Navigating reflux disease after achalasia treatments:Balancing risks and benefits

The peroral endoscopic myotomy(POEM)procedure has revolutionized the management of achalasia in many centres around the world as it offers patients a minimally invasive endoscopic solution to their dysphagia caused by achalasia.Alongside its success in alleviating dysphagia,concerns regarding postoperative gastroesophageal reflux disease have emerged as a pertinent issue which are not fully resolved.In this study,Nabi et al have comprehensively reviewed the topic of the prediction,prevention and management of gastroesophageal reflux after POEM.POEM is a purely endoscopic procedure which is usually performed without any anti-reflux procedure.Certain patients may be better served by a laparoscopic Heller’s myotomy and fundoplication and it is important that gastroenterologists and surgeons provide comprehensive risks and benefits of each achalasia treatment option so that patients can decide what treatment is best for them.This article by Nabi et al provides a comprehensive review of the current status of this issue to allow these discussions to occur.

Per-oral endoscopic myotomy is safe and effective for pediatric patients with achalasia:A long-term follow-up study

BACKGROUND Per-oral endoscopic myotomy(POEM)is emerging as a prefer treatment option for pediatric achalasia.However,data are limited on the long-term efficacy of POEM in children and adolescents with achalasia.AIM To evaluate the safety and long-term efficacy of POEM for pediatric patients with achalasia and compare those outcomes with adult patients.METHODS This retrospective cohort study was conducted in patients with achalasia who underwent POEM.Patients aged under 18 years were included in the pediatric group;patients aged between 18 to 65 years who underwent POEM in the same period were assigned to the control group.For investigation of long-term followup,the pediatric group were matched with patients from the control group in a 1:1 ratio.The procedure-related parameters,adverse events,clinical success,gastroesophageal reflux disease(GERD)after POEM,and quality of life(QoL)were evaluated.RESULTS From January 2012 to March 2020,POEM was performed in 1025 patients aged under 65 years old(48 in the pediatric group,1025 in the control group).No significant differences were observed in the occurrence of POEM complications between the two groups(14.6%vs 14.6%;P=0.99).Among the 34 pediatric patients(70.8%)who underwent follow-up for 5.7 years(range 2.6-10.6 years),clinical success was achieved in 35 patients(35/36;97.2%).No differences were observed in post-POEM GERD occurrence(17.6%vs 35.3%;P=0.10).QoL was significantly improved in both groups after POEM.CONCLUSION POEM is safe and effective for pediatric patients with achalasia.It can achieve significant symptoms relief and improve QoL.

Pathogenesis,clinical manifestations,diagnosis,and treatment progress of achalasia of cardia

Achalasia cardia,type of esophageal dynamic disorder,is a relatively rare primary motor esophageal disease characterized by the functional loss of plexus ganglion cells in the distal esophagus and lower esophageal sphincter.Loss of function of the distal and lower esophageal sphincter ganglion cells is the main cause of achalasia cardia,and is more likely to occur in the elderly.Histological changes in the esophageal mucosa are considered pathogenic;however,studies have found that inflammation and genetic changes at the molecular level may also cause achalasia cardia,resulting in dysphagia,reflux,aspiration,retrosternal pain,and weight loss.Currently,the treatment options for achalasia focus on reducing the resting pressure of the lower esophageal sphincter,helping to empty the esophagus and relieve symptoms.Treatment measures include botulinum toxin injection,inflatable dilation,stent insertion,and surgical myotomy(open or laparoscopic).Surgical procedures are often subject to controversy owing to concerns about safety and effectiveness,particularly in older patients.Herein,we review clinical epidemiological and experimental data to determine the prevalence,pathogenesis,clinical presentation,diagnostic criteria,and treatment options for achalasia to support its clinical management.

Repeat peroral endoscopic myotomy with simultaneous submucosal and muscle dissection as a salvage option for recurrent achalasia

BACKGROUND For recurrent achalasia after initial peroral endoscopic myotomy(POEM)failure,repeat POEM(Re-POEM)has been reported as a treatment option.However,severe esophageal interlayer adhesions caused by previous procedures impede the successful establishment of a submucosal tunnel and lead to aborted Re-POEM procedures.Our team previously described POEM with simultaneous submucosal and muscle dissection(POEM-SSMD)as a feasible solution for achalasia with severe interlayer adhesions.AIM To investigate the effectiveness and safety of Re-POEM with simultaneous submucosal and muscle dissection(Re-POEM-SSMD).METHODS A total of 1049 patients with achalasia who underwent successful endoscopic myotomy at the Digestive Endoscopic Center of Chinese PLA General Hospital from December 2014 to May 2022 were reviewed.Patients with recurrent achalasia who experienced initial POEM clinical failure were retrospectively included in this study.The primary endpoint was retreatment clinical success,defined as an Eckardt score≤3 during the postretreatment follow-up and no need for additional treatment.Procedure-related adverse events,changes in manometric lower esophageal sphincter(LES)pressure and reflux complications,as well as procedure-related parameters,were recorded.RESULTS Sixteen patients underwent Re-POEM(9 patients)or Re-POEM-SSMD(7 patients)successfully at a median of 45.5 mo(range,4-95 mo)after initial POEM.During a median followup period of 31 mo(range,7-96 mo),clinical success(Eckardt score≤3)was achieved in 8(88.9%)and 6(85.7%)patients after Re-POEM and Re-POEM-SSMD,respectively(P=0.849).The median Eckardt score dropped from 4(range,3-8)at preretreatment to 1(range,0-5)at postretreatment in the Re-POEM group(P=0.025)and from 5(range,2-8)to 2(range,0-4)in the Re-POEM-SSMD group(P<0.001).The mean manometric LES pressure decreased from 23.78±9.04 mmHg to 11.45±5.37 mmHg after Re-POEM(P<0.001)and from 26.80±7.48 mmHg to 11.05±4.38 mmHg after Re-POEM-SSMD(P<0.001).No serious adverse events were recorded in both groups.CONCLUSION In conclusion,Re-POEM-SSMD appears to be a safe and effective salvage therapy for recurrent achalasia with severe interlayer adhesions.

Early esophageal carcinomas in achalasia patient after endoscopic submucosal dissection combined with peroral endoscopic myotomy:A case report

BACKGROUND Achalasia is associated with high risk of esophageal carcinoma.However,the optimal endoscopic surgery for patients with early esophageal carcinoma concomitant with achalasia remains unclear.CASE SUMMARY A combination of concurrent endoscopic submucosal dissection(ESD)and modified peroral endoscopic myotomy(POEM)was performed on a 62-year-old male,who presented with multiple early esophageal carcinomas concomitant with achalasia.The patient exhibited an improvement in feeding obstruction,and presented no evidence of disease during the 3-year follow-up.CONCLUSION The combination of ESD and POEM is a feasible treatment modality for patients with early esophageal carcinoma concomitant with achalasia.

Direct cost variance analysis of peroral endoscopic myotomy vs heller myotomy for management of achalasia:A tertiary referral center experience

BACKGROUND Laparoscopic Heller myotomy(LHM)has been the traditional surgical treatment for achalasia.Recently,peroral endoscopic myotomy(POEM)has demonstrated similar clinical outcomes with shorter procedure times.Studies comparing the direct cost-effectiveness of POEM vs LHM are limited.AIM To compare costs of POEM vs LHM.METHODS Haider SA et al.Comparing costs:POEM vs Heller myotomy WJGE https://www.wjgnet.com 594 October 16,2023 Volume 15 Issue 10 This retrospective chart review aimed to compare the outcomes and cost of clinical care between patients who underwent POEM and LHM procedures for achalasia.The study was conducted at a tertiary academic center from January 2019 to December 2020.Clinical outcomes,including post-operative Eckardt scores and adverse events,were assessed and compared between the two groups.Direct cost variance analysis was utilized to evaluate the cost of clinical care incurred by patients undergoing POEM in the year preceding the procedure,during the index admission,and one year post-procedure,in comparison to patients undergoing LHM.RESULTS Of 30 patients were included(15 POEM and 15 LHM)in the study.Patients in the POEM group had a mean Eckardt score of 0.5±0.5 post-procedure,which was no different from patients in the LHM group(0.7±0.6,P=0.17)indicating comparative efficacy.However,the total costs of the admission for the procedure in the LHM group were on average$1827 more expensive than in the POEM group(P<0.01).Total healthcare costs one year prior to index procedure were$7777 higher in the LHM group,but not statistically different(P=0.34).The patients in the LHM group one year after the index procedure had accrued$19730.24 larger total cost,although this was not statistically different from POEM group(P=0.68).CONCLUSION Despite similar clinical outcomes,the cost of the index procedure admission for POEM was significantly lower than for LHM.The difference was primarily related to shorter time increments utilized in the operating room during the index procedure,and shorter length of hospital stay following POEM.

Pseudoachalasia: A peculiar case report and review of the literature

Pseudoachalasia is a rare secondary achalasia, which accounts for only a small subgroup of patients. We describe a 77-year-old woman with recent onset of dysphagia and typical esophageal manometric findings of achalasia. Moreover, esophageal manometric findings of vascular compression at 36 cm from the nose were associated with dysphagia. An upper endoscopy showed the absence of lesions both in the esophagus and gastro-esophageal junction, whilst a 15-mm ulcer on the gastric angulus was detected. The gastric ulcer resulted in being a diffuse signet ring cell carcinoma at histology, suggesting pseudoachalasia. An abdominal computed tomography scan showed an irregular concentric thickening of the gastro-esophageal junction wall extending for 7 cm and a dilated ascending thoracic aorta with no presence of the inferior vena cava, with an enlarged azygos as the source of vascular compression of esophagus. Moreover, cardia involvement from diffuse signet ring cell carcinoma of the gastric angulus was also recognized as the cause of dysphagia. The cancer was not suitable for a surgical approach in an old patient with cardiovascular comorbidities and support therapy was started. In our ambulatory series, pseudoachalasia was eventually diagnosed in 4.7% of 234 consecutive patients with esophageal manometric finding suggestive of achalasia. We also reviewed cases in the literature and aimed to evaluate the reported causes of pseudoachalasia.

Achalasia: A review of clinical diagnosis, epidemiology,treatment and outcomes

Achalasia is a neurodegenerative motility disorder of the oesophagus resulting in deranged oesophageal peristalsis and loss of lower oesophageal sphincter function.Historically,annual achalasia incidence rates were believed to be low,approximately 0.5-1.2 per 100000.More recent reports suggest that annual incidence rates have risen to 1.6 per 100000 in some populations.The aetiology of achalasia is still unclear but is likely to be multi-factorial.Suggested causes include environmental or viral exposures resulting in inflammation of the oesophageal myenteric plexus,which elicits an autoimmune response.Risk of achalasia may be elevated in a sub-group of genetically susceptible people.Improvement in the diagnosis of achalasia,through the introduction of high resolution manometry with pressure topography plotting,has resulted in the development of a novel classification system for achalasia.This classification system can evaluate patient prognosis and predict responsiveness to treatment.There is currently much debate over whether pneumatic dilatation is a superior method compared to the Heller’s myotomy procedure in the treatment of achalasia.A recent com-parative study found equal efficacy,suggesting that patient preference and local expertise should guide the choice.Although achalasia is a relatively rare condition,it carries a risk of complications,including aspiration pneumonia and oesophageal cancer.The risk of both squamous cell carcinoma and adenocarcinoma of the oesophagus is believed to be significantly increased in patients with achalasia,however the absolute excess risk is small.Therefore,it is currently unknown whether a surveillance programme in achalasia patients would be effective or cost-effective.

New endoscopic classification of achalasia for selection of candidates for peroral endoscopic myotomy

AIM:To propose a new endoscopic classification of achalasia for selecting patients appropriate for undergoing peroral endoscopic myotomy(POEM).METHODS:We screened out the data of patients with achalasia examined from October 2000 to September 2011 at our Digestive Endoscopic Center with endoscopic pictures clear enough to reveal the morphology of middle and lower esophagus.After analyzing the correlation between the endoscopic morphology of the esophageal lumen and POEM,we proposed a new endoscopic classification(Ling classification) of achalasia according to three kinds of endoscopically viewed structures:multi-ring structure,crescent-like structure and diverticulum structure.There were three types based on the criteria of Ling classification:type Ⅰ,smooth without multi-ring,crescent-like structure or diverticulum structure;type Ⅱ,with multi-ring or crescent-like structure but without diverticulum structure;and type Ⅲ,with diverticulum structure.Type Ⅱ was classified into three subtypes:Ling Ⅱa,Ling Ⅱb and Ling Ⅱc;and type Ⅲ also had three subtypes:Ling Ⅲl,Ling Ⅲr and Ling Ⅲlr.Two endoscopists made a final decision upon mutual agreement through discussion if their separately recorded characteristics were different.RESULTS:Among the 976 screened patients with achalasia,636 patients with qualified endoscopic pictures were selected for the analysis,including 405 males and 231 females.The average age was 42.7 years,ranging from 6 to 93 years.Type Ⅰ was the most commonly observed type of achalasia,accounting for 64.5%(410/636),and type Ⅲ was the least commonly observed type of achalasia,accounting for 2.8%(18/636).And type Ⅱ accounted for 32.7%(208/636) and subtype of Ling Ⅱa,Ling Ⅱb and Ling Ⅱc accounted for 14.6%(93/636),9.9%(63/636) and 8.2%(52/636),respectively.And subtype of Ling Ⅲl,Ling Ⅲr and Ling Ⅲlr accounted for 0.8%(5/636),0.3%(2/636) and 1.7%(11/636),respectively.CONCLUSION:A new endoscopic classification of achalasia is proposed that might help in determining the proper candidates for POEM.

Current status in the treatment options for esophageal achalasia

Recent advances in the treatment of achalasia include the use of high-resolution manometry to predict the outcome of patients and the introduction of peroral endoscopic myotomy(POEM).The first multicenter randomized,controlled,2-year follow-up study conducted by the European Achalasia Trial group indicated that laparoscopic Heller myotomy(LHM)was not superior to pneumatic dilations(PD).Publications on the long-term success of laparoscopic surgery continue to emerge.In addition,laparoscopic single-site surgery is applicable to advanced laparoscopic operations such as LHM and anterior fundoplication.The optimal treatment option is an ongoing matter of debate.In this review,we provide an update of the current progress in the treatment of esophageal achalasia.Unless new conclusive data prove otherwise,LHM is considered the most durable treatment for achalasia at the expense of increased reflux-associated complications.However,PD is the first choice for non-surgical treatment and is more costeffective.Repeated PD according to an"on-demand"strategy based on symptom recurrence can achieve long-term remission.Decision making should be based on clinical evidence that identifies a subcategory of patients who would benefit from specific treatment options.POEM has shown promise but its long-term efficacy and safety need to be assessed further.

Peroral endoscopic myotomy for achalasia in patients aged ≥ 65 years

AIM:To investigate the safety and efficacy of peroral endoscopic myotomy(POEM) for achalasia in patients aged ≥ 65 years.METHODS:From November 2011 to August 2014,15 consecutive patients(aged ≥ 65 years) diagnosed with achalasia were prospectively recruited and all underwent POEM at our institution. Eckardt score,lower esophageal sphincter(LES) pressure,esophageal diameter,SF-36 questionnaire,and procedure-related complications were used to evaluate the outcomes.RESULTS:All 15 patients were treated successfully by POEM,with a median operation time of 55 min. Median myotomy length was 10 cm. Three patients underwent circular myotomy and 12 full-thickness myotomies. Symptoms remitted in all cases during post-POEM f o l l o w- u p o f 6- 3 9 m o. E c k a r d t s c o r e r e d u c e d significantly(pre-operation vs post-operation:8.0 vs 1.0,P < 0.05). Median LES pressure decreased from 27.4 to 9.6 mm Hg(P < 0.05). Median diameter of the esophagus was significantly decreased(pre-operation vs post-operation:51.0 mm vs 30.0 mm,P < 0.05). Only one patient had reflux,which was resolved with oral proton pump inhibitors. No serious complications related to POEM were found. The quality of life of the 15 patients improved significantly after POEM.CONCLUSION:POEM is a safe and effective technique for treatment of achalasia in patients aged ≥ 65 years,with improvement in symptoms and quality of life.

Efficacy of peroral endoscopic myotomy vs other achalasia treatments in improving esophageal function

AIM: To assess and compare the esophageal function after peroral endoscopic myotomy(POEM) vs other conventional treatments in achalasia.METHODS: Chart review of all achalasia patients who underwent POEM, laparoscopic Heller myotomy(LHM) or pneumatic dilation(PD) at our institution between January 2012 and March 2015 was performed. Patient demographics, type of achalasia, prior treatments, pre- and post-treatment timed barium swallow(TBE) and high-resolution esophageal manometry(HREM) findings were compared between the three treatment groups. Patients who had both pre- and 2 mo posttreatment TBE or HREM were included in the final analysis. TBE parameters compared were barium column height, width and volume of barium remaining at 1 and 5 min. HREM parameters compared were basal lower esophageal sphincter(LES) pressures and LES-integrated relaxation pressures(IRP). Data are presented as mean ± SD, median [25th, 75 th percentiles] or frequency(percent). Analysis of variance, KruskalWallis test, Pearsons χ~2 test and Fishers Exact tests were used for analysis.RESULTS: A total of 200 achalasia patients were included of which 36 underwent POEM, 22 underwent PD and 142 underwent LHM. POEM patients were older(55.4 ± 16.8 years vs 46.5 ± 15.7 years, P = 0.013) and had higher BMI than LHM(29.1 ± 5.9 kg/m^2 vs 26 ± 5.1 kg/m^2, P = 0.012). More number of patients in POEM and PD groups had undergone prior treatments compared to LHM group(72.2% vs 68.2% vs 44.3% respectively, P = 0.003). At 2 mo post-treatment, all TBE parameters including barium column height, width and volume remaining at 1 and 5 min improved significantly in all three treatment groups(P = 0.01 to P < 0.001) except the column height at 1 min in PD group(P = 0.11). At 2 mo post-treatment, there was significant improvement in basal LES pressure and LES-IRP in both LHM(40.5 mm Hg vs 14.5 mm Hg and 24 mm Hg vs 7.1 mm Hg respectively, P < 0.001) and POEM groups(38.7 mm Hg vs 11.4 mm Hg and 23.6 mm Hg vs 6.6 mm Hg respectively, P < 0.001). However, when the efficacy of three treatments were compared to each other in terms of improvement in TBE or HREM parameters at 2 mo, there was no significant difference(P > 0.05).CONCLUSION: POEM, PD and LHM were all effective in improving esophageal function in achalasia at shortterm. There was no difference in efficacy between the three treatments.

Temporary self-expanding metallic stents for achalasia: A prospective study with a long-term follow-up

AIM: To compare the efficacy of self-expanding metallic stents (SEMSs) for the long-term clinical treatment of achalasia. METHODS: Ninety achalasic patients were treated with a temporary SEMS with a diameter of 20 mm (n = 30, group A), 25 mm (n = 30, group B) or 30 mm (n = 30, group C). Data on clinical symptoms, complications and treatment outcomes were collected, and follow-up was made at 6 mo and at 1, 3-5, 5-8, 8-10 and > 10 years, postoperatively.RESULTS: Stent placement was successful in all patients. Although chest pain occurrence was high, stent migration was less in group C than in groups A and B. The clinical remission rate at 5-8, 8-10 and > 10 years in group C was higher than that in the other two groups. The treatment failure rate was lower in group C (13%) than in groups A (53%) and B (27%). SEMSs in group C resulted in reduced dysphagia scores and lowered esophageal sphincter pressures, as well as normal levels of barium height and width during all the follow-up time periods. Conversely, these parameters increased over time in groups A and B. The primary patency in group C was longer than in groups A and B. CONCLUSION: A temporary SEMS with a diameter of 30 mm is associated with a superior long-term clinical efficacy in the treatment of achalasia compared with a SEMS with a diameter of 20 mm or 25 mm.

Childhood achalasia: A comprehensive review of disease, diagnosis and therapeutic management

Achalasia is an esophageal motility disorder character-ized by failure of lower esophageal sphincter(LES) relaxation and is rare in children. The most common symptoms are vomiting, dysphagia, regurgitation, and weight loss. Definitive diagnosis is made with barium swallow study and esophageal manometry. In adults, endoscopic biopsy is recommended to exclude malig-nancy however; it is not as often indicated in children. Medical management often fails resulting in recurrent symptoms and the ultimate definitive treatment is sur-gical. Laparoscopic Heller myotomy with or without an anti-reflux procedure is the treatment of choice and has become standard of care for children with achala-sia. Peroral endoscopic myotomy is a novel therapy uti-lized with increasing frequency for achalasia treatment in adults. More experience is needed to determine the safety, efficacy, and feasibility of peroral endoscopic myotomy in children.

Endoscope-guided pneumatic dilation for treatment of esophageal achalasia

Pneumatic dilation(PD) is considered to be the first line nonsurgical therapy for achalasia.The principle of the procedure is to weaken the lower esophageal sphincter by tearing its muscle fibers by generating radial force.The endoscope-guided procedure is done without fluoroscopic control.Clinicians usually use a lowcompliance balloon such as Rigiflex dilator to perform endoscope-guided PD for the treatment of esophageal achalasia.It has the advantage of determining mucosal injury during the dilation process,so that a repeat endoscopy is not needed to assess the mucosal tearing.Previous studies have shown that endoscope-guided PD is an efficient and safe nonsurgical therapy with results that compare well with other treatment modalities.Although the results may be promising,long-term follow-up is required in the near future.

Per-oral endoscopic myotomy:Major advance in achalasia treatment and in endoscopic surgery

Per-oral endoscopic myotomy(POEM)represents a natural orifice endoscopic surgery(NOTES)approach to laparoscopy Heller myotomy(LHM).POEM is arguably the most successful clinical application of NOTES.The growth of POEM from a single center in 2008 to approximately 60 centers worldwide in 2014 with several thousand procedures having been performed attests to the success of POEM.Initial efficacy,safety and acid reflux data suggest at least equivalence of POEM to LHM,the previous gold standard for achalasia therapy.Adjunctive techniques used in the West include impedance planimetry for real-time intraprocedural luminal assessment and endoscopic suturing for challenging mucosal defect closures during POEM.The impact of POEM extends beyond the realm of esophageal motility disorders as it is rapidly popularizing endoscopic submucosal dissection in the West and spawning offshoots that use the submucosal tunnel technique for a host of new indications ranging from resection of tumors to pyloromyotomy for gastroparesis.

Family case of achalasia cardia: Case report and review of literature

Achalasia cardia is an idiopathic disease that occurs as a result of inflammation and degeneration of myenteric plexi leading to the loss of postganglionic inhibitory neurons required for relaxation of the lower esophageal sphincter and peristalsis of the esophagus.The main symptoms of achalasia are dysphagia,regurgitation,chest pain and weight loss.At present,there are three main hypotheses regarding etiology of achalasia cardia which are under consideration,these are genetic,infectious and autoimmune.Genetic theory is one of the most widely discussed.Case report given below represents an inheritable case of achalasia cardia which was not diagnosed for a long time in an 81-year-old woman and her 58-year-old daughter.

Per-oral endoscopic myotomy for achalasia: An American perspective

Achalasia is an uncommon esophageal motility disorder characterized by the selective loss of enteric neurons leading to absence of peristalsis and impaired relaxation of the lower esophageal sphincter.Per-oral endoscopic myotomy(POEM) is a novel modality for the treatment of achalasia performed by gastroenterologists and surgeons.It represents a natural orifice transluminal endoscopic surgery(NOTES) approach to Heller myotomy.POEM has the minimal invasiveness of an endoscopic procedure that can duplicate results of the surgical Heller myotomy.POEM is conceptually similar to a surgical myotomy without the inherent external incisions and post-operative care associated with surgery.Initial high success and low complications rates promise a great future for this technique.In fact,POEM has been successfully performed on patients with end-stage achalasia as an initial treatment reserving esophagectomy for those without good response.The volume of POEMs performed worldwide has grown exponentially.In fact,surgeons who have performed Heller myotomy have embraced POEM as the preferred intervention for achalasia.However,the niche of POEM remains to be defined and long term results are awaited.We describe our experience with POEM having performed the first POEM outside of Japan in 2009,the evolution of our technique,and give our perspective on its future.

Upper esophageal sphincter abnormalities are strongly predictive of treatment response in patients with achalasia

AIM: To investigate the relationship between upper esophageal sphincter abnormalities achalasia treatment METHODS: We performed a retrospective study of 41 consecutive patients referred for high resolution esophageal manometry with a final manometric diagnosis of achalasia. Patients were sub-divided by presence or absence of Upper esophageal sphincter(UES) abnormality, and clinical and manometric profiles were compared.Correlation between UES abnormality and sub-type(i.e.,hypertensive, hypotensive or impaired relaxation) and a number of variables, including qualitative treatment response, achalasia sub-type, co-morbid medical illness,psychiatric illness, surgical history, dominant presentingsymptom, treatment type, age and gender were also evaluated.RESULTS: Among all 41 patients, 24(58.54%) had a UES abnormality present. There were no significant differences between the groups in terms of age, gender or any other clinical or demographic profiles. Among those with UES abnormalities, the majority were either hypertensive(41.67%) or had impaired relaxation(37.5%) as compared to hypotensive(20.83%), although this did not reach statistical significance(P = 0.42). There was no specific association between treatment response and treatment type received; however, there was a significant association between UES abnormalities and treatment response. In patients with achalasia and concomitant UES abnormalities, 87.5% had poor treatment response, while only 12.5% had favorable response. In contrast, in patients with achalasia and no UES abnormalities, the majority(78.57%) had good treatment response, as compared to 21.43% with poor treatment response(P = 0.0001). After controlling for achalasia sub-type, those with UES abnormality had 26 times greater odds of poor treatment response than those with no UES abnormality(P = 0.009). Similarly, after controlling for treatment type, those with UES abnormality had 13.9 times greater odds of poor treatment response compared to those with no UES abnormality(P = 0.017).CONCLUSION: The presence of UES abnormalities in patients with achalasia significantly predicted poorer treatment response as compared to those with normal UES function.

Effect of peroral esophageal myotomy for achalasia treatment: A Chinese study

AIM: To assess the safety and feasibility of peroral esophageal myotomy(POEM) in patients with achalasia.METHODS: From January 2012 to March 2014, 50 patients(28 men, 22 women; mean age: 42.8 years, range: 14-70 years) underwent POEM. Pre- and postoperative symptoms were quantified using the Eckardt scoring system. Barium swallow and esophagogastroscopy were performed before and after POEM, respectively. Esophageal motility was evaluated in all patients, both preoperatively and one month after POEM treatment, using a high-resolution manometry system. Manometry data, Eckardt scores, lower esophageal sphincter pressure and barium swallow results were used to evaluate the effect of the procedure.RESULTS: POEM was successfully completed for all patients. The mean procedure time was 55.4 ± 17.3 min and the mean total length of myotomy of the circular esophagus was 10.5 ± 2.6 cm. No specific complications occurred, with the exception of two patients that developed as ymptomatic pneumomediastinum and subcutaneous emphysema. Clinical improvement in symptoms was achieved in all patients. Approximately 77.5% of patients experienced weight gain 6 mo after POEM, with an average of 4.78 kg(range: 2-15 kg). The lower esophageal sphincter resting pressure, four second integrated relaxation pressure and Eckardt scores were all significantly reduced after POEM(Ps < 0.05). A small segment of proximal esophageal peristalsis appeared postoperatively in two patients, but without normal esophageal peristalsis. The average diameter of the esophageal lumen decreased significantly from 4.39 to 3.09 cm(P < 0.01). CONCLUSION: POEM can relieve achalasia symptoms, improve gastroesophageal junction relaxation and restore esophageal body motility function, but not normal esophageal peristalsis.