Achalasia Type Research Articles

Opioid Treatment and Excessive Alcohol Consumption Are Associated With Esophagogastric Junction Disorders.

Background/AimsThe influence of external factors such as opioids and alcohol has been extensively investigated for various segments of the gastrointestinal tract. However, the association between their use and the development of esophagogastric junction outflow obstruction disorders (EGJOODs) is unknown. Therefore, the aim of this study is to analyze prevalence and clinical relevance of opioids and alcohol intake in patients with EGJOODs.MethodsIn this single-center, retrospective study, we reviewed clinical and pharmacological data of 375 consecutive patients who had undergone high resolution impedance manometry for EGJOODs. EGJOODs were classified according to the Chicago classification version 3.0 and to recently published normal values for test meals. Demographics, manometric data, and symptoms were compared between different groups using Pearson’s chi-squared test, Fisher’s exact test, and multivariate analysis. A P < 0.05 was considered significant.ResultsEGJOOD was found in 30.7% (115/375) of all analyzed patients. The prevalence of opioids (14.8% vs 4.2%, P = 0.026) was significantly higher in patients with EGJOODs compared to patients without EGJOODs. Additionally, excessive alcohol consumption (12.2% vs 3.5%, P = 0.011) was associated with EGJOODs. Excessive alcohol consumption was especially frequent in the non-achalasia esophagogastric junction outflow obstruction subgroup (16.2%) and opioid use in the achalasia type III subgroup (20.0%).ConclusionsWe found a significant association between EGJOODs and opioid as well as excessive alcohol consumption. This underlines the importance of detailed history taking regarding medication and ethanol consumption in patients with dysphagia. Further prospective studies on mechanisms undelaying esophagogastric junction dysfunction due to opioids or alcohol are warranted.

Chronic daily opioid exposure is associated with dysphagia, esophageal outflow obstruction, and disordered peristalsis.

Opioid receptors are present in the esophagus, and chronic opioid therapy may be associated with esophageal dysfunction. Given the current opioid epidemic in the United States, the potential contribution of opioids to esophageal dysmotility is important from both public health and patient care perspectives.Therefore our aim is toinvestigate the potentialcontribution of opioids to dysphagia and the prevalence of major motor disorders in patients undergoing manometric evaluation. The anonymized electronic medical records of patients linked to their de-identified high-resolution manometry (HRM) studies were reviewed. The patients were grouped based on their opioid exposure history at the time of HRM: opioid-naïve and chronic daily users. The oral morphine milligram equivalent daily dose (MMED) of opioids was computed. KEYRESULTS: 10% of patients referred for esophageal HRM were taking opioid analgesics on a chronic daily basis, and they had a significantly higher prevalence of dysphagia than their opioid-naïve counterparts. The chronic daily opioid users displayed a significantly higher prevalence of achalasia type 3 (ACH3) and esophagogastric junction outflow obstruction (EGJOO) motility phenotypes. The MMED of opioids was a significant predictor of esophageal pressure metrics and motility diagnoses (P<0.0001). Chronic daily opioid intake is associated with impaired deglutitive LES relaxation and disorganized peristaltic sequence. While a minority of patients on chronic daily opioid therapy present with major esophageal motor disorders, they comprise nearly half of ACH3 and a third of EGJOO motility phenotypes.

Bridging the Gap between Advancements in the Evolution of Diagnosis and Treatment towards Better Outcomes in Achalasia.

Over the past few decades, there was an encouraging breakthrough in bridging the gap between advancements in the evolution of diagnosis and treatment towards a better outcome in achalasia. The purpose of this review is to provide updated knowledge on how the current evidence has bridged the gap between advancements in the evolution of diagnosis and treatment of esophageal achalasia. The advent of high-resolution manometry and standardization based on the Chicago classification has increased early recognition of the disease. These 3 clinical subtypes of achalasia can predict the outcomes of patients, and the introduction of POEM has revolutionized the choice of treatment. Previous evidence has shown that laparoscopic Heller myotomy (LHM) and anterior fundoplication were considered the most durable treatments for achalasia. Based on the current evidence, POEM has been evolving as a promising strategy and is effective against all 3 types of achalasia, but the efficacy of POEM is based on short- and medium-term outcome studies from a limited number of centers. Types I and II achalasia respond well to POEM, LHM, and PD, while most studies have shown that type III achalasia responds better to POEM than to LHM and PD. In general, among the 3 subtypes of achalasia, type II achalasia has the most favorable outcomes after medical or surgical therapies. The long-term efficacy of POEM is still unknown. The novel ENDOFLIP measures the changes in intraoperative esophagogastric junction dispensability, which enables a quantitative assessment of luminal patency and sphincter distension; however, this technology is in its infancy with little data to date supporting its intraoperative use. In the future, identifying immunomodulatory drugs and the advent of stem cell therapeutic treatments, including theoretically transplanting neuronal stem cells, may achieve a functional cure. In summary, it is important to identify the clinical subtype of achalasia to initiate target therapy for these patients.

First genotype-phenotype study reveals HLA-DQβ1 insertion heterogeneity in high-resolution manometry achalasia subtypes.

Achalasia is a primary oesophageal motility disorder. Although aetiology remains mainly unknown, a genetic risk variant, rs28688207 in HLA-DQB1, showed strong achalasia association suggesting involvement of immune-mediated processes in the pathogenesis. High-resolution manometry recognises three types of achalasia. The aim of our study was to perform the first genotype-phenotype analysis investigating the frequency of rs28688207 across the high-resolution manometry subtypes. This was a cross-sectional retrospective study. Achalasia patients from tertiary centres in the Czech Republic (n = 163), Germany (n = 114), Greece (n = 70) and controls were enrolled. All subjects were genotyped for the rs28688207 insertion. The Kruskal-Wallis test was used for the genotype-phenotype analysis. A total of 347 achalasia patients (type I - 89, II - 210, III - 48) were included. The overall frequency of the rs28688207 was 10.3%. The distribution of the insertion was significantly different across the high-resolution manometry subtypes (p = 0.038), being most prevalent in type I (14.6%), followed by type II (9.5%) and III (6.3%). The frequency of the HLA-DQB1 insertion differs among high-resolution manometry achalasia subtypes. The insertion is most prevalent in type I, suggesting that immune-mediated mechanisms triggered by the insertion may play a more prominent role in the pathogenesis of this subtype.

Emerging Issues in Esophageal Motility Diseases

With the advances in technology and medical knowledge, new diseases are being identified and investigated. Esophageal motility disorders have been re-defined using high-resolution manometry and their pathogenesis are being better understood. The use of opioid analgesics is increasing worldwide, particularly in the United States, but their chronic use can cause opioid-induced esophageal dysfunction, which mimics spastic motor disorders, including achalasia type 3 or 2 and esophagogastric junction outflow obstruction. Eosinophilic esophagitis is identified by eosinophilic infiltration confirmed on a pathological examination. The condition is often associated with esophageal motility abnormalities. On the other hand, recent studies have suggested that muscle-predominant eosinophilic infiltration, eosinophilic esophageal myositis, might manifest as spastic motor disorders, including achalasia or jackhammer esophagus. Lymphocytic esophagitis is an unusual esophageal condition, which is confirmed by the increased number of lymphocytes in the esophageal epithelium. Although several reports have supported the existence of lymphocytic esophagitis, it is still unclear whether lymphocytic esophagitis is a distinct disease entity or another spectrum of other esophageal diseases, such as gastroesophageal reflux disease or eosinophilic esophagitis. This review presents evidence and reports on the emerging issues in esophageal motility disorders, including opioid-induced esophageal dysfunction, eosinophilic esophagitis with eosinophilic esophageal myositis, and lymphocytic esophagitis.

Achalasia in a child confirmed by high-resolution manometry

Achalasia is a primary motor disease of the esophagus. It is rare in the pediatric population; fewer than 5% of patients are below 15 years of age. Progressive dysphagia is the most common presentation in adults. The clinical presentation in children does differ from adults. The various clinical features are nocturnal cough, recurrent pneumonia, vomiting, and feeding difficulties. The symptoms of achalasia may mimic gastroesophageal reflux disease in children. We report a 4-year-old boy presented with increasing difficulty in swallowing. Esophagram showed a smooth narrowing of the distal end and dilated esophagus. High-resolution manometry (HRM) had confirmed the diagnosis by fulfilling the criteria for achalasia Type 2. HRM has high sensitivity than conventional and may predict prognosis. He underwent Heller's myotomy with an anti-reflux procedure. The patient was asymptomatic after curative surgery. We report a rare case of achalasia in a 4-year-old boy confirmed by novel diagnostic technique HRM; hence, pediatric data of HRM are limited.

Reintervention After Heller Myotomy for Achalasia: Is It Inevitable?

Few studies of reintervention after Heller myotomy for achalasia set patients' expectations, assist therapeutic decision making, and direct follow-up. Therefore, we investigated the frequency and type of symptoms and reinterventions after myotomy based on achalasia type. From January 2006 to March 2013, 248 patients who had preoperative high-resolution manometry and a timed barium esophagram (TBE) underwent Heller myotomy, 62 (25%) for type I, 162 (65%) for type II, and 24 (10%) for type III achalasia. Postoperative surveillance, including TBE, was performed at 8 weeks, then annually. Median follow-up was 36 months. End points were all symptom types and modes of reintervention, endoscopic or surgical. Reintervention was based on both symptoms and objective TBE measurements. Eventually most patients (169 of 218; 69%) experienced at least one symptom after myotomy. Fifty patients underwent 85 reinterventions, 41 endoscopic only, 4 surgical only, and 5 both. Five-year freedom from reintervention was 62% for type I, 74% for type II, and 87% for type III, most occurring within 6 months, although later in type III. At 5 years, number of reinterventions per 100 patients was 72 for type I, 51 for type II, and 13 for type III. After each reintervention, there was approximately a 50% chance of another within 2 years. Patients' expectations when undergoing Heller myotomy for achalasia must be that symptoms will only be palliated, and patients who have worse esophageal function-achalasia type I-may require one or more postoperative reinterventions. Thus, we recommend that patients with achalasia have lifelong annual surveillance after Heller myotomy that includes TBE.

Peroral Endoscopic Myotomy (POEM) Is a Safe and Effective Treatment Modality for Achalasia Patients After Failed Pneumatic Dilatation (PD): Category Award (Esophagus)

Introduction: Peroral endoscopic myotomy (POEM) is a newly emerging treatment modality for achalasia as compared to conventional treatment like pneumatic dilatation (PD). Previous PD may make subsequent dissection and separation of tissue planes more challenging due to fibrosis. There is lack of a systematic study analyzing if POEM can be applied to patients with failed PD. We conducted this study to determine the safety and efficacy of POEM in the setting of prior PD. Methods: Medical records all the achalasia patients who underwent POEM at our institution between April 2014 and December 2017 were reviewed. Patients who underwent timed barium esophagram (TBE) and high-resolution manometry (HREM) prior to POEM along with two-month post-POEM esophageal pH study, TBE and HREM were included. Patients were categorized into two groups as: no prior PD (treatment naive) and prior PD group. Patients in either group may have had prior botulinum injection, however those with prior Heller’s myotomy were excluded. Demographics, procedural details, Eckardt’s scores, TBE, HREM and pH study findings were compared between the two groups. Eckhardt’s symptom score of <3 was considered as successful palliation of symptoms. Analysis of covariance was performed to assess the association between PD groups and change in outcomes from pre-POEM to 2-month post-POEM follow-up while adjusting for possible confounders. Results: A total of 83 patients (no prior PD=57; prior PD=26) met the study criteria. There were no significant differences in the age, gender, ethnicity, BMI, type of achalasia, myotomy length, operativetime, length of stay or complication rates between the two groups (table-1). Subjects with prior PD were likely to have longer duration of achalasia symptoms (p=0.029). There was a significant improvement in Eckardt score, TBE and HREM parameters for both groups (figure 1,2). On adjusted analysis, there was no significant difference in the pre-post POEM change in Eckardt score, TBE and HREM parameters amongst both groups. In the post-POEM pH study, proportion of patients with GERD symptoms, total abnormal acid exposure and abnormal DeMeester scores were similar in both groups. Conclusion: POEM appears to be a safe and effective treatment modality in achalasia patients with prior PD. Prior dilatation does not seem to have any obvious influence on the efficacy of POEM. POEM might emerge as the preferred approach for myotomy in patients with failed PD.318_A Figure 1. Patient characteristics, Procedure details and Outcomes318_B Figure 2. Comparison of Eckardt’s score and high-resolution manometry parameters (HREM) in patients with no prior pneumatic dilatation (PD) versus those with prior PD318_C Figure 3. Comparison of timed barium esophagram parameters (TBE) in patients with no prior pneumatic dilatation (PD) versus those with prior PD

Linitis Plastica Presenting as Dysphagia Thought to Be Pseudoachalasia

A 79 yr old M with past medical history of Barrett's esophagus s/p ablation presents with progressive dysphagia to solid foods. EGD showed stenosis at the GEJ, no tumor seen, but firm stricture. Biopsies showed unremarkable mucosa, negative for H. Pylori, but concern for extrinsic compression and congestive gastropathy. CT did not show any masses. Barium esophagram showed tapering of esophagus to the GEJ with a ‘bird's beak appearance. Manometry was confounded by a second high pressure zone beneath LES concerning for probe coiling. Manometry did not clearly meet any Chicago criteria. Possible diagnosis of achalasia type II questioned due to elements of preserved peristalsis. Repeat EGD again demonstrated severe stenosis, and a dilated esophagus. Biopsies were repeated which demonstrated no abnormalities. The patient was referred to thoracic surgery for surgical correction of achalasia. Third EGD with sequential dilation 21-33Fr dilators. Subsequently during admission for TIA, he had worsening dysphagia and CT chest demonstrated a mild thickening of the distal esophagus, previously seen but not reported. Repeat EGD again noted a marked narrowing that could not be traversed with standard endoscope but crossed with pediatric endoscope. In the stomach there were diffusely thickened folds and poor distensibility. EUS demonstrated irregular thickening of the mucosal layers and submucosal layers measuring 12mm thickness extending from the GEJ throughout the stomach to antrum. No lymphadenopathy noted. Biopsies demonstrated poorly differentiated carcinoma, immunostains were positive for AE1/3 and negative for CD45. Ki67 is positive in ˜70% tumor cells. PET scan showed widespread bone metastasis and hypermetabolic uptake in relation to the gastric mucosa. We describe a rare case of linitis plastica presenting as pseudoachalasia. However, the accuracy of endoscopy ranges widely, depending on the gross tumor growth pattern and the anatomic location of the tumor, with a sensitivity of only 33-73% observed in linitis plastica patients. Imaging and early endoscopy were concerning for achalasia, particularly in the setting of pathognomonic presence of “bird's beak” on barium swallow. Was questioned by manometry, however study had some uncertainty due to concern for possible coiling of the probe. This case serves to highlight the importance of EUS when endoscopy, imaging, and manometry are inconsistent.2969_A Figure 1 No Caption available.2969_B Figure 2 No Caption available.

FA02.04: LONG—TERM RESULTS OF PERORAL ENDOSCOPIC MYOTOMY (POEM) FOR ACHALASIA

Abstract Background POEM has gained trust by proved safety and short-term efficacy and at present, it is considered as a standard and safe method for treatment of achalasia. The aim of this prospective single-center case series was to assess the long-term efficacy of POEM with emphasis on post-POEM reflux and to summarize adverse events. Methods Since 2012 until 10/2017, a total of 223 achalatic patients underwent 233 POEMs. Follow-up visits at 3, 12, 24 and 36M were completed in 194, 144, 80 and 44 patients. Upper GI endoscopy, HRM and 24-hour pH metry were performed 3M after POEM; endoscopy was then repeated between 24–36M. Main outcomes were treatment success (Eckardt score &lt;3), recurrence rate, post-POEM reflux and adverse events. Results At 3, 12, 24 and 36 months, treatment success was achieved in 97% (CI 95%; 95–100), 99% (97–100), 94% (88–100) and 93% (86–100) of patients. A total of 15 patients experienced treatment failure (n = 5) or recurrence (n = 10). The recurrences occurred most often in patients with achalasia type I (4 out of 35, 11.4%) followed by type II (5 out of 144; 3.5%) vs. none in type III (0 out of 21.0%); P = 0.022. At 3 months, reflux esophagitis was diagnosed in 68/194 patients. Abnormal acid exposure was detected in 68/194 (39.7%) patients. At 24–36 months reflux esophagitis was present in 15 from 51 patients (29%). The most common adverse event was capnoperitoneum with necessity of a puncture (57.6%), subcutaneous emphysema (36.6%). A total of 3 severe adverse events occured: 2 patients required a prolonged hospitalization due to fluido- and pneumofluidothorax. One patient (67 years) experienced electromechanical dissociation with fatal cardiac arrest during the procedure, the resuscitation was not successful. The autopsy revealed severe coronary disease and pulmonary hypertension (unrecognized prior to POEM), these conditions were considered likely to be the cause of the death. Conclusion POEM is effective treatment modality for achalasia with treatment success of 94% at 2 and 3 years. Reflux esophagitis and abnormal acid exposure are diagnosed in almost 40% of patients; reflux is successfully manageable with PPI. Eventhough POEM is considered a safe procedure, severe (fatal) adverse events may occur. Disclosure All authors have declared no conflicts of interest.

PS01.003: EVALUATION OF BOTH STANDARD AND NOVEL HRM METRICS OF THE UPPER ESOPHAGEAL SPHINCTER (UES) IN ACHALASIA AND REFLUX DISEASE. APPLICATION OF THE CONTRACTILE INTEGRAL IN THE UES

Abstract Background The literature is still lacking thorough manometric analysis of the function of the Upper Esophageal Sphincter (UES) among patients with motility disorders. Assessment of the High Resolution Manometry (HRM) features of the UES may be the key in further understanding the manometric profile of achalasia and even predicting treatment outcome. Furthermore, the Contractile Integral (CI) may be a more representative measure of contractility of the UES too. Methods Achalasia patients (study group) and a control group of individuals underwent HRM. Resting pressure, residual pressure, UES length and the Landmark UES-CI corrected for respiration were analyzed and compared between the two groups. The UES-CI metric was calculated according to the method applied for the Distal Contractile Integral (DCI). Results 24 achalasia patients and 24 subjects consisting the control group with mean age 55.2 and 56.1, respectively, were enrolled. Although the mean UES length was found significantly lower in our study group (3.2 vs. 4.3, P = 0), mean residual pressure was found significantly higher among the same group as compared to controls (12.5 vs. 3, P = 0.01). Interestingly, we found a trend towards lower values of the corrected UES-CI in achalasia compared to the control group (132 vs. 207.8, P = 0.08). The resting pressure did not differ between the two groups. Conclusion Increased residual pressure values of the UES in achalasia compared to control group is a reasonable finding that indicates that UES may also be affected by the neuronal damage in this disorder or that the pressurization phenomenon (mainly in achalasia type II) disrupts the function of the UES during swallowing. However, results on the UES-CI in resting phase cannot confirm the hypothesis of higher risk of aspiration among achalasia patients whose esophageal lumen is known to present with incomplete clearance and stasis. Disclosure All authors have declared no conflicts of interest.

Management of achalasia cardia: Expert consensus statements.

Achalasia cardia (AC) is a frequently encountered motility disorder of the esophagus resulting from an irreversible degeneration of neurons. Treatment modalities are palliative in nature, and there is no curative treatment available for AC as of now. Significant advancements have been made in the management of AC over last decade. The introduction of high resolution manometry and per-oral endoscopic myotomy (POEM) has strengthened the diagnostic and therapeutic armamentarium of AC. High resolution manometry allows for the characterization of the type of achalasia, which in turn has important therapeutic implications. The endoscopic management of AC has been reinforced with the introduction of POEM that has been found to be highly effective and safe in palliating the symptoms in short-term to mid-term follow-up studies. POEM is less invasive than Heller's myotomy and provides the endoscopist with the opportunity of adjusting the length and orientation of esophageal myotomy according to the type of AC. The management of achalasia needs to be tailored for each patient, and the role of pneumatic balloon dilatation, POEM, or Heller's myotomy needs to be revisited. In this review, we discuss the important aspects of diagnosis as well as management of AC. The statements presented in the manuscript reflect the cumulative efforts of an expert consensus group.

Gender, medication use and other factors associated with esophageal motility disorders in non-obstructive dysphagia

BackgroundHigh-resolution esophageal manometry (HREM) is the diagnostic test of choice for evaluation of non-obstructive dysphagia. Studies regarding the predictors of esophageal dysmotility are limited. Therefore, our aim was to study the prevalence of and factors associated with esophageal motility disorders in patients with non-obstructive dysphagia.MethodsWe performed a retrospective review of all patients with non-obstructive dysphagia who underwent HREM in a tertiary center between 1 January 2014 and 31 December 2015. After obtaining IRB approval (16–051), clinical records were scrutinized for demographic data, symptoms, medication use, upper endoscopic findings and esophageal pH findings. HREM plots were classified per Chicago Classification version 3.0. Primary outcome was prevalence of esophageal motility disorders; secondary outcomes assessed predictive factors.ResultsIn total, 155 patients with non-obstructive dysphagia (55 ± 16 years old, 72% female) were identified. HREM diagnosis was normal in 49% followed by ineffective esophageal motility in 20%, absent contractility in 7.1%, achalasia type II in 5.8%, outflow obstruction in 5.2%, jackhammer esophagus in 4.5%, distal esophageal spasm in 3.9%, fragment peristalsis in 1.9%, achalasia type I in 1.9%, and achalasia type III in 0.6%. Men were five times more likely to have achalasia than women [odds ratio (OR) 5.3, 95% confidence interval (CI): 2.0–14.2; P = 0.001]. Patients with erosive esophagitis (OR 2.9, 95% CI: 1.1–7.7; P = 0.027) or using calcium channel blockers (OR 3.0, 95% CI: 1.2–7.4; P = 0.015) were three times more likely to have hypomotility disorders.ConclusionFrom this study, we concluded that HREM diagnosis per Chicago Classification version 3.0 was normal in 49% of patients with non-obstructive dysphagia. Male gender, erosive esophagitis and use of calcium channel blockers were predictive of esophageal motility disorders.

Tu1184 AFTER PERORAL ENDOSCOPIC MYOTOMY (POEM), POST-TREATMENT ESOPHAGOGASTRIC JUNCTION DISTENSIBILITY BY ENDOLUMENAL FUNCTIONAL LUMEN IMAGING PROBE (ENDOFLIP) PREDICTS TREATMENT SUCCESS BETTER THAN MANOMETRY OR TIMED BARIUM EMPTYING

Peroral endoscopic myotomy (POEM) has emerged as a useful method to treat achalasia. Prior studies suggest that post-treatment basal LES pressure (LESP) and emptying on timed barium esophagram (TBE) correlate with symptom improvement; newer studies suggest that esophagogastric junction (EJG) distensibility index (DI) by EndoFLIP also correlates with response to therapy. Our aim was to compare post-POEM EndoFLIP DI, LESP, and TBE in patients with successful versus failed symptom improvement. Retrospective review of a prospectively maintained database of patients undergoing POEM at a single center. Patients with prior myotomy and fundoplication were excluded. Data collected included (a) demographics, symptoms, Eckardt score, and manometric diagnosis at presentation, (b) findings at the 3-month follow-up including Eckardt score, distensibility index (DI) at 30-40-50 ml assessed by EndoFLIP, TBE at 5 minutes, and LESP measured by high-resolution manometry. Treatment success was defined as Eckardt score ≤3. We evaluated the relationship between objective outcomes (DI, TBE, LESP) and treatment success at 3 months, through linear regression. Data are presented as mean (SD) or n (%). 22 patients were included: 4 (18%) Achalasia type I, 9 (41%) Achalasia type II, 5 (23%) Achalasia type III, 4 (18%) EGJ outflow obstruction. Mean age was 57.4, 55% were male, mean BMI was 27.4, baseline mean Eckardt score was 7.14. At 3 month follow-up, mean Eckardt score had decreased from 7.14 to 1.23; 20 patients (91%) achieved treatment success. Linear regression was calculated to predict Eckardt success based on each individual objective outcome. A statistically significant association was found was between treatment success and EndoFLIP DI at 30 ml (R2 of 0.194, p <0.040). There was no significant association between treatment success and DI at 40 ml and 50 ml, mean LESP, or complete emptying by TBE (Table 1). POEM is effective for treating achalasia. A higher EGJ DI at 30 ml on EndoFLIP correlates with treatment success, and thus may be the best predictor for post-treatment success. Data collection is ongoing in order to confirm this finding in a larger cohort with longer follow-up.Tabled 1Table 1. Linear RegressionObjective OutcomeR2CorrelationP-valueDI at 30 ml on EndoFLIP0.194-0.2250.040DI at 40 ml on EndoFLIP0.153-0.2120.072DI at 50 ml on EndoFLIP0.082-0.1950.196LESP0.047-0.0250.330TBE0.042-0.0770.375 Open table in a new tab

Tu1172 LONG - TERM RESULTS OF PERORAL ENDOSCOPIC MYOTOMY (POEM) FOR ACHALASIA

Per-oral endoscopic myotomy (POEM) has gained trust by proved safety and short-term efficacy and at present, it is considered as a standard and safe method for treatment of achalasia. The aim of this prospective single-center case series was to assess the long-term clinical outcome of POEM with emphasis on post-POEM reflux evaluated by pH monitoring, endoscopy findings, reflux symptoms and use of proton pump inhibitors (PPIs) and to summarize adverse events of this procedure. Since 2012 until October 2017, a total of 223 patients with achalasia underwent 233 POEM procedures. Follow-up visits at 3, 12, 24 and 36 months were completed in 194, 144, 80 and 44 patients. Upper GI endoscopy, high-resolution manometry (HRM) and 24-hour pH monitoring were performed 3 months after POEM; endoscopy was then repeated between 24-36 months. Main outcomes were treatment success defined as Eckardt score < 3, recurrence rate, post-POEM reflux and adverse events. At 3, 12, 24 and 36 months, treatment success was achieved in 97% (CI 95%; 95-100), 99% (97-100), 94% (88-100) and 93% (86-100) of patients. A total of 15 patients experienced treatment failure (n=5) or recurrence (n=10). The recurrences occurred most often in patients with achalasia type I (4 out of 35, 11.4%) followed by type II (5 out of 144; 3.5%) vs. none in type III (0 out of 21.0%); p=0.022. At 3 months, reflux esophagitis was diagnosed in 68/194 patients (35%; severe esophagitis LA C or D in 8 patients). Abnormal acid exposure was detected in 68/194 (39.7%) patients. At 24-36 months, endoscopy was performed in 51 patients and reflux esophagitis was present in 15 patients (29%). A proton pump inhibitor was administered to 37% and 38% of patients at 3 and 24M, respectively. The most common adverse event was capnoperitoneum with necessity of a puncture (57.6%), subcutaneous emphysema (36.6%). Periprocedural bleeding, mucosal injury and fever were observed in less than 7% of patients. A total of three severe adverse events occured: two patients required a prolonged hospitalization due to fluidothorax and pneumofluidothorax, both patients recovered uneventfully. A 67-years old female patient experienced electromechanical dissociation with fatal cardiac arrest during the procedure, the resuscitation was not successful. The autopsy revealed severe coronary artery disease and pulmonary hypertension (unrecognized prior to POEM), these conditions were considered likely to be the cause of the death. POEM is effective treatment modality for achalasia with treatment success of 94% at 2 and 3 years. Reflux esophagitis and abnormal esophageal acid exposure are diagnosed in almost 40% of patients; reflux is successfully manageable with proton pump inhibitors. Eventhough POEM is considered a safe procedure, severe (fatal) adverse events may occur.

Mo1527 - Increased use of Opioids Among Achalasia type 3 and Esophagogastric Junction Outflow Obstruction (EGJOO) Patients: A Review of 262 Achalasia Patients from a Highvolume Tertiary Referral Center

Mo1527 - Increased use of Opioids Among Achalasia type 3 and Esophagogastric Junction Outflow Obstruction (EGJOO) Patients: A Review of 262 Achalasia Patients from a Highvolume Tertiary Referral Center

Laparoscopic Heller Myotomy vs Per Oral Endoscopic Myotomy: Patient-Reported Outcomes at a Single Institution

Although laparoscopic Heller myotomy (LHM) has been the standard of care for achalasia, per oral endoscopic myotomy (POEM) has gained popularity as a viable alternative. This retrospective study aimed to compare patient-reported outcomes between LHM and POEM in a consecutive series of achalasia patients with more than 1 year of follow-up. We reviewed demographic and procedure-related data for patients who underwent either LHM or POEM for achalasia between January 2011 and May 2016. Phone interviews were conducted assessing post-procedure achalasia symptoms via the Eckardt score and achalasia severity questionnaire (ASQ). Demographics, disease factors, and survey results were compared between LHM and POEM patients using univariate analysis. Significant predictors of procedure failure were analyzed using univariate and multivariate analysis. There were no serious complications in 110 consecutive patients who underwent LHM or POEM during the study period, and 96 (87%) patients completed phone surveys. There was a nonsignificant trend toward better patient-reported outcomes with POEM. There were significant differences in patient characteristics including sex, achalasia type, mean residual lower esophageal pressure (rLESP), and follow-up time. The only univariate predictors of an unsatisfactory Eckardt score or ASQ were longer follow-up and lower rLESP, with follow-up length being the only predictor on multivariate analysis. There were significant demographic and clinical differences in patient selection for POEM vs LHM in our group. Although the 2 procedures have similar patient-reported effectiveness, subjective outcomes seem to decline as a result of time rather than procedure type.

Current Status of Peroral Endoscopic Myotomy.

Peroral endoscopic myotomy (POEM) has been established as an optional treatment for achalasia. POEM is an endoluminal procedure that involves dissection of esophageal muscle fibers followed by submucosal tunneling. Inoue first attempted to use POEM for the treatment of achalasia in humans. Expanded indications of POEM include classic indications such as type I, type II, type III achalasia, failed prior treatments, including Botulinum toxin injection, endoscopic balloon dilation, laparoscopic Heller myotomy, and hypertensive motor disorders such as diffuse esophageal spasm, jackhammer esophagus. Contraindications include prior radiation therapy to the esophagus and prior extensive esophageal mucosal resection/ablation involving the POEM field. Most of the complications are minor and self-limited and can be managed conservatively. As POEM emerged as the main treatment for achalasia, various adaptations to tunnel endoscopic surgery have been attempted. Tunnel endoscopic surgery includes POEM, peroral endoscopic tumor resection, gastric peroral endoscopic pyloromyotomy. POEM has been widely accepted as a treatment for all types of achalasia, even for specific cases such as achalasia with failed prior treatments, and hypertensive motor disorders.

Long-term outcome of myotomy and fundoplication based on intraoperative real-time high-resolution manometry in achalasia patients.

BackgroundCurrent treatment options for achalasia of the esophagus predominantly consist of endoscopic myotomy or laparoscopic myotomy combined with a partial fundoplication. The intraoperative use of conventional manometry has previously been proposed with various results. The aim of the present study was to introduce the use of high-resolution manometry (HRM) during surgical treatment for achalasia and to assess the long-term outcome of this technique.MethodsWe enrolled achalasia patients within the time period November 2013 to July 2016 who underwent HRM and evaluation of Eckardt scores (ES) before and after tailored laparoscopic myotomy and fundoplication with intraoperative recording using HRM.ResultsTwenty patients were classified as having achalasia type I (20%), type II (55%), or type III (25%). During surgery, 9 myotomies were extended and 13 fundoplications were modified according to HRM findings. Mean resting (16.1 vs. 41.9 mmHg) and residual (9 vs. 28.7 mmHg) pressures of the lower esophageal sphincter and ES (0.7 vs. 6.9) were significantly eliminated postoperatively over a mean follow-up time of 17.7 months.ConclusionsThe use of intraoperative HRM gives us the advantage of simultaneous real-time estimation of intraluminal pressures of the esophagus and the ability to identify the exact points that produce pressure during laparoscopy. Consequently, it may be the key to the tailoring of the Heller-Dor technique and improving the outcomes for achalasia patients.

Can the upper esophageal sphincter contractile integral help classify achalasia?

Background:The use of high-resolution manometry (HRM) in achalasia patients has revealed abnormal findings concerning upper esophageal sphincter (UES) function. The introduction of the UES contractile integral (UES-CI), as with the distal contractile integral (DCI), may complement the interpretation of the manometric study of achalasia subtypes, defined by the Chicago Classification v3.0.Methods:Patients were classified into achalasia subtypes based on HRM. UES length (cm), UES resting pressure (mmHg), and UES residual pressure (mmHg) were recorded. UES-CI (mmHg·sec·cm) was calculated in a manner similar to that used for the DCI measurement at rest (landmark CI), corrected for respiration, and its relation to achalasia subtypes was evaluated.Results:Twenty-four achalasia patients with mean age 55.29 years were included. Of these, 16.6% (n=4) were diagnosed with achalasia type I, 58.3% (n=14) with type II, and 25% (n=6) with type III. The landmark UES-CI, mean UES-CI, UES-CI corrected for respiration, and UES resting pressure were found to be significantly higher among patients with achalasia type II compared to the other types (1768.9 vs. 677.1, P=0.03; 1827.1 vs. 3555.1, P=0.036; 174.2 vs. 72.8, P=0.027; and 108.1 vs. 55.8, P=0.009, respectively).Conclusions:We introduce the CI index as a tool for the manometric evaluation of the UES in achalasia. UES resting pressure, landmark UES-CI and mean UES-CI were significantly higher in achalasia patients with panesophageal pressurization compared to types I and III. This finding may reflect a protective reaction against the risk of aspiration in this group, but further studying and clinical correlation is required.