This editorial is an analysis the review article by Nabi et al recently published in this journal.Achalasia Cardia is a disease whose pathophysiology is still unclear.It is known that there is inflammation of unknown ...This editorial is an analysis the review article by Nabi et al recently published in this journal.Achalasia Cardia is a disease whose pathophysiology is still unclear.It is known that there is inflammation of unknown aetiology leading to loss of ganglion cells in the muscularis propria.The end result is lower oesophageal sphincter spasm,loss of receptive relaxation,decreased oesophageal peristalsis,all leading on to varying degrees of dysphagia.The treatment of this condition is palliative in nature,performed by myotomy of the lower oesophagus either surgically or endoscopically.Gastroesophageal reflux disease(GERD)has been associated with the myotomy performed,particularly with the Peroral Endoscopic Myotomy(POEM)procedure.Nabi et al have provided an excellent overview of the latest developments in predicting,preventing,evaluating,and managing GERD subsequent to POEM.Based on this theme,this review article explores the concept of using histology of the oesophageal muscle layer,to grade the disease and thereby help tailoring the length/type of myotomy performed during the POEM procedure.In the future,will a histology based algorithm available preoperatively,help modify the POEM procedure,thereby decreasing the incidence of GERD associated with POEM?展开更多
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.Stu...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.展开更多
AIM:To compare the outcome of acid reflux prevention by Dor fundoplication after laparoscopic Heller myotomy(LHM)for achalasia.METHODS:Electronic database PubMed,Ovid(Evidence-Based Medicine Reviews,EmBase and Ovid ME...AIM:To compare the outcome of acid reflux prevention by Dor fundoplication after laparoscopic Heller myotomy(LHM)for achalasia.METHODS:Electronic database PubMed,Ovid(Evidence-Based Medicine Reviews,EmBase and Ovid MEDLINE)and Cochrane Library were searched between January 1995 and September 2012.Bibliographic citation management software(EndNote X3)was used for extracted literature management.Quality assessment of random controlled studies(RCTs)and non-RCTs was performed according to the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0and a modification of the Newcastle-Ottawa Scale,respectively.The data were analyzed using Review Manager(Version 5.1),and sensitivity analysis was performed by sequentially omitting each study.RESULTS:Finally,6 studies,including a total of 523achalasia patients,compared Dor fundoplication with other types of fundoplication after LHM(Dor-other group),and 8 studies,including a total of 528 achalasia patients,compared Dor fundoplication with no fundoplication after LHM(Dor-no group).Dor fundoplication was associated with a significantly higher recurrence rate of clinical regurgitation and pathological acid reflux compared with the other fundoplication group(OR=7.16,95%CI:1.25-40.93,P=0.03,and OR=3.79,95%CI:1.23-11.72,P=0.02,respectively).In addition,there were no significant differences between Dor fundoplication and no fundoplication in all subjects.Other outcomes,including complications,dysphagia,postoperative physiologic testing,and operation-related data displayed no significant differences in the two comparison groups.CONCLUSION:Dor fundoplication is not the optimum procedure after LHM for achalasia.We suggest more attention should be paid on quality of life among different fundoplications.展开更多
AIM:To evaluate the efficacy and safety of Heller myotomy (HM) for recurrent achlasia, performed after different methods of first-line treatment. METHODS: We searched for studies published in PubMed from 1966 to March...AIM:To evaluate the efficacy and safety of Heller myotomy (HM) for recurrent achlasia, performed after different methods of first-line treatment. METHODS: We searched for studies published in PubMed from 1966 to March 2008 on treatment of recurrent achalasia with HM after failure with different methods of first-line treatment. The efficacy of HM was assessed by a pooled estimate of response rate with individual studies weighted proportionally to sample size. RESULTS: Sixteen studies were eligible and included in the review. The results showed that HM has a better remission rate for recurrent achalasia after failure of HM [weighted mean (SD)] of 86.9% (21.8%) compared with 81.6% (23.8%) for pneumatic dilatation (PD). One study evaluated the efficacy of HM after failure of PD combined with botulinum toxin injection (83%). The most common complications were perforation and gastroesophageal reflux. CONCLUSION: HM has the best efficacy in patients with recurrent achlasia who were treated with HM as first-line treatment. Future studies should focus on how to increase the success rate and decrease the complications of HM.展开更多
BACKGROUND Esophagogastric junction outflow obstruction(EGJOO) is a rare syndrome,characterized by an elevation of the integrated relaxation pressure of the lower esophageal sphincter, not accompanied by alterations i...BACKGROUND Esophagogastric junction outflow obstruction(EGJOO) is a rare syndrome,characterized by an elevation of the integrated relaxation pressure of the lower esophageal sphincter, not accompanied by alterations in esophageal motility that may lead to the criteria for achalasia. We were unable to find any prior report of the combination of Heller myotomy with anterior partial fundoplication(Dor) as the treatment for EGJOO. We herein report a case of EGJOO treated with laparoscopic Heller myotomy combined with Dor fundoplication.CASE SUMMARY A 26-year-old man presented with a 3-year history of solid dysphagia and a 30-kg weight loss. He was treated with oral nifedipine, isosorbide, and omeprazole,without resolution of symptoms. An upper gastrointestinal series(barium swallow) revealed a "bird's beak" sign. Esophagogastroduodenoscopy was positive for Los Angeles grade A peptic esophagitis. High-resolution esophageal manometry was compatible with EGJOO. Esophageal pH monitoring showed pathological acid reflux both in orthostatic and decubitus position. An 8-cm laparoscopic Heller myotomy combined with an anterior 220° Dor fundoplication was performed. Solid diet was introduced on postoperative day 2, and the patient was discharged home the same day. At 17-mo follow-up, he reported no symptoms. Barium swallow was compatible with complete radiologic resolution.Both esophageal manometry and upper endoscopy showed normal findings 9 mo after the operation.CONCLUSION Surgical treatment with Heller myotomy and Dor fundoplication is a potential treatment option for EGJOO refractory to medical treatment.展开更多
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...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.展开更多
AIM: To present our experience of laparoscopic Heller stretching myotomy followed by His angle reconstruction as surgical approach to esophageal achalasia.METHODS: Thirty-two patients underwent laparoscopic Heller myo...AIM: To present our experience of laparoscopic Heller stretching myotomy followed by His angle reconstruction as surgical approach to esophageal achalasia.METHODS: Thirty-two patients underwent laparoscopic Heller myotomy; an anterior partial fundoplication in 17,and angle of His reconstruction in 15 cases represented the antireflux procedure of choice.RESULTS: There were no morbidity and mortality recorded in both anterior funduplication and angle of His reconstruction groups. No differences were detected in terms of recurrent dysphagia, p.o. reflux or medical therapy.CONCLUSION: To reduce the incidence of recurrent achalasia after laparoscopic Heller myotomy, we believe that His' angle reconstruction is a safe and effective alternative to the anterior fundoplication.展开更多
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 ...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.展开更多
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 endosco...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.展开更多
Peroral endoscopic myotomy(POEM) is an innovative,minimally invasive, endoscopic treatment for esophageal achalasia and other esophageal motility disorders, emerged from the natural orifice transluminal endoscopic sur...Peroral endoscopic myotomy(POEM) is an innovative,minimally invasive, endoscopic treatment for esophageal achalasia and other esophageal motility disorders, emerged from the natural orifice transluminal endoscopic surgery procedures, and since the first human case performed by Inoue in 2008, showed exciting results in international level, with more than 4000 cases globally up to now. POEM showed superior characteristics than the standard 100-year-old surgical or laparoscopic Heller myotomy(LHM), not only for all types of esophageal achalasia [classical(Ⅰ), vigorous(Ⅱ), spastic(Ⅲ), Chicago Classification], but also for advanced sigmoid type achalasia(S1 and S2), failed LHM, or other esophageal motility disorders(diffuse esophageal spasm, nutcracker esophagus or Jackhammer esophagus). POEM starts with a mucosal incision, followed by submucosal tunnel creation crossing the esophagogastric junction(EGJ) and myotomy. Finally the mucosal entry is closed with endoscopic clip placement. POEM permitted relatively free choice of myotomy length and localization. Although it is technically demanding procedure, POEM can be performed safely and achieves very good control of dysphagia and chest pain. Gastroesophageal reflux is the most common troublesome side effect, and is well controllable with proton pump inhibitors. Furthermore, POEM opened the era of submucosal tunnel endoscopy, with many other applications. Based on the same principles with POEM, in combination with new technological developments, such as endoscopic suturing, peroral endoscopic tumor resection(POET), is safely and effectively applied for challenging submucosal esophageal, EGJ and gastric cardia tumors(submucosal tumors), emerged from muscularis propria. POET showed up to know promising results, however, it is restricted to specialized centers. The present article reviews the recent data of POEM and POET and discussed controversial issues that need further study and future perspectives.展开更多
Esophageal achalasia in children is rare but ultimately requires endoscopic or surgical treatment. Historically, Heller esophagomyotomy has been recommended as the treatment of choice. The refinement of minimally inva...Esophageal achalasia in children is rare but ultimately requires endoscopic or surgical treatment. Historically, Heller esophagomyotomy has been recommended as the treatment of choice. The refinement of minimally invasive techniques has shifted the trend of treatment toward laparoscopic Heller myotomy(LHM) in adults and children with achalasia. A review of the available literature on LHM performed in patients < 18 years of age was conducted. The pediatric LHM experience is limited to one multiinstitutional and several single-institutional retrospective studies. Available data suggest that LHM is safe and effective. There is a paucity of evidence on the need for and superiority of concurrent antireflux procedures. In addition, a more complete portrayal of complications and long-term(> 5 years) outcomes is needed. Due to the infrequency of achalasia in children, these characteristics are unlikely to be defined without collaboration between multiple pediatric surgery centers. The introduction of peroral endoscopic myotomy and single-incision techniques, continue the trend of innovative approaches that may eventually become the standard of care.展开更多
Achalasia cardia is a primary oesophageal motility disorder of unknown aetiology characterized manometrically by insufficient relaxation of the lower oesophageal sphincter (LES) and loss of oesophageal peristalsis;rad...Achalasia cardia is a primary oesophageal motility disorder of unknown aetiology characterized manometrically by insufficient relaxation of the lower oesophageal sphincter (LES) and loss of oesophageal peristalsis;radiographically by aperistalsis, oesophageal dilation with minimal LES opening, bird-beak appearance, poor emptying of barium;and endoscopically by dilated oesophagus with retained saliva, liquid and undigested food particles in the absence of mucosal stricturing or tumour. Achalasia cardia patients usually present with difficulty in swallowing both solids and liquids and this may be associated with regurgitation, heartburn and chest pains. Treatment options include medical or pharmacologic therapy, botulinum toxin injection, pneumatic dilation and oesophagocardiomyotomy or the Heller myotomy with or without antireflux procedure and recently the POEM (Perioral oesophageal myotomy). Herein, we present our experience with four cases managed surgically via thoracotomy without antireflux surgery over a 5-year period, from January 2015 to June 2019 at the Komfo Anokye Teaching Hospital, the second largest teaching hospital in Ghana.展开更多
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 reducin...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.展开更多
BACKGROUND Bleeding from Zenker’s diverticulum is extremely rare.At present,there are no guidelines for the management of bleeding Zenker’s diverticulum because of its rarity.Per-oral endoscopic myotomy(Z-POEM)is a ...BACKGROUND Bleeding from Zenker’s diverticulum is extremely rare.At present,there are no guidelines for the management of bleeding Zenker’s diverticulum because of its rarity.Per-oral endoscopic myotomy(Z-POEM)is a precision myotomy technique and minimally invasive procedure for the treatment of Zenker’s diverticulum.We present a systematic review and a rare case of bleeding Zenker’s diverticulum that was effectively treated using Z-POEM.CASE SUMMARY A 72-year-old presented after 3 d of hematemesis.He had a 2-year history of progressive dysphagia and reported no antiplatelet,anticoagulant,or nonsteroidal anti-inflammatory drug use.His vital signs were stable,and the hematocrit was 36%.Previous gastroscopy and barium swallow had revealed Zenker’s diverticulum before the bleeding occurred.We performed gastroscopy and found a 5-mm ulcer with a minimal blood clot and spontaneously resolved bleeding.Z-POEM for definitive treatment was performed to reduce accumulation of food and promote ulcer healing.He had no complications and no bleeding;at the follow-up 6 mo later,the ulcer was healed.CONCLUSION Z-POEM can be definitive prevention for bleeding ulcer in Zenker’s diverticulum that promotes ulcer healing,reducing the risk of recurrent bleeding.Z-POEM is also a definitive endoscopic surgery for treatment of Zenker’s diverticulum.展开更多
目的比较腹腔镜Heller手术(laparoscopic heller myotomy,LHM)和经口内镜下肌切开术(peroral endoscopic myotomy,POEM)治疗贲门失弛缓症的临床疗效,探讨POEM术后胃食管反流并发症的治疗策略。方法采用回顾性队列研究的方法,收集2012年1...目的比较腹腔镜Heller手术(laparoscopic heller myotomy,LHM)和经口内镜下肌切开术(peroral endoscopic myotomy,POEM)治疗贲门失弛缓症的临床疗效,探讨POEM术后胃食管反流并发症的治疗策略。方法采用回顾性队列研究的方法,收集2012年10月至2017年4月我院收治的61例贲门失弛缓症患者的临床资料,其中30例行腹腔镜Heller手术加部分胃底折叠术(Dor)为腹腔镜组(LHM组);31例行经口内镜下肌切开术为内镜组(POEM组),随访至2019年4月,比较两组患者的基本资料、手术情况、临床疗效以及胃食管反流并发症(包括胃食管反流症状、病理性酸反流、食管炎)的情况。结果患者均顺利完成手术,无围术期死亡。LHM组和POEM组患者在手术时间、术中出血量、围术期并发症、平均住院日、住院费用等方面差异无统计学意义。LHM组和POEM组的治疗有效率分别为86.7%(26/30)和90.3%(28/31),差异无统计学意义。两组患者术后Ecardt评分、下段食管静息压较术前均明显下降(P<0.001),但两组之间比较,差异无统计学意义;POEM组术后胃食管反流症状(3/27 vs 11/20,P=0.018)、病理性酸反流(4/26 vs 12/18,P=0.024)、食管炎(2/28 vs 9/22,P=0.023)发生率显著高于LHM组。临床相关胃食管反流发生率在POEM组更高(1/29 vs 7/24,P=0.026)。结论 LHM与POEM治疗贲门失弛缓症的安全性及中远期疗效相近,但是POEM手术缺乏抗反流措施,可导致胃食管反流发生率升高,术后应密切随访并积极干预。展开更多
目的:探讨腹腔镜Heller肌切开联合胃底折叠术(1aparoscopic Heller myotomy with a Toupet fundoplication,LHT)治疗贲门失弛缓症的临床价值:方法:回顾分析2000年4月至2008年4月我院为48例责门失弛缓症患者行LHT的临床资料。结果...目的:探讨腹腔镜Heller肌切开联合胃底折叠术(1aparoscopic Heller myotomy with a Toupet fundoplication,LHT)治疗贲门失弛缓症的临床价值:方法:回顾分析2000年4月至2008年4月我院为48例责门失弛缓症患者行LHT的临床资料。结果:手术均获成功,无中转开腹。手术时间65~150min,平均86min,术中出血5—50ml。术后平均住院5.2d。随访1~24个月,术前吞咽困难症状均缓解。结论:LHT具有定位准确、安全、可靠、创伤小、痛苦轻、疗效好等优点,同时可提高手术质量,减少并发症?LHT治疗责门失弛缓症值得临床推广。展开更多
文摘This editorial is an analysis the review article by Nabi et al recently published in this journal.Achalasia Cardia is a disease whose pathophysiology is still unclear.It is known that there is inflammation of unknown aetiology leading to loss of ganglion cells in the muscularis propria.The end result is lower oesophageal sphincter spasm,loss of receptive relaxation,decreased oesophageal peristalsis,all leading on to varying degrees of dysphagia.The treatment of this condition is palliative in nature,performed by myotomy of the lower oesophagus either surgically or endoscopically.Gastroesophageal reflux disease(GERD)has been associated with the myotomy performed,particularly with the Peroral Endoscopic Myotomy(POEM)procedure.Nabi et al have provided an excellent overview of the latest developments in predicting,preventing,evaluating,and managing GERD subsequent to POEM.Based on this theme,this review article explores the concept of using histology of the oesophageal muscle layer,to grade the disease and thereby help tailoring the length/type of myotomy performed during the POEM procedure.In the future,will a histology based algorithm available preoperatively,help modify the POEM procedure,thereby decreasing the incidence of GERD associated with POEM?
文摘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.
基金Supported by National Natural Science Foundation of China,Grant 81172373
文摘AIM:To compare the outcome of acid reflux prevention by Dor fundoplication after laparoscopic Heller myotomy(LHM)for achalasia.METHODS:Electronic database PubMed,Ovid(Evidence-Based Medicine Reviews,EmBase and Ovid MEDLINE)and Cochrane Library were searched between January 1995 and September 2012.Bibliographic citation management software(EndNote X3)was used for extracted literature management.Quality assessment of random controlled studies(RCTs)and non-RCTs was performed according to the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0and a modification of the Newcastle-Ottawa Scale,respectively.The data were analyzed using Review Manager(Version 5.1),and sensitivity analysis was performed by sequentially omitting each study.RESULTS:Finally,6 studies,including a total of 523achalasia patients,compared Dor fundoplication with other types of fundoplication after LHM(Dor-other group),and 8 studies,including a total of 528 achalasia patients,compared Dor fundoplication with no fundoplication after LHM(Dor-no group).Dor fundoplication was associated with a significantly higher recurrence rate of clinical regurgitation and pathological acid reflux compared with the other fundoplication group(OR=7.16,95%CI:1.25-40.93,P=0.03,and OR=3.79,95%CI:1.23-11.72,P=0.02,respectively).In addition,there were no significant differences between Dor fundoplication and no fundoplication in all subjects.Other outcomes,including complications,dysphagia,postoperative physiologic testing,and operation-related data displayed no significant differences in the two comparison groups.CONCLUSION:Dor fundoplication is not the optimum procedure after LHM for achalasia.We suggest more attention should be paid on quality of life among different fundoplications.
文摘AIM:To evaluate the efficacy and safety of Heller myotomy (HM) for recurrent achlasia, performed after different methods of first-line treatment. METHODS: We searched for studies published in PubMed from 1966 to March 2008 on treatment of recurrent achalasia with HM after failure with different methods of first-line treatment. The efficacy of HM was assessed by a pooled estimate of response rate with individual studies weighted proportionally to sample size. RESULTS: Sixteen studies were eligible and included in the review. The results showed that HM has a better remission rate for recurrent achalasia after failure of HM [weighted mean (SD)] of 86.9% (21.8%) compared with 81.6% (23.8%) for pneumatic dilatation (PD). One study evaluated the efficacy of HM after failure of PD combined with botulinum toxin injection (83%). The most common complications were perforation and gastroesophageal reflux. CONCLUSION: HM has the best efficacy in patients with recurrent achlasia who were treated with HM as first-line treatment. Future studies should focus on how to increase the success rate and decrease the complications of HM.
基金Supported by Research and Events Support Fund at Hospital de Clínicas de Porto Alegre
文摘BACKGROUND Esophagogastric junction outflow obstruction(EGJOO) is a rare syndrome,characterized by an elevation of the integrated relaxation pressure of the lower esophageal sphincter, not accompanied by alterations in esophageal motility that may lead to the criteria for achalasia. We were unable to find any prior report of the combination of Heller myotomy with anterior partial fundoplication(Dor) as the treatment for EGJOO. We herein report a case of EGJOO treated with laparoscopic Heller myotomy combined with Dor fundoplication.CASE SUMMARY A 26-year-old man presented with a 3-year history of solid dysphagia and a 30-kg weight loss. He was treated with oral nifedipine, isosorbide, and omeprazole,without resolution of symptoms. An upper gastrointestinal series(barium swallow) revealed a "bird's beak" sign. Esophagogastroduodenoscopy was positive for Los Angeles grade A peptic esophagitis. High-resolution esophageal manometry was compatible with EGJOO. Esophageal pH monitoring showed pathological acid reflux both in orthostatic and decubitus position. An 8-cm laparoscopic Heller myotomy combined with an anterior 220° Dor fundoplication was performed. Solid diet was introduced on postoperative day 2, and the patient was discharged home the same day. At 17-mo follow-up, he reported no symptoms. Barium swallow was compatible with complete radiologic resolution.Both esophageal manometry and upper endoscopy showed normal findings 9 mo after the operation.CONCLUSION Surgical treatment with Heller myotomy and Dor fundoplication is a potential treatment option for EGJOO refractory to medical treatment.
文摘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.
文摘AIM: To present our experience of laparoscopic Heller stretching myotomy followed by His angle reconstruction as surgical approach to esophageal achalasia.METHODS: Thirty-two patients underwent laparoscopic Heller myotomy; an anterior partial fundoplication in 17,and angle of His reconstruction in 15 cases represented the antireflux procedure of choice.RESULTS: There were no morbidity and mortality recorded in both anterior funduplication and angle of His reconstruction groups. No differences were detected in terms of recurrent dysphagia, p.o. reflux or medical therapy.CONCLUSION: To reduce the incidence of recurrent achalasia after laparoscopic Heller myotomy, we believe that His' angle reconstruction is a safe and effective alternative to the anterior fundoplication.
文摘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.
文摘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.
文摘Peroral endoscopic myotomy(POEM) is an innovative,minimally invasive, endoscopic treatment for esophageal achalasia and other esophageal motility disorders, emerged from the natural orifice transluminal endoscopic surgery procedures, and since the first human case performed by Inoue in 2008, showed exciting results in international level, with more than 4000 cases globally up to now. POEM showed superior characteristics than the standard 100-year-old surgical or laparoscopic Heller myotomy(LHM), not only for all types of esophageal achalasia [classical(Ⅰ), vigorous(Ⅱ), spastic(Ⅲ), Chicago Classification], but also for advanced sigmoid type achalasia(S1 and S2), failed LHM, or other esophageal motility disorders(diffuse esophageal spasm, nutcracker esophagus or Jackhammer esophagus). POEM starts with a mucosal incision, followed by submucosal tunnel creation crossing the esophagogastric junction(EGJ) and myotomy. Finally the mucosal entry is closed with endoscopic clip placement. POEM permitted relatively free choice of myotomy length and localization. Although it is technically demanding procedure, POEM can be performed safely and achieves very good control of dysphagia and chest pain. Gastroesophageal reflux is the most common troublesome side effect, and is well controllable with proton pump inhibitors. Furthermore, POEM opened the era of submucosal tunnel endoscopy, with many other applications. Based on the same principles with POEM, in combination with new technological developments, such as endoscopic suturing, peroral endoscopic tumor resection(POET), is safely and effectively applied for challenging submucosal esophageal, EGJ and gastric cardia tumors(submucosal tumors), emerged from muscularis propria. POET showed up to know promising results, however, it is restricted to specialized centers. The present article reviews the recent data of POEM and POET and discussed controversial issues that need further study and future perspectives.
文摘Esophageal achalasia in children is rare but ultimately requires endoscopic or surgical treatment. Historically, Heller esophagomyotomy has been recommended as the treatment of choice. The refinement of minimally invasive techniques has shifted the trend of treatment toward laparoscopic Heller myotomy(LHM) in adults and children with achalasia. A review of the available literature on LHM performed in patients < 18 years of age was conducted. The pediatric LHM experience is limited to one multiinstitutional and several single-institutional retrospective studies. Available data suggest that LHM is safe and effective. There is a paucity of evidence on the need for and superiority of concurrent antireflux procedures. In addition, a more complete portrayal of complications and long-term(> 5 years) outcomes is needed. Due to the infrequency of achalasia in children, these characteristics are unlikely to be defined without collaboration between multiple pediatric surgery centers. The introduction of peroral endoscopic myotomy and single-incision techniques, continue the trend of innovative approaches that may eventually become the standard of care.
文摘Achalasia cardia is a primary oesophageal motility disorder of unknown aetiology characterized manometrically by insufficient relaxation of the lower oesophageal sphincter (LES) and loss of oesophageal peristalsis;radiographically by aperistalsis, oesophageal dilation with minimal LES opening, bird-beak appearance, poor emptying of barium;and endoscopically by dilated oesophagus with retained saliva, liquid and undigested food particles in the absence of mucosal stricturing or tumour. Achalasia cardia patients usually present with difficulty in swallowing both solids and liquids and this may be associated with regurgitation, heartburn and chest pains. Treatment options include medical or pharmacologic therapy, botulinum toxin injection, pneumatic dilation and oesophagocardiomyotomy or the Heller myotomy with or without antireflux procedure and recently the POEM (Perioral oesophageal myotomy). Herein, we present our experience with four cases managed surgically via thoracotomy without antireflux surgery over a 5-year period, from January 2015 to June 2019 at the Komfo Anokye Teaching Hospital, the second largest teaching hospital in Ghana.
文摘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.
文摘BACKGROUND Bleeding from Zenker’s diverticulum is extremely rare.At present,there are no guidelines for the management of bleeding Zenker’s diverticulum because of its rarity.Per-oral endoscopic myotomy(Z-POEM)is a precision myotomy technique and minimally invasive procedure for the treatment of Zenker’s diverticulum.We present a systematic review and a rare case of bleeding Zenker’s diverticulum that was effectively treated using Z-POEM.CASE SUMMARY A 72-year-old presented after 3 d of hematemesis.He had a 2-year history of progressive dysphagia and reported no antiplatelet,anticoagulant,or nonsteroidal anti-inflammatory drug use.His vital signs were stable,and the hematocrit was 36%.Previous gastroscopy and barium swallow had revealed Zenker’s diverticulum before the bleeding occurred.We performed gastroscopy and found a 5-mm ulcer with a minimal blood clot and spontaneously resolved bleeding.Z-POEM for definitive treatment was performed to reduce accumulation of food and promote ulcer healing.He had no complications and no bleeding;at the follow-up 6 mo later,the ulcer was healed.CONCLUSION Z-POEM can be definitive prevention for bleeding ulcer in Zenker’s diverticulum that promotes ulcer healing,reducing the risk of recurrent bleeding.Z-POEM is also a definitive endoscopic surgery for treatment of Zenker’s diverticulum.
文摘目的比较腹腔镜Heller手术(laparoscopic heller myotomy,LHM)和经口内镜下肌切开术(peroral endoscopic myotomy,POEM)治疗贲门失弛缓症的临床疗效,探讨POEM术后胃食管反流并发症的治疗策略。方法采用回顾性队列研究的方法,收集2012年10月至2017年4月我院收治的61例贲门失弛缓症患者的临床资料,其中30例行腹腔镜Heller手术加部分胃底折叠术(Dor)为腹腔镜组(LHM组);31例行经口内镜下肌切开术为内镜组(POEM组),随访至2019年4月,比较两组患者的基本资料、手术情况、临床疗效以及胃食管反流并发症(包括胃食管反流症状、病理性酸反流、食管炎)的情况。结果患者均顺利完成手术,无围术期死亡。LHM组和POEM组患者在手术时间、术中出血量、围术期并发症、平均住院日、住院费用等方面差异无统计学意义。LHM组和POEM组的治疗有效率分别为86.7%(26/30)和90.3%(28/31),差异无统计学意义。两组患者术后Ecardt评分、下段食管静息压较术前均明显下降(P<0.001),但两组之间比较,差异无统计学意义;POEM组术后胃食管反流症状(3/27 vs 11/20,P=0.018)、病理性酸反流(4/26 vs 12/18,P=0.024)、食管炎(2/28 vs 9/22,P=0.023)发生率显著高于LHM组。临床相关胃食管反流发生率在POEM组更高(1/29 vs 7/24,P=0.026)。结论 LHM与POEM治疗贲门失弛缓症的安全性及中远期疗效相近,但是POEM手术缺乏抗反流措施,可导致胃食管反流发生率升高,术后应密切随访并积极干预。
文摘目的:探讨腹腔镜Heller肌切开联合胃底折叠术(1aparoscopic Heller myotomy with a Toupet fundoplication,LHT)治疗贲门失弛缓症的临床价值:方法:回顾分析2000年4月至2008年4月我院为48例责门失弛缓症患者行LHT的临床资料。结果:手术均获成功,无中转开腹。手术时间65~150min,平均86min,术中出血5—50ml。术后平均住院5.2d。随访1~24个月,术前吞咽困难症状均缓解。结论:LHT具有定位准确、安全、可靠、创伤小、痛苦轻、疗效好等优点,同时可提高手术质量,减少并发症?LHT治疗责门失弛缓症值得临床推广。