Median Eckardt Score Research Articles

Esophageal impedance planimetry during per-oral endoscopic myotomy guides myotomy extent

IntroductionPeroral endoscopic myotomy (POEM) is the standard treatment for achalasia. Functional luminal imaging probe (FLIP) technology enables objective measurement of lower esophageal sphincter (LES) geometry, with literature linking specific values to improved post-POEM outcomes. Our study assesses FLIP’s intraoperative use in evaluating myotomy extent in real-time.MethodsRetrospective data from all patients undergoing POEM with intraoperative FLIP measurements were extracted from June 2020 to January 2023. The primary endpoint was intraoperative FLIP measurements, management changes, and symptom improvement (Eckardt score).ResultsFourteen patients (age 56 ± 14 years, BMI 28 ± 7 kg/m2) were identified. Most patients were female (64%). Predominantly, patients presented with type II achalasia (50%). FLIP measurements were taken before and after myotomy, demonstrating increases in mean distensibility index (DI) 1.6 ± 1. 4 to 5.4 ± 2.1 mm2/mmHg (p < 0.05) and mean diameter (Dmin) 6 ± 1.8 to 10.9 ± 2.3 mm (p < 0.05) at 50 ml balloon fill. Additional myotomy was performed in one patient when an inadequate increase in FLIP values were noted. Mean operative time was 98 ± 28 min, and there were no intraoperative complications. At the 30-day follow-up, median Eckardt score decreased from mean a preoperative score of 7 ± 2 to a post-operative mean of 2 ± 3, with 10 patients (78%) having a score ≤ 2. In total, four patients experienced symptom recurrence, with repeat FLIP values revealing a significant decrease in DI from 7 ± 2.2 post-POEM to 2.5 ± 1.5 at recurrence. FLIP technology identified LES pathology in 3 out of 4 (75%) patients, facilitating referral to LES-directed therapy.ConclusionOur study adds to the literature supporting the use of FLIP technology during the POEM procedure, with most patients achieving ideal values after a standard-length myotomy. This suggests the potential benefits of shorter myotomies guided by FLIP to achieve comparable outcomes and reduce postoperative GERD risk. Collaborative standardization of study designs and outcome measures is crucial for facilitating prospective trials and cross-setting outcome comparisons.Graphical abstract

Clinical outcomes and manometry results of peroral endoscopic myotomy in patients with achalasia: experience in a Latin American referral centre

IntroductionCurrently there is little information in Latin America on the clinical outcome and manometric evolution of patients with Achalasia undergoing peroral endoscopic myotomy (POEM). Primary outcomeEvaluate the manometric and clinical changes in adult patients with achalasia after peroral endoscopic myotomy at a referral center in Bogotá, Colombia. MethodsObservational, analytical, longitudinal study. Adult patients with achalasia according to the Chicago 4.0 criteria were included. Sociodemographic, clinical and manometric variables were described. To compare the pre- and post-surgical variables, the Student’s or Wilcoxon’s t test was used for the quantitative variables according to their normality, and McNemar’s chi-square for the qualitative variables. Results29 patients were included, 55.17% (n = 16) women, with a mean age at the time of surgery of 48.2 years (±11.33). The mean post-procedure evaluation time was 1.88 ± 0.81 years. After the procedure, there was a significant decrease in the proportion of patients with weight loss (37.93% vs 21.43% p = 0.0063), chest pain (48.28% vs 21.43, p = 0.0225) and the median Eckardt score (8 (IQR 8–9) vs 2 (IQR 1–2), p < 0.0001). In addition, in fourteen patients with post-surgical manometry, significant differences were found between IRP values (23.05 ± 14.83 mmHg vs 7.69 ± 6.06 mmHg, p = 0.026) and in the mean lower esophageal sphincter tone (9.63 ± 7.2 mmHg vs 28.8 ± 18.60 mmHg, p = 0.0238). ConclusionPeroral endoscopic myotomy has a positive impact on the improvement of symptoms and of some manometric variables (IRP and LES tone) in patients with achalasia.

Effectiveness and safety of peroral endoscopic myotomy in patients with achalasia

Aim: This study aimed to present the outcomes in terms of efficacy and complications of the POEM procedure in adult patients diagnosed with achalasia and to investigate the potential effects of traditional risk factors such as age, gender, and obesity on these outcomes.&#x0D; Material and Methods: A total of 51 patients who underwent a POEM procedure were retrospectively evaluated from January 2021 to July 2023. The main outcome measured was the rate of clinical success, determined by achieving an Eckardt score of 3 or lower two months after the procedure. Secondary outcomes involved any adverse events, ICU admissions, and the presence of reflux symptoms at the two-month post-procedure mark.&#x0D; Results: The mean age of the patients was 49.3 ± 13.3 years, and the duration of symptoms ranged between 6 months and 10 years. Preoperative median Eckardt scores were 9, ranging between 5 and 12. At the 2nd month post-procedure, 96.1% of patients had an Eckardt score of 3 or lower, with a median reduction of 8 points (IQR = 6 – 8, p &lt; 0.001). Among the patients, 13.7% encountered adverse events, comprising 3.9% with pneumomediastinum, 1.9% with mediastinitis, and 1.9% with intra-tunnel bleeding. At the 2nd month post-procedure, 17.6% of patients exhibited reflux esophagitis. No mortality was observed in any of the patients.&#x0D; Conclusion: POEM is an effective, safe, and minimally invasive treatment for achalasia that represents a promising therapeutic option, offering symptomatic relief, improved quality of life, and boasting a high clinical success rate. Although a small percentage of patients experienced adverse events, these were manageable and did not result in mortality.

Resultados clínicos y manométricos de la miotomía endoscópica peroral en pacientes con acalasia: experiencia en un centro de referencia latinoamericano

IntroductionCurrently there is little information in Latin America on the clinical outcome and manometric evolution of patients with Achalasia undergoing peroral endoscopic myotomy (POEM). Primary outcomeEvaluate the manometric and clinical changes in adult patients with achalasia after peroral endoscopic myotomy at a referral center in Bogotá, Colombia. MethodsObservational, analytical, longitudinal study. Adult patients with achalasia according to the Chicago 4.0 criteria were included. Sociodemographic, clinical and manometric variables were described. To compare the pre- and post-surgical variables, the Student's or Wilcoxon's t test was used for the quantitative variables according to their normality, and McNemar's chi-square for the qualitative variables. Results29 patients were included, 55.17% (n=16) women, with a mean age at the time of surgery of 48.2 years (±11.33). The mean post-procedure evaluation time was 1.88±0.81 years. After the procedure, there was a significant decrease in the proportion of patients with weight loss (37.93% vs 21.43% p 0.0063), chest pain (48.28% vs 21.43, p 0.0225) and the median Eckardt score (8 (IQR 8 -9) vs 2(IQR 1-2), p <0.0001). In addition, in fourteen patients with post-surgical manometry, significant differences were found between IRP values (23.05±14.83mmHg vs 7.69±6.06mmHg, p 0.026) and in the mean lower esophageal sphincter tone (9.63±7.2mmHg vs 28.8±18.60mmHg, p 0.0238). ConclusionPeroral endoscopic myotomy has a positive impact on the improvement of symptoms and of some manometric variables (IRP and LES tone) in patients with achalasia.

Presence of esophageal contractility after achalasia treatment is associated with improved esophageal emptying.

Some achalasia patients exhibit esophageal contractile activity on follow-up after treatment, yet its importance remains unclear. We aimed to identify factors associated with presence of contractility after treatment and to assess its impact on timed barium esophagram (TBE) and clinical outcomes. Patients with type I or II achalasia on baseline high-resolution manometry (HRM) who completed HRM, TBE, and functional lumen imaging probe (FLIP) after treatment were retrospectively identified. Contractility was defined on post-treatment HRM as presence of at least 1 supine swallow with DCI ≥100 mmHg s cm. One hundred twenty-two patients were included (mean age 48 ± 17 years, 50% female). At follow-up evaluation after treatment (54% peroral endoscopic myotomy, 24% pneumatic dilation, 22% laparoscopic Heller myotomy), 61 (50%) patients had contractility on HRM. Patients with contractility (compared to those without) more frequently had type II achalasia (84% vs 57%, p = 0.001) and a post-treatment normal EGJ opening classification on FLIP (69% vs 49%; p < 0.001). In the subgroup of patients with post-treatment integrated relaxation pressure <15 mmHg and normal EGJ opening on FLIP (n = 53), those with contractility had a lower median column height on TBE at 1 min (4 vs 7 cm, p = 0.002) and 5 min (0 vs 5 cm, p = 0.001). In patients with "abnormal" EGJ metrics, patients with contractility showed lower symptom scores (median Eckardt score 2 vs 3, p = 0.03). Occurring more frequently in type II achalasia, and if adequate EGJ opening is achieved after treatment, esophageal contractility may contribute to improved esophageal emptying and improved symptoms in non-spastic achalasia. Preservation of esophageal body muscle could improve outcomes in these patients.

Efficacy and safety of peroral endoscopic myotomy for esophageal diverticula.

Background and study aims Epiphrenic diverticula are rare and mainly occur in patients with underlying esophageal motility disorders. The current standard treatment is surgical diverticulectomy often combined by myotomy and is associated with significant adverse event (AE) rates. The aim of this study was to examine the efficacy and safety of peroral endoscopic myotomy in reducing esophageal symptoms in patients with esophageal diverticula. Patients and methods We performed a retrospective cohort study including patients with an esophageal diverticulum who underwent POEM between October 2014 and December 2022. After informed consent, data were extracted from medical records and patients completed a survey by telephone. The primary outcome was treatment success, defined as Eckardt score below 4 with a minimal reduction of 2 points. Results Seventeen patients (mean age 71 years, 41.2 % female) were included. Achalasia was confirmed in 13 patients (13 /17, 76.5 %), Jackhammer esophagus in two patients (2 /17, 11.8 %), diffuse esophageal spasm in one patient (1 /17, 5.9 %) and in one patient no esophageal motility disorder was found (1 /17, 5.9 %). Treatment success was 68.8 % and only one patient (6.3 %) underwent retreatment (pneumatic dilatation). Median Eckardt scores decreased from 7 to 1 after POEM (p < 0.001). Mean size of the diverticula decreased from 3.6 cm to 2.9 cm after POEM (p < 0.001). Clinical admission was one night for all patients. AEs occurred in two patients (11.8 %) which were classified as grade II and IIIa (AGREE classification). Conclusions POEM is effective and safe to treat patients with esophageal diverticula and an underlying esophageal motility disorder.

Repeat peroral endoscopic myotomy with simultaneous submucosal and muscle dissection as a salvage option for recurrent achalasia

For recurrent achalasia after initial peroral endoscopic myotomy (POEM) failure, repeat POEM (Re-POEM) has been reported as a treatment option. However, severe esophageal interlayer adhesions caused by previous procedures impede the successful establishment of a submucosal tunnel and lead to aborted Re-POEM procedures. Our team previously described POEM with simultaneous submucosal and muscle dissection (POEM-SSMD) as a feasible solution for achalasia with severe interlayer adhesions. To investigate the effectiveness and safety of Re-POEM with simultaneous submucosal and muscle dissection (Re-POEM-SSMD). A total of 1049 patients with achalasia who underwent successful endoscopic myotomy at the Digestive Endoscopic Center of Chinese PLA General Hospital from December 2014 to May 2022 were reviewed. Patients with recurrent achalasia who experienced initial POEM clinical failure were retrospectively included in this study. The primary endpoint was retreatment clinical success, defined as an Eckardt score ≤ 3 during the postretreatment follow-up and no need for additional treatment. Procedure-related adverse events, changes in manometric lower esophageal sphincter (LES) pressure and reflux complications, as well as procedure-related parameters, were recorded. Sixteen patients underwent Re-POEM (9 patients) or Re-POEM-SSMD (7 patients) successfully at a median of 45.5 mo (range, 4-95 mo) after initial POEM. During a median follow-up period of 31 mo (range, 7-96 mo), clinical success (Eckardt score ≤ 3) was achieved in 8 (88.9%) and 6 (85.7%) patients after Re-POEM and Re-POEM-SSMD, respectively (P = 0.849). The median Eckardt score dropped from 4 (range, 3-8) at preretreatment to 1 (range, 0-5) at postretreatment in the Re-POEM group (P = 0.025) and from 5 (range, 2-8) to 2 (range, 0-4) in the Re-POEM-SSMD group (P < 0.001). The mean manometric LES pressure decreased from 23.78 ± 9.04 mmHg to 11.45 ± 5.37 mmHg after Re-POEM (P < 0.001) and from 26.80 ± 7.48 mmHg to 11.05 ± 4.38 mmHg after Re-POEM-SSMD (P < 0.001). No serious adverse events were recorded in both groups. In conclusion, Re-POEM-SSMD appears to be a safe and effective salvage therapy for recurrent achalasia with severe interlayer adhesions.

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.

OGBN P03 Per oral endoscopic myotomy (POEM) for primary achalasia: single-centre, retrospective analysis of 128 patients

Abstract Background Achalasia is a neurodegenerative motility disorder of the oesophagus, presenting with the main symptoms of dysphagia, weight loss, chest pain, and regurgitation. Surgical myotomy is considered the gold standard treatment. However, peroral endoscopic myotomy (POEM) seems to be a safe and effective alternative option which was introduced in 2008. POEM is a procedure performed endoscopically, which allows transection of the muscular fibres of the distal oesophagus and of the lower oesophageal sphincter. In our centre POEM has become a more frequent management option to treat primary achalasia when compared to surgical myotomy. The aim of the study is to analyse the outcomes from a single centre experience. Methods From June 2015 to May 2022, 128 patients underwent a POEM procedure to treat primary achalasia. We performed a retrospective analysis focusing on short term outcomes. Results All 128 patients underwent gastroscopy and manometry as part of the pre-operative workup to diagnose achalasia. Out of the 128 patients, 66 (52%) were women with age ranging from 17 to 79. BMI values ranged from 17 to 42. At 3/128 occasions the procedure was abandoned due to technical difficulty with all 3 patients at the early days of performing POEM highlighting the learning curve of the procedure. 6/128 patients had ongoing symptoms of achalasia post POEM and went on to have a laparoscopic Heller's myotomy. Median length of stay is 2 days (1–11). 6/128 had Clavien Dindo complications class 2 and 2/128 patients required aspiration of peumoperitoneum intra-op and one patient requiring chest drain insertion for surgical emphysema. 15/128 patients had a post-operative water soluble contrast swallow study to exclude leak following challenging cases or concerns for perforation. The median Eckardt score at last follow-up decreased from 7 to 1. Conclusions Our results show that POEM is a safe procedure to treat primary achalasia with minimal complications and preferable outcomes for patients in terms of symptom control. It can performed safely by experienced oesophageal surgeons and there are very good short-term outcomes. In our unit POEM is the primary treatment modality for achalasia.

Efficacy and Safety of Peroral Endoscopic Myotomy for Esophageal Achalasia and Achalasia-Related Diseases in Patients Aged 75 Years and Over.

Peroral endoscopic myotomy (POEM) has become a popular treatment for esophageal achalasia and other esophageal motility disorders. However, its efficacy and safety in elderly patients are unclear. To clarify that, we reviewed the medical records of patients who underwent POEM in our hospital. A total of 11 patients who underwent POEM for esophageal achalasia (n = 10) and jackhammer esophagus (n = 1) were included. Procedural success, defined as the completion of an esophageal and gastric myotomy, was 100%. Clinical success, defined as an Eckardt score of 3 or less, without the use of additional treatments at 2 months, was 100%. The median Eckardt score significantly decreased after the POEM (baseline vs. 2 months after POEM; 7 (2–8) vs. 0 (0–1), p < 0.01). In the second and third years, the cumulative treatment effect maintenance rate was 88.9%. All patients taking antithrombotic agents had safe operations with the temporary discontinuation of these agents. There were four adverse events (two pneumoperitoneum, one mucosal injury, and one pneumonia), all of which improved with fasting or antibiotics. In conclusion, POEM is an effective and safe treatment for esophageal achalasia and achalasia-related diseases in patients aged 75 years and over.

558 OUTCOMES OF PER ORAL ENDOSCOPIC MYOTOMY IN ACHALASIA IN PATIENTS WITH END-STAGE ESOPHAGUS

Abstract Per oral endoscopic myotomy (POEM) has emerged as a favorable alterative to Heller myotomy for achalasia. However data is limited on the effectiveness in palliation of symptoms in patients who have an esophagus with a sigmoid/tortuous configuration, or a mega-esophagus with width more than 5 cm, due to long-standing achalasia. Our objective is to investigate the outcomes after POEM procedure in patients diagnosed with achalasia and considered end-stage. Methods A retrospective cohort study was conducted in a large hospital between April 2014 and July 2019. A total of 504 patients were identified with 218 undergoing POEM during the study time period of which 57 patients had a sigmoid or tortuous esophagus, and/or had a barium column width of more than 5 cm on timed barium esophagograms (TBE). Primary outcome was symptom relief during follow-up, defined as a post-operative Eckardt score ≤ 3. We also explored integrated resting pressure (IRP) on manometry, barium column height and width on TBE, complications and procedure related parameters. Statistical analyses were performed using R. Results Significant decrease in median Eckardt scores were observed, 7.5 [6,8.8] pre-operatively to 0 [0,1] at 2 months (p &amp;lt; 0.001). At 2 years, 12 of 14 patients (85%), reported scores of ≤3. Improvements at 2 months were noted in median IRP (25.4 mmHg [15.5, 35.9] vs. 4.0 mmHg [2.2,9.0]), 1 min TBE height (11.5 cm [7.5,15.0] vs. 6.8 cm [4.7,9.0]) and width (5.0 cm [4.1,6.1] vs. 2.8 cm [1.9,3.1]), p &amp;lt; 0.001. At 2 years, they were 9.5 cm [5,12.8] and 3.0 cm [2.4,4.5], respectively. Post-operative pH studies in 35(61%) patients demonstrated a DeMeester score ≥ 14.72 in 17(49%) patients. Almost all patients reported return to activities of daily living within 7 days. Conclusion POEM is an effective and safe modality in achalasia patients with end-stage esophagus. Patients in this cohort historically have had poor outcome to interventions and our data shows excellent short-to-medium term outcome with low morbidity after POEM. Given its efficacy, minimal invasiveness and short return to function, POEM is a reasonable first and gold standard palliative therapy in this difficult cohort and should be attempted before considering esophagectomy.

Revisional Therapy for Recurrent Symptoms After Heller Myotomy for Achalasia

PurposeSymptom recurrence after initial surgical management of esophageal achalasia occurs in 10–25% of patients. The aim of this study was to analyze safety and efficacy of revisional therapy after failed Heller myotomy (HM). MethodsA retrospective review of a prospective database was performed searching for patients with recurrent symptoms after primary surgical therapy for achalasia. Patients with previously failed HM were considered for the final analysis. The Foregut questionnaire, and the Atkinson and Eckardt scales were used to assess severity of symptoms. Objective investigations routinely included upper gastrointestinal endoscopy and barium swallow study. Redo treatments consisted of endoscopic pneumatic dilation (PD), laparoscopic HM, hybrid Ivor Lewis esophagectomy, or stapled cardioplasty. A yearly clinical and endoscopic follow-up was scheduled in all patients. ResultsOver a 20-year period, 26 patients with a median age of 66 years (IQR 19.5) underwent revisional therapy after failed HM for achalasia at a tertiary-care university hospital. The median time after index procedure was 10 years (IQR 21). Revisional therapy consisted of endoscopic pneumatic dilation (n=13), laparoscopic HM and fundoplication (n=10), esophagectomy (n=2), and stapled cardioplasty and fundoplication (n=1). Nine (34.6%) of these patients required further endoscopic or surgical treatments. There was no mortality, and the overall complication rate was 7.7%. At a median follow-up of 42 months (range 10–149), a significant decrease of dysphagia, regurgitation, chest pain, respiratory symptoms, and median Eckardt score (p<0.05) was noted. ConclusionIn specialized and multidisciplinary centers, revisional therapy for achalasia is feasible, safe, and effective.

Per-oral endoscopic dual myotomy for the treatment of achalasia

BackgroundRepeat per-oral endoscopic myotomy is occasionally performed for persistent/recurrent symptoms in patients with achalasia, and yields favorable outcomes. We investigated a novel technique, per-oral endoscopic dual myotomy (dual-POEM), where a second myotomy was performed during a single session to augment the efficacy and avoid repeat interventions. The aim of this study was to evaluate its feasibility, safety and efficacy.MethodsConsecutive patients diagnosed with achalasia who underwent dual-POEM (1/2018–5/2019) were prospectively collected and retrospectively analyzed. Patients with baseline Eckardt score ≥ 9, ≥ 10 years of symptoms, and/or having prior interventions other than myotomy received dual-POEM. The primary outcome was clinical success (Eckardt score ≤ 3). Secondary outcomes were procedure-related adverse events, change in lower esophageal sphincter (LES) pressure, and reflux complications.ResultsSeventeen patients received dual-POEM. Procedure-related adverse events were observed in 2 (11.8%) patients (mucosal injury and pneumonitis). Both were minor in severity. During a median follow-up of 33 months (interquartile range, IQR [31,35]; range, 19–36), clinical success was achieved in 16 (94.1%) patients. The median Eckardt score decreased from 9 (IQR [8, 11.5]; range 7–12) to 1 (IQR [1, 2]; range 0–4) (P < 0.001), and LES pressure decreased from 25.8 mmHg (IQR [21.7, 33.5]; range 17.7–46.3) to 7.4 mmHg (IQR [6.3, 10.4]; range 2.2–12.6) (P < 0.001). Seven (41.2%) patients developed postprocedural reflux either by gastroesophageal reflux disease questionnaire or esophagitis endoscopically, all successfully treated with proton pump inhibitors.ConclusionDual-POEM preliminarily demonstrated high efficacy with a favorable safety profile in patients with achalasia with predictors of treatment failure.

Prospective evaluation of the efficacy of peroral endoscopic myotomy in patients with achalasia.

Peroral endoscopic myotomy (POEM) is an endoscopic alternative to surgical myotomy in patients with achalasia. This study aimed to evaluate the efficacy and clinical outcomes of POEM.A total of 20 patients with achalasia who underwent POEM between October 2016 and November 2017 were prospectively recruited. The intraoperative esophagogastric junction distensibility index (mm2/mm Hg) was measured pre- and post-myotomy using an endoluminal functional lumen imaging probe. Clinical response was defined as Eckardt score ≤3. Health-related quality of life was measured by the 36-item short-form health survey score.POEM was successfully completed in all cases. The median procedure time was 68.5 minutes (range 50.0–120.0), and the median myotomy length was 13 cm (range 11–18). Major adverse events were encountered in 2 cases. Overall, clinical responses were observed in all patients during a median follow-up of 11.9 months (range 1.2–26.2). Postoperative esophagogastric junction distensibility index was significantly higher than baseline (from 1.3 [range 0.8–6.9] to 6.3 [range 25–19.2], P < .001). The median Eckardt scores were decreased after POEM (5 [range 2–11] to 1 [range 0–3], P < .001), and the 36-item short-form health survey score was also improved significantly after POEM (67.5 [range 34.5–93.9] to 85.7 [range 53.4–93.3], P = .004).POEM is an effective treatment for achalasia, based on the improvement of both symptoms and objective measures.Clinicaltrial.gov NCT 02989883

Intraoperative diagnosis and treatment of Achalasia using EndoFLIP during Heller Myotomy and Dor fundoplication

Manometry is the gold standard diagnostic test for achalasia. However, there are incidences where manometry cannot be obtained preoperatively, or the results of manometry is inconsistent with the patient's symptomatology. We aim to determine if intraoperative use of EndoFLIP can provide a diagnosis of achalasia and provide objective information during Heller myotomy and Dor fundoplication. To determine the intraoperative diagnostic EndoFLIP values for patients with achalasia, we determined the optimal cut-off points of the distensibility index (DI) between patients with a diagnosis of achalasia and patients with a diagnosis of hiatal hernia. To evaluate the usefulness of EndoFLIP values during Heller myotomy and Dor fundoplication, we obtained a cohort of patients with EndoFLIP values obtained after Heller myotomy and after Dor fundoplication as well as Eckardt score before and after surgery. Our analysis of 169 patients (133 hiatal hernia and 36 achalasia) showed that patients with DI < 0.8 have a >99% probability of having achalasia, while DI > 2.3 have a >99% probability of having hiatal hernia. Patients with a DI 0.8-1.3 have a 95% probability of having achalasia, and patients with a DI of 1.4-2.2 have a 94% probability of having a hiatal hernia. There were 40 patients in the cohort to determine objective data during Heller myotomy and Dor fundoplication. The DI increased from a median of 0.7 to 3.2 after myotomy and decreased to 2.2 after Dor fundoplication (p < 0.001). The median Eckardt score went down from a median of 4.5 to 0 (p < 0.001). Our study shows that intraoperative use of EndoFLIP can facilitate the diagnosis of achalasia and is used as an adjunct to diagnose achalasia when symptoms are inconsistent. The routine use of EndoFLIP during Heller myotomy and Dor fundoplication provides objective data during the operation in a group of patients with excellent short-term outcomes.

Peroral endoscopic myotomy provides effective palliation in type III achalasia

BackgroundType III achalasia outcomes have historically been met with limited success after conventional laparoscopic Heller myotomy (LHM) and pneumatic dilation. Peroral endoscopic myotomy (POEM) has emerged as a promising alterative for a multitude of reasons. Our objective was to investigate POEM outcomes in palliating type III achalasia. MethodsA retrospective analysis of a prospectively maintained database was conducted in a tertiary care institution between April 2014 and July 2019. The primary outcome was postoperative Eckardt score. We also explored the effect of lower esophageal sphincter (LES) integrated resting pressure (IRP) on manometry, barium column height and width, and complications. Standard statistical methods were applied using R. ResultsA total of 518 patients in the achalasia database were identified, with 308 patients undergoing LHM and 210 undergoing POEM during the study period. POEM was used for type III achalasia in 36 patients (median age, 60 years; 61.7% male), with a median operative time of 85 minutes (interquartile range [IQR], 71-115 minutes) and follow-up of 1 year (IQR, 0.16-2.25 years). Within the POEM group, 11 patients (33%) had previous interventions, including Botox injections to the LES (n = 7), pneumatic dilation (n = 1), and LHM (n = 3). A significant decrease in median Eckardt score was observed (7 preoperatively [IQR, 6-8.75] vs 0 postoperatively [IQR, 0-1]; P < .01). Similar improvements after POEM were noted in median LES IRPs (25.5 mmHg vs 4.5 mmgHg; P < .01), 1-minute barium column height (10 cm vs 0 cm; P < .01), and 1-minute barium column width (2 cm vs 0 cm; P < .01). Patients reported a return to activities of daily living in a median of 7 days (IQR, 3-7 days). Three patients experienced complications, including mucosal perforation resolving with conservative management (n = 1), readmission for bleeding duodenal ulcer responding to proton pump inhibitors (n = 1), and readmission for dysphagia and rehydration (n = 1). Postoperative esophageal pH studies were conducted in 21 patients (62%), demonstrating a Demeester score of >14.72 in 13 patients (62%). ConclusionsPOEM provides effective and durable palliation for type III achalasia, as demonstrated by symptom relief, esophageal manometry, and radiographic measurement. Considering its low morbidity profile, POEM should be considered as first-line therapy in this challenging disease subtype.

Advanced achalasia: good candidate for peroral endoscopic myotomy.

Peroral endoscopic myotomy (POEM) has been increasingly accepted as the first-line treatment of achalasia. However, laparoscopic Heller myotomy or esophagectomy still remains as the mainstay treatment for advanced achalasia featured with megaesophagus and/or sigmoid-shaped esophagus. Although the efficacy of POEM for advanced achalasia with sigmoid-shaped esophagus has been described, little is known about the role of POEM for patients with megaesophagus. The aim of our study is to evaluate the efficacy and safety of POEM for advanced achalasia with megaesophagus. Patients who received initial examinations and underwent POEM in our hospital from June 2013 to December 2018 were identified and data were retrospectively analyzed. The advanced achalasia was defined as megaesophagus with a diameter of ≥6cm. The primary outcome was clinical success. The secondary outcomes were technical success and adverse events. A total of 112 patients (50 females, 44.6%) were included with a mean age of 44.8years. The median symptom duration was 6.5years (IQR:3.0-13.0years). Modified POEM techniques were used in 27.7% (31/112) of patients. Technical success rate was 99.1% (112/113) per procedure. Clinical success was seen in 93.1% patients with median Eckardt score decreasing from 8.0 to 1.0 (P < 0.001) during a median 31.0months of follow-up. The mean LES pressure decreased from 29.5mmHg to 14.2mmHg after POEM (P < 0.05). Procedure-related adverse events occurred in 8.9% patients. Reflux disease was observed postoperatively in 26.7% of patients. POEM is also indicated for patients with advanced achalasia with a favorable safety and efficacy.

505 SURPRISING LACK OF CORRELATION BETWEEN INTEGRATED RELAXATION PRESSURE LEVEL AND SYMPTOM SEVERITY IN PATIENTS WITH ACHALASIA

Abstract With high resolution manometry (HRM), achalasia is defined as an elevated integrated relaxation pressure (IRP) and the absence of normal esophageal peristalsis. Since achalasia symptoms are attributed in part to incomplete LES relaxation, IRP values might be expected to directly correlate with symptom severity. The aim of this study was to evaluate the relationship between IRP values and symptom severity assessed by the Eckardt score in patients with achalasia. Methods We searched the database of our Center for Esophageal Diseases for patients who had HRM showing achalasia (IRP &amp;gt; 15 mmHg and absent peristalsis) between May 2017 and August 2019. All patients with achalasia seen in our Center routinely complete the Eckardt score questionnaire evaluating the severity of achalasia symptoms in each of four categories (dysphagia, chest pain, regurgitation and weight loss). Pearson correlation coefficient was used to assess the relationship between median IRP and Eckardt score; an R2 value &amp;gt;0.5 was considered clinically meaningful. Results We identified 91 subjects with achalasia (mean age 62.9 ± 16.5 years; 39 men, 52 women; 27 Type 1, 28 Type 2, 36 Type 3). We found no clinically meaningful correlation between median IRP and the total Eckardt score (R2 = 0.043) (Figure 1). Furthermore, we found no clinically meaningful correlation between median IRP and any individual component of the Eckardt score (dysphagia R2 = 0.008, chest pain R2 = 0.001, regurgitation R2 = 0.035, weight loss R2 = 0.049). Finally, in subgroup analyses we found no clinically meaningful correlation between median IRP and Eckardt scores (total or any of its individual components) for any of the 3 achalasia subtypes. Conclusion We found no clinically meaningful correlation between IRP and total Eckardt score, or between IRP and any individual component of the Eckardt score for patients with achalasia of any type. This suggests that once the IRP value exceeds 15 mmHg, further elevations in IRP have little effect on symptoms, and that factors other than IRP such as esophageal body dysmotility and hypersensitivity might contribute to symptom perception in achalasia.

340 EXPANDING THE ROLE OF POEM TO ESOPHAGEAL EPIPHRENIC DIVERTICULA—FEASIBLE, SAFE AND EFFECTIVE.

Abstract Epiphrenic diverticula (ED) is a rare disorder which can be associated with significant surgical morbidity. Presence of an esophageal motility disorder, often achalasia, is classically associated with ED with some arguing that symptoms are primarily attributed to the motility disorder rather than the diverticula itself. The role of peroral endoscopic myotomy (POEM) is expanding for palliation of achalasia. The objective of our study is to investigate the outcomes of POEM in patients with epiphrenic diverticula. Methods A retrospective analysis of a prospectively maintained database was conducted in a tertiary care institution between April 2014 and July 2019. A total of 217 patients receiving a POEM during the study time period were identified with 13 patients having ED. Video recordings of POEM with and without ED were compared for technical differences. Patient demographics, prior esophageal procedures and epiphrenic diverticula characteristics were collected. Primary outcome was post-operative Eckardt scores. We also explored integrated resting pressure (IRP) on manometry, barium column height and width, complications and patient reported outcomes. Standard statistical methods were applied using R. Results Among 13 patients with ED (median age 74.2, 69% male), 7 small and 6 large diverticula were identified. No post-operative complications were noted. The median Eckardt score significantly decreased from 8 [IQR 5–9] pre POEM to 0 [IQR 0–2] post POEM, with similar improvements in median IRPs (24.5 mmHg [IQR 16.9–31.3] vs. 4.3 mmHg [IQR 2.4–7.6], 1 min barium column height (9.2 cm [IQR 6.3–17.9] vs. 3.2 cm [IQR 0–7.1] and 1 min barium column width (3.3 cm [IQR 2.7–3.5] vs. 0.75 cm [IQR 0–3.7]. Post-operative pH studies were conducted in 7 (53.8%) patients demonstrating a DeMeester score of more than 14.72 in 5 (71.4%) patients. Conclusion We demonstrate that POEM is technically feasible, safe and associated with excellent outcomes in patients with small and large diverticula. In our study cohort no further surgical therapy was required to address the diverticula. Reflux was managed medically. Considering its low morbidity profile POEM should be considered for therapy in selected patients with epiphrenic diverticula.

The timed barium swallow and its relationship to symptoms in achalasia: Analysis of surface area and emptying rate.

Timed barium swallow (TBS) is used to objectively measure response following achalasia therapy; however, findings can be discordant with symptoms. We hypothesized that measurement of surface area of the residual barium column would improve its utility in measuring outcome. In a single-center cohort, achalasia patients undergoing therapy between September 2015-2016 who had TBS were included. Four metrics of emptying were studied: Post-therapy residual barium (a) absolute height and (b) surface area and percentage reduction in (c) residual height (%H) and (d) surface area (%SA) compared to pretherapy. Metrics were evaluated against symptom response (Eckardt score). Twenty-four achalasics (median age 43year; 13 males) were included; 14 received pneumatic dilatation, and 10 had peroral endoscopic myotomy. Treatment resulted in significant reduction in median Eckardt score (7 to 1; P=.03), mean residual barium column height (14.7±8.7 to 7.9±6.0cm; P=.01) and surface area (52.7±43.5 to 24.5±23.6cm2 ; P=.02). There were 4 (17%) initial non-responders (Eckardt>3). % SA was best at discriminating between responders and non-responders (area under curve 0.85±0.08; sensitivity 100%, specificity 80%). Concordance with symptomatic response following therapy was 83% when using 45% as the cutoff for surface area reduction compared to pretherapy. Eight patients whose static barium height was discordant with symptoms became concordant when % SA was used as a measure of response. Change in barium surface area is a superior measure of esophageal emptying and better correlates with treatment response than the conventional 5-minute barium height in defining objective response to achalasia therapy.