Peroral Endoscopic Myotomy in a Patient with Achalasia Cardia with Prior Heller’s Myotomy

Achalasia cardia is an esophageal myenteric plexus disorder characterized by absence of or incomplete lower esophageal sphincter relaxation and esophageal aperistalsis; Heller’s myotomy is the main treatment of choice due to a lower failure rate. Recently, peroral endoscopic myotomy (POEM) has been reported as an alternative treatment for achalasia due to persistent symptoms after Heller’s myotomy. An Indian male, aged 18 years, was admitted to the hospital due to dysphagia which had started more than 3 years ago. He also complained of occasional regurgitation and retrosternal pain with Eckardt score 6. Heller’s myotomy was performed 2 years ago. Barium swallow showed achalasia cardia and upper gastrointestinal endoscopy found liquid residue and resistance at the gastroesophageal junction. Esophageal manometry is concluded as achalasia cardia type II with a median integrated relaxation pressure (IRP) of 25.6 mm Hg. He underwent POEM; with the help of a submucosal tunnel, an extension of up to 1 cm beyond the gastroesophageal junction could be achieved with a posterior orientation of myotomy. There were no adverse events after the POEM procedure. He was treated with a soft diet for 10 days and other supportive treatments. Following POEM, barium swallow showed a significant improvement and esophageal manometry exhibited that the basal lower esophageal sphincter pressure was normal with complete relaxation on swallowing and normal median IRP. The post-procedure Eckardt score was 0. We reported an achalasia patient who received POEM after unsuccessful Heller’s myotomy and showed clinical improvement.

Download Full-text

Su1513 Early Results of PerOral Endoscopic Myotomy Using Hybrid Knife TM vs Laparoscopic Heller's Myotomy for Achalasia Cardia

Gastrointestinal Endoscopy ◽

10.1016/j.gie.2013.03.1166 ◽

2013 ◽

Vol 77 (5) ◽

pp. AB352 ◽

Cited By ~ 2

Author(s):

Amit P. Maydeo ◽

Suryaprakash Bhandari ◽

Nitin Joshi ◽

Mukta Bapat ◽

Rajan Y. Daftary ◽

...

Keyword(s):

Peroral Endoscopic Myotomy ◽

Achalasia Cardia ◽

Heller’S Myotomy ◽

Early Results ◽

Heller's Myotomy ◽

Endoscopic Myotomy

Download Full-text

PERORAL ENDOSCOPIC MYOTOMY IN TREATMENT OF THE ESOPHAGEAL ACHALASIA AT CHILDREN

PEDIATRIA Journal named after G N SPERANSKY ◽

10.24110/0031-403x-2020-99-6-241-246 ◽

2020 ◽

Vol 99 (6) ◽

pp. 241-246

Author(s):

Yu.A. Kozlov ◽

◽

A.A. Smirnov ◽

A.A. Rasputin ◽

P.A. Baradieva ◽

...

Keyword(s):

Esophageal Achalasia ◽

Peroral Endoscopic Myotomy ◽

Heller’S Myotomy ◽

Endoscopic Method ◽

Therapeutic Procedures ◽

Heller's Myotomy ◽

Prolonged Observation ◽

Endoscopic Myotomy ◽

Esophageal Sphincter

Etiological treatment of esophageal achalasia are absent. None of the currently available treatment methods can restore normal esophageal peristalsis and the functionality of the lower esophageal sphincter, thereby alleviating dysphagia and other symptoms of achalasia. Therapeutic procedures currently used for the effective treatment of achalasia of the esophagus are represented by laparoscopic Heller's myotomy and endoscopic balloon dilatation of the esophagus. According to the literature, Heller's myotomy is considered as a method of choice in children, since it provides more reliable results in comparison with pneumatic expansion during prolonged observation. Peroral endoscopic myotomy (POEM) is a new endoscopic method for the treatment of esophageal achalasia, first reported by P. Pasricha in experiment, and then H. Inoue performed this operation in adult patients. There are only a few studies on the use of POEM in children and adolescents. Existing studies have demonstrated the feasibility of this procedure in children, low level of complications and excellent results with short-term observation. Several studies have reported high efficacy in the use of POEM in children, ranging from 90% to 100%. Reports of the occurrence of complications after POEM in children are sporadic and are represented by the formation of subcutaneous emphysema, carboperitoneum, retroperitoneum and mediastinal emphysema. Obviously, detailed studies with longer observation are required before the role of POEM in the treatment of esophageal achalasia in children can be established. If preliminary results are confirmed, POEM can be a real alternative to Heller's myotomy in pediatric patients. This study is intended to explore the potential and safety of the use of POEM for the treatment of achalasia in children based on a review of existing data in the scientific literature.

Download Full-text

What to do when Heller's myotomy fails? Pneumatic dilatation, laparoscopic remyotomy or peroral endoscopic myotomy: A systematic review

Journal of Minimal Access Surgery ◽

10.4103/jmas.jmas_94_17 ◽

2018 ◽

Vol 14 (3) ◽

pp. 177 ◽

Cited By ~ 9

Author(s):

ArnulfoF Fernández ◽

Sonia Fernández-Ananín ◽

Carmen Balagué ◽

David Sacoto ◽

EduardoMaria Targarona

Keyword(s):

Systematic Review ◽

Pneumatic Dilatation ◽

Peroral Endoscopic Myotomy ◽

Heller’S Myotomy ◽

Heller's Myotomy ◽

Endoscopic Myotomy

Download Full-text

Evaluation of Short-term Outcomes of Laparoscopic Heller Cardiomyotomy with Dor Fundoplication Versus Pneumatic Dilatation for Treatment of Achalasia

10.21203/rs.3.rs-95486/v1 ◽

2020 ◽

Author(s):

Islam Khaled ◽

Gad M. Behairy ◽

Mohamed Saeed ◽

Sara Abdulaziz ◽

Leena S. Omar ◽

...

Keyword(s):

Lower Esophageal Sphincter ◽

Pneumatic Dilatation ◽

Pneumatic Dilation ◽

Dor Fundoplication ◽

Therapeutic Success ◽

Esophageal Motility Disorder ◽

Eckardt Score ◽

Esophageal Sphincter ◽

Dor’S Fundoplication

Abstract Background: Achalasia is a rare esophageal motility disorder of unknown cause. However, the best treatment modality for achalasia is controversial. Treatment consists of disruption of the lower esophageal sphincter, classically either by endoscopic pneumatic dilation or laparoscopic Heller’s myotomy combined with an anti-reﬂux procedure. The study aim was to compare laparoscopic Heller cardiomyotomy plus Dor Fundoplication with pneumatic dilatation for treatment of achalasia.Methods: In this interventional study, we included 50 adult patients diagnosed as having achalasia by performing either a barium study or by the absence of peristalsis and impaired relaxation of the lower esophageal sphincter on esophageal manometry. The patients were randomly classified into two groups according to the intervention performed: pneumatic dilation or laparoscopic Heller’s cardiomyotomy with Dor’s fundoplication(LHCM). Follow-up evaluations were performed after 8 and 16 months.Results: In total, 50 patients with achalasia and an Eckardt symptom score > 3 were managed by two different interventions according to their groups.After 16 months of follow up the height of a barium-contrast column after 5 min was significantly lower in the LHCM group than in the pneumatic dilation group. There were no other statistically significant differences in the primary or secondary outcomes(Eckardt score, lower esophageal sphincter, and quality of life) between the two groups.Conclusion: After 16 months of follow-up, the rates of therapeutic success and number of complications were nearly similar between LHCM and pneumatic dilation. We conclude that either treatment is suitable as an initial treatment for achalasia.

Download Full-text

The relationship between the interruption of the lower esophageal sphincter and relief of dysphagia after per-oral endoscopic myotomy for achalasia

Endoscopic Ultrasound ◽

10.4103/eus.eus_30_20 ◽

2020 ◽

Vol 9 (4) ◽

pp. 252 ◽

Cited By ~ 2

Author(s):

Siyu Sun ◽

Sheng Wang ◽

Xiang Liu ◽

Nan Ge ◽

Guoxin Wang ◽

...

Keyword(s):

Lower Esophageal Sphincter ◽

Per Oral Endoscopic Myotomy ◽

Endoscopic Myotomy ◽

Esophageal Sphincter ◽

Per Oral ◽

The Relationship

Download Full-text

Outcome of Pneumatic Balloon Dilatation in Achalasia Cardia

Journal of Advances in Internal Medicine ◽

10.3126/jaim.v10i1.37083 ◽

2021 ◽

Vol 10 (1) ◽

pp. 8-13

Author(s):

Shankar Baral ◽

Bidhan NIdhi Paudel ◽

Ajit Khanal ◽

Jiwan Thapa ◽

Bhuwneshwer Yadhav ◽

...

Keyword(s):

Observational Study ◽

Lower Esophageal Sphincter ◽

Poor Response ◽

Lower Esophageal Sphincter Pressure ◽

Pneumatic Dilatation ◽

Response To Treatment ◽

Sphincter Pressure ◽

Achalasia Cardia ◽

Type Iii ◽

Esophageal Sphincter

Background: Achalasia Cardia is a rare esophageal motility disorder. Among various treatment options, Pneumatic Dilatation (PD) is the most widely used and cost effective modality till date. This is the first observational study aiming to evaluate the short term response and complications of PD for Achalasia Cardia in Nepal. Methods: This prospective observational study was conducted between 28th Jan 2020 to 27th Jan 2021. It included 39 patients with Achalasia Cardia diagnosed by clinical presentation, esophagoscopy, barium esophagogram and high resolution manometry. Two patients of Type III achalasia were excluded from study. Thirty seven patients underwent pneumatic dilatation with 30 mm Rigiflex balloon (Boston Scientific, USA) for a duration of 1 minute. Response was assessed by Eckardts score at 3 and 6 months. Result: Among 39 cases (mean age= 39.03±15.017 years, 59% men), commonest was Type II Achalasia (71.8%) followed by Type I (23.1%) and Type III (5.1%). Dysphagia was present in all patients (100%), followed by weight loss (84.6%), regurgitation (79.5%) and chest pain (35.9%). Mean basal Eckardts score and Lower Esophageal Sphincter pressure of the study population was 7.81±1.24 and 24.40±6.83 respectively. Response to pneumatic dilatation was 89.2%. Eckardts score changed significantly from7.81±1.24 to 1.03±1.82 at 6 months (p<0.001). None of the patients had major complications. Younger age (23±6.377 years) had poor response to treatment, while predilatation Lower Esophageal Sphincter pressure, gender and type of achalasia did not affect the treatment outcome. Conclusion: PD is safe and effective treatment modality for Achalasia. Younger patients have poor response to treatment with Pneumatic Dilatation.

Download Full-text

Esophagus

Mayo Clinic General Surgery ◽

10.1093/med/9780190650506.003.0007 ◽

2020 ◽

pp. 91-109

Author(s):

Jad M. Abdelsattar ◽

Moustafa M. El Khatib ◽

T. K. Pandian ◽

Samuel J. Allen ◽

David R. Farley

Keyword(s):

Anastomotic Leak ◽

Lower Esophageal Sphincter ◽

Thoracic Duct ◽

Esophageal Manometry ◽

Heller Myotomy ◽

Gastroesophageal Junction ◽

Esophageal Surgery ◽

Gastric Cardia ◽

Iatrogenic Perforation ◽

Cricopharyngeus Muscle

The esophagus is a hollow muscular tube approximately 25 cm in length, extending from the cricopharyngeus muscle to the gastroesophageal junction at the gastric cardia. It is the only organ that uses peristalsis. Achalasia is defined as failure of lower esophageal sphincter relaxation with concurrent esophageal aperistalsis. Esophageal manometry is the standard for diagnosing achalasia and DES. Achalasia is managed surgically with a Heller myotomy. Esophageal surgery may result in an iatrogenic perforation, thoracic duct injury, or anastomotic leak.

Download Full-text

Esophageal manometry in the opossum.

AJP Endocrinology and Metabolism ◽

10.1152/ajpendo.1977.233.3.e152 ◽

1977 ◽

Vol 233 (3) ◽

pp. E152

Author(s):

K Schulze ◽

W J Dodds ◽

J Christensen ◽

J D Wood

Keyword(s):

Animal Model ◽

Lower Esophageal Sphincter ◽

Esophageal Manometry ◽

Lower Esophageal Sphincter Pressure ◽

Upper Esophageal Sphincter ◽

Sphincter Pressure ◽

Coronal Section ◽

Esophageal Sphincter ◽

Human Esophagus

The opossum esophagus is commonly used as an animal model of the human esophagus. We used esophageal manometry in normal animals to provide basal data about normal esophageal motor functions in vivo in this species. At rest, separate and distinct high pressure zones can be recorded at the level of the lower esophageal sphincter, diaphragmatic hiatus, aortic arch, and upper esophageal sphincter. Each zone demonstrates a characteristic pattern of pressures in the radii of the coronal section and a characteristic response to swallowing. The hiatal and aortic zones can be mistaken for the esophageal sphincters. Pressures in the sphincters fall with swallowing. Peristalsis is not bolus-dependent and occurs with 98% of swallows. Pressures generated by peristalsis are greater in the middle of the esophagus than at the ends. Values for resting lower esophageal sphincter pressure and the characteristics of peristalsis were reproducible between different studies in the same animals.

Download Full-text

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.

Download Full-text