Surgeon variability in repair of hiatal hernia at the time of bariatric surgery.

BACKGROUND: Hiatal hernia (HH) is estimated to affect between 20 and 50% of patients undergoing bariatric surgery. However, there is no consensus regarding the preoperative assessment and intraoperative repair of HH. The aim of this study was to evaluate the variation in surgeon assessment and repair of HH during bariatric surgery across a multi-hospital healthcare system. METHODS: A retrospective cohort analysis was conducted using data obtained from the metabolic and bariatric accreditation quality improvement program (MBSAQIP) and institutional medical records. All adult patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) were included. Preoperative assessment of HH was defined as either EGD or upper GI/Esophagram (UGI) within one year of surgery. Surgeons were evaluated individually and by hospital. Chi-square analysis and ANOVA were performed. RESULTS: From January 2018 to February 2023, 3,487 bariatric surgeries were performed across 4 hospitals and 11 surgeons (2481 SG and 1006 RYGB). HH were concurrently repaired during 24% of operations. The rate of HH repair in SG was 25 and 22% in RYGB (p = 0.06). Preoperatively, 41% of patients underwent EGD and 23% had an UGI. HH was diagnosed in 22% of EGDs. Patients who underwent preoperative EGD had higher rates of HH repair than those without a preop EGD (33% vs. 17%; p < 0.001). The rate of preoperative EGD utilization by surgeon varied significantly from 3 to 92% (p < 0.001) as did HH repair rates between surgeons (range 8-57%; p < 0.001). Even among patients with a preoperatively diagnosed HH, the repair rate ranged 20-91% between individual surgeons (p < 0.001). CONCLUSION: Within a healthcare system there was significant heterogeneity in approach to assessment and repair of HH during bariatric surgery. This appears to be mediated by multiple factors, including utilization of preoperative studies, individual surgeon differences, and differences between hospitals.

Association between bariatric surgery preoperative chemoprophylaxis and postoperative bleeding.

BACKGROUND: Use of chemoprophylaxis for prevention of venous thromboembolism (VTE) after bariatric surgery is a generally accepted principle; however, the optimal strategy in terms of medication type and pre- and postoperative dosing is uncertain. In our healthcare system, four hospitals performed bariatric surgery and utilized differing protocols for VTE prophylaxis. The analysis sought to evaluate the association of differing prophylaxis strategies on bleeding and VTE occurrence. METHODS: Adult patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from 2018 to 2021 at four hospitals were studied. Patients were grouped by whether or not they received preoperative chemoprophylaxis. The primary outcome was postoperative bleeding, defined as requiring a blood transfusion or reoperation for bleeding within 30 days. Bivariate analyses were performed with Chi-square and Wilcoxon Rank tests where applicable. Multivariate logistic regression was performed for the outcome of postoperative bleeding. RESULTS: A total of 2145 bariatric surgeries were evaluated (33.6% RYGB, 66.4% SG). Among 1712 patients who underwent surgery at Hospitals A, B, and C, 93.1% received preoperative VTE prophylaxis, compared with 1 patient (0.1%) among 433 patients operated on at Hospital D. Postoperative bleeding occurred more frequently in patients who received preoperative VTE prophylaxis versus those who did not (3.7% vs 1.1%; p < 0.01). After multivariable regression analysis, only RYGB (OR 3.59; p < 0.01) and preoperative VTE prophylaxis (OR 3.54; p = 0.02) were significantly associated with postoperative bleeding. Rates of VTE for patients receiving preoperative VTE prophylaxis or no prophylaxis were not significantly different (0.6% vs. 0.2%; p = 0.26). DISCUSSION: Preoperative VTE prophylaxis prior to bariatric surgery was associated with postoperative bleeding without differences in VTE occurrence. These results call into question the routine use of VTE chemoprophylaxis for all patients undergoing bariatric surgery and favor selective usage.

Increased bleeding risk with enoxaparin venothromboembolism prophylaxis compared with heparin in patients undergoing bariatric surgery.

BACKGROUND: Perioperative venothromboembolism (VTE) chemoprophylaxis is an established tenant of bariatric surgery; however, there is little comparative data to guide medication choice. The objective of this study was to determine if a change in VTE prophylaxis from heparin to enoxaparin was associated with differing rates of postoperative bleeding and VTE occurrence after bariatric surgery. METHODS: This retrospective cohort study included patients 18 years or older who underwent primary bariatric surgery (sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB)) at a single institution between March 2012 and December 2021. Subcutaneous unfractionated heparin was utilized for VTE prophylaxis from March 2012 through February 2018 and then enoxaparin was used from March 2018 through December 2021. Postoperative bleeding was defined as requiring a blood transfusion or reoperation for bleeding within 30 days of surgery. Chi-square test was used to test for differences between groups. RESULTS: There were 2159 patients who underwent bariatric surgery with 1324 (61.3%) patients in the heparin group and 835 (38.7%) in the enoxaparin group. Overall, 1,503 (69.6%) patients underwent SG and 656 (30.4%) RYGB. There was no difference in the ratio of SG to RYGB between the heparin and enoxaparin groups. Most patients were female (n = 1709, 79.2%) with a median age of 43.2 years (interquartile range (IQR): 35.6-52.2), and median BMI of 44.9 (IQR: 40.9-50.5). Overall postoperative bleeding occurred more frequently in the enoxaparin group (n = 26, 3.1%) compared with the heparin group (n = 12, 0.9%) (p < 0.01). Additionally, reoperation for bleeding was more frequent with enoxaparin (enoxaparin 0.8% vs. heparin 0.2%, p = 0.04). There was no difference in VTE occurrence between the two groups (heparin: n = 14, 1.1%, enoxaparin: n = 7, 0.8% (p = 0.61)). CONCLUSIONS: An institutional change from heparin to enoxaparin for bariatric surgery perioperative VTE prophylaxis was associated with a significant increase in postoperative bleeding, with no difference in VTE complications.

Myotomy technique and esophageal contractility impact blown-out myotomy formation in achalasia: an in silico investigation.

We used in silico models to investigate the impact of the dimensions of myotomy, contraction pattern, the tone of the esophagogastric junction (EGJ), and musculature at the myotomy site on esophageal wall stresses potentially leading to the formation of a blown-out myotomy (BOM). We performed three sets of simulations with an in silico esophagus model, wherein the myotomy-influenced region was modeled as an elliptical section devoid of muscle fibers. These sets investigated the effects of the dimensions of myotomy, differing esophageal contraction types, and differing esophagogastric junction (EGJ) tone and wall stiffness at the myotomy affected region on esophageal wall stresses potentially leading to BOM. Longer myotomy was found to be accompanied by a higher bolus volume accumulated at the myotomy site. With respect to esophageal contractions, deformation at the myotomy site was greatest with propagated peristalsis, followed by combined peristalsis and spasm, and pan-esophageal pressurization. Stronger EGJ tone with respect to the wall stiffness at the myotomy site was found to aid in increasing deformation at the myotomy site. In addition, we found that an esophagus with a shorter myotomy performed better at emptying the bolus than that with a longer myotomy. Shorter myotomies decrease the chance of BOM formation. Propagated peristalsis with EGJ outflow obstruction has the highest chance of BOM formation. We also found that abnormal residual EGJ tone may be a co-factor in the development of BOM, whereas remnant muscle fibers at myotomy site reduce the risk of BOM formation.NEW & NOTEWORTHY Blown-out myotomy (BOM) is a complication observed after myotomy, which is performed to treat achalasia. In silico simulations were performed to identify the factors leading to BOM formation. We found that a short myotomy that is not transmural and has some structural architecture intact reduces the risk of BOM formation. In addition, we found that high esophagogastric junction tone due to fundoplication is found to increase the risk of BOM formation.

Outcomes of 100 Patients More Than 4 Years After POEM for Achalasia.

OBJECTIVE: We aim to describe the long-term follow-up data from our institution's POEM experience. SUMMARY BACKGROUND DATA: Per-oral endoscopic myotomy (POEM) is a well-established endoscopic therapy for achalasia with excellent short-term efficacy, but long-term outcomes data are limited. METHODS: Patients older than 4 years removed from POEM for treatment of achalasia were studied. Clinical success was defined as an Eckardt Symptom (ES) score ≤3 and freedom from reintervention for achalasia. Patients underwent esophagogastroduodenoscopy (EGD), high-resolution manometry, impedance planimetry, and timed barium esophagram (TBE) preoperatively and at least 4 years postoperatively. Objective gastroesophageal reflux disease (GERD) was defined LA Grade B or worse esophagitis on EGD. RESULTS: One hundred and nineteen consecutive patients were included. Five patients died or had catastrophic events unrelated to achalasia or POEM. One hundred of the remaining patients (88%, 100/114) had long-term data available. Clinical follow-up for all patients was greater than 4 years postoperatively and the mean was 55 months. Mean current ES was significantly improved from preop (n = 100, 1 ±â€Š1 vs 7 ±â€Š2, P < 0.001). Overall clinical success was 88% and 92%. Five patients had a current ES >3 and 4 patients required procedural reintervention on the lower esophageal sphincter. Reinterventions were successful in 75% of patients (3/4), with current ES ≤3. The rate of objective GERD was 33% (15/45). Esophageal physiology was improved with a decrease in median integrated relaxation pressure (11 ±â€Š4 vs 33 ±â€Š15 mm Hg, P < 0.001), a decrease in median TBE column height (3 ±â€Š3 vs 13 ±â€Š8 cm, P < 0.001), and an increase in median distensibility index (5.1 ±â€Š2 vs 1.1 ±â€Š1 mm2/mm Hg, P < 0.001). CONCLUSIONS: POEM provides durable symptom relief and improvement in physiologic esophagogastric junction relaxation parameters over 4.5 years postoperatively. Reinterventions are rare and effective.

Comparison of preoperative, intraoperative, and follow-up functional luminal imaging probe measurements in patients undergoing myotomy for achalasia.

BACKGROUND AND AIMS: The functional luminal imaging probe (FLIP) is a novel catheter-based device that measures esophagogastric junction (EGJ) distensibility index (DI) in real time. Previous studies have demonstrated DI to be a predictor of post-treatment clinical outcomes in patients with achalasia. We sought to evaluate EGJ DI in patients with achalasia before, during, and after peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM) and to assess the correlation of DI with postoperative outcomes. METHODS: DI (defined as the minimum cross-sectional area at the EGJ divided by distensive pressure) was measured at 4 time points in patients undergoing surgical myotomy for achalasia: (1) during outpatient preoperative endoscopy (preoperative DI), (2) at the start of each operation after the induction of anesthesia (induction DI), (3) at the conclusion of each operation (postmyotomy DI), and (4) at routine follow-up endoscopy 12 months postoperatively (follow-up DI). Routine Eckardt symptom score, endoscopy, timed barium esophagram, and pH study were obtained 12 months postoperatively. RESULTS: Forty-six patients (35 POEM, 11 LHM) underwent FLIP measurements at all 4 time points. Preoperative and induction mean DI were similar for both groups (POEM, 1 vs .9 mm2/mm Hg; LHM, 1.7 vs 1.5 mm2/mm Hg). POEM resulted in a significant increase in DI (induction .9 vs postmyotomy 7 mm2/mm Hg, P < .001). There was a subsequent decrease in DI in the follow-up period (postmyotomy 7 vs follow-up 4.8 mm2/mm Hg, P < .01), but DI at follow-up was still significantly improved from preoperative values (P < .001). For LHM patients, DI also increased as a result of surgery (induction 1.5 vs postmyotomy 5.9 mm2/mm Hg, P < .001); however, the increase was smaller than in POEM patients (DI increase 4.4 vs 6.2 mm2/mm Hg, P < .05). After LHM, DI also decreased in the follow-up period, but this change was not statistically significant (5.9 vs 4.4 mm2/mm Hg, P = .29). LHM patients with erosive esophagitis on follow-up endoscopy had a significantly higher postmyotomy DI compared with those without esophagitis (9.3 vs 4.8 mm2/mm Hg, P < .05). CONCLUSIONS: EGJ DI improved dramatically as a result of both POEM and LHM, with POEM resulting in a larger increase. Mean DI decreased at intermediate follow-up but remained well above previously established thresholds for symptom recurrence. DI at the conclusion of LHM was predictive of erosive esophagitis in the postoperative period, which supports the potential use of FLIP for calibration of partial fundoplication construction during LHM.

Blown-out myotomy: an adverse event of laparoscopic Heller myotomy and peroral endoscopic myotomy for achalasia.

BACKGROUND AND AIMS: Although laparoscopic Heller myotomy (LHM) or peroral endoscopic myotomy (POEM) is highly effective, 10% to 20% of patients with achalasia remain symptomatic after treatment. In evaluating such patients, we have observed a pattern of failure associated with a pseudodiverticulum, or blown-out myotomy (BOM), in the distal esophagus. We aimed to assess risk factors and patient-reported outcomes associated with a BOM. METHODS: We reviewed our manometry database for patients with achalasia previously treated with LHM or POEM. We included patients who had a post-treatment esophagram within 1 year of their follow-up manometry. A BOM was defined radiographically as a wide-mouthed outpouching (>50% increase in esophageal diameter) in the area of the myotomy. RESULTS: One hundred twenty-nine patients with achalasia who underwent treatment were included; 23 (17.8%) had a BOM. Comparing patients with a BOM with those without, post-treatment Eckardt scores were significantly greater (5 vs 2, P = .002), type III achalasia was more common (39.1% vs 14.2%, P = .005), and LHM was more common than POEM (73.9% vs 26.1%, P = .013). The integrated relaxation pressure was also significantly greater in the BOM group (15.0 mm Hg vs 11.0 mm Hg, P = .025). CONCLUSIONS: BOM is a common adverse event after myotomy for achalasia but is not seen after pneumatic dilation. Pretreatment type III achalasia, LHM as opposed to POEM, and a greater post-treatment integrated relaxation pressure were risk factors for developing a BOM. We speculate that esophageal wall strain in the area weakened by myotomy, whether from residual spastic contractility or continued esophageal outflow obstruction, may be the underlying mechanism of BOM development.

Addressing the gap in laparoscopic common bile duct exploration training for rural surgeons: imparting procedural ability is not enough.

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) is an underutilized therapy for choledocholithiasis. The driving factors of this practice gap are poorly defined. We sought to evaluate the attitudes and practice patterns of surgeons who underwent training courses using an LCBDE simulator. METHODS: Surgeons completed a half-day simulator-based LCBDE curriculum at national courses, including the American College of Surgeons Advanced Skills Training for Rural Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons annual meeting. Attitudes were assessed with Likert surveys immediately before and after curriculum completion. Follow-up surveys were distributed electronically. RESULTS: 159 surgeons completed training during six courses. Surgeon attitudes regarding the overall superiority of LCBDE vs. ERCP shifted towards favoring LCBDE after course participation (4.0 vs 3.3; Likert scale 1-5, p < 0.001). 44% of surgeons completed follow-up surveys at a mean of 3 years post-course. Surgeons remained confident in their ability to perform LCBDE, with only 14% rating their skill as a significant barrier to practice, as compared with 43% prior to course participation (p < 0.01). However, only 28% of surgeons saw an increase in LCBDE volume. Deficiencies in operating room (OR) staff knowledge and instrument availability were the most significant barriers to post-course practice implementation and were inversely correlated with LCBDE case volume (ρ = - 0.44 and - 0.47, both p < 0.01). Surgeons for whom OR staff knowledge of LCBDE was not a significant barrier performed nearly 4 times more LCBDE than those who rated staff knowledge as a moderate, strong, or complete barrier. CONCLUSIONS: Surgeons trained at an LCBDE course retained long-term confidence in their procedural ability. Practice implementation was hindered by deficiencies in OR staff knowledge and instrument availability. Surgeons with knowledgeable operating room staff performed significantly more LCBDEs than those with less capable assistance. These barriers should be addressed in future curricula to improve procedural adoption.

Intraoperative use of FLIP is associated with clinical success following POEM for achalasia.

BACKGROUND: Esophagogastric junction distensibility index (DI), measured using the functional luminal imaging probe (FLIP), correlates with symptomatic outcomes after interventions for achalasia. The objective of this study was to determine if the intraoperative measurement of DI using FLIP was associated with improved clinical outcomes following per-oral endoscopic myotomy (POEM) for achalasia when compared with procedures in which FLIP was not utilized. METHODS: Patients undergoing POEM from 2012 to 2017 at a single institution by a single surgeon were studied. Use of FLIP during this time period was based on catheter and technician availability, resulting in two patient cohorts. In patients in whom FLIP was used, operative video recordings were reviewed to determine when DI measurements led to the performance of additional myotomy. Postoperative Eckardt symptom scores (ES) at 12 months and postoperative physiologic studies were compared between patients with and without intraoperative FLIP. Associations were assessed using Mann-Whitney U and Chi-square tests. RESULTS: 143 patients were included in the analysis (61 with intraoperative FLIP and 82 without FLIP). Video recordings were available for 85% of the FLIP cohort. Review of these operative recordings revealed that 65% of patients who underwent FLIP had additional myotomy performed following the initial postmyotomy FLIP measurement. At 12 months after POEM, the FLIP cohort had significantly more clinical successes (defined as ES ≤ 3) than patients in whom FLIP was not used (93% vs. 81%, p < 0.05). CONCLUSIONS: Use of intraoperative FLIP during POEM resulted in the surgeon performing additional myotomy in over half of cases and was associated with improved clinical outcomes. This study demonstrates the potential for a FLIP-tailored myotomy to improve outcomes in patients undergoing surgical myotomy for achalasia.

Intraoperative FLIP distensibility during POEM varies according to achalasia subtype.

BACKGROUND: The functional luminal imaging probe (FLIP) can be used to measure the esophagogastric junction distensibility index (DI) during myotomy for achalasia and increased DI has been shown to predict superior clinical outcomes. The objective of this study was to determine if the intraoperative DI and the changes produced by per oral endoscopic myotomy (POEM) differed between achalasia subtypes. METHODS: FLIP measurements were performed during POEM for achalasia at a single institution. DI (defined as the minimum cross-sectional area (CSA) at the EGJ divided by distensive pressure) was measured at three time points: after induction of anesthesia, after submucosal tunneling, and after myotomy. Measurements were reported at the 40 mL fill volume for the 8 cm FLIP (EF-325) and at the 60 mL fill volume for the 16 cm FLIP (EF-322). Measurements were compared using chi-square and Kruskal-Wallis tests. RESULTS: 142 patients had intraoperative FLIP performed during POEM for achalasia between 2012 and 2019 (30 type I, 68 type II, 27 type III, and 17 variant). Patients with type I achalasia had a significantly higher induction DI (median 1.7 mm2/mmHg) than type II (0.8 mm2/mmHg), type III (0.9 mm2/mmHg), and variants (1.1 mm2/mmHg; p < 0.001). These differences persisted after submucosal tunneling and final DI after myotomy was also significantly higher in type I patients (median 8.0 mm2/mmHg) compared to type II (5.8 mm2/mmHg), type III (3.9 mm2/mmHg), and variants (5.4 mm2/mmHg; p < 0.001). Achalasia subtypes were found to have similar CSA at all time points, whereas pressure differed with type I having the lowest pressure and type III the highest. CONCLUSION: The DI at each operative step during POEM was found to differ significantly between achalasia subtypes. These differences in DI were due to pressure, as CSA was similar between subtypes. Achalasia subtype should be accounted for when using FLIP as an intraoperative calibration tool and in future studies examining the relationship between DI and clinical outcomes.

Intraoperative assessment of esophageal motility using FLIP during myotomy for achalasia.

BACKGROUND: The functional luminal imaging probe (FLIP) can evaluate esophagogastric junction (EGJ) distensibility and esophageal peristalsis in real time. FLIP measurements performed during diagnostic endoscopy can accurately discriminate between healthy controls and patients with achalasia based on EGJ-distensibility and distinct motility patterns termed repetitive antegrade contractions (RACs) and repetitive retrograde contractions (RRCs). We sought to evaluate real-time motility changes in patients undergoing surgical myotomy for achalasia. METHODS: FLIP measurements using a stepwise volumetric distention protocol were performed at three time points during assessment and performance of laparoscopic Heller myotomy and POEM: (1) During preoperative outpatient endoscopy, (2) Intraoperatively following induction of anesthesia, and (3) Intraoperatively after myotomy completion. EGJ-distensibility, contractility, RACs, and RRCs were measured. RESULTS: FLIP measurements were performed in 32 patients. The EGJ-distensibility index was similar between the preoperative and initial operative measurements (1.1 vs 1.4 mm2/mmHg, p = NS). There was a significant increase in distensibility following surgical myotomy (1.4 to 4.7 mm2/mmHg, p < 0.01). Intraoperative contractile patterns varied between achalasia subtypes. Contractility was seen in < 20% of assessments in patients with types I and II achalasia. Type III patients demonstrated contractility in 100% of assessments, with 70% exhibiting RRCs and 60% RACs. There was a reduction in the frequency of RRC presence (70% to 20%), and contractile vigor (80% to 0% of patients with lumen occluding contractions) in type III patients following surgical myotomy. CONCLUSIONS: This first report of real-time intraoperative measurement of esophageal motility using FLIP demonstrates the feasibility of such assessments during surgical myotomy for achalasia. Patients with type I and II achalasia exhibited rare intraoperative contractility, while the presence of motility was the norm in those with type III. Patients with type III achalasia demonstrated an immediate reduction in repetitive contraction motility patterns and contractile vigor following myotomy.

Complications of Antireflux Surgery.

Antireflux surgery anatomically restores the antireflux barrier and is a therapeutic option for proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease or PPI intolerance. Laparoscopic fundoplication is the standard antireflux surgery, though its popularity has declined due to concerns regarding wrap durability and adverse events. As the esophagogastric junction is an anatomically complex and dynamic area subject to mechanical stress, wraps are susceptible to disruption, herniation or slippage. Additionally, recreating an antireflux barrier to balance bidirectional bolus flow is challenging, and wraps may be too tight or too loose. Given these complexities it is not surprising that post-fundoplication symptoms and complications are common. Perioperative mortality rates range from 0.1 to 0.2% and prolonged structural complications occur in up to 30% of cases. Upper gastrointestinal endoscopy with a comprehensive retroflexed examination of the fundoplication and barium esophagram are the primary tests to assess for structural complications. Management hinges on differentiating complications that can be managed with medical and lifestyle optimization versus those that require surgical revision. Reoperation is best reserved for severe structural abnormalities and troublesome symptoms despite medical and endoscopic therapy given its increased morbidity and mortality. Though further data are needed, magnetic sphincter augmentation may be a safer alternative to fundoplication.

Treatment of Idiopathic Achalasia with Per-Oral Esophageal Myotomy.

Achalasia is a rare esophageal motility disorder that necessitates the disruption of the lower esophageal sphincter. Patients with achalasia should be evaluated in a systematic, multidisciplinary fashion. Workup should include upper endoscopy, esophagography, and high-resolution manometry. The gold standard for surgical treatment is laparoscopic Heller myotomy with partial fundoplication. Per-oral esophageal myotomy is a novel endoscopic technique that has gained considerable traction over the past decade. The procedure includes the creation of a submucosal tunnel and a selective circular myotomy of the lower esophageal sphincter. Common intra-operative hazards include bleeding within the submucosal tunnel and capnoperitoneum. Significant complications are rare. Patients experience excellent dysphagia relief that is on par with laparoscopic Heller myotomy at moderate-term follow up. Post-operative gastroesophageal reflux disease occurs in greater than one-third of patients, and the vast majority of cases are readily controlled with an anti-secretory medication. Although data is sparse, there is a growing body of literature that supports the long-term durability of per-oral esophageal myotomy.

Per-oral Endoscopic Myotomy (POEM) After the Learning Curve: Durable Long-term Results With a Low Complication Rate.

OBJECTIVE: We aimed to report long-term outcomes for patients undergoing per-oral endoscopic myotomy (POEM) after our initial 15-case learning curve. BACKGROUND: POEM has become an established, natural-orifice surgical approach for treating esophageal motility disorders. To date, published outcomes and comparative-effectiveness studies have included patients from the early POEM experience. METHODS: Consecutive patients undergoing POEM after our initial 15 cases, with a minimum of 1-year postoperative follow-up, were included. Treatment success was defined as an Eckardt score ≤3 without reintervention. Gastroesophageal reflux was defined by abnormal pH-testing or reflux esophagitis >Los Angeles grade A. RESULTS: Between January 2012 and March 2015, 115 patients underwent POEM at a single, high-volume center. Operative time was 101 ±â€Š29 minutes, with 95% (109/115) of patients discharged on postoperative day 1. Clavien-Dindo grade III complications occurred in 2.7%, one of which required diagnostic laparoscopy to rule out Veress needle injury to the gall bladder. The rate of grade I complications was 15.2%. At an average of 2.4 years post-POEM (range 12-52 months), the overall success rate was 92%. Objective evidence of reflux was present in 40% for all patients and 33% for patients with a body mass index <35 kg/m and no hiatal hernia. CONCLUSIONS: POEM performed by experienced surgeons provided durable symptomatic relief in 94% of patients with nonspastic achalasia and 90% of patients with type 3 achalasia/spastic esophageal motility disorders, with a low rate of complications. The rate of gastroesophageal reflux was comparable with prior studies of both POEM and laparoscopic Heller myotomy.

Efficacy of transoral fundoplication vs omeprazole for treatment of regurgitation in a randomized controlled trial.

BACKGROUND & AIMS: Transoral esophagogastric fundoplication (TF) can decrease or eliminate features of gastroesophageal reflux disease (GERD) in some patients whose symptoms persist despite proton pump inhibitor (PPI) therapy. We performed a prospective, sham-controlled trial to determine if TF reduced troublesome regurgitation to a greater extent than PPIs in patients with GERD. METHODS: We screened 696 patients with troublesome regurgitation despite daily PPI use with 3 validated GERD-specific symptom scales, on and off PPIs. Those with at least troublesome regurgitation (based on the Montreal definition) on PPIs underwent barium swallow, esophagogastroduodenoscopy, 48-hour esophageal pH monitoring (off PPIs), and high-resolution esophageal manometry analyses. Patients with GERD and hiatal hernias ≤2 cm were randomly assigned to groups that underwent TF and then received 6 months of placebo (n = 87), or sham surgery and 6 months of once- or twice-daily omeprazole (controls, n = 42). Patients were blinded to therapy during follow-up period and reassessed at 2, 12, and 26 weeks. At 6 months, patients underwent 48-hour esophageal pH monitoring and esophagogastroduodenoscopy. RESULTS: By intention-to-treat analysis, TF eliminated troublesome regurgitation in a larger proportion of patients (67%) than PPIs (45%) (P = .023). A larger proportion of controls had no response at 3 months (36%) than subjects that received TF (11%; P = .004). Control of esophageal pH improved after TF (mean 9.3% before and 6.3% after; P < .001), but not after sham surgery (mean 8.6% before and 8.9% after). Subjects from both groups who completed the protocol had similar reductions in GERD symptom scores. Severe complications were rare (3 subjects receiving TF and 1 receiving the sham surgery). CONCLUSIONS: TF was an effective treatment for patients with GERD symptoms, particularly in those with persistent regurgitation despite PPI therapy, based on evaluation 6 months after the procedure. Clinicaltrials.gov no: NCT01136980.

High-Resolution Impedance Manometry Metrics of the Esophagogastric Junction for the Assessment of Treatment Response in Achalasia.

OBJECTIVES: We aimed to evaluate the value of novel high-resolution impedance manometry (HRIM) metrics, bolus flow time (BFT), and esophagogastric junction (EGJ) contractile integral (CI), as well as EGJ pressure (EGJP) and the integrated relaxation pressure (IRP), as indicators of treatment response in achalasia. METHODS: We prospectively evaluated 75 patients (ages 19-81, 32 female) with achalasia during follow-up after pneumatic dilation or myotomy with Eckardt score (ES), timed-barium esophagram (TBE), and HRIM. Receiver-operating characteristic (ROC) curves for good symptomatic outcome (ES≤3) and good radiographic outcome (TBE column height at 5 min<5 cm) were generated for each potential predictor of treatment response (EGJP, IRP, BFT, and EGJ-CI). RESULTS: Follow-up occurred at a median (range) 12 (3-291) months following treatment. A total of 49 patients had good symptomatic outcome and 46 had good radiographic outcome. The area-under-the-curves (AUCs) on the ROC curve for symptomatic outcome were 0.55 (EGJP), 0.62 (IRP), 0.77 (BFT) and 0.56 (EGJ-CI). The AUCs for radiographic outcome were 0.64 (EGJP), 0.48 (IRP), 0.73 (BFT), and 0.65 (EGJ-CI). Optimal cut-points were determined as 11 mm Hg (EGJP), 12 mm Hg (IRP), 0 s (BFT), and 30 mm Hg•cm (EGJ-CI) that provided sensitivities/specificities of 57%/46% (EGJP), 65%/58% (IRP), 78%/77% (BFT), and 53%/62% (EGJ-CI) to predict symptomatic outcome and 57%/66% (EGJP), 57%/41% (IRP), 76%/69% (BFT), and 57%/66% (EGJ-CI) to predict radiographic outcome. CONCLUSIONS: BFT, a novel HRIM metric, provided an improved functional assessment over manometric measures of EGJP, IRP, and EGJ-CI at follow-up after achalasia treatment and may help direct clinical management.

Evaluation of the need for routine esophagram after peroral endoscopic myotomy (POEM).

BACKGROUND: Peroral endoscopic myotomy (POEM) is a novel surgical option for the treatment of achalasia. Most centers perform a routine esophagram on postoperative day (POD) #1 to rule esophageal perforation and leaks. In this study, we sought to determine the clinical utility of routine contrast studies post-POEM. METHODS: POEM was performed using an anterior submucosal tunnel and selective myotomy of the circular muscle layer. A routine contrast esophagram was obtained on POD #1. We conducted a retrospective review of the radiologists' interpretations of these studies and compared them to patient's clinical course. RESULTS: Seventy-eight patients were included. Among these, two complications occurred. One patient was non-compliant with postoperative nil per os orders and developed epigastric pain suspicious for a leak that was demonstrated on esophagram. Another patient had subcutaneous emphysema on POD #1 esophagram, a finding that was also present on physical examination, without esophageal leakage. Another esophagram in an asymptomatic patient was suspicious for submucosal tunnel hematoma which prompted a return to the operating room with negative results. Overall, 56 patients had abnormal studies. POD #1 esophagram demonstrated a sensitivity of 100 % and specificity of 45 % in identifying clinically significant complications. CONCLUSIONS: In this series, we found routine esophagram to have a high sensitivity but a very low specificity in detecting clinically significant complications. Routine esophagram after POEM may not be necessary.

The effect of incremental distal gastric myotomy lengths on EGJ distensibility during POEM for achalasia.

BACKGROUND: During peroral esophageal myotomy (POEM) for the treatment of achalasia, the optimal distal gastric myotomy length is unknown. In this study, we used a functional lumen imaging probe (FLIP) to intraoperatively measure the effect of variable distal myotomy lengths on esophagogastric junction (EGJ) distensibility. METHODS: EGJ distensibility index (DI) (minimum cross-sectional area divided by intrabag pressure) was measured with FLIP after each operative step. Each patient's myotomy was performed in four increments from proximal to distal: (1) an esophageal myotomy (from 6 cm proximal to the EGJ to 1 cm proximal to it), (2) a myotomy ablating the lower esophageal sphincter (LES) complex (from 1 cm proximal to the EGJ to 1 cm distal to it), (3) an initial gastric extension (from 1 cm distal to the EGJ to 2 cm distal), and (4) a final gastric extension (from 2 cm distal to the EGJ to 3 cm distal). RESULTS: Measurements were taken in 16 achalasia patients during POEM. POEM resulted in an overall increase in DI (pre 1.2 vs. post 7.2 mm(2)/mmHg, p < .001). Initial creation of the submucosal tunnel resulted in a threefold increase in DI (1.2 vs. 3.6 mm(2)/mmHg, p < .001). When the myotomy was then performed in a stepwise fashion from proximal to distal, the initial esophageal myotomy component had no effect on DI. Subsequent myotomy extension across the LES complex resulted in an increase in DI, as did the initial gastric myotomy extension (to 2 cm distal to the EGJ). The final gastric myotomy extension (to 3 cm distal) had no further effect. CONCLUSIONS: During POEM, creation of the submucosal tunnel prior to myotomy resulted in a marked improvement in EGJ physiology. Myotomy extension across the LES complex and to 2 cm onto the gastric wall resulted in the normalization of EGJ distensibility, whereas subsequent extension to 3 cm distal to the EGJ did not increase compliance further.

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.

Esophagogastric junction distensibility measurements during Heller myotomy and POEM for achalasia predict postoperative symptomatic outcomes.

BACKGROUND: The functional lumen imaging probe (FLIP) is a novel diagnostic tool that can be used to measure esophagogastric junction (EGJ) distensibility. In this study, we performed intraoperative FLIP measurements during laparoscopic Heller myotomy (LHM) and peroral esophageal myotomy (POEM) for treatment of achalasia and evaluated the relationship between EGJ distensibility and postoperative symptoms. METHODS: Distensibility index (DI) (defined as the minimum cross-sectional area at the EGJ divided by distensive pressure) was measured with FLIP at two time points during LHM and POEM: (1) at baseline after induction of anesthesia, and (2) after operation completion. RESULTS: Measurements were performed in 20 patients undergoing LHM and 36 undergoing POEM. Both operations resulted in an increase in DI, although this increase was larger with POEM (7 ± 3.1 vs. 5.1 ± 3.4 mm(2)/mmHg, p < .05). The two patients (both LHM) with the smallest increases in DI (1 and 1.6 mm(2)/mmHg) both had persistent symptoms postoperatively and, overall, LHM patients with larger increases in DI had lower postoperative Eckardt scores. In the POEM group, there was no correlation between change in DI and symptoms; however, all POEM patients experienced an increase in DI of >3 mm(2)/mmHg. When all patients were divided into thirds based on final DI, none in the lowest DI group (<6 mm(2)/mmHg) had symptoms suggestive of reflux (i.e., GerdQ score >7), as compared with 20 % in the middle third (6-9 mm(2)/mmHg) and 36 % in the highest third (>9 mm(2)/mmHg). Patients within an "ideal" final DI range (4.5-8.5 mm(2)/mmHg) had optimal symptomatic outcomes (i.e., Eckardt ≤ 1 and GerdQ ≤ 7) in 88 % of cases, compared with 47 % in those with a final DI above or below that range (p < .05). CONCLUSIONS: Intraoperative EGJ distensibility measurements with FLIP were predictive of postoperative symptomatic outcomes. These results provide initial evidence that FLIP has the potential to act as a useful calibration tool during operations for achalasia.