Gastric myotomy length affects severity but not rate of post-procedure reflux: 3-year follow-up of a prospective randomized controlled trial of double-scope per-oral endoscopic myotomy (POEM) for esophageal achalasia.
Adult
Digestive System Surgical Procedures
/ adverse effects
Esophageal Achalasia
/ surgery
Esophagitis, Peptic
/ epidemiology
Female
Follow-Up Studies
Gastroesophageal Reflux
/ epidemiology
Humans
Incidence
Male
Middle Aged
Myotomy
/ adverse effects
Natural Orifice Endoscopic Surgery
/ adverse effects
Postoperative Complications
/ epidemiology
Prospective Studies
Treatment Outcome
Achalasia
GI endoscopy
Gastro-esophageal reflux (GERD)
Per-oral endoscopic myotomy (POEM)
Therapeutic endoscopy
Journal
Surgical endoscopy
ISSN: 1432-2218
Titre abrégé: Surg Endosc
Pays: Germany
ID NLM: 8806653
Informations de publication
Date de publication:
07 2020
07 2020
Historique:
received:
06
06
2019
accepted:
21
08
2019
pubmed:
30
8
2019
medline:
16
6
2021
entrez:
30
8
2019
Statut:
ppublish
Résumé
Since Inoue performed the first POEM in 2008, safety and efficacy have been well-established. Early studies focused on refining the technique and avoiding incomplete myotomy. Following the discovery that many patients with abnormal acid exposure are asymptomatic, the focus shifted to post-POEM reflux, but no studies have identified any associated procedural factors. In this study, we examined the intermediate-term results of our previous randomized controlled trial, with particular attention to post-POEM reflux. Previously, 100 consecutive patients were randomized to either double- or single-scope POEM. Endoscopy was conducted 2 months post-POEM and annually thereafter. Patients were included in the present study if they completed endoscopy ≥ 6 months post-POEM, and the clinical results of both groups were analyzed with particular attention to clinical efficacy and post-POEM reflux. Median follow-up was 3 years, and most myotomies were performed in the posterior location. The final gastric myotomy length was longer in the double-scope group (3.3 vs. 2.6 cm). Clinical efficacy (≥ 80%) and rates of post-POEM reflux (~ 60%) were similar; however, there was a higher incidence of moderate esophagitis (Los Angeles Grade B) in the double-scope group (25% vs. 4%). There were no cases of severe esophagitis (Los Angeles Grade C/D). Among patients with normal endoscopy at 2 months, > 40% developed erosive esophagitis on intermediate-term follow-up. This is the first study to demonstrate a procedural factor that increases post-POEM esophagitis. Gastric myotomy > 2.5 cm results in increased rates of moderate esophagitis without improving clinical efficacy. Some patients developed esophagitis in a delayed fashion, emphasizing the importance of ongoing surveillance. We also believe that preserving the gastric sling fibers may help to reduce reflux rates. The double-scope method may help to control myotomy length (2.0-2.5 cm) and direction (lesser curve to avoid the gastric sling) to help maximize clinical efficacy while minimizing post-POEM reflux.
Sections du résumé
BACKGROUND
Since Inoue performed the first POEM in 2008, safety and efficacy have been well-established. Early studies focused on refining the technique and avoiding incomplete myotomy. Following the discovery that many patients with abnormal acid exposure are asymptomatic, the focus shifted to post-POEM reflux, but no studies have identified any associated procedural factors. In this study, we examined the intermediate-term results of our previous randomized controlled trial, with particular attention to post-POEM reflux.
METHODS
Previously, 100 consecutive patients were randomized to either double- or single-scope POEM. Endoscopy was conducted 2 months post-POEM and annually thereafter. Patients were included in the present study if they completed endoscopy ≥ 6 months post-POEM, and the clinical results of both groups were analyzed with particular attention to clinical efficacy and post-POEM reflux.
RESULTS
Median follow-up was 3 years, and most myotomies were performed in the posterior location. The final gastric myotomy length was longer in the double-scope group (3.3 vs. 2.6 cm). Clinical efficacy (≥ 80%) and rates of post-POEM reflux (~ 60%) were similar; however, there was a higher incidence of moderate esophagitis (Los Angeles Grade B) in the double-scope group (25% vs. 4%). There were no cases of severe esophagitis (Los Angeles Grade C/D). Among patients with normal endoscopy at 2 months, > 40% developed erosive esophagitis on intermediate-term follow-up.
CONCLUSIONS
This is the first study to demonstrate a procedural factor that increases post-POEM esophagitis. Gastric myotomy > 2.5 cm results in increased rates of moderate esophagitis without improving clinical efficacy. Some patients developed esophagitis in a delayed fashion, emphasizing the importance of ongoing surveillance. We also believe that preserving the gastric sling fibers may help to reduce reflux rates. The double-scope method may help to control myotomy length (2.0-2.5 cm) and direction (lesser curve to avoid the gastric sling) to help maximize clinical efficacy while minimizing post-POEM reflux.
Identifiants
pubmed: 31463720
doi: 10.1007/s00464-019-07079-0
pii: 10.1007/s00464-019-07079-0
doi:
Types de publication
Journal Article
Randomized Controlled Trial
Langues
eng
Sous-ensembles de citation
IM
Pagination
2963-2968Références
Inoue H, Minami H, Kobayashi Y, Sato Y, Kaga M, Suzuki M et al (2010) Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 42(4):265–271
pubmed: 20354937
Crespin OM, Liu LWC, Parmar A, Jackson TD, Hamid J, Shlomovitz E et al (2017) Safety and efficacy of POEM for treatment of achalasia: a systematic review of the literature. Surg Endosc 31(5):2187–2201
pubmed: 27633440
Bechara R, Ikeda H, Inoue H (2015) Peroral endoscopic myotomy: an evolving treatment for achalasia. Nat Rev Gastroenterol Hepatol 12(7):410–426
pubmed: 26035678
Andolfi C, Fisichella PM (2019) Meta-analysis of clinical outcome after treatment for achalasia based on manometric subtypes. Br J Surg 106(4):332–341
pubmed: 30690706
Kumbhari V, Familiari P, Bjerregaard NC, Pioche M, Jones E, Ko WJ et al (2017) Gastroesophageal reflux after peroral endoscopic myotomy: a multicenter case–control study. Endoscopy 49(7):634–642
pubmed: 28472834
Arevalo G, Sippey M, He J, Ali A, del Campo LM, Marks J (2019) “S093: Post-POEM reflux: who’s at risk?” in 2019 scientific session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Baltimore, Maryland, USA, 3-6 April 2019: podium abstracts. Surg Endosc 33(Suppl 1):1–77
Shiwaku H, Inoue H, Sasaki T, Yamashita K, Ohmiya T, Takeno S et al (2016) A prospective analysis of GERD after POEM on anterior myotomy. Surg Endosc 30(6):2496–2504
pubmed: 26416381
Grimes KL, Inoue H, Onimaru M, Ikeda H, Tansawet A, Bechara R et al (2016) Double-scope per oral endoscopic myotomy (POEM): a prospective randomized controlled trial. Surg Endosc 30(4):1344–1351
pubmed: 26173548
Baldaque-Silva F, Marques M, Vilas-Boas F, Maia JD, Sa F, Macedo G (2014) New transillumination auxiliary technique for peroral endoscopic myotomy. Gastrointest Endosc 79(4):544–545
pubmed: 24268533
Hungness ES, Sternbach JM, Teitelbaum EN, Kahrilas PJ, Pandolfino JE, Soper NJ (2016) Per-oral endoscopic myotomy (POEM) after the learning curve: durable long-term results with a low complication rate. Ann Surg 264(3):508–517
pubmed: 27513156
Teitelbaum EN, Dunst CM, Reavis KM, Sharata AM, Ward MA, DeMeester SR et al (2018) Clinical outcomes five years after POEM for treatment of primary esophageal motility disorders. Surg Endosc 32(1):421–427
pubmed: 28664434
Martinek J, Svecova H, Vackova Z, Dolezel R, Ngo O, Krajciova J et al (2018) Per-oral endoscopic myotomy (POEM): mid-term efficacy and safety. Surg Endosc 32(3):1293–1302
pubmed: 28799005
Inoue H, Sato H, Ikeda H, Onimaru M, Sato C, Minami H et al (2015) Per-oral endoscopic myotomy: a series of 500 patients. J Am Coll Surg 221(2):256–264
pubmed: 26206634
Li QL, Wu QN, Zhang XC, Xu MD, Zhang W, Chen SY et al (2018) Outcomes of per-oral endoscopic myotomy for treatment of esophageal achalasia with a median follow-up of 49 months. Gastrointest Endosc 87(6):1405–12.e3
Werner YB, Costamagna G, Swanstrom LL, von Renteln D, Familiari P, Sharata AM et al (2016) Clinical response to peroral endoscopic myotomy in patients with idiopathic achalasia at a minimum follow-up of 2 years. Gut 65(6):899–906
pubmed: 25934759
He C, Li M, Lu B, Ying X, Gao C, Wang S et al (2019) Long-term efficacy of peroral endoscopic myotomy for patients with achalasia: outcomes with a median follow-up of 36 months. Dig Dis Sci 64(3):803–810
pubmed: 30478767
Li H, Peng W, Huang S, Ren Y, Peng Y, Li Q et al (2019) The 2 years’ long-term efficacy and safety of peroral endoscopic myotomy for the treatment of achalasia: a systematic review. J Cardiothorac Surg 14(1):1
pubmed: 30606216
pmcid: 6318943
Inoue H, Shiwaku H, Iwakiri K, Onimaru M, Kobayashi Y, Minami H et al (2018) Clinical practice guidelines for peroral endoscopic myotomy. Dig Endosc 30(5):563–579
pubmed: 30022514
Chandan S, Mohan BP, Chandan OC, Jha LK, Mashiana HS, Hewlett AT et al (2019) Clinical efficacy of per-oral endoscopic myotomy (POEM) for spastic esophageal disorders: a systematic review and meta-analysis. Surg Endosc. https://doi.org/10.1007/s00464-019-06819-6
pubmed: 31583465
Khashab MA, Messallam AA, Onimaru M, Teitelbaum EN, Ujiki MB, Gitelis ME et al (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
pubmed: 25634487
Khan MA, Kumbhari V, Ngamruengphong S, Ismail A, Chen YI, Chavez YH et al (2017) Is POEM the answer for management of spastic esophageal disorders? A systematic review and meta-analysis. Dig Dis Sci 62(1):35–44
pubmed: 27858325
Rohof WO, Salvador R, Annese V, des Varannes SB, Chaussade S, Costantini M et al (2013) Outcomes of treatment for achalasia depend on manometric subtype. Gastroenterology 144(4):718–725 quiz e13–14
pubmed: 23277105
Oelschlager BK, Chang L, Pellegrini CA (2003) Improved outcome after extended gastric myotomy for achalasia. Arch Surg 138(5):490–495 discussion 5–7
pubmed: 12742951
Sanaka MR, Thota PN, Parikh MP, Hayat U, Gupta NM, Gabbard S et al (2018) Peroral endoscopic myotomy leads to higher rates of abnormal esophageal acid exposure than laparoscopic Heller myotomy in achalasia. Surg Endosc 33(7):2284–2292
pubmed: 30341655
Zaninotto G, Leusink A, Markar SR (2019) Management of achalasia in 2019. Curr Opin Gastroenterol 35(4):356–366
Sharata AM, Dunst CM, Pescarus R, Shlomovitz E, Wille AJ, Reavis KM et al (2015) Peroral endoscopic myotomy (POEM) for esophageal primary motility disorders: analysis of 100 consecutive patients. J Gastrointest Surg 19(1):161–170 discussion 70
pubmed: 25183406
Ramchandani M, Nabi Z, Reddy DN, Talele R, Darisetty S, Kotla R et al (2018) Outcomes of anterior myotomy versus posterior myotomy during POEM: a randomized pilot study. Endoscopy international open. 6(2):E190–e8
Teitelbaum EN, Sternbach JM, El Khoury R, Soper NJ, Pandolfino JE, Kahrilas PJ et al (2016) The effect of incremental distal gastric myotomy lengths on EGJ distensibility during POEM for achalasia. Surg Endosc 30(2):745–750
pubmed: 26092005
Tanaka S, Kawara F, Toyonaga T, Inoue H, Bechara R, Hoshi N et al (2018) Two penetrating vessels as a novel indicator of the appropriate distal end of peroral endoscopic myotomy. Dig Endosc 30(2):206–211
pubmed: 28846807