Spastic Esophageal Disorders Research Articles

POEM for Spastic Esophageal Disorders

Increasing recognition of the effectiveness of peroral endoscopic myotomy (POEM) therapy for achalasia (NEJM JW Gastroenterol Jul 28 2014) has

International multicenter experience with peroral endoscopic myotomy for the treatment of spastic esophageal disorders refractory to medical therapy (with video)

Limited data exist on the use of peroral endoscopic myotomy (POEM) for therapy of spastic esophageal disorders (SEDs). To study the efficacy and safety of POEM for the treatment of patients with diffuse esophageal spasm, jackhammer esophagus, or type III (spastic) achalasia. Retrospective study. International, multicenter, academic institutions. All patients who underwent POEM for treatment of SEDs refractory to medical therapy at 11 centers were included. POEM. Eckardt score and adverse events. A total of 73 patients underwent POEM for treatment of SEDs (diffuse esophageal spasm 9, jackhammer esophagus 10, spastic achalasia 54). POEM was successfully completed in all patients, with a mean procedural time of 118 minutes. The mean length of the submucosal tunnel was 19 cm, and the mean myotomy length was 16 cm. A total of 8 adverse events (11%) occurred, with 5 rated as mild, 3 moderate, and 0 severe. The mean length of hospital stay was 3.4 days. There was a significant decrease in Eckardt scores after POEM (6.71 vs 1.13; P = .0001). Overall, clinical response was observed in 93% of patients during a mean follow-up of 234 days. Chest pain significantly improved in 87% of patients who reported chest pain before POEM. Repeat manometry after POEM was available in 44 patients and showed resolution of initial manometric abnormalities in all cases. Retrospective design and selection bias. POEM offers a logical therapeutic modality for patients with SEDs refractory to medical therapy. Results from this international study suggest POEM as an effective and safe platform for these patients.

Is Peroral Endoscopic Myotomy Effective for the Treatment of Spastic Esophageal Disorders Refractory to Medical Therapy?

Is Peroral Endoscopic Myotomy Effective for the Treatment of Spastic Esophageal Disorders Refractory to Medical Therapy?

Peroral endoscopic myotomy.

Peroral endoscopic myotomy (POEM) incorporates concepts of natural orifice translumenal endoscopic surgery and achieves endoscopic myotomy by utilizing a submucosal tunnel as an operating space. Although intended for the palliation of symptoms of achalasia, there is mounting data to suggest it is also efficacious in the management of spastic esophageal disorders. The technique requires an understanding of the pathophysiology of esophageal motility disorders as well as knowledge of surgical anatomy of the foregut. POEM achieves short term response in 82% to 100% of patients with minimal risk of adverse events. In addition, it appears to be effective and safe even at the extremes of age and regardless of prior therapy undertaken. Although infrequent, the ability of the endoscopist to manage an intraprocedural adverse event is critical as failure to do so could result in significant morbidity. The major late adverse event is gastroesophageal reflux which appears to occur in 20% to 46% of patients. Research is being conducted to clarify the optimal technique for POEM and a personalized approach by measuring intraprocedural esophagogastric junction distensibility appears promising. In addition to esophageal disorders, POEM is being studied in the management of gastroparesis (gastric pyloromyotomy) with initial reports demonstrating technical feasibility. Although POEM represents a paradigm shift the management of esophageal motility disorders, the results of prospective randomized controlled trials with long-term follow up are eagerly awaited.

Peroral Endoscopic Myotomy (POEM) for Esophageal Primary Motility Disorders: Analysis of 100 Consecutive Patients

IntroductionPeroral endoscopic myotomy (POEM) is a flexible endoscopic approach to the lower esophageal sphincter (LES) providing access for a myotomy to relieve dysphagia. The technique has been adopted worldwide due to reports of excellent short-term clinical outcomes. We report on a consecutive patient cohort with clinical and objective outcomes representing the establishment of a POEM program within a busy esophageal surgical practice. MethodsComprehensive data was collected prospectively on all patients undergoing POEM from October 2010 to November 2013 at a single institution. Patients were classified based on high-resolution manometry (HRM). Operative data and immediate outcomes were reviewed. Symptom scores, HRM, and timed barium swallow (TBS) were performed prior to the procedure. Patients were asked to undergo routine postoperative testing 6–12 months after surgery with the addition of standard 24-h pH to the preoperative protocol. Morbidity was defined as requiring additional procedures or prolonged hospital stay >2 days. ResultsOne hundred POEM patients were included in the final analysis. The mean age was 58 years (18–83 years). Primary presenting symptoms included dysphagia 81, chest pain 10, and regurgitation 9. The mean follow-up was 16 months. HRM diagnoses were 75 achalasia (30 type I, 43 type II, 2 type III), 12 nutcracker esophagus, 5 diffuse esophageal spasm (DES), and 8 isolated hypertensive non-relaxing LES.The mean operative time was 128 min. The median hospital length of stay (LOS) was 1 day. The overall morbidity was 6 %; all were treated endoscopically or with conservative management without further sequelae (three had intra-tunnel leak diagnosed on routine esophagram and one developed a postoperative intra-tunnel hemorrhage, one developed Ogilvie’s, and one required prolonged intubation for CO2 retention).The average LES resting/residual pressure significantly decreased (44.3/22.2 to 19.6/11.7 in millimeters of mercury). Esophageal emptying improved from 40 to 90 % on TBS with 93 % patients demonstrating >90 % emptying at 1 min. Of the achalasia patients, 36 % (17/47) showed some return of normal peristalsis (≥70 % peristalsis) on post-op HRM.Abnormal acid exposure was present on postoperative testing in 38 % (26/68). Of these, 14 were asymptomatic. No reflux patient required additional antireflux procedure.Eckardt scores decreased from 6 to 1. Dysphagia was improved or eradicated in 97 % with a complete resolution accomplished in 89 %. Complete dysphagia relief was better for achalasia patients (46/47 patients; 97.8 %) vs. non-achalasia patients (17/24; 70.8 %). Of those with preoperative chest pain, 91.5 % reported complete relief.Four patients have refractory dysphagia. Two non-achalasia patients underwent subsequent laparoscopic Heller myotomy and two are improved following serial endoscopic dilatations. ConclusionThis study represents the largest POEM series to date that includes objective data. Despite reflux in one/three of patients, POEM provides excellent relief of dysphagia (97 %) and chest pain (91.5 %) for patients with esophageal spastic disorders with acceptable procedural morbidity.

Submucosal endoscopy: the new frontier of therapeutic endoscopy.

Peroral endoscopic myotomy (POEM) and submucosal tunneling and endoscopic resection (STER) have been recently described as minimally invasive therapies for achalasia and gastrointestinal subepithelial tumors originating from the muscularis propria, respectively. This review illustrates the latest developments in the field of submucosal endoscopy, focuses on POEM and sheds light on STER. Multiple studies from the United States, Asia and Europe have shown that POEM is an effective and safe procedure for achalasia when performed by experienced operators with adequate clinical response in 80-90% of patients. Nonetheless, POEM requires a demanding skill set that involves both advanced endoscopic skills and knowledge of surgical anatomy. In addition, the endoscopist must have the capability to manage procedural complications. Similarly, STER appears to be an effective therapy for treatment of small and medium sized gastrointestinal tumors originating from the muscularis propria. POEM and STER offer minimally invasive and effective treatment alternatives for patients with achalasia, spastic esophageal disorders and upper gastrointestinal tumors originating from the muscularis propria.

PTU-158 Botulinum Toxin Use In Oesophageal Dysmotility

IntroductionOesophageal dysmotility represents a treatment challenge, with many patients refractory to medical management. There is a lack of evidence for the treatment of oesophageal dysmotility, with only a handful of...

750 Per-Oral Endoscopic Myotomy (POEM) for Esophageal Spastic Disorders: Analysis of 100 Patients

750 Per-Oral Endoscopic Myotomy (POEM) for Esophageal Spastic Disorders: Analysis of 100 Patients

733 International Multicenter Experience With PerOral Endoscopic Myotomy (POEM) for the Treatment of Spastic Esophageal Disorders Refractory to Medical Therapy

according to the ASGE lexicon’s severity grading system. The length of procedure (LOP) and LOP per centimeter myotomy were trended in consecutive POEM procedures and used as a marker to determine the learning curve. Results: A total of 26 patients (mean age 46, 15 Female) underwent POEM for treatment of achalasia (type I 1, type II 19, type III 2) or SED (Jackhammer Esophagus 4). POEM was successfully performed in the endoscopy suite and completed in all patients (anterior approach 24, posterior approach 2) with a mean LOP of 135 minutes (range 69-216 min). The mean length of submucosal tunnel was 13 cm (range 9-24). The mean myotomy length was 10 (range 7-19cm) (esophageal 7 cm, cardia 3 cm). There was significant decrease in Eckhardt score after POEM (8.27 vs. 0.95, pZ!0.0001). Overall, clinical response was observed in 25 (96%) patients. Abnormal acid exposure (symptomatic and asymptomatic) occurred in 7 (27%) patients. The mean LES pressure decreased significantly after POEM (28 vs. 18, pZ0.05). A total of 3 complications occurred in 3 patients with 1 complication rated as mild, 2 moderate and none severe. Mucosotomy occurred in 2 (7%) patients and were successfully treated with endoscopic closure. The mean length of hospital stay was 2.6 days (range 1-10). The mean LOP significantly decreased after 13 procedures (142 min vs. 114 min pZ0.04). Similarly, the mean LOP per cm myotomy significantly decreased after 13 procedures (15.5min/cm vs. 11 min/cm pZ0.009). Conclusions: POEM can be effectively and safely performed by experienced gastroenterologists in a tertiary care endoscopy unit. The learning curve for POEM plateaus at around 13 cases for experienced endoscopists. 733 International Multicenter Experience With PerOral Endoscopic Myotomy (POEM) for the Treatment of Spastic Esophageal Disorders Refractory to Medical Therapy Mouen Khashab*, Ahmed a. Messallam, Manabu Onimaru, Ezra N. Teitelbaum, Michael B. Ujiki, Matthew E. Gitelis, Rani J. Modayil, Eric S. Hungness, Stavros N. Stavropoulos, Mohamad H. El Zein, Hironari Shiwaku, Rastislav Kunda, Alessandro Repici, Hitomi Minami, Philip W. Chiu, Jeffrey Ponsky, Amit P. Maydeo, Haruhiro Inoue Johns Hopkins Medical Institute, Baltimore, MD; Nagazaki University Hospital, Nagazaki, Japan; Winthrop University Hospital, Rock Hill, SC; Showa University Northern Yokohama Hospital, Yokohama, Japan; Fukuoka University Faculty of Medicine, Fukuoka, Japan; Aarhus University Hospital, Aarhus, Denmark; University Hospitals Case Medical Center, Cleveland, OH; Institute of Digestive Disease The Chinese University of Hong Kong, Shatin, Hong Kong; NorthShore University HealthSystem, Evanston, IL; Humanitas research hospital, Milano, Italy; Northwestern Univeristy, Chicago, IL; Baladota institute of digestive sciences, Mumbai, India Background: POEM is potentially an ideal endoscopic therapy for refractory spastic esophageal disorders (SED) since it not only allows myotomy of the lower esophageal sphincter (LES) but also of the esophageal body, where the hypertensive contractions occur. Limited data exist on the use of POEM for therapy of these difficult-to-treat disorders. Aims: To study the efficacy and safety of POEM for the treatment of patients with diffuse esophageal spasm (DES), Jackhammer esophagus (JE), or type III (spastic) achalasia. Methods: All patients who underwent POEM for treatment of SED refractory to medical therapy at 11 centers (5 US, 2 European, 4 Asian) were included. Diagnosis was based on manometric findings. Relevant clinical, manometric, and endoscopic data were abstracted and preand post-procedural symptoms (e.g. Eckardt scores) and manometry were recorded. Clinical response was defined by improvement of symptoms and decrease in Eckardt score to %3. Adverse events were graded according to the ASGE lexicon’s severity grading system. Results: A total of 68 patients (mean age 58 years, 45.5% Female) underwent POEM for treatment of SED [DES 8 (11.7%), JE 10 (14.7%), type III achalasia 50 Table 1. Studies using Plastic Stents for Endoscopic Drainage Study No. of Patients Clinical success (%) All Adverse Events Varadarajulu 2013 20 95 0

732 Can Gastroenterologists Perform POEM Safely and Effectively in the Endoscopy Suite Without a Surgeon?

POEM is a novel endoscopic treatment for achalasia and other spastic esophageal disorders (SED). It requires a demanding skill set that involves both advanced endoscopic skills and knowledge of surgical anatomy and complication management. Most published data comes from procedures performed by surgeons in operating rooms. The safety, efficacy, and learning curve of POEM when performed by gastroenterologists in the endoscopy unit are currently unknown.

Genesis of multipeaked waves of the esophagus: repetitive contractions or motion artifact?

Multipeaked waves (MPW) in the distal esophagus occur frequently in patients with esophageal spastic motor disorders and diabetes mellitus and are thought to represent repetitive esophageal contractions. We aimed to investigate whether the relative motion between a stationary pressure sensor and contracted peristaltic esophageal segment that moves with respiration leads to the formation of MPW. We mathematically modeled the effect of relative movement between a moving pressure segment and a fixed pressure sensor on the pressure waveform morphology. We conducted retrospective analysis of 100 swallow-induced esophageal contractions in 10 patients, who demonstrated >30% MPW on high-resolution manometry (HRM) during standardized swallows. Finally, using HRM, we determined the effects of suspended breathing and hyperventilation on the waveform morphology in 10 patients prospectively. Modeling revealed that relative movement between a stationary pressure sensor and a moving contracted segment, contraction duration, contraction amplitude, respiratory frequency, and depth of respiration affects the waveform morphology. Retrospective analysis demonstrated a close temporal association with the onset of second and subsequent contractions in MPW with respiratory phase reversals. Numbers of peaks in MPW and respiratory phase reversals were closely related to the duration of contraction. In the prospective study, suspended breathing and hyperventilation resulted in a significant decrease and increase in the MPW frequency as well as the number of peaks within MPW respectively. We conclude that MPW observed during clinical motility studies are not indicative of repetitive esophageal contraction; rather they represent respiration-related movement of the contracted esophageal segment in relation to the stationary pressure sensor.

T1226 Genesis of Multi-Peaked Waves of the Esophagus: Repetitive Contractions or Motion Artifact?

Sampath NJ, Bhargava V, Mittal RK. Genesis of multipeaked waves of the esophagus: repetitive contractions or motion artifact?. Am J Physiol Gastrointest Liver Physiol 298: G927–G933, 2010. First published April 1, 2010; doi:10.1152/ajpgi.00044.2010.—Multipeaked waves (MPW) in the distal esophagus occur frequently in patients with esophageal spastic motor disorders and diabetes mellitus and are thought to represent repetitive esophageal contractions. We aimed to investigate whether the relative motion between a stationary pressure sensor and contracted peristaltic esophageal segment that moves with respiration leads to the formation of MPW. We mathematically modeled the effect of relative movement between a moving pressure segment and a fixed pressure sensor on the pressure waveform morphology. We conducted retrospective analysis of 100 swallow-induced esophageal contractions in 10 patients, who demonstrated 30% MPW on high-resolution manometry (HRM) during standardized swallows. Finally, using HRM, we determined the effects of suspended breathing and hyperventilation on the waveform morphology in 10 patients prospectively. Modeling revealed that relative movement between a stationary pressure sensor and a moving contracted segment, contraction duration, contraction amplitude, respiratory frequency, and depth of respiration affects the waveform morphology. Retrospective analysis demonstrated a close temporal association with the onset of second and subsequent contractions in MPW with respiratory phase reversals. Numbers of peaks in MPW and respiratory phase reversals were closely related to the duration of contraction. In the prospective study, suspended breathing and hyperventilation resulted in a significant decrease and increase in the MPW frequency as well as the number of peaks within MPW respectively. We conclude that MPW observed during clinical motility studies are not indicative of repetitive esophageal contraction; rather they represent respiration-related movement of the contracted esophageal segment in relation to the stationary pressure sensor.

Advances in esophageal motor disorders

Esophageal motor disorders, often leading to dysphagia and chest pain, continue to pose diagnostic and therapeutic problems. In the past 12 months important new information regarding esophageal motor disorders was published. This information will be reviewed in this paper. A number of studies have addressed the issue of heterogeneity in achalasia, the best defined esophageal motility disorder. The spastic esophageal motility disorders nutcracker esophagus and diffuse esophageal spasm may coexist with gastroesophageal reflux disease, which has consequences for the management of patients with these disorders. The entity labelled ineffective esophageal motility is associated with reflux esophagitis, but also with morbid obesity. For the detection of disordered transit caused by ineffective esophageal motility, application of intraluminal impedance monitoring in conjunction with manometry leads to improved diagnosis. New data on the effect of Nissen fundoplication on esophageal motility were published during the last year. Recent knowledge on the heterogeneity of achalasia and the association of spastic esophageal motor disorders and ineffective motility with reflux disease will help the clinician in the management of patients with these disorders.

Noncardiac Chest Pain

Noncardiac chest pain (NCCP) affects approximately 1 quarter of the adult population in the United States. The pathophysiology of the disorder remains to be fully elucidated. Identified underlying mechanisms for esophageal pain include gastroesophageal reflux disease (GERD), esophageal dysmotility, and visceral hypersensitivity. Aggressive antireflux treatment has been the main therapeutic strategy for GERD-related NCCP. NCCP patients with or without spastic esophageal motor disorders are responsive to pain modulators. The value of botulinum toxin injection, endoscopic treatment for GERD, and antireflux surgery in alleviating NCCP symptoms is limited.

Long Myotomy With Antireflux Repair for Esophageal Spastic Disorders

This report presents the long-term subjective and objective results of esophageal myotomy and fundoplication by thoracotomy in the treatment of esophageal spastic disorders. From 1977 to 1995, a total of 16 patients with esophageal spastic disorders were referred to our unit and underwent a myotomy with an added partial (n = 12) or total (n = 4) fundoplication. The median follow-up was 6 years. Assessments included clinical evaluation, esophagogram, radionuclide emptying, manometry, 24-hour pH studies, and endoscopy. From the global results, patients with pure spastic disorders (n = 8) were compared to patients with spastic disorders with an accompanying epiphrenic diverticulum (n = 8). There were no deaths, and morbidity was minimal. Preoperative symptoms were similar in all patients with spastic disorders. After surgery, the clinical outcome was significantly better in patients with spastic disorders in the presence of a diverticulum. Delays in esophageal emptying persisted after surgery. Patients with pure spastic disorders showed more diffuse functional abnormalities. Patients with a diverticulum had dysfunction mostly in the distal esophagus. Both groups showed signs of coordination and relaxation abnormalities in the lower esophageal sphincter. Myotomy with antireflux surgery resulted in decreased propulsion and contraction pressure. The resting pressure and relaxation at the level of the lower esophageal sphincter improved, but the coordination abnormalities remained. Failure resulted from either reflux complications (n = 1) or obstruction (n = 4). Patients with spastic disorders plus a diverticulum showed better clinical results and improved esophageal function after surgery when compared to patients with pure spastic disorders. ( J Gastrointest Surg 2002;6:713–722)

Treatment of chest pain in patients with noncardiac, nonreflux, nonachalasia spastic esophageal motor disorders using botulinum toxin injection into the gastroesophageal junction

OBJECTIVE: The aim of this study was to determine if botulinum toxin injection in the gastroesophageal junction improves symptoms in patients with noncardiac chest pain with a spastic esophageal motility disorder. METHODS: Twenty-nine noncardiac chest pain patients with nonachalasia, nonreflux-related spastic esophageal motility disorders were enrolled in this open label trial of botulinum toxin injection at the gastroesophageal junction. Chest pain was the major complaint in all patients. Symptoms of chest pain, dysphagia, regurgitation, and heartburn were scored before and 1 month after botulinum toxin injection. A response to botulinum toxin was defined as at least a 50% reduction in the symptom score with a possible total chest pain score of 4. The duration of response was defined as the time period, between the time of injection and the point in time, at which the severity of the symptoms returned to the preinjection score. RESULTS: Seventy-two percent of the patients responded with at least 50% reduction in chest pain. In these responders, there was a 79% reduction in the mean chest pain score from a preinjection score of 3.7 to a postinjection score of 0.78 ( p < 0.0001). The mean duration of the response for chest pain in these patients was 7.3 ± 4.1 months (range 1–18 months). There was also a significant reduction in the mean regurgitation score, dysphagia score, and total symptom score ( p < 0.0001). CONCLUSIONS: Botulinum toxin injection at the gastroesophageal junction leads to significant symptomatic improvement in patients with spastic esophageal motility disorders whose major complaint is chest pain.

Treatment of chest pain in patients with non-achalasia spastic esophageal motor disorders using botulinum toxin injection

Treatment of chest pain in patients with non-achalasia spastic esophageal motor disorders using botulinum toxin injection

Practical approaches to dysphagia caused by esophageal motor disorders.

Dysphagia is a common symptom with which patients present. This review focuses primarily on the esophageal motor disorders that result in dysphagia. Following a brief description of the normal swallowing mechanisms and the messengers involved, more specific motor abnormalities are discussed. The importance of achalasia, as the only pathophysiologically defined esophageal motor disorder, is discussed in some detail, including recent developments in pathogenesis and treatment options. Other esophageal spastic disorders are described, with relevant manometric tracings included. In recent years, the importance of gastroesophageal reflux as a primary cause of esophageal dysmotility has been recognized, and this is also discussed. In addition, the motility disturbances that develop after surgical fundoplication are reviewed.

Long myotomy with antireflux operation for esophageal spastic disorders

Long myotomy with antireflux operation for esophageal spastic disorders

Long myotomy with antireflux operation for esophageal spastic disorders

Long myotomy with antireflux operation for esophageal spastic disorders