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Albéniz E, Marra-López Valenciano C, Estremera-Arévalo F, Sánchez-Yagüe A, Montori S, Rodríguez de Santiago E. POEM from A to Z: current perspectives. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2025; 117:4-13. [PMID: 37073708 DOI: 10.17235/reed.2023.9602/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
The "third space endoscopy" or also called "submucosal endoscopy" is a reality we can transfer to our patients since 2010. Various modifications of the submucosal tunneling technique allow access to the submucosa or deeper layers of the gastrointestinal tract. In addition to peroral endoscopic myotomy for the treatment of achalasia, also called esophageal POEM, other variants have emerged that make it possible to treat different esophageal motility disorders, esophageal diverticula, subepithelial tumors of various locations, gastroparesis, reconnection of complete esophageal strictures or even thanks to exceptional endoscopists, pediatric disorders such as Hirschsprung's disease. Although some technical aspects are yet to be standardized, these procedures are becoming widespread worldwide and will likely become the standard treatment of these pathologies soon.
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Affiliation(s)
- Eduardo Albéniz
- Endoscopy Unit. Gastroenterology, Hospital Universitario de Navarra (HUN). Navarrabiomed. UPNA. IdiSNA, España
| | | | - Fermín Estremera-Arévalo
- Endoscopy Unit. Gastroenterology , Hospital Universitario de Navarra (HUN). Navarrabiomed. UPNA, IdiSNA, España
| | | | - Sheyla Montori
- Gastrointestinal Endoscopy Research Unit, Hospital Universitario de Navarra (HUN). Navarrabiomed. UPNA, IdiSNA, Spain
| | - Enrique Rodríguez de Santiago
- Gastroenterology and Hepatology , Hospital Universitario Ramón y Cajal. Universidad de Alcalá. IRYCIS. CIBERehd. ISCIII, Spain
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Evensen H, Hjermstad MJ, Cvancarova M, Kristensen V, Larssen L, Skattum J, Hauge T, Sandstad O, Medhus AW. Quality of life in patients with achalasia: Associations with Eckardt score and objective treatment outcomes after peroral endoscopic myotomy. Endosc Int Open 2022; 10:E1570-E1576. [PMID: 36531682 PMCID: PMC9754863 DOI: 10.1055/a-1968-7682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 10/25/2022] [Indexed: 10/31/2022] Open
Abstract
Background and study aims Knowledge on self-reported quality of life (QoL) in achalasia and QoL improvements after peroral endoscopic myotomy (POEM) is limited. Furthermore, the clinical role of QoL in achalasia follow-up has not been evaluated. The present study aimed to examine QoL in achalasia patients before and after POEM and assess associations between QoL, Eckardt score (ES) and objective results. Patients and methods This was a single-center prospective study of treatment-naïve achalasia patients with 12-month follow-up after POEM including manometry, upper endoscopy, 24-hour pH registration, and timed barium esophagogram. QoL data were registered using European Organisation for Research and Treatment of Cancer core questionnaire (QLQ-C30) and esophageal module (QLQ-OES18). Comparison with a reference population was performed to assess impact of achalasia on QoL and effect of therapy. Mixed models for repeated measures were applied. Results Fifty patients (26 females) with a median age of 47 years (18-76) were included. Before treatment, all QoL domains were significantly impaired compared with an age- and gender-adjusted reference population ( P < 0.05). No significant QoL-differences were found after POEM, except for fatigue and nausea/vomiting. Clinically relevant QoL improvement was observed in ≥ 50 % of the patients in all QoL domains, except for physical and role functioning. QoL was significantly associated with ES ( P < 0.05) but not with objective results. Conclusions Achalasia is associated with severe QoL impairment. Following POEM, a significant and clinically relevant QoL improvement is observed. QoL is associated with ES, but not with objective results after POEM.
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Affiliation(s)
- Helge Evensen
- Department of Gastroenterology, Oslo University Hospital, Norway,Faculty of Medicine, University of Oslo, Norway
| | - Marianne Jensen Hjermstad
- Regional Advisory Unit for Palliative Care, Dept. of Oncology, Oslo University Hospital, Norway,European Palliative Care Research Centre (PRC), Dept. of Oncology, Oslo University Hospital, Norway,Institute of Clinical Medicine, University of Oslo, Norway
| | - Milada Cvancarova
- Department of Gastroenterology, Oslo University Hospital, Norway,Faculty of Health Sciences, Oslo Metropolitan University, Norway
| | - Vendel Kristensen
- Department of Gastroenterology, Oslo University Hospital, Norway,Unger-Vetlesen Institute, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Lene Larssen
- Department of Gastroenterology, Oslo University Hospital, Norway
| | - Jorunn Skattum
- Department of Abdominal Surgery, Innlandet Hospital Trust, Hamar, Norway
| | - Truls Hauge
- Department of Gastroenterology, Oslo University Hospital, Norway,Faculty of Medicine, University of Oslo, Norway
| | - Olav Sandstad
- Department of Gastroenterology, Oslo University Hospital, Norway
| | - Asle W. Medhus
- Department of Gastroenterology, Oslo University Hospital, Norway
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Rosa-E-Silva L, Pontes RMA, Vendrame GLME, Xavier FAL, Kreling GAD, Bellinati PQ. IMPAIRED QUALITY OF LIFE IN CHAGAS ACALASIA PATIENTS AND ASSOCIATED CLINICAL FACTORS. ARQUIVOS DE GASTROENTEROLOGIA 2022; 59:281-287. [PMID: 35830042 DOI: 10.1590/s0004-2803.202202000-50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/25/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND No study has focused on Health-Related Quality of Life (HRQoL) for Chagas Achalasia patients. Objective: To compare HRQoL between Chagas Achalasia patients and the general population; and to correlate HRQoL with clinical factors that can affect it. METHODS Sixty Chagas Achalasia patients and 50 controls were evaluated. All patients underwent esophageal manometry for the diagnosis of achalasia and esophagogram to determine the grade of megaesophagus. Three questionnaires were used: 1) clinical: the following data were collected: demographic, medical history, body mass index, occurrence of six esophageal symptoms (Esophageal Symptom Score: number of symptoms reported by patients), duration of dysphagia; 2) socio-economic-cultural status evaluation: patients and controls answered seven questions about their socio-economic-cultural conditions; 3) HRQoL: the validated Brazilian-Portuguese version of the Short-form Health Survey (SF-36) questionnaire (license QM020039) was used. It measures health in eight domains: 3a) four physical: physical functioning, role limitations relating to physical health, bodily pain, and general health perception; 3b) four mental: vitality, social functioning, role limitations relating to emotional health, and mental health. These domains can be summarized into Physical and Mental Summary scores. We analyzed correlations between SF-36 Physical/Mental Summary Component scores and the following clinical factors: Esophageal Symptom Score, duration of dysphagia, body mass index, grades of megaesophagus (defined by the esophagogram) and presence/absence of megacolon (defined by opaque enema). RESULTS Patients and controls had similar age, gender, medical history, and socio-economic-cultural lifestyles (P>0.05). All patients had dysphagia and megaesophagus. SF-36 scores were significantly lower in Chagas Achalasia patients than controls for all eight domains (physicals: P<0.002; mentals: P<0.0027). The Physical and Mental Summary Component scores were also lower in Chagas Achalasia patients than controls (P<0.0062). For patients, the Physical Summary score was negatively correlated to Esophageal Symptom Score (P=0.0011) and positively correlated to body mass index (P=0.02). No other correlations were found. CONCLUSION Chagas Achalasia patients have an impaired HRQoL in all physical and mental domains. Patients reporting more symptoms had worse physical domains. Patients with higher body mass index had better physical domains.
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Affiliation(s)
- Lucilene Rosa-E-Silva
- Universidade Estadual de Londrina, Centro de Ciências da Saúde, Departamento de Clínica Médica, Londrina, PR, Brasil
| | - Rose Meire Albuquerque Pontes
- Universidade Estadual de Londrina, Centro de Ciências da Saúde, Departamento de Clínica Médica, Londrina, PR, Brasil
| | | | | | - Gabriel Afonso Dutra Kreling
- Universidade Estadual de Londrina, Centro de Ciências da Saúde, Departamento de Clínica Médica, Londrina, PR, Brasil
| | - Philipe Quagliato Bellinati
- Universidade Estadual de Londrina, Centro de Ciências da Saúde, Departamento de Clínica Médica, Londrina, PR, Brasil
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Zhong C, Tan S, Ren Y, Lü M, Peng Y, Fu X, Tang X. Quality of Life Following Peroral Endoscopic Myotomy for Esophageal Achalasia: A Systematic Review and Meta-Analysis. Ann Thorac Cardiovasc Surg 2020; 26:113-124. [PMID: 32132346 PMCID: PMC7303313 DOI: 10.5761/atcs.ra.19-00273] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 12/26/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is a novel minimally invasive intervention for treating esophageal achalasia. Previous publications have proved its excellent efficacy and safety, and even shown it could improve patients' quality of life (QoL). So, we conducted this study to explore the changes of QoL following POEM. METHODS A comprehensive literature search was conducted on PubMed, EMBASE, and Cochrane Library covering the period from January 2009 to April 2019. The statistical analysis was carried out using Review Manager 5.3. RESULTS A total of 12 studies including 549 patients were identified, which assessed the QoL using validated questionnaires administered. After POEM, the SF-36 questionnaire score of each domain (physical function, role physical function, body pain, general health (GH), social function, vitality, emotional role function, mental health) was significantly increased (p < 0.05). Meanwhile, mental component scale (MCS) and physical component scale (PCS) scores were all improved in patients after POEM procedure (MCS: 12.11, 95% confidence interval [CI], 4.67-19.55, p = 0.001, I2 = 88%, PCS: 17.01, 95% CI, 2.91-31.11, p = 0.02, I2 = 97%). The gastroesophageal reflux disease health-related quality of life questionnaires (GERD-HRQL) also decreased significantly after POEM (13.01, 95% CI, 9.98-16.03, p < 0.00001, I2 = 30%). CONCLUSIONS Our current evidence suggests there is significant improvement in QoL after POEM procedure.
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Affiliation(s)
- Chunyu Zhong
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shali Tan
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yutang Ren
- Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Muhan Lü
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yan Peng
- 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
| | - Xiaowei Tang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
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Li DF, Xiong F, Yu ZC, Zhang HY, Liu TT, Tian YH, Shi RY, Lai MG, Song Y, Xu ZL, Zhang DG, Yao J, Wang LS. Effect and safety of mark-guided vs standard peroral endoscopic myotomy: A retrospective case control study. World J Gastroenterol 2020; 26:973-983. [PMID: 32206007 PMCID: PMC7081014 DOI: 10.3748/wjg.v26.i9.973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/09/2020] [Accepted: 01/19/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is a promising therapeutic modality for esophageal achalasia worldwide. However, clinical failure and adverse events of POEM have still been concerned. AIM To compare the efficacy and safety of a novel mark-guided POEM with standard POEM. METHODS A total of 133 patients with esophageal achalasia who underwent POEM from May 2013 to May 2019 were enrolled in this retrospective study. Of the 133 patients, there were 64 patients in the mark-guided POEM group and 69 patients in the standard POEM group. The clinical success, procedural duration and adverse events were compared between the two groups at 3 mo, 12 mo and 24 mo postoperatively. RESULTS Characteristic baseline was similar in the mark-guided POEM group and standard POEM group. The clinical success was comparable between the two groups, ranging from 92% to 98%, at 3 mo, 12 mo and 24 mo postoperatively (all P > 0.5). Eckart score, Gastroesophageal Reflux Disease Questionnaire score and SF-36 score were not different between the two groups after treatment (all P > 0.05). No severe adverse events occurred in the two groups. However, mark-guided POEM required shorter procedural duration, and less use of proton pump inhibitors and lower incidence of reflux symptoms than the standard POEM (all P < 0.001). CONCLUSION Mark-guided POEM and standard POEM were both effective and safe for the treatment of esophageal achalasia. However, the mark-guided POEM was characterized by shorter procedural duration, less use of proton pump inhibitors and lower incidence of reflux symptoms.
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Affiliation(s)
- De-Feng Li
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Feng Xiong
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Zhi-Chao Yu
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Hai-Yang Zhang
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Ting-Ting Liu
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Yan-Hui Tian
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Rui-Yue Shi
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Ming-Guang Lai
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Yang Song
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Zheng-Lei Xu
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Ding-Guo Zhang
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Jun Yao
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
| | - Li-Sheng Wang
- Department of Gastroenterology, the Second Clinical Medicine College (Shenzhen People's Hospital) of Jinan University, Shenzhen 518020, Guangdong Province, China
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Ahmed Y, Othman MO. Peroral endoscopic myotomy (POEM) for achalasia. J Thorac Dis 2019; 11:S1618-S1628. [PMID: 31489229 PMCID: PMC6702399 DOI: 10.21037/jtd.2019.07.84] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 07/19/2019] [Indexed: 12/12/2022]
Abstract
Achalasia is an uncommon disorder that results from the degeneration of ganglion cells of the myenteric plexus in the lower esophageal wall. It is manifested by a loss of peristalsis in the lower part of the esophagus and failure of the lower esophageal sphincter (LES) to relax. Peroral endoscopic myotomy (POEM) is a minimally invasive intervention that aims to treat achalasia. It is regarded as the endoscopic equivalent of Heller myotomy. POEM is a form of natural orifice transluminal endoscopic surgery that is completed by creating a submucosal tunnel in the lower part of esophagus to reach the inner circular muscle bundles of the LES to perform myotomy, while preserving the outer longitudinal muscle bundles. The result is decreased resting pressure of the LES, facilitating the passage of ingested material. POEM was initially introduced to treat achalasia by targeting the LES. POEM has expanded to include gastric POEM (G-POEM), myotomy of the pyloric sphincter to treat gastroparesis, and per rectal endoscopic myotomy to treat adult Hirschsprung's disease.
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Affiliation(s)
- Yahya Ahmed
- Baylor St Luke’s Medical Center, Houston, TX, USA
| | - Mohamed O. Othman
- Baylor St Luke’s Medical Center, Houston, TX, USA
- Division of Gastroenterology, Baylor College of Medicine, Houston, TX, USA
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Tan Y, Lv L, Wang X, Zhu H, Chu Y, Luo M, Li C, Zhou H, Huo J, Liu D. Efficacy of anterior versus posterior per-oral endoscopic myotomy for treating achalasia: a randomized, prospective study. Gastrointest Endosc 2018; 88:46-54. [PMID: 29571969 DOI: 10.1016/j.gie.2018.03.009] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 03/11/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Per-oral endoscopic myotomy (POEM) has been demonstrated to be safe and effective for treating achalasia. Two approaches-anterior myotomy and posterior myotomy-are used during POEM. However, little is known about the comparison between the 2 different approaches. The objective of the study is to compare the safety and short-term efficacy of the 2 approaches for treating achalasia. METHODS From October 2015 to December 2016, 63 consecutive patients with achalasia without prior treatment or sigmoid-type esophagus were prospectively recruited. They were randomly assigned to an anterior or posterior myotomy group. Clinical data about general characteristics, operative parameters, pre- and postoperative Eckardt score, esophageal manometry results, 24-hour pH test, and adverse events were recorded and compared between the 2 groups. RESULTS The anterior group included 31 patients and the posterior group 32 patients. All patients underwent POEM successfully, and treatment success (defined as an Eckardt score ≤3) was achieved in all patients during a mean follow-up of 15.5 months. Mean Eckardt score, lower esophageal sphincter pressure, and 4-second integrated relaxation pressure were significantly decreased (6.2 ± 1.3, 37.5 ± 6.7 mm Hg, and 27.3 ± 4.9 mm Hg vs .70 ± .70, 12.8 ± 2.8 mm Hg, and 11.1 ± 2.3 mm Hg, respectively; P < .01). There was no significant difference between the 2 groups in terms of general characteristics, treatment success, pre- and postoperative esophageal manometry, Eckardt score, and adverse events (P > .05). CONCLUSIONS The short-term treatment efficacy, manometry outcomes, and adverse events were comparable between the anterior and posterior myotomy groups. Large-scale studies with long-term follow-up are warranted for a more definitive conclusion. (Clinical trial registration number: ChiCTR-ICR-15007211.).
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Affiliation(s)
- Yuyong Tan
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Liang Lv
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xuehong Wang
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Hongyi Zhu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yi Chu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Min Luo
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Chenjie Li
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Hejun Zhou
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jirong Huo
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Deliang Liu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
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Life after per-oral endoscopic myotomy: long-term outcomes of quality of life and their association with Eckardt scores. Gastrointest Endosc 2018; 87:1415-1420.e1. [PMID: 29410304 DOI: 10.1016/j.gie.2018.01.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 01/10/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The clinical efficacy of per-oral endoscopic myotomy (POEM) has been commonly established by reduction in the Eckardt score (<3) after the procedure. However, achalasia can lead to significant impairment in the patient's quality of life that may go beyond the 4 classic achalasia symptoms as measured by the Eckardt score. The aims of our study were to evaluate the effect of POEM on short-term and long-term health-related quality of life (HRQOL) and to assess the association between HRQOL and Eckardt scores. METHODS Single-center, prospective, cohort study of consecutive POEMs during a 3-year period. Eckardt and HRQOL scores as measured by the short-form survey questionnaire (SF-36) were obtained at baseline and at various intervals after POEM. Comparison of the mean scores was described by using univariate linear regression. The association between Eckardt scores and HRQOL were calculated by using a linear, mixed-model analysis. RESULTS POEM was performed in 143 consecutive patients (54% male; mean ± standard deviation [SD] age, 56.9 ± 17.9 years). At long-term follow-up (mean 16.4 months, range 12-40), both the HRQOL baseline mental and physical component scores improved significantly from 61.5 ± 2.2 to 71.2 ± 3.6; (P < .021) and from 55.8 ± 2.2 to 63.6 ± 3.3; (P = < .034), respectively. Mixed-model analysis showed a significant association between Eckardt and all HRQOL scores (P < .001). CONCLUSION POEM improved all dimensions of HRQOL as measured by the SF-36 survey at both short-term and long-term follow-up. A strong association was seen between Eckardt scores and all HRQOL domains. Further studies with the use of disease-specific HRQOL instruments are warranted. (Clinical trial registration number: NCT01832779.).
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Outcomes and quality of life assessment after per oral endoscopic myotomy (POEM) performed in the endoscopy unit with trainees. Surg Endosc 2018; 32:3046-3054. [DOI: 10.1007/s00464-017-6015-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 12/19/2017] [Indexed: 12/21/2022]
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Misra L, Fukami N, Nikolic K, Trentman TL. Peroral endoscopic myotomy: procedural complications and pain management for the perioperative clinician. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2017; 10:53-59. [PMID: 28260955 PMCID: PMC5330187 DOI: 10.2147/mder.s115632] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Achalasia refers to the lack of smooth muscle relaxation of the distal esophagus. Although nonsurgical treatments such as pneumatic dilatation of the distal esophagus and botulinum toxin injections have been performed, these procedures have limited duration. Similarly, surgical treatment with Heller myotomy is associated with complications. At our institution, we perform the peroral endoscopic myotomy (POEM) in qualified patients. Briefly, POEM involves endoscopic creation of a mid-esophageal submucosal bleb, creation of a submucosal tunnel with the endoscope, and then a distal myotomy, resulting in relaxation of the distal esophagus. The aim of our study is to document perioperative pain and associated pain management for our initial patients undergoing POEM and to review the literature for perioperative complications of this procedure. Therefore, anesthetic and pain management for our initial eleven patients undergoing POEM were reviewed. Patient demographics, pre-POEM pain medication history, perioperative pain medication requirements, and post-POEM pain scores were examined. We found post-POEM pain was usually in the mild–moderate range; a combination of medications was effective (opioids, nonsteroidal anti-inflammatory drugs, acetaminophen). Our literature search revealed a wide frequency range of complications such as pneumoperitoneum and subcutaneous emphysema, with rare serious events such as capnopericardium leading to cardiac arrest. In conclusion, our experience with POEM suggests pain and can be managed adequately with a combination of medications; the procedure appears to be safe and reasonable to perform in an outpatient endoscopy unit.
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Affiliation(s)
| | - Norio Fukami
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Phoenix, AZ, USA
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POEM vs Laparoscopic Heller Myotomy and Fundoplication: Which Is Now the Gold Standard for Treatment of Achalasia? J Gastrointest Surg 2017; 21:207-214. [PMID: 27844266 DOI: 10.1007/s11605-016-3310-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 10/13/2016] [Indexed: 01/31/2023]
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Wang XH, Tan YY, Zhu HY, Li CJ, Liu DL. Full-thickness myotomy is associated with higher rate of postoperative gastroesophageal reflux disease. World J Gastroenterol 2016; 22:9419-9426. [PMID: 27895430 PMCID: PMC5107706 DOI: 10.3748/wjg.v22.i42.9419] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 09/12/2016] [Accepted: 10/10/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To compare long-term occurrence of gastroesophageal reflux disease (GERD) between two different types of peroral endoscopic myotomy (POEM) for achalasia. METHODS We included all patients with achalasia who underwent POEM at our hospital from August 2011 to October 2012 and had complete GERD evaluation with ≥ 3 years of follow-up. They were divided into circular or full-thickness myotomy groups according to the depth of myotomy. Demographics, Eckardt score, manometry results, 24-h pH monitoring, and GERD symptoms were recorded and compared between the two groups. RESULTS We studied 56 patients (32 circular myotomy and 24 full-thickness myotomy) with complete GERD evaluation. There was no significant difference between the two groups in terms of treatment success (defined as Eckardt score ≤ 3), postoperative Eckardt score, mean basal lower esophageal sphincter pressure, and 4-s integrated relaxation pressure (4sIRP). Postoperative abnormal esophageal acid exposure was found in 25 patients (44.6%). A total of 13 patients (23.2%) had GERD symptoms and 12 had esophagitis (21.4%). Clinically relevant GERD (abnormal esophageal acid exposure associated with GERD symptoms and/or esophagitis) was diagnosed in 13 patients (23.2%). Multivariate analysis revealed that full-thickness myotomy and low level of postoperative 4sIRP were predictive factors for clinically relevant GERD. CONCLUSION Efficacy and manometry are comparable between achalasia patients treated with circular or full-thickness myotomy. But patients with full-thickness myotomy and low postoperative 4sIRP have more GERD.
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Uppal DS, Wang AY. Update on the endoscopic treatments for achalasia. World J Gastroenterol 2016; 22:8670-8683. [PMID: 27818585 PMCID: PMC5075544 DOI: 10.3748/wjg.v22.i39.8670] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 08/20/2016] [Accepted: 09/14/2016] [Indexed: 02/06/2023] Open
Abstract
Achalasia is the most common primary motility disorder of the esophagus and presents as dysphagia to solids and liquids. It is characterized by impaired deglutitive relaxation of the lower esophageal sphincter. High-resolution manometry allows for definitive diagnosis and classification of achalasia, with type II being the most responsive to therapy. Since no cure for achalasia exists, early diagnosis and treatment of the disease is critical to prevent end-stage disease. The central tenant of diagnosis is to first rule out mechanical obstruction due to stricture or malignancy, which is often accomplished by endoscopic and fluoroscopic examination. Therapeutic options include pneumatic dilation (PD), surgical myotomy, and endoscopic injection of botulinum toxin injection. Heller myotomy and PD are more efficacious than pharmacologic therapies and should be considered first-line treatment options. Per oral endoscopic myotomy (POEM) is a minimally-invasive endoscopic therapy that might be as effective as surgical myotomy when performed by a trained and experienced endoscopist, although long-term data are lacking. Overall, therapy should be individualized to each patient's clinical situation and based upon his or her risk tolerance, operative candidacy, and life expectancy. In instances of therapeutic failure or symptom recurrence re-treatment is possible and can include PD or POEM of the wall opposite the site of prior myotomy. Patients undergoing therapy for achalasia require counseling, as the goal of therapy is to improve swallowing and prevent late manifestations of the disease rather than to restore normal swallowing, which is unfortunately impossible.
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Tan Y, Zhu H, Li C, Chu Y, Huo J, Liu D. Comparison of peroral endoscopic myotomy and endoscopic balloon dilation for primary treatment of pediatric achalasia. J Pediatr Surg 2016; 51:1613-1618. [PMID: 27339081 DOI: 10.1016/j.jpedsurg.2016.06.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 06/01/2016] [Accepted: 06/03/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Both peroral endoscopic myotomy (POEM) and endoscopic balloon dilation (EBD) are effective method for pediatric achalasia, however little is known about the comparison between them. Herein we compare the safety and efficacy of them for primary treatment of pediatric achalasia. METHODS We retrospectively reviewed the medical records of pediatric patients who received POEM or EBD for their primary therapy of achalasia at our hospital from January 2007 to June 2015, they were divided into the POEM group and EBD group. Demographics, and data about safety and efficacy were retrospectively collected and compared between the two groups. RESULTS A total of 21 patients (Female/male: 11/10, aged 6~17year-old) were enrolled, 12 of them received POEM, while the other 9 received EBD. As for the short-term efficacy, the treatment success (Eckardt score≤3) rate of POEM and EBD 3, 6 and 12months after the primary treatment were comparable (100% vs 100%, 100% vs 88.9%, 100% vs 66.7%, P>0.05). As for the medium to long-term efficacy, the treatment success rate of POEM 24 and 36months after the primary treatment was higher than that of EBD (100% vs 44.4%, 100% vs 33.3%, P<0.05). Two cases in the POEM group suffered from esophagitis, and there was no significant difference between POEM and EBD (P>0.05). No severe complications were observed during operation and periodical follow-up. CONCLUSIONS Short-term efficacy of POEM and EBD for primary treatment of pediatric achalasia was comparable, however POEM could result in a better intermediate and long-term efficacy. Large scale, randomized study is necessary for a confirmed conclusion.
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Affiliation(s)
- Yuyong Tan
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China
| | - Hongyi Zhu
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China
| | - Chenjie Li
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China
| | - Yi Chu
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China
| | - Jirong Huo
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China
| | - Deliang Liu
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China.
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Wang X, Tan Y, Lv L, Zhu H, Chu Y, Li C, Liu D. Peroral endoscopic myotomy versus pneumatic dilation for achalasia in patients aged ≥ 65 years. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2016; 108:637-641. [PMID: 27649684 DOI: 10.17235/reed.2016.4488/2016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIM Both peroral endoscopic myotomy (POEM) and pneumatic dilation (PD) has proved to be effective for treating achalasia in patients aged ≥ 65 years. However little is known about the comparison between POEM and PD. The aim of the study was to compare the safety and efficacy of POEM and PD for the treatment of achalasia in these patients. METHODS We retrospectively reviewed the medical records of patients aged 65 years-old or more who received POEM or PD for the treatment of achalasia at our hospital from January 2010 to December 2015, they were divided into the POEM group and the PD group. Demographics and data about safety and efficacy were collected retrospectively and compared between the two groups. RESULTS A total of 31 patients were enrolled, and 21 of them received POEM, while the other 10 received PD. The treatment success (Eckardt score ≤ 3) rate of POEM and PD at 3, 6, 12, 24 and 36 months after the treatment were comparable (p > 0.05). Treatment failure was noticed in 3 cases, 1 of them was in the POEM group and the other 2 in the PD group, there was no significant difference (p > 0.05). Multivariate analysis showed that sigmoid-type achalasia was a predictive factor of treatment failure. No severe complications were observed during operation and periodical follow-up. CONCLUSION Short-term and intermediate efficacy of POEM and PD for treating achalasia in patients aged ≥ 65 years was comparable. A large scale, randomized study with long-term follow-up is necessary in order to make a definitive conclusion.
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Affiliation(s)
- Xuehong Wang
- the Second Xiangya Hospital of Central South University
| | - Yuyong Tan
- Gastroenterology, The Second Xiangya Hospital of Central South University, China
| | - Liang Lv
- the Second Xiangya Hospital of Central South University
| | - Hongyi Zhu
- the Second Xiangya Hospital of Central South University
| | - Yi Chu
- The Second Xiangya Hospital of Central South University
| | - Chenjie Li
- the Second Xiangya Hospital of Central South University
| | - Deliang Liu
- Gastroenterology, The Second Xiangya Hospital of Central South Unive, China
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Crespin OM, Liu LWC, Parmar A, Jackson TD, Hamid J, Shlomovitz E, Okrainec A. Safety and efficacy of POEM for treatment of achalasia: a systematic review of the literature. Surg Endosc 2016; 31:2187-2201. [PMID: 27633440 DOI: 10.1007/s00464-016-5217-y] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 08/23/2016] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Peroral endoscopic myotomy (POEM) is a novel intervention for the treatment of achalasia, which combines the advantages of endoscopic access and myotomy. The purpose of this study was to perform a systematic review of the literature to evaluate the efficacy and safety of POEM. METHODS The systematic review was conducted following the PRISMA guidelines. Evidence-Based Medicine Reviews, Cochrane Central Register of Controlled Trials, Ovid MEDLINE (R) including in-process and non-indexed citations were searched for POEM studies using the keywords: esophageal achalasia, POEM, endoscopy, natural orifice surgery, laparoscopic Heller myotomy (LHM), and related terms. Eckardt score, lower esophageal sphincter (LES) pressure, and reported complications were the main outcomes. Two authors reviewed the search result independently. A third reviewer resolved all disagreements. Data abstraction was pilot-tested and approved by all authors. Data were examined for clinical, methodological, and statistical heterogeneity with the aim of determining whether evidence synthesis using meta- analysis was possible. RESULTS The search strategy retrieved 2894 citations. After removing duplicates and applying the exclusion criteria, 54 studies were selected for full-text review of which a total of 19 studies were considered eligible for further analysis. There were 10 retrospective and 9 prospective studies, including 1299 POEM procedures. No randomized control trial (RCT) was identified. Overall, the pre- and post-POEM Eckardt scores and LES pressure were significantly different. The most frequently reported complications were mucosal perforation, subcutaneous emphysema, pneumoperitoneum, pneumothorax, pneumomediastinum, pleural effusion, and pneumonia. The median follow-up was 13 months (range 3-24). CONCLUSION POEM is a safe and effective alternative for the treatment of achalasia. However, only short-term follow-up data compared with LHM are available. RCTs and long-term follow-up studies are needed to establish the efficacy and safety of POEM in the management of patients with achalasia.
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Affiliation(s)
- Oscar M Crespin
- Division of General Surgery, University Health Network, Toronto, ON, Canada. .,Department of Surgery, University of Toronto, Toronto, ON, Canada.
| | - Louis W C Liu
- Division of Gastroenterology, University Health Network, Toronto, ON, Canada
| | - Ambica Parmar
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Timothy D Jackson
- Division of General Surgery, University Health Network, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jemila Hamid
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Eran Shlomovitz
- Division of General Surgery, University Health Network, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of Interventional Radiology, University Health Network, Toronto, ON, Canada
| | - Allan Okrainec
- Division of General Surgery, University Health Network, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
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Vigneswaran Y, Ujiki MB. Peroral endoscopic myotomy: An emerging minimally invasive procedure for achalasia. World J Gastrointest Endosc 2015; 7:1129-1134. [PMID: 26468336 PMCID: PMC4600178 DOI: 10.4253/wjge.v7.i14.1129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 08/25/2015] [Accepted: 09/08/2015] [Indexed: 02/05/2023] Open
Abstract
Peroral endoscopic myotomy (POEM) is an emerging minimally invasive procedure for the treatment of achalasia. Due to the improvements in endoscopic technology and techniques, this procedure allows for submucosal tunneling to safely endoscopically create a myotomy across the hypertensive lower esophageal sphincter. In the hands of skilled operators and experienced centers, the most common complications of this procedure are related to insufflation and accumulation of gas in the chest and abdominal cavities with relatively low risks of devastating complications such as perforation or delayed bleeding. Several centers worldwide have demonstrated the feasibility of this procedure in not only early achalasia but also other indications such as redo myotomy, sigmoid esophagus and spastic esophagus. Short-term outcomes have showed great clinical efficacy comparable to laparoscopic Heller myotomy (LHM). Concerns related to postoperative gastroesophageal reflux remain, however several groups have demonstrated comparable clinical and objective measures of reflux to LHM. Although long-term outcomes are necessary to better understand durability of the procedure, POEM appears to be a promising new procedure.
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Liu XJ, Tan YY, Yang RQ, Duan TY, Zhou JF, Zhou XL, Liu DL. The Outcomes and Quality of Life of Patients with Achalasia after Peroral Endoscopic Myotomy in the Short-Term. Ann Thorac Cardiovasc Surg 2015; 21:507-512. [PMID: 26156194 PMCID: PMC4905026 DOI: 10.5761/atcs.oa.15-00066] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 06/17/2015] [Indexed: 12/18/2022] Open
Abstract
PURPOSE To assess the short-term efficacy and quality of life (QOL) of patients with achalasia after peroral endoscopic myotomy (POEM). METHODS Thirty-five achalasia patients underwent POEM from May 2013 to December 2013. The data on clinical evaluation and QOL before therapy, at 1 month and 6 months postoperation were collected and analyzed. RESULTS All the thirty-five patients underwent POEM successfully. By comparing the data of the preoperative with that of 1 month and 6 months after POEM respectively, we found that: mean Eckardt score decreased (6.83 vs 0.51, 6.83 vs 0.46, all P <0.05), esophagus diameter reduced (47.97 mm vs 32.00 mm, 47.97 mm vs 28.50 mm, all P <0.05), and esophageal manometry declined (29.5 mmHg vs 11.5 mmHg, 29.5 mmHg vs 10.3 mmHg, all P <0.05). Complications occurred in 14.3% (5/35) of the cases, and no recurrence was observed. At each time point, postoperative QOL scores were higher than those of preoperative (P <0.05). CONCLUSIONS POEM is safe and effective for treating achalasia in the short-term, it can relieve clinic symptoms as well as improve patients' QOL.
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Affiliation(s)
- Xiao-Juan Liu
- Department of Gastroenterology, Liuzhou Traditional Chinese Medical Hospital, the Third Affiliated Hospital of Guangxi University of Chinese Medicine, LiuZhou, China
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Kumbhari V, Khashab MA. Peroral endoscopic myotomy. World J Gastrointest Endosc 2015; 7:496-509. [PMID: 25992188 PMCID: PMC4436917 DOI: 10.4253/wjge.v7.i5.496] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 11/15/2014] [Accepted: 01/20/2015] [Indexed: 02/05/2023] Open
Abstract
Peroral endoscopic myotomy (POEM) incorporates concepts of natural orifice translumenal endoscopic surgery and achieves endoscopic myotomy by utilizing a submucosal tunnel as an operating space. Although intended for the palliation of symptoms of achalasia, there is mounting data to suggest it is also efficacious in the management of spastic esophageal disorders. The technique requires an understanding of the pathophysiology of esophageal motility disorders as well as knowledge of surgical anatomy of the foregut. POEM achieves short term response in 82% to 100% of patients with minimal risk of adverse events. In addition, it appears to be effective and safe even at the extremes of age and regardless of prior therapy undertaken. Although infrequent, the ability of the endoscopist to manage an intraprocedural adverse event is critical as failure to do so could result in significant morbidity. The major late adverse event is gastroesophageal reflux which appears to occur in 20% to 46% of patients. Research is being conducted to clarify the optimal technique for POEM and a personalized approach by measuring intraprocedural esophagogastric junction distensibility appears promising. In addition to esophageal disorders, POEM is being studied in the management of gastroparesis (gastric pyloromyotomy) with initial reports demonstrating technical feasibility. Although POEM represents a paradigm shift the management of esophageal motility disorders, the results of prospective randomized controlled trials with long-term follow up are eagerly awaited.
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