TP6.2.14 Outcome of POEM (Per-oral endoscopic myotomy) for achalasia

Aims Laparoscopic Heller’s myotomy (LHM) has been the surgical gold standard for treatment of oesophageal achalasia. Peroral endoscopic myotomy (POEM) has been proposed as an alternative technique. The aim of this study was to assess the safety and efficacy of POEM for achalasia in our unit. Methods We have operated on 202 patients for oesophageal achalasia since 2005: 107 had LHM, 86 had POEM, and 9 had an oesophagectomy. We assessed the clinical outcome of POEM comparing pre- and postoperative endoscopic, radiologic and manometric findings, as well as Eckardt-, GERD- and DsQoL score for achalasia. All follow-up patients were offered endoscopy. Results Data were completed for the first 45 POEM patients. The average age was 45 years. 18 patients (40%) had prior achalasia treatment. The median hospital stay was 2 days (2-5). There was no mortality, but 4 patients (9%) had post-operative complications. The median follow-up was 24 months (12-49). Clinical success (Eckardt score ≤ 3) was achieved in 39 patients (87%). Thirteen patients (29%) were taking PPIs for chest symptoms. Eleven of these underwent pH studies of whom only 1 had a DeMeester score > 14.5. Of the 24 patients who had post-operative endoscopy, 40% was diagnosed with oesophagitis grade A, yet only 5 of them were symptomatic. Conclusions POEM appears to be safe and effective and warrants consideration as first-line therapy in expert achalasia centres. Longer term randomized studies comparing the outcomes of POEM with LHM and pneumatic dilatation will determine its place in the treatment of achalasia.

Third-Space Endoscopy: Recent Updates

Third space or submucosal space is a potential space which on expansion allows the endoscopist to execute a multitude of therapeutic procedures for various gastrointestinal diseases like achalasia, subepithelial tumors, Zenker’s diverticulum, and refractory gastroparesis. Third space was first utilized for performing endoscopic myotomy in cases with achalasia cardia about a decade ago. Since then, the field of submucosal endoscopy has witnessed an exponential growth. The present review focuses on recent advances in the field of third-space endoscopy. With regard to per-oral endoscopic myotomy (POEM) in achalasia cardia, several recent studies have evaluated the long-term outcomes of POEM, compared endoscopic myotomy with pneumatic dilatation (PD) and surgical myotomy, and evaluated the outcomes of short- versus long-esophageal myotomy. In addition, the utility of multiple dose antibiotic prophylaxis to prevent infections after POEM has been questioned. Overall, the results from these studies indicate that POEM is a durable treatment modality, equally effective to Heller’s myotomy and superior to PD. With regard to gastric-POEM (G-POEM), recent studies suggest only modest efficacy in cases with refractory gastroparesis. Therefore, quality studies are required to identify predictors of response to optimize the outcomes of G-POEM in these cases. Another third-space endoscopy procedure that has gained popularity is endoscopic division of septum in cases with esophageal diverticula including Zenker’s POEM and epiphrenic diverticula POEM (Z-POEM and D-POEM, respectively). The technique of diverticulotomy using the principles of submucosal endoscopy appears safe and effective in short term. Data on term outcomes are awaited and comparative trials with flexible endoscopic myotomy required. Per-rectal endoscopic myotomy (PREM) is the most recent addition to third space endoscopy procedures for the management of short-segment Hirschsprung’s disease. Limited data suggest that PREM may be a promising alternative surgery in these cases. However, quality studies with long-term follow-up are required to validate the outcomes of PREM.

Achalasia in Children—Clinical Presentation, Diagnosis, Long-Term Treatment Outcomes, and Quality of Life

Background: In spite of the introduction of peroral endoscopic myotomy (POEM), Heller myotomy (HM) remains the mainstay of treatment and the role of pneumatic dilatation (PD) is being debated. The aim of this study was to present a single-center experience in the diagnostic approach and treatment of esophageal achalasia (EA), including the long-term assessment of the QoL. Methods: Data collection was based on the retrospective analysis of clinical notes and prospective interviews with patients and their parents. Results: The study group consisted of 60 patients with EA (F: 26, M: 34), with a median age of 12.0 (1–17) years at diagnosis. The time from the first symptoms until the diagnosis was 1.0 year (0.5–2.0) and the most common were: regurgitation (91.3%), dysphagia (84.8%), and chest pain (47.8%). The diagnostic approach showed a high sensitivity for barium X-ray follow through, esophageal manometry, and endoscopy. Overall, a long-term good outcome of HM was achieved in 27 out of 37 patients (73%) and it was negatively affected by the time between the first symptoms and the diagnosis. Out of the 16 patients who underwent PD before HM, a good outcome was achieved in 14 patients (87.5%), compared to 13 out of 21 patients (62%) who only underwent HM (p = 0.22). Concomitant fundoplication was routinely performed, and 18% required post-operative endoscopic dilatation. At the end of the 12.1 (0.7–26.6)-year follow up, most patients had a good QoL, which significantly corresponded with the treatment outcomes. Conclusions: Patients suspected of EA should undergo a thorough clinical evaluation including a manometry, a barium X-ray, and an endoscopy. HM is a safe and effective treatment for achalasia and the outcome is not worsened by a preceding endoscopic PD. In most patients, HM alleviates symptoms, although an impaired QoL is common in long-term follow ups.

Resolution of symptoms after Heller's cardiomyotomy with DOR fundoplication versus endoscopic balloon dilatation in patients with achalasia Cardia at tertiary care hospital

Objective: The objective was to compare symptoms improvement following Heller's myotomy with DOR fundoplication (HM-DOR) and endoscopic pneumatic dilatation (PD) for the treatment of achalasia cardia at one year follow up. Methods: This prospective comparative study was conducted at department of upper GI and minimally invasive surgery, Civil hospital Karachi from February 2016- January 2019. All patients diagnosed as a case of achalasia cardia on esophageal manometry were included in this study. Subjects were grouped into two treatment groups: Endoscopic Pneumatic Dilatation(PD) and laparoscopic Heller's myotomy with DOR fundoplication (HM-DOR). Results: A total of 42 patients were taken into study, of which 21 patients were randomly assigned in each of the two groups (surgery and endoscopic). Mean age of patients undergoing laparoscopic Heller’s myotomy and endoscopic pneumatic balloon dilatation was 34±8.59 and 37±12.87 years respectively. Treatment success in PD group was 52% (11/21) as compared to HM-DOR group which was 76% (16/21). Post Eckardt scores reduction at 1 year follow up between PD and HM-DOR were statistically significant (p<0.001). Patient satisfaction measured by likert's scale was significantly more in the surgery group. Conclusion: The efficacy of HM appears to be greater than PD for improvement in dysphagia and overall patients satisfaction score over a 1 year follow up period. Keywords: Esophageal achalasia, Heller’s myotomy (HM), Endoscopic pneumatic dilatation (PD). Continuous...

Optional Management of Achalasia in 2021: Dilatation or Myotomy

Achalasia cardia is a primary motility disorder of the esophagus, defined by lack of normal esophageal peristalsis along with inadequate relaxation of lower esophageal sphincter . The mainstay of management in achalasia includes pneumatic dilatation, Heller’s myotomy and peroral endoscopic myotomy (POEM). Pneumatic dilatation and Heller’s myotomy have gained maturity over several decades. The current best practice with regard to pneumatic dilatation is graded and on-demand dilatation in appropriately selected cases with type I and II achalasia. Laparoscopic Heller’s myotomy plus partial fundoplication is minimally invasive with reduced postoperative reflux and has virtually replaced open Heller’s myotomy with or without fundoplication. The subtyping of achalasia using high-resolution manometry bears prognostic significance and may help in choosing appropriate therapeutic modality in these patients. Since all the three modalities are effective for type I and II achalasia, the choice among these depends on the availability, expertise, and patient’s preferences. On the other hand, POEM is more effective than pneumatic dilatation and Heller’s myotomy and, therefore, preferred in type III achalasia. Although POEM is effective across the spectrum of esophageal motility disorders, the incidence of gastroesophageal reflux is high and needs to be considered while choosing among various options in these patients. In cases with failed POEM, redo POEM appears to be effective in alleviating symptoms.

Outcome of Pneumatic Balloon Dilatation in Achalasia Cardia

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.

Advances and caveats in modern achalasia management

Achalasia is a rare esophageal motility disorder characterized by the incomplete relaxation of the lower esophageal sphincter (LES) and impaired peristaltic activity. The advent of high-resolution manometry (HRM) and the rapidly evolving role of therapeutic endoscopy have revolutionized the approach to the diagnosis and management of achalasia patients in the last decade. With advances in HRM technology and methodology, fluoroscopy and EndoFlip, achalasia can be differentiated into therapeutically meaningful phenotypes with a high degree of accuracy. Further, the newest treatment option, per-oral endoscopic myotomy (POEM), has become a staple therapy following the last 10 years of experience, and recent randomized trials appear to show no difference between POEM, graded pneumatic dilatation and surgical Heller myotomy in terms of short- and long-term efficacy or complication rate. On the other hand, how treatment outcomes are measured as well as the risk of reflux following therapy remain areas of contention. This review aims to summarize the recent advancements in achalasia testing and therapy, describes the recent randomized clinical trials as well as their potential setbacks, and touches on the future of personalizing achalasia treatment.

Achalasia Cardia: A Comprehensive Review

Achalasia cardia is the best characterised oesophageal motility disorder. It is characterised by progressive ganglion cell degeneration in the oesophageal myenteric plexus, which results in impaired lower oesophageal sphincter (LES) relaxation upon swallowing and aperistalsis in the distal smooth muscle segment of the oesophagus. The usual presenting features are dysphagia to both liquids and solids from onset, regurgitation of undigested food, retrosternal pain, heartburn, and weight loss. Initial investigations include upper gastrointestinal (GI) endoscopy and timed barium oesophagogram, whereas high resolution manometry is diagnostic. Therapy in achalasia cardia is directed towards biochemical or mechanical reduction in LES pressures. If candidates are fit for surgery, pneumatic dilatation, peroral endoscopic myotomy, and laparoscopic Heller’s myotomy are the mainstays of therapy that act by mechanical disruption of LES. On the other hand, botulinum toxin and pharmacotherapy (nitrates and calcium channel blockers) act by biochemical reduction of LES and are reserved for surgically unfit patients with limited life expectancy because of their short-lived efficacy. Oesophagectomy is reserved for treating refractory longstanding cases, who have previously failed multiple therapies.

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

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.