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Wilson T, Chen JW. The Pressure Is On: Optimizing Pneumatic Dilation for Achalasia. Gastrointest Endosc Clin N Am 2025; 35:651-663. [PMID: 40412996 DOI: 10.1016/j.giec.2025.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2025]
Abstract
Pneumatic dilation (PD) is a minimally invasive, outpatient treatment modality for achalasia that involves expansion of a rigid balloon across the esophagogastric junction (EGJ) to promote EGJ opening. Its efficacy has been demonstrated especially in type I and II achalasia; however, repeat dilation is often necessary. Younger age, male sex, and type III achalasia are negative predictors for treatment success in achalasia using PD. Careful patient selection and shared decision-making with the patients are essential to optimize treatment success and establish realistic outcome expectations.
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Affiliation(s)
- Tj Wilson
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA. https://twitter.com/TjwilsonMD
| | - Joan W Chen
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
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Lin KL, Lin WY, Wang YP, Luo JC, Hou MC, Lang HC, Lu CL. Epidemiology and practice patterns of achalasia in Taiwan: A nationwide population-based cohort study. J Chin Med Assoc 2025; 88:383-388. [PMID: 39915913 DOI: 10.1097/jcma.0000000000001214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/14/2025] Open
Abstract
BACKGROUND Achalasia is a rare disease of gastrointestinal motility characterized by impaired esophageal peristalsis and reduced esophageal sphincter relaxation. However, data on its epidemiology and outcomes in Taiwan are limited. This study aimed to assess the incidence, characteristics, and clinical management of achalasia in Taiwan. METHODS Patients who were newly diagnosed with achalasia between 2001 and 2013 were recruited from the Taiwan National Health Insurance Research Database. The study obtained data on the age, sex, urbanization, socioeconomic status, area of residence, diagnostic methods, and interventional management of the patients. Incidence, diagnostic modalities, treatment methods, malignancy, and mortality outcomes were analyzed. RESULTS In total, 206 new achalasia cases were identified. The mean annual incidence in Taiwan was 1.64 (95% confidence interval, 1.22-2.05) per 100 000 persons. The mean age of the patients at diagnosis was 51.8 years. The age-specific incidence of achalasia peaked in patients aged between 70 and 80 years and above 80 years. For achalasia diagnosis, endoscopy, computed tomography (CT), barium studies, and manometry were performed in 123 (59.71%), 97 (47.09%), 49 (23.79%), and 11 patients (5.34 %), respectively. During long-term follow-up, seven patients (3.39%) developed esophageal cancer, and 39 patients (18.93%) died. The median survival was 10.65 years after achalasia diagnosis, with a 10-year survival rate of 76.22%. CONCLUSION This is the first population-based epidemiological study on achalasia in Taiwan, revealing the incidence of achalasia before the era of high-resolution manometry. Clinicians should be vigilant about the development of esophageal cancer and mortality during long-term follow-ups. There is also room to enhance the utilization of various diagnostic tools for achalasia.
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Affiliation(s)
- Kai-Liang Lin
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Wei-Yu Lin
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yen-Po Wang
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Brain Science, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Jiing-Chyuan Luo
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Ming-Chih Hou
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Hui-Chu Lang
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Ching-Liang Lu
- Endoscopy Center for Diagnosis and Treatment, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Brain Science, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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Chadu Junior JB, Oliveira JAD, Faion AG, Zilberstein B. SHORT AND LONG-TERM RESULTS OF LAPAROSCOPIC ESOPHAGOCARDIOMYOTOMY WITH FUNDOPLICATION (HELLER-PINOTTI SURGERY) IN THE TREATMENT OF NON-ADVANCED ACHALASIA (MEGAESOPHAGUS). ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2024; 37:e1803. [PMID: 38896699 PMCID: PMC11182623 DOI: 10.1590/0102-6720202400010e1803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 02/01/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Videolaparoscopic esophagocardiomyotomy with fundoplication has been a widely used technique for the treatment of achalasia. This study analyzes the safety and effectiveness of the technique in the treatment of non-advanced achalasia (megaesophagus) in a Brazilian federal university public hospital. AIMS To evaluate the short- and long-term results of videolaparoscopic treatment of non-advanced megaesophagus in a public university hospital in Brazil, employing the esophagocardiomyotomy technique with fundoplication. METHODS The medical records of 44 patients who underwent surgical treatment for non-advanced achalasia at the Clinical Hospital of Federal University of Uberlândia (UFU-MG), Minas Gerais, from January 2001 to July 2021 were analyzed. The following data were evaluated: gender, age, etiology, radiological classification of Rezende-Alves and Ferreira-Santos, immediate and late complications (mean follow-up of 31.4 months), need or not for conversion to open access, postoperative reflux, performance or not of endoscopic esophageal dilation in the preoperative period, postoperative mortality, frequency of pre and postoperative symptoms (persistent dysphagia, regurgitation, heartburn, vomiting, odynophagia, and weight loss), surgery time, hospital stay, duration of dysphagia, pre and postoperative weight, and Eckardt score. RESULTS Among the analyzed patients, 23 (52.3%) were male, and 21 (47.7%) were female, with a mean age of 50.8 years. No early complications were recorded and there were 27.2% cases of late gastroesophageal reflux. Postoperative weight gain was 81.8% and the success rate of surgery according to the Eckardt score was 84.1%. CONCLUSIONS Esophagocardiomyotomy with fundoplication is an effective and safe technique for the treatment of non-advanced achalasia.
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Affiliation(s)
- João Bosco Chadu Junior
- Universidade Federal de Uberlândia, Digestive Surgery Unit - Uberlândia (MG), Brazil
- Faculdade São Leopoldo Mandic, Minimally Invasive Surgery, Master of Medical Sciences - Campinas (SP), Brazil
| | | | - Adilson Gomes Faion
- Universidade Federal de Uberlândia, Digestive Surgery Unit - Uberlândia (MG), Brazil
| | - Bruno Zilberstein
- Faculdade São Leopoldo Mandic, Minimally Invasive Surgery, Master of Medical Sciences - Campinas (SP), Brazil
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Vespa E, Barchi A, Passaretti S, Danese S, Savarino EV. Pneumatic dilation for achalasia in the "POEM era": Still a valuable ally. Dig Liver Dis 2024; 56:778-785. [PMID: 37932169 DOI: 10.1016/j.dld.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/18/2023] [Accepted: 10/23/2023] [Indexed: 11/08/2023]
Abstract
Endoscopic treatments such as peroral endoscopic myotomy (POEM) and pneumatic dilation (PD) are commonly used to treat achalasia. Although POEM has gained popularity due to its high efficacy, the technique is more complex and may be associated with a higher risk of long-term complications compared to PD. This narrative review will focus on efficacy and safety of PD and POEM, and their suitability for different patient populations. While evidence suggests that POEM may be preferred for type III achalasia, PD remains a valuable alternative for patients with a straight, non-dilated esophagus, who prioritize the preservation of anatomical integrity and a lower risk of post-procedural gastroesophageal reflux disease (GERD). While PD carries a non negligibile risk of perforation, it has an excellent safety profile in terms of GERD and is minimally likely to cause permanent esophageal deformation. PD can be repeated with minimal risks to maintain symptom relief, whereas reversing permanent anatomical modifications related to POEM is difficult. The choice of treatment for achalasia should be patient-tailored, considering benefits and drawbacks of each intervention. The importance of personalized approach in the "POEM era" is highlighted, emphasizing the reasons why PD should still be considered a valuable option in the therapeutic armamentarium for achalasia. Areas requiring further research will be also outlined.
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Affiliation(s)
- Edoardo Vespa
- Division of Gastroenterology and Gastrointestinal Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy.
| | - Alberto Barchi
- Division of Gastroenterology and Gastrointestinal Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy; Università Vita-Salute San Raffaele, Milan, Italy
| | - Sandro Passaretti
- Division of Gastroenterology and Gastrointestinal Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Silvio Danese
- Division of Gastroenterology and Gastrointestinal Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy; Università Vita-Salute San Raffaele, Milan, Italy
| | - Edoardo Vincenzo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy; Gastroenterology Unit, Azienda Ospedale Università of Padua, Padua, Italy
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Vauquelin B, Quénéhervé L, Pioche M, Barret M, Wallenhorst T, Chabrun E, Coron E, Roman S, Mion F, Chaussade S, Ponchon T, Olivier R, Rivière P, Zerbib F, Berger A. Factors associated with early failure of peroral endoscopic myotomy in achalasia. Gastrointest Endosc 2024; 99:349-357.e3. [PMID: 37806398 DOI: 10.1016/j.gie.2023.10.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/21/2023] [Accepted: 10/10/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND AND AIMS Achalasia can be treated very effectively with peroral endoscopic myotomy (POEM), but factors associated with early failure remain to be determined, especially in European cohorts. METHODS All consecutive adult patients who underwent a first POEM to treat primary achalasia were included in this multicenter retrospective study. Early failure was defined by an Eckardt score (ES) >3 at 3 months after POEM. When evaluating factors predictive of early failure, 2 cohorts were considered: one consisted of the total population, for whom only basic variables were collected, and the other a cohort built for a case-control study that included matched early-failure and early-success patients (ratio, 1:2). RESULTS Among 746 patients, the early failure rate was 9.4%. Predictive factors were age ≤45 years (P = .019), achalasia types I and III (P < .001), and the development of a severe adverse event during the procedure (P = .023). In the case-control study, the only additional independent risk factor for early failure was a high pre-POEM ES (P = .001). Only the retrosternal pain subscore was significantly associated with the early failure rate. CONCLUSION The early failure rate of POEM used to treat primary achalasia is <10%. Younger age, type I/III achalasia, and a high pre-POEM ES were significantly associated with failure.
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Affiliation(s)
- Blandine Vauquelin
- Gastroenterology and Hepatology Department, INSERM CIC 1401, Haut-Lévêque University Hospital, Bordeaux, France
| | - Lucille Quénéhervé
- Gastroenterology Department, University Hospital of Brest, Brest, France
| | - Mathieu Pioche
- Department of Gastroenterology, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon University, Inserm U1032, LabTAU, Lyon, France
| | - Maximilien Barret
- Gastroenterology Department, Cochin University Hospital, AP-HP, Paris, France
| | - Timothée Wallenhorst
- Department of Gastroenterology, Pontchaillou University Hospital, Rennes, France
| | - Edouard Chabrun
- Gastroenterology and Hepatology Department, INSERM CIC 1401, Haut-Lévêque University Hospital, Bordeaux, France
| | - Emmanuel Coron
- Department of Gastroenterology and Hepatology, University Hospital of Geneva (HUG), Geneva, Switzerland
| | - Sabine Roman
- Digestive Physiology, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon University Hospital, Inserm U1032, LabTAU, Lyon, France
| | - François Mion
- Digestive Physiology, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon University Hospital, Inserm U1032, LabTAU, Lyon, France
| | - Stanislas Chaussade
- Gastroenterology Department, Cochin University Hospital, AP-HP, Paris, France
| | - Thierry Ponchon
- Department of Gastroenterology, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon University, Inserm U1032, LabTAU, Lyon, France
| | - Raphael Olivier
- Department of Gastroenterology, Nantes University Hospital, Nantes, France
| | - Pauline Rivière
- Gastroenterology and Hepatology Department, INSERM CIC 1401, Haut-Lévêque University Hospital, Bordeaux, France
| | - Frank Zerbib
- Gastroenterology and Hepatology Department, INSERM CIC 1401, Haut-Lévêque University Hospital, Bordeaux, France
| | - Arthur Berger
- Gastroenterology and Hepatology Department, INSERM CIC 1401, Haut-Lévêque University Hospital, Bordeaux, France.
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Kim N. Esophageal Diseases. SEX/GENDER-SPECIFIC MEDICINE IN CLINICAL AREAS 2024:55-93. [DOI: 10.1007/978-981-97-0130-8_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Dervin H, Endersby J, Sanagapalli S, Mills H, Sweis R. Assessing the diagnostic yield of achalasia using provocative testing in high-resolution esophageal manometry: Serial diagnostic study. Neurogastroenterol Motil 2023; 35:e14668. [PMID: 37846024 DOI: 10.1111/nmo.14668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 07/27/2023] [Accepted: 08/19/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Chicago Classification v4.0 recommends that if achalasia is demonstrated with single water swallows (SWS); provocative testing is not required. We determine whether provocative testing in patients with suspected achalasia can change manometric findings and reproduce symptoms. METHODS Between 2016 and 2022, 127 consecutive manometry studies of patients with achalasia were retrospectively analyzed. All patients underwent SWS, a solid meal (SM) and/or a rapid drink challenge (RDC). Demographic data, fluoroscopy, gastroscopy, and pre-and post-treatment Eckardt scores were collated. KEY RESULTS Of 127 achalasia patients (50.6 ± 16.6 years and 54.6% male), all completed a SM and 116 (91.3%) completed RDC; overall 83 were naïve (65.4%) to previous therapy. 15.4% patients with normal integrated relaxation pressure (IRP) on SWS demonstrated obstruction with RDC. SM gave a different achalasia phenotype in 44.9% of patients (p ⟨ 0.001). Twelve patients with normal IRP during SWS had persistent/recurrent obstruction during provocative testing; 83.3% had previous achalasia therapy. None of 13 patients with Type III (TIII) achalasia with SWS exhibited a change in manometric findings with provocative testing. Impedance bolus heights were lower in patients with TIII achalasia and those with normal IRP with SWS. During the SM, symptoms were reproduced in 56.7% of patients. Forty-six of 103 patients (44.7%) underwent therapy based upon the final achalasia subtype which was defined by the provocative test result of the high-resolution manometry (HRM) study. All treatments were effective, regardless of the achalasia subtype. CONCLUSIONS AND INFERENCES Manometric findings remain unchanged when TIII achalasia is diagnosed with SWS. In patients with normal IRP, Type I, or Type II achalasia during SWS, provocative testing can alter achalasia phenotype or uncover achalasia where diagnosis is unclear. Further, it can reproduce symptoms. Such findings can personalize and guide effective therapeutic decisions.
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Affiliation(s)
- Humayra Dervin
- GI Physiology Unit, University College London, London, UK
| | - James Endersby
- GI Physiology Unit, University College London, London, UK
| | - Santosh Sanagapalli
- GI Physiology Unit, University College London, London, UK
- St Vincent's Hospital, Sydney, Victoria, Australia
| | - Holly Mills
- GI Physiology Unit, University College London, London, UK
| | - Rami Sweis
- GI Physiology Unit, University College London, London, UK
- University College London, London, UK
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Denzer U, Müller M, Kreuser N, Thieme R, Hoffmeister A, Feisthammel J, Niebisch S, Gockel I. [Therapy of esophageal motility disorders]. Laryngorhinootologie 2023; 102:824-838. [PMID: 37263277 DOI: 10.1055/a-1949-3583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2020 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.
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Affiliation(s)
- Ulrike Denzer
- Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg - Standort Marburg, Marburg, Germany
| | - Michaela Müller
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - Nicole Kreuser
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - René Thieme
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Juergen Feisthammel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Stefan Niebisch
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
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Bar N, Vélez C, Pasricha TS, Thurm T, Ben-Ami Shor D, Dekel R, Ron Y, Staller K, Kuo B. Safety of Pneumatic Dilation in Older Adults with Achalasia: An International Multicenter Cross-Sectional Study. J Clin Med 2023; 12:6682. [PMID: 37892819 PMCID: PMC10607090 DOI: 10.3390/jcm12206682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 10/03/2023] [Accepted: 10/20/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Pneumatic dilation (PD) is an effective first line treatment option for many patients with achalasia. PD use may be limited in adults with achalasia who are older than 65 because of concern for adverse events (AE), and less efficacious therapies are often utilized. We explored the periprocedural safety profile of PD in older adults. METHODS An international real world cross-sectional study of patients undergoing PD between 2006-2020 in two tertiary centers. Thirty-day AEs were compared between older adults (65 and older) with achalasia and younger patients. RESULTS A total of 252 patients underwent 319 PDs. In 319 PDs, 18 (5.7%) complications occurred: 6 (1.9%) perforations and 12 (3.8%) emergency department referrals with benign (non-perforation) chest pain, of which 9 (2.8%) were hospitalized. No bleeding or death occurred within 30 days. Perforation rates were similar in both age groups and across achalasia subtypes. Advanced age was protective of benign chest pain complications in univariate analysis, and the limited number of AEs precluded multivariable analysis. CONCLUSIONS The safety of PD in older adults is at least comparable to that of younger patients and should be offered as an option for definitive therapy for older patients with achalasia. Our results may affect informed consent discussions.
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Affiliation(s)
- Nir Bar
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (T.T.); (D.B.-A.S.); (R.D.); (Y.R.)
- Center for Neurointestinal Health, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (C.V.); (T.S.P.); (K.S.); (B.K.)
| | - Christopher Vélez
- Center for Neurointestinal Health, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (C.V.); (T.S.P.); (K.S.); (B.K.)
| | - Trisha S. Pasricha
- Center for Neurointestinal Health, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (C.V.); (T.S.P.); (K.S.); (B.K.)
| | - Tamar Thurm
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (T.T.); (D.B.-A.S.); (R.D.); (Y.R.)
| | - Dana Ben-Ami Shor
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (T.T.); (D.B.-A.S.); (R.D.); (Y.R.)
| | - Roy Dekel
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (T.T.); (D.B.-A.S.); (R.D.); (Y.R.)
| | - Yishai Ron
- Gastroenterology and Hepatology Department, Tel Aviv Medical Center, Tel Aviv Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (T.T.); (D.B.-A.S.); (R.D.); (Y.R.)
| | - Kyle Staller
- Center for Neurointestinal Health, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (C.V.); (T.S.P.); (K.S.); (B.K.)
| | - Braden Kuo
- Center for Neurointestinal Health, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; (C.V.); (T.S.P.); (K.S.); (B.K.)
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10
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Wessels EM, Schuitenmaker JM, Bastiaansen BAJ, Fockens P, Masclee GMC, Bredenoord AJ. Efficacy and safety of peroral endoscopic myotomy for esophageal diverticula. Endosc Int Open 2023; 11:E546-E552. [PMID: 37251790 PMCID: PMC10219786 DOI: 10.1055/a-2071-6744] [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: 02/21/2023] [Accepted: 04/03/2023] [Indexed: 05/31/2023] Open
Abstract
Background and study aims Epiphrenic diverticula are rare and mainly occur in patients with underlying esophageal motility disorders. The current standard treatment is surgical diverticulectomy often combined by myotomy and is associated with significant adverse event (AE) rates. The aim of this study was to examine the efficacy and safety of peroral endoscopic myotomy in reducing esophageal symptoms in patients with esophageal diverticula. Patients and methods We performed a retrospective cohort study including patients with an esophageal diverticulum who underwent POEM between October 2014 and December 2022. After informed consent, data were extracted from medical records and patients completed a survey by telephone. The primary outcome was treatment success, defined as Eckardt score below 4 with a minimal reduction of 2 points. Results Seventeen patients (mean age 71 years, 41.2 % female) were included. Achalasia was confirmed in 13 patients (13 /17, 76.5 %), Jackhammer esophagus in two patients (2 /17, 11.8 %), diffuse esophageal spasm in one patient (1 /17, 5.9 %) and in one patient no esophageal motility disorder was found (1 /17, 5.9 %). Treatment success was 68.8 % and only one patient (6.3 %) underwent retreatment (pneumatic dilatation). Median Eckardt scores decreased from 7 to 1 after POEM (p < 0.001). Mean size of the diverticula decreased from 3.6 cm to 2.9 cm after POEM (p < 0.001). Clinical admission was one night for all patients. AEs occurred in two patients (11.8 %) which were classified as grade II and IIIa (AGREE classification). Conclusions POEM is effective and safe to treat patients with esophageal diverticula and an underlying esophageal motility disorder.
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Affiliation(s)
- Elise M Wessels
- Amsterdam University Medical Centres, Gastroenterology & Hepatology, Amsterdam, Netherlands
| | - Jeroen M Schuitenmaker
- Amsterdam University Medical Centres, Gastroenterology & Hepatology, Amsterdam, Netherlands
| | | | - Paul Fockens
- Amsterdam University Medical Centres, Gastroenterology & Hepatology, Amsterdam, Netherlands
| | - Gwen M C Masclee
- Amsterdam University Medical Centres, Gastroenterology & Hepatology, Amsterdam, Netherlands
| | - Albert J Bredenoord
- Amsterdam University Medical Centres, Gastroenterology & Hepatology, Duivendrecht, Netherlands
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Cohen DL, Avivi E, Bermont A, Shibli F, Azzam N, Hijazi B, Baker FA, Richter V, Shirin H, Mari A. Correlation between Lower Esophageal Sphincter Metrics on High-Resolution Manometry and the Clinical Presentation of Patients with Newly Diagnosed Achalasia. Diagnostics (Basel) 2023; 13:1136. [PMID: 36980444 PMCID: PMC10047697 DOI: 10.3390/diagnostics13061136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/05/2023] [Accepted: 03/15/2023] [Indexed: 03/19/2023] Open
Abstract
BACKGROUND Achalasia is characterized by aperistalsis with poor relaxation of the lower esophageal sphincter (LES). We aimed to systematically assess whether LES metrics on high-resolution manometry (HRM) correlate with the symptomatic or endoscopic presentation of patients with achalasia. METHODS A retrospective study was performed at two tertiary medical centers. All cases of newly diagnosed, untreated achalasia were reviewed for demographics, symptoms, and endoscopic findings. These were correlated with HRM metrics, including LES basal pressure (LESP), integrated relaxation pressure (IRP), percent LES relaxation, and esophagogastric junction (EGJ) morphology. RESULTS 108 achalasia patients were included; 56 (51.9%) were men, with a mean overall age of 55.6 ± 17.9 years old. Achalasia subtypes included 23.1% with Type I, 65.7% Type II, and 11.1% Type III. Mean LESP was 40.9 ± 13.7 mmHg, IRP 26.8 ± 11.5 mmHg, with 36% ± 20% LES relaxation. On univariate analyses, a higher IRP was associated with age < 50 (p = 0.028), female sex (p = 0.030), Arab ethnicity (p < 0.001), weight loss (p = 0.016), a tortuous esophagus (p = 0.036), and resistance at the EGJ (p = 0.033). However, on multivariate regression analyses, only ethnicity remained significantly associated with IRP. No unique variables were associated with either LESP or percent LES relaxation. Achalasia subtype and Eckardt score were not associated with any LES metrics. Non-Type 1 EGJ morphology was associated with a lower LESP. CONCLUSIONS LES metrics on HRM do not appear to correlate with the clinical or endoscopic presentation of patients with untreated achalasia.
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Affiliation(s)
- Daniel L. Cohen
- The Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir (Assaf Harofeh) Medical Center, Zerifin 703000, Israel
| | - Eyal Avivi
- The Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir (Assaf Harofeh) Medical Center, Zerifin 703000, Israel
| | - Anton Bermont
- The Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir (Assaf Harofeh) Medical Center, Zerifin 703000, Israel
| | - Fahmi Shibli
- Gastroenterology and Hepatology Institute, HaEmek Medical Center, Afula 1834111, Israel
| | - Narges Azzam
- Gastroenterology and Endoscopy Unit, Nazareth EMMS Hospital, Nazareth 16100, Israel
| | - Basem Hijazi
- Faculty of Medicine, Bar Ilan University, Safed 1311502, Israel
| | - Fadi Abu Baker
- Gastroenterology and Hepatology Institute, Hillel Yaffe Medical Center, Hadera 38100, Israel
| | - Vered Richter
- The Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir (Assaf Harofeh) Medical Center, Zerifin 703000, Israel
| | - Haim Shirin
- The Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir (Assaf Harofeh) Medical Center, Zerifin 703000, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Amir Mari
- Gastroenterology and Endoscopy Unit, Nazareth EMMS Hospital, Nazareth 16100, Israel
- Faculty of Medicine, Bar Ilan University, Safed 1311502, Israel
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12
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Winston JM, Mann FAT, Dean L. Management and outcomes of 13 dogs treated with a modified Heller myotomy and Dor fundoplication for lower esophageal sphincter achalasia-like syndrome. Vet Surg 2023; 52:315-329. [PMID: 36458673 DOI: 10.1111/vsu.13912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 09/30/2022] [Accepted: 10/17/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To report the management and outcomes of dogs treated for lower esophageal sphincter achalasia-like syndrome (LES-AS) with modified Heller myotomy, Dor fundoplication, and with the use of a temporary gastrostomy tube. STUDY DESIGN Retrospective. SAMPLE POPULATION Thirteen client-owned dogs. METHODS Medical records and a client survey were used to assess frequency of vomiting/regurgitation, quality of life (QoL), bodyweight, and feeding modifications at the following time points: prior to referral, postoperatively from discharge to first recheck (4-6 weeks), and from first recheck to survey (48 months). Postoperative and gastrostomy tube complications were surveyed and recorded. Pretreatment and 4-6 weeks postoperative videofluoroscopic swallow studies (VFSS) were compared. Two-sided t-tests were used to compare outcomes between survey time points. RESULTS Postoperative VFSS scores (available in 9 dogs) improved over preoperative scores in 6 dogs, and 12/13 dogs survived to discharge. One dog was euthanized 3 days postoperatively due to aspiration pneumonia. Postoperative gastrostomy tube complications occurred in half of the dogs that survived to discharge. According to the owners, scores assigned to vomiting/regurgitation improved by 180% (P = .004), QoL by 100% (P = .004), and bodyweight by 63% (P = .035). CONCLUSION Modified Heller myotomy with Dor fundoplication and the use of a temporary gastrostomy tube improved clinical signs and owners' perceived quality of life in half of the dogs treated for LES-AS in our clinical setting. Oral sildenafil therapy discontinued postoperatively suggests that surgery was equally efficacious. CLINICAL SIGNIFICANCE Modified Heller myotomy with Dor fundoplication and temporary gastrostomy tube is a treatment option with potentially sustained benefits for dogs that have LES-AS.
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Affiliation(s)
- John M Winston
- University of Missouri Veterinary Health Center, Columbia, Missouri, USA
| | - F A Tony Mann
- University of Missouri Veterinary Health Center, Columbia, Missouri, USA
| | - Lauren Dean
- University of Missouri Veterinary Health Center, Columbia, Missouri, USA
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13
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Denzer UW, Müller M, Kreuser N, Thieme R, Hoffmeister A, Feisthammel J, Niebisch S, Gockel I. [Therapy of esophageal motility disorders]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:183-197. [PMID: 35835360 DOI: 10.1055/a-1833-9299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2020 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.
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Affiliation(s)
- Ulrike W Denzer
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - Michaela Müller
- Klinik und Poliklinik für Gastroenterologie, Endokrinologie, Stoffwechsel und klinische Infektiologie, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - Nicole Kreuser
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - René Thieme
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Albrecht Hoffmeister
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Juergen Feisthammel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Stefan Niebisch
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitatsklinikum Leipzig, Leipzig, Germany
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14
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Laparoscopic Esocardiomyotomy-Risk Factors and Implications of Intraoperative Mucosal Perforation. Life (Basel) 2023; 13:life13020340. [PMID: 36836695 PMCID: PMC9963844 DOI: 10.3390/life13020340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 01/20/2023] [Accepted: 01/23/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Mucosal perforation during laparoscopic esocardiomyotomy is quite frequent, and its consequences cannot always be neglected. The purpose of the study is to investigate the risk factors for intraoperative mucosal perforation and its implications on the postoperative outcomes and the functional results three months postoperatively. MATERIAL AND METHODS We retrospectively identified the patients with laparoscopic esocardiomyotomy performed at Sf. Maria Hospital Bucharest, in the period between January 2017-January 2022 and collected the data (preoperative-clinic, manometric and imaging, intra-and postoperative). To identify the risk factors for mucosal perforations, we used logistic regression analysis. RESULTS We included 60 patients; intraoperative mucosal perforation occurred in 8.33% of patients. The risk factors were: the presence of tertiary contractions (OR = 14.00, 95%CI = [1.23, 158.84], p = 0.033206), the number of propagated waves ≤6 (OR = 14.50), 95%CI = [1.18, 153.33], p < 0.05), the length of esophageal myotomy (OR = 1.74, 95%CI = [1.04, 2.89] p < 0.05), the length of esocardiomyotomy (OR = 1.74, 95%CI = [1.04, 2.89] p < 0.05), and a protective factor-the intraoperative upper endoscopy (OR = 0.037, 95%CI = [0.003, 0.382] p < 0.05). CONCLUSIONS Identifying risk factors for this adverse intraoperative event may decrease the incidence and make this surgery safer. Although mucosal perforation resulted in prolonged hospital stays, it did not lead to significant differences in functional outcomes.
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Penagini R, de Bortoli N, Savarino E, Arsiè E, Tolone S, Greenan G, Visaggi P, Maniero D, Mauro A, Consonni D, Gyawali CP. Rapid Drink Challenge During High-resolution Manometry for Evaluation of Esophageal Emptying in Treated Achalasia. Clin Gastroenterol Hepatol 2023; 21:55-63. [PMID: 35240328 DOI: 10.1016/j.cgh.2022.02.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/09/2022] [Accepted: 02/16/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Incomplete esophageal emptying is a key variable predicting symptom relapse after achalasia treatment. Although optimally evaluated using the timed barium esophagogram (TBE), incomplete esophageal emptying can also be identified on rapid drink challenge (RDC) performed during high-resolution manometry. METHODS We evaluated if RDC differentiates complete from incomplete esophageal emptying in treated patients with achalasia, against a TBE gold standard. Unselected treated patients with achalasia with both TBE (200 mL of low-density barium suspension) and RDC (200 mL of water in sitting position) were enrolled in 5 tertiary referral centers. TBE barium column height at 1, 2, and 5 minutes were compared with RDC variables: pressurizations >20 mmHg, maximal RDC pressurization, proportion of RDC time occupied by pressurizations, trans-esophagogastric junction gradient, and integrated relaxation pressure. RESULTS Of 175 patients recruited (mean age, 59 years; 47% female), 138 (79%) were in clinical remission. Complete TBE emptying occurred in 45.1% at 1 minute, 64.0% at 2 minutes, and 73.1% at 5 minutes. RDC integrated relaxation pressure correlated strongly with TBE column height, and a 10-mmHg threshold discriminated complete from incomplete emptying at all 3 TBE time points with area under receiver operating characteristic curves of 0.85, 0.87, and 0.85, respectively. This threshold had high negative predictive values for complete emptying (88% at 2 minutes, 94% at 5 minutes), and modest positive predictive values for incomplete emptying (77% at 2 minutes, 62% at 5 minutes). CONCLUSIONS RDC during high-resolution manometry is an effective surrogate for TBE in assessing esophageal emptying in treated patients with achalasia.
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Affiliation(s)
- Roberto Penagini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Nicola de Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Elena Arsiè
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Salvatore Tolone
- Surgery Unit, Department of Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Garrett Greenan
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri
| | - Pierfrancesco Visaggi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Daria Maniero
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Aurelio Mauro
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; San Matteo Hospital Foundation, University of Pavia, Endoscopy Unit, Pavia, Italy
| | - Dario Consonni
- Epidemiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri
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16
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Schlottmann F, Herbella FAM, Patti MG. Achalasia. Dysphagia 2023. [DOI: 10.1016/b978-0-323-99865-9.00006-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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17
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Tatsuta T, Sato H, Fujiyoshi Y, Abe H, Shiwaku A, Shiota J, Sato C, Ominami M, Hata Y, Fukuda H, Ogawa R, Nakamura J, Ikebuchi Y, Yokomichi H, Fukuda S, Inoue H. Subtype of Achalasia and Integrated Relaxation Pressure Measured Using the Starlet High-resolution Manometry System: A Multicenter Study in Japan. J Neurogastroenterol Motil 2022; 28:562-571. [PMID: 36250363 PMCID: PMC9577579 DOI: 10.5056/jnm21254] [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: 12/29/2021] [Accepted: 04/25/2022] [Indexed: 11/25/2022] Open
Abstract
Background/Aims ManoScan and Sandhill high-resolution manometry (HRM) systems are used worldwide; however, the diagnosis of achalasia on the Starlet HRM system is not fully characterized. Furthermore, the impact of calcium channel blockers and nitrites in treating achalasia has not been investigated using HRM. Management of recurrent cases is a priority issue, although few studies have examined patient characteristics. Methods We conducted a multicenter, large-scale database analysis. First, the diagnosis of treatment-naive achalasia in each HRM system was investigated. Next, patient characteristics were compared between type I-III achalasia, and the impact of patient characteristics, including calcium channel blocker and nitrite use for integrated relaxation pressure (IRP) values, were analyzed. Finally, patient characteristics with recurrent achalasia were elucidated. Results The frequency of type I achalasia with Starlet was significantly higher than that with ManoScan and Sandhill HRM systems. In achalasia, multivariate analysis identified male sex, advanced age, long disease duration, obesity, type I achalasia, and sigmoid type as risk factors related to normal IRP values (< 26 mmHg). Calcium channel blockers and nitrites use had no significant impact on the IRP values, although achalasia symptoms were indicated to be alleviated. In recurrent cases, the IRP value was significantly lower, and advanced age, long disease duration, and sigmoid type were more common than in treatment-naive patients. Conclusions We should cautiously interpret the type of achalasia and IRP values in the Starlet HRM system. Symptoms of recurrent cases are related to disease progression rather than IRP values, which should be considered in decision making.
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Affiliation(s)
- Tetsuya Tatsuta
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Hiroki Sato
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.,Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, OH, USA
| | - Yusuke Fujiyoshi
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hirofumi Abe
- Department of Gastroenterology, Kobe University Hospital, Kobe, Japan
| | - Akio Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Junya Shiota
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
| | - Chiaki Sato
- Division of Advanced Surgical Science and Technology, Tohoku University School of Medicine, Sendai, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yoshitaka Hata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hisashi Fukuda
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Ryo Ogawa
- Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Yuichiro Ikebuchi
- Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine Tottori University Faculty of Medicine, Yonago, Japan
| | - Hiroshi Yokomichi
- Department of Health Sciences, University of Yamanashi, Yamanashi, Japan
| | - Shinsaku Fukuda
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
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18
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Cohen DL, Bermont A, Richter V, Azzam N, Shirin H, Dickman R, Mari A. Integrated Relaxation Pressure (IRP) Distinguishes between Reflux-Predominant and Dysphagia-Predominant Phenotypes of Esophageal "Absent Contractility". J Clin Med 2022; 11:6287. [PMID: 36362515 PMCID: PMC9655163 DOI: 10.3390/jcm11216287] [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] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/22/2022] [Accepted: 10/24/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Patients with absent contractility (AC) often suffer from either reflux or dysphagia. It remains unclear what factors determine which phenotype patients present with. We sought to evaluate if high-resolution manometry metrics, especially integrated relaxation pressure (IRP), could explain this. Methods: Cases of AC from three medical centers were reviewed for demographic, clinical, and manometric data. Cases with an IRP between 10−15 mmHg or subsequent diagnosis of achalasia were excluded. Results: 69 subjects were included (mean age 56.1; 71% female). A total of 41 (59.4%) were reflux-predominant. The reflux-predominant group was younger (51.1 vs. 63.5, p = 0.002) and had lower median LES basal pressures (7.5 vs. 12.5 mmHg, p = 0.014) and IRP values (1.5 vs. 5.6 mmHg, p < 0.001) compared to the dysphagia group. When divided into tertiles, the trend in symptoms between LES basal pressure tertiles was not significant. However, the trend for IRP was significant (p < 0.001). For example, in the lowest IRP tertile, 91.3% of subjects were reflux-predominant compared to only 26.1% in the highest tertile, while the dysphagia-predominant group increased from 8.7% to 73.9%. In a regression model controlling for age and using IRP tertile 1 as the reference, having an IRP in tertile 2 increased the likelihood of having dysphagia-predominant disease by 7, while being in tertile 3 increased the likelihood by 22. Conclusions: IRP helps distinguish between the reflux-predominant and dysphagia-predominant phenotypes of AC. This may have therapeutic clinical consequences as procedures such as fundoplication to tighten the LES may benefit patients with reflux and a low IRP, while procedures like peroral endoscopic myotomy (POEM) to disrupt the LES may benefit patients with dysphagia and a relatively high IRP.
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Affiliation(s)
- Daniel L. Cohen
- The Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir (Assaf Harofeh) Medical Center, Zerifin 703000, Israel
| | - Anton Bermont
- The Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir (Assaf Harofeh) Medical Center, Zerifin 703000, Israel
| | - Vered Richter
- The Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir (Assaf Harofeh) Medical Center, Zerifin 703000, Israel
| | - Narjes Azzam
- Gastroenterology and Endoscopy Unit, Nazareth EMMS Hospital, Nazareth 16100, Israel
| | - Haim Shirin
- The Gonczarowski Family Institute of Gastroenterology and Liver Diseases, Shamir (Assaf Harofeh) Medical Center, Zerifin 703000, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Ram Dickman
- Division of Gastroenterology, Rabin Medical Center, Beilinson Hospital, Petach Tikva 4941492, Israel
| | - Amir Mari
- Gastroenterology and Endoscopy Unit, Nazareth EMMS Hospital, Nazareth 16100, Israel
- Faculty of Medicine, Bar Ilan University, Safed 1311502, Israel
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19
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Visaggi P, Ghisa M, Del Corso G, Baiano Svizzero F, Mariani L, Tolone S, Frazzoni M, Buda A, Bellini M, Savarino V, Penagini R, Gyawali CP, Savarino EV, de Bortoli N. Chicago classification v4.0 protocol improves specificity and accuracy of diagnosis of oesophagogastric junction outflow obstruction. Aliment Pharmacol Ther 2022; 56:606-613. [PMID: 35751633 PMCID: PMC9544646 DOI: 10.1111/apt.17101] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/09/2022] [Accepted: 06/09/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Chicago classification version 4.0 (CCv4.0) introduced stringent diagnostic criteria for oesophagogastric junction outflow obstruction (EGJOO), in order to increase the clinical relevance of the diagnosis, although this has not yet been demonstrated. AIMS To determine the prevalence of EGJOO using CCv4.0 criteria in patients with CCv3.0-based EGJOO, and to assess if provocative manoeuvres can predict a conclusive CCv4.0 diagnosis of EGJOO. METHODS Clinical presentation, high resolution manometry (HRM) with rapid drink challenge (RDC), and timed barium oesophagogram (TBE) data were extracted for patients diagnosed with EGJOO as per CCv3.0 between 2018 and 2020. Patients were then re-classified according to CCv4.0 criteria, using clinically relevant symptoms (dysphagia and/or chest pain), and abnormal barium emptying at 5 min on TBE. Receiver operating characteristic (ROC) analyses identified HRM predictors of EGJOO. RESULTS Of 2010 HRM studies, 144 (7.2%) fulfilled CCv3.0 criteria for EGJOO (median age 61 years, 56.9% female). Upon applying CCv4.0 criteria, EGJOO prevalence decreased to 1.2%. On ROC analysis, integrated relaxation pressure during RDC (RDC-IRP) was a significant predictor of a conclusive EGJOO diagnosis by CCv4.0 criteria (area under the curve: 96.1%). The optimal RDC-IRP threshold of 16.7 mm Hg had 87% sensitivity, 97.1% specificity, 95.7% negative predictive value and 91.3% positive predictive value for a conclusive EGJOO diagnosis; lower thresholds (10 mmHg, 12 mmHg) had better sensitivity but lower specificity. CONCLUSION CCv4.0 criteria reduced the prevalence of EGJOO by 80%, thereby refining the diagnosis and identifying clinically relevant outflow obstruction. Elevated RDC-IRP can predict conclusive EGJOO per CCv4.0.
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Affiliation(s)
- Pierfrancesco Visaggi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and SurgeryUniversity of PisaPisaItaly
| | - Matteo Ghisa
- Division of Gastroenterology, Department of Surgery, Oncology and GastroenterologyUniversity of PaduaPaduaItaly,Gastroenterology Unit, Department of Oncological Gastrointestinal SurgeryS. Maria del Prato HospitalFeltreItaly
| | | | - Federica Baiano Svizzero
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and SurgeryUniversity of PisaPisaItaly
| | - Lucia Mariani
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and SurgeryUniversity of PisaPisaItaly
| | - Salvatore Tolone
- Division of Surgery, Department of SurgeryUniversity of Campania Luigi VanvitelliCasertaItaly
| | - Marzio Frazzoni
- Gastroenterology Digestive Pathophysiology UnitBaggiovara HospitalModenaItaly
| | - Andrea Buda
- Division of Gastroenterology, Department of Surgery, Oncology and GastroenterologyUniversity of PaduaPaduaItaly
| | - Massimo Bellini
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and SurgeryUniversity of PisaPisaItaly
| | - Vincenzo Savarino
- Division of Gastroenterology, Department of Internal Medicine (DIMI)University of GenoaGenoaItaly
| | - Roberto Penagini
- Gastroenterology and Endoscopy Unit ‐ Department of Pathophysiology and TransplantationFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico ‐ University of MilanMilanItaly
| | - C. Prakash Gyawali
- Division of GastroenterologyUniversity Washington University School of MedicineSt. LouisMissouriUSA
| | - Edoardo V. Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and GastroenterologyUniversity of PaduaPaduaItaly
| | - Nicola de Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and SurgeryUniversity of PisaPisaItaly
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20
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Mohammed A, Garg R, Paranji N, Samineni AV, Thota PN, Sanaka MR. Pneumatic dilation for esophageal achalasia: patient selection and perspectives. Scand J Gastroenterol 2022; 57:650-659. [PMID: 35114867 DOI: 10.1080/00365521.2022.2034940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 01/18/2022] [Accepted: 01/21/2022] [Indexed: 02/04/2023]
Abstract
Achalasia is an esophageal motility disorder characterized by esophageal aperistalsis and impaired relaxation of the lower esophageal sphincter. Treatment is palliative, aimed at decreasing the lower esophageal sphincter pressure. Pneumatic dilation (PD) is a safe and effective treatment for achalasia. Several other invasive and minimally invasive treatment modalities, such as Laparoscopic Heller Myotomy (LHM) and Peroral Endoscopic Myotomy (POEM), also have a comparable safety and efficacy profile to PD. The current review focuses on the indications, contraindications, techniques, and outcomes of PD in various patient populations and its comparison to LHM and POEM. This review also provides relevant information to help endoscopists identify those patients who will benefit the most from PD.
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Affiliation(s)
- Abdul Mohammed
- Department of Hospital Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Rajat Garg
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Neethi Paranji
- Department of Gastroenterology and Hepatology, MetroHealth Medical Center, Cleveland, OH, USA
| | - Aneesh V Samineni
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Prashanthi N Thota
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Madhusudhan R Sanaka
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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21
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Maydeo A. Achalasia Cardia: Balloon, Tunnel, or Knife? JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0041-1740490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractAchalasia cardia is a rare esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter during swallowing and aperistalsis of the esophageal smooth muscles. The treatment approaches to achalasia include nonsurgical treatment with medications (nitrates, calcium channel blockers), endoscopic treatment (balloon pneumatic dilation [PD], botulinum toxin injection [BTI], peroral endoscopic myotomy [POEM]), and surgery (laparoscopic Heller's myotomy [LHM]). The subtype of achalasia (the Chicago Classification) governs the ideal treatment. For the commonly encountered achalasia subtype I and II, PD, LHM, and POEM all have similar efficacy. However, for type III achalasia, POEM seems to be the best line of treatment. Among high-risk elderly patients or those with comorbidities, BTI is preferred. The choice of treatment should be minimally invasive therapy with good short-term and sustained long-term effects with negligible adverse events. POEM seems to be evolving as a first-line therapy among the available therapies. Here, we review the treatment options among achalasia cardia patients with special attention to post-POEM gastroesophageal reflux disease and its management.
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Affiliation(s)
- Amit Maydeo
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospital, Mumbai, Maharashtra, India
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22
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Dorsey YC, Song EJ, Leiman DA. Beyond the Eckardt Score: Patient-Reported Outcomes Measures in Esophageal Disorders. Curr Gastroenterol Rep 2021; 23:29. [PMID: 34850300 DOI: 10.1007/s11894-021-00831-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW To provide an overview of patient reported outcome measures (PROMs) and summarize their role in assessing undifferentiated dysphagia and common esophageal disorders, including achalasia, eosinophilic esophagitis (EoE), and gastroesophageal reflux disease (GERD). RECENT FINDINGS Given the subjective nature of swallowing disorders, accurate diagnoses often rely on capturing the patient experience. As a result, the number of PROMs used to characterize esophageal symptoms is increasing with a recent particular emphasis on EoE. Overall, esophageal-focused PROMs are used to interpret patient symptoms and quality of life, diagnosis, and symptom changes over time. There are limitations with each instrument, including factors affecting validity, reliability, accessibility, patient participation, and logistical implementation. PROM instruments can be helpful tools in the diagnosis and treatment of esophageal disorders. Instruments should be chosen based on factors such as target population and setting, including research, clinical, and quality improvement efforts. Future research should address how best to implement PROMs and integrate the obtained data with patient care.
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Affiliation(s)
- Y Claire Dorsey
- Division of Gastroenterology, Duke University School of Medicine, Duke Clinical Research Institute, 200 Morris Street, Durham, NC, 27701, USA
| | - Erin J Song
- Department of Medicine, Duke University, Durham, NC, USA
| | - David A Leiman
- Division of Gastroenterology, Duke University School of Medicine, Duke Clinical Research Institute, 200 Morris Street, Durham, NC, 27701, USA. .,Duke Clinical Research Institute, Durham, NC, USA.
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23
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Lee Y, Tai W, Wu K, Yao C, Chuah S. Per oral endoscopic myotomy for achalasia: A Taiwanese single‐center experience. ADVANCES IN DIGESTIVE MEDICINE 2021. [DOI: 10.1002/aid2.13287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Yu‐Chi Lee
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
| | - Wei‐Chen Tai
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of Medicine Chang Gung University Taoyuan Taiwan
| | - Keng‐Liang Wu
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of Medicine Chang Gung University Taoyuan Taiwan
| | - Chih‐Chien Yao
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
| | - Seng‐Kee Chuah
- Division of Hepatogastroenterology, Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of Medicine Chang Gung University Taoyuan Taiwan
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24
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Mari A, Abu Baker F, Pellicano R, Khoury T. Diagnosis and Management of Achalasia: Updates of the Last Two Years. J Clin Med 2021; 10:3607. [PMID: 34441901 PMCID: PMC8397142 DOI: 10.3390/jcm10163607] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/10/2021] [Accepted: 08/12/2021] [Indexed: 02/06/2023] Open
Abstract
Achalasia is a rare neurodegenerative disorder causing dysphagia and is characterized by abnormal esophageal motor function as well as the loss of lower esophageal sphincter (LES) relaxation. The assessment and management of achalasia has significantly progressed in recent years due to the advances in high-resolution manometry (HRM) technology along with the improvements and innovations of therapeutic endoscopy procedures. The recent evolution of HRM technology with the inclusion of an adjunctive test, fluoroscopy, and EndoFLIP has enabled more precise diagnoses of achalasia to be made and the subgrouping into therapeutically meaningful subtypes. Current management possibilities include endoscopic treatments such as Botulinum toxin injected to the LES and pneumatic balloon dilation. Surgical treatment includes laparoscopic Heller myotomy and esophagectomy. Furthermore, in recent years, per oral endoscopic myotomy (POEM) has established itself as a principal endoscopic therapeutic alternative to the traditional laparoscopic Heller myotomy. The latest randomized trials report that POEM, pneumatic balloon dilatation, and laparoscopic Heller's myotomy have comparable effectiveness and complications rates. The aim of the current review is to provide a practical clinical approach to dysphagia and to shed light on the most recent improvements in diagnostics and treatment of achalasia over the last two years.
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Affiliation(s)
- Amir Mari
- Department of Gastroenterology, Nazareth Hospital, Faculty of Medicine, Bar-Ilan University, Safed 16100, Israel
| | - Fadi Abu Baker
- Hillel Yaffe Medical Center, Department of Gastroenterology and Hepatology, Hadera 38100, Israel;
| | | | - Tawfik Khoury
- Galilee Medical Center, Department of Gastroenterology, Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 13100, Israel;
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25
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Brindise E, Khashab MA, El Abiad R. Insights into the endoscopic management of esophageal achalasia. Ther Adv Gastrointest Endosc 2021; 14:26317745211014706. [PMID: 34017943 PMCID: PMC8114742 DOI: 10.1177/26317745211014706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/07/2021] [Indexed: 01/21/2023] Open
Abstract
Achalasia is a primary esophageal motility disorder characterized by the loss of inhibitory neurons in the myenteric plexus, resulting in impaired relaxation of the esophagogastric junction. Achalasia is an incurable disease, and the treatment modalities are aimed at disruption of the esophagogastric junction and vary widely from pharmacological to endoscopic to surgical. Traditional endoscopic therapy includes pneumatic dilation, botulinum toxin injection, and peroral endoscopic myotomy. This review aims to provide an overview of the endoscopic management of achalasia, while focusing on the utilization of peroral endoscopic myotomy and other novel approaches.
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Affiliation(s)
- Elizabeth Brindise
- Division of Gastroenterology and Hepatology, The University of Iowa, Iowa City, IA, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Rami El Abiad
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals & Clinics, The University of Iowa, 4612 JCP, Iowa City, IA 52241, USA
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26
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Ando R, Sato C, Fukutomi T, Okamoto H, Takaya K, Taniyama Y, Unno M, Kamei T. A case of esophageal achalasia presenting with empyema and septic shock differentiated from esophageal rupture. Clin J Gastroenterol 2021; 14:422-426. [PMID: 33527334 DOI: 10.1007/s12328-021-01349-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 01/17/2021] [Indexed: 10/22/2022]
Abstract
The patient was a 44-year-old man with a history of schizophrenia. He had a history of esophageal dysphagia and vomiting and presented with sudden strong epigastric pain. He was taken to a medical emergency center in a state of septic shock. Computed tomography revealed a left thoracic abscess, and esophageal rupture was suspected. He was referred to our department for treatment. Gastrointestinal series and gastrointestinal endoscopy revealed marked esophageal dilation and strong contraction of the lower esophageal sphincter. We, therefore, diagnosed the patient with empyema thoracis secondary to aspiration pneumonia due to esophageal achalasia. Conservative treatment with antibiotics and computed tomography-guided chest drainage was initiated, but the inflammation persisted. Thus, we successfully performed a per-oral endoscopic myotomy to manage achalasia symptoms.
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Affiliation(s)
- Ryohei Ando
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Chiaki Sato
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
| | - Toshiaki Fukutomi
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Hiroshi Okamoto
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Kai Takaya
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Yusuke Taniyama
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
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27
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Pesce M, Sweis R. Advances and caveats in modern achalasia management. Ther Adv Chronic Dis 2021; 12:2040622321993437. [PMID: 33786159 PMCID: PMC7958157 DOI: 10.1177/2040622321993437] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 01/15/2021] [Indexed: 12/18/2022] Open
Abstract
Achalasia is a rare esophageal motility disorder characterized by the incomplete
relaxation of the lower esophageal sphincter (LES) and impaired peristaltic
activity. The advent of high-resolution manometry (HRM) and the rapidly evolving
role of therapeutic endoscopy have revolutionized the approach to the diagnosis
and management of achalasia patients in the last decade. With advances in HRM
technology and methodology, fluoroscopy and EndoFlip, achalasia can be
differentiated into therapeutically meaningful phenotypes with a high degree of
accuracy. Further, the newest treatment option, per-oral endoscopic myotomy
(POEM), has become a staple therapy following the last 10 years of experience,
and recent randomized trials appear to show no difference between POEM, graded
pneumatic dilatation and surgical Heller myotomy in terms of short- and
long-term efficacy or complication rate. On the other hand, how treatment
outcomes are measured as well as the risk of reflux following therapy remain
areas of contention. This review aims to summarize the recent advancements in
achalasia testing and therapy, describes the recent randomized clinical trials
as well as their potential setbacks, and touches on the future of personalizing
achalasia treatment.
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Affiliation(s)
- Marcella Pesce
- Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Naples, Italy
| | - Rami Sweis
- University College London Hospital, GI Services, 235 Euston Rd, London, NW1 2BU, UK
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28
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Dirks RC, Kohn GP, Slater B, Whiteside J, Rodriguez NA, Docimo S, Pryor A, Stefanidis D. Is peroral endoscopic myotomy (POEM) more effective than pneumatic dilation and Heller myotomy? A systematic review and meta-analysis. Surg Endosc 2021; 35:1949-1962. [PMID: 33655443 DOI: 10.1007/s00464-021-08353-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 02/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Achalasia is a rare, chronic, and morbid condition with evolving treatment. Peroral endoscopic myotomy (POEM) has gained considerable popularity, but its comparative effectiveness is uncertain. We aim to evaluate the literature comparing POEM to Heller myotomy (HM) and pneumatic dilation (PD) for the treatment of achalasia. METHODS We conducted a systematic review of comparative studies between POEM and HM or PD. A priori outcomes pertained to efficacy, perioperative metrics, and safety. Internal validity of observational studies and randomized trials (RCTs) was judged using the Newcastle Ottawa Scale and the Cochrane Risk of Bias 2.0 tool, respectively. RESULTS From 1379 unique literature citations, we included 28 studies comparing POEM and HM (n = 21) or PD (n = 8), with only 1 RCT addressing each. Aside from two 4-year observational studies, POEM follow-up averaged ≤ 2 years. While POEM had similar efficacy to HM, POEM treated dysphagia better than PD both in an RCT (treatment "success" RR 1.71, 95% CI 1.34-2.17; 126 patients) and in observational studies (Eckardt score MD - 0.43, 95% CI - 0.71 to - 0.16; 5 studies; I2 21%; 405 patients). POEM needed reintervention less than PD in an RCT (RR 0.19, 95% CI 0.08-0.47; 126 patients) and HM in an observational study (RR 0.33, 95% CI 0.16, 0.68; 98 patients). Though 6-12 months patient-reported reflux was worse than PD in 3 observational studies (RR 2.67, 95% CI 1.02-7.00; I2 0%; 164 patients), post-intervention reflux was inconsistently measured and not statistically different in measures ≥ 1 year. POEM had similar safety outcomes to both HM and PD, including treatment-related serious adverse events. CONCLUSIONS POEM has similar outcomes to HM and greater efficacy than PD. Reflux remains a critical outcome with unknown long-term clinical significance due to insufficient data and inconsistent reporting.
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Affiliation(s)
- Rebecca C Dirks
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall 125, Indianapolis, IN, 46202, USA.
| | - Geoffrey P Kohn
- Department of Surgery, Monash University Eastern Health Clinical School, Melbourne, VIC, Australia
| | - Bethany Slater
- Division of Pediatric Surgery, University of Chicago, Chicago, IL, USA
| | - Jake Whiteside
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall 125, Indianapolis, IN, 46202, USA
| | - Noe A Rodriguez
- Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Salvatore Docimo
- Department of Surgery, Stony Brook Medicine, Stony Brook, NY, USA
| | - Aurora Pryor
- Department of Surgery, Stony Brook Medicine, Stony Brook, NY, USA
| | - Dimitrios Stefanidis
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall 125, Indianapolis, IN, 46202, USA
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Abstract
Achalasia is an esophageal motility disorder characterized by aberrant peristalsis and insufficient relaxation of the lower esophageal sphincter. Patients most commonly present with dysphagia to solids and liquids, regurgitation, and occasional chest pain with or without weight loss. High-resolution manometry has identified 3 subtypes of achalasia distinguished by pressurization and contraction patterns. Endoscopic findings of retained saliva with puckering of the gastroesophageal junction or esophagram findings of a dilated esophagus with bird beaking are important diagnostic clues. In this American College of Gastroenterology guideline, we used the Grading of Recommendations Assessment, Development and Evaluation process to provide clinical guidance on how best to diagnose and treat patients with achalasia.
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30
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Barret M, Guillaumot MA, Leandri C, Leblanc S, Coriat R, Belle A, Chaussade S. Intraoperative high-resolution esophageal manometry during peroral endoscopic myotomy. Sci Rep 2020; 10:14198. [PMID: 32848175 PMCID: PMC7450054 DOI: 10.1038/s41598-020-71136-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 08/10/2020] [Indexed: 02/06/2023] Open
Abstract
Peroral endoscopic myotomy is an accepted treatment of achalasia. Some of the treatment failures can be attributable to an insufficient length of the myotomy on the gastric side, because of a more technically challenging submucosal dissection. We assessed the feasibility and the impact of an intraoperative esophageal manometry during the peroral endoscopic myotomy procedure. A high-resolution manometry catheter was introduced through the nostril before the endoscope, and left in place during the peroral endoscopic myotomy procedure. The lower esophageal sphincter pressure was recorded throughout the peroral endoscopic myotomy. The myotomy was extended on the gastric side until the lower esophageal sphincter pressure dropped below 10 mmHg. We included 10 patients (mean age = 55 years old, 3 men) treated by peroral endoscopic myotomy for type I (3/10), type II (3/10), type III achalasia (3/10) or esophagogastric junction outflow obstruction (1/10). Manometric recording was possible in all patients. The median (IQR) lower esophageal sphincter resting pressure was 23 (17-37) mmHg before myotomy, 15 (13-19) mmHg at the end of the tunnel, and 7 (6-11) mmHg at the end of the myotomy. In 4 patients out of 10, the myotomy was extended on the base of the intraoperative manometry findings. High-resolution esophageal manometry is feasible during the peroral endoscopic myotomy procedure, and leads to increase the length of the gastric myotomy in 4 out of 10 patients. However, the cumbersome nature of intraoperative high-resolution manometry during peroral endoscopic myotomy and the high frequency of gastro-esophageal reflux disease after extended gastric myotomy suggest to limit this technique to selected patients refractory to a first myotomy.
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Affiliation(s)
- Maximilien Barret
- Gastroenterology Department, Cochin Hospital, Assistance Publique-Hôpitaux de Paris and University of Paris, 27 rue du Faubourg St Jacques, 75014, Paris, France.
| | - Marie-Anne Guillaumot
- Gastroenterology Department, Cochin Hospital, Assistance Publique-Hôpitaux de Paris and University of Paris, 27 rue du Faubourg St Jacques, 75014, Paris, France
| | - Chloé Leandri
- Gastroenterology Department, Cochin Hospital, Assistance Publique-Hôpitaux de Paris and University of Paris, 27 rue du Faubourg St Jacques, 75014, Paris, France
| | - Sarah Leblanc
- Gastroenterology Department, Cochin Hospital, Assistance Publique-Hôpitaux de Paris and University of Paris, 27 rue du Faubourg St Jacques, 75014, Paris, France
| | - Romain Coriat
- Gastroenterology Department, Cochin Hospital, Assistance Publique-Hôpitaux de Paris and University of Paris, 27 rue du Faubourg St Jacques, 75014, Paris, France
| | - Arthur Belle
- Gastroenterology Department, Cochin Hospital, Assistance Publique-Hôpitaux de Paris and University of Paris, 27 rue du Faubourg St Jacques, 75014, Paris, France
| | - Stanislas Chaussade
- Gastroenterology Department, Cochin Hospital, Assistance Publique-Hôpitaux de Paris and University of Paris, 27 rue du Faubourg St Jacques, 75014, Paris, France
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31
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Oude Nijhuis RAB, Prins LI, Mostafavi N, van Etten-Jamaludin FS, Smout AJPM, Bredenoord AJ. Factors Associated With Achalasia Treatment Outcomes: Systematic Review and Meta-Analysis. Clin Gastroenterol Hepatol 2020; 18:1442-1453. [PMID: 31622735 DOI: 10.1016/j.cgh.2019.10.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 09/26/2019] [Accepted: 10/04/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Identification of factors associated with achalasia treatment outcome might help physicians select therapies based on patient characteristics. We performed a systematic review and meta-analysis to identify factors associated with treatment response. METHODS We searched MEDLINE, EMBASE, and the Cochrane Library through February 21, 2019, for randomized controlled trials and cohort, case-control, and cross-sectional studies that reported patient-specific outcomes of treatment (botulinum toxin injection, pneumatic dilation, peroral endoscopic myotomy, or laparoscopic Heller myotomy). We assessed the methodologic quality of the included studies using the quality in prognosis studies tool. We planned qualitative and quantitative analyses. RESULTS We analyzed data from 75 studies (8 randomized controlled trials, 27 prospective cohort studies, and 40 retrospective studies) on a total of 34 different factors associated with outcomes (3 demographic, 17 clinical, and 14 diagnostic factors). Qualitative assessment showed age, manometric subtype, and presence of a sigmoid-shaped esophagus as factors associated with outcomes of treatment for achalasia with a strong level of evidence. The cumulative evidence for the association with chest pain, symptom severity, and lower esophageal sphincter pressure was inconclusive. A meta-analysis confirmed that older age (mean difference, 7.9 y; 95% CI, 1.5-14.3 y) and manometric subtype 3 (odds ratio, 7.1; 95% CI, 4.1-12.4) were associated with clinical response. CONCLUSIONS In a systematic review and meta-analysis, we found age and manometric subtype to be associated with outcomes of treatment for achalasia. This information should be used to guide treatment decisions.
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Affiliation(s)
- Renske A B Oude Nijhuis
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands.
| | - Leah I Prins
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Nahid Mostafavi
- Biostatistical Unit, Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Andreas J P M Smout
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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32
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Ramchandani M, Pal P. Management of achalasia in 2020: Per-oral endoscopic myotomy, Heller’s or dilatation? INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii200012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Mohan Ramchandani
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Partha Pal
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
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33
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Hoshikawa Y, Hoshino S, Kawami N, Tanabe T, Hanada Y, Takenouchi N, Goto O, Kaise M, Iwakiri K. Possible new endoscopic finding in patients with achalasia: "Gingko leaf sign". Esophagus 2020; 17:208-213. [PMID: 31227944 DOI: 10.1007/s10388-019-00684-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 06/16/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND The diagnosis of achalasia can occasionally be difficult because of the low prevalence of apparent endoscopic abnormal findings, such as dilation and food residue, and lack of "esophageal rosette" in some patients. We have found a new endoscopic finding "Gingko leaf sign", which consists of not being able to see the full extent of the esophageal palisade vessels and a Gingko leaf-shaped morphology of a longitudinal section of the esophagogastric junction at the end of a deep inspiration, in some achalasia patients without "esophageal rosette". The aim of the study was to investigate the prevalence of "Gingko leaf sign" in these patients. METHODS We retrospectively compared the prevalence of "Gingko leaf sign" between 11 achalasia patients without "esophageal rosette" and 22 age-/gender-matched healthy subjects. The diagnoses of achalasia were based on the results of high-resolution manometry. We also investigated the characteristics of the patients with "Gingko leaf sign". RESULTS All the patients had "Gingko leaf sign", in contrast to none of the healthy subjects (p < 0.001). Four of 11 patients did not require any therapy. Six of seven patients did not relapse after balloon dilatation, but one patient required per-oral endoscopic myotomy 8 months after balloon dilatation. CONCLUSION All our achalasia patients without "esophageal rosette" had "Gingko leaf sign". It is possibly a useful endoscopic finding in achalasia patients without "esophageal rosette".
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Affiliation(s)
- Yoshimasa Hoshikawa
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Shintaro Hoshino
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Noriyuki Kawami
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Tomohide Tanabe
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Yuriko Hanada
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Nana Takenouchi
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Osamu Goto
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Mitsuru Kaise
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.
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Hernández-Mondragón O, Solórzano-Pineda O, González-Martínez M, Blancas-Valencia J. Gastroesophageal reflux disease after peroral endoscopic myotomy: Short-term, medium-term, and long-term resultsGastroesophageal reflux disease after peroral endoscopic myotomy (POEM). REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2020. [DOI: 10.1016/j.rgmxen.2019.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Spiliopoulos S, Sabharwal T, Adam A. Esophageal Intervention in Malignant and Benign Esophageal Disease. IMAGE-GUIDED INTERVENTIONS 2020:710-719.e2. [DOI: 10.1016/b978-0-323-61204-3.00088-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2025]
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Durability of pneumatic dilation monotherapy in treatment-naive achalasia patients. BMC Gastroenterol 2019; 19:181. [PMID: 31711439 PMCID: PMC6849288 DOI: 10.1186/s12876-019-1104-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 10/29/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Pneumatic dilation (PD) is often billed as a "short term" treatment for achalasia but anecdotally can last years. This study sought to explore how long a single pneumatic dilation may induce symptom remission in a treatment-naïve achalasia patient. METHODS A single center, retrospective chart review of patients with an ICD-9 or - 10 code of achalasia between 2005 and 2017 was performed. Treatment naïve patients with manometric diagnosis of primary achalasia were included. Outcomes (success or failure); single vs multiple PD; age; and estimated duration of effect were evaluated. Each patient underwent a single PD unless re-intervention was required for relapse. RESULTS 83 patients (52% female, median 51.6 ± 3.6 years) were included. 43% underwent 2 PD and 13% underwent 3 PD. There was no significant relation between age, gender, and number of PDs. After 1 PD, 87.5% of patients reported > 1 year of symptom remission. 80.5% of relapsed patients reported success after a 2nd dilation. 1 PD was more likely to result in success than multiple PDs (p < 0.001). The measured median duration of remission after 1 PD was 4.23 years, and for 2 PDs, 3.71 years. The median estimated remission time after 1 PD was 8.5 years (CI 7.3-9.7, p = 0.03). CONCLUSIONS PD is a safe, durable treatment for achalasia. A single PD is likely to last years. A second PD, if required, also has a high likelihood of success.
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Multicenter Evaluation of Clinical Efficacy and Safety of Per-oral Endoscopic Myotomy in Children. J Pediatr Gastroenterol Nutr 2019; 69:523-527. [PMID: 31259787 DOI: 10.1097/mpg.0000000000002432] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Per-oral endoscopic myotomy (POEM) is a recommended treatment modality for achalasia, but there is little published data for its use in children. The objective of the present study was to evaluate whether POEM is clinically effective and safe for children. METHODS International multicenter retrospective study conducted in 14 tertiary centers that included consecutive children who underwent POEM between January 2012 and August 2018. Outcomes, such as clinical response were assessed whenever available. Adverse events and factors associated with clinical failure were also investigated. RESULTS A total of 117 patients (mean ± SD age: 14.2 ± 3.7 years) underwent POEM for achalasia (type I, n = 36; type II n=66; type III, n=8). Among these, 30 (26%) were pretreated (botulinum injection and/or pneumatic dilatation). Mean ± SD baseline Eckardt score was 7.5 ± 2.0. Clinical success was achieved in 90.6% of cases (95%CI [83.8%;95.2%]) in the intention-to-treat analysis. The mean ± SD Eckardt score post-POEM was 0.9 ± 1.2 (P < 0.001). The mean duration of follow-up time 545 days (range: 100-1612). A total of 7 adverse events occurred (4 mucosotomies, 2 subcutaneous emphysema, 1 esopleural fistula). Gastroesophageal reflux symptoms were seen in 17 patients (15%); missing data for 10 patients (9%). There was a trend towards more frequent clinical failure in achalasia associated with genetic disorders (40% vs 8%, P = 0.069). CONCLUSIONS POEM in pediatric patients appears to be effective and safe, although there was a trend towards more frequent clinical failure achalasia associated with genetic disorders. Further studies are needed to assess the long-term outcomes, especially the consequences of GERD.
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Ponds FA, Fockens P, Lei A, Neuhaus H, Beyna T, Kandler J, Frieling T, Chiu PWY, Wu JCY, Wong VWY, Costamagna G, Familiari P, Kahrilas PJ, Pandolfino JE, Smout AJPM, Bredenoord AJ. Effect of Peroral Endoscopic Myotomy vs Pneumatic Dilation on Symptom Severity and Treatment Outcomes Among Treatment-Naive Patients With Achalasia: A Randomized Clinical Trial. JAMA 2019; 322:134-144. [PMID: 31287522 PMCID: PMC6618792 DOI: 10.1001/jama.2019.8859] [Citation(s) in RCA: 243] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Case series suggest favorable results of peroral endoscopic myotomy (POEM) for treatment of patients with achalasia. Data comparing POEM with pneumatic dilation, the standard treatment for patients with achalasia, are lacking. OBJECTIVE To compare the effects of POEM vs pneumatic dilation as initial treatment of treatment-naive patients with achalasia. DESIGN, SETTING, AND PARTICIPANTS This randomized multicenter clinical trial was conducted at 6 hospitals in the Netherlands, Germany, Italy, Hong Kong, and the United States. Adult patients with newly diagnosed achalasia and an Eckardt score greater than 3 who had not undergone previous treatment were included. The study was conducted between September 2012 and July 2015, the duration of follow-up was 2 years after the initial treatment, and the final date of follow-up was November 22, 2017. INTERVENTIONS Randomization to receive POEM (n = 67) or pneumatic dilation with a 30-mm and a 35-mm balloon (n = 66), with stratification according to hospital. MAIN OUTCOMES AND MEASURES The primary outcome was treatment success (defined as an Eckardt score ≤3 and the absence of severe complications or re-treatment) at the 2-year follow-up. A total of 14 secondary end points were examined among patients without treatment failure, including integrated relaxation pressure of the lower esophageal sphincter via high-resolution manometry, barium column height on timed barium esophagogram, and presence of reflux esophagitis. RESULTS Of the 133 randomized patients, 130 (mean age, 48.6 years; 73 [56%] men) underwent treatment (64 in the POEM group and 66 in the pneumatic dilation group) and 126 (95%) completed the study. The primary outcome of treatment success occurred in 58 of 63 patients (92%) in the POEM group vs 34 of 63 (54%) in the pneumatic dilation group, a difference of 38% ([95% CI, 22%-52%]; P < .001). Of the 14 prespecified secondary end points, no significant difference between groups was demonstrated in 10 end points. There was no significant between-group difference in median integrated relaxation pressure (9.9 mm Hg in the POEM group vs 12.6 mm Hg in the pneumatic dilation group; difference, 2.7 mm Hg [95% CI, -2.1 to 7.5]; P = .07) or median barium column height (2.3 cm in the POEM group vs 0 cm in the pneumatic dilation group; difference, 2.3 cm [95% CI, 1.0-3.6]; P = .05). Reflux esophagitis occurred more often in the POEM group than in the pneumatic dilation group (22 of 54 [41%] vs 2 of 29 [7%]; difference, 34% [95% CI, 12%-49%]; P = .002). Two serious adverse events, including 1 perforation, occurred after pneumatic dilation, while no serious adverse events occurred after POEM. CONCLUSIONS AND RELEVANCE Among treatment-naive patients with achalasia, treatment with POEM compared with pneumatic dilation resulted in a significantly higher treatment success rate at 2 years. These findings support consideration of POEM as an initial treatment option for patients with achalasia. TRIAL REGISTRATION Netherlands Trial Register number: NTR3593.
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Affiliation(s)
- Fraukje A. Ponds
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Aaltje Lei
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Horst Neuhaus
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Torsten Beyna
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Jennis Kandler
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Thomas Frieling
- Department of Gastroenterology, Helios Klinikum Krefeld, Düsseldorf, Germany
| | - Philip W. Y. Chiu
- Institute of Digestive Disease, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Justin C. Y. Wu
- Institute of Digestive Disease, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hongkong, China
| | - Vivien W. Y. Wong
- Institute of Digestive Disease, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Guido Costamagna
- Digestive Endoscopy Unit, Agostino Gemelli University Hospital, Universita Cattolica del Sacro Cuore, Rome, Italy
- IHU IAS Strasbourg University, Strasbourg, France
| | - Pietro Familiari
- Digestive Endoscopy Unit, Agostino Gemelli University Hospital, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Peter J. Kahrilas
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - André J. P. M. Smout
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Albert J. Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Harvey PR, Coupland B, Mytton J, Evison F, Patel P, Trudgill NJ. Outcomes of pneumatic dilatation and Heller's myotomy for achalasia in England between 2005 and 2016. Gut 2019; 68:1146-1151. [PMID: 30606814 DOI: 10.1136/gutjnl-2018-316544] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 11/25/2018] [Accepted: 11/30/2018] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Achalasia is a disorder characterised by failed relaxation of the lower oesophageal sphincter. The aim of this study was to examine, at a national level, the long-term outcomes of achalasia therapies. METHODS Hospital Episode Statistics include diagnostic and procedural data for all English National Health Service-funded hospital admissions. Subjects with a code for achalasia who had their initial treatment between January 2006 and December 2015 were grouped by treatment; pneumatic dilatation (PD) or surgical Heller's myotomy (HM). Procedural failure was defined as time to a further episode of the same therapy or a change to a different therapy. Up to three PDs were permitted without being considered a therapy failure. RESULTS 6938 subjects were included; 3619 (52.2%) were men and median age at diagnosis was 59 (IQR 43-75) years. 4748 (68.4%) initially received PD and 2190 (31.6%) HM. The perforation rate following PD was 1.6%. Mortality at 30 days was 0.0% for HM and 1.9% for PD, and <8% after perforation following PD. Factors associated with increased mortality after PD included age quintile 66-77 (OR 4.55 (95% CI 2.00 to 10.38), p<0.001), >77 (9.78 (4.33 to 22.06), p<0.001); Charlson comorbidity score >4 (2.87 (2.08 to 3.95), p<0.001); previous HM (2.47 (1.33 to 4.62), p<0.001); and repeat PD 1-3 (1.58 (1.15 to 2.16), p=0.005), >3 (1.97 (1.21 to 3.19), p=0.006). Durability of up to 3 PD and HM over 10 years of follow-up was 86.2% and 81.9%, respectively (p<0.001). DISCUSSION The efficacy of PD for achalasia appears to be greater than HM over 10 years. There was no mortality associated with HM, but 1.9% of subjects died within 30 days of PD. Mortality was associated with increasing age, comorbidity, previous HM and repeat PD.
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Affiliation(s)
- Philip R Harvey
- Department of Gastroenterology, Sandwell and West Birmingham Hospitals, West Bromwich, UK.,Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Ben Coupland
- Department of Health Informatics, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Jemma Mytton
- Department of Health Informatics, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Felicity Evison
- Department of Health Informatics, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Prashant Patel
- Department of Health Informatics, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Nigel J Trudgill
- Department of Gastroenterology, Sandwell and West Birmingham Hospitals, West Bromwich, UK
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Therapeutic Outcome of Achalasia Based on High-Resolution Manometry: A Korean Multicenter Study. Am J Ther 2019; 26:e452-e461. [DOI: 10.1097/mjt.0000000000000677] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Schizas D, Kapsampelis P, Tsilimigras DI, Kanavidis P, Moris D, Papanikolaou IS, Karamanolis GP, Theodorou D, Liakakos T. The 100 most cited manuscripts in esophageal motility disorders: a bibliometric analysis. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:310. [PMID: 31475180 PMCID: PMC6694239 DOI: 10.21037/atm.2019.06.34] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 05/10/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The use of bibliometrics can help us identify the most impactful articles on a topic or scientific discipline and their influence on clinical practice. We aimed to identify the 100 most cited articles covering esophageal motility disorders and examine their key characteristics. METHODS The Web of Science database was utilized to perform the search, using predefined search terms. The returned dataset was filtered to include full manuscripts written in the English language. After screening, we identified the 100 most cited articles and analyzed them for title, year of publication, names of authors, institution, country of the first author, number of citations and citation rate. RESULTS The initial search returned 29,521 results. The top 100 articles received a total of 20,688 citations. The most cited paper was by Inoue et al. (665 citations) who first described peroral endoscopic myotomy (POEM) for treating achalasia. The article with the highest citation rate was the third version of the Chicago Classification system, written by Kahrilas and colleagues. Gastroenterology published most papers on the list (n=32) and accrued the highest number of citations (6,675 citations). Peter Kahrilas was the most cited author (3,650 citations) and, along with Joel Richter, authored the highest number of manuscripts (n=14). Most articles were produced in the USA (n=66) between the years 1991 and 2000 (n=32). CONCLUSIONS By analyzing the most influential articles, this work is a reference on the articles that shaped our understanding of esophageal motility disorders, thus serving as a guide for future research.
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Affiliation(s)
- Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Panagiotis Kapsampelis
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Diamantis I. Tsilimigras
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Prodromos Kanavidis
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Ioannis S. Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine and Research Institute, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Georgios P. Karamanolis
- Gastroenterology Unit, Second Department of Surgery, National and Kapodistrian University of Athens, Aretaieio University Hospital, Athens, Greece
| | - Dimitrios Theodorou
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
| | - Theodore Liakakos
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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Hernández-Mondragón OV, Solórzano-Pineda OM, González-Martínez M, Blancas-Valencia JM. Gastroesophageal reflux disease after peroral endoscopic myotomy: Short-term, medium-term, and long-term results. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2019; 85:4-11. [PMID: 31174905 DOI: 10.1016/j.rgmx.2019.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 11/01/2018] [Accepted: 04/24/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND AIMS Achalasia is characterized by incomplete relaxation of the lower esophageal sphincter and esophageal aperistalsis. The efficacy of peroral endoscopic myotomy (POEM) is similar to that of the Heller myotomy, with an apparently greater prevalence of gastroesophageal reflux disease. Our aim was to determine the presence of GERD in a post-POEM cohort of Mexican patients with achalasia and follow-up of at least 12 months. MATERIALS AND METHODS A retrospective cohort study was conducted on post-POEM patients with a minimum of 12 months of follow-up, within the time frame of 2012 to 2017. Pregnant patients were excluded. Serial endoscopy, pH study, and GERDQ application were performed. Univariate and bivariate data analyses were carried out and statistical significance was set at a P<0.05. RESULTS Sixty-eight patients had post-POEM follow-up for 12 months. Of those patients, follow-up continued to 24 months for 58, 36 months for 47, 48 months for 39, and 60 months for 25. Mean patient age was 47.8±14.3 years, 57.3% of the patients were women, 77.9% were treatment-naïve, and 54.4% had type II achalasia. The pH study, endoscopy, and questionnaire were positive in 73, 28, and 18% at 3 months; 48, 35, and 13% at 6 months, and 55, 30, and 15% at 12 months, respectively. Once the proton pump inhibitor was begun, the percentages decreased to 5, 2, and 6% at 24 months; 6, 2, and 8% at 36 months; 4,1, and 6% at 48 months; and 3, 1, and 4% at 60 months, respectively. There was no relation between the efficacy of POEM and the presence or intensity of GERD. There were no secondary complications due to gastroesophageal reflux. CONCLUSIONS The post-POEM prevalence of GERD was 50% in the short term (12 months), with no evidence of complications at the medium term or long term (60 months). Gastroesophageal reflux was adequately controlled through proton pump inhibitors administration in over 95% of the cases.
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Affiliation(s)
- O V Hernández-Mondragón
- Departamento de Endoscopia Digestiva, Hospital de Especialidades Centro Médico Nacional Siglo XXI, Ciudad de México, México.
| | - O M Solórzano-Pineda
- Departamento de Endoscopia Digestiva, Hospital de Especialidades Centro Médico Nacional Siglo XXI, Ciudad de México, México
| | - M González-Martínez
- Departamento de Endoscopia Digestiva, Hospital de Especialidades Centro Médico Nacional Siglo XXI, Ciudad de México, México
| | - J M Blancas-Valencia
- Departamento de Endoscopia Digestiva, Hospital Ángeles Metropolitano, Ciudad de México, México
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Grobman ME, Hutcheson KD, Lever TE, Mann FA, Reinero CR. Mechanical dilation, botulinum toxin A injection, and surgical myotomy with fundoplication for treatment of lower esophageal sphincter achalasia-like syndrome in dogs. J Vet Intern Med 2019; 33:1423-1433. [PMID: 30968469 PMCID: PMC6524387 DOI: 10.1111/jvim.15476] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 02/26/2019] [Indexed: 12/17/2022] Open
Abstract
Background Megaesophagus (ME) carries a poor long‐term prognosis in dogs. In people, lower esophageal sphincter (LES) achalasia is a rare cause of ME that may respond to targeted intervention. Dogs with lower esophageal sphincter achalasia‐like syndrome (LES‐AS) have been described recently, warranting investigation of analogous targeted treatment. Hypothesis/Objectives Evaluate response of dogs with LES‐AS to LES mechanical dilation and botulinum toxin A (BTA) injections, with or without surgical myotomy and fundoplication. We hypothesized that clinical and videofluoroscopic swallow study (VFSS) features of LES‐AS would improve after treatment targeting functional LES obstruction. Animals Fourteen client‐owned dogs with LES‐AS diagnosed by VFSS. Methods Retrospective study. Dogs diagnosed with LES‐AS underwent treatment between April 2015 and December 2017. Outcome measures included client perception of clinical severity, body weight (BW), body condition score (BCS), regurgitation frequency, and VFSS parameters (ME, esophageal motility, gastric filling). Dogs with positive responses were considered candidates for LES myotomy with fundoplication. Results By a median IQR of 21 (IQR, 14‐25) days after mechanical dilation and BTA, clients reported clinical improvement in 100% of dogs, BW increased 20.4% (IQR, 12.7%‐25%), pre‐ and post‐treatment BCS was 3 (IQR, 3‐4) and 5 (IQR, 4‐5), respectively, and frequency of regurgitation decreased by 80% (IQR, 50%‐85%). Duration of effect was 40 (IQR, 17‐53) days. Despite clinical improvement, ME and abnormal esophageal motility persisted in 14 dogs. Six dogs subsequently underwent myotomy and fundoplication and maintained improvement observed after mechanical dilation and BTA. Conclusions and Clinical Importance Dogs with LES‐AS experienced significant, temporary, clinical improvement after mechanical dilation and BTA. Preliminary results suggest myotomy with fundoplication provide lasting clinical benefit despite persistence of ME.
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Affiliation(s)
- M E Grobman
- Department of Veterinary Medicine and Surgery, University of Missouri College of Veterinary Medicine, Columbia, Missouri
| | - K D Hutcheson
- Department of Veterinary Medicine and Surgery, University of Missouri Columbia College of Veterinary Medicine Ringgold Standard Institution, Columbia, Missouri
| | - T E Lever
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri Columbia School of Medicine Ringgold Standard Institution, Columbia, Missouri
| | - F A Mann
- Department of Veterinary Medicine and Surgery, University of Missouri Columbia College of Veterinary Medicine Ringgold Standard Institution, Columbia, Missouri
| | - C R Reinero
- Department of Veterinary Medicine and Surgery, University of Missouri, Columbia, Missouri
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Abstract
OBJECTIVES Pediatric achalasia is a rare neurodegenerative disorder of the esophagus that requires treatment. Different diagnostic and treatment modalities are available, but there are no data that show how children can best be diagnosed and treated. We aimed to identify current practices regarding the diagnostic and therapeutic approach toward children with achalasia. METHODS Information on the current practice regarding the management of pediatric achalasia was collected by an online-based survey sent to members of the European and North American Societies for Pediatric Gastroenterology Hepatology and Nutrition involved in pediatric achalasia care. RESULTS The survey was completed by 38 centers from 24 countries. Within these centers, 108 children were diagnosed with achalasia in the last year (median 2, range 0-15). Achalasia was primarily managed by a pediatric gastroenterologist (76%) and involved a multidisciplinary team in 84% of centers, also including a surgeon (87%), radiologist (61%), dietician (37%), speech pathologist (8%), and psychologist (5%). Medical history taking and physical examination were considered most important to establish the diagnosis (50%), followed by (a combination of) manometry (45%) or contrast swallow (21%). Treatment of first choice was Heller myotomy (58%), followed by pneumatic dilation (46%) and peroral endoscopic myotomy (29%). CONCLUSION This study shows a great heterogeneity in the management of pediatric achalasia amongst different centers worldwide. These findings stress the need for well-designed intervention trials in children with achalasia. Given the rarity of this disease, we recommend that achalasia care should be managed in centers with access to appropriate diagnostic and treatment modalities.
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Evensen H, Kristensen V, Larssen L, Sandstad O, Hauge T, Medhus AW. Outcome of peroral endoscopic myotomy (POEM) in treatment-naive patients. A systematic review. Scand J Gastroenterol 2019; 54:1-7. [PMID: 30650313 DOI: 10.1080/00365521.2018.1549271] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Achalasia is a primary motility disorder of the esophagus characterized by aperistalsis and failure of lower esophageal sphincter (LES) relaxation. Treatment of achalasia aims at reducing LES pressure. The common treatment modalities are laparoscopic Heller myotomy and pneumatic dilatation, but during the last decade, a promising treatment, per oral endoscopic myotomy (POEM), has been introduced. The aim of the present study was to perform a systematic review of the literature to assess the outcome of POEM in treatment-naive patients. MATERIALS AND METHODS A systematic literature search in PubMed, Embase and Cochrane databases was performed using the terms 'Achalasia AND (POEM OR peroral endoscopic myotomy OR per-oral endoscopic myotomy)'. Inclusion criteria were: original article; English language; n ≥ 20 with ≥90% treatment-naive patients; follow-up ≥3 months; and outcome evaluation of POEM including symptom score and objective tests. Exclusion criteria were: reviews and meta-analyses; pediatric data; duplicates; and articles with overlapping data material. RESULTS Of the 1641 articles identified, seven were included. The included studies all reported a short-term clinical success of >90%. Clinical success including post-POEM reflux was mainly estimated by symptom scorings. There were few procedure-related complications. CONCLUSIONS The studies of treatment-naive patients indicate a high rate of clinical success. Nevertheless, a more systematic and standardized evaluation is recommended to improve the reports on outcome of POEM. The follow-up rate should be high and the evaluation protocol should include both symptom scoring and objective testing with predefined treatment goals.
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Affiliation(s)
- Helge Evensen
- a Department of Gastroenterology , Oslo University Hospital.,b Faculty of Medicine , University of Oslo
| | | | - Lene Larssen
- a Department of Gastroenterology , Oslo University Hospital
| | - Olav Sandstad
- a Department of Gastroenterology , Oslo University Hospital
| | - Truls Hauge
- a Department of Gastroenterology , Oslo University Hospital.,b Faculty of Medicine , University of Oslo
| | - Asle W Medhus
- a Department of Gastroenterology , Oslo University Hospital
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Baram A, Essa RA. Determining long-term outcome of transthoracic Heller's myotomy when other methods fail: A single centere cases series. INTERNATIONAL JOURNAL OF SURGERY OPEN 2019. [DOI: 10.1016/j.ijso.2019.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Andrási L, Paszt A, Simonka Z, Ábrahám S, Rosztóczy A, Lázár G. Laparoscopic Surgery for Epiphrenic Esophageal Diverticulum. JSLS 2018; 22:JSLS.2017.00093. [PMID: 30022807 PMCID: PMC6035909 DOI: 10.4293/jsls.2017.00093] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background and Objectives: We wanted to assess our surgical results focusing on the patients' quality of life. We present our experience with laparoscopic surgery for epiphrenic esophageal diverticulum. Short- and long-term results of surgical therapy were analyzed. Methods: Eight patients were examined with a symptom-causing epiphrenic diverticulum. Patients underwent complex gastroenterologic examinations before and after surgery. Laparoscopic transhiatal epiphrenic diverticulectomy, Heller cardiomyotomy, and Dor anterior partial fundoplication were performed on 7 patients. One patient underwent only diverticulectomy, where no motility disorder was present. Results from surgical treatments and changes in patients' pre- and postoperative complaints were evaluated. Results: In all cases except 1, the preoperative examination showed dysmotility of the esophagus. The average duration of the surgeries was 165 (130–195) minutes; blood loss was minimal. One patient developed bleeding in the early postoperative period, and a second laparoscopy was required. No other intraoperative complication was detected, and no mortality occurred. In one case, a staple line leak developed (1/8 [12.5%]), which was resolved with conservative therapy. Functional check-ups confirmed adequate esophageal function. The total symptom score for the patients was 6.3 points before surgery, and it decreased to 1.6 (P < .001) after surgery, an average of 74% subjective improvement. During the follow-up period (mean, 60 months; 10–138 months), proton pump inhibitor therapy was started in 4 patients to treat gastroesophageal reflux. In 3 cases, drug therapy was successful; in one case, Nissen antireflux surgery was performed. Conclusion: Laparoscopic transhiatal diverticulectomy and Heller–Dor surgery are effective interventions with low morbidity. Patient quality of life significantly improves in the long term, but gastroesophageal reflux disease may occur.
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Affiliation(s)
| | | | | | | | - András Rosztóczy
- 1st Department of Medicine, Albert Szent-Györgyi Health Center, University of Szeged, Szeged, Hungary
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Zaninotto G, Bennett C, Boeckxstaens G, Costantini M, Ferguson MK, Pandolfino JE, Patti MG, Ribeiro U, Richter J, Swanstrom L, Tack J, Triadafilopoulos G, Markar SR, Salvador R, Faccio L, Andreollo NA, Cecconello I, Costamagna G, da Rocha JRM, Hungness ES, Fisichella PM, Fuchs KH, Gockel I, Gurski R, Gyawali CP, Herbella FAM, Holloway RH, Hongo M, Jobe BA, Kahrilas PJ, Katzka DA, Dua KS, Liu D, Moonen A, Nasi A, Pasricha PJ, Penagini R, Perretta S, Sallum RAA, Sarnelli G, Savarino E, Schlottmann F, Sifrim D, Soper N, Tatum RP, Vaezi MF, van Herwaarden-Lindeboom M, Vanuytsel T, Vela MF, Watson DI, Zerbib F, Gittens S, Pontillo C, Vermigli S, Inama D, Low DE. The 2018 ISDE achalasia guidelines. Dis Esophagus 2018; 31:5087687. [PMID: 30169645 DOI: 10.1093/dote/doy071] [Citation(s) in RCA: 175] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.
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Affiliation(s)
- G Zaninotto
- Department of Surgery and Cancer, Imperial College, London, UK
| | - C Bennett
- Office of Research and Innovation, Royal College of Surgeons in Ireland, Ireland
| | - G Boeckxstaens
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - M Costantini
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - M K Ferguson
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - J E Pandolfino
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - M G Patti
- Department of Medicine and Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - U Ribeiro
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - J Richter
- Department of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - L Swanstrom
- Institute of Image-Guided Surgery, Strasbourg, France; Interventional Endoscopy and Foregut Surgery, Oregon Health Science University, Portland, Oregon, USA
| | - J Tack
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - G Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford Esophageal Multidisciplinary Program in Innovative Research Excellence (SEMPIRE), Stanford University, Stanford, California, USA
| | - S R Markar
- Department of Surgery and Cancer, Imperial College, London, UK
| | - R Salvador
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - L Faccio
- Division of Surgery, Padova University Hospital, Padova, Italy
| | - N A Andreollo
- Faculty of Medical Science, State University of Campinas, Campinas, São Paulo, Brazil
| | - I Cecconello
- Digestive Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - G Costamagna
- Digestive Endoscopy Unit, A. Gemelli Hospital, Catholic University, Rome, Italy
| | - J R M da Rocha
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - E S Hungness
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - P M Fisichella
- Department of Surgery, Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
| | - K H Fuchs
- Department of Surgery, AGAPLESION-Markus-Krankenhaus, Frankfurt, Germany
| | - I Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - R Gurski
- Department of Surgery, School of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - F A M Herbella
- Department of Surgery, School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - R H Holloway
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, The University of Adelaide, Adelaide, Australia
| | - M Hongo
- Department of Medicine, Kurokawa Hospital, Taiwa, Kurokawa, Miyagi, Japan
| | - B A Jobe
- Esophageal and Lung Institute, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania, USA
| | - P J Kahrilas
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - D A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - K S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - D Liu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - A Moonen
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - A Nasi
- Digestive Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - P J Pasricha
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - R Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico; Department of Pathophysiology and Transplantation; Università degli Studi, Milan, Italy
| | - S Perretta
- Institute for Image Guided Surgery IHU-Strasbourg, Strasbourg, France
| | - R A A Sallum
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - G Sarnelli
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - E Savarino
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - F Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - D Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - N Soper
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - R P Tatum
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - M F Vaezi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - M van Herwaarden-Lindeboom
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - T Vanuytsel
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - M F Vela
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - D I Watson
- Department of Surgery, Flinders University, Adelaide, Australia
| | - F Zerbib
- Department of Gastroenterology, University of Bordeaux, Bordeaux, France
| | - S Gittens
- ECD Solutions, Atlanta, Georgia, USA
| | - C Pontillo
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - S Vermigli
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - D Inama
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - D E Low
- Department of Thoracic Surgery Virginia Mason Medical Center, Seattle, Washington, USA
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Ramchandani M, Nageshwar Reddy D, Nabi Z, Chavan R, Bapaye A, Bhatia S, Mehta N, Dhawan P, Chaudhary A, Ghoshal UC, Philip M, Neuhaus H, Deviere J, Inoue H. Management of achalasia cardia: Expert consensus statements. J Gastroenterol Hepatol 2018; 33:1436-1444. [PMID: 29377271 DOI: 10.1111/jgh.14097] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 01/14/2018] [Indexed: 12/14/2022]
Abstract
Achalasia cardia (AC) is a frequently encountered motility disorder of the esophagus resulting from an irreversible degeneration of neurons. Treatment modalities are palliative in nature, and there is no curative treatment available for AC as of now. Significant advancements have been made in the management of AC over last decade. The introduction of high resolution manometry and per-oral endoscopic myotomy (POEM) has strengthened the diagnostic and therapeutic armamentarium of AC. High resolution manometry allows for the characterization of the type of achalasia, which in turn has important therapeutic implications. The endoscopic management of AC has been reinforced with the introduction of POEM that has been found to be highly effective and safe in palliating the symptoms in short-term to mid-term follow-up studies. POEM is less invasive than Heller's myotomy and provides the endoscopist with the opportunity of adjusting the length and orientation of esophageal myotomy according to the type of AC. The management of achalasia needs to be tailored for each patient, and the role of pneumatic balloon dilatation, POEM, or Heller's myotomy needs to be revisited. In this review, we discuss the important aspects of diagnosis as well as management of AC. The statements presented in the manuscript reflect the cumulative efforts of an expert consensus group.
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Affiliation(s)
- Mohan Ramchandani
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - D Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Radhika Chavan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Amol Bapaye
- Department of Digestive Diseases and Endoscopy, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra, India
| | - Shobna Bhatia
- Department of Gastroenterology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Nilay Mehta
- Department of Gastroenterology, Vedanta Institute of Medical Sciences, Ahmedabad, Gujarat, India
| | - Pankaj Dhawan
- Department of Gastroenterology, Bhatia General Hospital, Mumbai, Maharashtra, India
| | - Adarsh Chaudhary
- Department of Surgical Gastroenterology, Medanta The Medicity, Gurgaon, Haryana, India
| | - Uday C Ghoshal
- Department of Gastroenterology, SGPGI, Lucknow, Uttar Pradesh, India
| | - Mathew Philip
- Gastroenterology, PVS Memorial Hospital, Ernakulam, Kerala, India
| | - Horst Neuhaus
- Department of Internal Medicine, Evangelical Hospital Düsseldorf, Dusseldorf, Nordrhein-Westfalen, Germany
| | - Jacques Deviere
- Department of Gastroenterology, Erasmus Hospital, Bruxelles, Belgium
| | - Haruhiro Inoue
- Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
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50
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Felix VN. Results of pneumatic dilation in treating achalasia: predictive factors. Ann N Y Acad Sci 2018; 1434:124-131. [PMID: 29766515 DOI: 10.1111/nyas.13844] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/07/2018] [Accepted: 04/11/2018] [Indexed: 12/14/2022]
Abstract
Forced pneumatic dilatation (PD) of the cardia is one of the most consecrated therapeutic measures for esophageal achalasia. The procedure only achieved better standardization with the appearance of the Rigiflex balloon. Results and predictive factors of success and failure of PD are reviewed, right after the description of the main technical aspects of the procedure. The success rates, providing control of dysphagia for about 1 year from the procedure using the Rigiflex balloon, are quite satisfactory, with success in more than 75% of patients. It is generally observed that good responses sustained for more than 5 years appear in at least 40% of cases. However, approximately half of the patients submitted to PD require additional dilation and a subgroup of them will undergo surgical treatment to attain adequate control of dysphagia. PD is a method with a low rate of acute complications, with esophageal perforation, the most severe of them, not affecting more than 5% of the cases. The best results could be potentially obtained when predictive factors of success were considered before choosing PD as a therapeutic option, but prospective studies in this field are missing until now.
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