Endoscopic management of gastrointestinal motility disorders – part 1: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Abstract

Main RecommendationsESGE recommends the use of a graded pneumatic dilation protocol in achalasia, starting with a 30-mm dilation and followed by a 35-mm dilation at a planned interval of 2 – 4 weeks, with a subsequent 40-mm dilation when there is insufficient relief, over both a single balloon dilation procedure or the use of a larger balloon from the outset.Strong recommendation, high quality of evidence, level of agreement 100 %.ESGE recommends being cautious in treating spastic motility disorders other than achalasia with peroral endoscopic myotomy (POEM).Strong recommendation, very low quality of evidence, level of agreement 87.5 %.ESGE recommends against the routine use of botulinum toxin injections to treat patients with non-achalasia hypercontractile esophageal motility disorders (Jackhammer esophagus, distal esophageal spasm). However, if, in individual patients, endoscopic injection of botulinum toxin is chosen, ESGE recommends performing injections into four quadrants of the lower esophageal sphincter and in the lower third of the esophagus.Strong recommendation, low quality of evidence, level of agreement 78.6 %.ESGE recommends that endoscopic pylorus-directed therapy should be considered only in patients with symptoms suggestive of gastroparesis in combination with objective proof of delayed gastric emptying using a validated test, and only when medical therapy has failed.Strong recommendation, very low quality of evidence, level of agreement 100 %.ESGE recommends against the use of botulinum toxin injection in the treatment of unselected patients with gastroparesis. Strong recommendation, high quality of evidence, level of agreement 92.9 %.ESGE recommends consideration of gastric peroral endoscopic myotomy (G-POEM) in carefully selected patients only, because it is an emerging procedure with limited data on effectiveness, safety, and durability. G-POEM should be performed in expert centers only, preferably in the context of a clinical trial.Strong recommendation, low quality of evidence, level of agreement 100 %.

Motilitätsstörungen des Ösophagus

“…Botulinumtoxin A, ein Neurotoxin, das die Freisetzung von Acetylcholin an den Nervenendungen im Plexus myentericus hemmt, wirkt hier der durch [19]. Es handelt sich um eine Therapieoption für Patienten mit hoher Komorbi-dität, die ein invasiveres Verfahren nicht tolerieren [16,18].…”

“…Auch bei der ÖGÜ-Obstruktion und denspastischenMotilitätsstörungenwird Botox eingesetzt, weist jedoch niedrige Erfolgsraten als bei der Achalasie auf, weswegen die Leitlinien einen eher zurückhaltenden Einsatz empfehlen [16,20].…”

“…Die PD gilt neben der POEM als die effektivste nichtchirurgische Behandlungsmöglichkeit der Achalasie [16] [21]. Während die initialenErfolgsratender PD mit 85 % angegeben werden, liegt die Langzeitremission nach einmaliger PD nach 10 Jahren nur bei etwa 40 %, und mehr als die Hälfte der Patienten muss wiederholt dilatiert werden [22].…”

“…Kurzzeitergebnisse in größeren Fallserien und Studien zeigen Erfolgsraten der POEM von mehr als 90 %. Insbesondere Patienten mit Typ-III-Achalasie profitieren von dieser Art der langstreckigen Myotomie [16].…”

Peroral endoscopic myotomy (POEM) is more cost-effective than laparoscopic Heller myotomy in the short term for achalasia: economic evaluation from a randomized controlled trial

“…Inoue et al 15 introduced the concept of natural orifice transluminal endoscopic surgery (NOTES) 16 17 associated with submucosal dissection 18 and named this technique peroral endoscopic myotomy (POEM). Studies have shown that the short- to mid-term efficacy of POEM is greater than 90 % and that the procedure is associated with less postoperative pain 19 20 21 22 23 24 25 . However, this procedure is frequently associated with some common adverse effects, such as pneumoperitoneum and surgical emphysema 26 .…”