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.

Peroral endoscopic myotomy vs laparoscopic myotomy and partial fundoplication for esophageal achalasia: A single-center randomized controlled trial

BACKGROUND Achalasia is a rare benign esophageal motor disorder characterized by incomplete relaxation of the lower esophageal sphincter(LES). The treatment of achalasia is not curative, but rather is aimed at reducing LES pressure. In patients who have failed noninvasive therapy, surgery should be considered. Myotomy with partial fundoplication has been considered the first-line treatment for non-advanced achalasia. Recently, peroral endoscopic myotomy(POEM), a technique that employs the principles of submucosal endoscopy to perform the equivalent of a surgical myotomy,has emerged as a promising minimally invasive technique for the management of this condition.AIM To compare POEM and laparoscopic myotomy and partial fundoplication(LM-PF) regarding their efficacy and outcomes for the treatment of achalasia.METHODS Forty treatment-naive adult patients who had been diagnosed with achalasia based on clinical and manometric criteria(dysphagia score ≥ II and Eckardt score > 3) were randomized to undergo either LM-PF or POEM. The outcome measures were anesthesia time, procedure time, symptom improvement, reflux esophagitis(as determined with the Gastroesophageal Reflux Disease Questionnaire), barium column height at 1 and 5 min(on a barium esophagogram), pressure at the LES, the occurrence of adverse events(AEs), length of stay(LOS), and quality of life(QoL).RESULTS There were no statistically significant differences between the LM-PF and POEM groups regarding symptom improvement at 1, 6, and 12 mo of follow-up(P = 0.192, P = 0.242, and P = 0.242, respectively). However, the rates of reflux esophagitis at 1, 6, and 12 mo of follow-up were significantly higher in the POEM group(P = 0.014, P < 0.001, and P = 0.002, respectively). There were also no statistical differences regarding the manometry values, the occurrence of AEs, or LOS. Anesthesia time and procedure time were significantly shorter in the POEM group than in the LM-PF group(185.00 ± 56.89 and 95.70 ± 30.47 min vs 296.75 ± 56.13 and 218.75 ± 50.88 min,respectively;P = 0.001 for both). In the POEM group, there were improvements in all domains of the QoL questionnaire, whereas there were improvements in only three domains in the LM-PF group.CONCLUSION POEM and LM-PF appear to be equally effective in controlling the symptoms of achalasia,shortening LOS, and minimizing AEs. Nevertheless, POEM has the advantage of improving all domains of QoL, and shortening anesthesia and procedure times but with a significantly higher rate of gastroesophageal reflux.

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.

Laparoscopic Heller-Dor operation for patients with achalasia

Background Laparoscopic Heller cardiomyotomy and Dor fundoplication is the surgical procedure of choice for esophageal achalasia. The aim of this study was to investigate the clinical outcome of laparoscopic Heller-Dor procedure in our initial series of 25 patients with achalasia. Methods Between October 2003 and January 2006, a total of 25 patients with achalasia underwent laparoscopic Heller-Dor operation. Among them, 9 were male and 16 were female with an average age of （41.5 ± 5.1） years （21- 66）. All the patients received upper gastrointestinal series （barium swallow）, esophagogastroscopy, esophageal manometry to exclude esophageal carcinoma and to confirm the diagnosis, and 21 patients also had 24-hour ambulatory pH studies. All the patients were operated by laparoscopic modified Heller＇s myotomy with Dor fundoplication. In addition, 2 of them had combined laparoscopic cholecystectomy ± excision of hepatic hemangioma and laparoscopic cholecystectomy, respectively. Results The average operating time was （110.6± 12.9） minutes （range, 60-180）, operative blood loss averaged （18.6±7.1） ml （5-50）, the median time to oral feeding was （1.6±0.4） days （1-4） and the median hospital stay was （12.6± 1.2） days （10-20）. There was no conversion to open surgery. Intraoperative mucosal perforation was encountered in six patients and was repaired in all of them by laparoscopic suture. All the patients had an uneventful recovery without postoperative complication. After a median follow-up of （10.6 ± 7.2） months （1 -27）, 24 patients were asymptomatic and 1 had mild postoperative dysphagia. Conclusions Laparoscopic Heller-Dor operation had the advantages of reduced compromise of the cardiopulmonary function, with less disruption of the supporting structures （phrenoesophageal membrane） of the antireflux mechanism, requiting simpler general anesthesia and providing excellent exposure permitting an easy fundoplication, less pain and reduced morbidity, shorter hospitalization and faster convalescence.