Peroral endoscopic myotomy compared with pneumatic dilation for newly diagnosed achalasia

Meng, Fandong; Li, Peng; Wang, Yongjun; Ji, Ming; Wu, Yongdong; Yu, Li; Niu, Yuxin; Lv, Fujing; Li, Wei; Li, Wenyan; Zhai, Huihong; Wu, Shanshan; Zhang, Shutian

doi:10.1007/s00464-017-5530-0

Cited by 51 publications

(36 citation statements)

References 27 publications

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“…Hence, the 40-mm Rigiflex dilator was not used in our study, which was performed in the Asian countries. [22][23][24] In this study, because of the small sample size, no statistically significant difference was observed between the two therapies in the multivariate analysis of symptom return in types II and III achalasia. However, in multivariate analysis, POEM tended to show better outcomes than BD in type III achalasia (HR 11.88, P = 0.082; the difference was not statistically significant because of the small number of patients) rather than in type I (HR 4.69, P = 0.02) or type II (HR 7.08, P = 0.066) achalasia (Table 4).…”

Section: Discussionmentioning

confidence: 59%

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Superior clinical outcomes of peroral endoscopic myotomy compared with balloon dilation in all achalasia subtypes

Kim

Jung

et al. 2019

J of Gastro and Hepatol

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Background and Aim Optimal treatment modalities for each of the three subtypes of achalasia are still under debate. Differences in prognosis and long‐term outcomes between peroral endoscopic myotomy (POEM) and balloon dilation (BD) are also unclear. We aimed to compare the treatment outcomes of BD and POEM in each subtype of achalasia by using information from the manometry database of a tertiary referral center in Korea. Methods Data from 5207 esophageal manometry procedures performed between 1989 and 2016 were analyzed. The medical records and results of esophagography and esophagogastroduodenoscopy were also reviewed. Results We identified 264 patients (116 men and 148 women) with diagnosis of achalasia during the study period. POEM and BD were carried out on 64 and 177 patients, respectively. There was a significant difference in the time to relapse between the POEM group and the BD group (P = 0.002). At the 24‐month follow‐up, the clinical success rates of POEM and BD were 91.8% and 68.0%, respectively. The hazard ratio of symptom return was 6.54 for BD compared with POEM (95% confidence interval 2.12–20.22, P = 0.001). After a follow‐up period of 24 months, the success rate of POEM was significantly higher than that of BD for all subtypes of achalasia. However, only that of types I and II was statistically significant (type 1: 92.0% vs 51.1%, P = 0.004; type 2: 92.3% vs 59.8%, P = 0.007; and type3: 91.7% vs 55.6%, P = 0.051). Conclusions Peroral endoscopic myotomy was more effective than BD in providing mid‐long‐term remission in patients with all manometric subtypes of achalasia.

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Section: Discussionmentioning

confidence: 59%

“…And we did not use a 40‐mm balloon, and as for most Asian patients, 30‐ or 35‐mm‐diameter dilators are the most appropriate. Hence, the 40‐mm Rigiflex dilator was not used in our study, which was performed in the Asian countries …”

Section: Discussionmentioning

confidence: 99%

Superior clinical outcomes of peroral endoscopic myotomy compared with balloon dilation in all achalasia subtypes

Kim

Jung

et al. 2019

J of Gastro and Hepatol

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“…Twenty articles were included in the review (1575 patients) ( Fig . ). Three studies reported data on botulinum toxin (58 patients), 11 on pneumatic dilatation (485 patients), nine on LHM (583 patients) and seven on POEM (449 patients) ( Tables and ).…”

Section: Resultsmentioning

confidence: 99%

“…A score from 0 to 3 was given to each symptom and a total score of 3 or less defined success. The remaining studies used the Eckardt score, and a score of 3 or less was used to define clinical remission.…”

Section: Resultsmentioning

confidence: 99%

Meta-analysis of clinical outcome after treatment for achalasia based on manometric subtypes

Andolfi

Fisichella

2019

British Journal of Surgery

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Background: The introduction of high-resolution manometry and the Chicago classification has made it possible to diagnose achalasia and predict treatment response accurately. The aim of this study was to compare the effect of the different treatments available on symptomatic outcomes across all achalasia subtypes. Methods: The study was conducted according to PRISMA and MOOSE guidelines. A literature search of PubMed and MEDLINE databases was undertaken to identify all relevant articles reporting clinical outcomes of patients with achalasia after botulinum toxin injection, pneumatic dilatation, laparoscopicHeller myotomy (LHM) and peroral endoscopic myotomy (POEM) based on manometric subtypes. Patients were grouped according to the Chicago classification and the success rate in treating symptoms was measured as the primary endpoint.Results: Twenty studies (1575 patients) were selected, and data on botulinum toxin, pneumatic dilatation, LHM and POEM were extracted. Success rates for LHM in type I, II and III achalasia were 81, 92 and 71 per cent respectively. Those for POEM were 95, 97 and 93 per cent respectively. POEM was more likely to be successful than LHM for both type I (odds ratio (OR) 2⋅97, 95 per cent c.i. 1⋅09 to 8⋅03; P = 0⋅032) and type III (OR 3⋅50, 1⋅39 to 8⋅77; P = 0⋅007) achalasia. The likelihood of success of POEM and LHM for type II achalasia was similar.Conclusion: Pneumatic dilatation had a lower but still acceptable success rate compared with POEM or LHM in patients with type II achalasia. POEM is an excellent treatment modality for type I and type III achalasia, although it did not show any superiority over LHM for type II achalasia.

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“…Current evidence suggests little diff erence in effi cacy between PD, laparoscopic Heller myotomy, or per-oral endoscopic myotomy (POEM) for managing achalasia as measured by patient-reported outcomes ( 13,14 ), but PD oft en requires sequential treatments with progressively larger dilators (30, 35, and 40 mm) to achieve that equivalent effi cacy. Current practice is to begin conservatively with a 30 mm dilation and to determine the need for subsequent dilations based on clinical response as assessed aft er a relatively brief follow-up interval.…”

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confidence: 99%

Assessing Esophageal Function in Achalasia: The Old and the New

Triggs

Kahrilas

2018

American Journal of Gastroenterology

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Achalasia is currently diagnosed according to the Chicago Classifi cation v3.0 using highresolution manometry and treatment focuses on disruption of the esophagogastric junction. A paper in this issue examines the utility of a timed barium esophagram with a 13 mm tablet challenge in differentiating achalasia from other diagnoses, fi nding 100% sensitivity. However, a large proportion of patients with non-achalasia dysphagia are also identifi ed. Another paper in this issue proposes utilizing intraprocedure functional luminal imaging probe measurement during pneumatic dilation as a guide for upsizing dilations. This appears promising, but prospective validation is necessary before this becomes standard of care. Am J Gastroenterol 2018; 113:213-215; doi: 10.1038/ajg.2017 High-resolution manometry (HRM), along with the analysis algorithms initially put forth in the Chicago Classifi cation (CC), and most recently updated in 2015 have led to a major reclassifi cation of esophageal motility disorders ( 1 ). Nowhere is this evolution more evident than in our concept of achalasia, now diff erentiated into three subtypes and proving to be substantially more prevalent than previously recognized ( 2,3 ). In fact, many disorders previously rendered to alternative diagnoses, or deemed to be "non-specifi c, " are also now recognized to be either achalasia subtypes or cases of incompletely expressed achalasia ( 4 ). In parallel with the global adoption of the CC, the functional luminal imaging probe (FLIP) has emerged as a novel technology capable of quantifying the distensibility of the esophagogastric junction (EGJ), and reduced EGJ distensibility has proven to be a key abnormality in achalasia. In fact, the detection of reduced EGJ distensibility can be complimentary to HRM in achalasia cases with equivocal, or even negative, HRM fi ndings ( 5 ). Furthermore, FLIP measurements can be made in real time with sedated patients, thereby off ering the potential to tailor treatment as the treatment is in progress. Together, these developments have reinvigorated our thinking about the management of esophageal motor disorders in general and achalasia in particular. Contained in this issue of the Journal are two papers pertinent to achalasia management: one exploring how an old methodology, the timed barium esophagram (TBE), fi ts into the new CC diagnostic paradigms, and the second on how FLIP might facilitate a more effi cient protocol for pneumatic dilation (PD) in achalasia therapeutics.In the fi rst paper, Blonski et al. ( 6 ) report on a retrospective analysis of 309 patients comparing TBE (including a 13 mm barium tablet challenge) with HRM in the detection and diff erentiation of achalasia, EGJ outfl ow obstruction (EGJOO), and non-achalasia dysphagia as defi ned by CC v3.0. Applying post hoc determined cutoff s for barium retention height at 1 and 5 min, they report a sensitivity and specifi city for TBE of 85% and 86%, respectively, for distinguishing achalasia from EGJOO and nonachalasia dysphagia using a retaine...

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Peroral endoscopic myotomy compared with pneumatic dilation for newly diagnosed achalasia

Abstract: In the intermediate term, the remission rate of symptoms associated with POEM therapy was better than that with PD for newly diagnosed achalasia, especially in patients with type III achalasia. The short-term outcomes of the two therapies were similar.

Cited by 51 publications

References 27 publications

Superior clinical outcomes of peroral endoscopic myotomy compared with balloon dilation in all achalasia subtypes

Superior clinical outcomes of peroral endoscopic myotomy compared with balloon dilation in all achalasia subtypes

Meta-analysis of clinical outcome after treatment for achalasia based on manometric subtypes

Assessing Esophageal Function in Achalasia: The Old and the New

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