Surgical Endoscopy

, Volume 29, Issue 9, pp 2841–2850 | Cite as

Peroral endoscopic myotomy for advanced achalasia with sigmoid-shaped esophagus: long-term outcomes from a prospective, single-center study

  • Jian-Wei Hu
  • Quan-Lin Li
  • Ping-Hong Zhou
  • Li-Qing Yao
  • Mei-Dong Xu
  • Yi-Qun Zhang
  • Yun-Shi Zhong
  • Wei-Feng Chen
  • Li-Li Ma
  • Wen-Zheng Qin
  • Ming-Yan Cai
Dynamic Manuscript

Abstract

Background

The sigmoid-shaped esophagus is considered to be the advanced stage of achalasia, in which the esophageal lumen is significantly dilated, swerved, and rotated. In consideration of the efficacy of peroral endoscopic myotomy (POEM) for early achalasia, it may also offer another option for the treatment of advanced achalasia with sigmoid-shaped esophagus. Our purpose was to evaluate the feasibility and long-term efficacy of POEM for patients with sigmoid-type achalasia.

Methods

32 consecutive patients with sigmoid-type achalasia (S1 type in 29 patients and S2 type in 3 patients) were prospectively included. Primary outcome was symptom relief during follow-up, defined as an Eckardt score ≤3. Secondary outcomes were procedure-related adverse events, the resting lower esophageal sphincter (LES) pressure, clinical reflux complications, and procedure-related parameters.

Results

All cases received POEM successfully. The mean operation time was 63.7 min (range 22–130 min). No serious complications related to POEM were encountered. During a mean follow-up period of 30.0 months (range 24–44 months), treatment success was achieved e in 96.8 % of cases (mean score pre- vs. post-treatment 7.8 vs. 1.4; P < 0.001). Mean LES pressure also decreased from a mean of 37.9 to 12.9 mmHg after POEM (P < 0.001). One patient experienced only partial symptom relief and additional balloon dilations were carried out to relief the symptoms twice. The overall clinical reflux complication rate of POEM for sigmoid-type achalasia was 25.8 %.

Conclusion

The 2-year outcomes of POEM for advanced achalasia with sigmoid-shaped esophagus were excellent, resulting in long-term symptom relief in over 96 % cases and without serious complications. The morphological changes of esophagus may make subsequent endoscopic tunneling more challenging and time-consuming, but do not prevent successful POEM.

Keywords

Peroral endoscopic myotomy Sigmoid-shaped esophagus Advanced achalasia 

Notes

Acknowledgments

This study was supported by the grants from the Major Project of Shanghai Municipal Science and Technology Committee (11411950502 and 13411950801), Academic Leader Training Project of Shanghai Municipal Commission of Health and Family Planning (13B038), National Natural Science Foundation of China (81302098, 81370588, 81201902 and 81470811), and Natural Science Foundation of Shanghai (13ZR1452300).

Disclosures

Drs. Hu J.-W, Li Q.-L, Zhou P.-H, Yao L.-Q, Xu M.-D, Zhang Y.-Q, Zhong Y.-S, Chen W.-F, Ma L.-L, Qin W.-Z, and Cai M.-Y have no conflicts of interest or financial ties to disclose.

Supplementary material

Video 1

An example of the peroral endoscopic myotomy (POEM) procedure for a 49-year-old man with sigmoid type achalasia (WMV 53319 kb)

References

  1. 1.
    Eckardt AJ, Eckardt VF (2011) Treatment and surveillance strategies in achalasia: an update. Nat Rev Gastroenterol Hepatol 8(6):311–319CrossRefPubMedGoogle Scholar
  2. 2.
    Shiino Y, Houghton SG, Filipi CJ, Awad ZT, Tomonaga T, Marsh RE (1999) Manometric and radiographic verification of esophageal body decompensation for patients with achalasia. J Am Coll Surg 189(2):158–163CrossRefPubMedGoogle Scholar
  3. 3.
    Mattioli S, Di Simone MP, Bassi F, Pilotti V, Felice V, Pastina M et al (1996) Surgery for esophageal achalasia: long-term results with three different techniques. Hepatogastroenterology 43(9):492–500PubMedGoogle Scholar
  4. 4.
    Howard JM, Ryan L, Lim KT, Reynolds JV (2011) Oesophagectomy in the management of end-stage achalasia: case reports and a review of the literature. Int J Surg 9(3):204–208CrossRefPubMedGoogle Scholar
  5. 5.
    Devaney EJ, Iannettoni MD, Orringer MB, Marshall B (2001) Esophagectomy for achalasia. Patient selection and clinical experience. Ann Thorac Surg 72(3):854–858CrossRefPubMedGoogle Scholar
  6. 6.
    Peters JH, Kauer WKH, Crookes PF, Ireland AP, Bremner CG, DeMeester TR (1995) Esophageal resection with colon interposition for end-stage achalasia. Arch Surg 130(6):632–637CrossRefPubMedGoogle Scholar
  7. 7.
    Panchanatheeswaran K, Parshad R, Rohila J, Saraya A, Makharia GK, Sharma R (2013) Laparoscopic Heller’s cardiomyotomy: a viable treatment option for sigmoid oesophagus. Interact Cardiovasc Thorac Surg 16(1):49–54PubMedCentralCrossRefPubMedGoogle Scholar
  8. 8.
    Sweet MP, Nipomnick I, Gasper WJ, Bagatelos K, Ostroff JW, Fisichella PM et al (2008) The outcome of laparoscopic Heller myotomy for achalasia is not influenced by the degree of esophageal dilatation. J Gastrointest Surg 12(1):159–165CrossRefPubMedGoogle Scholar
  9. 9.
    Patti MG, Feo CV, Diener U, Tamburini A, Arcerito M, Safadi B et al (1999) Laparoscopic Heller myotomy relieves dysphagia in achalasia when the esophagus is dilated. Surg Endosc 13(9):843–847CrossRefPubMedGoogle Scholar
  10. 10.
    NOSCAR POEM White Paper Committee, Stavropoulos SN, Desilets DJ, Fuchs KH, Gostout CJ, Haber G et al (2014) Per-oral endoscopic myotomy white paper summary. Gastrointest Endosc 80(1):1–15CrossRefGoogle Scholar
  11. 11.
    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):265–271CrossRefPubMedGoogle Scholar
  12. 12.
    Zhou PH, Li QL, Yao LQ, Xu MD, Chen WF, Cai MY et al (2013) Peroral endoscopic remyotomy for failed Heller myotomy: a prospective single-center study. Endoscopy 45(3):161–166CrossRefPubMedGoogle Scholar
  13. 13.
    Von Renteln D, Fuchs KH, Fockens P, Bauerfeind P, Vassiliou MC, Werner YB et al (2013) Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study. Gastroenterology 145(2):309–311CrossRefGoogle Scholar
  14. 14.
    Eleftheriadis N, Inoue H, Ikeda H, Onimaru M, Yoshida A, Hosoya T et al (2012) Training in peroral endoscopic myotomy (POEM) for esophageal achalasia. Ther Clin Risk Manag 8:329–342PubMedCentralCrossRefPubMedGoogle Scholar
  15. 15.
    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(5):1526–1533PubMedCentralCrossRefPubMedGoogle Scholar
  16. 16.
    Duranceau A, Liberman M, Martin J, Ferraro P (2012) End-stage achalasia. Dis Esophagus 25:319–330CrossRefPubMedGoogle Scholar
  17. 17.
    Molena D, Yang SC (2012) Surgical management of end-stage achalasia. Semin Thorac Cardiovasc Surg 24:19–26CrossRefPubMedGoogle Scholar
  18. 18.
    Pinotti HW, Cecconello I, Mariano da Rocha J, Zilberstein B (1991) Resection for achalasia of the esophagus. Hepatogastroenterology 38:470–473PubMedGoogle Scholar
  19. 19.
    Orringer MB, Stirling MC (1989) Esophageal resection for achalasia: indications and results. Ann Thorac Surg 47:340–345CrossRefPubMedGoogle Scholar
  20. 20.
    Li QL, Chen WF, Zhou PH, Yao LQ, Xu MD, Hu JW et al (2013) Peroral endoscopic myotomy for the treatment of achalasia: a clinical comparative study of endoscopic full-thickness and circular muscle myotomy. J Am Coll Surg 217(3):442–451CrossRefPubMedGoogle Scholar
  21. 21.
    Ren Z, Zhong Y, Zhou P, Xu M, Cai M, Li L et al (2012) Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases). Surg Endosc 6(11):3267–3272CrossRefGoogle Scholar
  22. 22.
    Chen WF, Li QL, Zhou PH, Yao LQ, Xu MD, Zhang YQ, et al (2014) Long-term outcomes of peroral endoscopic myotomy for achalasia in pediatric patients: a prospective, single-center study. Gastrointest Endosc. doi: 10.1016/j.gie.2014.06.035
  23. 23.
    Cai MY, Zhou PH, Yao LQ, Zhu BQ, Liang L, Li QL (2014) Thoracic CT after peroral endoscopic myotomy for the treatment of achalasia. Gastrointest Endosc 80(6):1046–1055Google Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Jian-Wei Hu
    • 1
  • Quan-Lin Li
    • 1
  • Ping-Hong Zhou
    • 1
  • Li-Qing Yao
    • 1
  • Mei-Dong Xu
    • 1
  • Yi-Qun Zhang
    • 1
  • Yun-Shi Zhong
    • 1
  • Wei-Feng Chen
    • 1
  • Li-Li Ma
    • 1
  • Wen-Zheng Qin
    • 1
  • Ming-Yan Cai
    • 1
  1. 1.Endoscopy Center and Endoscopy Research Institute, Zhongshan HospitalFudan UniversityShanghaiChina

Personalised recommendations