Original article
Clinical endoscopy
Effect of peroral endoscopic myotomy on esophagogastric junction physiology in patients with achalasia

https://doi.org/10.1016/j.gie.2013.01.006Get rights and content

Background

Pneumatic dilation and laparoscopic Heller myotomy improve parameters of esophageal function such as lower esophageal sphincter (LES) pressure, esophageal emptying, and esophagogastric junction (EGJ) distensibility.

Objective

To evaluate the effect of peroral endoscopic myotomy (POEM) on esophagogastric function.

Design

Prospective trial.

Setting

Endoscopy department at a university hospital.

Patients

All consecutive patients aged >17 years with achalasia and an Eckardt score of ≥3.

Intervention

Before and 3 months after POEM, 10 consecutive patients underwent esophageal manometry, timed barium esophagograms, and EndoFLIP as well as an EGD.

Main Outcome Measurements

Eckardt symptom score, LES resting pressure, centimeters of barium stasis, EGJ distensibility, and reflux esophagitis.

Results

Compared with scores before POEM, patient symptom scores were significantly reduced (1, interquartile range [IQR 0-1] vs 8 [IQR 4-8]; P = .005). LES pressure decreased significantly (6.0 mm Hg [IQR 2.6-7.4] vs 19.0 mm Hg [IQR 13.0-28.0]; P = .008). Esophageal emptying increased significantly, and a 5-minute barium column measured 2.3 cm (IQR 0-3.2 cm) versus 10.1 cm (IQR 5.7-10.8 cm; P = .005). EGJ distensibility increased significantly (6.7 mm2/mm Hg [IQR 3.8-16.6] vs 1.0 mm2/mm Hg [IQR 0.4-2.3]; P = .02) at 50 mL. In 6 of 10 patients, reflux esophagitis was seen. Of these patients, 3 reported reflux symptoms.

Limitations

Small number of patients, short-term follow-up.

Conclusion

POEM improves esophagogastric function and suggests favorable long-term results based on Eckardt score, esophageal manometry, esophageal emptying, and EGJ distensibility. Long-term follow-up of larger series will determine whether the high rate of reflux esophagitis affects the clinical application of POEM.

Section snippets

Study design

This prospective, observational study was approved by the Medical Ethics Committee of the Academic Medical Centre, University of Amsterdam in Amsterdam (June 16, 2011, NCT01405469).

Patients

Adult patients with achalasia based on esophageal manometry and a patient symptom score of ≥3 were included in the study. Exclusion criteria included previous esophageal or gastric surgery, malignant or premalignant esophageal lesions, and a severe sigmoid-shaped esophagus.

Outcome measurements

Before and 3 months after POEM treatment,

Patients

Between August 2011 and January 2012, 10 patients (4 female) with a median age of 43 years (IQR 31-66 years) underwent a POEM procedure for symptomatic achalasia. Achalasia was established in all patients by using esophageal manometry, and all patients gave written, informed consent. Three patients (33.3%) had received achalasia treatment before. Two patients underwent up to 3 pneumatic dilation procedures, with a maximum balloon size of 40 mm, and 1 patient was treated 2 years before with a

POEM

The POEM procedure was safely performed in all patients. No technical difficulties occurred perioperatively. All patients were discharged after 3 days of hospital stay. The pretreatment median Eckardt score was 8 IQR 4-8 compared with a 3-month posttreatment score of 1 (0-1) (P = .005).

Discussion

In this study, we evaluated the effect of POEM on esophagogastric function parameters in patients with achalasia. All patients were successfully treated with regard to symptoms, in line with other reports.9, 10 This study is the first, however, that shows that POEM also significantly improved esophagogastric junction physiology as shown by decreased LES pressure, improved esophageal emptying, and improved EGJ distensibility.

Evaluation of esophagogastric function parameters is of great interest

References (18)

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DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

See CME section; p. 142.

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