Peroral endoscopic myotomy for Jackhammer esophagus: to cut or not to cut the lower esophageal sphincter

Abstract

Background and study aims: With the success of peroral endoscopic myotomy (POEM) in treatment of achalasia, its successful application to other spastic esophageal motility disorders such as Jackhammer esophagus has been noted. The question of whether the lower esophageal sphincter (LES) should be included in the myotomy for Jackhammer esophagus is a topic of current debate. Here, we report our experience and results with four patients with Jackhammer esophagus treated with POEM. The clinical and manometric results are presented and their potential implications are discussed. Patients and methods: Between January 2014 and July 2015, four patients underwent POEM for treatment of Jackhammer esophagus at our center. Manometry was performed prior to and after POEM. All patients met the Chicago classification criteria for Jackhammer esophagus and received a barium esophagram and endoscopic examination before having POEM. Results: All patients had uneventful procedures without any intraoperative or post-procedure complications. Patients in which the LES was included during POEM had resolution or significant improvement in symptoms. One patient in whom the LES was preserved had resolution of chest pain but developed significant dysphagia and regurgitation. Subsequently this individual received a repeat POEM which included the LES, resulting in symptom resolution. Conclusions: POEM is a suitable treatment for patients with Jackhammer esophagus. Until there are larger-scale randomized studies, we speculate that based on our clinical experience and physiologic and manometric observations, obligatory inclusion of the LES is justified to reduce the risk of symptom development from iatrogenic ineffective esophageal motility or subsequent progression to achalasia.

Diagnosis and Treatment Strategy of Achalasia Subtypes and Esophagogastric Junction Outflow Obstruction Based on High-Resolution Manometry

“…It has shown that more than 90% of patients with type III achalasia were successfully cured by POEM with appropriate length of myotomy. Since POEM was first performed in Japan for resolving uncomplicated achalasia, its excellent outcomes allowed us to expand the range of disorders to include advanced sigmoid achalasia, failed surgical myotomy and even other spastic esophageal motility disorders [14] such as distal esophageal spasm [15] and Jackhammer esophagus [16]. The outcome of POEM for achalasia remains excellent up to 3 years after operation [12].…”

A case of ventilatory impairment during per-oral endoscopic myotomy under general anesthesia

“…Several recent reports have demonstrated its efficacy and safety [2,3]. Since then, POEM has been considered a good treatment option when the condition cannot be controlled by medication.…”

Dysphagia severity is related to the amplitude of distal contractile integral in patients with Jackhammer esophagus

“…As a consequence, therapies are still not standardized and include a broad spectrum of potential medical and surgical interventions. Certainly, this is absolutely unsatisfying, since physicians should be able to clarify potential symptom relief, especially when novel DCI decreasing therapies like peroral endoscopic myotomy are suggested for this novel diagnosis . Therefore, this study was designed to explore dysphagia and chest pain in patients with JE and to determine eventual associations between clinical presentation and manometric findings, crucial for subsequent therapies.…”