Influence of Lower Esophageal Sphincter Manometric Characteristics on the Technical Success of Peroral Endoscopic Myotomy in Achalasia: A Prospective Cohort Study

A lung abscess is defined as an infectious process with suppuration and cavitation. Lung abscess is more frequent in patients predisposed to aspiration due to achalasia. In the pre-antibiotic era, the mortality of patients with lung abscess was higher whereas today with the appropriate antibiotic therapy we can save these patients. The emergence of antibiotic-resistant strains is becoming a concern in such patients. Achalasia is an esophageal motility disorder characterized by loss of peristalsis and insufficient relaxation of the lower esophageal sphincter (LES). Per-oral endoscopic myotomy (POEM) should be considered the preferred treatment for achalasia because of its low invasiveness and high efficacy. The authors report a challenging case of a woman with achalasia, dysphagia, cough, weight loss who progressed to lung abscess caused by Pseudomonas aeruginosa and Klebsiella pneumoniae treated with antibiotics and POEM. This case report contributes to expanding knowledge on the management of lung abscess and achalasia, highlighting the importance of treatment with antibiotic therapy and POEM. Early treatment contributes to improving outcome and cutting socio-economic costs. Key facts to ameliorate to improve prognosis and length of hospital admission could be a swifter diagnosis and consensus on the antibiotic therapy.

Management of recurrent symptoms after per-oral endoscopic myotomy in achalasia

The recent development of per oral endoscopic myotomy (POEM) has been a game changer in the management of patients with achalasia. However, approximately 1 in 10 patients will not experience clinical success. The aim of this mini-review is to describe the current state of knowledge about the risk factors associated with POEM failure for the treatment of achalasia. Suspected risk factors are detailed into pre-, intra-, and post-procedural factors and put into perspective. Pre-procedural factors have been described, such as pre-treatment Eckardt score, previous treatments for achalasia, sigmoid type esophagus, significant esophageal dilatation, non-type II achalasia, young age and long duration of symptoms. An intra-procedural factor, mucosal injury during POEM, has also been associated with POEM failure. The occurrence of post-POEM GERD was identified as a controversial post-procedural factor associated with failure. The presumed mechanisms of POEM failure are incomplete myotomy or ineffective LES disruption, as confirmed by high-resolution manometry. However, when manometry confirms a significant decrease in LES pressure, it is likely that either impaired peristalsis or a morphologic abnormality such as extreme esophageal dilatation or severe tortuosity, which are not treated by POEM, should be suspected. Notably, a recently described adverse effect of POEM is the formation of a pseudo-diverticulum at the site of the myotomy (blown out myotomy). We finally stress the importance of performing a complete workup in case of POEM failure as different mechanisms of POEM failure should lead to different management.

Outcomes of laparoscopic Heller myotomy in obese patients with achalasia are suboptimal along with the increased risk of gastroesophageal reflux disease (GERD). The impact of obesity on treatment success and GERD after peroral endoscopic myotomy (POEM) are not well known. Hence, our study aims were to compare the clinical outcomes and rates of GERD after POEM in nonobese versus obese patients with achalasia. Chart review of all achalasia patients who underwent POEM at our institution between April 2014 and June 2018. Patients with timed barium esophagram (TBE) and high-resolution esophageal manometry (HREM) before POEM along with post-POEM TBE, HREM, and esophageal pH study were included. Patients were categorized into 2 groups, nonobese (body mass index <30 kg/m) and obese (body mass index ≥30 kg/m). Patient demographics, TBE, HREM, pH study findings, and Eckardt scores were compared between the 2 groups. A total of 89 patients (46 nonobese; 43 obese) met the study criteria. There were no significant differences in age, gender, achalasia subtype, operative time, length of stay and complication rates between the 2 groups. Treatment success (Eckardt score ≤3) was similar in both groups (97.7% nonobese vs. 92.7% obese, P=0.35). Abnormal DeMeester scores on pH study (>14.72) were similar in nonobese and obese patients (58.7% vs. 46.5%, P=0.25). Symptomatic GERD was also similar in both groups (17.8% in nonobese vs. 20% in obese, P=0.79). POEM is an equally safe and effective treatment option for both nonobese and obese patients with achalasia in the short-term. Interestingly, POEM does not lead to higher rates of GERD in obese compared with nonobese patients.

Clinical Practice Update: The Use of Per-Oral Endoscopic Myotomy in Achalasia: Expert Review and Best Practice Advice From the AGA Institute

Objective. To evaluate the perioperative period and results of peroral endoscopic myotomy (POEM) in patients with achalasia.Material and methods. During the period 2017–2023, POEM was performed in 150 patients aged 15 to 80 years (mean age 53 ± 15,4 years) (94 women, 56 men). The duration of the disease ranged from 6 months to 40 years (mean value 5,8 ± 6,67 years). The average dysphagia value according to the Eckadt scale before surgery was 11.12±0.75.Results. Technical difficulties with tunnel formation due to the presence of fibrosis of varying severity were noted in 24 (16.1 %) patients. The presence of fibrosis resulted in a slight increase in the duration of the intervention at the tunnel formation stage 85.0 (80.0; 120.0) minutes versus 95 (80.0; 120.0) (p=0.87554). Adverse events during the procedure were observed in 5 (3.33 %) patients: no differences were noted between patients with stages II–III and IV of the disease (3 versus 2) (p=0.22). No differences were found in the frequency of complications between patients with or without fibrosis in the submucosal layer (p=0.1922). Oral food and fluid intake were restored in all patients. The Eckadt scale score ranged from 0 to 4 (mean 1.48±0.98). There was no statistically significant difference in the frequency of esophagitis in patients with stages II–III of the disease and stage IV (26 versus 5) (p=0.49).Conclusion. POEM in patients with esophageal achalasia is an effective intervention, regardless of the stage of the disease with a low frequency of intraand postoperative complications. Previous treatment is not a predictor of the occurrence of fibrosis in the submucosal layer, does not affect the frequency of intraoperative complications and does not significantly increase the duration of the intervention. The stage of the disease does not affect the frequency of intraoperative complications and erosive esophagitis.

Symptomatic epiphrenic diverticula are mostly treated surgically with laparoscopic diverticulectomy, myotomy and anterior fundoplication. However, in case the patient does not agree with surgical therapy or is contraindicated, there are limited ways of alternative treatment. We present a case report of a 72-year-old female patient with severe dysphagia, regurgitation, paroxysmal cough, weight loss and malnutrition who was diagnosed with achalasia and large epiphrenic diverticulum. She did not give consent to the proposed surgical treatment. Alternatively, peroral endoscopic myotomy (POEM) was carried out. In one-year follow up, we observed complete symptom resolution, significant weight gain, improvement of nutritional status and no complications. We suggest that POEM could serve as an effective and safe alternative treatment for patients with achalasia and esophageal epiphrenic diverticula.

Background/Aims:This retrospective single-center study aimed to assess the safety of early feeding in patients who met certain criteria following peroral endoscopic myotomy (POEM).Materials and Methods:Data from 100 patients who underwent POEM at our center between January and December 2022 were collected. Early feeding was defined as the introduction of clear liquid foods at 4 hours post procedure. At 4 and 24 hours, the pain was rated using the visual analog scale (VAS) in all patients. Patients without intraoperative complications (pneumoperitoneum requiring needle drainage, severe arterial bleeding requiring the use of hemostatic forceps, severe mucosal injury) and severe pain (VAS score > 6) and nausea-vomiting at the fourth postoperative hour were given the early feeding approach. In patients who did not meet these requirements, enteral feeding was initiated after 24 hours (late feeding).Results:Among the 100 patients, 50 patients were categorized early feeding. No patients had a control esophagogram. In the early and late enteral feeding groups, VAS scores were 4 (0-6) and 6 (1-8) (P < .001) at 4 hours and 1 (0-3) and 1 (0-6) (P = .043) at 24 hours, respectively. No severe complications were developed after early feeding. The median hospital stay in the early feeding group was 1 (1-3) day. There was no emergency readmission in any of early feeding patients.Conclusion:Our study showed early feeding following POEM can be begun in achalasia patients who do not have intraoperative complications, severe pain, or nausea/vomiting.

The relationship between cardiac muscularis propria and clinical outcomes of peroral endoscopic myotomy in achalasia

Symptom scales for achalasia after per-oral endoscopic myotomy (POEM) are lacking. This study aimed to propose a new scale based on the conventional Eckardt score (c-ES) and evaluate persistent symptoms that impair patients' quality of life (QOL) post-POEM. Dysphagia, regurgitation, and chest pain frequencies were assessed using a 6-point scale modified-ES (m-ES) after POEM, with "occasional" symptoms on the c-ES further subdivided into three-period categories on m-ES. Symptom severity was further evaluated using a 5-point scale ranging from 1 to 5 points, with a score ≥ 3 points defined as persistent symptoms impairing QOL. We analyzed the correlation between the m-ES and severity score, diagnostic performance of the m-ES for persistent symptoms, and overlaps between each residual symptom. Overall, 536 patients (median follow-up period, 2.9years) post-POEM were included in this multicenter study. Significant correlations were observed between the m-ES and severity scores for dysphagia (r = 0.67, p < 0.01), regurgitation (r = 0.73, p < 0.01), and chest pain (r = 0.85, p < 0.01). Twenty-six patients (4.9%) had persistent symptoms post-POEM, and 23 of them had m-ES-specific symptom frequency ≥ once a month, which was determined as the optimal frequency threshold for screening persistent symptoms. The total m-ES predicted persistent symptoms more accurately than the total c-ES (area under the curve: 0.95 vs. 0.79, p < 0.01). Furthermore, dysphagia and chest pain were the major residual symptoms post-POEM covering 91.4% of regurgitation. The new post-POEM scale successfully evaluated the QOL-based patient symptom severities. Our study implied the possibility of a simpler scale using residual dysphagia and chest pain.

Tu1523 Per-Oral Endoscopic Myotomy in Achalasia: Experience From a Tertiary Reference Center in Turkey

Patients with reflux-related esophageal stricture after POEM were clinically similar to patients with recurrent achalasia, such as dysphagia and regurgitation. This study aimed to compare the clinical differences between reflux-related stricture and recurrent achalasia, as well as to evaluate the efficacy and safety of endoscopic treatment for reflux-related stricture. From June 2015 to January 2023, we reviewed 1946 patients with achalasia who underwent POEM. Among these, data from 42 patients with reflux-related strictures and 151 patients with recurrence after POEM were collected. After propensity score matching (PSM), baseline characteristics and procedure-related parameters were retrospectively evaluated. With similar baseline characteristics between the two groups after PSM, the reflux-related stricture group showed higher rates of regurgitation, heartburn, mucosal edema, mucosal ulcer, and grade C/D esophagitis compared with the recurrence group. The mean LES resting pressure on high-resolution manometry (HRM) was lower in the reflux-related stricture than in the recurrence group (2.8 ± 5.3 vs. 21.1 ± 16.7 mmHg, p = 0.014). Nine endoscopic radial incisions (ERI), eight endoscopic balloon dilations (EBD), and 25 proton pump inhibitors were administered in patients with reflux-related esophageal stricture after POEM. At follow-up of 24 months, the rate of re-stricture was similar between the ERI and EBD groups (33.3% vs. 50.0%, p = 0.637). Multivariate analysis revealed submucosal fibrosis was associated with reflux-related stricture after POEM (OR 2.367, 95% CI 1.274-5.618, p = 0.041). Despite symptomatic similarities, reflux-related stricture and recurrent achalasia after POEM could be distinguished by symptoms, HRM, and endoscopic presentations. Furthermore, ERI and EBD are safe and effective treatments for reflux-related esophageal stricture after POEM.

Tu2053 Management of Recurrent Symptoms After PerOral Endoscopic Myotomy in Achalasia

Clinical Success and Correlation of Eckardt Scores with Barium Esophagram After Peroral Endoscopic Myotomy in Achalasia

Su1093 “Esophageal Remodeling” After Peroral Endoscopic Myotomy in Achalasia