Per-Oral Endoscopic Myotomy for Esophagogastric Junction Outflow Obstruction: A Multicenter Pilot Study

Jacobs, Chelsea; Perbtani, Yaseen B.; Yang, Dennis; Al‐Haddad, Mohammad; Obaitan, Ite; Othman, Mohamed O.; Groth, Shawn S.; Sethi, Amrita; Agarunov, Emil; Repici, Alessandro; Maselli, Roberta; Galtieri, Alessia; Moremen, Jacob R.; Jenkins, Haley N.; Samarasena, Jason; Chang, Kenneth J.; Draganov, Peter V.

doi:10.1016/j.cgh.2020.08.048

Cited by 18 publications

(6 citation statements)

References 6 publications

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“…Peroral endoscopic myotomy (POEM) is a minimally invasive endoscopic technique developed to treat esophageal achalasia 12 . The indications for this technique have since expanded beyond its original intention, including non-achalasia spastic esophageal disorders and Zenker’s diverticulum, and pyloromyotomy for gastroparesis 13 14 15 16 . The advent of “third-space” endoscopy presents a unique, potentially less invasive, opportunity to advance the treatment of OPD in PD patients.…”

Section: Introductionmentioning

confidence: 99%

Cricopharyngeal peroral endoscopic myotomy improves oropharyngeal dysphagia in patients with Parkinson’s disease

Szczęśniak

Omari

et al. 2021

Endosc Int Open

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Background and study aims Oropharyngeal dysphagia (OPD) is prevalent in patients with Parkinson’s disease (PD). Upper esophageal sphincter (UES) dysfunction is an important pathophysiological factor for OPD in PD. The cricopharyngeus (CP) is the main component of UES. We assessed the preliminary efficacy of cricopharyngeal peroral endoscopic myotomy (C-POEM) as a treatment for dysphagia due to UES dysfunction in PD. Patients and methods Consecutive dysphagic PD patients with UES dysfunction underwent C-POEM. Swallow metrics derived using high-resolution pharyngeal impedance manometry (HRPIM) including raised UES integrated relaxation pressure (IRP), raised hypopharyngeal intrabolus pressure (IBP), reduced UES opening caliber and relaxation time defined UES dysfunction. Sydney Swallow Questionnaire (SSQ) and Swallowing Quality of Life Questionnaire (SWAL-QOL) at before and 1 month after C-POEM measured symptomatic improvement in swallow function. HRPIM was repeated at 1-month follow-up. Results C-POEM was performed without complications in all (n = 8) patients. At 1 month, there was an improvement in both the mean SSQ (from 621.5 to 341.8, mean difference –277.3, 95 %CI [–497.8, –56.7], P = 0.02) and SWAL-QOL (from 54.9 to 68.3, mean difference 9.1, 95 %CI [0.7, 17.5], P = 0.037) scores. Repeat HRPIM confirmed a decrease in both the mean UES IRP (13.7 mm Hg to 3.6 mm Hg, mean difference –10.1 mm Hg, 95 %CI [–16.3, –3.9], P = 0.007) and the mean hypopharyngeal IBP (23.5 mm Hg to 10.4 mm Hg, mean difference –11.3 mm Hg, 95 %CI [–17.2, –5.4], P = 0.003). Conclusions In dysphagic PD patients with UES dysfunction, C-POEM is feasible and enhances UES relaxation and reduces sphincteric resistance to flow during the swallow, thereby improving dysphagia symptoms.

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Section: Introductionmentioning

confidence: 99%

Cricopharyngeal peroral endoscopic myotomy improves oropharyngeal dysphagia in patients with Parkinson’s disease

Szczęśniak

Omari

et al. 2021

Endosc Int Open

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“…The EGJOO cohort who underwent POEM was carefully selected, and 13 or the 28 patients were excluded based on FLIP panometry results. Jacobs et al found a similar success rate of 94% at a median follow-up of 117 days after POEM in a retrospective study of 55 EGJOO patients, 88% of whom had abnormal FLIP prior to myotomy (EGJ-DI 2.8 mm 2 /mmHg) [48]. Triggs et al found that 24 of 34 patients with idiopathic EGJOO had an EGJ-DI < 2 mm 2 /mmHg on FLIP panometry, and 15 of those 24 patients received achalasia-type treatment (myotomy, pneumatic dilation, or botulinum toxin injection); the nine patients for whom pre and posttreatment scores were available had a drop of 3 points between median pre and posttreatment Eckhardt scores (P ¼ 0.68) [9].…”

Section: Functional Luminal Imaging Probe Panometry Guiding Esophagog...mentioning

confidence: 79%

Functional luminal imaging probe in the evaluation of esophago-gastric junction outflow obstruction

Ellison

Nguyen²

2022

Current Opinion in Gastroenterology

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Purpose of reviewEsophagogastric junction outflow obstruction (EGJOO) comprises a heterogeneous group of conditions that demonstrate impaired deglutitive relaxation of the esophagogastric junction (EGJ) with intact esophageal peristalsis on high-resolution manometry. Functional luminal imaging probe (FLIP) panometry is a powerful tool that can help to clarify the etiology of this manometric diagnosis. The aim of this review is to summarize the use of FLIP for the evaluation and management of EGJOO.Recent findingsFLIP panometry provides measures of esophageal compliance at the EGJ and information on esophageal body contractile responses to balloon distention that have important implications for the management of patients with EGJOO. After excluding anatomic causes of impaired EGJ distensibility, FLIP panometry is useful in differentiating true lower esophageal sphincter dysfunction from manometric artifact. FLIP panometry has been shown to be useful in determining the need for invasive treatment in patients with EGJOO, and in intraoperative tailoring of myotomy procedures.SummaryFLIP panometry is easy to perform during endoscopy and provides useful information for characterizing the EGJOO population. FLIP panometry can be used to guide treatment and improve outcomes in the management of patients with EGJOO.

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“…26 Per-oral endoscopic myotomy (POEM) has also been demonstrated in several trials to treat EGJOO with a clinical success rate greater than 93% and associated lowering of the IRP by greater than 10 mmHg on average. 27,28 POEM has also been utilized safely and effectively in patients with prior foregut surgery including RYGB and Heller myotomy and therefore represents a potential therapy for patients who develop symptoms of esophageal motility disorders after HH repair. [29][30][31] Given the known safety and efficacy of endoscopic techniques in the management of EGJOO and related primary motility disorders, esophagomyotomy can likely be reserved as secondary therapy for patients with persistently symptomatic EGJOO or the presumably small fraction who progress to achalasia.…”

Section: Discussionmentioning

confidence: 99%

Esophagogastric Junction Outflow Obstruction and Hiatal Hernia: Is Hernia Repair Alone Sufficient?

DeLong

Liu

Taylor

et al. 2022

JSLS

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Introduction: Esophagogastric junction outflow obstruction (EGJOO) is attributed to primary/idiopathic causes or secondary/mechanical causes, including hiatal hernias (HH). While patients with HH and EGJOO (HH+EGJOO) may undergo HH repair without myotomy, it is unclear if an underlying motility disorder is missed by therapy which addresses only the secondary EGJOO cause. The goal of this study was to determine if HH repair alone is sufficient management for HH+EGJOO patients. Methods: A retrospective review of patients who underwent HH repair between January 1, 2016 and January 31, 2020 was performed. Patients who underwent high-resolution esophageal manometry (HREM) within one year before HH repair were included. Patients with and without EGJOO on pre-operative HREM were compared. Results: Sixty-three patients were identified. Pre-operative HREM findings included: 43 (68.3%) normal, 13 (20.6%) EGJOO, 4 (6.3%) minor disorder or peristalsis, 2 (3.2%) achalasia, and 1 (1.6%) major disorder of peristalsis. No differences between patients with EGJOO or normal findings on pre-operative manometry were found in pre-operative demographics/risk factors, pre-operative symptoms, and pre-operative HREM, except higher integrated relaxation pressure in EGJOO patients. No differences were noted in length of stay, 30-day complications, long-term persistent symptoms, or recurrence with mean follow-up of 26-months. Of the 3 (23.1%) EGJOO patients with persistent symptoms, 2 underwent HREM demonstrating persistent EGJOO and none required endoscopic/surgical myotomy. Conclusion: Most HH+EGJOO patients experienced symptom resolution following HH repair alone and none required additional intervention to address a missed primary motility disorder. Further study is required to determine optimal management of patients with persistent EGJOO following HH repair.

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Per-Oral Endoscopic Myotomy for Esophagogastric Junction Outflow Obstruction: A Multicenter Pilot Study

Cited by 18 publications

References 6 publications

Cricopharyngeal peroral endoscopic myotomy improves oropharyngeal dysphagia in patients with Parkinson’s disease

Cricopharyngeal peroral endoscopic myotomy improves oropharyngeal dysphagia in patients with Parkinson’s disease

Functional luminal imaging probe in the evaluation of esophago-gastric junction outflow obstruction

Esophagogastric Junction Outflow Obstruction and Hiatal Hernia: Is Hernia Repair Alone Sufficient?

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