The evolution of the treatment of esophageal achalasia. Chronicle of a 35-year journey.

Over the last few decades, significant improvement has been made in both the evaluation and treatment of esophageal achalasia. The Chicago classification, today in version 4.0, is now the standard for diagnosis of achalasia, providing a classification into 3 subtypes with important therapeutic and prognostic implications. Therapy, which was at first mostly limited to pneumatic dilatation, today includes minimally invasive surgery and peroral endoscopic myotomy, allowing for a more tailored approach to patients and better treatment of recurrent symptoms. This review chronicles my personal experience with achalasia over the last 35 years, describing the progress made in the treatment of patients with achalasia.

Quantification of interstitial cells of Cajal and fibrosis during gastric per-oral endoscopic myotomy and its association with clinical outcomes.

Background and study aims Alterations to interstitial cells of Cajal (ICC) and collagen fibrosis have been implicated in the pathogenesis of gastroparesis. We aimed to evaluate the feasibility and safety of pyloric muscle sampling during gastric peroral endoscopic myotomy (G-POEM) and the association between pyloric ICC density and degree of fibrosis with clinical outcomes. Patients and methods This was a single-center prospective study of gastroparetic patients who underwent G-POEM and intraprocedural pyloric muscle biopsies between January 2022 and April 2023. ICC count was estimated using CD117 stain and trichome for collagen fibrosis. Clinical response to G-POEM was defined as an improvement of ≥ 1 point on the Gastroparesis Cardinal Symptom Index. Results Fifty-six patients (median age 60 years, 71.4% women) underwent G-POEM (100% technical success; 71.4% clinical response). ICC depletion (< 10/high-power field) and fibrosis were encountered in 70.4% and 75% of the cases, respectively. There was no difference in mean ICC count between G-POEM responders vs. non-responders (7±3.6 vs. 7.7±3.3; P = 0.9). There was no association between ICC density or degree of fibrosis with the etiology of gastroparesis, duration of symptoms, gastric emptying rate, or pyloric impedance planimetry. Patients who did not respond to G-POEM had a significantly higher degree of moderate/severe fibrosis when compared with those who responded (81.3% vs. 25%; P = 0.0002). Conclusions Pyloric muscle biopsies during G-POEM was feasible and safe. ICC depletion and pyloric muscle fibrosis are common in gastroparetic patients. The degree of fibrosis may be related to pyloric dysfunction and clinical response to G-POEM. Additional studies are needed to confirm these results.

Long-term efficacy of peroral endoscopic myotomy for achalasia under different criteria.

BACKGROUND: Peroral endoscopic myotomy (POEM) has emerged as a widely accepted treatment for achalasia, with limited studies for over 2 years. Additionally, traditional measurements of achalasia after POEM have deficiencies. The study aimed to analyze the long-term outcomes of POEM under different criteria. METHODS: Patients with achalasia who received POEM between November 2012 and March 2021 were recruited. Patients and characteristics were shown, and risk factors related to two novel definitions of recurrence, symptomatic reflux, and reflux esophagitis were analyzed. RESULTS: Three hundred and twenty-one patients were included. At a median follow-up of 52 months, twenty-three failures happened (7.17%) under the modified criterion, and forty-seven failures occurred (14.64%) under the normal standard. Hospitalization (P = 0.027) and esophageal myotomy length (P = 0.039) were significantly associated with long-term efficacy under the modified and normal criteria, respectively. Fifty-two patients (16.20%) reported reflux symptoms and endoscopy performed in 88 patients revealed reflux esophagitis in 22 cases (25.00%). There were no predictors in the analysis of symptomatic reflux and gender (P = 0.010), LESP (P = 0.013), IRP (P = 0.015), and the esophageal myotomy length (P = 0.032) were statistically related to reflux esophagitis. CONCLUSION: POEM is an extremely safe and effective treatment for achalasia with long-term follow-up. Shorter hospitalization and shorter esophageal myotomy length may decrease the incidence of recurrence under the modified and normal criteria, respectively. Long-term outcomes of POEM are unpredictable. No risk factors were related to symptomatic reflux, and male patients with low preoperative LESP and IRP needed relatively shorter esophageal myotomy to prevent reflux esophagitis.

Evaluation of measurement errors in the Patient-Oriented Eczema Measure (POEM) outcome.

BACKGROUND: The Patient-Oriented Eczema Measure (POEM) is the recommended core outcome instrument for atopic dermatitis (AD) symptoms. POEM is reported by recalling the presence/absence of seven symptoms in the last 7 days. OBJECTIVE: To evaluate measurement errors in POEM recordings due to imperfect recall. METHODS: Using data from a clinical trial of 247 AD patients aged 12-65 years, we analysed the reported POEM score (r-POEM) and the POEM derived from the corresponding daily scores for the same seven symptoms without weekly recall (d-POEM). We quantified recall error by comparing the r-POEM and d-POEM for 777 patient-weeks collected from 207 patients, and estimated two components of recall error: (1) recall bias due to systematic errors in measurements and (2) recall noise due to random errors in measurements, using a bespoke statistical model. RESULTS: POEM scores have a relatively low recall bias, but a high recall noise. Recall bias was estimated at 1.2 points lower for the r-POEM on average than the d-POEM, with a recall noise of 5.7 points. For example, a patient with a recall-free POEM of 11 (moderate) could report their POEM score anywhere from 5 to 14 (with 95% probability) because of recall error. Model estimates suggested that patients tend to recall itch and dryness more often than experienced (positive bias of less than 1 day), but less often for the other symptoms (bleeding, cracking, flaking, oozing/weeping and sleep disturbance; negative bias ranging 1-4 days). CONCLUSIONS: In this clinical trial data set, we found that patients tended to slightly underestimate their symptoms when reporting POEM, with significant variation in how well they were able to recall the frequency of their symptoms every time they reported POEM. A large recall noise should be taken into consideration when interpreting POEM scores.

Mid-gastric peroral endoscopic myotomy in the treatment of post-sleeve gastrectomy gastric tube twist: Four cases.

Background and study aims Laparoscopic sleeve gastrectomy (LSG) may lead to symptomatic mid-gastric twist in 0.1% to 4% of cases. Endoscopic balloon dilatation often fails, requiring a switch to Roux-en-Y bypass. Submucosal endoscopic treatment is expanding, so we propose a new technique of fibrosis incision after tunnelization, called medio-gastric peroral endoscopic myotomy (MG-POEM). Patients and methods Four patients aged 41 to 70 years underwent MG-POEM in 2020 for symptomatic post-LSG medio-gastric twist. The aim was to describe the technique, and document the efficacy, using the Gastric Outlet Obstruction Scoring System (GOOSS) score and a quality-of-life scale (QOLS). The procedures consisted of a POEM with myotomy and fibrosis incision. Results Median preoperative GOOSS and QOLS were 1/3 ([0-3] and 1.75/10 [0-10], respectively. All procedures were technically successful. One patient had immediate postoperative complications, which were treated conservatively. The median follow-up was 18 months. All patients had improved quality of life and food intake, with median postoperative GOOSS and QOLS of 3/3 and 6,5/10 [6-8], respectively. Two patients required additional pneumatic dilatation for scarring strictures. Follow-up endoscopies and esophagograms showed that the twist had disappeared. Conclusions MG-POEM shows promise for safe and effective management of post-LSG mid-gastric twist, despite requiring a high level of endoscopic skill to perform submucosal tunneling.

Transoral incisionless fundoplication with or without hiatal hernia repair for gastroesophageal reflux disease after peroral endoscopic myotomy.

Background and study aims Gastroesophageal reflux disease (GERD) following peroral endoscopic myotomy (POEM) occurs in 40% to 60% of patients. There are limited data evaluating antireflux surgery or transoral incisionless fundoplication (TIF) for refractory post-POEM GERD. Patients and methods In a single-center prospective cohort study, consecutive patients with medically refractory post-POEM regurgitation and/or GERD treated with TIF or combined laparoscopic hernia repair and TIF (cTIF) were evaluated. Baseline evaluation: GERD-Health Related Quality of Life (GERD-HQRL) and Reflux Symptom Questionnaire 7-day recall (RESQ-7) questionnaires, EGD, high-resolution manometry (HRM), 48-hour pH test off proton pump inhibitors (PPIs) and impedance planimetry of the esophagogastric junction (EGJ) to calculate the diameter distensibility index (EGJ-DI). A PPI was taken twice daily for 2 weeks after TIF and restarted later if required. Patients returned 9 to 12 months after treatment when all preoperative studies were repeated. Quality of life, pH studies and EGJ metrics before and after antireflux surgery were compared. Results Seventeen patients underwent TIF (n=2, 12%) or cTIF (n=15, 88%) a mean 25±15 months after POEM. At follow-up a mean of 9±1 months after TIF/cTIF, patients required less frequent daily PPIs (n=0.001), were more satisfied (P=0.008), had improved GERD-HQRL (P=0.001), less intensity and frequency of GERD (P=0.001) and fewer reflux episodes (P=0.04) by pH testing. There was no change in EGJ-DI, EGJ diameter, integrated relaxation pressure, % total time pH <4, or DeMeester score. Conclusions TIF and cTIF for difficult-to-control post-POEM GERD appear safe, decrease PPI use and reflux episodes, and improve QOL without significant change in IRP, EGJ compliance, diameter or esophageal acid exposure time.

Outcomes after per-oral endoscopic myotomy for Zenker's diverticula (Z-POEM) and correlation with impedance planimetry (FLIP).

INTRODUCTION: Zenker's diverticulum (ZD) is a false pulsion diverticulum of the cervical esophagus. It is typically found in older adults and manifests with dysphagia. The purpose of this study is to describe our experience with Per-oral endoscopic myotomy for Zenker's (Z-POEM) and intraoperative impedance planimetry (FLIP). METHODS: We performed a single institution retrospective review of patients undergoing Z-POEM in a prospective database between 2014 and 2022. Upper esophageal sphincter (UES) distensibility index (DI, mm2/mmHg) was measured by FLIP before and after myotomy. The primary outcome was clinical success. Secondary outcomes included technical failure, adverse events, and quality of life as assessed by the gastroesophageal health-related quality of life (GERD-HRQL), reflux severity index (RSI), and dysphagia score. A statistical analysis of DI was done with the paired t-test (p < 0.05). RESULTS: Fifty-four patients underwent Z-POEM, with FLIP measurements available in 30 cases. We achieved technical success and clinical success in 54/54 (100%) patients and 46/54 patients (85%), respectively. Three patients (6%) experienced contained leaks. Three patients were readmitted: one for aforementioned contained leak, one for dysphagia, and one post-operative pneumonia. Three patients with residual dysphagia underwent additional endoscopic procedures, all of whom had diverticula > 4 cm. Following myotomy, mean DI increased by 2.0 ± 1.7 mm2/mmHg (p < 0.001). In those with good clinical success, change in DI averaged + 1.6 ± 1.1 mm2/mmHg. Significant improvement was found in RSI and GERD-HRQL scores, but not dysphagia score. CONCLUSION: Z-POEM is a safe and feasible for treatment of ZD. We saw zero cases of intraoperative abandonment. We propose that large diverticula (> 4 cm) are a risk factor for poor outcomes and may require additional endoscopic procedures. An improvement in DI is expected after myotomy, however, the ideal range is still not known.

Using impedance planimetry to define the end of a peroral endoscopic myotomy.

INTRODUCTION: Peroral endoscopic myotomy (POEM) is a minimally invasive endoscopic option for management of achalasia. Adequate distal myotomy is necessary for relief of symptoms, but when too long may also increase risk of reflux. The objective of this study is to evaluate clinical outcomes after POEM and final length of gastric myotomy using impedance planimetry (EndoFLIP). METHODS: A retrospective review of 34 consecutive patients undergoing POEM with EndoFLIP were included. EndoFLIP measurements, including esophagogastric junction distensibility index (DI), minimum diameter (Dmin), and cross-sectional area (CSA) were recorded at 30- and 40-mL balloon-fill pre- and post- myotomy. The myotomy was considered complete when DI ≥ 3.4 mm2/mmHg. Postoperative Eckardt score (ES) was determined at initial postoperative visit and most recent follow-up. Linear and logistic regression were used to evaluate the association between gastric myotomy length and post-myotomy EndoFLIP measurements on postoperative ES and GERD. Wilcoxon rank-sum test was used to compare gastric myotomy lengths and EndoFLIP parameters in relation to clinical success and development of GERD, and paired t-test to compare EndoFLIP measurements and ES pre- and post-myotomy. RESULTS: Final length of gastric myotomy measured 1 cm in 1 (2.9%), 1.5 cm in 11 (32.4%), 2.0 cm in 19 (55.9%), and 2.5 cm in 3 (8.8%) patients. Mean preoperative ES was 6.6 ± 2.2. All patients achieved ES < 3 postoperatively, which was maintained in 88.5% of patients at a median of 7.5 months of follow-up. Gastric myotomy length and post-myotomy EndoFLIP values were not associated with postoperative Eckardt scores or GERD. DISCUSSION: Early and late symptom relief was achieved in 100 and 88.5% of patients, respectively, at a gastric myotomy length of 1-2.5 cm. Using EndoFLIP to define a completed myotomy at DI of 3.4 mm2/mmHg yielded variable lengths of gastric myotomy.

Malaysian joint societies' consensus recommendations on diagnosis and management of disorders of esophagogastric junction outflow.

Disorders of esophagogastric junction (EGJ) outflow, including achalasia and EGJ outflow obstruction, are motility disorders characterized by inadequate relaxation of lower esophageal sphincter with or without impaired esophageal peristalsis. Current guidelines are technical and less practical in the Asia-Pacific region, and there are still massive challenges in timely diagnosis and managing these disorders effectively. Therefore, a Malaysian joint societies' task force has developed a consensus on disorders of EGJ outflow based on the latest evidence, while taking into consideration the practical relevance of local and regional context and resources. Twenty-one statements were established after a series of meetings and extensive review of literatures. The Delphi method was used in the consensus voting process. This consensus focuses on the definition, diagnostic investigations, the aims of treatment outcome, non-surgical or surgical treatment options, management of treatment failure or relapse, and the management of complications. This consensus advocates the use of high-resolution esophageal manometry for diagnosis of disorders of EGJ outflow. Myotomy, via either endoscopy or laparoscopy, is the preferred treatment option, while pneumatic dilatation can serve as a secondary option. Evaluation and management of complications including post-procedural reflux and cancer surveillance are recommended.

Triangle Tip-Jet Knife used as “probe mode” can reduce the risk of mucosal damage during incision and tunneling phase of peroral endoscopic myotomy (POEM) procedures

Peroral endoscopic myotomy (POEM) is a minimally invasive endoscopic technique for the treatment of achalasia and its use has been widely spread in recent years. The Triangle Tip-Jet (TTJ) (Olympus Triangle TipKnife-J, KD645L) has become very popular in this field and currently one of the most used knives for POEM procedures. It has the capability of knife dissection along with submucosal injection and its triangle tip shape is especially useful for pulling tissue during the myotomy phase. However, its length may be too long in situations such as tight esophagogastric junction (EGJ), narrow submucosa due to fibrosis, trimming after mucosal incision and/or less experienced endoscopists3 in which preserving the integrity of the mucosa is vitally important. Distal attachment conical caps like ST Hood (DH28GR,29CR; Fujifilm, Tokyo, Japan) are commonly used for POEM, resting the distal end of the TTJ on the cap, with only the triangular tip protruding. By using straight caps, you can get a wider view and greater maneuverability, however is more difficult to calculate the distance between the triangle tip and the distal attachment end due to its straight shape. The T-shape of the distal TTJ tip was designed for its use in an open position. In this way, while using straight caps and/or less experiences endoscopists during challenging procedures (tight EGJ, submucosal fibrosis) can make them feel unsafe during incision and/or tunneling phase. Herein, we suggest the use of the TTJ knife in “probe mode”4 to reduce the distal knife length from 4.5 mm to 0.3 mm, thus allowing a greater control of the knife tip. In addition, the TTJ probe mode can be safely used with both contact and non-contact currents, which are becoming increasingly popular in recent years. (AU)

Peroral Endoscopic Myotomy for Achalasia after Bariatric Surgery: A Case Report and Review of the Literature.

INTRODUCTION: Achalasia following bariatric surgery is a rare phenomenon with diverse potential physiopathological origins. AIMS: This article aims to explore the hypothetical physiopathological connection between bariatric surgery and the subsequent onset of achalasia. MATERIAL AND METHODS: A review was conducted to identify studies reporting cases of peroral endoscopic myotomy (POEM) after bariatric procedures and detailing the outcomes in terms of the technical and clinical success. Additionally, a case of a successful POEM performed on a patient two years after undergoing laparoscopic sleeve gastrectomy (LSG) is presented. RESULTS: The selection criteria yielded eight studies encompassing 40 patients treated with POEM for achalasia after bariatric surgery: 34 after Roux-en-Y gastric bypass (RYGB) and 6 after LSG. The studies reported an overall technical success rate of 97.5%, with clinical success achieved in 85% of cases. Adverse events were minimal, with only one case of esophageal leak treated endoscopically. However, a postprocedural symptomatic evaluation was notably lacking in most of the included studies. CONCLUSIONS: Achalasia poses a considerable challenge within the bariatric surgery population. POEM has emerged as a technically viable and safe intervention for this patient demographic, providing an effective treatment option where surgical alternatives for achalasia are limited. Our findings highlight the promising outcomes of POEM in these patients, but the existing data remain limited. Hence, prospective studies are needed to elucidate the optimal pre-surgical assessment and timing of endoscopic procedures for optimizing outcomes.

Patient Position in Operative Endoscopy.

It is well known by surgeons that patient positioning is fundamental to exposing the organs when performing an operation via laparoscopy, as gravity can help move the organs and facilitate the exposure of the surgical site. But is it also important for endoscopic procedures? This paper examines various types of endoscopic operations and addresses the issue of the patient's position. The patient's position can be changed not only by rotating the patient along the head-toe axis but also by tilting the surgical bed, as is undertaken during laparoscopic surgical procedures. In particular, it is useful to take into account the effect of gravity on lesion exposure, tumour traction during dissection, crushing by body weight, risk of sample drop, risk of damage to adjacent organs, and anatomical exposure for procedures with radiological support. The endoscopist should always keep in mind the patient's anatomy and the position of the endoscope during operative procedures, not limited to considering only intraluminal vision.

Precision Endoscopy in Peroral Myotomies for Motility Disorders of the Upper Gastrointestinal Tract: Current Insights and Prospective Avenues-A Comprehensive Review.

Our review delves into the realm of peroral endoscopic myotomies (POEMs) in the upper gastrointestinal tract (UGT). In recent years, POEMs have brought about a revolution in the treatment of UGT motility disorders. Esophageal POEM, the first to be introduced, has now been validated as the primary treatment for achalasia. Subsequently developed, G-POEM displays promising results in addressing refractory gastroparesis. Over time, multiple endoscopic myotomy techniques have emerged for the treatment of Zenker's diverticulum, including Z-POEM, POES, and hybrid approaches. Despite the well-established efficacy outcomes, new challenges arise in the realm of POEMs in the UGT. For esophageal POEM, the future scenario lies in customizing the myotomy extent to the minimum necessary, while for G-POEM, it involves identifying patients who can optimally benefit from the treatment. For ZD, it is crucial to validate an algorithm that considers various myotomy options according to the diverticulum's size and in relation to individual patients. These challenges align with the concept of precision endoscopy, personalizing the technique for each subject. Within our text, we comprehensively examine each myotomy technique, analyzing indications, outcomes, and adverse events. Additionally, we explore the emerging challenges posed by myotomies within the context of the evolving field of precision endoscopy.

Peroral Endoscopic Myotomy (POEM) and Laparoscopic Heller Myotomy with Dor Fundoplication for Esophagogastric Junction Outflow Obstruction (EGJOO): a Comparison of Outcomes and Impact on Physiology.

INTRODUCTION: Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility disorder characterized by failure of lower esophageal sphincter (LES) relaxation with preserved peristalsis. Studies have shown that Heller myotomy with Dor fundoplication (HMD) and per oral endoscopic myotomy (POEM) are effective treatments for EGJOO. However, there is paucity of data comparing the efficacy and impact of these two procedures. Therefore, the aim of this study was to compare outcomes and impact on esophageal physiology in patients undergoing HMD or POEM for primary EGJOO. METHODS: This was a retrospective review of patients who underwent either HMD or POEM for primary EGJOO at our institution between 2013 and 2021. Favorable outcome was defined as an Eckardt score ≤ 3 at 1 year after surgery. GERD-HRQL questionnaire, endoscopy, pH monitoring, and high-resolution manometry (HRM) results at baseline and 1 year after surgery were compared pre- and post-surgery and between groups. Objective GERD was defined as DeMeester score > 14.7 or LA grade C/D esophagitis. RESULTS: The final study population consisted of 52 patients who underwent HMD (n = 35) or POEM (n = 17) for EGJOO. At a mean (SD) follow-up of 24.6 (15.3) months, favorable outcome was achieved by 30 (85.7%) patients after HMD and 14 (82.4%) after POEM (p = 0.753). After HMD, there was a decrease GERD-HRQL total score (31 (22-45) to 4 (0-19); p < 0.001), and objective reflux (54.2 to 25.9%; p = 0.033). On manometry, there was a decrease in LES resting pressure (48 (34-59) to 13 (8-17); p < 0.001) and IRP (22 (17-28) to 8 (3-11); p < 0.001), but esophageal body characteristics did not change (p > 0.05). Incomplete bolus clearance improved (70% (10-90) to 10% (0-40); p = 0.010). After POEM, there was no change in the GERD-HRQL total score (p = 0.854), but objective reflux significantly increased (0 to 62%; p < 0.001). On manometry, there was a decrease in LES resting pressure (43 (30-68) to 31 (5-34); p = 0.042) and IRP (23 (18-33) to 12 (10-32); p = 0.048), DCI (1920 (1600-5500) to 0 (0-814); p = 0.035), with increased failed swallows (0% (0-30) to 100% (10-100); p = 0.032). Bolus clearance did not improve (p = 0.539). Compared to HMD, POEM had a longer esophageal myotomy length (11 (7-15)-vs-5 (5-6); p = 0.001), more objective reflux (p = 0.041), lower DCI (0 (0-814)-vs-1695 (929-3101); p = 0.004), and intact swallows (90 (70-100)-vs-0 (0-40); p = 0.006), but more failed swallows (100 (10-100); p = 0.018) and incomplete bolus clearance (90 (90-100)-vs-10 (0-40); p = 0.004). CONCLUSION: Peroral endoscopic myotomy and Heller myotomy with Dor fundoplication are equally effective at relieving EGJOO symptoms. However, POEM causes worse reflux and near complete loss of esophageal body function.

High-fat diet, but not duration of lactation, increases mammary gland lymphatic vessel function and subsequent growth of inflammatory breast cancer cells.

Inflammatory breast cancer (IBC) presents as rapid-onset swelling and breast skin changes caused by tumor emboli in the breast and breast skin lymphatics. IBC has been linked with obesity and duration of breastfeeding, but how these factors affect IBC tumor progression is not clear. We modeled the simultaneous effects of diet and weaning in mice on in vivo lymphatic function; on IBC tumor growth; and on aspects of the mammary gland microenvironment before and after IBC (SUM149) xenograft inoculation. We hypothesized that weaning status and diet would have synergistic effects on lymphatic function and the breast microenvironment to enhance IBC tumor growth. Changes in lymphatic structure and function were characterized with in vivo near-infrared fluorescence (NIRF) imaging. Mice were fed either a high-fat diet (HFD; 60 kcal%) or a normal/low-fat diet (LFD; 10 kcal%), bred twice, and subjected to either normal-duration nursing (NW) or forced weaning (FW). SUM149 IBC tumors were implanted at 14 months; images were obtained before and after implantation. Multiparous mice fed HFD showed increased pre-tumor lymphatic pulsing in both the FW and NW groups relative to mice fed LFD. HFD promoted tumor growth independent of weaning time (P = 0.04). Pre-tumor lymphatic pulsing was associated with tumor volume at 8 weeks (P = 0.02) and was significantly correlated with expression of the lymphatic tracking ligand CCL21 (P = 0.05, Table 1). HFD significantly increased the numbers of monocyte-derived IBA1+, CD163+, and CD11c+ cells (P < 0.0001, P < 0.0001, P = 0.0005) in the contralateral, non-tumor-bearing mammary gland. Numbers of lymphangiogenic podoplanin+/IBA1+ macrophages were increased in the ducts of HFD and FW mice (all P < 0.003). HFD in nulliparous mice had a similar increase in lymphatic pulsing at 14 weeks (P = 0.006), indicating that this functional change was independent of parity. We conclude that HFD induced increases in mammary gland lymphatic function, assessed as pulsing rate before tumor initiation, and correlated with inflammation in the mammary gland and increased SUM149 tumor growth. The relationship between diet, lymphatic pulsing, and tumor growth warrants further investigation.

Comparison of the Clinical Efficacy, Safety, and Postoperative Outcomes Between Peroral Esophageal Myotomy and Laparoscopic Heller's Myotomy With Fundoplication: A Systematic Review.

Achalasia, a neurodegenerative disease caused by the progressive destruction of ganglion cells in the myenteric plexus, is accompanied by incomplete relaxation of the lower esophageal sphincter. Laparoscopic Heller's myotomy (LHM) coupled with fundoplication has been the gold standard procedure for achalasia. Peroral esophageal myotomy (POEM) has recently gained popularity as it is minimally invasive, has fewer adverse events, and has excellent short-term outcomes. So, we aimed to compare the clinical efficacy, safety, and postoperative outcomes between LHM and POEM. We did a systematic review by following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines for 2020 and exploring research databases such as PUBMED and PMC Central, Google Scholar, and Research Gate. After appropriate screenings, articles relevant to the review were scrutinized based on the eligibility criteria. Quality assessment tools such as the Newcastle-Ottawa Scale (NOS) and the assessment of multiple systematic reviews (AMSTAR) were used to finalize the articles. A total of 11 articles (seven observational studies, two RCTs, and two systematic reviews) were included in the review after a quality check. The study included 2127 patients, classified into 981 for POEM and 1146 for LHM, who had undergone treatment for achalasia. Most of the studies had a follow-up of ≤ two years. Comparing efficacy, POEM had similar results to LHM in terms of Eckardt scores. However, abnormal DeMeester scores were found in POEM. Adverse events were significantly higher in LHM when compared to POEM in terms of safety. Peroral esophageal myotomy also stood out as having a shorter procedure time, a shorter hospital stay, and lesser odds of being a clinical failure. As for postoperative outcomes, despite treatment with proton pump inhibitors, LHM was more effective in preventing the development of esophagitis compared to POEM due to partial fundoplication. Postoperative reflux and the development of esophagitis remain certain with POEM and need to be followed up with more studies with longer follow-ups. However, POEM still stands as a better choice compared to LHM in terms of efficacy and safety.

Peroral Endoscopic Myotomy May Be Safe in Solid-Organ Transplant Patients With Achalasia.

Peroral endoscopy myotomy (POEM) is a safe and effective therapy for achalasia among the general population. However, data regarding its safety and efficacy in organ transplant recipients are lacking. These patients present unique risks and challenges because of chronic immunosuppression. We present 3 cases of successful POEM performed safely for achalasia in patients with previous solid-organ transplantation without interruption of their immunosuppression medications. This case series suggests that POEM may be safe in solid-organ transplant recipients.

Peroral endoscopic myotomy (POEM) in the treatment of severe postfundoplication dysphagia.

Although uncommon, chronic postfundoplication dysphagia (PFD) is a serious complication of antireflux surgery. Currently, reoperation is the only possible solution as endoscopic pneumatic or hydraulic dilation are not effective. At present, POEM represents a standard method for the treatment of esophageal achalasia; however, in patients with PFD it is an experimental approach whose clinical effectiveness is unknown. Our case report describes a female patient who suffered from severe PFD after two surgeries (fundoplication and subsequent reoperation). Dysphagia and progressive weight loss had developed over the years and all treatment attempts (several sessions of dilation) were unsuccessful. Subsequently, esophageal resection was considered as the last resort. After a discussion in a multidisciplinary team and additional examinations (EndoFLIP), POEM was performed without any complications, and the procedure had an excellent effect without any adverse events.

Topical Application of a Formulation Containing Pea Proteins and Xyloglucan in Adult Patients with Atopic Dermatitis: A Double-blind, Parallel, Randomized, Placebo-controlled, Multicenter Study.

Objective: Atopic dermatitis (AD) management requires long-term use of drugs that come with side effects. Compounds such as xyloglucan (XG) and pea proteins (PP) are emerging alternatives to corticosteroids that have shown to restore skin barrier function in preclinical studies. This double-blind, parallel, randomized, placebo-controlled clinical trial investigated the efficacy and safety of XG and PP, in adult AD patients. Methods: Fourty-two patients with AD were randomly assigned 1:1 to receive a XG+PP treatment or the vehicle without XG+PP twice/day for 14 consecutive days for assessment at baseline, Day 8 and Day 15; follow-up visit was 14 days after the end of treatment (Day 28). Efficacy was evaluated using the Scoring Atopic Dermatitis (SCORAD) index, AD severity index (ADSI) score and patient-oriented eczema measure (POEM). Safety and tolerability were monitored as the occurrence of Adverse Events (AEs). Results: At baseline, both groups exclusively included moderate/severe AD cases. At Day 8, six patients treated with XG+PP displayed complete resolution of AD, while 15 patients had mild AD. At Day 28, 16 patients no longer had eczema, whereas five patients displayed mild AD. Notably, 21 patients in the vehicle group still displayed moderate/severe AD. Conclusion: XG and PP promote rapid and long-lasting relief, supporting its use as a safe alternative to mainstay corticosteroid treatments for AD management. The study protocol has been registered in the ISRCTN registry (TN66879853).

Distal Esophageal Spasm: An Updated Review.

Distal esophageal spasm is characterized by premature contractions of the distal esophageal smooth muscle leading to non-obstructive dysphagia and non-cardiac chest pain. Diagnosis requires the presence of symptoms along with evidence of at least 20% premature contractions in the setting of a normal lower esophageal sphincter relaxation on high-resolution manometry. New updates to the Chicago Classification have improved the diagnostic accuracy of this method. Functional lumen imaging probe is a growing diagnostic modality that gives a more complete picture of esophageal motility. Pharmacologic treatment remains inadequate. Endoscopic myotomy might be of benefit for non-achalasia esophageal motility disorders. More research is required to better understand the pathophysiology and develop safe and long-lasting management for this disease.