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de Sire R, Capogreco A, Massimi D, Alfarone L, Mastrorocco E, Pellegatta G, Hassan C, Repici A, Maselli R. Per oral endoscopic myotomy for achalasia. Best Pract Res Clin Gastroenterol 2024; 71:101930. [PMID: 39209417 DOI: 10.1016/j.bpg.2024.101930] [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: 03/03/2024] [Revised: 05/05/2024] [Accepted: 06/04/2024] [Indexed: 09/04/2024]
Abstract
Achalasia, characterized by impaired lower esophageal sphincter (LES) relaxation and failed peristalsis, stands out as the most widely recognized primary esophageal motility disorder. It manifests with dysphagia to solid and liquid foods, chest pain, regurgitation, and weight loss, leading to significant morbidity and healthcare burden. Traditionally, surgical Heller myotomy and pneumatic dilation were the primary therapeutic approaches for achalasia. However, in 2009, Inoue and colleagues introduced a groundbreaking endoscopic technique called peroral endoscopic myotomy (POEM), revolutionizing the management of this condition. This review aims to comprehensively examine the recent advancements in the POEM technique for patients diagnosed with achalasia, delving into critical aspects, such as the tailoring of the myotomy, the prevention of intraprocedural adverse events (AEs), the evaluation of long-term outcomes, and the feasibility of retreatment in cases of therapeutic failure.
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Affiliation(s)
- Roberto de Sire
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy.
| | - Antonio Capogreco
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy
| | - Davide Massimi
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy
| | - Ludovico Alfarone
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy
| | - Elisabetta Mastrorocco
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy
| | - Gaia Pellegatta
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy
| | - Cesare Hassan
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, 20072, Pieve Emanuele, Italy
| | - Alessandro Repici
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, 20072, Pieve Emanuele, Italy
| | - Roberta Maselli
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, 20072, Pieve Emanuele, Italy
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Mandarino FV, Vespa E, Barchi A, Fasulo E, Sinagra E, Azzolini F, Danese S. Precision Endoscopy in Peroral Myotomies for Motility Disorders of the Upper Gastrointestinal Tract: Current Insights and Prospective Avenues-A Comprehensive Review. Life (Basel) 2023; 13:2143. [PMID: 38004283 PMCID: PMC10672509 DOI: 10.3390/life13112143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/28/2023] [Accepted: 10/29/2023] [Indexed: 11/26/2023] Open
Abstract
Our review delves into the realm of peroral endoscopic myotomies (POEMs) in the upper gastrointestinal tract (UGT). In recent years, POEMs have brought about a revolution in the treatment of UGT motility disorders. Esophageal POEM, the first to be introduced, has now been validated as the primary treatment for achalasia. Subsequently developed, G-POEM displays promising results in addressing refractory gastroparesis. Over time, multiple endoscopic myotomy techniques have emerged for the treatment of Zenker's diverticulum, including Z-POEM, POES, and hybrid approaches. Despite the well-established efficacy outcomes, new challenges arise in the realm of POEMs in the UGT. For esophageal POEM, the future scenario lies in customizing the myotomy extent to the minimum necessary, while for G-POEM, it involves identifying patients who can optimally benefit from the treatment. For ZD, it is crucial to validate an algorithm that considers various myotomy options according to the diverticulum's size and in relation to individual patients. These challenges align with the concept of precision endoscopy, personalizing the technique for each subject. Within our text, we comprehensively examine each myotomy technique, analyzing indications, outcomes, and adverse events. Additionally, we explore the emerging challenges posed by myotomies within the context of the evolving field of precision endoscopy.
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Affiliation(s)
- Francesco Vito Mandarino
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Edoardo Vespa
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Alberto Barchi
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Ernesto Fasulo
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto San Raffaele Giglio, 90015 Cefalù, Italy
| | - Francesco Azzolini
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Silvio Danese
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
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Khaiser A, Baig M, Forcione D, Bechtold M, Puli SR. Efficacy and Safety of Peroral Endoscopic Myotomy (POEM) in Achalasia: An Updated Meta-analysis. Middle East J Dig Dis 2023; 15:235-241. [PMID: 38523886 PMCID: PMC10955992 DOI: 10.34172/mejdd.2023.352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 07/06/2023] [Indexed: 03/26/2024] Open
Abstract
Background: Heller myotomy has been considered the standard surgical treatment for patients with achalasia. Since the initiation of peroral endoscopic myotomy (POEM), it has represented an alternative for treating patients with achalasia. Over the years, numerous prospective and retrospective studies with POEM use for achalasia have been published. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of POEM in patients with achalasia. Methods: Publications investigating the safety and efficacy of POEM in patients with achalasia were searched in Medline, Ovid Journals, Medline non-indexed citations, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Pooling was conducted by both fixed and random effects models. Results: The initial search identified 328 reference articles; of these, 34 relevant articles were selected and reviewed. Data was extracted from 20 studies (n=1753) which met the inclusion criteria. In pooled analysis, the clinical success of POEM at 3 months was 94% (95% CI=93-95). The pooled clinical success of POEM at 12 months was 91% (95% CI=90-92). The pooled rate of gastroesophageal reflux disease (GERD) was 21% (95% CI=19-23), esophagitis was reported in 16% (95% CI=15-18), pneumomediastinum in 4% (95% CI=3-6), cervical emphysema in 12% (95% CI=10-13), pneumoperitoneum in 8% (95% CI=7-10), pneumothorax in 5% (95% CI=4 - 6), pleural effusion in 3% (95% CI=2-3), post-operative bleeding in 4.29% (95% CI=1.91 -7.61) and aspiration pneumonia in 3.08% (95% CI=1.13-5.97) of the patients after POEM. Conclusion: This meta-analysis suggests that POEM is a highly effective and safe endoscopic treatment for patients with achalasia and a reasonable alternative to Heller myotomy.
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Affiliation(s)
- Afshin Khaiser
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Muhammad Baig
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - David Forcione
- Department of Gastroenterology and Hepatology, Boca Raton Regional Hospital, Boca Raton, FL, USA
| | - Matthew Bechtold
- Department of Gastroenterology and Hepatology, University of Missouri-Columbia, Columbia, MO, USA
| | - Srinivas R. Puli
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
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Loh R, Noverati N, Goldberg I, Josloff K, Schiavone G, Halegoua-DeMarzio D, Schlachterman A. Safe Use of POEM in a Patient With Decompensated Cirrhosis and Severe Achalasia. ACG Case Rep J 2023; 10:e01144. [PMID: 37753108 PMCID: PMC10519461 DOI: 10.14309/crj.0000000000001144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 09/28/2023] Open
Abstract
Patients with both achalasia and decompensated cirrhosis can often present a therapeutic challenge because portal hypertension has generally been considered a contraindication to definitive therapies for achalasia. This case report depicts a patient who presented with progressive dysphagia, weight loss, and large-volume ascites; was diagnosed with type II achalasia and decompensated cirrhosis without esophageal varices; and underwent peroral endoscopic myotomy after preprocedural transjugular intrahepatic portosystemic shunt placement. Our case highlights the importance of multidisciplinary care and need for definitive therapies for these complex patients at high risk of malnutrition and sarcopenia.
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Affiliation(s)
- Rebecca Loh
- Thomas Jefferson University Hospital, Philadelphia, PA
| | | | | | - Kevan Josloff
- Thomas Jefferson University Hospital, Philadelphia, PA
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Hernández Mondragón OV, Solórzano Pineda OM. Peroral esophageal myotomy for esophageal motility disorders. Minerva Gastroenterol (Torino) 2023; 69:193-208. [PMID: 37191670 DOI: 10.23736/s2724-5985.22.02987-4] [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: 05/17/2023]
Abstract
The concept of third space endoscopy first described in 2007, was adapted and performed in humans in 2010 by Inoue et al. in a group of patients with esophageal achalasia (EA). Since then, esophageal endoscopic myotomy (E-POEM), has been performed in more than 10,000 patients worldwide up to now. Safety and efficacy have been confirmed at early, mid and long-term evaluations, in different gastrointestinal diseases including achalasia, refractory gastroparesis, and other esophageal motility disorders (EMD). Nowadays, this treatment has shown to be not only an excellent option, but also with its excellent outcomes, the first option in certain clinical scenarios such as type III achalasia. Thus, the minimal invasive nature of POEM gives us multiple advantages compared with the classical treatments that includes pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM), including not only clinical aspects but also economical. High resolution manometry (HRM) has substantially redefined the actual approach of esophageal motility disorders with the major changes in instrumental use, diagnostic algorithms, and therapeutics. The previous Chicago's classification V 3.0 clearly improved our knowledge about pathophysiology of spastic esophageal motor disorders, however, with its recent update (Chicago V 4.0), multiple changes in diagnosis and treatment are expected. In the present article, we aimed to review and analyze the most important aspects about the results of E-POEM in the management of EMD according to the view of the new Chicago's classification V 4.0.
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Affiliation(s)
| | - Omar M Solórzano Pineda
- Department of Gastrointestinal Endoscopy, XXI Century National Medical Center, Mexico City, Mexico
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Weng CY, He CH, Zhuang MY, Xu JL, Lyu B. Peroral endoscopic longer vs shorter esophageal myotomy for achalasia treatment: A systematic review and meta-analysis. World J Gastrointest Surg 2022; 14:247-259. [PMID: 35432766 PMCID: PMC8984519 DOI: 10.4240/wjgs.v14.i3.247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/09/2021] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) has been demonstrated to be safe and effective in the treatment of achalasia. Longer myotomy is the standard POEM procedure for achalasia but when compared with shorter myotomy, its effectiveness is not as well known.
AIM To compare the clinical effectiveness of longer and shorter myotomy.
METHODS PubMed, EmBase, Cochrane Library, web of science and clinicaltrials.gov were queried for studies comparing shorter and longer POEM for achalasia treatment. The primary outcome was clinical success rate. Secondary outcomes comprised of operative time, adverse events (AEs) rate, gastroesophageal reflux disease (GERD) and procedure-related parameters. The Mantel-Haenszel fixed-effects model was primarily used for the analysis. Publication bias was assessed.
RESULTS Six studies were included in this analysis with a total of 514 participants. During the follow-up period of 1-28.7 mo, longer and shorter myotomy in treating achalasia showed similar excellent effectiveness [overall clinical success (OR = 1, 95%CI: 0.46-2.17, P = 1, I2: 0%; subgroup of abstract (OR = 1.19, 95%CI: 0.38 to 3.73; P = 0.76; I2: 0%); subgroup of full text (OR = 0.86 95%CI: 0.30 to 2.49; P = 0.78; I2: 0%)]. Shorter myotomy had significantly reduced mean operative time compared with the longer procedure. There were no statistically significant differences in AEs rates, including GERD (overall OR = 1.21, 95%CI: 0.76-1.91; P = 0.42; I2: 9%; subgroup of abstract OR = 0.77, 95%CI: 0.40-1.47; P = 0.43; I2: 0%; subgroup of full text OR = 1.91, 95%CI: 0.98-3.75; P = 0.06; I2: 0%), hospital stay (overall MD = -0.07, 95%CI: -0.30 to 0.16; P = 0.55; I2: 24%; subgroup of abstract MD = 0.20, 95%CI: -0.25 to 0.65; P = 0.39; I2: 0; subgroup of full text MD = -0.16, 95%CI: -0.42 to 0.10; P = 0.23; I2: 42%), and major bleeding (overall OR = 1.25, 95%CI: 0.58-2.71; P = 0.56; I2: 0%) between the two procedures. These differences remained statistically non-significant in all sensitivity analyses.
CONCLUSION POEM was effective in treating achalasia. Shorter and longer myotomy procedures provided similar therapeutic effects in terms of long-term effectiveness. In addition, shorter myotomy reduced the operative time.
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Affiliation(s)
- Chun-Yan Weng
- Department of Gastroenterology, The First Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang Province, China
| | - Cheng-Hai He
- Department of Gastroenterology, The Affiliated Hospital of Hangzhou Normal University, Hangzhou 310006, Zhejiang Province, China
| | - Ming-Yang Zhuang
- Internal Medicine of Chinese Medicine, The First Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang Province, China
| | - Jing-Li Xu
- Department of Surgery, The First Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang Province, China
| | - Bin Lyu
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang Chinese Medicine University, Hangzhou 310006, Zhejiang Province, China
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Ueda C, Abe H, Tanaka S, Kawara F, Toyonaga T, Ariyoshi R, Sako T, Sakaguchi H, Ikezawa N, Urakami S, Nakai T, Kodama Y. Peroral endoscopic myotomy for advanced achalasia with megaesophagus. Esophagus 2021; 18:922-931. [PMID: 33837865 DOI: 10.1007/s10388-021-00833-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/23/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The outcomes of peroral endoscopic myotomy for advanced achalasia are not well known. This study aimed to evaluate the outcomes of peroral endoscopic myotomy for achalasia with megaesophagus, which is one of the characteristics of advanced achalasia. METHODS In total, 234 patients with achalasia who underwent peroral endoscopic myotomy in our hospital from April 2015 to March 2019 were included in this retrospective observational study. Megaesophagus was defined as a maximum esophageal diameter of 6 cm or more. Outcomes, including clinical success (Eckardt score ≤ 3 without retreatment) at the 1-year follow-up, technical success, and perioperative complications, were investigated and compared between patients with and without megaesophagus. RESULTS Eleven patients (4.7%) were diagnosed with megaesophagus. The clinical success rate achieved was 63.6% in patients with megaesophagus, with a significant decrease in the Eckardt score (6 vs. 2, p = 0.003) and integrated relaxation pressure (28 mmHg vs. 9 mmHg, p = 0.028). The technical success rate was 100%. However, patients with megaesophagus had a significantly lower clinical success rate than those without megaesophagus (63.6% vs. 96.0%, p = 0.002). Furthermore, patients with megaesophagus had significantly higher rates of major adverse events than those without megaesophagus (18.2% vs. 2.7%, p = 0.048). CONCLUSIONS Peroral endoscopic myotomy improved achalasia-related symptoms, and this was technically feasible in patients with megaesophagus. However, the clinical success rate was somewhat low, and the rate of major adverse events was high. Therefore, peroral endoscopic myotomy should be carefully performed for advanced achalasia with megaesophagus.
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Affiliation(s)
- Chise Ueda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Hirofumi Abe
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
| | - Shinwa Tanaka
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Fumiaki Kawara
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Takashi Toyonaga
- Division of Endoscopic Medicine, Kobe University Hospital, Kobe, Japan
| | - Ryusuke Ariyoshi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Tomoya Sako
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Hiroya Sakaguchi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Nobuaki Ikezawa
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Satoshi Urakami
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Tatsuya Nakai
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
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McKay SC, Dunst CM, Sharata AM, Fletcher R, Reavis KM, Bradley DD, DeMeester SR, Müller D, Parker B, Swanström LL. POEM: clinical outcomes beyond 5 years. Surg Endosc 2021; 35:5709-5716. [PMID: 33398572 DOI: 10.1007/s00464-020-08031-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 09/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The short-term success of peroral endoscopic myotomy (POEM) is well documented but the durability of the operation is questioned. The aim of this study was to evaluate the clinical outcomes of the POEM procedure for esophageal motility disorders in a large cohort in which all patients had at least 5 years of follow-up. METHODS All patients from a single center who underwent a POEM between October 2010 and September 2014 were followed for long-term clinical outcomes. Postoperative Eckardt symptom scores of short term and ≥ 5 years were collected through phone interview. Clinical success was defined as an Eckardt score < 3. Overall success was defined as Eckardt score < 3 and freedom from additional interventions. RESULTS Of 138 patients, 100 patients were available for follow-up (mean age 56, 52% male). The indication for operation was achalasia in 94. The mean follow-up duration was 75 months (range: 60-106 months). Dysphagia was improved in 91% of patients. Long-term overall success was achieved in 79% of patients (80% of achalasia patients, 67% of DES patients). Preoperative mean Eckardt score was 6. At 6 months, it was 1, and at 75 months, it was 2 (p = 0.204). Five-year freedom from intervention was 96%. Overall, 7 patients had additional treatments: 1 balloon dilation (35 mm), 4 laparoscopic Heller myotomy, and 2 redo POEM at a mean of 51 months post-POEM. Ninety-three percent expressed complete satisfaction with POEM. CONCLUSION A multitude of studies has shown the early benefits of POEM. Here, we show that nearly 80% of patients report clinical success with no significant decrement in symptom scores between their short- and long-term follow-up. Clearly POEM is an effective option for achalasia with durable long-term treatment efficacy.
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Affiliation(s)
- Sarah C McKay
- Foundation for Surgical Innovation and Education, Portland, OR, USA
| | - Christy M Dunst
- Foundation for Surgical Innovation and Education, Portland, OR, USA. .,The Oregon Clinic: Gastrointestinal and Minimally Invasive Surgery Division, Portland, OR, USA. .,Providence Portland Medical Center, 4805 NE Glisan Ave, Portland, OR, 97213, USA.
| | - Ahmed M Sharata
- Foundation for Surgical Innovation and Education, Portland, OR, USA.,Providence Portland Medical Center, 4805 NE Glisan Ave, Portland, OR, 97213, USA
| | - Reid Fletcher
- Foundation for Surgical Innovation and Education, Portland, OR, USA.,Providence Portland Medical Center, 4805 NE Glisan Ave, Portland, OR, 97213, USA
| | - Kevin M Reavis
- Foundation for Surgical Innovation and Education, Portland, OR, USA.,The Oregon Clinic: Gastrointestinal and Minimally Invasive Surgery Division, Portland, OR, USA.,Providence Portland Medical Center, 4805 NE Glisan Ave, Portland, OR, 97213, USA
| | - Daniel Davila Bradley
- Foundation for Surgical Innovation and Education, Portland, OR, USA.,The Oregon Clinic: Gastrointestinal and Minimally Invasive Surgery Division, Portland, OR, USA.,Providence Portland Medical Center, 4805 NE Glisan Ave, Portland, OR, 97213, USA
| | - Steven R DeMeester
- Foundation for Surgical Innovation and Education, Portland, OR, USA.,The Oregon Clinic: Gastrointestinal and Minimally Invasive Surgery Division, Portland, OR, USA
| | - Dolores Müller
- Foundation for Surgical Innovation and Education, Portland, OR, USA
| | - Brett Parker
- Foundation for Surgical Innovation and Education, Portland, OR, USA.,Providence Portland Medical Center, 4805 NE Glisan Ave, Portland, OR, 97213, USA
| | - Lee L Swanström
- Foundation for Surgical Innovation and Education, Portland, OR, USA.,IHU Strasbourg, Strasbourg, France
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9
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Huang S, Ren Y, Peng W, Gao Q, Peng Y, Gong W, Tang X. Peroral endoscopic shorter versus longer myotomy for the treatment of achalasia: a comparative retrospective study. Esophagus 2020; 17:477-483. [PMID: 32361976 DOI: 10.1007/s10388-020-00739-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 04/14/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Peroral esophageal myotomy (POEM) is a novel endoscopic treatment for achalasia. It has gained popularity worldwide among surgeons and endoscopists, but no studies have compared peroral endoscopic short with long myotomy for achalasia. We aimed to compare the clinical efficacy and safety between peroral endoscopic shorter and longer myotomy. METHODS The retrospective study enrolled 129 achalasia patients who underwent POEM from July 2011 to September 2017. Based on the myotomy length (ML), patients were divided into shorter myotomy (SM) group (ML ≤ 7 cm, n = 36) and longer myotomy (LM) group (ML > 7 cm, n = 74). Procedure-related parameters, symptom scores, adverse events and manometric data were compared between two groups. RESULTS The mean ML was 6.0 ± 0.6 cm in SM group, and 11.5 ± 3.1 cm in LM group (p < 0.001). The mean operation time was significantly less in SM group than LM group (46.6 ± 18.5 min vs 62.1 ± 25.2 min, p = 0.001). During a mean follow-up period of 28.7 months, treatment success (Eckardt score ≤ 3) was achieved in 94.4% (34/36) of patients in SM group and 91.9% (68/74) in LM group (p = 0.926). There was no statistical difference in the incidence of intraoperative complications (8.4% vs 8.2%, p = 0.823) and reflux rate (8.3% vs. 14.9%, p = 0.510) between two groups. CONCLUSIONS Peroral endoscopic shorter myotomy is comparable with longer myotomy for treating achalasia with regard to clinical efficacy and has the advantage of shorter procedure time.
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Affiliation(s)
- Silin Huang
- Departmemt of Gastroenterology, Shenzhen Hospital, Southern Medical University, No.1333 Xinhu Road, Baoan District, Shenzhen, 518000, China
| | - Yutang Ren
- Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Wei Peng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China
| | - Qiaoping Gao
- Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yan Peng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China
| | - Wei Gong
- Departmemt of Gastroenterology, Shenzhen Hospital, Southern Medical University, No.1333 Xinhu Road, Baoan District, Shenzhen, 518000, China.
| | - Xiaowei Tang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China.
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Feng Z, Liu ZM, Yuan XL, Ye LS, Wu CC, Tan QH, Hu B. Peroral endoscopic myotomy for management of gastrointestinal motility disorder. World J Clin Cases 2020; 8:2116-2126. [PMID: 32548141 PMCID: PMC7281049 DOI: 10.12998/wjcc.v8.i11.2116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/27/2020] [Accepted: 04/28/2020] [Indexed: 02/05/2023] Open
Abstract
Achalasia is a type of esophageal motility disorder, consisting of relaxation dysfunction of the lower esophagus and disturbed esophageal peristalsis. Related clinical symptoms include dysphagia, regurgitation, chest pain, and weight loss. Traditional treatment options include endoscopic botulinum toxin injection, endoscopic pneumatic dilation, and laparoscopic Heller's myotomy. These therapies mainly relieve symptoms by reducing the pressure on the lower esophageal sphincter and reducing blood flow resistance at the esophagogastric junction. Based on endoscopic submucosal dissection and natural orifice transluminal endoscopic surgery, peroral endoscopic myotomy (POEM) is a purely endoscopic method of myotomy with minimal invasiveness and a low rate of adverse events when performed by experienced operators. Since then, numerous studies have shown the significant clinical efficacy and safety of POEM. The purpose of this article is to introduce different modified POEMs, special indications for different POEMs, and their advantages as well as disadvantages.
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Affiliation(s)
- Zhe Feng
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Zi-Ming Liu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xiang-Lei Yuan
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Lian-Song Ye
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Chun-Cheng Wu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Qing-Hua Tan
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Bing Hu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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Khashab MA, Sanaei O, Rivory J, Eleftheriadis N, Chiu PWY, Shiwaku H, Ogihara K, Ismail A, Abusamaan MS, El Zein MH, Wong VW, Billioux VG, Kumbhari V, Kalloo AN, Ponchon T, Pioche M. Peroral endoscopic myotomy: anterior versus posterior approach: a randomized single-blinded clinical trial. Gastrointest Endosc 2020; 91:288-297.e7. [PMID: 31408652 DOI: 10.1016/j.gie.2019.07.034] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 07/24/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) has become the mainstay for the treatment of achalasia at many institutions around the world since its inception in 2008. POEM can be performed using either the anterior or posterior approach. The primary aim of this study was to compare the efficacy of the anterior and posterior approaches at 1 year after POEM. METHODS This is a single-blinded, randomized, noninferiority international clinical trial. Eligible participants were adult patients with a confirmed diagnosis of achalasia via high-resolution esophageal manometry. Patients were randomly allocated with a 1:1 ratio to receive POEM with anterior or posterior approach. The primary aim was to compare the rate of clinical success (Eckardt score <3) of anterior and posterior approaches at 1 year. RESULTS One hundred fifty patients were randomized to receive either anterior (n = 73) or posterior (n = 77) POEM. One hundred forty-eight patients received the POEM treatment, and 138 patients completed the 1-year follow-up and were included in the primary efficacy analysis. Technical success was achieved in 71 patients (97.3%) in the anterior group versus 77 patients (100%) in the posterior group (P = .23). The median (interquartile range) length of hospital stay after the procedure was 2 (1-3) days for both groups. Adverse events occurred in 15 patients (10%), 8 patients (11%) in the anterior group and 7 patients (9%) in the posterior group (P = .703). Clinical success was achieved in 90% of patients in the anterior group and 89% of patients in the posterior group. Abnormal esophageal acid exposure was detected in 29 of 59 patients (49%) and 25 of 60 patients (42%) in the anterior and posterior groups, respectively (P = .67). GERD questionnaire scores were also not significantly different between the study groups. In both groups, quality of life improved after POEM for all 36-Item Short-Form Health Survey measures and was similar between both groups. CONCLUSIONS Posterior myotomy during POEM was not inferior to anterior myotomy in terms of efficacy and safety in the treatment of patients with achalasia. (Clinical trial registration number: NCT02454335.).
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Affiliation(s)
- Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Jerome Rivory
- Endoscopy and Gastroenterology Unit, Edouard Herriot Hospital, Lyon, France
| | - Nicholas Eleftheriadis
- Endoscopy Department, Gastroenterology Unit, Metropolitan Hospital Athens, Athens, and Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Philip Wai Yan Chiu
- Division of Upper GI & Metabolic Surgery, Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Kumi Ogihara
- Department of Gastroenterology and Hepatology, Nagazaki University Hospital, Nagazaki, Japan
| | - Amr Ismail
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mohammed S Abusamaan
- Division of General Internal Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Mohamad H El Zein
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vivien W Wong
- Division of Upper GI & Metabolic Surgery, Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Veena G Billioux
- Bayview Pediatrics, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Anthony N Kalloo
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Thierry Ponchon
- Endoscopy and Gastroenterology Unit, Edouard Herriot Hospital, Lyon, France
| | - Mathieu Pioche
- Endoscopy and Gastroenterology Unit, Edouard Herriot Hospital, Lyon, France
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12
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Khashab MA, Vela MF, Thosani N, Agrawal D, Buxbaum JL, Abbas Fehmi SM, Fishman DS, Gurudu SR, Jamil LH, Jue TL, Kannadath BS, Law JK, Lee JK, Naveed M, Qumseya BJ, Sawhney MS, Yang J, Wani S. ASGE guideline on the management of achalasia. Gastrointest Endosc 2020; 91:213-227.e6. [PMID: 31839408 DOI: 10.1016/j.gie.2019.04.231] [Citation(s) in RCA: 129] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 04/22/2019] [Indexed: 12/11/2022]
Abstract
Achalasia is a primary esophageal motor disorder of unknown etiology characterized by degeneration of the myenteric plexus, which results in impaired relaxation of the esophagogastric junction (EGJ), along with the loss of organized peristalsis in the esophageal body. The criterion standard for diagnosing achalasia is high-resolution esophageal manometry showing incomplete relaxation of the EGJ coupled with the absence of organized peristalsis. Three achalasia subtypes have been defined based on high-resolution manometry findings in the esophageal body. Treatment of patients with achalasia has evolved in recent years with the introduction of peroral endoscopic myotomy. Other treatment options include botulinum toxin injection, pneumatic dilation, and Heller myotomy. This American Society for Gastrointestinal Endoscopy Standards of Practice Guideline provides evidence-based recommendations for the treatment of achalasia, based on an updated assessment of the individual and comparative effectiveness, adverse effects, and cost of the 4 aforementioned achalasia therapies.
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Affiliation(s)
- Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Marcelo F Vela
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Nirav Thosani
- Interventional Gastroenterologists of the University of Texas, Department of Internal Medicine, McGovern Medical School, Houston, Texas, USA
| | - Deepak Agrawal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Syed M Abbas Fehmi
- Division of Gastroenterology/Hepatology, University of California, San Diego, San Diego, California, USA
| | - Douglas S Fishman
- Section of Pediatric Gastroenterology, Baylor College of Medicine; Texas Children's Hospital, Houston, Texas, USA
| | | | - Laith H Jamil
- Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Terry L Jue
- The Permanente Medical Group, Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Bijun Sai Kannadath
- Interventional Gastroenterologists of the University of Texas, Department of Internal Medicine, McGovern Medical School, Houston, Texas, USA
| | - Joanna K Law
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Jeffrey K Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Mariam Naveed
- Division of Gastroenterology and Hepatology, University of Iowa Hospital & Clinics, Iowa City, Iowa, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, Archbold Medical Group, Thomasville, Georgia, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Julie Yang
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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13
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Quitadamo P, Tambucci R, Mancini V, Cristofori F, Baldassarre M, Pensabene L, Francavilla R, Di Nardo G, Caldaro T, Rossi P, Mallardo S, Maggiora E, Staiano A, Cresi F, Salvatore S, Borrelli O. Esophageal pH-impedance monitoring in children: position paper on indications, methodology and interpretation by the SIGENP working group. Dig Liver Dis 2019; 51:1522-1536. [PMID: 31526716 DOI: 10.1016/j.dld.2019.07.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/02/2019] [Accepted: 07/20/2019] [Indexed: 12/11/2022]
Abstract
Multichannel intraluminal impedance pH (MII-pH) monitoring currently represents the gold standard diagnostic technique for the detection of gastro-esophageal reflux (GER), since it allows to quantify and characterize all reflux events and their possible relation with symptoms. Over the last ten years, thanks to its strengths and along with the publication of several clinical studies, its worldwide use has gradually increased, particularly in infants and children. Nevertheless, factors such as the limited pediatric reference values and limited therapeutic options still weaken its current clinical impact. Through an up-to-date review of the available scientific evidence, our aim was to produce a position paper on behalf of the working group on neurogastroenterology and acid-related disorders of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) on MII-pH monitoring technique, indications and interpretation in pediatric age, in order to standardise its use and to help clinicians in the diagnostic approach to children with GER symptoms.
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Affiliation(s)
- Paolo Quitadamo
- Department of Pediatrics, A.O.R.N. Santobono-Pausilipon, Naples, Italy; Department of Translational Medical Science,"Federico II", University of Naples, Italy.
| | - Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy; Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Valentina Mancini
- Department of Pediatrics and Neonatology, Saronno Hospital, Saronno, Italy
| | - Fernanda Cristofori
- Department of Pediatrics, Giovanni XXIII Hospital, Aldo MoroUniversity of Bari, Bari, Italy
| | - Mariella Baldassarre
- Department of Biomedical Science and Human Oncology-neonatology and Nicu section, University "Aldo Moro", Bari, Italy
| | - Licia Pensabene
- Department of Medical and Surgical Sciences, Pediatric Unit, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Ruggiero Francavilla
- Department of Pediatrics, Giovanni XXIII Hospital, Aldo MoroUniversity of Bari, Bari, Italy
| | - Giovanni Di Nardo
- NESMOS Department, School of Medicine and Psychology, Sapienza University of Rome, Sant'Andrea University Hospital, Rome, Italy
| | - Tamara Caldaro
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Rossi
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - Saverio Mallardo
- Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - Elena Maggiora
- Neonatology and Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Annamaria Staiano
- Department of Translational Medical Science,"Federico II", University of Naples, Italy
| | - Francesco Cresi
- Neonatology and Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Silvia Salvatore
- Pediatric Department, Ospedale "F. Del Ponte", University of Insubria, Varese, Italy
| | - Osvaldo Borrelli
- Division of Neurogastroenterology and Motility, Department of Paediatric Gastroenterology, UCL Institute ofChild Health and Great OrmondStreet Hospital, London, UK
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14
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Per-oral endoscopic myotomy and gastroesophageal reflux: Where do we stand after a decade of "POETRY"? Indian J Gastroenterol 2019; 38:287-294. [PMID: 31478146 DOI: 10.1007/s12664-019-00980-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 07/18/2019] [Indexed: 02/04/2023]
Abstract
Per-oral endoscopic myotomy (POEM) was introduced nearly a decade ago. Since then, the literature on its safety and efficacy has been ever increasing. Initial studies focused solely on the feasibility and efficacy of this procedure in patients with idiopathic achalasia. Subsequent studies analyzed the incidence of gastroesophageal reflux disease (GERD) in addition to the efficacy of POEM. These studies depict a high incidence of GERD after POEM. However, vast majority of these studies lacked a comprehensive evaluation of GERD after POEM. Consequently, it is difficult to provide a true estimate of the incidence of GERD in these patients. Majority of the patients with post-POEM GERD are asymptomatic and those with symptoms usually respond well to proton pump inhibitors. However, the long-term consequences of asymptomatic GERD with increased esophageal acid exposure are not well known. These patients should probably undergo regular surveillance due to theoretical risks of complications like Barrett's esophagus and esophageal adenocarcinoma. It should be acknowledged that there is no well-controlled study to support the strategy of surveillance in this group of patients. Given the high incidence of GERD after POEM, it is time to devise minimally invasive novel strategies to prevent and manage post-POEM GERD. The current literature suggests that the technique of POEM and other factors like type of achalasia do not influence the occurrence of GERD after POEM. Therefore, the endoscopists will need to think out of the box to prevent post-POEM GERD.
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15
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Chai NL, Li HK, Linghu EQ, Li ZS, Zhang ST, Bao Y, Chen WG, Chiu PWY, Dang T, Gong W, Han ST, Hao JY, He SX, Hu B, Hu B, Huang XJ, Huang YH, Jin ZD, Khashab MA, Lau J, Li P, Li R, Liu DL, Liu HF, Liu J, Liu XG, Liu ZG, Ma YC, Peng GY, Rong L, Sha WH, Sharma P, Sheng JQ, Shi SS, Seo DW, Sun SY, Wang GQ, Wang W, Wu Q, Xu H, Xu MD, Yang AM, Yao F, Yu HG, Zhou PH, Zhang B, Zhang XF, Zhai YQ. Consensus on the digestive endoscopic tunnel technique. World J Gastroenterol 2019; 25:744-776. [PMID: 30809078 PMCID: PMC6385014 DOI: 10.3748/wjg.v25.i7.744] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 12/19/2018] [Accepted: 01/09/2019] [Indexed: 02/06/2023] Open
Abstract
With the digestive endoscopic tunnel technique (DETT), many diseases that previously would have been treated by surgery are now endoscopically curable by establishing a submucosal tunnel between the mucosa and muscularis propria (MP). Through the tunnel, endoscopic diagnosis or treatment is performed for lesions in the mucosa, in the MP, and even outside the gastrointestinal (GI) tract. At present, the tunnel technique application range covers the following: (1) Treatment of lesions originating from the mucosal layer, e.g., endoscopic submucosal tunnel dissection for oesophageal large or circular early-stage cancer or precancerosis; (2) treatment of lesions from the MP layer, per-oral endoscopic myotomy, submucosal tunnelling endoscopic resection, etc.; and (3) diagnosis and treatment of lesions outside the GI tract, such as resection of lymph nodes and benign tumour excision in the mediastinum or abdominal cavity. With the increasing number of DETTs performed worldwide, endoscopic tunnel therapeutics, which is based on DETT, has been gradually developed and optimized. However, there is not yet an expert consensus on DETT to regulate its indications, contraindications, surgical procedure, and postoperative treatment. The International DETT Alliance signed up this consensus to standardize the procedures of DETT. In this consensus, we describe the definition, mechanism, and significance of DETT, prevention of infection and concepts of DETT-associated complications, methods to establish a submucosal tunnel, and application of DETT for lesions in the mucosa, in the MP and outside the GI tract (indications and contraindications, procedures, pre- and postoperative treatments, effectiveness, complications and treatments, and a comparison between DETT and other operations).
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Affiliation(s)
- Ning-Li Chai
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Hui-Kai Li
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - En-Qiang Linghu
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Shu-Tian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Yu Bao
- Department of Gastroenterology and Hepatology, Sichuan Cancer Hospital and Institute, Chengdu 610000, Sichuan Province, China
| | - Wei-Gang Chen
- Department of Gastroenterology, First Affiliated Hospital of School of Medicine, Shihezi University, Shihezi 832002, Xinjiang Uygur Autonomous Region, China
| | - Philip WY Chiu
- Department of Surgery, Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong, China
| | - Tong Dang
- Department of Gastroenterology, the Second Affiliated Hospital of Baotou Medical College, Baotou 014030, Inner Mongolia Autonomous Region, China
| | - Wei Gong
- Department of Gastroenterology, Shenzhen Hospital of Southern Medical University, Shenzhen 518000, Guangdong Province, China
| | - Shu-Tang Han
- Gastrointestinal Endoscopy Center, Affiliated Hospital of Nanjing Traditional Chinese Medicine University, Nanjing 210029, Jiangsu Province, China
| | - Jian-Yu Hao
- Department of Gastroenterology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Shui-Xiang He
- Department of Gastroenterology, the First Affiliated Hospital of Xi’an Jiao Tong University, Xi’an 710000, Shaanxi Province, China
| | - Bing Hu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- Department of Endoscopy, Eastern Hepatobiliary Surgical Hospital Affiliated to Naval Medical University, Shanghai 200438, China
| | - Bing Hu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- Department of Endoscopy, Eastern Hepatobiliary Surgical Hospital Affiliated to Naval Medical University, Shanghai 200438, China
| | - Xiao-Jun Huang
- Department of Gastroenterology, the Second Hospital of Lanzhou University, Lanzhou 730030, Gansu Province, China
| | - Yong-Hui Huang
- Department of Gastroenterology, Peking University Third Hospital, Beijing 100191, China
| | - Zhen-Dong Jin
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, the Johns Hopkins University School of Medicine, Baltimore, MD 21218, United States
| | - James Lau
- Department of Gastrointestinal Endoscopy, Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong, China
| | - Peng Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Rui Li
- Department of Gastroenterology, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - De-Liang Liu
- Department of Gastroenterology, Second Xiangya Hospital of Central South University, Changsha 410000, Hunan Province, China
| | - Hai-Feng Liu
- Department of Gastroenterology, General Hospital of Chinese People’s Armed Police Forces, Beijing 100039, China
| | - Jun Liu
- Division of Gastroenterology, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Xiao-Gang Liu
- Department of Gastroenterology, Sichuan Provincial People’s Hospital, Chengdu 610072, Sichuan Province, China
| | - Zhi-Guo Liu
- Department of Gastroenterology, Xijing Hospital, Air Force Medical University, Xi’an 710032, Shaanxi Province, China
| | - Ying-Cai Ma
- Department of Digestion, Qinghai Provincial People’s Hospital, Xining 810007, Qinghai Province, China
| | - Gui-Yong Peng
- Department of Gastroenterology, Southwest Hospital, Army Medical University, Chongqing 400038, China
| | - Long Rong
- Department of Gastroenterology, Peking University First Hospital, Beijing 100034, China
| | - Wei-Hong Sha
- Department of Gastroenterology and Hepatology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
| | | | - Jian-Qiu Sheng
- Department of Gastroenterology, Beijing Military General Hospital, Beijing 100700, China
| | - Shui-Sheng Shi
- Endoscopy Center, the Second Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | | | - Si-Yu Sun
- Endoscopy Center, Shengjing Hospital, China Medical University, Shenyang 110004, Liaoning Province, China
| | - Gui-Qi Wang
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100020, China
| | - Wen Wang
- Department of General Surgery, Fuzhou General Hospital, Fuzhou 350025, Fujian Province, China
| | - Qi Wu
- Endoscopy Center, Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Hong Xu
- Endoscopy Center, the First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Mei-Dong Xu
- Endoscopy Center, Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Ai-Ming Yang
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing 100730, China
| | - Fang Yao
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100020, China
| | - Hong-Gang Yu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan University, Wuhan 430060, Hubei Province, China
| | - Ping-Hong Zhou
- Endoscopy Center, Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Bin Zhang
- Endoscopy Center, China-Japan Union Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Xiao-Feng Zhang
- Department of Gastroenterology, Hangzhou First People’s Hospital, Hangzhou 310006, Zhejiang Province, China
| | - Ya-Qi Zhai
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
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Lee Y, Brar K, Doumouras AG, Hong D. Peroral endoscopic myotomy (POEM) for the treatment of pediatric achalasia: a systematic review and meta-analysis. Surg Endosc 2019; 33:1710-1720. [PMID: 30767141 DOI: 10.1007/s00464-019-06701-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/06/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Achalasia is a rare primary esophageal dysmotility disorder in children. Peroral endoscopic myotomy (POEM) is a novel endoscopic technique which has shown promising results for treating achalasia in adults. However, limited data on efficacy and safety in pediatric patients are available. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of POEM in pediatric achalasia. METHODS We searched MEDLINE, Embase, PubMed, and Web of Science databases through July 2018. Studies were eligible for inclusion if they conducted POEM in pediatric patients. Main outcomes were Eckardt score and lower esophageal sphincter (LES) pressure before and after POEM. Secondary outcomes were clinical success rate and adverse events associated with POEM. Two reviewers independently reviewed the studies, collected data, and assessed quality of evidence using Methodological Index for Non-Randomized Studies (MINORS). Pooled estimates were calculated using random effects meta-analyses. Heterogeneity was quantified using the inconsistency statistic, and funnel plot was used to assess publication bias. RESULTS A total of 12 studies with 146 pediatric patients (53.68% female) underwent POEM for the treatment of achalasia (mean duration of disease of 19.48 months). There was a significant reduction in Eckardt score by 6.88 points (Mean Difference (MD) 6.88, 95% confidence interval (CI), 6.28-7.48, P < .001) and LES pressure by 20.73 mmHg (MD 20.73, 95% CI, 15.76-25.70, P < .001) following POEM. At least 93% of the patients experienced improvement or resolution of achalasia symptoms both short and long terms after POEM, with small proportion of patients experiencing minor adverse effects which could be managed conservatively. CONCLUSIONS POEM is efficacious and safe for treating achalasia in pediatric populations. Large comparative or randomized trials are warranted to confirm the efficacy and safety of POEM compared to other surgical procedures for achalasia.
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Affiliation(s)
- Yung Lee
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.,Centre for Minimal Access Surgery (CMAS), Division of General Surgery, Department of Surgery, McMaster University St. Joseph's Healthcare, 50 Charlton Avenue East Hamilton, Hamilton, ON, L8N 4A6, Canada
| | - Karanbir Brar
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Aristithes G Doumouras
- Centre for Minimal Access Surgery (CMAS), Division of General Surgery, Department of Surgery, McMaster University St. Joseph's Healthcare, 50 Charlton Avenue East Hamilton, Hamilton, ON, L8N 4A6, Canada
| | - Dennis Hong
- Centre for Minimal Access Surgery (CMAS), Division of General Surgery, Department of Surgery, McMaster University St. Joseph's Healthcare, 50 Charlton Avenue East Hamilton, Hamilton, ON, L8N 4A6, Canada.
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Li H, Peng W, Huang S, Ren Y, Peng Y, Li Q, Wu J, Fu X, Tang X. The 2 years' long-term efficacy and safety of peroral endoscopic myotomy for the treatment of achalasia: a systematic review. J Cardiothorac Surg 2019; 14:1. [PMID: 30606216 PMCID: PMC6318943 DOI: 10.1186/s13019-018-0811-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 12/03/2018] [Indexed: 02/08/2023] Open
Abstract
AIM In this retrospective review, we aimed to investigate the long-term efficacy and safety of POEM with follow-up period over 2 years. MATERIALS AND METHODS A systematic review related to POEM for achalasia was conducted. A literature search was performed in Pubmed, Medline, Ovid, Cochrane and EBSCO databases on November 2017. The following postoperative outcomes were extracted: Eckardt score, lower esophageal sphincter pressure, complications and clinical success. RESULTS The total number of patients was 373. The mean operative time was 66.7 min and the overall rate of complications was 21.2%. The mean follow-up period was 30.0 months. The overall clinical success rate was 92.9% and the rate of gastroesophageal reflux disease was 10.2%. Rate of mortality after POEM was 0. CONCLUSIONS Our study demonstrated that POEM is effective and safe for treating achalasia during the long-term followed up over 2 years.
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Affiliation(s)
- Huan Li
- Department of Gastroenterology, Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099 Sichuan Province China
| | - Wei Peng
- Department of Gastroenterology, Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099 Sichuan Province China
| | - Shu Huang
- Department of Gastroenterology, the People’s Hospital of Lianshui, Huaian, China
| | - Yutang Ren
- Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China
| | - Yan Peng
- Department of Gastroenterology, Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099 Sichuan Province China
| | - Qing Li
- Department of Gastroenterology, Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099 Sichuan Province China
| | - Jiao Wu
- Department of Gastroenterology, Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099 Sichuan Province China
| | - Xiangsheng Fu
- Department of Gastroenterology, Affiliated Hospital of North Sichuan Medical College, Road Wenhua 63#, Region Shunqing, Sichuan, 637000 China
| | - Xiaowei Tang
- Department of Gastroenterology, Affliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099 Sichuan Province China
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Chuah SK, Lim CS, Liang CM, Lu HI, Wu KL, Changchien CS, Tai WC. Bridging the Gap between Advancements in the Evolution of Diagnosis and Treatment towards Better Outcomes in Achalasia. BIOMED RESEARCH INTERNATIONAL 2019; 2019:8549187. [PMID: 30881999 PMCID: PMC6381566 DOI: 10.1155/2019/8549187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 01/02/2019] [Accepted: 01/20/2019] [Indexed: 02/05/2023]
Abstract
Over the past few decades, there was an encouraging breakthrough in bridging the gap between advancements in the evolution of diagnosis and treatment towards a better outcome in achalasia. The purpose of this review is to provide updated knowledge on how the current evidence has bridged the gap between advancements in the evolution of diagnosis and treatment of esophageal achalasia. The advent of high-resolution manometry and standardization based on the Chicago classification has increased early recognition of the disease. These 3 clinical subtypes of achalasia can predict the outcomes of patients, and the introduction of POEM has revolutionized the choice of treatment. Previous evidence has shown that laparoscopic Heller myotomy (LHM) and anterior fundoplication were considered the most durable treatments for achalasia. Based on the current evidence, POEM has been evolving as a promising strategy and is effective against all 3 types of achalasia, but the efficacy of POEM is based on short- and medium-term outcome studies from a limited number of centers. Types I and II achalasia respond well to POEM, LHM, and PD, while most studies have shown that type III achalasia responds better to POEM than to LHM and PD. In general, among the 3 subtypes of achalasia, type II achalasia has the most favorable outcomes after medical or surgical therapies. The long-term efficacy of POEM is still unknown. The novel ENDOFLIP measures the changes in intraoperative esophagogastric junction dispensability, which enables a quantitative assessment of luminal patency and sphincter distension; however, this technology is in its infancy with little data to date supporting its intraoperative use. In the future, identifying immunomodulatory drugs and the advent of stem cell therapeutic treatments, including theoretically transplanting neuronal stem cells, may achieve a functional cure. In summary, it is important to identify the clinical subtype of achalasia to initiate target therapy for these patients.
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Affiliation(s)
- Seng-Kee Chuah
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
| | - Chee-Sang Lim
- Department of Hepatology, Hospital Selayang, Lebuh Raya Selayang-Kepong, Batu Caves, Selangor, Malaysia
| | - Chih-Ming Liang
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
| | - Hung-I Lu
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, 833 Kaohsiung, Taiwan
| | - Keng-Liang Wu
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
| | - Chi-Sin Changchien
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
| | - Wei-Chen Tai
- Gastrointestinal Motility Unit, Division of Gastroenterology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 833 Kaohsiung, Taiwan
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Campagna RAJ, Hungness ES. Treatment of Idiopathic Achalasia with Per-Oral Esophageal Myotomy. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018; 20:114-119. [PMID: 30872910 DOI: 10.1016/j.tgie.2018.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Achalasia is a rare esophageal motility disorder that necessitates the disruption of the lower esophageal sphincter. Patients with achalasia should be evaluated in a systematic, multidisciplinary fashion. Workup should include upper endoscopy, esophagography, and high-resolution manometry. The gold standard for surgical treatment is laparoscopic Heller myotomy with partial fundoplication. Per-oral esophageal myotomy is a novel endoscopic technique that has gained considerable traction over the past decade. The procedure includes the creation of a submucosal tunnel and a selective circular myotomy of the lower esophageal sphincter. Common intra-operative hazards include bleeding within the submucosal tunnel and capnoperitoneum. Significant complications are rare. Patients experience excellent dysphagia relief that is on par with laparoscopic Heller myotomy at moderate-term follow up. Post-operative gastroesophageal reflux disease occurs in greater than one-third of patients, and the vast majority of cases are readily controlled with an anti-secretory medication. Although data is sparse, there is a growing body of literature that supports the long-term durability of per-oral esophageal myotomy.
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Affiliation(s)
- Ryan A J Campagna
- Department of Surgery, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 650, Chicago, Illinois, 60611
| | - Eric S Hungness
- Department of Surgery, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 650, Chicago, Illinois, 60611
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Systematic Review and Meta-Analysis of Perioperative Outcomes of Peroral Endoscopic Myotomy (POEM) and Laparoscopic Heller Myotomy (LHM) for Achalasia. Surg Laparosc Endosc Percutan Tech 2018; 27:123-131. [PMID: 28472017 DOI: 10.1097/sle.0000000000000402] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIMS AND OBJECTIVES Laparoscopic Heller myotomy (LHM) is the preferred surgical method for treating achalasia. However, peroral endoscopic myotomy (POEM) is providing good short-term results. The objective of this systematic review and meta-analysis was to compare the safety and efficacy of LHM and POEM. MATERIALS AND METHODS A search of PubMed, Cochrane database, Medline, Embase, Science Citation Index, and current contents for English-language articles comparing LHM and POEM between 2007 and 2016 was performed. Variables analyzed included prior endoscopic treatment, prior medical treatment, prior Heller myotomy, operative time, overall complications rate, postoperative gastroesophageal reflux disease (GERD), length of hospital stay, postoperative pain score, and long-term GERD. RESULTS Seven trials consisting of 483 (LHM=250, POEM=233) patients were analyzed. Preoperative variables, for example, prior endoscopic treatment [odds ratio (OR), 1.32; 95% confidence interval (CI), 0.23-4.61; P=0.96], prior medical treatment [weighted mean difference (WMD), 1.22; 95% CI, 0.52-2.88; P=0.65], and prior Heller myotomy (WMD, 0.47; 95% CI, 0.13-1.67; P=0.25) were comparable. Operative time was 26.28 minutes, nonsignificantly longer for LHM (WMD, 26.28; 95% CI, -11.20 to 63.70; P=0.17). There was a comparable overall complication rate (OR, 1.25; 95% CI, 0.56-2.77; P=0.59), postoperative GERD rate (OR, 1.27; 95% CI, 0.70-2.30; P=0.44), length of hospital stay (WMD, 0.30; 95% CI, -0.24 to 0.85; P=0.28), postoperative pain score (WMD, -0.26; 95% CI, -1.58 to 1.06; P=0.70), and long-term GERD (WMD, 1.06; 95% CI, 0.27-4.1; P=0.08) for both procedures. There was a significantly higher short-term clinical treatment failure rate for LHM (OR, 9.82; 95% CI, 2.06-46.80; P<0.01). CONCLUSIONS POEM compares favorably to LHM for achalasia treatment in short-term perioperative outcomes. However, there was a significantly higher clinical treatment failure rate for LHM on short-term postoperative follow-up. Presently long-term postoperative follow-up data for POEM beyond 1 year are unavailable and eagerly awaited.
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Hu HQ, Li HK, Xiong Y, Zhang XB, Zhi JL, Wang XX, Linghu EQ. Establishment of animal model of gastroesophageal reflux disease by per-oral endoscopic tunneling: a preliminary study. J Thorac Dis 2018; 10:1607-1613. [PMID: 29707312 PMCID: PMC5906314 DOI: 10.21037/jtd.2018.02.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 01/26/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND Although a variety of antireflux procedures and medications are used to treat gastroesophageal reflux disease (GERD), reliable large-animal models of GERD that can be used to objectively compare the efficacy of these treatments are lacking. We developed a method to establish large animal models of GERD by endoscopic sphincterotomy to develop an endoscopic treatment for GERD. METHODS In this study six flesh swine carcasses were used. A full thickness incision was made at the esophageal site 5 cm above the dentate line by per-oral endoscopic tunneling. Esophageal radiography was conducted before and after surgery to observe changes at the site of the lower esophagus 5 cm above the dentate line and in the cardia. RESULTS There was no significant change in the diameter of the esophageal site 5 cm above the dentate line before and after surgery, while the cardiac orifice significantly relaxed after surgery and enabled the contrast agent to smoothly travel through. The difference in diameter was statistically significant (P<0.05). CONCLUSIONS Our experiments showed that it is a minimally invasive and mature technology of establishing GERD animal models by using the per-oral endoscopic tunneling technique, and might be a new method to establishing GERD large animal models.
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Affiliation(s)
- Hai-Qing Hu
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
- Department of Gastroenterology and Hepatology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010058, China
| | - Hui-Kai Li
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Ying Xiong
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Xiao-Bin Zhang
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Jun-Li Zhi
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Xiao-Xiao Wang
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - En-Qiang Linghu
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
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Yang D, Draganov PV. Expanding Role of Third Space Endoscopy in the Management of Esophageal Diseases. ACTA ACUST UNITED AC 2018; 16:41-57. [PMID: 29435819 DOI: 10.1007/s11938-018-0169-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OPINION STATEMENT: "Third space" endoscopy, also commonly referred as submucosal endoscopy, is founded on the principle that the deeper layers of the gastrointestinal (GI) tract can be accessed by tunneling in the submucosal space without compromising the integrity of the overlying mucosa. Peroral endoscopic myotomy (POEM), endoscopic submucosal dissection (ESD), and submucosal tunneling endoscopic resection (STER) are innovative techniques within the field of third space endoscopy in the management of esophageal disorders. POEM has become an accepted minimally invasive therapy for achalasia and related motility disorders with excellent short-term results, with early studies yielding similar efficacy to surgical myotomy and increased durability when compared to pneumatic balloon dilation (PBD). Data are needed to establish long-term outcomes with POEM, with particular interest on the incidence of gastroesophageal reflux, which appears to be higher than initially anticipated. ESD, a mature endoscopic resection technique in Asia, has recently gained traction in the West as a viable option for the management of early Barrett's esophagus (BE) neoplasia. Compared to standard endoscopic mucosal resection (EMR), ESD allows the en bloc resection of lesions irrespective of size, which may facilitate histological interpretation and reduce recurrence rates. Large prospective randomized controlled trials are needed to validate the efficacy and safety of this technique and to further define its role in the endoscopic armamentarium in early BE neoplasia. STER is an attractive technique that theoretically permits the resection of subepithelial esophageal tumors (SETs) arising from the deeper GI layers. Initial studies from highly experienced endoscopic centers support its technical feasibility and safety, although these results should be interpreted with caution due to variability arising from small numbers and heterogeneity among studies. Overall, third space endoscopy is an expanding field within endoscopic therapeutics for the treatment of esophageal diseases. While initial results have been very promising, large prospective studies, long-term data, and structured training programs with the establishment of competency parameters are needed before third space endoscopy can be advocated outside of highly specialized centers.
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Affiliation(s)
- Dennis Yang
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, 1329 SW 16th Street Suite 5262, Gainesville, FL, 32608, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, 1329 SW 16th Street Suite 5262, Gainesville, FL, 32608, USA.
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Cho YK, Kim SH. Current Status of Peroral Endoscopic Myotomy. Clin Endosc 2018; 51:13-18. [PMID: 29397656 PMCID: PMC5806926 DOI: 10.5946/ce.2017.165] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/16/2017] [Accepted: 01/10/2018] [Indexed: 12/17/2022] Open
Abstract
Peroral endoscopic myotomy (POEM) has been established as an optional treatment for achalasia. POEM is an endoluminal procedure that involves dissection of esophageal muscle fibers followed by submucosal tunneling. Inoue first attempted to use POEM for the treatment of achalasia in humans. Expanded indications of POEM include classic indications such as type I, type II, type III achalasia, failed prior treatments, including Botulinum toxin injection, endoscopic balloon dilation, laparoscopic Heller myotomy, and hypertensive motor disorders such as diffuse esophageal spasm, jackhammer esophagus. Contraindications include prior radiation therapy to the esophagus and prior extensive esophageal mucosal resection/ablation involving the POEM field. Most of the complications are minor and self-limited and can be managed conservatively. As POEM emerged as the main treatment for achalasia, various adaptations to tunnel endoscopic surgery have been attempted. Tunnel endoscopic surgery includes POEM, peroral endoscopic tumor resection, gastric peroral endoscopic pyloromyotomy. POEM has been widely accepted as a treatment for all types of achalasia, even for specific cases such as achalasia with failed prior treatments, and hypertensive motor disorders.
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Affiliation(s)
- Young Kwan Cho
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Eulji University College of Medicine, Seoul, Korea
| | - Seong Hwan Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Eulji University College of Medicine, Seoul, Korea
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25
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Smith SP, Louie BE. The current state of per oral endoscopic myotomy for achalasia. J Vis Surg 2017; 3:122. [PMID: 29078682 DOI: 10.21037/jovs.2017.07.11] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 07/21/2017] [Indexed: 12/19/2022]
Abstract
Achalasia is an acquired neuromuscular disorder that has been treated using a variety of modalities throughout medical history. Recently, the technique of per oral endoscopic myotomy (POEM) was introduced to treat the disease using a truly minimally invasive, natural orifice technique that is rapidly being adopted across the world. This review outlines the development of POEM, the technique itself, and gives a comparison to other procedures, specifically laparoscopic Heller myotomy (LHM).
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Affiliation(s)
- Shane P Smith
- Swedish Medical Center and Cancer Institute, Seattle, WA, USA
| | - Brian E Louie
- Swedish Medical Center and Cancer Institute, Seattle, WA, USA
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26
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Haito-Chavez Y, Inoue H, Beard KW, Draganov PV, Ujiki M, Rahden BHA, Desai PN, Pioche M, Hayee B, Haji A, Saxena P, Reavis K, Onimaru M, Balassone V, Nakamura J, Hata Y, Yang D, Pannu D, Abbas A, Perbtani YB, Patel LY, Filser J, Roman S, Rivory J, Mion F, Ponchon T, Perretta S, Wong V, Maselli R, Ngamruengphong S, Chen YI, Bukhari M, Hajiyeva G, Ismail A, Pieratti R, Kumbhari V, Galdos-Cardenas G, Repici A, Khashab MA. Comprehensive Analysis of Adverse Events Associated With Per Oral Endoscopic Myotomy in 1826 Patients: An International Multicenter Study. Am J Gastroenterol 2017; 112:1267-1276. [PMID: 28534521 DOI: 10.1038/ajg.2017.139] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 03/02/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The safety of peroral endoscopic myotomy (POEM) is still debated since comprehensive analysis of adverse events (AEs) associated with the procedure in large multicenter cohort studies has not been performed. To study (1) the prevalence of AEs and (2) factors associated with occurrence of AEs in patients undergoing POEM. METHODS Patients who underwent POEM at 12 tertiary-care centers between 2009 and 2015 were included in this case-control study. Cases were defined by the occurrence of any AE related to the POEM procedure. Control patients were selected for each AE case by matching for age, gender, and disease classification (achalasia type I and II vs. type III/spastic esophageal disorders). RESULTS A total of 1,826 patients underwent POEM. Overall, 156 AEs occurred in 137 patients (7.5%). A total of 51 (2.8%) inadvertent mucosotomies occurred. Mild, moderate, and severe AEs had a frequency of 116 (6.4%), 31 (1.7%), and 9 (0.5%), respectively. Multivariate analysis demonstrated that sigmoid-type esophagus (odds ratio (OR) 2.28, P=0.05), endoscopist experience <20 cases (OR 1.98, P=0.04), use of a triangular tip knife (OR 3.22, P=0.05), and use of an electrosurgical current different than spray coagulation (OR 3.09, P=0.02) were significantly associated with the occurrence of AEs. CONCLUSIONS This large study comprehensively assessed the safety of POEM and highly suggests POEM as a relatively safe procedure when performed by experts at tertiary centers with an overall 7.5% prevalence of AEs. Severe AEs are rare. Sigmoid-type esophagus, endoscopist experience, type of knife, and current used can be considered as predictive factors of AE occurrence.
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Affiliation(s)
- Yamile Haito-Chavez
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | | | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Michael Ujiki
- Department of Surgery, NorthShore University Health System, Evanston, Illinois, USA
| | - Burkhard H A Rahden
- Department of General, Visceral, Vascular and Pediatric Surgery, University Medical Center, Wìrzburg, Germany
| | | | - Mathieu Pioche
- Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France
| | - Bu Hayee
- Department of Gastroenterology, King's College Hospital NHS Foundation Trust, London, UK
| | - Amyn Haji
- Department of Gastroenterology, King's College Hospital NHS Foundation Trust, London, UK
| | - Payal Saxena
- Department of Gastroenterology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | | | - Manabu Onimaru
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Valerio Balassone
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Jun Nakamura
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Yoshitaka Hata
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Davinderbir Pannu
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Ali Abbas
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Yaseen B Perbtani
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Lava Y Patel
- Department of Surgery, NorthShore University Health System, Evanston, Illinois, USA
| | - Jorg Filser
- Department of General, Visceral, Vascular and Pediatric Surgery, University Medical Center, Wìrzburg, Germany
| | - Sabine Roman
- Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France
| | - Jerome Rivory
- Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France
| | - Francois Mion
- Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France
| | - Thierry Ponchon
- Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France
| | - Silvana Perretta
- Department of Gastrointestinal and Endocrine Surgery, University of Strasbourg, Strasbourg, France
| | - Vivien Wong
- Department of Gastrointestinal and Endocrine Surgery, University of Strasbourg, Strasbourg, France
| | - Roberta Maselli
- Gastroenterology, Humanitas Clinical and Research Hospital, IRCCS, Rozzano, Italy
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Majidah Bukhari
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Gulara Hajiyeva
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Amr Ismail
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Renata Pieratti
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Gerson Galdos-Cardenas
- The International Health Department-Global Disease Epidemiology and Control-The Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Alessandro Repici
- Gastroenterology, Humanitas Clinical and Research Hospital, IRCCS, Rozzano, Italy
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Akimoto T, Goto O, Nishizawa T, Yahagi N. Endoscopic closure after intraluminal surgery. Dig Endosc 2017; 29:547-558. [PMID: 28181699 DOI: 10.1111/den.12839] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 02/06/2017] [Indexed: 02/06/2023]
Abstract
Endoscopic submucosal dissection is established as a curative endoscopic method for gastrointestinal epithelial neoplasms with a high possibility of complete en bloc resection; however, postoperative adverse events of bleeding and delayed perforation remain. To prevent or minimize them, several techniques for endoscopic mucosal closure have been introduced, such as using endoscopic clips, combined use of hemoclips and supplement devices, and specially designed endoscopic suturing devices. Furthermore, endoscopic full-thickness suturing technique for gastrointestinal wall defect has been developed based on the concept in natural orifice transluminal endoscopic surgery and endoscopic full-thickness resection. Several closure techniques, including over-the-scope clip, threaded bars inserted in a hollow needle, stitches or staplers, and a curved needle and thread are reported. Secure closure of the iatrogenic defect may further expand the range of therapeutic endoscopy. Accumulation of evidence for the efficacy of endoscopic closure and establishment of these techniques are desired.
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Affiliation(s)
- Teppei Akimoto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, School of Medicine, Keio University, Tokyo, Japan
| | - Osamu Goto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, School of Medicine, Keio University, Tokyo, Japan
| | - Toshihiro Nishizawa
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, School of Medicine, Keio University, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, School of Medicine, Keio University, Tokyo, Japan
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Tyberg A, Seewald S, Sharaiha RZ, Martinez G, Desai AP, Kumta NA, Lambroza A, Sethi A, Reavis KM, DeRoche K, Gaidhane M, Talbot M, Saxena P, Zamarripa F, Barret M, Eleftheriadis N, Balassone V, Inoue H, Kahaleh M. A multicenter international registry of redo per-oral endoscopic myotomy (POEM) after failed POEM. Gastrointest Endosc 2017; 85:1208-1211. [PMID: 27756611 DOI: 10.1016/j.gie.2016.10.015] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 10/05/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Per-oral endoscopic myotomy (POEM) has become an accepted treatment for patients with achalasia. Despite its excellent efficacy rate of greater than 80%, a small percentage of patients remain symptomatic after the procedure. Limited data exist as to the best management for recurrence of symptoms after POEM. We present the first international, multicenter experience on the efficacy and safety of a repeat POEM in the management of achalasia. METHODS Patients who underwent a redo POEM from 15 centers in 9 countries were included in a dedicated registry. Technical success was defined as successful completion of a second myotomy. Clinical success was defined as an Eckardt score of less than or equal to 3 after the second myotomy. Adverse events including anesthesia-related, operative, and postoperative adverse events were recorded. RESULTS Forty-six patients were included in the study. The average age was 49.3 ± 16.78 years. Twenty (45%) patients were male. The mean pre-redo-POEM Eckardt score was 4.3 ± 2.48. Technical success was achieved in 46 (100%) patients. Clinical success was achieved in 41 patients (85%). The average post-POEM Eckardt score was 1.64 ± 1.67, with a significant difference of 2.58 (P < .00001). Eight patients (17%) had adverse events consisting of procedural bleeding, all managed endoscopically. There were no deaths. No POEMs were aborted or required surgical conversion or assistance. DISCUSSION For patients with persistent symptoms after POEM, repeat POEM appears to be an efficacious and safe technique. Further randomized trials comparing redo POEM versus Heller should be considered. (Clinical trial registration number: NCT02162589.).
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Affiliation(s)
- Amy Tyberg
- Division of Gastroenterology & Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Stefan Seewald
- GastroZentrum Hirslanden, Klinik Hirslanden, Zurich, Switzerland
| | - Reem Z Sharaiha
- Division of Gastroenterology & Hepatology, Weill Cornell Medicine, New York, New York, USA
| | | | - Amit P Desai
- Division of Gastroenterology & Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Nikhil A Kumta
- Division of Gastroenterology & Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Arnon Lambroza
- Division of Gastroenterology & Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Amrita Sethi
- Digestive and Liver Disease, Columbia University Medical Center, New York, New York, USA
| | - Kevin M Reavis
- Providence Portland Cancer Center, Portland, Oregon, USA
| | - Ketisha DeRoche
- Division of Gastroenterology & Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Monica Gaidhane
- Division of Gastroenterology & Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Michael Talbot
- Division of Gastroenterology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Payal Saxena
- Division of Gastroenterology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | | | - Maximilien Barret
- Department of Gastroenterology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Valerio Balassone
- Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Haruhiro Inoue
- Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Michel Kahaleh
- Division of Gastroenterology & Hepatology, Weill Cornell Medicine, New York, New York, USA
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Per-oral Endoscopic Myotomy (POEM) After the Learning Curve: Durable Long-term Results With a Low Complication Rate. Ann Surg 2017; 264:508-17. [PMID: 27513156 DOI: 10.1097/sla.0000000000001870] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We aimed to report long-term outcomes for patients undergoing per-oral endoscopic myotomy (POEM) after our initial 15-case learning curve. BACKGROUND POEM has become an established, natural-orifice surgical approach for treating esophageal motility disorders. To date, published outcomes and comparative-effectiveness studies have included patients from the early POEM experience. METHODS Consecutive patients undergoing POEM after our initial 15 cases, with a minimum of 1-year postoperative follow-up, were included. Treatment success was defined as an Eckardt score ≤3 without reintervention. Gastroesophageal reflux was defined by abnormal pH-testing or reflux esophagitis >Los Angeles grade A. RESULTS Between January 2012 and March 2015, 115 patients underwent POEM at a single, high-volume center. Operative time was 101 ± 29 minutes, with 95% (109/115) of patients discharged on postoperative day 1. Clavien-Dindo grade III complications occurred in 2.7%, one of which required diagnostic laparoscopy to rule out Veress needle injury to the gall bladder. The rate of grade I complications was 15.2%. At an average of 2.4 years post-POEM (range 12-52 months), the overall success rate was 92%. Objective evidence of reflux was present in 40% for all patients and 33% for patients with a body mass index <35 kg/m and no hiatal hernia. CONCLUSIONS POEM performed by experienced surgeons provided durable symptomatic relief in 94% of patients with nonspastic achalasia and 90% of patients with type 3 achalasia/spastic esophageal motility disorders, with a low rate of complications. The rate of gastroesophageal reflux was comparable with prior studies of both POEM and laparoscopic Heller myotomy.
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Hungness ES, Jorge JM. Per-Oral Esophageal Myotomy: Is It a Safe and Durable Procedure for Achalasia? Adv Surg 2017; 51:193-205. [PMID: 28797340 DOI: 10.1016/j.yasu.2017.03.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Eric S Hungness
- Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, 676 North St. Clair Street, Suite 650, Chicago, IL 60611, USA.
| | - Juaquito M Jorge
- Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, 251 East Huron, Galter 3-150, Chicago, IL 60611, USA
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Guo H, Yang H, Zhang X, Wang L, Lv Y, Zou X, Ling T. Long-term outcomes of peroral endoscopic myotomy for patients with achalasia: a retrospective single-center study. Dis Esophagus 2017; 30:1-6. [PMID: 28375443 DOI: 10.1093/dote/dow011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 11/07/2016] [Indexed: 12/11/2022]
Abstract
Peroral endoscopic myotomy (POEM) has been widely applied to the treatment of achalasia. The aim of this study is to retrospectively investigate the long-term outcome of POEM in patients with achalasia. Patients undergoing POEM at our center with a minimum follow-up of 3 years were enrolled in this study. Relief of patients' symptom was defined as the primary outcome. Secondary outcomes included lower esophageal sphincter pressure, esophageal emptying, symptoms relapse, and clinical reflux adverse events. The Chi-square test was performed to determine the potential predictors of surgical failure. Sixty-seven patients (aged 40.7 ± 15.3 years) were recruited in the study, with a mean follow-up period of 40.1 ± 2.8 months. At the final follow-up, the median Eckardt score reduced from 7.6 ± 2.3 preoperatively to 1.9 ± 1.7 (P < 0.001), the lower esophageal sphincter pressure was reduced from 35.4 ± 13.7 mmHg preoperatively to 8.9 ± 4.1 mmHg (P < 0.001), and the height of the barium column at 5 min after barium swallowed was reduced from 9.7 ± 1.6 cm preoperatively to 2.9 ± 2.1 cm (P < 0.001). Eight patients had symptoms relapse and nine patients developed reflux esophagitis. Type III achalasia was found to be indicative of surgical failure. POEM was a promising treatment for patients with achalasia, which can yield a long-term relief of the symptom and a low rate of clinical reflux adverse events.
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Werner YB, von Renteln D, Noder T, Schachschal G, Denzer UW, Groth S, Nast JF, Kersten JF, Petzoldt M, Adam G, Mann O, Repici A, Hassan C, Rösch T. Early adverse events of per-oral endoscopic myotomy. Gastrointest Endosc 2017; 85:708-718.e2. [PMID: 27609778 DOI: 10.1016/j.gie.2016.08.033] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 08/25/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The recently developed technique of per-oral endoscopic myotomy (POEM) has been shown to be effective for the therapy of esophageal motility disorders. Limited information is available about POEM adverse events (AEs). METHODS POEM was performed on 241 patients (58% male; mean age, 47.4 ± 16.4 years) under general anesthesia over 61 months. The main outcome was the rate of intra- and post-procedural AEs. Post-procedural checks comprised clinical and laboratory examinations and endoscopy, with further follow-ups performed at 3, 6, and 12 months. RESULTS Of the 241 procedures, 238 were successfully completed (mean procedure time, 100.2 ± 39.5 min). Reasons for abortion were excessive submucosal fibrosis preventing submucosal tunneling. Three patients had severe procedural-related AEs (SAE rate, 1.2%); 1 case of pneumothorax required intra-procedural drainage, and 2 patients had delayed SAEs (1 ischemic gastric cardia perforation and 1 hemothorax, both leading to surgery). The overall rate of minor AEs was 31.1%, mainly prolonged intra-procedural bleeding (>15 min hemostasis) and defects of the mucosa overlying the tunnel; none led to clinically relevant signs or symptoms. Patients experiencing any AE had a significantly prolonged hospital stay (P = .037) and a trend toward prolonged procedure time (P = .094). Neck/upper thoracic emphysema and free abdominal air were noted in 31.5% and 35.7%, respectively (95.3% drained), but without relevant sequelae. CONCLUSIONS POEM has a low rate of SAEs; minor AEs are more frequent but lack a consistent definition. Therefore, based on our experience and literature analysis, we suggest a classification of AEs for POEM. (Clinical trials registration number: NCT01405417.).
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Affiliation(s)
- Yuki B Werner
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Gastronterology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel von Renteln
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Tania Noder
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Guido Schachschal
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Ulrike W Denzer
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Groth
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jan F Nast
- Department of Gastronterology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jan F Kersten
- Department of Medical Biometry and Epidemiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Petzoldt
- Department of Anaesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Oliver Mann
- Department of General and Abdominal Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Research Hospital and Humanitas University, Milan, Italy
| | - Cesare Hassan
- Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Misra L, Fukami N, Nikolic K, Trentman TL. Peroral endoscopic myotomy: procedural complications and pain management for the perioperative clinician. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2017; 10:53-59. [PMID: 28260955 PMCID: PMC5330187 DOI: 10.2147/mder.s115632] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Achalasia refers to the lack of smooth muscle relaxation of the distal esophagus. Although nonsurgical treatments such as pneumatic dilatation of the distal esophagus and botulinum toxin injections have been performed, these procedures have limited duration. Similarly, surgical treatment with Heller myotomy is associated with complications. At our institution, we perform the peroral endoscopic myotomy (POEM) in qualified patients. Briefly, POEM involves endoscopic creation of a mid-esophageal submucosal bleb, creation of a submucosal tunnel with the endoscope, and then a distal myotomy, resulting in relaxation of the distal esophagus. The aim of our study is to document perioperative pain and associated pain management for our initial patients undergoing POEM and to review the literature for perioperative complications of this procedure. Therefore, anesthetic and pain management for our initial eleven patients undergoing POEM were reviewed. Patient demographics, pre-POEM pain medication history, perioperative pain medication requirements, and post-POEM pain scores were examined. We found post-POEM pain was usually in the mild–moderate range; a combination of medications was effective (opioids, nonsteroidal anti-inflammatory drugs, acetaminophen). Our literature search revealed a wide frequency range of complications such as pneumoperitoneum and subcutaneous emphysema, with rare serious events such as capnopericardium leading to cardiac arrest. In conclusion, our experience with POEM suggests pain and can be managed adequately with a combination of medications; the procedure appears to be safe and reasonable to perform in an outpatient endoscopy unit.
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Affiliation(s)
| | - Norio Fukami
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Phoenix, AZ, USA
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Outcomes in patients with over 1-year follow-up after peroral endoscopic myotomy (POEM). Surg Endosc 2016; 31:1550-1557. [DOI: 10.1007/s00464-016-5130-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 07/13/2016] [Indexed: 12/21/2022]
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Uppal DS, Wang AY. Update on the endoscopic treatments for achalasia. World J Gastroenterol 2016; 22:8670-8683. [PMID: 27818585 PMCID: PMC5075544 DOI: 10.3748/wjg.v22.i39.8670] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 08/20/2016] [Accepted: 09/14/2016] [Indexed: 02/06/2023] Open
Abstract
Achalasia is the most common primary motility disorder of the esophagus and presents as dysphagia to solids and liquids. It is characterized by impaired deglutitive relaxation of the lower esophageal sphincter. High-resolution manometry allows for definitive diagnosis and classification of achalasia, with type II being the most responsive to therapy. Since no cure for achalasia exists, early diagnosis and treatment of the disease is critical to prevent end-stage disease. The central tenant of diagnosis is to first rule out mechanical obstruction due to stricture or malignancy, which is often accomplished by endoscopic and fluoroscopic examination. Therapeutic options include pneumatic dilation (PD), surgical myotomy, and endoscopic injection of botulinum toxin injection. Heller myotomy and PD are more efficacious than pharmacologic therapies and should be considered first-line treatment options. Per oral endoscopic myotomy (POEM) is a minimally-invasive endoscopic therapy that might be as effective as surgical myotomy when performed by a trained and experienced endoscopist, although long-term data are lacking. Overall, therapy should be individualized to each patient's clinical situation and based upon his or her risk tolerance, operative candidacy, and life expectancy. In instances of therapeutic failure or symptom recurrence re-treatment is possible and can include PD or POEM of the wall opposite the site of prior myotomy. Patients undergoing therapy for achalasia require counseling, as the goal of therapy is to improve swallowing and prevent late manifestations of the disease rather than to restore normal swallowing, which is unfortunately impossible.
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Patel K, Abbassi-Ghadi N, Markar S, Kumar S, Jethwa P, Zaninotto G. Peroral endoscopic myotomy for the treatment of esophageal achalasia: systematic review and pooled analysis. Dis Esophagus 2016; 29:807-819. [PMID: 26175119 DOI: 10.1111/dote.12387] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Peroral endoscopic myotomy (POEM) is a novel approach to performing esophageal myotomy for the treatment of achalasia. This review aims to assess subjective and objective metrics of achalasia treatment efficacy, perioperative adverse events and the incidence of postoperative gastroesophageal reflux disease in patients treated with POEM. Secondary aims include a pooled analysis comparison of the clinical outcomes and procedural safety of POEM versus laparoscopic Heller's myotomy (LHM). A systematic review of the literature, up to and including January 15, 2015, was conducted for studies reporting POEM outcomes. Studies comparing POEM to LHM were also included for the purpose of pooled analysis. Outcomes from 1122 POEM patients, from 22 studies, are reported in this systematic review. Minor operative adverse events included capno/pneumo-peritoneum (30.6%), capno/pneumo-thorax (11.0%) and subcutaneous emphysema (31.6%). Major operative adverse events included mediastinal leak (0.3%), postoperative bleeding (1.1%) and a single mortality (0.09%). There was an improvement in lower esophageal sphincter pressure and timed barium esophagram column height of 66% and 80% post-POEM, respectively. Symptom improvement was demonstrated with a pre- and post-POEM Eckardt score ± standard deviation of 6.8 ± 1.0 and 1.2 ± 0.6, respectively. Pre- and post-POEM endoscopy showed esophagitis in 0% and 19% of patients, respectively. The median (interquartile range) points scored for study quality was 15 (14-16) out of total of 32. Pooled analysis of three comparative studies between LHM and POEM showed similar results for adverse events, perforation rate, operative time and a nonsignificant trend toward a reduced length of hospital stay in the POEM group. In conclusion, POEM is a safe and effective treatment for achalasia, showing significant improvements in objective metrics and achalasia-related symptoms. Randomized comparative studies of LHM and POEM are required to determine the most effective treatment modality for achalasia.
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Affiliation(s)
- K Patel
- Department of Upper Gastro-Intestinal Surgery, East Surrey Hospital, Redhill, UK
| | - N Abbassi-Ghadi
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - S Markar
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - S Kumar
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - P Jethwa
- Department of Upper Gastro-Intestinal Surgery, East Surrey Hospital, Redhill, UK
| | - G Zaninotto
- Department of Surgery and Cancer, Imperial College London, London, UK.
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Crespin OM, Liu LWC, Parmar A, Jackson TD, Hamid J, Shlomovitz E, Okrainec A. Safety and efficacy of POEM for treatment of achalasia: a systematic review of the literature. Surg Endosc 2016; 31:2187-2201. [PMID: 27633440 DOI: 10.1007/s00464-016-5217-y] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 08/23/2016] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Peroral endoscopic myotomy (POEM) is a novel intervention for the treatment of achalasia, which combines the advantages of endoscopic access and myotomy. The purpose of this study was to perform a systematic review of the literature to evaluate the efficacy and safety of POEM. METHODS The systematic review was conducted following the PRISMA guidelines. Evidence-Based Medicine Reviews, Cochrane Central Register of Controlled Trials, Ovid MEDLINE (R) including in-process and non-indexed citations were searched for POEM studies using the keywords: esophageal achalasia, POEM, endoscopy, natural orifice surgery, laparoscopic Heller myotomy (LHM), and related terms. Eckardt score, lower esophageal sphincter (LES) pressure, and reported complications were the main outcomes. Two authors reviewed the search result independently. A third reviewer resolved all disagreements. Data abstraction was pilot-tested and approved by all authors. Data were examined for clinical, methodological, and statistical heterogeneity with the aim of determining whether evidence synthesis using meta- analysis was possible. RESULTS The search strategy retrieved 2894 citations. After removing duplicates and applying the exclusion criteria, 54 studies were selected for full-text review of which a total of 19 studies were considered eligible for further analysis. There were 10 retrospective and 9 prospective studies, including 1299 POEM procedures. No randomized control trial (RCT) was identified. Overall, the pre- and post-POEM Eckardt scores and LES pressure were significantly different. The most frequently reported complications were mucosal perforation, subcutaneous emphysema, pneumoperitoneum, pneumothorax, pneumomediastinum, pleural effusion, and pneumonia. The median follow-up was 13 months (range 3-24). CONCLUSION POEM is a safe and effective alternative for the treatment of achalasia. However, only short-term follow-up data compared with LHM are available. RCTs and long-term follow-up studies are needed to establish the efficacy and safety of POEM in the management of patients with achalasia.
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Affiliation(s)
- Oscar M Crespin
- Division of General Surgery, University Health Network, Toronto, ON, Canada. .,Department of Surgery, University of Toronto, Toronto, ON, Canada.
| | - Louis W C Liu
- Division of Gastroenterology, University Health Network, Toronto, ON, Canada
| | - Ambica Parmar
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Timothy D Jackson
- Division of General Surgery, University Health Network, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jemila Hamid
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Eran Shlomovitz
- Division of General Surgery, University Health Network, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of Interventional Radiology, University Health Network, Toronto, ON, Canada
| | - Allan Okrainec
- Division of General Surgery, University Health Network, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
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Pannu D, Yang D, Abbitt PL, Draganov PV. Prospective evaluation of CT esophagram findings after peroral endoscopic myotomy. Gastrointest Endosc 2016; 84:408-15. [PMID: 26907745 DOI: 10.1016/j.gie.2016.02.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 02/10/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) is a procedure with potential for serious adverse events. Postprocedure imaging is routinely done, yet there is no consensus on the optimal imaging protocol. We describe a novel and simple CT esophagram protocol for evaluation after POEM and for reporting the full spectrum of radiographic findings and subsequent interventions. METHODS This was a single-center prospective study of consecutive patients treated with POEM evaluated with CT esophagram. RESULTS Eighty-four consecutive patients who had POEM performed underwent CT esophagrams. The most common findings were pneumomediastinum (85.7%), pneumoperitoneum (66.7%), subcutaneous emphysema (52.4%), and pleural effusion (46.4%). Other findings included retroperitoneal air (38.1%), pneumothorax (19%), atelectasis (14.3%), intramural air in the esophagus and/or stomach (13.1%), pericardial effusion (2.4%), and pneumopericardium (2.4%). Five patients required intervention based on CT findings. In 1 patient, a leak was detected on CT esophagram before any clinical manifestation, facilitating prompt intervention and avoiding potential serious outcomes. Four patients were diagnosed with pneumonia and were treated with antibiotics. There was frequent postprocedural atelectasis, which prompted the introduction of routine incentive spirometry in all postoperative POEM cases. CONCLUSIONS CT esophagram is a simple and accessible imaging test for routine postoperative POEM evaluation. Numerous and dramatic postprocedure radiographic findings may be expected and demonstrated with this imaging modality. Although most of these findings may not require intervention, some are of potential significance, and early identification may help modify postprocedure management. ( CLINICAL TRIAL REGISTRATION NUMBER NCT01832779.).
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Affiliation(s)
- Davinderbir Pannu
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Dennis Yang
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Patricia L Abbitt
- Department of Radiology, University of Florida, Gainesville, Florida, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
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Werner YB, Costamagna G, Swanström LL, von Renteln D, Familiari P, Sharata AM, Noder T, Schachschal G, Kersten JF, Rösch T. Clinical response to peroral endoscopic myotomy in patients with idiopathic achalasia at a minimum follow-up of 2 years. Gut 2016; 65:899-906. [PMID: 25934759 DOI: 10.1136/gutjnl-2014-308649] [Citation(s) in RCA: 168] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 03/31/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND The recently developed technique for peroral endoscopic myotomy (POEM) has been shown to be effective in several short-term studies. Longer term outcome data are largely non-existent. OBJECTIVE To systematically report clinical outcome with a minimum post-POEM follow-up of 2 years. DESIGN All patients treated consecutively by POEM for achalasia at three centres were retrospectively analysed, with a minimum follow-up of 2 years. The main outcome was the rate of POEM failures (Eckardt score >3) related to follow-up time. RESULTS Of 85 patients treated, five (5.9%) cases were excluded due to protocol violation or loss to follow-up; the remaining 80 patients (mean age 44.9 years, 54% men) were followed clinically for 29 months (range 24-41). Initial clinical response was observed in 77 cases (96.3%). Clinical recurrences (later failures) were seen in a further 14 cases (17.7%), accounting for a total failure rate of 21.5%. In a multivariate analysis, age and endoscopic reflux signs were independent predictors of treatment success. Of the 17 failures, eight were among the first 10 cases treated in the participating centres. Reflux-associated sequelae included one case of a severe reflux-associated stricture requiring dilatation, and two patients with minor transient Eckardt score elevations curable by proton pump inhibitor (PPI) treatment. Endoscopic signs of reflux oesophagitis, mostly Los Angeles grade A/B, were seen in 37.5% (37/72) at the 2-year control. CONCLUSIONS In this multicentre retrospective analysis, a high initial success rate of POEM is followed by a mid-term recurrence rate of 18%. Reflux oesophagitis, albeit mild, is frequent and should probably be treated by regular low-dose PPI therapy. TRIAL REGISTRATION NUMBER NCT 01405417 (UKE study).
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Affiliation(s)
- Yuki B Werner
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany Department of Gastroenterology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Guido Costamagna
- Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Daniel von Renteln
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany Department of Gastroenterology, Centre Hospitalier de L'Université de Montreal, Montreal, Quebec, Canada
| | - Pietro Familiari
- Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Tania Noder
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Guido Schachschal
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jan F Kersten
- Department of Medical Biometry and Epidemiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Abstract
OPINION STATEMENT Submucosal endoscopy has introduced new and important aspects into gastrointestinal endoscopic therapeutics by opening the way to interventions even outside of the GI tract. At present, innovative techniques for submucosal endoscopy in different esophageal diseases include peroral endoscopic myotomy (POEM) for idiopathic achalasia and related motility disorders, submucosal tunneling endoscopic resection (STER) for submucosal tumors arising from the muscularis propria, and endoscopic submucosal tunneling dissection (ESTD) for superficial esophageal neoplastic lesions. POEM for achalasia-still a rare disease-is currently evaluated in comparison to endoscopic and surgical standard therapies, while this procedure enabling a long thoracic myotomy might constitute an advantage over the laparoscopic approach in treatments of spastic esophageal diseases. Removal of smaller submucosal esophageal tumors may appear tempting, but the clinical indications are limited by the facts that the vast majority of such smaller tumors are asymptomatic and benign.For all these innovative and technically demanding techniques, learning curves have to be taken into account, not only with regard to technical competence but also to clinical assessment, ranging from proper indication and patient selection to the management of (potential) complications and logistics/back-up. Although preliminary results from high-skilled endoscopic centers have been very encouraging, long-term data as well as prospective randomized controlled trials are needed to validate the efficacy and safety of the modalities.
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Peroral Endoscopic Myotomy for Esophageal Achalasia: Outcomes of the First 100 Patients With Short-term Follow-up. Ann Surg 2016; 263:82-7. [PMID: 25361224 DOI: 10.1097/sla.0000000000000992] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Aim of this study is to report the mid-term outcomes of a large series of patients treated with peroral endoscopic myotomy (POEM) in a single European center. BACKGROUND POEM is a recently developed treatment of achalasia, which combines the efficacy of surgical myotomy, with the benefits of an endoscopic procedure. Previous studies, including few patients with a short-term follow-up, showed excellent results on dysphagia relief. METHODS The first 100 adult patients treated in a single tertiary referral center were retrospectively identified and included in this study (41 men, mean age 48.4 years). Patients were treated according to a standard technique. Follow-up data, including clinical evaluation, and results of esophagogastroduodenoscopy (EGD), manometry, and pH monitoring were collected and analyzed. RESULTS POEM was completed in 94% of patients. Mean operative time was 83 minutes (49-140 minutes). No complications occurred. Patients were fed after a median of 2 days (1-4 days). A mean follow-up of 11 months (3-24 months) was available for 92 patients. Clinical success was documented in 94.5% of patients. Twenty-four-hour pH monitoring documented Gastro-Esophageal Reflux Disease (GERD) in 53.4% of patients. However, only a minority of patients had heartburn (24.3%) or esophagitis (27.4%), and these patients were successfully treated with proton-pump inhibitors. CONCLUSIONS Our results confirm the efficacy of POEM in a large series of patients, with a mean follow-up of 11 months. Should our results be confirmed by long-term follow-up studies, POEM may become one of the first-line therapies of achalasia in the next future.
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Modayil R, Stavropoulos SN. A Western Perspective on "New NOTES" from POEM to Full-thickness Resection and Beyond. Gastrointest Endosc Clin N Am 2016; 26:413-432. [PMID: 27036906 DOI: 10.1016/j.giec.2015.12.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Most new natural orifice translumenal endoscopic surgery procedures originated in Asia; therefore, most data come from operators and a health care environment different from those in the West. We provide a Western perspective. We discuss East-West differences; review areas in which the United States is leading the way; and discuss the vagaries of coding and reimbursement. In the United States, reimbursement remains problematic. A Current Procedural Terminology code for peroral endoscopic myotomy is inevitable given the rapidly accumulating overwhelmingly positive outcomes data. However, coordinated efforts may help accelerate the process.
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Affiliation(s)
- Rani Modayil
- Winthrop University Hospital, 222 Station Plaza North Suite 429, Mineola, NY 11501, USA
| | - Stavros N Stavropoulos
- Columbia University, 161 Fort Washington Ave., New York, NY 10032, USA; Temple University, 3401 N Broad St., Philadelphia, PA 19140, USA; Program in Advanced GI Endoscopy (P.A.G.E.), Winthrop University Hospital, 222 Station Plaza North Suite 429, Mineola, NY 11501, USA.
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Marano L, Pallabazzer G, Solito B, Santi S, Pigazzi A, De Luca R, Biondo FG, Spaziani A, Longaroni M, Di Martino N, Boccardi V, Patriti A. Surgery or Peroral Esophageal Myotomy for Achalasia: A Systematic Review and Meta-Analysis. Medicine (Baltimore) 2016; 95:e3001. [PMID: 26962813 PMCID: PMC4998894 DOI: 10.1097/md.0000000000003001] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 01/23/2016] [Accepted: 02/11/2016] [Indexed: 12/15/2022] Open
Abstract
To date very few studies with small sample size have compared peroral esophageal myotomy (POEM) with the current surgical standard of care, laparoscopic Heller myotomy (LHM), in terms of efficacy and safety, and no recommendations have been proposed.To investigate the efficacy and safety of POEM compared with LHM, for the treatment of achalasia.The databases of Pubmed, Medline, Cochrane, and Ovid were systematically searched between January 1, 2005 and January 31, 2015, with the medical subject headings (MeSH) and keywords "achalasia," "POEM," "per oral endoscopic myotomy," and "peroral endoscopic myotomy," "laparoscopic Heller myotomy" (LHM), "Heller myotomy."All types of study designs including adult patients with diagnosis of achalasia were selected. Studies that did not report the comparison between endoscopic and surgical treatment, experimental studies in animal models, single case reports, technical reports, reviews, abstracts, and editorials were excluded.The total number of included patients was 486 (196 in POEM group and 290 in LHM group).There were no differences between POEM and LHM in reduction in Eckardt score (MD = -0.659, 95% CI: -1.70 to 0.38, P = 0.217), operative time (MD = -0.354, 95% CI: -1.12 to 0.41, P = 0.36), postoperative pain scores (MD = -1.86, 95% CI: -5.17 to 1.44, P = 0.268), analgesic requirements (MD = -0.74, 95% CI: -2.65 to 1.16, P = 0.445), and complications (OR = 1.11, 95% CI: 0.5-2.44, P = 0.796). Length of hospital stay was significantly lower for POEM (MD = -0.629, 95% CI: -1.256 to -0.002, P = 0.049). There was a trend toward significant reduction in symptomatic gastroesophageal reflux rate in favors of LHM compared to POEM group (OR = 1.81, 95% CI: 1.11-2.95, P = 0.017).All included studied were not randomized. Furthermore all selected studies did not report the results of follow-up longer than 1 year and most of them included patients who were both treatment naive and underwent previous endoscopic or surgical interventions for achalasia.POEM represents a safe and efficacy procedure comparable to the safety profile of LHM for achalasia at a short-term follow-up. Long-term clinical trials are urgently needed.
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Affiliation(s)
- Luigi Marano
- From the General, Minimally Invasive and Robotic Surgery, Department of Surgery, "San Matteo degli Infermi Hospital"-ASL Umbria 2, Spoleto (PG), Italy (LM, AS, AP), Esophageal Surgery Unit, Tuscany Regional Referral Center for the Diagnosis and Treatment of Esophageal Disease, Cisanello Hospital, Pisa, Italy (GP, BS, SS), Division of Colon and Rectal Surgery, Department of Surgery, University of California, Irvine, Orange, CA (AP), Department of Surgical Oncology, National Cancer Research Centre-Istituto Tumori "G. Paolo II", Bari, Italy (RDL), Department of Abdominal and Thoracic Minimally Invasive Surgery, "San Giuseppe Moscati" Hospital, Avellino, Italy (FGB), Department of Surgery, "San Giovanni Battista Hospital"-ASL Umbria 2, Foligno (PG), Italy (ML), Department of Internal Medicine, Surgical, Neurological Metabolic Disease and Geriatric Medicine, Second University of Naples, Naples, Italy (NDM), and Institute of Gerontology and Geriatrics, Department of Medicine, University of Perugia, Perugia, Italy (VB)
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Onimaru M, Inoue H, Ikeda H, Sato C, Sato H, Phalanusitthepha C, Santi EG, Grimes KL, Ito H, Kudo SE. Greater curvature myotomy is a safe and effective modified technique in per-oral endoscopic myotomy (with videos). Gastrointest Endosc 2016; 81:1370-7. [PMID: 25686872 DOI: 10.1016/j.gie.2014.11.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 11/05/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Per-oral endoscopic myotomy (POEM) for achalasia with esophagocardiomyotomy in the lesser curvature (LC myotomy) is now established and accepted widely. However, in some cases LC myotomy is precluded by previous procedures, such as Heller myotomy, or by other anatomic considerations that obscure the normal dissection planes. It may also be difficult to identify the esophagogastric junction (EGJ), which can result in an incomplete gastric myotomy and poor rates of symptom relief. On the other hand, the angle of His is always located in the greater curvature of the stomach and serves as a consistent, definite landmark of the gastric side. OBJECTIVE To evaluate esophagocardiomyotomy in the greater curvature (GC myotomy) as an alternative POEM technique in cases where a prior LC myotomy or supervening anatomic constraints make identification of the EGJ technically challenging. DESIGN Prospective. SETTING Single-center study. PATIENTS Twenty-one achalasia patients who received POEM with GC myotomy. INTERVENTIONS POEM. MAIN OUTCOME MEASUREMENTS Efficacy and safety of GC myotomy measured in terms of reduction in lower esophageal sphincter (LES) pressures, improvement in Eckardt scores, and development of intraoperative or postoperative adverse events. RESULTS Identification of the EGJ was achieved in all cases, resulting in a mean gastric myotomy length of 2.6±1.1 cm. Mean LES pressure and Eckardt symptom scores decreased significantly (21.2±7.3 vs 10.5±2.7 mm Hg, 5 [2-8] vs 1 [0-5], respectively) (P<.01). Endoscopic evidence of gastroesophageal reflux was identified in 52% of patients (11/21) postmyotomy; however, only 9.5% (2/11) were symptomatic, and these patients were successfully controlled with proton pump inhibitors. No severe adverse events were encountered. LIMITATIONS Single center. CONCLUSIONS GC myotomy is a promising, safe modification of the POEM technique and may be especially useful in cases of redo POEM, POEM post-Heller myotomy, or when the EGJ is difficult to recognize because of supervening anatomic constraints.
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Affiliation(s)
- Manabu Onimaru
- Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Haruhiro Inoue
- Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Haruo Ikeda
- Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Chiaki Sato
- Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hiroki Sato
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | | | - Esperanza Grace Santi
- Section of Gastroenterology and Digestive Endoscopy, De La Salle University Medical Center, Cavite, Philippines
| | - Kevin L Grimes
- Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Hiroaki Ito
- Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
| | - Shin-ei Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
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Eleftheriadis N, Inoue H, Ikeda H, Onimaru M, Maselli R, Santi G. Submucosal tunnel endoscopy: Peroral endoscopic myotomy and peroral endoscopic tumor resection. World J Gastrointest Endosc 2016; 8:86-103. [PMID: 26839649 PMCID: PMC4724034 DOI: 10.4253/wjge.v8.i2.86] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 10/19/2015] [Accepted: 11/24/2015] [Indexed: 02/05/2023] Open
Abstract
Peroral endoscopic myotomy (POEM) is an innovative, minimally invasive, endoscopic treatment for esophageal achalasia and other esophageal motility disorders, emerged from the natural orifice transluminal endoscopic surgery procedures, and since the first human case performed by Inoue in 2008, showed exciting results in international level, with more than 4000 cases globally up to now. POEM showed superior characteristics than the standard 100-year-old surgical or laparoscopic Heller myotomy (LHM), not only for all types of esophageal achalasia [classical (I), vigorous (II), spastic (III), Chicago Classification], but also for advanced sigmoid type achalasia (S1 and S2), failed LHM, or other esophageal motility disorders (diffuse esophageal spasm, nutcracker esophagus or Jackhammer esophagus). POEM starts with a mucosal incision, followed by submucosal tunnel creation crossing the esophagogastric junction (EGJ) and myotomy. Finally the mucosal entry is closed with endoscopic clip placement. POEM permitted relatively free choice of myotomy length and localization. Although it is technically demanding procedure, POEM can be performed safely and achieves very good control of dysphagia and chest pain. Gastroesophageal reflux is the most common troublesome side effect, and is well controllable with proton pump inhibitors. Furthermore, POEM opened the era of submucosal tunnel endoscopy, with many other applications. Based on the same principles with POEM, in combination with new technological developments, such as endoscopic suturing, peroral endoscopic tumor resection (POET), is safely and effectively applied for challenging submucosal esophageal, EGJ and gastric cardia tumors (submucosal tumors), emerged from muscularis propria. POET showed up to know promising results, however, it is restricted to specialized centers. The present article reviews the recent data of POEM and POET and discussed controversial issues that need further study and future perspectives.
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Familiari P, Greco S, Gigante G, Calì A, Boškoski I, Onder G, Perri V, Costamagna G. Gastroesophageal reflux disease after peroral endoscopic myotomy: Analysis of clinical, procedural and functional factors, associated with gastroesophageal reflux disease and esophagitis. Dig Endosc 2016; 28:33-41. [PMID: 26173511 DOI: 10.1111/den.12511] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 06/16/2015] [Accepted: 07/08/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Peroral endoscopic myotomy (POEM) does not include any antireflux procedure, resulting in a certain risk of iatrogenic gastroesophageal reflux disease (GERD). The aim of the present study was to evaluate the incidence of iatrogenic GERD after POEM and identify preoperative, perioperative and postoperative factors associated with GERD. METHODS All patients treated at a single center who had a complete GERD evaluation after POEM were included in the study. Demographics, preoperative and follow-up data, results of functional studies and procedural data were collected and analyzed. RESULTS A total of 103 patients (mean age 46.6 years, 47 males) were included. Postoperative altered esophageal acid exposure was attested in 52 patients (50.5%). A total of 19 patients (18.4%) had heartburn and 21 had esophagitis (20.4%). Overall, a clinically relevant GERD (altered esophageal acid exposure, associated with heartburn and/or esophagitis) was diagnosed in 30 patients (29.1%). Correlation between the severity of esophageal acid exposure with heartburn and esophagitis after POEM was found. Patients with heartburn had a lower postoperative 4-second integrated relaxation pressure compared to patients without symptoms (7.6 ± 3.8 mmHg vs 10.01 ± 4.4 mmHg, p<0.05). No correlations were identified with patient sex, age, postoperative body mass index, esophageal shape (sigmoid vs non sigmoid), lower esophageal sphincter pressure, length of myotomy, previous therapies and type of achalasia at high-resolution manometry. CONCLUSIONS Preoperative, perioperative or postoperative factors minimally correlated with GERD after POEM. Clinically relevant GERD was identified in less than one-third of patients, but all patients were well controlled with medical therapy.
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Affiliation(s)
- Pietro Familiari
- Digestive Endoscopy Unit, Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Santi Greco
- Digestive Endoscopy Unit, Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Gigante
- Digestive Endoscopy Unit, Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anna Calì
- Digestive Endoscopy Unit, Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Graziano Onder
- Department of Geriatrics, Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vincenzo Perri
- Digestive Endoscopy Unit, Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
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Stavropoulos SN, Modayil R, Friedel D. The State of The Art in Per-Oral Endoscopic Myotomy. Semin Thorac Cardiovasc Surg 2016; 28:137-46. [DOI: 10.1053/j.semtcvs.2015.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2015] [Indexed: 02/07/2023]
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Chan SM, Wu JCY, Teoh AYB, Yip HC, Ng EKW, Lau JYW, Chiu PWY. Comparison of early outcomes and quality of life after laparoscopic Heller's cardiomyotomy to peroral endoscopic myotomy for treatment of achalasia. Dig Endosc 2016; 28:27-32. [PMID: 26108140 DOI: 10.1111/den.12507] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 06/12/2015] [Accepted: 06/17/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIM This retrospective cohort study compared clinical outcomes and quality of life after peroral endoscopic myotomy (POEM) against laparoscopic Heller myotomy (LHM) for treatment of achalasia. METHODS Patient demographics, operation time, intraoperative blood loss, hospital stay, time to resume diet and analgesic requirement were recorded. Clinical outcomes including recurrence of dysphagia, need for reintervention, and occurrence of gastroesophageal reflux disease (GERD) were recorded. RESULTS From 2001 to 2014, 33 patients underwent POEM whereas 23 patients received LHM. Patients LHM had with longer mean operative time (P = 0.02), more blood loss (P = 0.001) and higher requirement for analgesics (P = 0.009) than those treated by POEM. Hospital stay and time to resume diet were similar. Both POEM and LHM achieved similar dysphagia scores at postoperative 4 weeks, 3 months and 6 months. Twenty-six percent of LHM patients and 15.2% of POEM patients sustained gastroesophageal reflux disease (GERD) after treatment (P = 0.311). Six patients required regular proton pump inhibitor three after POEM and three after LHM (P = 0.639). Thirteen percent of LHM patients sustained recurrent dysphagia and one required reintervention. There was no recurrence in the POEM group. Follow-up duration (mean [SD]) for the LHM group was significantly longer (60 [42] months vs 6 [4] months; P = 0.001). There was also no difference in all four aspects of GERD-related quality of life outcomes. CONCLUSION Compared to LHM, POEM achieved shorter operative time, less blood loss and pain. POEM is comparable to LHM for treatment of achalasia with similar incidence of GERD after the procedure.
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Affiliation(s)
| | - Justin Che Yuen Wu
- Medicine and Therapeutics, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
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Khashab MA, El Zein M, Kumbhari V, Besharati S, Ngamruengphong S, Messallam A, Abdelgalil A, Saxena P, Tieu AH, Raja S, Stein E, Dhalla S, Garcia P, Singh VK, Pasricha PJ, Kalloo AN, Clarke JO. Comprehensive analysis of efficacy and safety of peroral endoscopic myotomy performed by a gastroenterologist in the endoscopy unit: a single-center experience. Gastrointest Endosc 2016. [PMID: 26212369 DOI: 10.1016/j.gie.2015.06.013] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The safety and efficacy of peroral endoscopic myotomy (POEM) when performed by gastroenterologists in the endoscopy unit are currently unknown. The aims of this study were to assess (1) the safety and efficacy of POEM in which all procedures were performed by 1 gastroenterologist in the endoscopy unit, and (2) the predictors of adverse events and nonresponse. METHODS All consecutive patients who underwent POEM at 1 tertiary center were included. Clinical response was defined by a decrease in the Eckardt score to 3 or lower. Adverse events were graded according to the American Society for Gastrointestinal Endoscopy lexicon's severity grading system. RESULTS A total of 60 consecutive patients underwent POEM in the endoscopy suite with a mean procedure length of 99 minutes. The mean length of submucosal tunnel was 14 cm and the mean myotomy length was 11 cm. The median length of hospital stay was 1 day. Among 52 patients with a mean follow-up period of 118 days (range 30-750), clinical response was observed in 48 patients (92.3%). There was a significant decrease in Eckardt score after POEM (8 vs 1.19, P < .0001). The mean lower esophageal sphincter pressure decreased significantly after POEM (29 mm Hg vs 11 mm Hg, P < .0001). A total of 10 adverse events occurred in 10 patients (16.7%): 7 rated as mild, 3 as moderate, and none as severe. Procedure length was the only predictor of adverse events (P = .01). pH impedance testing was completed in 25 patients, and 22 (88%) had abnormal acid exposure, but positive symptom correlation was present in only 6 patients. All patients with symptomatic reflux were successfully treated with proton pump inhibitors. CONCLUSIONS POEM can be effectively and safely performed by experienced gastroenterologists at a tertiary care endoscopy unit. Adverse events are infrequent, and most can be managed intraprocedurally. Post-POEM reflux is frequent but can be successfully managed medically.
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Affiliation(s)
- Mouen A Khashab
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mohamad El Zein
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Sepideh Besharati
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Ahmed Messallam
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Ahmed Abdelgalil
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Payal Saxena
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Alan H Tieu
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Shreya Raja
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Ellen Stein
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Sameer Dhalla
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Patricia Garcia
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Pankaj J Pasricha
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Anthony N Kalloo
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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