Morphologic Restoration After Peroral Endoscopic Myotomy in Sigmoid-type Achalasia

Abstract

Background/Aims Achalasia is a chronic, progressive motility disorder of the esophagus. The sigmoid-type achalasia is an advanced stage of achalasia characterized by severe dilatation and tortuous angulation of the esophageal body. Peroral endoscopic myotomy (POEM) has been reported to provide excellent clinical outcomes for achalasia, including the sigmoid type, but the restoration of esophageal morphology and function remain poorly described. The aim of our study is to investigate esophageal restoration after POEM for sigmoid-type achalasia. Methods From 98 patients with achalasia who underwent POEM in the Yonsei University Health System from 2013 to 2018, we recruited 13 patients with sigmoid-type achalasia (7 male; mean age 53.3 years) and assessed morphological and manometric changes in the esophagus. Results Clinical success (Eckardt score < 3) was achieved in all cases. After POEM, the average angle of esophageal tortuosity became more obtuse (91.5° vs 114.6°, P = 0.046), esophageal body diameter decreased (67.6 vs 49.8 mm, P = 0.002), and esophagogastric junction opening widened (6.4 vs 9.5 mm, P = 0.048). Patients whose esophageal tortuosity did not improve had longer durations of symptoms than patients with improvement (80.2 vs 636 months, P < 0.001). An absence of peristalsis was observed in all patients pre-and post-POEM. Conclusions POEM resulted in excellent clinical outcomes and morphologic improvement in sigmoid-type achalasia. These results suggest that the improvement of esophageal tortuosity through POEM reflects a reduced esophageal burden.

Quantification of Esophageal Angulation in Sigmoid Achalasia: Are We There Yet?

“…In this study by Yoon et al, 1 the mean angle of esophageal tortuosity increased from 91.5 ± 13.9° before POEM to 114.6 ± 17.5° after POEM signifying a reduction in the esophageal burden. 1 Similar conclusions were drawn in another recent study by Maruyama and colleagues, 4 where the average esophageal angulation changed from 88.4 ± 23.1° before POEM to 109.5 ± 16.7° after POEM ( P < 0.01). The results of both these studies suggest that there is no difference in the short-term outcomes between sigmoid achalasia (90-135°) and advanced sigmoid achalasia (< 90°).…”

“…The results of both these studies suggest that there is no difference in the short-term outcomes between sigmoid achalasia (90-135°) and advanced sigmoid achalasia (< 90°). 1 , 4 Besides these studies, a couple of other studies with relatively longer follow-up concluded that the pre-operative degree of esophageal flexion does not affect the outcomes of surgery in sigmoid achalasia. 5 , 6 The outcomes in these studies compels us to question the utility of quantifying the esophageal angulation or change in esophageal angulation if there is no effect on the final consequences.…”

“…We read the manuscript entitled “Morphologic restoration after peroral endoscopic myotomy in sigmoid-type achalasia” with great interest. 1 In this manuscript, the authors evaluated the change in esophageal tortuosity after per-oral endoscopic myotomy (POEM) as described by the “Descriptive rules for achalasia of the esophagus.” 2 Timed barium esophagogram (TBE) is commonly utilized to document the success after POEM or any other treatment modality. The traditional rules of assessing the clinical success using TBE, ie, greater than 50% reduction in barium height may not apply to sigmoid achalasia.…”

“…We acknowledge the fact that firm conclusions cannot be drawn based on the results of just 2 cases that we described in this report. In this study by Yoon and colleagues, 1 the diameter of esophagus and esophagogastric junction opening to assess objective changes in TBE after POEM have also been described. In fact, these parameters are easier to quantify when compared to fine changes in esophageal angles which may be confounded by interobserver variability.…”

Efficacy and Safety of Peroral Endoscopic Myotomy for Sigmoid-Type Achalasia: A Systematic Review and Meta-Analysis

“…However, the dilated, swerved, and rotated tortuous esophageal body may make POEM more technically challenging. Nowadays, some researchers have reported the promising results of POEM in sigmoid-type achalasia (6,(12)(13)(14)(15)(16)(17)(18). Therefore, we conducted this systematic review and meta-analysis aiming to explore the clinical outcome of POEM for sigmoid-type achalasia.…”