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Surgical Endoscopy

Published in:

01-03-2019

Myotomy length informed by high-resolution esophageal manometry (HREM) results in improved per-oral endoscopic myotomy (POEM) outcomes for type III achalasia

Authors: Erica D. Kane, Vikram Budhraja, David J. Desilets, John R. Romanelli

Published in: Surgical Endoscopy | Issue 3/2019

Abstract

Introduction

High-resolution esophageal manometry (HREM) is essential in characterizing achalasia subtype and the extent of affected segment to plan the myotomy starting point during per-oral endoscopic myotomy (POEM). However, evidence is lacking that efficacy is improved by tailoring myotomy to the length of the spastic segment on HREM. We sought to investigate whether utilizing HREM to dictate myotomy length in POEM impacts postoperative outcomes.

Methods

Comparative analysis of HREM-tailored to non-tailored patients from a prospectively collected database of all POEMs at our institution January 2011 through July 2017. A tailored myotomy is defined as extending at least the length of the diseased segment, as initially measured on HREM.

Results

Forty patients were included (11 tailored versus 29 non-tailored). There were no differences in patient age (p = 0.6491) or BMI (p = 0.0677). Myotomy lengths were significantly longer for tailored compared to non-tailored overall (16.6 ± 2.2 versus 13.5 ± 1.8; p < 0.0001), and for only type III achalasia (15.9 ± 2.4 versus 12.7 ± 1.2; p = 0.0453), likely due to more proximal starting position in tailored cases (26.0 ± 2.2 versus 30.0 ± 2.7; p < 0.0001). Procedure success (Eckardt < 3) was equivalent across groups overall (p = 0.5558), as was postoperative Eckardt score (0.2 ± 0.4 versus 0.8 ± 2.3; p = 0.4004). Postoperative Eckardt score was significantly improved in the tailored group versus non-tailored for type III only (0.2 ± 0.4 versus 1.3 ± 1.5; p = 0.0435). A linear correlation was seen between increased length and greater improvement in Eckardt score in the non-tailored group (p = 0.0170).

Conclusions

Using HREM to inform surgeons of the proximal location of the diseased segment resulted in longer myotomies, spanning the entire affected segment in type III achalasia, and in lower postoperative Eckardt scores. Longer myotomy length is often more easily achieved with POEM than with Heller myotomy, which raises the question of whether POEM results in better outcomes for type III achalasia, as types I and II do not generally have measurable spastic segments.

Pandolfino JE, Gawron AJ (2015) Achalasia: a systematic review. JAMA 313(18):1841–1852CrossRefPubMed

Sadowski DC, Ackah F, Jiang B, Svenson LW (2010) Achalasia: incidence, prevalence, and survival. A population-based study. Neurogastroenterol Motil 22:256–261CrossRef

Eckardt VF (2001) Clinical presentation and complications of achalasia. Gastrointest Endosc Clin N Am 11:281–292CrossRefPubMed

Chandrasekhara V, Desilets D, Falk GW, Inoue H, Romanelli JR, Savides TJ, Stavropoulos SN, Swanstrom LL, ASGE PIVI Committee (2015) The American Society for Gastrointestinal Endoscopy PIVI (Preservation and incorporation of valuable endoscopic innovations on peroral endoscopic myotomy). Gastrointest Endosc 81:1087–1099CrossRefPubMed

Pasricha PJ, Hawari R, Ahmed I, Chen J, Cotton PB et al (2007) Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy 39:761–764CrossRefPubMed

Inoue H, Minami H, Kobayashi Y, Sato Y, Kaga M et al (2010) Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 42:265–271CrossRefPubMed

Inoue H, Sato H, Ikeda H, Onimaru M, Sato C, et al. (2015) Per-oral endoscopic myotomy: a series of 500 patients. JACS 221:256–264

Bechara R, Onimaru M, Ikeda H, Inoue H (2016) Per-oral endoscopic myotomy, 1000 cases later: pearls, pitfalls, and practical considerations. Gastrointest Endosc 84:330–338CrossRefPubMed

Bredenoord AJ, Fox M, Kahrilas PJ, Pandolfino JE, Schwizer W, Smout AJ, International High Resolution Manometry Working Group (2012) Chicago classification criteria of esophageal motility disorders defined in high resolution esophageal pressure topography. Neurogastroenterol Motil 24(Suppl 1):57–65CrossRefPubMedPubMedCentral

10.

Rohof WO, Salvador R, Annese V, Bruley des Varannes S, Chaussade S, Costantini M, Elizalde JI, Gaudric M, Smout AJ, Tack J, Busch OR, Zaninotto G, Boeckxstaens GE (2013) Outcomes of treatment for achalasia depend on manometric subtype. Gastroenterology 144(4):718–725 (quiz e13–e14)CrossRefPubMed

11.

Salvador R, Costantini M, Zaninotto G, Morbin T, Rizzetto C, Zanatta L, Ceolin M, Finotti E, Nicoletti L, Da Dalt G, Cavallin F (2010) The preoperative manometric pattern predicts the outcome of surgical treatment for esophageal achalasia. J Gastrointest Surg 14(11):1635–1645CrossRefPubMed

12.

Kim WH, Cho JY, Ko WJ, Hong SP, Hahm KB, Cho JH, Lee TH, Hong SJ (2009) Comparison of the outcomes of peroral endoscopic myotomy for achalasia according to manometric subtype. Gut Liver 11(5):642–647CrossRef

13.

Pandolfino JE, Fox MR, Bredenoord AJ, Kahrilas PJ (2009) High-resolution manometry in clinical practice: utilizing pressure topography to classify oesophageal motility abnormalities. Neurogastroenterol Motil 21:796–806CrossRefPubMedPubMedCentral

14.

Kahrilas PJ, Bredenoord AJ, Fox M, Gyawali CP, Roman S et al (2015) The Chicago classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil 27(2):160–174CrossRef

15.

Kahrilas PJ, Katzka D, Richter JE (2017 Nov) Clinical practice update: the use of per-oral endoscopic myotomy in achalasia: expert review and best practice advice from the AGA institute. Gastroenterology 153(5):1205–1211CrossRefPubMedPubMedCentral

16.

Pandolfino JE, Kwiatek MA, Nealis T, Bulsiewicz W, Post J, Kahrilas PJ (2008) Achalasia: a new clinically relevant classification by high-resolution manometry. Gastroenterology 135:1526–1533CrossRefPubMedPubMedCentral

17.

Pratap N, Kalapala R, Darisetty S, Joshi N, Ramchandani M, Banerjee R, Lakhtakia S, Gupta R, Tandan M, Rao GV, Reddy DN (2011) Achalasia cardia subtyping by high-resolution manometry predicts the therapeutic outcome of pneumatic balloon dilatation. J Neurogastroenterol Motil 17:48–53CrossRefPubMedPubMedCentral

18.

Ou YH, Nie XM, Li LF, Wei ZJ, Jiang B (2016) High-resolution manometric subtypes as a predictive factor for the treatment of achalasia: a meta-analysis and systematic review. J Dig Dis 17:222–235CrossRefPubMed

19.

Rahden BH, Filser J, Al-Nasser M, Germer CT (2017) Surgical treatment of achalasia—endoscopic or laparoscopic? Proposal for a tailored approach. Chirurg 88(3):204–210CrossRefPubMed

20.

Lee H, Chung H, Lee TH, Hong KS, Youn YH, Park JH, Park HS, Park H, Korean Achalasia Study Team (KAST) (2017) Therapeutic outcome of achalasia based on high-resolution manometry: a Korean multicenter study. Am J Ther

21.

Crespin OM, Tatum RP, Xiao K, Martin AV, Khandelwal S, Pellegrini CA, Oelschlager BK (2017) The relationship between manometric subtype and outcomes of surgical treatment for patients with achalasia: Achalasia: manometric subtypes. Surg Endosc 31:5066–5075CrossRefPubMed

22.

Kumbhari V, Tieu AH, Onimaru M, El Zein MH, Teitelbaum EN et al (2015) Peroral endoscopic myotomy (POEM) vs laparoscopic Heller myotomy (LHM) for the treatment of type III achalasia in 75 patients: a multicenter comparative study. Endosc Int Open 3:E195–E201CrossRefPubMedPubMedCentral

23.

Kahrilas PJ, Bredenoord AJ, Fox M, Gyawali CP, Roman S, Smout AJPM, Pandolfino JE (2017) Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes. Gastroenterol Hepatol 14:677–688

24.

Ihara E, Muta K, Fukaura K, Nakamura K (2017) Diagnosis and treatment strategy of achalasia subtypes and esophagogastric junction outflow obstruction based on high-resolution manometry. Digestion 95(5):29–35CrossRefPubMed

25.

Greene CL, Chang EJ, Oh DS, Worell SG, Hagen JA, DeMeester SR (2015) High resolution manometry sub-classification of achalasia: does it really matter? Surg Endosc 29(6):1363–1367CrossRefPubMed

26.

Chen X, Li Q-p, Ji G-z, Ge X-x, Zhang X-h, Miao L (2015) Two-year follow-up for 45 patients with achalasia who underwent peroral endoscopic myotomy. Eur J Cardiothroac Surg 47:890–896CrossRef

27.

Zhang W, Linghu E-Q (2017) Peroral endoscopic myotomy for type III achalasia of Chicago classification: outcomes with a minimum follow-up of 24 months. J Gastrointest Surg 21:785–791CrossRefPubMed

28.

Khashab MA, Messallam AA, Onimaru M, Teitelbaum EN, Ujiki MB, Gitelis ME, Modayil RJ, Hungness ES, Stavropoulos SN, El Zein MH, Shiwaku H, Kunda R, Repici A, Minami H, Chiu PW, Ponsky J, Kumbhari V, Saxena P, Maydeo AP, Inoue H (2015) International multicenter experience with peroral endoscopic myotomy for the treatment of spastic esophageal disorders refractory to medical therapy (with video). Gastrointest Endosc 81(5):1170–1177CrossRefPubMed

29.

Martinek J, Svecova H, Vackova Z, Dolezel R, Ngo O, Krajciova J, Kieslichova E, Janousek R, Pazdro A, Harustiak T, Zdrhova L, Loudova P, Stirand P, Spicak J (2018) Per-oral endoscopic myotomy (POEM): mid-term efficacyand safety. Surg Endosc 32(3):1293–1302CrossRefPubMed

30.

Khan MA, Kumbhari V, Ngamruenengphong S, Ismail A, Chen Y et al (2017) Is POEM the answer for management of spastic esophageal disorders? A systematic review and meta-analysis. Dig Dis Sci 62:35–44CrossRefPubMed

31.

Guo H, Yang H, Zhang X, Wang L, Lv Y, Zou X, Ling T (2017) Long-term outcomes of peroral endoscopic myotomy for patients with achalasia: a retrospective single-center study. Dis Esophagus 30(5):1–6CrossRefPubMed

32.

Ju H, Ma Y, Liang K, Zhang C, Tian Z (2016) Function of high-resolution manometry in the analysis of peroral endoscopic myotomy for achalasia. Surg Endosc 30:1094–1099CrossRefPubMed

Title: Myotomy length informed by high-resolution esophageal manometry (HREM) results in improved per-oral endoscopic myotomy (POEM) outcomes for type III achalasia
Authors: Erica D. Kane
Vikram Budhraja
David J. Desilets
John R. Romanelli
Publication date: 01-03-2019
Publisher: Springer US
Published in: Surgical Endoscopy / Issue 3/2019
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI: https://doi.org/10.1007/s00464-018-6356-0

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Myotomy length informed by high-resolution esophageal manometry (HREM) results in improved per-oral endoscopic myotomy (POEM) outcomes for type III achalasia

Abstract

Introduction

Methods

Results

Conclusions

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusions

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