Muscular thickness of lower esophageal sphincter and therapeutic outcomes in achalasia: A prospective study using high‐frequency endoscopic ultrasound

Li, Shih-Wei; Tseng, Ping‐Huei; Chen, Chien-Chuan; Liao, Wei‐Chih; Liu, Kao–Lang; Lee, Jang-Ming; Lee, Yi–Chia; Chuah, Seng‐Kee; Wu, Ming–Shiang; Wang, Hsiu–Po

doi:10.1111/jgh.13816

Cited by 11 publications

(9 citation statements)

References 46 publications

(56 reference statements)

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“…In the 30 years since these studies, the number of studies that use different EUS techniques and include more participants have increased. Our results agree with many of these studies, where most of the individuals in the present study had a thickened LEMP[ 5 - 7 ]. This suggests that LEMP thickness may be of value in achalasia diagnosis.…”

Section: Discussionsupporting

confidence: 94%

“…While its etiology remains uncertain, achalasia is characterized by the destruction of inhibitory ganglion cells in the myenteric plexus, causing severe myopathy in smooth muscles and leading to aperistalsis and impaired relaxation of the lower esophageal sphincter (LES)[ 1 , 2 ]. In addition, thickened lower esophageal muscularis propria (LEMP) has been observed in individuals with achalasia in vivo and during autopsies[ 3 - 7 ]. LEMP hypertrophy may be a response to esophageal functional obstruction or a primary lesion[ 2 ].…”

Section: Introductionmentioning

confidence: 99%

“…However, treatment history, type of mucosal damage, and reflux symptoms were included in a newly developed risk prediction scoring system[ 17 ]. Considering that the POEM procedure is performed directly on the muscularis propria and LEMP thickness is associated with the postprocedural balloon catheter dilation outcome[ 7 ], LEMP thickness is thought to be associated with POEM outcome. However, no correlation between muscle thickness and prognosis at 1 year after POEM has been reported[ 18 , 19 ], and few studies with longer follow-up periods include assessment of the relationship between LEMP thickness and POEM outcomes.…”

Section: Introductionmentioning

confidence: 99%

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Endoscopic ultrasound-measured muscular thickness of the lower esophageal sphincter and long-term prognosis after peroral endoscopic myotomy for achalasia

Liao

Xiao

et al. 2020

WJG

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BACKGROUND People with achalasia typically have a thick lower esophageal muscularis propria (LEMP), and peroral endoscopic myotomy (POEM) has been effective in treating most patients. LEMP thickness may be associated with the outcomes and prognosis after POEM. However, more evidence is needed regarding the relationship between LEMP thickness and patient prognosis after POEM. AIM To assess the association between LEMP thickness, measured using endoscopic ultrasound (EUS), and long-term prognosis, especially relapse, after POEM for achalasia. METHODS All medical records, including EUS data, of patients who underwent POEM to treat achalasia at Shengjing Hospital of China Medical University from January 2012 to September 2018 were retrospectively reviewed. LEMP thickness was measured by EUS, and a thickness of ≥ 3 mm was defined as thickened. The severity of patient symptoms was evaluated using the Eckardt score. Relapse was defined as a 3-point rise in the Eckardt score after a period of clinical remission. The relationship between patient characteristics, muscle thickness, and recurrence was analyzed. RESULTS Eighty-two patients (32 males and 50 females, aged 17-78 years) and 85 POEM procedures were included. In total, 76.8% (63/82 patients) of patients had a thickened muscularis propria. Older age and longer disease course were associated with muscularis propria thickening ( P < 0.05). The mean postoperative follow-up time was 35.4 ± 17.2 mo (range, 8-87.5 mo) in 60 patients. Five patients with Eckardt scores > 3 refused further management after their symptoms were relieved. The relapse rate was 12.73% (7/55 cases). Five patients, four of whom had muscularis propria thickening, had disease recurrence within 12 mo after the procedure. Achalasia relapsed in one patient who had a thickened muscularis propria after 24 mo and in another patient who did not have a thickened muscularis propria after 30 mo. Patients with recurrence were typically younger and had a shorter disease course ( P < 0.05). The relapse rate in patients with a non-thickened muscularis propria tended to be higher (18.2%, 2/11 patients) than that in patients with a thickened muscularis propria (11.4%, 5/44 patients), although no significant difference was found. Age (hazard ratio = 0.92; 95% confidence interval: 0.865-0.979; P < 0.05) and being male (hazard ratio = 7.173; 95% confidence interval: 1.277-40.286; P < 0.05) were identified as risk factors for symptomatic recurrence by multivariable analysis using the Cox model. CONCLUSION Patients with a thickened muscularis are typically older and have a longer disease course. Younger age and the male sex are associated with increased recurrence. Patients with a thin muscularis propria may be prone to relapse, although further validation is needed.

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Section: Discussionsupporting

confidence: 94%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Endoscopic ultrasound-measured muscular thickness of the lower esophageal sphincter and long-term prognosis after peroral endoscopic myotomy for achalasia

Liao

Xiao

et al. 2020

WJG

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“…The Rigiflex dilator is the commonly used dilator with a fully inflated diameter that usually ranges from 3 cm or more to achieve maximal pressure for a satisfactory result. Dilations can be performed by either a fluoroscopy-guided procedure [12, 13, 26] or endoscopy-guided procedure [9, 14]. Dilation sessions and the inflation time needed for a successful dilation vary between patients and are operator dependent.…”

Section: Treatment Evolution: From Conventional Treatment To Perormentioning

confidence: 99%

Bridging the Gap between Advancements in the Evolution of Diagnosis and Treatment towards Better Outcomes in Achalasia

Chuah

Lim

Liang

et al. 2019

BioMed Research International

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Over the past few decades, there was an encouraging breakthrough in bridging the gap between advancements in the evolution of diagnosis and treatment towards a better outcome in achalasia. The purpose of this review is to provide updated knowledge on how the current evidence has bridged the gap between advancements in the evolution of diagnosis and treatment of esophageal achalasia. The advent of high-resolution manometry and standardization based on the Chicago classification has increased early recognition of the disease. These 3 clinical subtypes of achalasia can predict the outcomes of patients, and the introduction of POEM has revolutionized the choice of treatment. Previous evidence has shown that laparoscopic Heller myotomy (LHM) and anterior fundoplication were considered the most durable treatments for achalasia. Based on the current evidence, POEM has been evolving as a promising strategy and is effective against all 3 types of achalasia, but the efficacy of POEM is based on short- and medium-term outcome studies from a limited number of centers. Types I and II achalasia respond well to POEM, LHM, and PD, while most studies have shown that type III achalasia responds better to POEM than to LHM and PD. In general, among the 3 subtypes of achalasia, type II achalasia has the most favorable outcomes after medical or surgical therapies. The long-term efficacy of POEM is still unknown. The novel ENDOFLIP measures the changes in intraoperative esophagogastric junction dispensability, which enables a quantitative assessment of luminal patency and sphincter distension; however, this technology is in its infancy with little data to date supporting its intraoperative use. In the future, identifying immunomodulatory drugs and the advent of stem cell therapeutic treatments, including theoretically transplanting neuronal stem cells, may achieve a functional cure. In summary, it is important to identify the clinical subtype of achalasia to initiate target therapy for these patients.

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“…Esophageal muscle layer thickness was identified as the most important clinical factor affecting duration of POEM procedures. As for mid- and long-term outcomes of POEM, a few studies have suggested that a thick preoperative esophageal muscle layer might be a predictor of failure of PD 7 . Patients whose esophageal muscle layers were < 1.3 mm thick exhibited a significantly higher mid-term success rate after PD than those with thicker esophageal muscle layers (100 % vs. 36.3 %, P = 0.01).…”

Section: Introductionmentioning

confidence: 99%

Clinical impact of peroral endoscopic myotomy for esophageal motility disorders on esophageal muscle layer thickness

et al. 2019

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Background and study aims Previously, we reported that esophageal muscle layer thickness was associated with technical complexity of peroral endoscopic myotomy (POEM). However, there are no data regarding the mid-term effects of POEM procedures on esophageal muscle layer thickness. Therefore, we conducted this study to elucidate mid-term effects of POEM procedures, and to examine whether postoperative changes in esophageal muscle layer thickness were related to particular clinico-pathological features in patients with esophageal motility disorders. Patients and methods Seventy-four consecutive patients with esophageal motility disorders who underwent POEM at Kobe University Hospital from April 2015 to December 2016 were prospectively recruited into this study. First, we investigated the esophageal muscle layer thickness values obtained at 1 year after POEM. Second, we evaluated the effects of a reduction in muscle layer thickness on various clinico-pathological features. Results At 1 year after POEM, mean thickness of the inner circular muscle at 0 cm, 5 cm, and 10 cm from the esophagogastric junction was 1.06 ± 0.45 mm, 0.99 ± 0.36 mm, and 0.97 ± 0.44 mm, respectively. Among all sites, muscle layer thickness had significantly decreased after POEM. However, univariate logistic regression analysis demonstrated that no clinical factors were associated with esophageal muscle layer thickness after POEM procedure. Conclusions We demonstrated for the first time that thickness of the esophageal muscle layer was significantly decreased after POEM. This result reveals that changes in esophageal muscle layer thickness caused by esophageal motility disorders are reversible.

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Muscular thickness of lower esophageal sphincter and therapeutic outcomes in achalasia: A prospective study using high‐frequency endoscopic ultrasound

Abstract: Thickening of the outer longitudinal muscle at the lower esophageal sphincter is associated with poor mid-term treatment outcomes for achalasia patients treated with pneumatic dilatation.

Cited by 11 publications

References 46 publications

Endoscopic ultrasound-measured muscular thickness of the lower esophageal sphincter and long-term prognosis after peroral endoscopic myotomy for achalasia

Endoscopic ultrasound-measured muscular thickness of the lower esophageal sphincter and long-term prognosis after peroral endoscopic myotomy for achalasia

Bridging the Gap between Advancements in the Evolution of Diagnosis and Treatment towards Better Outcomes in Achalasia

Clinical impact of peroral endoscopic myotomy for esophageal motility disorders on esophageal muscle layer thickness

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