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Minimally invasive surgery for non-achalasia primary esophageal motility disorders is currently underused

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Mini-invasive Surgery
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Fernando A. M. Herbella
Fernando A. M. Herbella
Fernando A. M. Herbella
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Francisco Schlottmann at Hospital Alemán
Francisco Schlottmann
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Abstract

Surgical treatment for non-achalasia primary esophageal motility disorders is reserved for few situations. Proper selection of patients brings good outcomes with low morbidity, which makes surgical therapy an adequate therapeutic option. High resolution manometry reclassifies esophageal motility disorders. Interestingly, literature is scarce on surgical therapy for this new classification with per oral endoscopic myotomy as the leading treatment.
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Herbella
et al
. Mini-invasive Surg 2019;3:24
DOI: 10.20517/2574-1225.2019.20 Mini-invasive Surgery
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Minimally invasive surgery for non-achalasia
primary esophageal motility disorders is currently
underused
Fernando A. M. Herbella1, Francisco Schlottmann2
1Department of Surgery, Federal University of Sao Paulo, Sao Paulo, SP 04037-003, Brazil.
2Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires C1118 AAT, Argentina.
Correspondence to: Dr. Fernando A. M. Herbella, Department of Surgery, Escola Paulista de Medicina, Federal University of
Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP 04037-003, Brazil. E-mail: herbella.dcir@epm.br
How to cite this article: Herbella FAM, Schlottmann F. Minimally invasive surgery for non-achalasia primary esophageal
motility disorders is currently underused.
Mini-invasive Surg
2019;3:24. http://dx.doi.org/10.20517/2574-1225.2019.20
Received: 2 Jul 2019 Accepted: 16 Jul 2019 Published: 12 Aug 2019
Science Editor: Giulio Belli Copy Editor: Cai-Hong Wang Production Editor: Tian Zhang
Abstract
Surgical treatment for non-achalasia primary esophageal motility disorders is reserved for few situations. Proper
selection of patients brings good outcomes with low morbidity, which makes surgical therapy an adequate
therapeutic option. High resolution manometry reclassifies esophageal motility disorders. Interestingly, literature
is scarce on surgical therapy for this new classification with per oral endoscopic myotomy as the leading
treatment.
Keywords:
Esophageal manometry, motility disorders, distal esophageal spasm, jackhammer esophagus
High resolution manometry reclassifies esophageal motility disorders based on the Chicago 3.0
classification[1]. Even though there is a certain correspondence between previous and current
classications[2], a distinct nomenclature arrived based on newly developed - and putatively more objective
and accurate - parameters. Thus, primary esophageal motility disorders (PEMD) are probably better
diagnosed and evaluated.
Achalasia is surely the most understood PEMD. Other PEMD are not as well comprehended nor have
dened therapy options. ese other diseases dened by specic manometric pictures may occur as PEMD
or secondary to gastroesophageal reux disease (GERD)[3]. If GERD is present, the motility abnormality is
Page 2 of 3 Herbella et al. Mini-invasive Surg 2019;3:24 I http://dx.doi.org/10.20517/2574-1225.2019.20
considered secondary, and treatment is directed toward reux. In the absence of GERD, therapy is aimed at
the modulation of the esophageal dysmotility with pharmacological agents or at the permeabilization of the
gastroesophageal junction with endoscopic or surgical procedures[4].
Surgical treatment for non-achalasia PEMD was reserved for few situations during the conventional
manometry era. Cardiomyotomy (Heller’s operation) and fundoplication are used for patients with
hypertensive lower esophageal sphincter, diuse esophageal spasm or nutcracker esophagus and obstructive
symptoms[5,6]. Proper selection of patients is linked to good outcomes with low morbidity, which makes
surgical therapy an adequate therapeutic option. Interestingly, literature is scarce on surgical therapy for
this new classication with per oral endoscopic myotomy (POEM) as the leading treatment.
Ineffective esophageal motility is not treated by surgery. Hypertensive lower esophageal sphincter is no
longer a PEMD according to Chicago 3.0.
ere are no studies on Heller’s myotomy for distal esophageal spasm (previously diuse spasm) based on
the new classication. Some case reports of POEM for distal spasm have been reported[7-9] with multicenter
studies encompassing a larger number of patients but always inferior to 20 in total[10]. Experience with
the method is too short to draw conclusions. e same is true for jackhammer esophagus: no studies on
Heller’s myotomy and few case reports for POEM[9,11]. A recent systematic review compiling these small
series[12] showed a clinical success of 90%.
Esophagogastric junction outow obstruction is an altered motility pattern contemplated by Chicago 3.0
classication. Most cases are associated to mechanical obstruction especially aer operations in the area.
Few cases are considered PEMD[13]. Interestingly, some cases treated by Heller’s myotomy[13-15] showed good
outcomes while POEM did not show good results[16].
In conclusion, Heller’s myotomy and fundoplication are currently underused for the treatment of non-
achalasia PEMD. POEM is the preferred treatment, but long-term results with larger series are still elusive.
DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and design of the study and performed data analysis and
interpretation: Herbella FAM, Schlottmann F
Availability of data and materials
Not applicable.
Financial support and sponsorship
None.
Conflicts of interest
All authors declared that there are no conicts of interest.
Ethical approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Herbella et al. Mini-invasive Surg 2019;3:24 I http://dx.doi.org/10.20517/2574-1225.2019.20 Page 3 of 3
Copyright
© e Author(s) 2019.
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Article
  • Oct 2018
Background Noncardiac chest pain (NCCP) is recurrent angina pectoris-like pain without evidence of coronary heart disease in conventional diagnostic evaluation. In gastroenterology, managing of patients with NCCP is ambiguous to detect gastroesophageal reflux and hypercontractile esophageal motility disorders. Recently, peroral endoscopic myotomy (POEM) was established as treatment option in achalasia. However, limited data exist on the effectivity of POEM in NCCP with hypercontractile esophageal motility disorders. Material and methods In this prospective study (POEM-HYPE), we evaluated 14 patients with NCCP and hypercontractile esophageal motility disorders (type III achalasia, n = 7; hypercontractile esophagus, n = 6; distal esophageal spasm, n = 1). All patients underwent standardized diagnostic work-up including esophagogastroduodenoscopy with esophageal biopsies, high-resolution esophageal manometry, and combined intraluminal impedance and pH testing before and 3 weeks after POEM. A standardized symptom questionnaire was disposed before POEM, 3 weeks after, and every 6 months after the POEM. Results After POEM, 12 patients showed significant symptom relief (pre-Eckardt score: 7.78 ± 1.47, 3 weeks post: 1.64 ± 1.44, 6 months: 2.0 ± 1.84 and 1.86 ± 1.89 after 15.0 ± 10.0 months post-intervention). High-resolution manometry showed significant reduction in integrated relaxation pressure (pre-POEM: 24.74 ± 18.9 mm Hg, post-POEM: 13.8 ± 16.5 mm Hg) and distal contractile integral (pre-POEM: 2880 ± 3700 mmHg*s*cm, post-POEM: 1109 ± 1042 mmHg*s*cm). One lesion of the submucosal tunnel occurred as a moderate adverse event and was handled endoscopically. The long-term clinical success rate was 85.7 %. No severe gastroesophageal reflux occurred after interventions. Two patients required secondary therapy with injection of botulinum toxin in the tubular esophagus and balloon dilation. Conclusion The results suggest that POEM is an effective and safe therapeutic option for patients with NCCP and hypercontractile esophageal motility disorders.
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Ten Initial Cases of Peroral Endoscopic Myotomy for Treatment of Esophageal Motility Disorders at Okayama University Hospital
Article
  • Apr 2018
  • ACTA MED OKAYAMA
Peroral endoscopic myotomy (POEM) for treatment of esophageal motility disorders has recently been reported to be highly effective and less invasive than other treatment. POEM was recently introduced in Okayama University Hospital under the supervision of a physician from a high-volume center. To verify the safety and efficacy of POEM during its introduction in our institution. We examined 10 cases in whom POEM was performed between January 2016 and April 2017. The patients included 7 men and 3 women, with a median age (range) of 49 years (17-74) and median symptom duration of 6 years (1-21). Seven patients had a straight esophagus, and the remaining 3 had a sigmoid esophagus. According to the Chicago classification, 6 patients were diagnosed with type I achalasia, 2 with type II achalasia, and 2 with distal esophagus spasm. Treatment outcomes and adverse events were evaluated. Treatment success was defined as a > 3 decrease in Eckardt score or a score of <3 at the time of discharge. The treatment success rate was 90%, with the average Eckardt score decreasing significantly, from 4.7 to 0.9 (p<0.05). No mucosal perforation, severe infection, mediastinitis, severe bleeding, or gastroesophageal reflux occurred intraoperatively or postoperatively. POEM was introduced to Okayama University Hospital, and the first 10 cases were accomplished safely and effectively under the supervision of an expert physician from a high-volume center.
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Clinical presentation and disease course of patients with esophagogastric junction outflow obstruction
Article
  • Jun 2017
Esophagogastric junction outflow obstruction, characterized by preserved peristalsis in conjunction with an elevated integrated relaxation pressure, can result from specific anatomic variants or may represent achalasia in evolution. There is limited information on the clinical significance of this diagnosis. The aim of this study is to describe the clinical characteristics and outcomes in our cohort of patients with esophagogastric junction outflow obstruction. Consecutive adult patients who had undergone high-resolution esophageal manometry between February 2013 and November 2015 with a diagnosis of esophagogastric junction outflow obstruction were identified. Electronic medical records were reviewed to determine: (1) secondary causes of esophagogastric junction outflow obstruction; (2) treatment; and (3) natural history. Improvement in symptoms noted during follow-up evaluation was considered to be a favorable outcome. Worsening of symptoms or no change in symptoms was considered to be an unfavorable outcome. Of 874 manometries performed during this time period, 83 met the criteria for esophagogastric junction outflow obstruction. Of these patients, 11 had secondary causes: paraesophageal hernia (4), Nissen fundoplication (2), esophageal stricture (3), prior laparoscopic band placement (1), and diverticulum (1). All of these secondary causes were identified by barium esophagram. The remaining 72 patients were categorized as idiopathic esophagogastric junction outflow obstruction. Two patients developed type II achalasia on follow-up. An additional two patients had no symptoms as testing was performed for preoperative evaluation prior to bariatric surgery, leaving 68 patients for symptom follow-up analysis. Of these, 19 had a favorable outcome, 18 had an unfavorable outcome, and 31 were lost to follow-up. Of those with a favorable outcome, 6 patients underwent treatment: medication (3), botulinum toxin injection followed by laparoscopic Heller myotomy (1), botulinum toxin injection and medication (1), and bougie dilation (1). Of the 18 patients with an unfavorable outcome, 6 patients underwent treatment: botulinum toxin injection (5) and medication (1). Computed tomography scan or endoscopic ultrasound was performed in 40% of patients with available follow-up and none of these studies revealed secondary causes. The overall median follow-up time was 5 months. Esophagogastric outflow obstruction is a manometric finding of unclear significance. Secondary causes should first be excluded with structural studies. The evolution of esophagogastric junction outflow obstruction to achalasia is rare. Symptoms in patients with esophagogastric junction outflow obstruction do not always require treatment and treatment response is variable. The challenge in managing these patients lies in distinguishing which patients will need intervention. Further studies are needed for consideration of subgrouping this disease or modifying the categorization into clinically relevant entities.
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