Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                
Skip to main content
Springer Nature Link
Log in

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

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Abbreviations

LES:

Lower esophageal sphincter

HREM:

High-resolution esophageal manometry

POEM:

Per-oral endoscopic myotomy

EGJOO:

Esophagogastric junction outflow obstruction

LHM:

Laparoscopic Heller myotomy

BMI:

Body mass index

IRP:

Integrated relaxation pressure

Botox:

Botulinum toxin

References

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

    Article  PubMed  Google Scholar 

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

    Article  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  4. 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 81:1087–1099

    Article  PubMed  Google Scholar 

  5. 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 39:761–764

    Article  CAS  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  7. 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

    Google Scholar 

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

    Article  PubMed  Google Scholar 

  9. 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):57–65

    Article  PubMed  PubMed Central  Google Scholar 

  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)

    Article  PubMed  Google Scholar 

  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):1635–1645

    Article  PubMed  Google Scholar 

  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):642–647

    Article  Google Scholar 

  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 21:796–806

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  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):160–174

    Article  CAS  Google Scholar 

  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):1205–1211

    Article  PubMed  PubMed Central  Google Scholar 

  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 135:1526–1533

    Article  PubMed  PubMed Central  Google Scholar 

  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 17:48–53

    Article  PubMed  PubMed Central  Google Scholar 

  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 17:222–235

    Article  PubMed  Google Scholar 

  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):204–210

    Article  PubMed  Google Scholar 

  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 31:5066–5075

    Article  PubMed  Google Scholar 

  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–E201

    Article  PubMed  PubMed Central  Google Scholar 

  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

    Google Scholar 

  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):29–35

    Article  CAS  PubMed  Google Scholar 

  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):1363–1367

    Article  PubMed  Google Scholar 

  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 47:890–896

    Article  Google Scholar 

  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 21:785–791

    Article  PubMed  Google Scholar 

  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):1170–1177

    Article  PubMed  Google Scholar 

  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):1293–1302

    Article  PubMed  Google Scholar 

  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 62:35–44

    Article  PubMed  Google Scholar 

  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):1–6

    Article  CAS  PubMed  Google Scholar 

  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 30:1094–1099

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, Baystate Medical Center, University of Massachusetts Medical School, 759 Chestnut Street, Springfield, MA, 01199, USA

    Erica D. Kane & John R. Romanelli

  2. Division of Gastroenterology, Department of Medicine, Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA, USA

    Vikram Budhraja & David J. Desilets

Authors
  1. Erica D. Kane
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Vikram Budhraja
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. David J. Desilets
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. John R. Romanelli
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Erica D. Kane.

Ethics declarations

Disclosures

Dr. John R. Romanelli is a consultant for Covidien but no funding or support was received for this work. Drs. David J. Desilets, Vikram Budhraja, and Erica D. Kane have no conflicts of interest or financial ties to disclose.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kane, E.D., Budhraja, V., Desilets, D.J. et al. Myotomy length informed by high-resolution esophageal manometry (HREM) results in improved per-oral endoscopic myotomy (POEM) outcomes for type III achalasia. Surg Endosc 33, 886–894 (2019). https://doi.org/10.1007/s00464-018-6356-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-018-6356-0

Keywords

Search

Navigation