Japanese guidelines for peroral endoscopic myotomy: 1st edition

Gandhi

Journal of Digestive Endoscopy

2021

Peroral endoscopic myotomy (POEM) is an accepted treatment for achalasia cardia (AC), and results are comparable to those of laparoscopic Heller myotomy (LHM). In recent years, several reports have confirmed higher incidence of gastroesophageal reflux (GER) following POEM. This review evaluates the current evidence regarding post-POEM GER, critically examines the potential contributing factors responsible for GER, limitations of the current available functional testing, and precautions and preventive measures, and provides future directions for research. Factors conclusively contributing to increased post-POEM GER include injury to the sling fibers of the lower esophageal sphincter, length of gastric myotomy > 2 cm, and others. Historically, these same factors have been implicated for development of GER after surgical (laparoscopic) myotomy. Although less invasive, optimal technique of POEM may be important to control post-POEM GER. Most post-POEM GER occurs during the immediate post-POEM period, is mild, and is easily treatable using proton-pump inhibitors. GER incidence plateaus at 2 years and is comparable to that after LHM. Patients should therefore be prescribed proton-pump inhibitors for at least 2 years. Antireflux procedures (ARPs) are infrequently required in these patients as the incidence of refractory GER is low. Novel ARPs have been recently described and are currently under evaluation. Conclusive diagnosis of GER is a clinical challenge. Most patients are asymptomatic, and GER is diagnosed only on abnormal esophageal acid exposure (EAE). Studies have demonstrated that current measures to diagnose GER are inadequate, inaccurate, and cannot differentiate between true GER and abnormal EAE due to food fermentation in the distal esophagus. The Lyon Consensus criteria should be implemented for confirmation of diagnosis of GER. Finally, the review recommends an evidence-based clinical algorithm for evaluation and management of post-POEM GER and provides guidelines for future research in this field.

Section: The Issue Of Post-poem Germentioning

confidence: 99%

Gastroesophageal Reflux after Peroral Endoscopic Myotomy: Myth or Reality?

Gandhi

Journal of Digestive Endoscopy

2021

“…Recently, POEM has been established as a minimally invasive method for treating achalasia (6). This treatment is effective and safe, even in elderly patients, and exhibits favorable short-and long-term prognoses (6,7). Sato et al (8) performed peroral endoscopic biopsies of the muscular layer termed POEM-b, with histopathological and immunohistochemical analysis of POEM-b samples showing signs of neurodegeneration rather than inflammatory infiltration into the muscle layer (8).…”

Section: Introductionmentioning

confidence: 99%

“…The proposed causative factors for achalasia are diverse and multifactorial, with complex interactions between autoimmune and inflammatory responses that can be initiated by viral infections in genetically susceptible patients (2). One causative agent includes the herpes simplex virus (HSV), a neurotrophic virus that predominates in squamous epithelium, varicella-zoster virus, measles virus and human papillomavirus (4,5,7,12). In addition, HSV type 1 (HSV 1) DNA and RNA have been detected in the tissues of all patients with achalasia, but not in the tissues of control subjects (13).…”

Section: Introductionmentioning

confidence: 99%

Detection of cytokine storm in patients with achalasia using ELISA

et al. 2021

Self Cite

Esophageal achalasia is characterized by abnormal peristaltic movements of the esophageal body and impaired relaxation of the lower esophageal sphincter (LES). However, its etiology remains unknown. In our previous study, it was shown that in the LES of patients with achalasia, hsv1-miR-H1 was overexpressed, ATG16L1 expression was downregulated and interleukin (IL)-1β levels were upregulated. However, systemic features were not evaluated. Herein, the plasma cytokine levels in patients with achalasia were determined. Plasma was collected from patients at Nagasaki University Hospital between February 2013 and March 2016, both before and after peroral endoscopic myotomy (POEM). Cytokine analysis was performed using plasma collected from 10 healthy individuals (control group) and 12 patients with achalasia using the Bio-Plex Pro™ Human Cytokine 27-plex assay kit. The levels of IL-17, IL-1β, C-C motif chemokine ligand 2, IL-4, IL-5, IL-1ra, IL-7, IL-12, interferon-γ, IL-2, fibroblast growth factor-2, colony-stimulating factor (CSF)2 and CSF3 were significantly higher in patients with achalasia compared with the control subjects. However, the levels did not differ between plasma samples collected before and after POEM. Thus, the occurrence of a cytokine storm was confirmed in the patients with achalasia.

“…However, in recent years, per-oral endoscopic myotomy (POEM) has been established as an alternative minimally invasive method of treating esophageal achalasia (6). This treatment is effective and safe, even in elderly patients, allowing for short and long-term prognoses (6,7). Sato et al (8) performed per-oral endoscopic biopsies from the muscle layer during POEM, called POEM-b.…”

Section: Introductionmentioning

confidence: 99%

“…Currently, the proposed causal factors are varied and multifactorial, and are hypothesized to involve complex interactions between the autoimmune and inflammatory response, and this may be initiated by viral infections in patients who are genetically susceptible (2). Causal viral agents include (but not limited to) herpes simplex virus, which is a neurotropic virus that exhibits a predilection for squamous epithelium, as well as varicella-zoster, measles and human papillomavirus (4,5,7,10). Moreover, it has been reported that HSV type 1 (HSV-1) DNA and RNA is detectable in all tissues from patients with achalasia, but not in the control tissues (11).…”

Section: Introductionmentioning

confidence: 99%

Autophagy‑related 16‑like 1 is influenced by human herpes virus 1‑encoded microRNAs in biopsy samples from the lower esophageal sphincter muscle during per‑oral endoscopic myotomy for esophageal achalasia

et al. 2020

Self Cite

Esophageal achalasia is characterized by abnormal peristalsis of the esophageal body and impaired relaxation of the lower esophageal sphincter (LES); however, its etiology remains unknown. One of the potential causes of esophageal achalasia is herpes simplex virus type 1 (HSV-1). Following infection with HSV-1, a complex interaction between the autoimmune and inflammatory responses is initiated. Viral microRNAs (miRNAs/miRs) serve a crucial role in this interaction. In the present study, the expression of E3 ubiquitin-protein ligase component n-recognition 1 (UBR1) and autophagy-related 16-like 1 (ATG16L1) was assessed in patients with sporadic and classic achalasia as potential targets of the viral miRNAs. We assessed the mRNA levels of target transcripts using reverse transcription-quantitative PCR. UBR1 expression was slightly decreased, although the difference was not significant. However, ATG16L1 expression was significantly decreased in the LES. In conclusion, ATG16L1 expression was reduced in the LES of achalasia patients; therefore, ATG16L1 might be a target of HSV1-miR-H1, and its reduction could be related to the disease mechanism.