Introduction
High-resolution esophageal manometry (HREM) is essential in characterizing achalasia subtype and the extent of affected segment to plan the myotomy starting point during per-oral ...endoscopic myotomy (POEM). However, evidence is lacking that efficacy is improved by tailoring myotomy to the length of the spastic segment on HREM. We sought to investigate whether utilizing HREM to dictate myotomy length in POEM impacts postoperative outcomes.
Methods
Comparative analysis of HREM-tailored to non-tailored patients from a prospectively collected database of all POEMs at our institution January 2011 through July 2017. A tailored myotomy is defined as extending at least the length of the diseased segment, as initially measured on HREM.
Results
Forty patients were included (11 tailored versus 29 non-tailored). There were no differences in patient age (
p
= 0.6491) or BMI (
p
= 0.0677). Myotomy lengths were significantly longer for tailored compared to non-tailored overall (16.6 ± 2.2 versus 13.5 ± 1.8;
p
< 0.0001), and for only type III achalasia (15.9 ± 2.4 versus 12.7 ± 1.2;
p
= 0.0453), likely due to more proximal starting position in tailored cases (26.0 ± 2.2 versus 30.0 ± 2.7;
p
< 0.0001). Procedure success (Eckardt < 3) was equivalent across groups overall (
p
= 0.5558), as was postoperative Eckardt score (0.2 ± 0.4 versus 0.8 ± 2.3;
p
= 0.4004). Postoperative Eckardt score was significantly improved in the tailored group versus non-tailored for type III only (0.2 ± 0.4 versus 1.3 ± 1.5;
p
= 0.0435). A linear correlation was seen between increased length and greater improvement in Eckardt score in the non-tailored group (
p
= 0.0170).
Conclusions
Using HREM to inform surgeons of the proximal location of the diseased segment resulted in longer myotomies, spanning the entire affected segment in type III achalasia, and in lower postoperative Eckardt scores. Longer myotomy length is often more easily achieved with POEM than with Heller myotomy, which raises the question of whether POEM results in better outcomes for type III achalasia, as types I and II do not generally have measurable spastic segments.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Achalasia is an esophageal motility disorder with three subtypes based on manometry that can treated with per-oral endoscopic myotomy (POEM). With the advent of impedance planimetry (EndoFLIP®), we ...hypothesized the three achalasia subtypes would have different pre-POEM EndoFLIP® diameter and distensibility index (DI) measurements but would be similar after POEM.BACKGROUNDAchalasia is an esophageal motility disorder with three subtypes based on manometry that can treated with per-oral endoscopic myotomy (POEM). With the advent of impedance planimetry (EndoFLIP®), we hypothesized the three achalasia subtypes would have different pre-POEM EndoFLIP® diameter and distensibility index (DI) measurements but would be similar after POEM.A single-institution, retrospective review of consecutive POEM cases by a single surgeon-endoscopist team from 04/07/2017 to 08/28/2023. Patients with a diagnosis of achalasia were stratified into type 1, 2, or 3 based on pre-POEM manometry. Patient characteristics, Eckardt scores, and pre-and-post-POEM diameter and DI were compared by subtype with descriptive, univariate, and multivariable linear regression statistics.METHODSA single-institution, retrospective review of consecutive POEM cases by a single surgeon-endoscopist team from 04/07/2017 to 08/28/2023. Patients with a diagnosis of achalasia were stratified into type 1, 2, or 3 based on pre-POEM manometry. Patient characteristics, Eckardt scores, and pre-and-post-POEM diameter and DI were compared by subtype with descriptive, univariate, and multivariable linear regression statistics.Sixty-four patients met inclusion criteria, of whom 9(14.1%) had Type 1, 36(56.3%) had Type 2, and 19(29.7%) had Type 3. There were no differences between Types with respect to median pre-POEM Eckardt scores (9IQR:7-9) vs. 8IQR:6-9 vs. 7IQR:5-8, p = 0.148), median post-POEM Eckardt scores (0IQR:0-1 vs. 0IQR:0-0 vs. 0IQR0-0.5, p = 0.112). EndoFLIP® data revealed variation in median pre-POEM diameter and DI between Subtypes (6.9IQR:6-8.5 vs. 5.5IQR:5-6.8 vs. 5IQR:5-6.1, p = 0.025 and 1.8IQR:1.3-3.2 vs. 0.9IQR:0.6-1.6 vs. 0.6IQR:0.5-0.8, p = 0.003, respectively), but not in the change in diameter or DI post-POEM (5.1IQR:4.3-5.9 vs. 5.1IQR:4.1-7.1 vs. 5.9IQR:5-6.4, p = 0.217 and 3.9IQR:2.5-4.7 vs. 3.4IQR:2.4-4.7 vs. 2.7IQR:2.3-3.7, p = 0.461, respectively). However, after adjusting for potentially confounding factors, pre- or post-POEM diameter and DI did not demonstrate statistically significant differences among subtypes.RESULTSSixty-four patients met inclusion criteria, of whom 9(14.1%) had Type 1, 36(56.3%) had Type 2, and 19(29.7%) had Type 3. There were no differences between Types with respect to median pre-POEM Eckardt scores (9IQR:7-9) vs. 8IQR:6-9 vs. 7IQR:5-8, p = 0.148), median post-POEM Eckardt scores (0IQR:0-1 vs. 0IQR:0-0 vs. 0IQR0-0.5, p = 0.112). EndoFLIP® data revealed variation in median pre-POEM diameter and DI between Subtypes (6.9IQR:6-8.5 vs. 5.5IQR:5-6.8 vs. 5IQR:5-6.1, p = 0.025 and 1.8IQR:1.3-3.2 vs. 0.9IQR:0.6-1.6 vs. 0.6IQR:0.5-0.8, p = 0.003, respectively), but not in the change in diameter or DI post-POEM (5.1IQR:4.3-5.9 vs. 5.1IQR:4.1-7.1 vs. 5.9IQR:5-6.4, p = 0.217 and 3.9IQR:2.5-4.7 vs. 3.4IQR:2.4-4.7 vs. 2.7IQR:2.3-3.7, p = 0.461, respectively). However, after adjusting for potentially confounding factors, pre- or post-POEM diameter and DI did not demonstrate statistically significant differences among subtypes.Achalasia subtypes did not demonstrate different pre-POEM diameters or DI as measured by EndoFLIP® nor are there differences after POEM completion. While achalasia subtypes may have slightly different pathophysiology based on manometry findings, similar pre- and post-POEM impedance planimetry findings, along with similar Eckardt scores, support the use of POEM in the treatment of any achalasia subtype.CONCLUSIONSAchalasia subtypes did not demonstrate different pre-POEM diameters or DI as measured by EndoFLIP® nor are there differences after POEM completion. While achalasia subtypes may have slightly different pathophysiology based on manometry findings, similar pre- and post-POEM impedance planimetry findings, along with similar Eckardt scores, support the use of POEM in the treatment of any achalasia subtype.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Achalasia is a rare disorder of esophageal motility that induces progressive intolerance to oral intake. Other esophageal dysmotility disorders include esophagogastric junction outflow ...obstruction (EGJOO), distal esophageal spasm (DES), hypercontractile esophagus (HE), and other minor disorders of peristalsis (MDP) and can present similarly to achalasia despite different pathophysiologies. Prior studies have demonstrated the safety and efficacy of POEM in the treatment of achalasia, but little is reported regarding POEM’s role in treating non-achalasia esophageal dysmotility disorders (NAEDD). This study aims to assess the safety and efficacy of POEM in the treatment of NAEDD.
Study design
This is a retrospective review of consecutive POEM cases from June 1, 2011, to February 1, 2021. NAEDD were characterized according to the Chicago classification. Primary outcome measure was the resolution of preoperative symptoms. Secondary outcomes include preoperative diagnosis, myotomy length, conversion to laparoscopic or open procedure, operative time, and length of stay (LOS). Technical success was defined as the completion of an 8 cm myotomy including the esophagogastric junction (EGJ) and extending 2 cm distal to the EGJ. Clinical success was defined as a postoperative Eckardt score ≤ 3.
Results
Of 124 cases of POEM performed during the study period, 17 were performed for NAEDD. Technical success was achieved in all 17 patients (100%). Of the fifteen patients that had documented postoperative Eckardt scores, 13 were ≤ 3, achieving a clinical success rate of 87%. Subgroup analysis (HE/MDP/DES vs. EGJOO) showed no significant differences in the preoperative or postoperative Eckardt scores between groups, and both groups demonstrated a significant decrease in Eckardt scores after POEM. No cases were aborted for technical or clinical reasons, and there were no adverse outcomes.
Conclusion
POEM is a safe and efficacious treatment modality for NAEDD. Further work is needed to develop optimal treatment strategies for this complex group of diseases.
Graphical abstract
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
It is thought the therapeutic benefit of per-oral endoscopic myotomy (POEM) in the treatment of esophageal dysmotility disorders is from longitudinal myotomy creation, but it is unknown if ...the submucosa contributes to the pathophysiology. This study investigates if submucosal tunnel (SMT) dissection alone contributes to POEM’s luminal changes as measured by EndoFLIP.
Methods
A single-center, retrospective review of consecutive POEM cases from June 1, 2011 to September 1, 2022 with intraoperative luminal diameter and distensibility index (DI) data as measured by EndoFLIP. Patients with diagnoses of achalasia or esophagogastric junction outflow obstruction were grouped by those with pre-SMT and post-myotomy measurements (Group 1) and those with a third measurement post-SMT dissection (Group 2). Outcomes and EndoFLIP data were analyzed using descriptive and univariate statistics.
Results
There were 66 patients identified, of whom 57 (86.4%) had achalasia, 32 (48.5%) were female, and median pre-POEM Eckardt score was 7 IQR: 6–9. There were 42 (64%) patients in Group 1, and 24 (36%) patients in Group 2, with no differences in baseline characteristics. In Group 2, SMT dissection changed luminal diameter by 2.15 IQR: 1.75–3.28cm, which comprised 38% of the median 5.6 IQR: 4.25–6.3cm diameter of complete POEM change. Similarly, the median post-SMT change in DI of 1 IQR: 0.5–1.2units comprised 30% of the median 3.35 2.4–3.98units overall change in DI. Post-SMT diameters and DI were both significantly lower than the full POEM.
Conclusions
Esophageal diameter and DI are significantly affected by SMT dissection alone, though not equaling the magnitude of diameter or DI changes from full POEM. This suggests that the submucosa does play a role in achalasia, presenting a future target for refining POEM and developing alternative treatment strategies.
Graphical abstract
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Per-oral endoscopic myotomy (POEM) has become an accepted minimally invasive alternative to Heller myotomy for the treatment of achalasia and other disorders of esophageal dysmotility. One ...associated adverse event is the inadvertent creation of capnoperitoneum. A proposed mechanism is that extension of the submucosal tunnel below the esophageal hiatus and onto the gastric wall leads to transmural perforation. We hypothesized that the use of impedance planimetry with the endoscopic functional luminal imaging probe (EndoFLIP) more accurately identifies the esophagogastric junction and helps to better define the myotomy’s ideal limits, thus lowering the incidence of inadvertent capnoperitoneum.
Methods
This is a single-center, retrospective review of consecutive POEM cases from 06/11/2011 to 08/08/2022, with EndoFLIP introduced in 2017. Patient and procedural characteristics, including the incidence of clinically significant capnoperitoneum and decompression, were analyzed using univariate and multivariable linear regression statistics.
Results
There were 140 POEM cases identified, 74 (52.9%) of which used EndoFLIP. Clinically significant capnoperitoneum was encountered in 26 (18.6%) cases, with no differences in patient characteristics between those who had capnoperitoneum and those who did not. There was a decreased incidence of capnoperitoneum in cases using EndoFLIP compared to those without (
n
= 6, 23% vs
n
= 20, 77%,
p
= 0.001), with zero instances in the final 56 cases. After adjusting for potentially confounding factors, EndoFLIP use was associated with a − 15.93% (95% confidence interval − 30.68%, − 1.18%) decrease in procedure duration.
Conclusions
The routine use of EndoFLIP during POEM was associated with decreased incidence of clinically significant capnoperitoneum, potentially due to improved myotomy tailoring and decreased duration of insufflation with shorter procedure times.
Graphical abstract
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
7.
Pancreatic and biliary stents Pfau, Patrick R., MD; Pleskow, Douglas K., MD; Banerjee, Subhas, MD ...
Gastrointestinal endoscopy,
03/2013, Volume:
77, Issue:
3
Journal Article
Peer reviewed
Biliary and pancreatic stents are used in a variety of benign and malignant conditions including strictures and leaks and in the prevention of post-ERCP pancreatitis.Both plastic and metal stents are ...safe, effective, and easy to use. SEMSs have traditionally been used for inoperable malignant disease. Covered SEMSs are now being evaluated for use in benign disease. Increasing the duration of patency of both plastic and metal stents remains an important area for future research.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
8.
Per-oral endoscopic myotomy white paper summary Stavropoulos, Stavros N., MD; Desilets, David J., MD; Fuchs, Karl-Hermann, MD ...
Gastrointestinal endoscopy,
07/2014, Volume:
80, Issue:
1
Journal Article
Peer reviewed
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Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background The Wallstent has remained the industry standard for biliary self-expanding metal stents (SEMSs). Recently, stents of differing designs, compositions, and diameters have been developed. ...Objective To compare the new nitinol 6-mm and 10-mm Zilver stents with the 10-mm stainless steel Wallstent and determine the mechanism of obstruction. Design Randomized, prospective, controlled study. Setting Nine centers experienced in SEMS placement during ERCP. Patients A total of 241 patients presenting between September 2003 and December 2005 with unresectable malignant biliary strictures at least 2 cm distal to the bifurcation. Main Outcome Measurement Stent occlusions requiring reintervention and death. Results At interim analysis, a significant increase in occlusions was noted in the 6-mm Zilver group at the P = .04 level, resulting in arm closure but continued follow-up. Final study arms were 64, 88, and 89 patients receiving a 6-mm Zilver, 10-mm Zilver, and 10-mm Wallstent, respectively. Stent occlusions occurred in 25 (39.1%) of the patients in the 6-mm Zilver arm, 21 (23.9%) of the patients in the 10-mm Zilver arm, and 19 (21.4%) of the patients in the 10-mm Wallstent arm ( P = .02). The mean number of days of stent patency were 142.9, 185.8, and 186.7, respectively ( P = .057). No differences were noted in secondary endpoints, and the study was ended at the 95% censored study endpoints. Biopsy specimens of ingrowth occlusive tissue revealed that 56% were caused by benign epithelial hyperplasia. Conclusions SEMS occlusions were much more frequent with a 6-mm diameter SEMS and equivalent in the two 10-mm arms despite major differences in stent design, material, and expansion, suggesting that diameter is the critical feature. Malignant tumor ingrowth produced only a minority of the documented occlusions.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
