Correlation of timed barium esophagography with Eckardt score in primary achalasia patients treated with peroral endoscopic myotomy

Abstract Background There is growing interest in developing impedance planimetry as a tool to enhance the clinical outcomes for endoscopic and surgical management of achalasia. The primary aim of this study was to determine whether impedance planimetry measurements can predict clinical response and reflux following peroral endoscopic myotomy (POEM). Methods A multicenter cohort study of patients with achalasia undergoing POEM was established from prospective databases and retrospective chart reviews. Patients who underwent impedance planimetry before and after POEM were included. Clinical response was defined as an Eckardt score of ≤ 3. Tenfold cross-validated area under curve (AUC) values were established for the different impedance planimetry measurements associated with clinical response and reflux development. Results Of the 290 patients included, 91.7 % (266/290) had a clinical response and 39.4 % (108/274) developed reflux following POEM. The most predictive impedance planimetry measurements for a clinical response were: percent change in cross-sectional area (%ΔCSA) and percent change in distensibility index (%ΔDI), with AUCs of 0.75 and 0.73, respectively. Optimal cutoff values for %ΔCSA and %ΔDI to determine a clinical response were a change of 360 % and 272 %, respectively. Impedance planimetry values were much poorer at predicting post-POEM reflux, with AUCs ranging from 0.40 to 0.62. Conclusion Percent change in CSA and distensibility index were the most predictive measures of a clinical response, with a moderate predictive ability. Impedance planimetry values for predicting reflux following POEM showed weak predictive capacity.

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Effects of Peroral Endoscopic Myotomy on Esophageal Function in the Treatment of Achalasia

Surgical Innovation ◽

10.1177/1553350620913133 ◽

2020 ◽

pp. 155335062091313

Author(s):

Bai Cang Zou ◽

Li Zhang ◽

Bin Qin ◽

Shen Hao Wang ◽

Yan Cheng ◽

...

Keyword(s):

Stent Implantation ◽

Clinical Symptoms ◽

Operation Time ◽

Peroral Endoscopic Myotomy ◽

Esophageal Stent ◽

Sphincter Pressure ◽

Esophageal Function ◽

Eckardt Score ◽

Endoscopic Myotomy ◽

Esophageal Sphincter

Peroral endoscopic myotomy (POEM) is a new technique to treat achalasia, but the effects on esophageal motor function and structure are still unclear. This study aimed to examine the esophageal function and anatomical changes of patients with achalasia treated with POEM. This was a retrospective study of 43 patients with achalasia treated with POEM between January 2013 and January 2016 at the Second Affiliated Hospital of Xi’an Jiaotong University. The patients were grouped as previous treatments for achalasia (n = 19) versus no previous treatment (n = 24). Surgical success (defined as Eckardt score ≤3 points or decreased by >3 points compared with baseline), recurrence, and reintervention were analyzed. Three patients (7.0%) were Eckardt grade I, 16 (37.2%) were grade II, and 24 (55.8%) were grade III. Operation time was 35 to 150 (median = 49) minutes. Both groups showed improvements in the Eckardt score after surgery (both P < .001), without a difference between the 2 groups ( P = .749). The maximal mean diameter of the esophagus was reduced, and the lower esophageal sphincter pressure was improved after surgery (both groups, all P < .001), without difference between the 2 groups (all P > .05). One case of failure was probably due to the presence of an esophageal stent. POEM has a high success rate and is possibly unaffected by previous treatments, except maybe stent implantation. Clinical symptoms of achalasia are significantly relieved by POEM; the function of the esophageal sphincter and the esophagus structure are improved. Previous esophageal stent implantation could increase failure likelihood, but this will have to be confirmed.

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Peroral endoscopic myotomy versus pneumatic dilation – result from a retrospective study with 1-year follow-up

Zeitschrift für Gastroenterologie ◽

10.1055/a-0821-7232 ◽

2019 ◽

Vol 57 (03) ◽

pp. 304-311 ◽

Cited By ~ 7

Author(s):

Zhongqing Zheng ◽

Chunshan Zhao ◽

Shuai Su ◽

Xiaofei Fan ◽

Wei Zhao ◽

...

Keyword(s):

Functional Data ◽

Peroral Endoscopic Myotomy ◽

Type I ◽

Exact Test ◽

Fisher's Exact Test ◽

Eckardt Score ◽

Reflux Symptoms ◽

Fisher’S Exact Test ◽

Endoscopic Myotomy

Abstract Background and aims On the basis of lesser rates of major adverse events and a short-term efficacy as Heller’s myotomy, there is a growing enthusiasm in favor of peroral endoscopic myotomy (POEM), whereas study comparing POEM and pneumatic dilatation (PD) is quite rare. The aim of this study was to evaluate the efficacy of POEM and PD in Chinese achalasia patients in a retrospectively designed study. Methods Patients with achalasia, who underwent either PD (n = 26) or POEM (n = 40) were retrospectively recruited from September 2010 through March 2016 at a single tertiary center. During the 1-year follow-up, clinical outcome and functional data of lower esophageal sphincter (LES) were recruited. Clinical symptoms were assessed by use of the Eckardt score. The primary outcome was therapeutic success (Eckardt score ≤ 3). Functional data of LES (4-second integrated relaxation pressure [4s-IRP], LES relax rate, and LESP) at baseline and 1 month after treatment were also evaluated. Data was analyzed by SPSS 13.0 version using a significance level of p < 0.05. Results The success rates were 24/26 (92.31 %), 25/26 (96.15 %), and 24/26 (92.31 %), respectively, with POEM, as compared with 35/40 (87.50 %), 29/40 (72.50 %), and 23/40 (57.50 %), respectively, with PD, 1 month, 3 months, and 1 year after treatment. Statistically significant difference was observed between the 2 therapies (at 3 months, Fisher’s exact test, p = 0.01; at 1 year, Fisher’s exact test, p < 0.0001). Compared with PD, the Eckardt score was lower with POEM 1 month, 3 months, and 1 year after treatment. More patients in POEM group reported gastroesophageal reflux symptoms (after 3 months 7/26 (26.92 %) vs. 2/40 (5.00 %), Fisher’s exact test, p = 0.01; after 1 year 6/26 (19.23 %) vs. 1/35 (2.86 %), Fisher’s exact test, p = 0.02). The postoperative 4s-IRP and LESP were both lower with POEM than with PD, respectively. Type I achalasia had a better response with POEM than with PD. Conclusion In this retrospective analysis with 1-year follow-up, POEM presents with a higher success rate and more reflux symptoms compared with PD. Change on LES function after treatment may explain the outcome in part. Type I achalasia may respond better to therapies compared with type II.

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Change in Eckardt Score with Peroral Endoscopic Myotomy (POEM) Versus Surgical Myotomy in Managing Adult Patients with Achalasia: A Meta-Analysis and Systematic Review

Gastroenterology ◽

10.1016/s0016-5085(17)32424-1 ◽

2017 ◽

Vol 152 (5) ◽

pp. S692

Author(s):

Harsha V. Moole ◽

Anthony Baldoni ◽

Sowjanya Kapaganti ◽

Vu Nguyen ◽

Ayesha Waqar ◽

...

Keyword(s):

Systematic Review ◽

Meta Analysis ◽

Peroral Endoscopic Myotomy ◽

Adult Patients ◽

Eckardt Score ◽

Endoscopic Myotomy

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Two-Person Technique of Peroral Endoscopic Myotomy for Achalasia with an Advanced Endoscopist and a Thoracic Surgeon: Initial Experience

Canadian Journal of Gastroenterology and Hepatology ◽

10.1155/2016/2656101 ◽

2016 ◽

Vol 2016 ◽

pp. 1-6 ◽

Cited By ~ 1

Author(s):

Madhusudhan R. Sanaka ◽

Ramprasad Jegadeesan ◽

Prashanthi N. Thota ◽

Udayakumar Navaneethan ◽

Rocio Lopez ◽

...

Keyword(s):

Peroral Endoscopic Myotomy ◽

Column Height ◽

Therapeutic Success ◽

Delayed Bleeding ◽

Eckardt Score ◽

Thoracic Surgeon ◽

Endoscopic Myotomy ◽

Barium Esophagogram ◽

Timed Barium Esophagogram

Background and Aims. We initiated peroral endoscopic myotomy (POEM) utilizing a two-person technique with combination of an advanced endoscopist and a thoracic surgeon with complementary skills. Our aim was to determine the feasibility and outcomes in initial 20 patients. Methods. In this observational study, main outcomes measured were therapeutic success in relieving symptoms (Eckardt score < 3), decrease in lower esophageal sphincter (LES) pressures, improvement in emptying on timed barium esophagogram (TBE), and complications.Results. POEM was successful in all 20 patients with a mean operative time of140.1+32.9minutes. Eckardt symptom scores decreased significantly at two-month follow-up (6.4+2.9versus0.25+0.45,p<0.001). Both basal and residual LES pressures decreased significantly (28.2+14.1 mmHg versus12.8+6.3and22.4+11.3versus6.3+3.4 mmHg,p=0.025and <0.001, resp.). Barium column height at 5 minutes on TBE reduced from6.8+4.9 cm to2.3+2.9 cm (p=0.05). Two patients (10%) had mucosal perforations and one had delayed bleeding (5%).Conclusions.Two-person technique of POEM with combination of an advanced endoscopist and a thoracic surgeon is highly successful with low risk of complications.

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Single-session endoscopic fundoplication after peroral endoscopic myotomy (POEM+F) for prevention of post gastroesophageal reflux – 1-year follow-up study

Endoscopy ◽

10.1055/a-1332-5911 ◽

2020 ◽

Author(s):

Amol Bapaye ◽

Parag Dashatwar ◽

Siddharth Dharamsi ◽

Rajendra Pujari ◽

Harshal P Gadhikar

Keyword(s):

Gastroesophageal Reflux ◽

Peroral Endoscopic Myotomy ◽

P Value ◽

Prior Therapy ◽

Eckardt Score ◽

Single Center Study ◽

Endoscopic Myotomy ◽

Endoscopic Fundoplication ◽

One Year

Background and Aim Peroral endoscopic myotomy (POEM) is an established treatment for achalasia cardia (AC), however post-POEM gastroesophageal reflux (GER) remains a significant problem. Concomitant endoscopic fundoplication following POEM (POEM+F) was recently described to reduce post-POEM GER. This single-center study reports medium-term outcomes of POEM+F. Patients and Methods Retrospective analysis of prospectively maintained database of patients undergoing POEM+F. Abstracted data – demographics, achalasia type, pre-POEM Eckardt score (ES), prior therapy, follow-up. Follow-up was 3-monthly for one-year. Follow-up assessments included post-POEM ES, GerdQ score, EGD – wrap integrity and esophagitis, and pH studies. GER was defined according to Lyon consensus. Data was recorded as mean (SD) or median (IQR), P-value < 0.05 was considered statistically significant. Results 25 patients underwent POEM+F, mean age (SD) – 40.13 (13.66) years, 12 females. POEM+F was technically successful in 23/25 (92%). Significant dysphagia improvement was seen in all 25 (mean [SD] pre- and post-POEM ES 8.21 [1.08] and 0.1 [0.3] respectively, p < 0.05). Mean total procedure and fundoplication time (SD) – 115.6 (27.2) and 46.7 (12.4) minutes respectively. Time reduced significantly after initial 5 cases. Median follow-up was 12-months (IQR 9 – 13). Intact wrap was seen in 19/23 (82.6%). GER (abnormal EAET) was seen in 2/18 (11.1%); one reported GerdQ > 8. Borderline GER (asymptomatic grade A esophagitis, normal EAET) was identified in 4/22 (18.1%). Two (8%) minor delayed adverse events required no intervention. Conclusions POEM+F is safe and reproducible. At 12-months follow-up, incidence of post-POEM+F GER was low and acceptable.

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A Meta-Analysis and Systematic Review of Prospective Trials: Eckardt Score with Peroral Endoscopic Myotomy (POEM) Versus Surgical Myotomy in Managing Adult Achalasia Patients

Gastroenterology ◽

10.1016/s0016-5085(17)34214-2 ◽

2017 ◽

Vol 152 (5) ◽

pp. S1264-S1265

Author(s):

Abhiram Duvvuri ◽

Vishnu Moole ◽

Anwesh Poosala ◽

Raghuveer R. Boddireddy ◽

Achuta Uppu ◽

...

Keyword(s):

Systematic Review ◽

Meta Analysis ◽

Peroral Endoscopic Myotomy ◽

Eckardt Score ◽

Prospective Trials ◽

Endoscopic Myotomy

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Advanced achalasia: good candidate for peroral endoscopic myotomy

Diseases of the Esophagus ◽

10.1093/dote/doaa097 ◽

2020 ◽

Author(s):

Shaotian Qiu ◽

Ningli Chai ◽

Yaqi Zhai ◽

Xiangyao Wang ◽

Yan Wang ◽

...

Keyword(s):

Adverse Events ◽

Clinical Success ◽

Laparoscopic Heller Myotomy ◽

Peroral Endoscopic Myotomy ◽

Symptom Duration ◽

Technical Success ◽

Technical Success Rate ◽

Eckardt Score ◽

Endoscopic Myotomy ◽

Favorable Safety

SUMMARY Peroral endoscopic myotomy (POEM) has been increasingly accepted as the first-line treatment of achalasia. However, laparoscopic Heller myotomy or esophagectomy still remains as the mainstay treatment for advanced achalasia featured with megaesophagus and/or sigmoid-shaped esophagus. Although the efficacy of POEM for advanced achalasia with sigmoid-shaped esophagus has been described, little is known about the role of POEM for patients with megaesophagus. The aim of our study is to evaluate the efficacy and safety of POEM for advanced achalasia with megaesophagus. Patients who received initial examinations and underwent POEM in our hospital from June 2013 to December 2018 were identified and data were retrospectively analyzed. The advanced achalasia was defined as megaesophagus with a diameter of ≥6 cm. The primary outcome was clinical success. The secondary outcomes were technical success and adverse events. A total of 112 patients (50 females, 44.6%) were included with a mean age of 44.8 years. The median symptom duration was 6.5 years (IQR:3.0–13.0 years). Modified POEM techniques were used in 27.7% (31/112) of patients. Technical success rate was 99.1% (112/113) per procedure. Clinical success was seen in 93.1% patients with median Eckardt score decreasing from 8.0 to 1.0 (P < 0.001) during a median 31.0 months of follow-up. The mean LES pressure decreased from 29.5 mmHg to 14.2 mmHg after POEM (P < 0.05). Procedure-related adverse events occurred in 8.9% patients. Reflux disease was observed postoperatively in 26.7% of patients. POEM is also indicated for patients with advanced achalasia with a favorable safety and efficacy.

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Outcomes of peroral endoscopic myotomy in patients with achalasia and prior bariatric surgery: A multicenter experience

Diseases of the Esophagus ◽

10.1093/dote/doab044 ◽

2021 ◽

Author(s):

S Bomman ◽

J S Klair ◽

M Ashat ◽

R El Abiad ◽

H Gerke ◽

...

Keyword(s):

Bariatric Surgery ◽

Clinical Success ◽

Botulinum Toxin Injection ◽

Clinical Success Rate ◽

Peroral Endoscopic Myotomy ◽

Pneumatic Dilation ◽

Type I ◽

Eckardt Score ◽

Endoscopic Myotomy ◽

The Mean

Summary Peroral endoscopic myotomy (POEM) in patients with achalasia who are status post bariatric surgery may be technically challenging due to postsurgical scarring and altered anatomy. The aim of the study was to assess the efficacy and safety of POEM for achalasia in patients with prior bariatric surgery. A review of prospectively maintained databases at three tertiary referral centers from January 2015 to January 2021 was performed. The primary outcome of interest was clinical success, defined as a post-treatment Eckardt score ≤ 3 or improvement in Eckardt score by ≥ 1 when the baseline score was <3, and improvement of symptoms. Secondary outcomes were adverse event rates and symptom recurrence. Sixteen patients status post Roux-en-Y gastric bypass (n = 14) and sleeve gastrectomy (n = 2) met inclusion criteria. Indications for POEM were achalasia type I (n = 2), type II (n = 9), and type III (n = 5). POEM was performed either by anterior or posterior approach. The pre-POEM mean integrated relaxation pressure was 26.2 ± 7.6 mm Hg. The mean total myotomy length was 10.2 ± 2.7 cm. The mean length of hospitalization was 1.4 ± 0.7 days. Pre- and postprocedure Eckardt scores were 6.1 ± 2.1 and 1.7 ± 1.8, respectively. The overall clinical success rate was 93.8% (15/16) with mean follow-up duration of 15.5 months. One patient had esophageal leak on postprocedure esophagram and managed endoscopically. Dysphagia recurred in two patients, which was successfully managed with pneumatic dilation with or without botulinum toxin injection. POEM appears to be safe and effective in the management of patients with achalasia who have undergone prior bariatric surgery.

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