Repeated Surgical or Endoscopic Myotomy for Recurrent Dysphagia in Patients After Previous Myotomy for Achalasia

Fumagalli, Uberto; Rosati, Riccardo; Pascale, Stefano De; Porta, Massimiliano Della; Carlani, Elisa; Pestalozza, Alessandra; Repici, Alessandro

doi:10.1007/s11605-015-3031-9

Cited by 46 publications

(34 citation statements)

References 21 publications

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“…The impact of prior treatment such as PBD or LHM on the success of POEM appears to be minimal as found in previous studies 20 21 22. However, significant submucosal fibrosis may be encountered in some of these patients, leading to technical difficulty or failure and prolonged procedure duration 23.…”

Section: Discussionmentioning

confidence: 74%

Per-oral endoscopic myotomy for achalasia cardia: outcomes in over 400 consecutive patients

et al. 2017

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Background and study aims Per-oral endoscopic myotomy (POEM) has emerged as an efficacious treatment modality for the management of achalasia cardia (AC) and non-achalasia spastic esophageal motility disorders. Initial results are encouraging. We analyzed the safety and efficacy of POEM in a large cohort of patients with AC. Patients and methods The data from patients who underwent POEM (from January 2013 to June 2016) was prospectively collected and analyzed. Clinical success was defined as Eckardt score ≤ 3 after POEM procedure. Objective parameters including high-resolution manometry (HRM) and timed barium swallow (TBS) were analyzed and compared before and after the procedure. Gastroesophageal reflux was analyzed using 24-hour pH impedance study and esophagogastro-duodenoscopy. Results A total of 408 patients (mean age 40 years, range 4 – 77 years) underwent POEM during the specified period. POEM could be successfully completed in 396 (97 %) patients. Clinical success rates at 1, 2 and 3 years were 94 %, 91 % and 90 %, respectively. Mean Eckardt score was 7.07 ± 1.6 prior to POEM and 1.27 ± 1.06 after POEM (P = 0.001) at 1 year. Significant improvement in esophageal emptying on TBE (> 50 %) was documented in 93.8 % patients who completed 1-year follow up. Pre-procedure and post-procedure mean lower esophageal sphincter pressure was 45 ± 16.5 mmHg and 15.6 ± 6.1 mmHg, respectively (P = 0.001). Technical and clinical success were comparable in naïve vs prior treated cases (97.3 % vs 96.8 %, P = 0.795) (95.7 % vs 92.6 %, P = 0.275). GERD was documented in 28.3 % patients with 24-hour pH-impedance study and erosive esophagitis was seen in 18.5 % of patients who underwent POEM. Conclusions POEM is safe, effective and has a durable response in patients with achalasia cardia. Prior treatment does not influence the outcomes of POEM.

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Section: Discussionmentioning

confidence: 74%

Per-oral endoscopic myotomy for achalasia cardia: outcomes in over 400 consecutive patients

et al. 2017

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“…The first-line treatment is still debated in the medical community: some authors prefer pneumatic endoscopic dilatation, others the endoscopic injection of botulinum toxin, and yet others surgery [1,2,[9][10][11][12][13][14].…”

Section: Discussionmentioning

confidence: 99%

Esophageal Achalasia: Predictive Value of Preoperative Resting Pressure of LES Correlated with Type of Fundoplication

et al. 2017

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Objective: The aim of the present study is to show the predictive value of the preoperative resting pressure of the lower esophageal sphincter (LES) correlated with the type of fundoplication (Nissen or Dor) after Heller myotomy in our series. Materials and Methods:From January 1998 to June 2010, 88 patients affected by esophageal achalasia underwent surgery at our unit. However, our study focused on a sample of 36 patients, because many data were lost or was never recorded. Among these, 14 patients underwent laparoscopic Heller myotomy plus Nissen fundoplication (group N), whereas 22 patients underwent laparoscopic Heller myotomy plus Dor fundoplication (group D). Clinical evaluation was performed using a modified DeMeester symptom scoring system consisting of the assessment of three symptoms: dysphagia, regurgitation, and heartburn. To each symptom was assigned a score from 0 to 3, depending on its severity, and the reduction in the severity of each symptom after surgery was assessed.Results: The surgical treatment is considered to be effective (p<0.0001). The preoperative resting pressures of LES were compared by Student's t-test, and it was found that patients who reported a greater improvement in the dysphagia symptom had a preoperative average pressure of LES that was significantly higher than that in other patients in both group N (p=0.03) and group D (p=0.01; p=0.003; p=0.001). The Dor treatment was shown to be more effective than the Nissen treatment (p<0.0001). Conclusion:The preoperative resting pressure of LES is a predictive factor of surgical success both before Dor fundoplication and before Nissen fundoplication, but its predictive power is influenced by the chosen type of fundoplication.Keywords: Achalasia, dysphagia, preoperative resting pressure of LES, predictive factors, fundoplication ÖZ Amaç: Bu çalışmanın amacı, serimizdeki Heller miyotomi sonrasında, funduplikasyon türü (Nissen veya Dor) ile ilişkili olarak alt özofageal sfinkterin (AÖS) preoperatif istirahat basıncının prediktif değerini göstermektir.Gereç ve Yöntem: Ocak 1998 ile Haziran 2010 arasında, özofageal akalazyadan etkilenen 88 hasta birimimizde ameliyat oldular. Ancak çalışmamızda, birçok verinin kaybolmasından veya hiç kaydedilmemiş olmasından dolayı, 36 hastaneden oluşan bir örnekleme odaklanıldı. Bu hastalardan 14'üne laparoskopik Heller miyotomi+Nissen fundoplikasyon (N grubu) uygulanırken, 22'sine laparoskopik Heller miyotomi+Dor fundoplikasyon (D grubu) uygulandı. Klinik değerlendirme, disfaji, regürjitasyon ve mide yanması olan üç semptomun değerlendirilmesini içeren modifiye DeMeester semptom skorlama sistemi kullanılarak yapıldı. Her bir semptoma 0 ile 3 arası bir puan verildi ve ameliyat sonrası her semptomun şiddetindeki azalma değerlendirildi.Bulgular: Cerrahi tedavinin etkili olduğu düşünülmektedir (p<0,0001). Ameliyat öncesi AÖS istirahat basınçları Student's t-test ile karşılaştırıldı. Disfaji semptomunda gelişme görülen hastalarda ameliyat öncesi ortalama AÖS basıncı, N grubu (p=0,03) ve D grubundaki (p...

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“…Per‐oral endoscopic myotomy has emerged as a less invasive treatment options for naïve as well as for prior treatment failure patients. The published literature suggests that POEM is a safe and efficacious alternative to LHM or PD for treatment of failed cases of AC . Vigneswarwan et al .…”

Section: Methodsmentioning

confidence: 99%

Management of achalasia cardia: Expert consensus statements

Ramchandani

Reddy

Nabi

et al. 2018

J of Gastro and Hepatol

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Achalasia cardia (AC) is a frequently encountered motility disorder of the esophagus resulting from an irreversible degeneration of neurons. Treatment modalities are palliative in nature, and there is no curative treatment available for AC as of now. Significant advancements have been made in the management of AC over last decade. The introduction of high resolution manometry and per-oral endoscopic myotomy (POEM) has strengthened the diagnostic and therapeutic armamentarium of AC. High resolution manometry allows for the characterization of the type of achalasia, which in turn has important therapeutic implications. The endoscopic management of AC has been reinforced with the introduction of POEM that has been found to be highly effective and safe in palliating the symptoms in short-term to mid-term follow-up studies. POEM is less invasive than Heller's myotomy and provides the endoscopist with the opportunity of adjusting the length and orientation of esophageal myotomy according to the type of AC. The management of achalasia needs to be tailored for each patient, and the role of pneumatic balloon dilatation, POEM, or Heller's myotomy needs to be revisited. In this review, we discuss the important aspects of diagnosis as well as management of AC. The statements presented in the manuscript reflect the cumulative efforts of an expert consensus group.

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Repeated Surgical or Endoscopic Myotomy for Recurrent Dysphagia in Patients After Previous Myotomy for Achalasia

Abstract: A redo myotomy should be considered in patients who underwent myotomy for achalasia and presenting with recurrent dysphagia. Preliminary results using POEM indicate that the technique can be safely used in patients who have undergone previous surgical myotomy.

Cited by 46 publications

References 21 publications

Per-oral endoscopic myotomy for achalasia cardia: outcomes in over 400 consecutive patients

Per-oral endoscopic myotomy for achalasia cardia: outcomes in over 400 consecutive patients

Esophageal Achalasia: Predictive Value of Preoperative Resting Pressure of LES Correlated with Type of Fundoplication

Management of achalasia cardia: Expert consensus statements

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