost of the 4 aforementioned achalasia therapies.
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Affiliation(s)
- Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Marcelo F Vela
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Nirav Thosani
- Interventional Gastroenterologists of the University of Texas, Department of Internal Medicine, McGovern Medical School, Houston, Texas, USA
| | - Deepak Agrawal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Syed M Abbas Fehmi
- Division of Gastroenterology/Hepatology, University of California, San Diego, San Diego, California, USA
| | - Douglas S Fishman
- Section of Pediatric Gastroenterology, Baylor College of Medicine; Texas Children's Hospital, Houston, Texas, USA
| | | | - Laith H Jamil
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Terry L Jue
- The Permanente Medical Group, Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Bijun Sai Kannadath
- Interventional Gastroenterologists of the University of Texas, Department of Internal Medicine, McGovern Medical School, Houston, Texas, USA
| | - Joanna K Law
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Jeffrey K Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Mariam Naveed
- Division of Gastroenterology and Hepatology, University of Iowa Hospital & Clinics, Iowa City, Iowa, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, Archbold Medical Group, Thomasville, Georgia, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Julie Yang
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Nickel F, Müller PC, de la Garza JR, Tapking C, Benner L, Fischer L, Steinemann DC, Rupp C, Linke GR, Müller-Stich BP. Heller myotomy versus endoscopic balloon dilatation for achalasia: A single center experience. Medicine (Baltimore) 2019; 98:e17714. [PMID: 31689807 PMCID: PMC6946323 DOI: 10.1097/md.0000000000017714] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 09/24/2019] [Accepted: 09/28/2019] [Indexed: 01/09/2023] Open
Abstract
This study aimed to compare clinical results, symptom relief, quality of life and patient satisfaction after the 2 most common procedures for achalasia treatment: laparoscopic Heller myotomy (LHM) and endoscopic balloon dilatation (EBD).Patients treated at University Hospital of Heidelberg with LHM or EBD were included. A retrospective chart review of perioperative data and a prospective follow-up of therapeutic efficiency, Gastrointestinal Quality of Life Index (GIQLI) and patient satisfaction was conducted.Follow-up data (mean follow-up: 75.1 ± 53.9 months for LHM group and 78.9 ± 45.6 months for EBD) were obtained from 36 patients (19 LHM; 17 EBD). Eckardt score (median (q1,q3): 2 (1,4) in both groups, P = .91, GIQLI (LHM: 117 (91.5, 126) vs EBD: 120 (116, 128), P = .495) and patient satisfaction (3 (2,3) vs 3 (2,4), P = .883) did not differ between groups. Fifteen patients (78.9%) in LHM group and 11 (64.7%) in EBD group (P = .562) stated they would undergo the intervention again. All patients with EBD had at least 2 dilatations (100%), whilst only 2 patients (10.5%) had dilatation after LHM (P < .001). There were no complications after EBD, but 2 after LHM (10.5%, P = .517).Both LHM and EBD are able to control symptoms and provide similar quality of life and patient satisfaction. However, reintervention rate was higher following EBD, hence LHM provided a more sustained treatment than EBD.
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Affiliation(s)
- Felix Nickel
- Department of General, Visceral and Transplant Surgery
| | | | | | | | - Laura Benner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 130.3, Heidelberg
| | - Lars Fischer
- Department of Surgery, Hospital Mittelbaden, Balger Strasse 50, 76532 Baden-Baden, Germany
| | - Daniel C. Steinemann
- Department of Surgery, St. Claraspital AG, Kleinriehenstrasse 30, 4058 Basel, Switzerland
| | - Christian Rupp
- Department of Internal Medicine, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Georg R. Linke
- Department of Surgery, Hospital STS Thun AG, Krankenhausstrasse 12, 3600 Thun, Switzerland
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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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15
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Tyberg A, Sharaiha RZ, Familiari P, Costamagna G, Casas F, Kumta NA, Barret M, Desai AP, Schnoll-Sussman F, Saxena P, Martínez G, Zamarripa F, Gaidhane M, Bertani H, Draganov PV, Balassone V, Sharata A, Reavis K, Swanstrom L, Invernizzi M, Seewald S, Minami H, Inoue H, Kahaleh M. Peroral endoscopic myotomy as salvation technique post-Heller: International experience. Dig Endosc 2018; 30:52-56. [PMID: 28691186 DOI: 10.1111/den.12918] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 07/04/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Treatment for achalasia has traditionally been Heller myotomy (HM). Despite its excellent efficacy rate, a number of patients remain symptomatic post-procedure. Limited data exist as to the best management for recurrence of symptoms post-HM. We present an international, multicenter experience evaluating the efficacy and safety of post-HM peroral endoscopic myotomy (POEM). METHODS Patients who underwent POEM post-HM from 13 centers from January 2012 to January 2017 were included as part of a prospective registry. Technical success was defined as successful completion of the myotomy. Clinical success was defined as an Eckardt score of ≤3 on 12-month follow up. Adverse events (AE) including anesthesia-related, operative, and postoperative complications were recorded. RESULTS Fifty-one patients were included in the study (mean age 54.2, 47% male). Technical success was achieved in 100% of patients. Clinical success on long-term follow up was achieved in 48 patients (94%), with a mean change in Eckardt score of 6.25. Seven patients (13%) had AE: six experienced periprocedural mucosal defect treated endoscopically and two patients developed mediastinitis treated conservatively. CONCLUSION For patients with persistent symptoms after HM, POEM is a safe salvation technique with good short-term efficacy. As a result of the challenge associated with repeat HM, POEM might become the preferred technique in this patient population. Further studies with longer follow up are needed.
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Affiliation(s)
- Amy Tyberg
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA
| | | | | | - Fernando Casas
- Gastroenterology, Bogota General Hospital, Bogota, Colombia
| | - Nikhil A Kumta
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA
| | | | - Amit P Desai
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA
| | - Felice Schnoll-Sussman
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA
| | | | | | | | - Monica Gaidhane
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA
| | | | | | - Valerio Balassone
- Gastroenterology, Showa University Northern Yokohama Hospital, Tokyo, Japan
| | | | - Kevin Reavis
- Gastroenterology, Portland Clinic, Portland, USA
| | | | | | - Stefan Seewald
- Gastroenterology, Klinik Hirslanden, Zurich, Switzerland
| | - Hitomi Minami
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Haruhiro Inoue
- Gastroenterology, Showa University Northern Yokohama Hospital, Tokyo, Japan
| | - Michel Kahaleh
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA
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Ngamruengphong S, Inoue H, Ujiki MB, Patel LY, Bapaye A, Desai PN, Dorwat S, Nakamura J, Hata Y, Balassone V, Onimaru M, Ponchon T, Pioche M, Roman S, Rivory J, Mion F, Garros A, Draganov PV, Perbtani Y, Abbas A, Pannu D, Yang D, Perretta S, Romanelli J, Desilets D, Hayee B, Haji A, Hajiyeva G, Ismail A, Chen YI, Bukhari M, Haito-Chavez Y, Kumbhari V, Saxena P, Talbot M, Chiu PWY, Yip HC, Wong VWY, Hernaez R, Maselli R, Repici A, Khashab MA. Efficacy and Safety of Peroral Endoscopic Myotomy for Treatment of Achalasia After Failed Heller Myotomy. Clin Gastroenterol Hepatol 2017; 15:1531-1537.e3. [PMID: 28189695 DOI: 10.1016/j.cgh.2017.01.031] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 01/21/2017] [Accepted: 01/23/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In patients with persistent symptoms after Heller myotomy (HM), treatment options include repeat HM, pneumatic dilation, or peroral endoscopic myotomy (POEM). We evaluated the efficacy and safety of POEM in patients with achalasia with prior HM vs without prior HM. METHODS We conducted a retrospective cohort study of 180 patients with achalasia who underwent POEM at 13 tertiary centers worldwide, from December 2009 through September 2015. Patients were divided into 2 groups: those with prior HM (HM group, exposure; n = 90) and those without prior HM (non-HM group; n = 90). Clinical response was defined by a decrease in Eckardt scores to 3 or less. Adverse events were graded according to criteria set by the American Society for Gastrointestinal Endoscopy. Technical success, clinical success, and rates of adverse events were compared between groups. Patients were followed up for a median of 8.5 months. RESULTS POEM was technically successful in 98% of patients in the HM group and in 100% of patients in the non-HM group (P = .49). A significantly lower proportion of patients in the HM group had a clinical response to POEM (81%) than in the non-HM group (94%; P = .01). There were no significant differences in rates of adverse events between the groups (8% in the HM group vs 13% in the non-HM group; P = .23). Symptomatic reflux and reflux esophagitis after POEM were comparable between groups. CONCLUSIONS POEM is safe and effective for patients with achalasia who were not treated successfully by prior HM. Although the rate of clinical success in patients with prior HM is lower than in those without prior HM, the safety profile of POEM is comparable between groups.
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Affiliation(s)
- Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Michael B Ujiki
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois
| | - Lava Y Patel
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois
| | - Amol Bapaye
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | | | - Shivangi Dorwat
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Jun Nakamura
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Yoshitaka Hata
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Valerio Balassone
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Thierry Ponchon
- Gastroenterology and Endoscopy Unit, Digestive Disease Department, L Pavillon-Edouard Herriot Hospital, Lyon, France
| | - Mathieu Pioche
- Gastroenterology and Endoscopy Unit, Digestive Disease Department, L Pavillon-Edouard Herriot Hospital, Lyon, France
| | - Sabine Roman
- Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France; INSERM U1032, Lyon, France
| | - Jérôme Rivory
- Gastroenterology and Endoscopy Unit, Digestive Disease Department, L Pavillon-Edouard Herriot Hospital, Lyon, France
| | - François Mion
- Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France; INSERM U1032, Lyon, France
| | - Aurélien Garros
- Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France; INSERM U1032, Lyon, France
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, Florida
| | - Yaseen Perbtani
- Division of Gastroenterology and Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, Florida
| | - Ali Abbas
- Division of Gastroenterology and Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, Florida
| | - Davinderbir Pannu
- Division of Gastroenterology and Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, Florida
| | - Dennis Yang
- Division of Gastroenterology and Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, Florida
| | - Silvana Perretta
- Department of Gastrointestinal and Endocrine Surgery, University of Strasbourg, Strasbourg, France
| | - John Romanelli
- Department of Surgery, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts
| | - David Desilets
- Division of Gastroenterology, Department of Medicine, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts
| | - Bu Hayee
- Department of Gastroenterology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Amyn Haji
- Department of Gastroenterology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Gulara Hajiyeva
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Amr Ismail
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Majidah Bukhari
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Yamile Haito-Chavez
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Payal Saxena
- Department of Gastroenterology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Michael Talbot
- University of New South Wales, Sydney, New South Wales, Australia
| | | | - Hon-Chi Yip
- Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | | | - Ruben Hernaez
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Roberta Maselli
- Digestive Endoscopy Unit, Humanitas Research Hospital, Milan, Italy Digestive Endoscopy Unit, Humanitas Unversity, Milan, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Research Hospital, Milan, Italy Digestive Endoscopy Unit, Humanitas Unversity, Milan, Italy
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland.
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Tyberg A, Seewald S, Sharaiha RZ, Martinez G, Desai AP, Kumta NA, Lambroza A, Sethi A, Reavis KM, DeRoche K, Gaidhane M, Talbot M, Saxena P, Zamarripa F, Barret M, Eleftheriadis N, Balassone V, Inoue H, Kahaleh M. A multicenter international registry of redo per-oral endoscopic myotomy (POEM) after failed POEM. Gastrointest Endosc 2017; 85:1208-1211. [PMID: 27756611 DOI: 10.1016/j.gie.2016.10.015] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 10/05/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Per-oral endoscopic myotomy (POEM) has become an accepted treatment for patients with achalasia. Despite its excellent efficacy rate of greater than 80%, a small percentage of patients remain symptomatic after the procedure. Limited data exist as to the best management for recurrence of symptoms after POEM. We present the first international, multicenter experience on the efficacy and safety of a repeat POEM in the management of achalasia. METHODS Patients who underwent a redo POEM from 15 centers in 9 countries were included in a dedicated registry. Technical success was defined as successful completion of a second myotomy. Clinical success was defined as an Eckardt score of less than or equal to 3 after the second myotomy. Adverse events including anesthesia-related, operative, and postoperative adverse events were recorded. RESULTS Forty-six patients were included in the study. The average age was 49.3 ± 16.78 years. Twenty (45%) patients were male. The mean pre-redo-POEM Eckardt score was 4.3 ± 2.48. Technical success was achieved in 46 (100%) patients. Clinical success was achieved in 41 patients (85%). The average post-POEM Eckardt score was 1.64 ± 1.67, with a significant difference of 2.58 (P < .00001). Eight patients (17%) had adverse events consisting of procedural bleeding, all managed endoscopically. There were no deaths. No POEMs were aborted or required surgical conversion or assistance. DISCUSSION For patients with persistent symptoms after POEM, repeat POEM appears to be an efficacious and safe technique. Further randomized trials comparing redo POEM versus Heller should be considered. (Clinical trial registration number: NCT02162589.).
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Affiliation(s)
- Amy Tyberg
- Division of Gastroenterology & Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Stefan Seewald
- GastroZentrum Hirslanden, Klinik Hirslanden, Zurich, Switzerland
| | - Reem Z Sharaiha
- Division of Gastroenterology & Hepatology, Weill Cornell Medicine, New York, New York, USA
| | | | - Amit P Desai
- Division of Gastroenterology & Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Nikhil A Kumta
- Division of Gastroenterology & Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Arnon Lambroza
- Division of Gastroenterology & Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Amrita Sethi
- Digestive and Liver Disease, Columbia University Medical Center, New York, New York, USA
| | - Kevin M Reavis
- Providence Portland Cancer Center, Portland, Oregon, USA
| | - Ketisha DeRoche
- Division of Gastroenterology & Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Monica Gaidhane
- Division of Gastroenterology & Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Michael Talbot
- Division of Gastroenterology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Payal Saxena
- Division of Gastroenterology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | | | - Maximilien Barret
- Department of Gastroenterology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Valerio Balassone
- Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Haruhiro Inoue
- Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Michel Kahaleh
- Division of Gastroenterology & Hepatology, Weill Cornell Medicine, New York, New York, USA
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Pooshani A, Frootan M, Abdi S, Jahani-Sherafat S, Kamani F. The evaluation of functional results before and after laparoscopic Heller myotomy for achalasia: a single center experience. GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2017; 10:S33-S37. [PMID: 29511469 PMCID: PMC5838178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AIM The aim of this study was to evaluate and compare the functional results before and after laparoscopic Heller myotomy for Iranian patients with achalasia. BACKGROUND Achalasia is a severe neuromuscular disorder of the esophagus, characterized by the loss of peristalsis and an inability of the lower esophageal sphincter (LES) to reach optimal relaxation. METHODS In this cross sectional study, patients who underwent Heller myotomy for achalasia via laparoscopy in Taleghani Hospital Tehran, Iran were evaluated. Symptoms including pressure of residual, integrated relaxation sphincter (IRP), pressure of free drinking, pressure of LES, dysphasia score and peristalsis movement was measured and recorded by manometry before and after (2 months) treating with Heller myotomy. RESULTS In this study, 23 patients with achalasia (12 females and 11 males) with a mean age of 30±3.5 years (minimum 20, maximum 44 years) who met the inclusion criteria of the study were examined. Results of this study showed that, all the diagnostic criteria that were measured before the treatment was significantly different from after the treatment (P<0.05). The average decline in LES, IRP, Residual Pressure, Free drinking esophagus, and dysphasia score were 23.1 mmHg, 16.24 mmHg, 18,7 mmHg, 18.9 mmHg, and 5.0 unit, respectively. Also the average increase of the peristalsis movement was 8.26±13.7 in 8 patients. CONCLUSION Considering the results of Heller myotomy surgery can be as a treatment of choice for achalasia. Free Drinking pressure can be a suitable criteria after treatment for evaluation and prediction of the reducing the dysphasia score after the surgery.
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Affiliation(s)
- Abdollah Pooshani
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Mojgan Frootan
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saeed Abdi
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Somayeh Jahani-Sherafat
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Freshteh Kamani
- Taleghani hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Findings of Esophagography for 25 Patients After Peroral Endoscopic Myotomy for Achalasia. AJR Am J Roentgenol 2016; 207:1185-1193. [DOI: 10.2214/ajr.16.16365] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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20
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Allaix ME, Patti MG. Toward a Tailored Treatment of Achalasia: An Evidence-Based Approach. J Laparoendosc Adv Surg Tech A 2016; 26:256-63. [PMID: 27002740 DOI: 10.1089/lap.2016.0067] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The treatment options in achalasia patients aim to improve symptoms by reducing the functional obstruction at the level of the gastroesophageal junction. Available treatment modalities are endoscopic botulinum toxin injection (EBTI), pneumatic dilatation (PD), laparoscopic Heller myotomy (LHM), and peroral endoscopic myotomy (POEM). We provide an evidence-based review of current indications, limitations, and future perspectives of these options for the treatment of achalasia. METHODS The PubMed/Medline electronic databases and the Cochrane Library were searched. Quality of evidence was assessed according to the GRADE system. RESULTS Functional outcomes after EBTI are significantly worse than those after PD or LHM. LHM with partial fundoplication is associated with low complication rates and provides excellent long-term results with lower need for additional treatment of recurrent dysphagia than PD. POEM is a new promising treatment option with good short-term outcomes and low morbidity in experienced hands. CONCLUSIONS LHM should be considered the procedure of choice for the treatment of achalasia in patients who are fit for surgery. Large randomized controlled trials with long follow-up are needed to validate the role of POEM.
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Affiliation(s)
| | - Marco Giuseppe Patti
- 2 Department of Surgery and Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine , Chicago, Illinois
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21
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Repeated Surgical or Endoscopic Myotomy for Recurrent Dysphagia in Patients After Previous Myotomy for Achalasia. J Gastrointest Surg 2016; 20:494-9. [PMID: 26589525 DOI: 10.1007/s11605-015-3031-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 11/12/2015] [Indexed: 01/31/2023]
Abstract
AIM Surgical myotomy of the lower esophageal sphincter has a 5-year success rate of approximately 91 %. Peroral endoscopic myotomy can provide similar results for controlling dysphagia. Some patients experience either persistent or recurrent dysphagia after myotomy. We present here a retrospective analysis of our experience with redo myotomy for recurrent dysphagia in patients with achalasia. METHODS From March 1996 to February 2015, 234 myotomies for primary or recurrent achalasia were performed in our center. Fifteen patients (6.4 %) had had a previous myotomy and were undergoing surgical redo myotomy (n = 9) or endoscopic redo myotomy (n = 6) for recurrent symptoms. RESULTS Patients presented at a median of 10.4 months after previous myotomy. Median preoperative Eckardt score was 6. Among the nine patients undergoing surgical myotomy, three esophageal perforations occurred intraoperatively (all repaired immediately). Surgery lasted 111 and 62 min on average (median) in the surgical and peroral endoscopic myotomy (POEM) groups, respectively. No postoperative complications occurred in either group. Median postoperative stay was 3 and 2.5 days in the surgical and POEM groups, respectively. In the surgical group, Eckardt score was <3 for seven out of nine patients after a mean follow-up of 19 months; it was <3 for all six patients in the POEM group after a mean follow-up of 5 months. CONCLUSIONS A redo myotomy should be considered in patients who underwent myotomy for achalasia and presenting with recurrent dysphagia. Preliminary results using POEM indicate that the technique can be safely used in patients who have undergone previous surgical myotomy.
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Eleftheriadis N, Inoue H, Ikeda H, Onimaru M, Maselli R, Santi G. Submucosal tunnel endoscopy: Peroral endoscopic myotomy and peroral endoscopic tumor resection. World J Gastrointest Endosc 2016; 8:86-103. [PMID: 26839649 PMCID: PMC4724034 DOI: 10.4253/wjge.v8.i2.86] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 08/01/2015] [Accepted: 11/25/2015] [Indexed: 02/05/2023] Open
Abstract
Peroral endoscopic myotomy (POEM) is an innovative, minimally invasive, endoscopic treatment for esophageal achalasia and other esophageal motility disorders, emerged from the natural orifice transluminal endoscopic surgery procedures, and since the first human case performed by Inoue in 2008, showed exciting results in international level, with more than 4000 cases globally up to now. POEM showed superior characteristics than the standard 100-year-old surgical or laparoscopic Heller myotomy (LHM), not only for all types of esophageal achalasia [classical (I), vigorous (II), spastic (III), Chicago Classification], but also for advanced sigmoid type achalasia (S1 and S2), failed LHM, or other esophageal motility disorders (diffuse esophageal spasm, nutcracker esophagus or Jackhammer esophagus). POEM starts with a mucosal incision, followed by submucosal tunnel creation crossing the esophagogastric junction (EGJ) and myotomy. Finally the mucosal entry is closed with endoscopic clip placement. POEM permitted relatively free choice of myotomy length and localization. Although it is technically demanding procedure, POEM can be performed safely and achieves very good control of dysphagia and chest pain. Gastroesophageal reflux is the most common troublesome side effect, and is well controllable with proton pump inhibitors. Furthermore, POEM opened the era of submucosal tunnel endoscopy, with many other applications. Based on the same principles with POEM, in combination with new technological developments, such as endoscopic suturing, peroral endoscopic tumor resection (POET), is safely and effectively applied for challenging submucosal esophageal, EGJ and gastric cardia tumors (submucosal tumors), emerged from muscularis propria. POET showed up to know promising results, however, it is restricted to specialized centers. The present article reviews the recent data of POEM and POET and discussed controversial issues that need further study and future perspectives.
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Abstract
A laparoscopic Heller myotomy with partial fundoplication is considered today in most centers in the United States and abroad the treatment of choice for patients with esophageal achalasia. Even though the operation has initially a very high success rate, dysphagia eventually recurs in some patients. In these cases, it is important to perform a careful work-up to identify the cause of the failure and to design a tailored treatment plan by either endoscopic means or revisional surgery. The best results are obtained by a team approach, in Centers where radiologists, gastroenterologists, and surgeons have experience in the diagnosis and treatment of this disease.
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Abdi S, Forotan M, Nikzamir A, Zomorody S, Jahani-Sherafat S. The early efficacy of Heller myotomy in the treatment of Iranian patients with achalasia. GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2016; 9:30-5. [PMID: 26744612 PMCID: PMC4702039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM The purpose of this study was to determine the efficacy of Heller myotomy for the treatment of achalasia in a referral center in Tehran, and investigate the clinical characteristics, manometric results and treatment responses among three achalasia subtypes in Iranian patients. BACKGROUND Esophageal achalasia is an unusual swallowing disorder, characterized by high pressure in the lower esophageal sphincter (LES) on swallowing, failure relaxation of the LES and the absence of peristalsis in esophageal. PATIENTS AND METHODS In this cross sectional study, clinical symptom and esophageal manometry before and 2 months after treating with Heller myotomy in 20 patients with achalasia who were referred to Taleghani Hospital, Tehran, in 2013 were evaluated. Patients' demographic, clinical features and response to treatment were analyzed using SPSS software (version 20, Chicago, IL, USA). RESULTS All the diagnostic criteria measured after the treatment were significantly different (P<0.05) before and after the therapy. The average decline in the length of the esophagus was 1.8 cm and dysphasia score was 7.25 units. Also an average decline in LES Resting Pressure, LES Residual Pressure, PIP, and IRP were 23.2 mmHg, 14.3 mmHg, 3.4 mmHg and 17.8 mmHg, respectively. CONCLUSION Results of this study showed that the Heller myotomy is highly effective in relieving dysphasia in patients with achalasia. Also, type II achalasia is the most common subtype of achalasia with a better response to Heller myotomy compared to the other types.
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Affiliation(s)
- Saeed Abdi
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mojgan Forotan
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Abdolrahim Nikzamir
- Biochemical Department, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saeedeh Zomorody
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Somayeh Jahani-Sherafat
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Revisional surgery after failed esophagogastric myotomy for achalasia: successful esophageal preservation. Surg Endosc 2015; 30:1754-61. [PMID: 26275539 DOI: 10.1007/s00464-015-4423-3] [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: 03/15/2015] [Accepted: 07/06/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Treatment failure with recurrent dysphagia after Heller myotomy occurs in fewer than 10 % of patients, most of whom will seek repeat surgical intervention. These reoperations are technically challenging, and as such, there exist only limited reports of reoperation with esophageal preservation. METHODS We retrospectively reviewed the records of patients who sought operative intervention from March 1998 to December 2014 for obstructed swallowing after esophagogastric myotomy. All patients underwent a systematic approach, including complete hiatal dissection, takedown of prior fundoplication, and endoscopic assessment of myotomy. Patterns of failure were categorized as: fundoplication failure, inadequate myotomy, fibrosis, and mucosal stricture. RESULTS A total of 58 patients underwent 65 elective reoperations. Four patients underwent esophagectomy as their initial reoperation, while three patients ultimately required esophagectomy. The remainder underwent reoperations with the goal of esophageal preservation. Of these 58, 46 were first-time reoperations; ten were second time; and two were third-time reoperations. Forty-one had prior operations via a trans-abdominal approach, 11 via thoracic approach, and 6 via combined approaches. All reoperations at our institution were performed laparoscopically (with two conversions to open). Inadequate myotomy was identified in 53 % of patients, fundoplication failure in 26 %, extensive fibrosis in 19 %, and mucosal stricture in 2 %. Intraoperative esophagogastric perforation occurred in 19 % of patients and was repaired. Our postoperative leak rate was 5 %. Esophageal preservation was possible in 55 of the 58 operations in which it was attempted. At median follow-up of 34 months, recurrent dysphagia after reoperation was seen in 63 % of those with a significant fibrosis versus 28 % with inadequate myotomy, 25 % with failed wrap, and 100 % with mucosal stricture (p = 0.10). CONCLUSIONS Laparoscopic reoperation with esophageal preservation is successful in the majority of patients with recurrent dysphagia after Heller myotomy. The pattern of failure has implications for relief of dysphagia with reoperative intervention.
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Kumagai K, Tsai JA, Thorell A, Lundell L, Håkanson B. Per-oral endoscopic myotomy for achalasia. Are results comparable to laparoscopic Heller myotomy? Scand J Gastroenterol 2015; 50:505-12. [PMID: 25712228 DOI: 10.3109/00365521.2014.934915] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Per-oral endoscopic myotomy (POEM) has recently been introduced as a minimal invasive alternative to conventional treatment for achalasia. This study aimed to clarify the feasibility and the short-term clinical efficacy of POEM as compared to laparoscopic Heller myotomy (LHM). METHODS Treatment outcomes were prospectively recorded and compared between the procedures in a nonrandomized fashion. Reduction rate (RR) in timed barium esophagogram (TBE) was calculated at 1, 2 and 5 min after barium ingestion as: RR = 1- postoperative barium height/preoperative barium height. Risk factors for treatment failure defined as the proportion of patients with RR <0.5 (1 min) and gastroesophageal reflux (GER) after POEM were analyzed. RESULTS Forty-two consecutive patients who underwent POEM were compared to 41 patients who had a LHM during the immediate time period prior to the introduction of POEM. Ninety percent of the cases reported complete symptom relief after POEM. The percentage of esophageal emptying and RR in TBE improved dramatically by both procedures without significant difference. A longer operation time (odds ratio [OR] 32.80, 95%CI 2.99-359.82, p = 0.004) and younger age (OR 26.81, 95%CI 2.09-344.03, p = 0.012) were the independent predictors of treatment failure after POEM. GER was observed in seven patients where previous dilatation (OR 8.59, 95%CI 1.16-63.45, p = 0.035) and higher body mass index (OR 8.69, 95%CI 1.13-66.63, p = 0.037) were the independent predictors for symptomatic GER after POEM. CONCLUSION POEM seems to be a safe and effective treatment option for achalasia in the short-term perspective; an effect well comparable to LHM.
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Affiliation(s)
- Koshi Kumagai
- Gastrocentrum, Karolinska University Hospital and CLINTEC, Karolinska Institutet , Stockholm , Sweden
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Minami H, Inoue H, Haji A, Isomoto H, Urabe S, Hashiguchi K, Matsushima K, Akazawa Y, Yamaguchi N, Ohnita K, Takeshima F, Nakao K. Per-oral endoscopic myotomy: emerging indications and evolving techniques. Dig Endosc 2015; 27:175-81. [PMID: 25040806 DOI: 10.1111/den.12328] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 06/27/2014] [Indexed: 12/14/2022]
Abstract
Esophageal achalasia is a benign esophageal motility disorder resulting from an impaired relaxation of the lower esophageal sphincter. The principles of treatment involve disruption of the sphincter at the esophagogastric junction. Treatment techniques include balloon dilatation, botulinum toxin injection, and surgical myotomy. In 2008, per-oral endoscopic myotomy (POEM) was introduced by Inoue et al. as an endoscopic myotomy with no skin incision. The procedure has been well accepted and widely applied owing to its minimal invasiveness and high cure rates. Moreover, there have been discussions on wider indications for POEM and new technical developments have been reported. The present article reviews the historical background and present status of POEM, as well as future prospects for its application in the treatment of esophageal achalasia.
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Affiliation(s)
- Hitomi Minami
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
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Orenstein SB, Raigani S, Wu YV, Pauli EM, Phillips MS, Ponsky JL, Marks JM. Peroral endoscopic myotomy (POEM) leads to similar results in patients with and without prior endoscopic or surgical therapy. Surg Endosc 2014; 29:1064-70. [PMID: 25249143 DOI: 10.1007/s00464-014-3782-5] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Accepted: 07/24/2014] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Traditional treatment for the esophageal motility disorder, achalasia, ranges from endoscopic botulinum toxin (Botox) injections or balloon dilatation, to laparoscopic or open surgical myotomy. Recent advances in endoscopic therapy have led to peroral endoscopic myotomy (POEM) as a viable alternative to traditional techniques for myotomy. Uncertainty exists as to whether the procedure is feasible for patients who have already received prior endoscopic or surgical procedures for therapy, as these groups experience higher failure rates as well as intraoperative mucosal perforations and technical difficulty during Heller myotomy. We describe our first 40 patients who have undergone POEM and compare outcomes between patients who have or have not received previous treatment for achalasia. METHODS AND PROCEDURES We evaluated our prospectively collected database of POEM procedures performed by two surgeons (JLP and JMM) at a single institution. Perioperative data was collected for operative and hospital outcomes. Patients completed pre- and postoperative GERD-Health-Related Quality of Life Questionnaires (GERD-HRQL) and SF-12 surveys for symptom scoring. RESULTS Forty patients received a POEM procedure between 2011 and 2013. Of these, 40% (n = 16) had had at least one prior endoscopic or surgical procedure. Nine had prior Botox injections, 7 had balloon dilations, 3 had both Botox and dilations, and 3 received prior laparoscopic Heller myotomy (two with Dor fundoplication). Mean operative time was 102 min for patients with prior procedures (Prior Tx) and 118 min for patients without any prior procedure (No Tx) (p = 0.07). Intraoperative complication rates for the Prior Tx group were 12.5 versus 16.7% for the No Tx group. Mean follow-up was 10 months. Both groups independently demonstrated clinical improvement in both the GERD-HRQL and SF-12 scores following POEM. There were no statistical differences between the two groups for GERD-HRQL reflux and dysphagia subset scores, or SF-12 mental component summary. CONCLUSION We found favorable outcomes following POEM in patients who have had prior endoscopic or surgical treatments for achalasia, as well as for patients without prior intervention. There were no significant differences between these two groups with regards to operative times, GERD-HRQL scores, and mental component SF-12 scores. One complication requiring intervention occurred in a patient that had received multiple prior Botox injections and balloon dilatations. POEM appears to be a viable alternative for treatment of achalasia compared to traditional techniques, however, long-term data are needed to establish the durability of this technique and to determine whether symptoms will recur necessitating re-intervention.
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Affiliation(s)
- Sean B Orenstein
- Department of Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
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Kim HM. Peroral endoscopic myotomy is expanding its indications: (j am coll surg 2013;217:598-605). J Neurogastroenterol Motil 2014; 20:276-7. [PMID: 24840383 PMCID: PMC4015209 DOI: 10.5056/jnm.2014.20.2.276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 11/30/2013] [Indexed: 11/26/2022] Open
Affiliation(s)
- Hee Man Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Korea
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Onimaru M, Inoue H, Ikeda H, Yoshida A, Santi EG, Sato H, Ito H, Maselli R, Kudo SE. Peroral endoscopic myotomy is a viable option for failed surgical esophagocardiomyotomy instead of redo surgical Heller myotomy: a single center prospective study. J Am Coll Surg 2013; 217:598-605. [PMID: 23891071 DOI: 10.1016/j.jamcollsurg.2013.05.025] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 05/31/2013] [Accepted: 05/31/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Surgical Heller myotomy has high rates of successful long-term results, but failed cases still remain. Moreover, the treatment strategy in patients with surgical myotomy failure is controversial. Recently, peroral endscopic myotomy (POEM) was reported to be efficient and safe in primary treatment of achalasia. In this study, we aimed to evaluate the efficacy and safety of POEM for surgical myotomy failure as a rescue second-line treatment, and we discuss the treatment options adapted in achalasia recurrence. STUDY DESIGN A total of 315 consecutive achalasia patients received POEM from September 2008 to December 2012 in our hospital. Eleven (3.5%) patients who had persistent or recurrent achalasia and had received surgical myotomy as a first-line treatment from other hospitals were included in this study. Patient background, barium swallow studies, esophagogastroduodenoscopy (EGD), manometry, and symptom scores were prospectively evaluated. In principle, all patients in whom surgical myotomy failed received pneumatic balloon dilatation (PBD) as the first line "rescue" treatment, and only if PBD failed were patients considered for rescue POEM. RESULTS The PBD alone was effective in 1 patient, and in the remaining 10 patients, rescue POEM was performed successfully without complications. Three months after rescue POEM, significant reduction in lower esophageal sphincter (LES) resting pressures (22.1 ± 6.6 mmHg vs 10.9 ± 4.5 mmHg, p < 0.01) and Eckardt symptom scores (6.5 ± 1.3 vs 1.1 ± 1.3, p < 0.001) were observed. CONCLUSIONS Short-term results of POEM for failed surgical myotomy were excellent. Long-term results are awaited.
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Affiliation(s)
- Manabu Onimaru
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan.
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Li QL, Chen WF, Zhou PH, Yao LQ, Xu MD, Hu JW, Cai MY, Zhang YQ, Qin WZ, Ren Z. Peroral endoscopic myotomy for the treatment of achalasia: a clinical comparative study of endoscopic full-thickness and circular muscle myotomy. J Am Coll Surg 2013; 217:442-51. [PMID: 23891074 DOI: 10.1016/j.jamcollsurg.2013.04.033] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 04/01/2013] [Accepted: 04/23/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND A circular muscle myotomy preserving the longitudinal outer esophageal muscular layer is often recommended during peroral endoscopic myotomy (POEM) for achalasia. However, because the longitudinal muscle fibers of the esophagus are extremely thin and fragile, and completeness of myotomy is the basis for the excellent results of conventional surgical myotomy, this modification needs to be further debated. Here, we retrospectively analyzed our prospectively maintained POEM database to compare the outcomes of endoscopic full-thickness and circular muscle myotomy. STUDY DESIGN According to the myotomy depth, 103 patients with full-thickness myotomy were assigned to group A, while 131 patients with circular muscle myotomy were assigned to group B. Symptom relief, procedure-related parameters and adverse events, manometry outcomes, and reflux complications were compared between groups. RESULTS The mean operation times were significantly shorter in group A compared with group B (p = 0.02). There was no increase in any procedure-related adverse event after full-thickness myotomy (all p < 0.05). During follow-up, treatment success (Eckardt score ≤ 3) persisted for 96.0% (95 of 99) of patients in group A and for 95.0% (115 of 121) of patients in group B (p = 0.75). There were no statistically significant differences in pre- and post-treatment D-value of symptom scores and lower esophageal sphincter pressures between groups (both p > 0.05). The overall clinical reflux complication rates were also similar (21.2% vs 16.5%, p = 0.38). CONCLUSIONS Short-term symptom relief and manometry outcomes of each method were comparable. Full-thickness myotomy significantly reduced the procedure time but did not increase the procedure-related adverse events or clinical reflux complications.
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Affiliation(s)
- Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
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Reasons and prevalence of reoperations after esophagomyotomy for achalasia. Surg Laparosc Endosc Percutan Tech 2013; 22:392-5. [PMID: 23047379 DOI: 10.1097/sle.0b013e3182632d7a] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Surgical esophagomyotomy has been shown to provide superior long-term symptom relief as compared with nonsurgical interventions. Failure of surgical treatment remains the center of controversy regarding this topic. METHODS A retrospective review was conducted of all patients who underwent surgical treatment of achalasia from January 2005 to July 2009 at Cleveland Clinic Florida. RESULTS A total of 66 patients (41 women and 25 men), with a mean age of 51 years (range, 24 to 86 y). Fifty-nine patients (89%) underwent laparoscopic surgery, including 2 (3%) with recurrent achalasia. One patient was converted to laparotomy. Twelve patients required a reintervention because of failure or complications (18%). Six cases were confirmed intraoperatively to be recurrent achalasia that necessitated redo Heller myotomy. CONCLUSIONS Early reoperations after Heller's Dor esophagomyotomy are mostly related to technical errors, whereas most late reoperations are related to recurrent disease. Laparoscopy seems to be safe and the preferred approach for primary as well as redo procedures.
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Abu Gazala M, Khalaila A, Shussman N, Abu Gazala S, Elazary R, Amar D, Kushnir D, Ponomernco O, Zamir G, Rivkind AI, Mintz Y. Transesophageal endoscopic myotomy for achalasia: recognizing potential pitfalls before clinical application. Surg Endosc 2011; 26:681-7. [PMID: 21993936 DOI: 10.1007/s00464-011-1937-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 09/13/2011] [Indexed: 12/20/2022]
Abstract
BACKGROUND Laparoscopic Heller esophagomyotomy is the standard of care for achalasia treatment. This procedure, although effective, must be performed with the patient under general anesthesia and is associated with several serious potential complications. The authors aimed to develop a method of performing transesophageal endoscopic esophagomyotomy (TEEM) that would obviate the need for both general anesthesia and external incisions while offering lower intra- and postoperative complications. METHODS The TEEM procedure was performed on eight pigs. For six of the pigs, the procedure aimed at survival. A mid-esophageal mucosal incision was performed using an endoscope, and a submucosal plane was developed. The lower esophageal sphincter (LES) muscle fibers were clearly visualized and divided. The mucosal incision was closed using fibrin sealant. After 2 weeks of survival, a gastrografin swallow study and necropsy were performed. RESULTS The TEEM procedure was performed successfully in all eight porcine models. The myotomy included the LES fibers and extended 4 to 6 cm proximally to the esophagus. The proximal gastric muscle was divided up to 1 to 2 cm. No injuries to the abdominal or mediastinal structures occurred. One pig died on postoperative day 1 due to an unrecognized pneumothorax. Two pigs had ischemic ulcers at the myotomy site. The last three pigs had an uneventful recovery. The mucosal incision site healed completely in all the survived pigs, and except for the pig with mediastinal sepsis, all ate heartily and gained weight as expected. CONCLUSION The TEEM procedure is technically feasible. Due to the morbidity encountered in the first three pigs, the reported technique was modified to include a slimmer endoscope, a shorter tunnel, and a partial-thickness myotomy. These changes together with an understanding of the pitfalls involved in this procedure led to successful results for the next three pigs. Nevertheless, the authors believe that TEEM is not yet ready for prime time. Perfection of the technique and development of dedicated instruments are mandatory before safe translation of this method to human patients.
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Affiliation(s)
- Mahmoud Abu Gazala
- Department of General Surgery, Hadassah Hebrew University Medical Center, P.O. Box 12000, 91120, Jerusalem, Israel.
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Kashiwagi H, Omura N. Surgical treatment for achalasia: when should it be performed, and for which patients? Gen Thorac Cardiovasc Surg 2011; 59:389-98. [PMID: 21674305 DOI: 10.1007/s11748-010-0765-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 12/13/2010] [Indexed: 01/11/2023]
Abstract
Achalasia is a rare motor disorder of the esophagus, characterized by the absence of peristalsis and impaired swallow-induced relaxation. In the past decade, evidence has been accumulated suggesting that achalasia may be an immune-mediated inflammatory disorder. With the advent of minimally invasive surgery, laparoscopic Heller myotomy (LHM) has slowly shifted the treatment of achalasia toward the greater use of surgical therapy. The goal of both surgical and nonsurgical treatment is to eliminate the outflow obstruction afforded by a nonrelaxing sphincter, relieving dysphagia and maintaining a barrier against gastroesophageal reflux (GER). Endoscopic botulinum toxin injection (EBTI) is safe, easy to perform, inexpensive, and effective in aged patients, and it is especially effective when the lower esophageal pressure is hypertonic. This therapeutic option is reserved for patients too ill to undergo any surgical procedure. Pneumatic dilation (PD) has been shown to be an effective and inexpensive treatment with few adverse effects. The long-term success rate of PD seems to drop progressively over time. Heller myotomy (HM) has shown the best clinical efficacy in achalasia as a first-line treatment. Multiple endoscopic treatments are associated with poorer outcomes after HM. EBTI also makes LHM more difficult and results in a worse surgical outcome. The inferior symptomatic outcomes after thoracoscopic HM may be caused by the difficulty in extending an adequate myotomy onto the stomach from the chest and the inability to create a fundoplication. LHM with Dor's fundoplication (LHM + Dor) is effective and is safer procedure for avoiding GER, dysphagia, mucosal perforation, and a pseudodiverticulum. LHM + Dor is also effective in the presence of sigmoid achalasia, but the clinical result is not as good as nonsigmoid achalasia. A few patients need esophagectomy for surgical failure of HM. However, considering the risk of esophagectomy, LHM + Dor is the first treatment option for patients with achalasia regardless of the degree of esophageal dilatation. This procedure is therefore considered to be an effective and safe treatment for patients of any age or with any condition.
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Affiliation(s)
- Hideyuki Kashiwagi
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-ku, Tokyo 105-8461, Japan.
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Craft RO, Aguilar BE, Flahive C, Merritt MV, Chapital AB, Schlinkert RT, Harold KL. Outcomes of minimally invasive myotomy for the treatment of achalasia in the elderly. JSLS 2011; 14:342-7. [PMID: 21333185 PMCID: PMC3041028 DOI: 10.4293/108680810x12924466007368] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Laparoscopic Heller myotomy can safely be performed in elderly patients and can provide significant symptom relief. Background: An increasing number of elderly patients diagnosed with achalasia are being referred for minimally invasive myotomy. Little data are available about the operative outcomes in this population. The objective of this study was to review our experience with this procedure in an elderly population. Methods: A retrospective review was performed of 51 consecutive patients, 65 years of age or older, diagnosed with achalasia who underwent a minimally invasive myotomy at our institution. Prior therapies, perioperative outcomes, and postoperative interventions were also analyzed. Results: Of the 51 patients, 28 (55%) had undergone prior endoscopic therapy, and 2 patients (7%) had a prior myotomy. Mean duration of symptoms was 10.9 years (range, 0.5 to 50). No perioperative mortality occurred, and the median hospital stay was 3 days. Two patients (3.8%) had complications, including a gastric mucosal injury and one atelectasia. Eleven patients (21%) required additional therapy postoperatively. Symptom improvement was described in all patients. Conclusion: Laparoscopic Heller myotomy can safely be performed in elderly patients, providing significant symptom relief. No evidence suggests that surgery should not be considered a first-line treatment. Advanced age does not appear to adversely affect outcomes of laparoscopic Heller myotomy.
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Affiliation(s)
- Randall O Craft
- Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, Arizona 85054, USA
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Rosemurgy AS, Morton CA, Rosas M, Albrink M, Ross SB. A single institution's experience with more than 500 laparoscopic Heller myotomies for achalasia. J Am Coll Surg 2010; 210:637-45, 645-7. [PMID: 20421021 DOI: 10.1016/j.jamcollsurg.2010.01.035] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Accepted: 01/20/2010] [Indexed: 12/21/2022]
Abstract
BACKGROUND Long-term symptom relief and patient satisfaction after Heller myotomy are being reported. Herein, we report the largest experience of laparoscopic Heller myotomy for the treatment of achalasia. STUDY DESIGN Since 1992, 505 patients have been prospectively followed after laparoscopic Heller myotomy. Until 2004, concomitant fundoplication was undertaken for a patulous hiatus, a large hiatal hernia, or to buttress the repair of an esophagotomy, then concomitant fundoplication became routinely applied. More recently, laparo-endoscopic single site (LESS) Heller myotomy has been performed when possible to improve cosmesis. Before and after myotomy, patients scored their symptoms. RESULTS Before myotomy, 60% of patients underwent endoscopic therapy; of these patients, 27% had Botox (Allergan) therapy alone, 52% underwent dilation therapy alone, and 21% had both. Esophagotomy occurred in 7% of patients. Concomitant diverticulectomy was undertaken in 7%, fundoplication was performed in 59%, and LESS Heller myotomy was done in 12%. Median length of stay was 1 day. With mean follow-up at 31 months, the severity of all symptoms improved significantly. After myotomy, 95% experienced symptoms less than once per week, 86% believed their outcome is satisfying or better, and 92% would undergo myotomy again, if necessary. Symptoms after myotomy are similar with or without fundoplication and regardless of the laparoscopic approach used. CONCLUSIONS Laparoscopic Heller myotomy safely and durably relieves symptoms of dysphagia. Confinement is short and satisfaction is very high. Relief of esophageal obstruction is paramount; the approach used or the application of a fundoplication has a lesser impact. Laparoscopic Heller myotomy, preferably with anterior fundoplication using a single site laparoscopic approach, is strongly encouraged for patients with symptomatic achalasia and is efficacious even after failures of dilation and/or Botox therapy.
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Affiliation(s)
- Alexander S Rosemurgy
- Department of Surgery, University of South Florida College of Medicine, Tampa General Hospital, Tampa, FL, USA
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