Extending Myotomy Both Downward and Upward Improves the Final Outcome in Manometric Pattern III Achalasia Patients

Salvador, Renato; Provenzano, Luca; Capovilla, Giovanni; Briscolini, Dario; Nicoletti, Loredana; Valmasoni, Michele; Moletta, Lucia; Merigliano, Stefano; Costantini, Mario

doi:10.1089/lap.2019.0035

Cited by 7 publications

(5 citation statements)

References 22 publications

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“…Other oesophageal spastic disorders are even rarer. More relevant, it is currently quite well accepted that in patients with spastic disorders a very long myotomy is instead necessary 45 46. The effects of pneumatic dilations and standard Heller myotomy are not very good in this subgroup of patients, more likely because the premature, spastic contraction of the mid-oesophagus and distal oesophagus are themselves creating an obstacle to the food advancement 47–51…”

Section: Discussionmentioning

confidence: 99%

Long versus short peroral endoscopic myotomy for the treatment of achalasia: results of a non-inferiority randomised controlled trial

Familiari

Andreis

Landi

et al. 2023

Gut

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ObjectivePeroral endoscopic myotomy (POEM) has become standard treatment for achalasia with comparable efficacy to surgery. In most of published series, the length of myotomy is 12–13 cm. Shorter cuts could have the advantage of shorter procedure time and possibly reduced gastro-oesophageal reflux disease (GORD) rate.DesignThis single-centre, patient-blinded, randomised, non-inferiority clinical trial included 200 patients, who were randomly allocated, to receive either a long-POEM (13 cm; 101 patients) or a short-POEM (8 cm; 99 patients). Primary outcome was defined as an Eckardt symptom score of ≤3 at 24 months after the procedure; a non-inferiority design was chosen with an accepted success range of 6% between the two treatments. Secondary outcomes included operating time, complication rate, postoperative manometry, GORD rate and quality of life.ResultsIn the intention-to-treat analysis, clinical success rates were 89.1% in the long-POEM and 98.0% in the short-POEM group, resulting in an absolute between-group difference of −8.9% (90% CI −14.5 to −3.3).Procedure time was significantly reduced in the short-POEM as compared with the long-POEM group (40 vs 50 min, p<0.0001). Severe adverse events occurred in one patient in both groups.No differences were observed in postoperative GORD: acid exposure >6% on pH monitoring study at 6 months was seen in 34.3% (long-POEM) vs 31.1% (short-POEM), while endoscopic oesophagitis was diagnosed in 37.6% vs 51.5% at 6 months and in 21% vs 24.5% at 24 months. Regular proton pump inhibitor use was not different either (36.8% vs 37.5%).ConclusionsOur study demonstrates non-inferiority of a shorter cut length of POEM as compared with the standard treatment, which saved some procedural time. GORD rate was not reduced by reducing cutting length.Trial registration numberNCT03450928.

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Section: Discussionmentioning

confidence: 99%

Long versus short peroral endoscopic myotomy for the treatment of achalasia: results of a non-inferiority randomised controlled trial

Familiari

Andreis

Landi

et al. 2023

Gut

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“…Some studies have also shown that satisfactory results can be obtained with LHM in such patients by elongating the myotomy. 49…”

Section: Discussionmentioning

confidence: 99%

“…Some studies have also shown that satisfactory results can be obtained with LHM in such patients by elongating the myotomy. 49 The risk of esophageal cancer after myotomy must be considered, even if the procedure is effective in controlling dysphagia. These cancers may develop several years after treatment, so they should be expected in the coming years after POEM as well.…”

Section: Discussionmentioning

confidence: 99%

Long-term Outcomes (5 Years or More) After Myotomy

Capovilla

Costantini

Provenzano

et al. 2022

Foregut: The Journal of the American Foregut Society

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Background: Surgical or endoscopic myotomy are good options for treating achalasia, as >80% of patients continue to report no symptoms at medium-term follow-up. Little is known about the long-term natural history of patients who have undergone myotomy, however, in terms of symptom control, need for retreatment, and complications. In this review we examined the long-term results at least 5 years after surgical or endoscopic myotomy. Methods: A narrative review of all studies reporting the results of surgical or endoscopic myotomy with a follow-up of 5 years or more was conducted. The main focus was on symptom relief, the incidence of GERD, and the need for retreatment. Results: Transthoracic or laparotomic approaches to Heller myotomy were mainly used in the last century, with long-term studies reporting symptom relief in the range of 73% to 95%, and a 4.4% to 45.5% incidence of GERD. The laparoscopic approach has been the gold standard for the last 20 years, eliminating dysphagia symptoms in 65% to 95% of patients. Per-oral endoscopic myotomy (POEM) is a valid method that achieves long-term symptom relief in up to 92% of patients. GERD remains an issue as it’s incidence after POEM exceeds that reported after laparoscopic myotomy. Conclusion: Surgical and endoscopic myotomy both achieve symptom control that persists for more than 5 years and can be accepted as an effective primary treatment for achalasia. However, the real role of the higher incidence of postoperative reflux carried by POEM should not be underestimated.

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“…This is probably because it enables the muscle fibers above the LES to be severed [ 8 ]. Moreover, some manometric studies showed that the LES is longer in type III achalasia than in the other two subtypes, and that extending the myotomy both upwards and downwards could ensure excellent results in this type of achalasia too [ 11 ].…”

Section: Laparoscopic Heller Myotomy (Lhm)mentioning

confidence: 99%