Peroral endoscopic myotomy and its use in non-achalasia disorders.

The aim of this review is to provide an overview of per-oral endoscopic myotomy (POEM) and its utilization in non-achalasia disorders of the esophagus. POEM, a relatively novel endoscopic technique, involves submucosal tunneling to access esophageal muscle layers, enabling selective myotomy and mitigating the consequences of motor disorders of the esophagus. POEM is an effective treatment modality for diffuse esophageal spasm providing resolution of chest pain and dysphagia in a majority of patients who have refractory symptoms despite medical therapy. The results of POEM are more equivocal compared to esophagogastric junction outflow obstruction (EGJOO). POEM in EGJOO has been shown to have a 93% clinical success rate in 6 months. POEM appears to be more effective in motor disorders that affect the lower esophageal sphincter, such as EGJOO and opioid-induced esophageal dysfunction. While the current data for POEM in other entities such as DES and HE are positive, more supportive data are required to make POEM a consistent recommendation for patients.

Clinical efficacy of per-oral endoscopic myotomy (POEM) for spastic esophageal disorders: a systematic review and meta-analysis.

BACKGROUND: POEM has been successfully performed in patients with spastic esophageal disorders (SED), such as diffuse esophageal spasm, jackhammer esophagus, and type 3 achalasia. We performed a systematic review and meta-analysis to evaluate its efficacy in these patients and if total average myotomy length and prior medical or endoscopic treatments affected clinical success. METHODS: PubMed, EMBASE, Google-Scholar, Scopus, and Cochrane Review were searched for studies on POEM in SED from 2008 to September 2018. Clinical success was determined by Eckardt score (≤ 3) at follow-up. Sub-group analysis was performed based on myotomy length and evaluates the effect of prior treatments on clinical success. RESULTS: 9 studies with 210 patients were included in the final analysis. We found that the pooled rate of clinical success for POEM was 89.6% (95% CI 83.5-93.1, 95% PI 83.4-93.7, I2 = 0%). In three studies (50 patients), where total myotomy length was < 10 cm, the pooled rate of clinical success was 91.1% (95% CI 79.5-96.4, I2 = 0%). In six studies (160 patients), the length was > 10 cms and the pooled rate of clinical success was 89.1% (95% CI 83.0-93.2, I2 = 0%). The difference between these results was not statistically significant (p = 0.69). Additionally, a meta-regression analysis showed that prior treatment status did not significantly affect the primary outcome (p = 0.43). CONCLUSIONS: While it is well known that POEM is a safe and effective treatment for spastic esophageal disorders, we conclude that variation in total myotomy length and prior endoscopic or medical treatments did not have a significant effect on clinical success.

Long-term outcomes of per-oral endoscopic myotomy in a patient with distal esophageal spasm followed up for 2.5 years: two sides of the same coin - A Case Report and Literature Review.

INTRODUCTION: Distal esophageal spasm (DES), a relatively rare condition, is characterized by simultaneous contractions of the distal esophagus and manifested by dysphagia and chest pain. Several treatment options are recommended, such as pharmacological therapy, endoscopic interventions, and surgical myotomy. Recently, per-oral endoscopic myotomy (POEM) has been adopted as an effective and less-invasive treatment due to its excellent short-term clinical outcomes. Nevertheless, few reports describe its long-term effects. CASE PRESENTATION: A 65-year-old woman complained of chest pain accompanied with dysphagia and weight loss for 4 months. A series of examinations suggested that she was suffering from DES and then POEM was performed. During the 2.5-year follow-up, we observed an exciting long-term outcome. Interestingly, hematoxylin and eosin staining verified a large number of eosinophils in the muscularis externa, which was absent in the mucosa of the esophagus of the patient. CONCLUSIONS: We herein report a case of DES who underwent POEM to eliminate persistent esophageal contractions. Eckardt score, esophageal emptying test, and high-resolution manometry were assumed to monitor the efficacy of POEM. During treatment and 2.5 years after operation, esophageal muscle biopsies and/or mucosal tissues were obtained. This case has been presented to describe that POEM could be a strategy for DES with a long-term curative effect and that eosinophils in the muscle layer of the esophagus might be involved in the pathogenesis of DES. What is more, we reviewed literature to find similar cases reported in the past.

Challenges of peroral endoscopic myotomy in the treatment of distal esophageal spasm.

OBJECTIVE: Distal esophageal spasm (DES) is a rare motility disorder characterized by premature and rapidly propagated contractions of the distal esophagus. Treatment options are limited and often poorly effective. Peroral endoscopic myotomy (POEM) seems an effective and attractive new treatment option for DES. In this case report we describe some of the difficulties that could arise. MATERIALS AND METHODS: A 84-year old man with therapy-refractory DES and complaints of severe dysphagia and chest pain underwent a POEM procedure under general anesthesia. A longer myotomy was performed to cleave the circular muscle layer from start till end of the spastic contractions. RESULTS: The length of the myotomy was 16 cm. Hyperactive spastic contractions during the procedure complicated the creation of the submucosal tunnel, extended the duration (134 vs. 60-90 min for achalasia), increased postoperative pain and prolonged hospital admission. Intravenously nitroglycerin peroperative diminished spastic contractions. Postoperative a remnant of spastic contractions was present, proximal to the myotomy, causing persistent symptoms. CONCLUSION: Performing POEM for DES is challenging due to reactive hyperactive spastic contractions during the procedure causing technical difficulties and an extended procedure. A long myotomy, several centimeters above the proximal border of the spastic region, is essential to prevent remnants of spasticity.

Is POEM the Answer for Management of Spastic Esophageal Disorders? A Systematic Review and Meta-Analysis.

BACKGROUND AND AIMS: Spastic esophageal disorders (SEDs) include spastic achalasia (type III), diffuse esophageal spasm (DES), and nutcracker/jackhammer esophagus (JH). Per-oral endoscopic myotomy (POEM) has demonstrated efficacy and safety in the treatment of achalasia. Recently, POEM has been indicated for the treatment of SEDs. We conducted a systematic review and meta-analysis to determine the clinical success and safety of POEM in SEDs. METHODS: We searched several databases from 01/01/2007 to 01/10/2016 to identify studies (with five or more patients) on POEM for the treatment of SEDs. Weighted pooled rates (WPRs) for clinical success and adverse events (AEs) were calculated for all SEDs. Clinical success was defined as Eckardt scores of ≤3 and/or improvement in severity of dysphagia based on achalasia disease-specific health-related quality of life questionnaire. The WPRs for clinical success and AEs were analyzed using fixed- or random-effects model based on heterogeneity. The proportionate difference in clinical success and post-procedure adverse event rates among individual types of SEDs was also calculated. RESULTS: A total of eight observational studies with 179 patients were included in the final analysis. Two studies were of good quality and six were of fair quality based on the National Institutes of Health quality assessment tool. The WPR with 95% confidence interval (CI) for cumulative clinical success of POEM in all SEDs was 87% (78, 93%), I 2 = 37%. The total number of patients for individual disorders, i.e., type III achalasia, JH, and DES, was 116, 37, and 18, respectively. The WPRs for clinical success of POEM for type III achalasia, DES, and JH were 92, 88, and 72%, respectively. Proportion difference of WPR for clinical success was significantly higher for type III achalasia in comparison with JH (20%, P = 0.01). The WPR with 95% CI for AEs of POEM in all SEDs was 14% (9, 20%), I 2 = 0%. The WPRs for post-procedure adverse events for type III achalasia, DES, and JH were 11, 14, and 16%, respectively. There was no difference in safety of POEM among individual SEDs. CONCLUSION: POEM is an effective and safe therapeutic modality for the treatment of spastic esophageal disorders.

The role of Heller myotomy and POEM for nonachalasia motility disorders.

The best-defined primary esophageal motor disorder is achalasia. However, symptoms such as dysphagia, regurgitation and chest pain can be caused by other esophageal motility disorders such as Diffuse Esophageal Spasm (DES), Nutcracker Esophagus (NE) and the Hypertensive Lower Esophageal Sphincter (HTN-LES). Most patients with DES and HTN-LES who complain of dysphagia improve after a myotomy. Patients with NE whose main complaint is chest pain, often do not have relief of the pain and can even develop dysphagia as a consequence of the myotomy. POEM is a relatively new procedure, and there are no studies with long-term follow-up and no prospective and randomized trials comparing it to surgical myotomy. Overall, the key to success is based on a complete evaluation and a careful patient selection. The best results, regardless of the technique, are in fact obtained in patients with outflow obstruction and impaired esophageal emptying, a picture similar to achalasia.

Per-oral endoscopic myotomy, 1000 cases later: pearls, pitfalls, and practical considerations.

BACKGROUND AND AIMS: Eight years have passed since the introduction of the per-oral endoscopy myotomy (POEM) procedure. POEM was initially received as an investigational procedure, but since the revelation of promising safety and efficacy data, it is becoming the preferred treatment for achalasia. With the recent completion of our 1000th POEM procedure, we share our experience and knowledge through the discussion of clinical pearls, pitfalls, and practical considerations. METHODS: The various aspects of the procedure and conditions that warrant special attention are discussed from our perspective, with a focus on areas in which there is currently limited evidence. RESULTS: The key points on patient position, submucosal tunneling, myotomy, closure, intraprocedural bleeding, and advanced sigmoid achalasia are presented. CONCLUSIONS: The dissemination of this information serves as a foundation for new POEM operators and as a catalyst for more-experienced operators to further refine and advance their POEM skills and stimulate international discourse and collaboration.

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

BACKGROUND: Limited data exist on the use of peroral endoscopic myotomy (POEM) for therapy of spastic esophageal disorders (SEDs). OBJECTIVE: To study the efficacy and safety of POEM for the treatment of patients with diffuse esophageal spasm, jackhammer esophagus, or type III (spastic) achalasia. DESIGN: Retrospective study. SETTING: International, multicenter, academic institutions. PATIENTS: All patients who underwent POEM for treatment of SEDs refractory to medical therapy at 11 centers were included. INTERVENTIONS: POEM. MAIN OUTCOME MEASUREMENTS: Eckardt score and adverse events. RESULTS: 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. LIMITATIONS: Retrospective design and selection bias. CONCLUSION: 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.

Thoracoscopic long myotomy in the prone position to treat rapid esophageal contractions with normal latency.

A 56-year-old woman with an 8-year history of dysphagia and chest pain received a diagnosis of diffuse esophageal spasm by esophageal high-resolution manometry (HRM). Approximately 2 years of medical therapy was ineffective, and the patient's symptoms were worsening. Therefore, surgery was considered to be the most optimal treatment for this patient. The right thoracoscopic approach was selected because a long myotomy from the distal to proximal level of the esophagus was needed based on the HRM findings. The operation was performed in the prone position with establishment of pneumothorax. The total length of the myotomy was 16 cm, and the operation was finished within 2 hours. After the operation, the symptoms were considerably improved and no contractions were detected by HRM. The HRM findings before the operation were classified as rapid contractions with normal latency based on the 2012 Chicago classification of esophageal motility. Treatment for patients with rapid esophageal contractions with normal latency has not been previously described; however, treatment for diffuse esophageal spasm was considered to be pertinent to this patient. In conclusion, right thoracoscopic esophageal long myotomy in the prone position with establishment of pneumothorax may be useful when a proximal-level esophagomyotomy is required based on preoperative mapping by HRM.

Diffuse esophageal spasm: the surgical approach.

Diffuse esophageal spasm (DES) is a rare primary motility disorder of unknown cause, that can be found in patients complaining of chest pain and dysphagia and in whom ischemic heart disease and GERD have been excluded. The manometric hallmark of DES is the presence of simultaneous contractions in the distal esophagus alternating with a normal peristalsis. Even at specialized esophageal motility laboratories, DES is considered an uncommon diagnosis. In this review, the authors discuss the clinical and diagnostic aspects of this disease, as well as the possible therapeutic options (medical, endoscopic or surgical therapy). Surgery (esophageal myotomy performed through a thoracotomy or with a thoracoscopic access) seems to have a better outcome than medical or endoscopic treatment, and it is considered "the last resource" in these patients. However, satisfactory results are reported, from highly skilled centers, in only about 70% of treated cases, certainly inferior to those achieved in other esophageal disorders. The role of surgery in this disease requires therefore further study, even if controlled trials are probably difficult to perform, due to the rarity of the disease.

[Pharyngeal constrictor muscles closure after total laryngectomy is that really beneficial?]. / Czy zszywanie zwieracza gardla dolnego po laryngektomii calkowitej jest korzystne?

UNLABELLED: High pressure of pharyngo-esophageal segment is the most important factor of impaired development of alaryngeal speech (esophageal speech, tracheoesophageal speech) after total laryngectomy. To prevent pharyngo-esophageal spasm in Department of Otolaryngology in Szczecin are used: pharyngoesophageal plastic surgery with interposition of vascular thyroid flap, two-layer (only mucosa) non-muscular pharyngeal closure and tree-layer closure (mucosa and muscle layer leaving inferior pharyngeal constrictor unsutured). AIM OF STUDY: The aim of this study was to compare the pharyngo-esophageal pressure between patients after pharyngo-esophageal plastic surgery and following the non-muscular pharyngeal closure. MATERIAL AND METHODS: One hundred eighty two subjects after total laryngectomy were enrolled in this study, and included 108 patients subjected to the pharyngo-esophageal plastic surgery, 44 patients who underwent the two-layer pharyngeal closure, and 30 patients with the tree-layer closure. To evaluate the pharyngo-esophageal pressures manometric tests were performed, and to asses the pharynx morphology videopharyngoscopy was used. RESULTS: The average pharyngo-esophageal pressure in the group after the pharyngo-esophageal plastic surgery was 32 (min.-5, max. 50) mmHg. After the two-layer non-muscular pharyngeal closure mean pressure was 35 (min.-17, max.-40) mmHg, and after the tree-layer non-muscular pharyngeal closure the average pressure was 22,42 (min. 5, max. 40) mmHg. The average pharyngo-esophageal pressure was significantly lower (p < 0.01) among patients after the tree-layer non-muscular closure. CONCLUSION: The study suggests that the tree-layer non-muscular pharyngeal closure with inferior pharyngeal constrictor unsutured is the preferable method to prevent pharyngo-esophageal spasm after total laryngectomy. However, the efficacy and safety of this surgical procedure should be explored in further multicenter studies.

Surgical treatment of primary esophageal motility disorders.

Named primary esophageal motility disorders (PEMD) present with specific manometric patterns classified as: (1) hypertensive lower esophageal sphincter, (2) nutcracker esophagus (also hypercontratile, hypertensive, or hypercontracting esophagus), (3) diffuse esophageal spasm, and (4) achalasia. These conditions, with the exception of achalasia, are rare, poorly understood, and inadequately studied. Treatment of these conditions is based on symptoms and aimed at symptomatic improvement. The authors reviewed current literature on surgical treatment of non-achalasia PEMD. The review shows that: (a) surgical therapy may be an attractive alternative in patients with PEMD; (b) proper selection of patients based on symptoms evaluation and esophageal function tests is essential; (c) laparoscopic myotomy with proximal extent tailored to manometric findings seems to be the ideal surgical therapy; and (d) esophagectomy may be necessary as a last resource due to multiple failures of surgical conservative treatment.