Systematic Review With Meta-Analysis: Chronic Opioid Use Is Associated With Esophageal Dysmotility in Symptomatic Patients

INTRODUCTION

We aimed to conduct a systematic review and meta-analysis to assess the impact of chronic opioid exposure on esophageal motility in patients undergoing manometric evaluation.

METHODS

Multiple databases were searched through October 2022 for original studies comparing the manometric results of patients who have used chronic opioids (for >90 days) with those who do not. The primary outcomes were esophageal dysmotility disorders. Three high-resolution manometry parameters were conducted as secondary outcomes. A random-effects model was applied to calculate the odds ratio (OR) and means difference (MD) along with a 95% confidence interval (CI).

RESULTS

Nine studies were included in this meta-analysis. Opioid use was associated with higher esophageal dysmotility disorders, including distal esophageal spasm (pooled OR 4.84, 95% CI 1.60-14.63, P = 0.005, I 2 = 96%), esophagogastric junction outflow obstruction (pooled OR 5.13, 95% CI 2.11-12.43, P = 0.0003, I 2 = 93%), and type III achalasia (pooled OR 4.15, 95% CI 2.15-8.03, P < 0.0001, I 2 = 64%). No significant differences were observed for hypercontractile esophagus, type I achalasia, or type II achalasia. The basal lower esophageal sphincter pressure (MD 3.02, 95% CI 1.55-4.50, P < 0.0001, I 2 = 90%), integrated relaxation pressure (MD 2.51, 95% CI 1.56-3.46, P < 0.00001, I 2 = 99%), and distal contractile integral (MD 640.29, 95% CI 469.56-811.03, P < 0.00001, I 2 = 91%) significantly differed between the opioid use and nonopioid use group. However, opioid use was associated with a lower risk of ineffective esophageal motility (pooled OR 0.68, 95% CI 0.49-0.95, P = 0.02, I 2 = 53%).

DISCUSSION

Chronic opioid exposure is associated with an increased frequency esophageal dysmotility disorders. Our results revealed that opioid use is significantly associated with type III achalasia but not with type I and II achalasia. Therefore, opioid treatment should be taken into account as a potential underlying risk factor when diagnosing these major esophageal motor abnormalities.

Opioid-Induced Esophageal Dysmotility (OIED) - A Case Report

Recent studies have shown that chronic opioid use is associated with an increased risk of symptomatic esophageal motility disorders. Opioid-induced esophageal dysfunction (OIED) is most often identified in patients taking high doses of opioids. This condition is associated with poorer treatment outcomes than primary motility disorders and management of these cases is further complicated by the presence of chronic pain, opioid addiction, and physical and psychological comorbidity.We present the case of a 68-year-old Caucasian woman with OIED, induced by the chronic intake of low-dose Fentanyl and Tramadol prescribed to treat severe back pain. The clinical course highlights the sometimes difficult diagnosis and management of this recently recognized condition.

Per-oral endoscopic myotomy for the treatment of non-achalasia esophageal dysmotility disorders: experience from a single high-volume center

BACKGROUND

Achalasia is a rare disorder of esophageal motility that induces progressive intolerance to oral intake. Other esophageal dysmotility disorders include esophagogastric junction outflow obstruction (EGJOO), distal esophageal spasm (DES), hypercontractile esophagus (HE), and other minor disorders of peristalsis (MDP) and can present similarly to achalasia despite different pathophysiologies. Prior studies have demonstrated the safety and efficacy of POEM in the treatment of achalasia, but little is reported regarding POEM's role in treating non-achalasia esophageal dysmotility disorders (NAEDD). This study aims to assess the safety and efficacy of POEM in the treatment of NAEDD.

STUDY DESIGN

This is a retrospective review of consecutive POEM cases from June 1, 2011, to February 1, 2021. NAEDD were characterized according to the Chicago classification. Primary outcome measure was the resolution of preoperative symptoms. Secondary outcomes include preoperative diagnosis, myotomy length, conversion to laparoscopic or open procedure, operative time, and length of stay (LOS). Technical success was defined as the completion of an 8 cm myotomy including the esophagogastric junction (EGJ) and extending 2 cm distal to the EGJ. Clinical success was defined as a postoperative Eckardt score ≤ 3.

RESULTS

Of 124 cases of POEM performed during the study period, 17 were performed for NAEDD. Technical success was achieved in all 17 patients (100%). Of the fifteen patients that had documented postoperative Eckardt scores, 13 were ≤ 3, achieving a clinical success rate of 87%. Subgroup analysis (HE/MDP/DES vs. EGJOO) showed no significant differences in the preoperative or postoperative Eckardt scores between groups, and both groups demonstrated a significant decrease in Eckardt scores after POEM. No cases were aborted for technical or clinical reasons, and there were no adverse outcomes.

CONCLUSION

POEM is a safe and efficacious treatment modality for NAEDD. Further work is needed to develop optimal treatment strategies for this complex group of diseases.

Esophageal spasm in infancy

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