Efficacy of peroral endoscopic myotomy for esophageal motility disorders after gastric surgery: Japan Achalasia Multicenter Study

Abstract

Objectives: Patients with esophageal motility disorders (EMDs) including achalasia after gastric surgery have not been thoroughly characterized. Furthermore, the efficacy of peroral endoscopic myotomy (POEM) in this population should be clarified. Methods:In this retrospective multicenter study of 3707 patients with EMDs, 31 patients (0.8%) had a history of gastric surgery. Patient characteristics and POEM efficacy were compared between patients with and without previous gastric surgery. Results:In patients with EMD after gastric surgery, age at EMD diagnosis was higher (72.0 years), male sex was predominant (90.3%), and the American Society of Anesthesiologists physical status score was higher (≥II, 48.4%). High-resolution manometry (HRM) findings did not reveal significant differences. In patients who underwent gastric surgery, atrophic gastritis was common (80.6%), and gastric cancer was the primary surgical indication (32.3%). Distal gastrectomy was performed in 28 patients (90.3%). POEM was effective (3.3% adverse events; 100% treatment success). The incidence rates of reflux esophagitis (RE) and symptomatic gastroesophageal reflux disease (GERD) were 60.0% and 16.7%, respectively, without significant intergroup differences, and severe RE was not observed in the long-term followup. Extended gastric myotomy was a risk factor for RE. Conclusion:Patients with gastric surgery often present severe disease manifestations; the surgical indication is mainly gastric cancer. HRM findings can be similarly used for diagnosis in patients with and without gastric surgery. POEM maintains safety and efficacy with acceptable RE and symptomatic GERD rates. To prevent RE, extended myotomy should be avoided.

Laparoscopic Heller myotomy with Dor fundoplication for esophageal achalasia treatment after distal gastrectomy and Billroth‐II reconstruction

“…The most effective treatment for this condition is surgical intervention. Reviewing the reports of esophageal achalasia after gastric surgery, 4,5 POEM seems to be the recent mainstay approach 6,7 . POEM is a minimally invasive and effective treatment for esophageal achalasia, and it is the endoscopic counterpart of laparoscopic Heller myotomy.…”

“…Reviewing the reports of esophageal achalasia after gastric surgery, 4,5 POEM seems to be the recent mainstay approach. 6,7 POEM is a minimally invasive and effective treatment for esophageal achalasia, and it is the endoscopic counterpart of laparoscopic Heller myotomy. Although laparoscopic Heller myotomy is the traditional treatment of choice for patients with achalasia, its performance in patients with prior gastric surgery may be challenging because of intraabdominal adhesions.…”

“…A Japanese multicenter study reported that the incidences of reflux esophagitis and symptomatic GER disease in patients who underwent POEM with a history of gastric surgery (90.3% being distal gastrectomy) were 60.0% and 16.7%, respectively. 6 Continuous GER is a risk factor for esophagitis and aspiration pneumonia. In cases of distal gastrectomy, bile reflux can occur, which can cause severe chemical pneumonia.…”

Endoscopic pressure study integrated system for the diagnosis of achalasia

“…Currently, the gold standard treatment for achalasia is peroral endoscopic myotomy (POEM). [15][16][17] The impact of POEM is evaluated using a symptom index (the Eckardt score) 18 and objective examinations such as endoscopy, BS, and FLIP. FLIP has demonstrated its clinical utility in assessing LES function both as a diagnostic tool for achalasia and as a device for measuring the patient's response to POEM.…”

Clinical characteristics of absent contractility and ineffective esophageal motility: a multicenter study in Japan

“…We conducted a multicenter study involving 14 high-volume centers in Japan, namely, the Japan Achalasia Multicenter study (JAMS) and analyzed a large number of patients with EMDs. 10,13 Consecutive series of patients with EMDs diagnosed using standard methods, including HRM, esophagography, and esophagogastroscopy, from 2010 and 2020, were enrolled in the JAMS. All diagnoses were performed by experts with extensive experience in the diagnosis of EMDs.…”