Morphologic Changes in Esophageal Body Movement During Bolus Transport After Peroral Endoscopic Myotomy in Type III Achalasia

Abstract

Background/AimsThe effect of peroral endoscopic myotomy (POEM) on esophageal body movement in achalasia is poorly understood. This study aims to evaluate morphological changes in esophageal body movement after POEM in type III achalasia by analyzing intraluminal ultrasound (US) images in comparison to type I and II achalasia. MethodsIntraluminal US images and impedance values of the distal esophagus from 47 achalasia patients who underwent POEM or pneumatic dilatation (PD) (30 patients in the POEM group and 17 patients in the PD group) with pre-and post-procedural high-resolution impedance manometry and intraluminal US examinations were analyzed. The muscle thickness (MT), muscle cross-sectional area, lumen cross-sectional area (LCSA), contractility and distensibility indices, swallow-to-distension interval, and distension duration during each bolus transport were analyzed. ResultsThe MT increased and LCSA decreased significantly (P < 0.001), but the contractility index was not improved after POEM or PD in type I achalasia. Baseline MT increased and LCSA decreased significantly after POEM and PD in type II achalasia (P < 0.001). In contrast, MT and the swallow-to-distension interval decreased and the distension LCSA/duration and contractility index increased after POEM in type III achalasia (P < 0.001). In contrast to type I and II achalasia, in type III achalasia, these effects were unique to the POEM group. ConclusionsPOEM decreased the esophageal LCSA by decreasing intrabolus pressure without improving contractility in type I and II achalasia. In contrast, POEM increased esophageal body distension and contractility and improved the inhibitory process during bolus transport in type III achalasia.

Gastroesophageal Reflux Waning Over Time in Endoscopic Versus Surgical Myotomy for the Treatment of Achalasia: A Systematic Review and Meta-Analysis

“…Because achalasia generates the opposite symptom of reflux by acting as a natural barrier, cardiomyotomy could imply acid exposure to a more sensitive esophageal mucosa, which was already affected by food stasis fermentation, with microscopic changes mimicking reflux and lymphocytic esophagitis [ 50 ]. A hypothesis to this waning between-group difference over time might be attributed to a late esophageal remodeling, which involves the improvement of the esophageal wall tortuosity, the lumen diameter reduction [ 51 ], and improvement in the clearance of food stasis, which prevents fermentation and decreases GERD in the endoscopic group. Another explanation could be the wrap loosening in the HMF group over time, which may lead to intrathoracic migration or hiatal hernia recurrence, partial or complete wrap disruption, and fundoplication failure [ 52 ].…”

The Differential Outcomes of Peroral Endoscopic Myotomy and Pneumatic Dilatation Upon Subtypes of Achalasia Indicate Pathophysiological Differences in Morphological Change of Esophageal Body

“…In conclusion, many other reports aimed to compare the outcomes of different treatments such as laparoscopic Heller myotomy, POEM, and PD, 2 , 3 and found limitations due to “heterogeneity” among the studies. Differently, Kim et al 1 by pathophysiological methods, reveals that the morphological structure alteration is explainable to functional impairment from the different subtypes of achalasia, therefore efficacy of POEM and PD is different across to the different subtype of achalasia. In other words, given that the different subtype of achalasia exists with the different etiology and pathophysiology, then, it is not logical for 1 therapeutic procedure to treat all different achalasia situations.…”

“…TO THE EDITOR: The article entitled “Morphologic changes in esophageal body movement during bolus transport after peroral endoscopic myotomy in type III achalasia” authored by Kim et al 1 published in your esteemed journal has been reviewed and discussed with great interest. This study presents that the different subtype of achalasia has different morphological abnormality in muscle contour at esophageal body that could be as one of the rationales when considering whether peroral endoscopic myotomy (POEM) or pneumatic dilatation (PD) could be a better way to the specific subtype of achalasia.…”

“…The evaluation was classified by Kim et al 1 as shown in Figure 1 . The impedance and intraluminal ultrasound images at distal esophagus were assessed from both of health subjects and patients whom underwent POEM or PD at pre- and post-procedure.…”

The Use of Intraoperative Esophageal Functional Luminal Imaging Probe for Prediction of Therapeutic Outcomes in Achalasia Patients

“…Authors obtained a good efficacy of POEM in consistent to other studies. 2 , 3 However, all of those cannot be for prediction in correlative to POEM efficacy. Thus, Hsing et al 1 suggested that the POC is one of critical indexes reflecting a good restoration of motility function of lower esophagus sphincter, which was seen in 8%, 67%, and 25% respectively from type-I, -II, and -III achalasia after POEM, ie, there is a better expectation from POEM in achalasia subtype II than I or III.…”