Pneumatic Dilation Research Articles

Mini-invasive approach for end-stage achalasia

End-stage achalasia is characterized by a significant esophageal dilatation

The outcome of primary per oral endoscopic myotomy (POEM) for treatment of achalasia: Norwegian single-center experience with long-term follow-up.

Per oral endoscopic myotomy (POEM) has become an established treatment for achalasia, but no Scandinavian studies with long-term follow-up exist. This study from a tertiary referral center in Norway investigates the short-, mid-, and long-term feasibility, safety, efficacy, and complications of POEM. Prospective data from the first 84 patients who underwent POEM from 2014 to 2019 were analyzed. The median follow-up time was 44 months. Clinical success was defined as the Eckardt score (ES) ⩽3, and reflux as pathological if the acid exposure time (pH < 4) was more than 6%. ES was used for symptom evaluation before, and at 6, 12, and up to 64 months after POEM. A total of 50 males and 34 females were included. A total of 43 (51%) were treatment naïve, 24 (28.6%) had been previously treated with botulinum toxin, pneumatic balloon dilatation, or both, and 17 (20.2%) were previously treated with Heller's myotomy. The median post-POEM ES at 12 months was 1 (0-9), compared to pre-POEM 7 (4-12) (p < 0.01). At 12 months after POEM, clinical success persisted in 74 patients (88.1%). Clinical success was the highest for patients who were naïve to treatment, 41/43 (95%), and lower for those previously treated with Heller's myotomy 12/17 (70.6%). Long-term follow-up at 5-6 years of 42 patients showed a clinical success rate of 94%. We experienced adverse events in five patients (6%). Post-POEM pathological reflux was found in 46% (28/61). After 3-4 years, the median ES was 1, and after 5-6 years, it was 2. POEM was safe and relieved the symptoms of achalasia significantly and persistently. The procedure had a better outcome in treatment naïve than previously treated patients. However, POEM is associated with significantly increased esophageal acid exposure. Norwegian single-center study: POEM had a clinical success rate of 94% after 5-6 years since its introduction at the center in 2014, providing a safe and effective treatment for achalasia.

Risk factors for clinical failure of peroral 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.

Is There a Role for Pneumatic Dilation in Primary Treatment of Achalasia? Pro: PD Should Always the First Choice for Achalasia Treatment.

Pneumatic dilatation (PD) should always be the first choice for achalasia treatment. In the following section, we will compare PD to other common achalasia procedures: intersphincteric botox injections (BTX), laparoscopic heller myotomy (LHM), and peroral endoscopic myotomy (POEM). We will focus on the limitation of studies leaning toward those procedures, and how PD data has proven good efficacy and safety. Will also discuss how in certain populations PD should always be the first choice.

Robotic Heller myotomy and Dor fundoplication: Twelve steps.

Achalasia is an esophageal motor disorder that is characterized by failure of the lower esophageal sphincter (LES) to relax and loss of peristalsis in the esophageal body.1 Treatment options focus on releasing the elevated pressure of the LES and include direct botulinum toxin injection, pneumatic dilation, per-oral endoscopic myotomy (POEM), and Heller myotomy. Botulinum toxin's effect is temporary, requiring repeated injections with progressively diminished efficacy over time. The effectiveness of pneumatic dilation has been shown in previous studies.

Surgical treatment of achalasia: results and quality of life

Abstract Achalasia is a primary defect of esophageal motility of unknown aetiology, characterised by peristaltic dysfunction of the esophagus and impaired relaxation of the lower esophageal sphincter. The most common symptoms are dysphagia, regurgitation, weight loss, and chest burning. There are various treatment options for achalasia: botulinum toxin injections, pneumatic dilatation, Heller myotomy, and peroral endoscopic myotomy. The aim of the study was to access the efficacy and quality of life of patients with achalasia after surgical treatment — laparoscopic Heller myotomy and Dor fundoplication. All of the patients after surgery had a high gastrointestinal quality of life index. For all patients, during the follow-up period (median 2.4 years), the intensity of clinical symptoms after the procedure declined. Laparoscopic Heller myotomy with Dor fundoplication is a safe and effective method of treating achalasia and can reduce clinical symptoms and improve patients' quality of life.

Pneumatic Dilation: Keep It in the Tool Box

Pneumatic Dilation: Keep It in the Tool Box

Accidentally Confirmed Relapse of Plummer-Vinson Syndrome during Esophageal Foreign Body Evaluation

Plummer-Vinson syndrome (PVS) is a complex condition characterized by a classic triad of dysphagia, iron deficiency anemia (IDA), and an upper esophageal web. Dysphagia represents the most important symptom of PVS and is usually observed with solid food. Therapeutic options for dysphagia include iron supplementation and/or endoscopic balloon dilation based on symptom severity. PVS can be treated easily and regular iron replacement therapy can prevent disease progression. We describe a 63-year-old woman diagnosed with a simple esophageal web, who underwent esophageal dilation 13 years prior to presentation. However, she revisited our center because of dysphagia secondary to an esophageal foreign body, and endoscopy revealed esophageal web relapse. Investigations revealed IDA, and the patient was eventually diagnosed as PVS. She underwent successful endoscopic dilation and denied recurrent dysphagia after continuous intake of iron tablets. We recommend continuous management of IDA, as well as endoscopic dilation and a multidisciplinary therapeutic approach to ensure favorable prognosis in PVS patients.

The effect of postoperative ventilation strategies on postoperative complications and outcomes in patients with esophageal atresia: Results from the Turkish Esophageal Atresia Registry.

Postoperative ventilatory strategies in patients with esophageal atresia (EA) and tracheoesophageal fistula (TEF) may have an impact on early postoperative complications. Our national Esophageal Atresia Registry was evaluated to define a possible relationship between the type and duration of respiratory support on postoperative complications and outcome. Among the data registered by 31 centers between 2015 and 2021, patients with esophago-esophageal anastomosis(EEA)/tracheoesophageal fistula(TEF) were divided into two groups; invasive ventilatory support (IV) and noninvasive ventilatory support and/or oxygen support (NIV-OS). The demographic findings, gestational age, type of atresia, associated anomalies, and genetic malformations were evaluated. We compared the type of repair, gap length, chest tube insertion, follow-up times, tensioned anastomosis, postoperative complications, esophageal dilatations, respiratory problems requiring treatment after the operation, and mortality rates. Among 650 registered patients, 502 patients with EEA/TEF repair included the study. Four hundred and seventy of patients require IV and 32 of them had NIV-OS treatment. The IV group had lower mean birth weights and higher incidence of respiratory problems when compared to NIV-OS group. Also, NIV-OS group had significantly higher incidence of associated anomalies than IV groups. The rates of postoperative complications and mortality were not different between the IV and NIV-OS groups. We demonstrated that patients who required invasive ventilation had a higher incidence of low birth weight and respiratory morbidity. We found no relation between mode of postoperative ventilation and surgical complications. Randomized controlled trials and clinical guidelines are needed to define the best type of ventilation strategy in children with EA/TEF.

How I Do It: Pneumatic Dilation

Large-caliber dilation is an important therapeutic approach in the management of achalasia, but there is significant variability in how this is performed and taught worldwide. This article reviews the personal approaches to large-caliber of 2 experienced esophagologists—focusing on how they were personally taught to do the procedure, how their technique has evolved over the decades since, and how they current perform dilation.

Consequences of anastomotic leaks after minimally invasive esophagectomy: A single-center experience

BackgroundAnastomotic leak (AL) after minimally invasive esophagectomy (MIE) is a well-described source of morbidity for patients undergoing surgical treatment of esophageal neoplasm. With improved early recognition and endoscopic management techniques, the long-term impact remains unclear. MethodsA retrospective review was conducted of patients who underwent MIE for esophageal neoplasm between January 2015 and June 2021 at a single institution. Cohorts were stratified by development of AL and subsequent management. Baseline demographics, perioperative data, and post-operative outcomes were examined. ResultsDuring this period, 172 MIEs were performed, with 35 of 172 (20.3%) complicated by an AL. Perioperative factors independently associated with AL were post-operative blood transfusion (leak rate 52.9% versus 16.8%; p = 0.0017), incompleteness of anastomotic rings (75.0% vs 19.1%; p = 0.027), and receiving neoadjuvant therapy (18.5% vs 30.8%; p < 0.0001). Inferior short-term outcomes associated with AL included number of esophageal dilations in the first post-operative year (1.40 vs 0.46, p = 0.0397), discharge disposition to a location other than home (22.9% vs 8.8%, p = 0.012), length of hospital stay (17.7 days vs 9.6 days; p = 0.002), and time until jejunostomy tube removal (134 days vs 79 days; p = 0.0023). There was no significant difference in overall survival between patients with or without an AL at 1 year (79% vs 83%) or 5 years (50% vs 47%) (overall log rank p = 0.758). ConclusionsIn this large single-center series of MIEs, AL was associated with inferior short-term outcomes including hospital length of stay, discharge disposition other than to home, and need for additional endoscopic procedures, without an accompanying impact on 1-year or 5-year survival. Key messageIn this large, single-center series of minimally invasive esophagectomies, anastomotic leak was associated with worse short-term outcomes including hospital length of stay, discharge disposition other than to home, and need for additional endoscopic procedures, but was not associated with worse long-term survival. The significant association between neoadjuvant therapy and decreased leak rates is difficult to interpret, given the potential for confounding factors, thus careful attention to modifiable pre- and peri-operative patient factors associated with anastomotic leak is warranted.

The emerging association between bronchiectasis and systemic sclerosis: assessing prevalence and potential causality.

Bronchiectasis has been observed in association with systemic sclerosis (SSc). Theorised aetiology includes aspiration related to oesophageal dysmotility, immunosuppressant medication use and the direct effect of collagen deposition on airway calibre. To detail bronchiectasis prevalence in an SSc population who have had a high-resolution computed tomography (HRCT) of the thorax. We assessed whether oesophageal dysmotility, demographic variables, SSc duration or subclass were associated with bronchiectasis. Participants in the Australian Scleroderma Cohort Study (ASCS) with a HRCT were included. The ASCS provided demographic and clinical data. HRCT studies were reviewed for bronchiectasis, oesophageal dilatation and interstitial lung disease (ILD). Traction bronchiectasis associated with ILD was recorded as a separate entity to bronchiectasis. Oesophageal dysmotility was defined by symptoms and/or oesophageal dilatation. Of the 256 participants, 16.4% (n = 42) had bronchiectasis. Logistic regression analysis revealed no significant association between bronchiectasis and oesophageal dysmotility (observed in 95.7%), any demographic variable, SSc duration or subclass. A negative association between bronchiectasis and ILD was observed (P = 0.009; odds ratio 0.322; 95% confidence intervals 0.137-0.756). Those with SSc appear to have an increased risk for bronchiectasis. Since bronchiectasis was not more frequent in participants with a longer duration of SSc, we hypothesise that its development is not related to immunosuppression alone. Oesophageal dysmotility was almost universal in our population such that its effect on bronchiectasis development could not be concluded. A negative association between bronchiectasis and ILD reflects that bronchiectasis occurring alongside ILD was recorded as a separate entity.

Impact of peroral endoscopic myotomy on high-resolution manometry findings and their association with the procedure’s outcomes

Peroral endoscopic myotomy (POEM) is conducted for patients with esophageal motility disorders based on high-resolution manometry (HRM) findings. However, the impact of POEM on HRM findings and the associations between post-POEM HRM and outcomes have not been clarified. In a multicenter, observational, cohort study, patients with achalasia treated by POEM received follow-up HRM. Associations between patient characteristics, POEM procedures, and post-POEM HRM findings, including integrated relaxation pressure (IRP) and distal contractile integral (DCI), were investigated. Furthermore, POEM procedure outcomes were compared with post-POEM HRM findings. Of 2171 patients, 151 (7.0%) showed residual high post-POEM IRP (≥26mm Hg; Starlet [Starmedical Ltd, Tokyo, Japan]). In a multivariate analysis, high pre-POEM IRPs (odds ratio [OR], 24.3) and gastric myotomy >2 cm (OR, .22) were found to be positive and negative predictive factors of high post-POEM IRPs, respectively. Peristalsis recovery (DCI≥500mm Hg/cm/s, at least 1 swallow; Starlet) was visible in 121 of 618 patients (19.6%) who had type II to III achalasia. High pre-POEM IRP (OR, 2.65) and DCI≥500 (OR, 2.98) predicted peristalsis recovery, whereas esophageal dilation (OR, .42) predicted a risk of no recovery. Extended myotomy did not reveal a significant impact on peristalsis recovery. High or low post-POEM IRP and DCI did not increase the incidence of clinical failure, reflux esophagitis, or symptomatic GERD. Extended gastric myotomy decreased IRP values, whereas peristalsis recovery depended on the characteristics of achalasia. A residual high post-POEM IRP does not necessarily mean clinical failure. Routine HRM follow-up is not recommended after POEM.

SUCCESSFUL TREATMENT OF REFRACTORY PEDIATRIC EOSINOPHILIC ESOPHAGITIS WITH DUPILUMAB

<h3>Introduction</h3> Eosinophilic esophagitis (EoE) is a chronic T-helper 2 (Th2) antigen driven disease characterized by eosinophilic infiltrates in the esophageal mucosa. Currently, there are no therapies approved by the United States Food and Drug Administration (FDA) for EoE in patients under twelve years of age. Expert guidance recommends the use of proton pump inhibitors (PPI), swallowed corticosteroids, elimination diets, and esophageal dilation<i>.</i> However, these interventions do not ameliorate symptoms and eosinophilic inflammation in all cases. Herein, we describe the successful treatment of a ten-year-old patient with EoE refractory to guideline-directed therapy with dupilumab. <h3>Case Description</h3> Our patient is a ten-year-old male with failure to thrive and EoE refractory to dietary change, swallowed corticosteroids, and PPI therapy. Due to the severity of his disease, the patient was initiated on monthly dupilumab injections. Following 6 months of dupilumab therapy (300mg subcutaneously Q4 weeks) he experienced endoscopic and histologic remission (0 eos/hpf). He remained in clinical and histologic remission more than 3 months after milk was reintroduced into the diet. <h3>Discussion</h3> We report the histologic, endoscopic, and symptomatic improvement in refractory pediatric EoE following treatment with monthly dupilumab in a ten-year-old male. Our findings suggest that the use of dupilumab can be extended to the pediatric population. Additionally, our case suggests that monthly injections, rather than the weekly injections utilized for adult EoE treatment, may be sufficient. Lastly, dupilumab also allowed for the liberalization of our patient's diet with sustained histologic and endoscopic resolution. In summary, dupilumab successfully treated refractory EoE and sustained disease remission despite allergen reintroduction.

Is There a Role for Pneumatic Dilation in Primary Treatment of Achalasia? Con: PD Outcomes are Too Variable and Surgical Myotomy With POEM or Heller is Better

Presently, we have 3 acceptable options for the treatment of achalasia: pneumatic dilation (PD), endoscopic myotomy (POEM), and laparoscopic myotomy (LM). Results from multicenter randomized trials demonstrate the superiority of myotomy over pneumatic dilation. While myotomy may be superior at relief of dysphagia, there may be circumstances where a thoughtful, individualized patient approach is more important.

Surgical management of achalasia cardia-analysis of immediate outcomes

Achalasia cardia is a motility disorder characterised by failure of relaxation of the lower oesophageal sphincter (LES) and associated with lack of peristalsis in the body of oesophagus. The mainstay of treatment in achalasia cardia is to reduce the LES pressure and improve oesophageal emptying by gravity. LHM is still considered the gold standard against which other methods are compared. The records of all patients who underwent surgery for achalasia cardia between August 2018 and December 2021 in the department of Surgical Gastroenterology, Government Rajaji Hospital and Madurai Medical College, Madurai, Tamil Nadu, India were reviewed retrospectively. Eighteen patients underwent surgery for achalasia cardia with median age of 32.5 years and the median duration of symptoms was 30 months. Seven patients had undergone pneumatic dilatation previously. Two patients who had mucosal injury had undergone pneumatic dilatation previously. The duration of surgery was significantly higher for the patients who underwent previous pneumatic dilatation when compared to those who did not undergo dilatation (200 minutes vs 170 minutes). The Eckardt score was zero in 12 patients in follow-up. One patient had a score of 1 and five patients had a score of 2. Laparoscopic Heller myotomy is the most effective current surgical management for achalasia cardia. It can be safely performed even in patients with prior pneumatic dilatations with lesser reintervention rates.

A Review of Peroral Endoscopic Myotomy for Achalasia

Peroral endoscopic myotomy (POEM) is a form of transluminal endoscopic natural orifice surgery (NOTES) that uses the beginnings of submucosal endoscopy to make the endoscopic equivalent of a surgical myotomy. POEM can be done in most patients who have primary idiopathic achalasia demonstrated manometrically symptomatic. Previous therapies for achalasia, such as pneumatic balloon dilation, botulinum toxin injection, or surgical myotomy, are not contraindications to POEM. Generally, POEM is done in 4 continuous steps: incision in the mucosa, construction of a submucosal tunnel, myotomy and closure of the incision in the mucosa. Endoscopic management has been revolutionary for the treatment of achalasia and other pathological entities, however, it must be performed in specialized centres and by endoscopist surgeons with extensive experience in the subject, to reduce the associated morbidity and mortality.

Management of End-Stage Achalasia

Background: End-stage Achalasia correspond to the final stage in the evolution of this disease, characterized by the presence of severe dysphagia and weight loss despite aggressive treatment, associated to massive esophageal dilatation and tortuosity of the esophagus, with loss of its axis and adopting a sigmoid-shape or L-shape distal esophagus. It is also called advanced sigmoid esophagus. The diagnosis is based on radiological evaluations, but different authors use different criteria to define end-stage. This fact makes difficult to compare the results, due to a great heterogeneity of the patients. Methods: Total of 65 reports contently treatment of patients with end stage achalasia were carefully review. Results: Until the year 2000 subtotal esophagectomy with gastric or long-colon interposition was employed as primary treatment or after several medical and endoscopic failed treatments. The mean mortality rate range 3% to 5%, with a high morbidity rate and 10 to 12 days of hospital stay. From 2000 to 2015 Laparoscopic Heller Myotomy (LHM) was employed as the primary treatment, with a mortality rate of 0%, low postoperative morbidity (6%-8%) and 2 days of Hospital stay. The long-term follow up was satisfactory in near 2/3 of the patients with end-stage esophagus. In the last years POEM (Peroral endoscopic Myotomy) has been employed mainly by Asian authors, reporting 0% mortality, high rate of postoperative morbidity (over 20%), a hospital stay of 5 to 7 days and a very short follow up, usually less than 2 years. Although the control of dysphagia is high, the main problem with this technique is the marked increase in pathologic acid reflux to the esophagus, with values near to 50% of the patients. It is not known the late effect 10 to 15 years after this procedure of this severe reflux in an aperistaltic esophagus, with retention of food and acid inside the esophageal lumen. Conclusion: Up to now Laparoscopic Heller Myotomy seems the best option for these patients with severe end-stage esophagus. If there is a failure after this procedure, thoracoscopic esophagectomy would be the best option.

Lessons learned from early experience of per oral endoscopic myotomy in children

Background/AimsAchalasia cardia (AC) is rare in children, and the standard treatment is open or Laparoscopic Heller's myotomy with or without fundoplication if pneumatic dilatation has failed. Per oral endoscopic myotomy (POEM) is a novel technique for management of achalasia with good results in adults. We report POEM in four children and the outcome with special emphasis on the technique and management of intra-operative complications. MethodFour children aged 7–15 years presenting with progressive dysphagia, cough, night-time aspirations, and weight loss of six months to one year were investigated with upper GI contrast study, flexible endoscopy and biopsy, oesophageal manometry, and a diagnosis of Type 1 & 2 AC was made. An experienced adult endoscopist in collaboration with the paediatric surgical team performed POEM. ResultsPOEM was performed successfully using ERBE HYBRID knife setup and waterjet injection for the submucosal tunnelling. Operative time was 25–40 min (mean 31 min). The hospital stay was 3–8 days with last 3 patients discharged on day three. No major intraoperative or post-operative complications were seen. The Eckardt score changed from above 4 to 0 at one-month follow-up. All four are well at one year post-operatively and beyond. Two patients had subcutaneous emphysema post-operatively. One developed pneumoperitoneum intra-operatively. ConclusionPOEM was successfully performed with only minor adverse events in experienced hands. Anticipation and preparation for potential intraoperative complications and assigned responsibilities to each team helped the safe completion in the shortest time. Rectifying pneumoperitoneum concurrently without interruption of the operation exemplified teamwork. Level of EvidenceIII

Mid-Term and Long-Term Outcomes of Peroral Endoscopic Myotomy for the Treatment of Achalasia: A Systematic Review and Meta-Analysis.

Peroral endoscopic myotomy (POEM) achieves a satisfactory short-term clinical response in patients with achalasia. However, data on mid- and long-term clinical outcomes are limited. We aimed to assess the mid- and long-term efficacy and safety of POEM in achalasia patients. Using the pre-designed search strategy, we identified relevant studies that evaluated the efficacy and safety of POEM with a minimum of 2-year follow-up in the Embase, Cochrane, and PubMed databases from inception to January 2021. Primary outcome was pooled mid- and long-term clinical success rate based on the Eckardt score. Secondary outcome was pooled long-term reflux-related adverse events. A total of 21 studies involving 2,698 patients were included. Overall, the pooled clinical success rates with 2-, 3-, 4-, and 5-year follow-ups were 91.3% (95% confidence interval [CI] 88.4-93.6%), 90.4% (95% CI 88.1-92.2%), 89.8% (95% CI 83.6-93.9%), and 82.2% (95% CI 76.6-86.7%), respectively. Besides, the pooled long-term clinical success rates for type I, II, and III achalasia were 86.1% (95% CI 80.9-90.1%; I2 = 0%), 87.9% (95% CI 84.2-90.8%; I2 = 48.354%), and 83.9% (95% CI 72.5-91.2%; I2 = 0%), respectively. Moreover, the pooled incidence of symptomatic reflux and reflux esophagitis was 23.9% (95% CI 18.7-29.9%) and 16.7% (95% CI 11.9-23.1%), respectively. POEM is associated with a long-term clinical success of 82.2% after 5years of follow-up. Randomized control trials comparing POEM with laparoscopic Heller myotomy or pneumatic dilation with longer follow-up periods are needed to further demonstrate the long-term safety and efficacy of POEM.