Impacto de la cardiomiotomía laparoscópica de Heller en la función del esfínter esofágico inferior y el diámetro del esófago / Impact of laparoscopic Heller cardiomyotomy on lower esophageal sphincter function and esophageal diameter

Introducción. La acalasia es un trastorno motor del esófago caracterizado por la ausencia de peristalsis y la alteración en la relajación del esfínter esofágico inferior. La cardiomiotomía laparoscópica de Heller más funduplicatura parcial es el tratamiento estándar. La mejoría sintomática ha sido bien documentada, pero no hay suficiente información objetiva respecto a los cambios fisiológicos y radiográficos luego del procedimiento. Métodos. Estudio de cohorte bidireccional de pacientes llevados a cardiomiotomía laparoscópica de Heller, entre los años 2018 y 2021, en el Hospital Universitario San Vicente Fundación de Medellín, Colombia. Se describen variables demográficas y clínicas. Se realizaron puntaje sintomático de Eckardt, manometría esofágica y radiografía de esófago en el pre y postoperatorio. Se hizo comparación de síntomas, presión basal del esfínter esofágico inferior, presión de relajación integrada y diámetro del esófago antes y después de la intervención. Resultados. Se incluyeron 24 pacientes. El 63 % fueron mujeres y la edad promedio fue de 44 años. Los valores promedio preoperatorios vs postoperatorios fueron: puntaje de Eckardt 10,6 vs 1,4 puntos (p<0,001), presión basal de 41,4 vs 18,1 mmHg (p=0,004) y presión de relajación integrada de 28,6 vs 12,5 mmHg (p=0,001). El diámetro del esófago no presentó cambios. No hubo correlación de síntomas con los cambios de presión del esfínter esofágico inferior. El tiempo de seguimiento fue de 20 meses. Conclusiones. La cardiomiotomía de Heller es un procedimiento altamente efectivo para el tratamiento definitivo de la acalasia, logrando una mejoría subjetiva y objetiva basada en síntomas y en parámetros de manometría, respectivamente

Introduction. Achalasia is a motor disorder of the esophagus characterized by the absence of peristalsis and impaired relaxation of the lower esophageal sphincter. Laparoscopic Heller ́s cardiomyotomy plus partial fundoplication is the standard treatment. Symptomatic improvement has been well documented, but there is insufficient objective information regarding physiologic and radiographic changes after the procedure. Methods. Bidirectional cohort study of patients underwent laparoscopic Heller ́s cardiomyotomy between 2018 and 2021 at the San Vicente Fundación University Hospital in Medellín, Colombia. Demographic and clinical variables are described. Eckardt symptom score, esophageal manometry, and esophageal radiography were performed pre and postoperatively. A comparison of symptoms, baseline lower esophageal sphincter pressure, integrated relaxation pressure, and esophageal diameter before and after intervention were performed.Results. 24 patients were included. 63% were women and the average age was 44 years. The preoperative vs. postoperative mean values were: Eckardt score 10.6 vs. 1.4 points (p<0.001), basal pressure of 41.4 vs. 18.1 mmHg (p=0.004) and integrated relaxation pressure of 28.6 vs. 12.5 mmHg (p=0.001). The diameter of the esophagus did not present changes. There was no correlation of symptoms with lower esophageal sphincter pressure changes. The follow-up time was 20 months. Conclusions. Heller cardiomyotomy is a highly effective procedure for the definitive treatment of achalasia, achieving subjective and objective improvements, based on symptoms and manometry parameters, respectively

Evaluating the Efficacy and Safety of Laparoscopic Heller Myotomy in Treating Achalasia

Introduction: Laparoscopic Heller myotomy (LHM) is widely recognized as the standard surgical treatment for esophageal achalasia. However, there is a lack of local data regarding the clinical characteristics of patients and the outcomes of this intervention. Methodology: This retrospective study analyzed patients who underwent LHM over an eight-year period. Demographic, operative, and postoperative variables were assessed. The Eckardt score was used to compare symptoms before and after the intervention. Continuous variables were presented as means. Results: Among the 39 patients assessed, 27 met the inclusion criteria. Of these, 51% were male, with an average age of 48 years. The average lower esophageal sphincter pressure was 36 mmHg. The mean operative time and bleeding were 133 minutes and 34 mL, respectively. The average length of the myotomy was 8.3 cm. Partial fundoplication was performed in all cases, and intraoperative endoscopy was conducted in 88% of the cases. Two intraoperative mucosal perforations occurred. The average length of hospital stay was 2.7 days. There was one medical complication but no mortality. Dysphagia significantly improved by 95%, and the mean Eckardt score decreased from 7.7 to 1.2 after surgery (p < 0.001). The average follow-up period was 24 months. Conclusion: LHM with partial fundoplication proves to be an effective and safe procedure for treating achalasia. It results in the resolution of dysphagia in 95% of cases and carries minimal morbidity. Therefore, LHM should be considered the definitive treatment of choice for achalasia.

Introducción: la miotomía de Heller laparoscópica (MHL) se considera el tratamiento quirúrgico estándar en acalasia esofágica. A nivel local se desconocen las características clínicas de los pacientes y los resultados de la intervención. Metodología: estudio retrospectivo que incluye pacientes llevados a MHL durante un periodo de 8 años. Se analizaron variables demográficas, operatorias y posoperatorias. Mediante el puntaje de Eckardt se compararon síntomas antes y después de la intervención. Las variables continuas se expresan en promedios. Resultados: 27 de 39 pacientes cumplieron los criterios de inclusión. El 51% fueron hombres y el promedio de edad fue de 48 años. La presión promedio del esfínter esofágico inferior fue de 36 mm Hg. El promedio de tiempo operatorio y sangrado fue de 133 minutos y 34 mL, respectivamente. La longitud promedio de la miotomía fue de 8,3 cm. Se adicionó funduplicatura parcial en todos los casos y en el 88% se realizó una endoscopia intraoperatoria. Se presentaron 2 perforaciones intraoperatorias de la mucosa. El promedio de estancia hospitalaria fue 2,7 días. Hubo una complicación médica y ninguna mortalidad. La disfagia mejoró en el 95% y el promedio del puntaje de Eckardt disminuyó de 7,7 a 1,2 luego de cirugía (p < 0,001). El seguimiento fue de 24 meses en promedio. Conclusión: la MHL con funduplicatura parcial es un procedimiento efectivo y seguro para el tratamiento de la acalasia. Se asocia a resolución de la disfagia en el 95% de los casos, su morbilidad es mínima y debe considerarse el tratamiento definitivo de elección.

A single-center research of peroral endoscopic myotomy for primary achalasia in patients over 60 years old / 中华消化内镜杂志

Objective:To explore the therapeutic effect of peroral endoscopic myotomy (POEM) for primary achalasia (AC) in patients aged over 60 years.Methods:Data of 146 patients aged ≥60 years (the elderly group) and 146 patients aged 18-59 years (the adult group) who received POEM from November 2010 to September 2019 at the Digestive Endoscopy Center of PLA General Hospital were retrospectively analyzed. Baseline data, surgery data, surgery-related complications and surgery-related efficacy were compared.Results:There was no significant difference in gender, Ling classification, HRM classification or previous treatment between the two groups ( P>0.05). All 292 patients successfully underwent POEM surgery. The clinical success (Eckardt score ≤3) rates in the elderly group and the adult group were 96.33% (105/109) and 96.77% (90/93), respectively with no significant difference between the two groups ( χ2=0.030， P>0.05). There was no significant difference in the length of myotomy between the two groups (7.09±2.49 cm VS 7.12±2.24 cm， t=0.472， P>0.05). Complications occurred in 26 cases (17.81%) in the elderly group and 21 cases (14.38%) in the adult group with no significant difference between the two groups ( χ2=0.634， P>0.05). There was no significant difference in the postoperative hospital stay (12.61±9.69 days VS 11.00±4.43 days, t=1.825, P>0.05) or the incidence of gastroesophageal reflux [43.33% (13/30) VS 51.52% (17/33), χ2=0.422, P>0.05] between the elderly group and the adult group. Conclusion:The efficacy of POEM for AC patients over 60 years old is equivalent to that of adult patients, and the incidence of complications is similar. POEM is safe and effective for AC patients over 60 years old.

Peroral endoscopic myotomy for achalasia: safety profile, complications and results of 94 patients / Miotomia endoscópica peroral para acalásia: perfil de segurança, complicações e resultados de 94 pacientes

ABSTRACT BACKGROUND: Achalasia is an esophageal motility disorder, with clinical presentation of dysphagia and regurgitation. This is a chronic condition with no cure. Current treatment options aim to reduce lower esophageal sphincter tone by pharmacological, endoscopic or surgical means, with the aim of improving patients' symptoms. Peroral endoscopic myotomy (POEM) is an alternative endoscopic surgery to Heller cardiomyotomy, in which the procedure is performed orally, by endoscopy, offering efficacy comparable to surgical myotomy, with relative ease and minimal invasion, without external incisions. AIMS: To study the safety of POEM by analyzing its results, adverse events and perioperative complications and the main ways to overcome them, in addition to evaluating the effectiveness of the procedure and the short-term postoperative quality of life. METHODS: A qualitative and quantitative, observational and cross-sectional study that analyzed patients who underwent the POEM in a reference center, from December 2016 to December 2022, maintaining the technical standard of pre-, peri- and postoperative protocol. RESULTS: A total of 94 patients were included in the study, and only three had postoperative complications. The average early postoperative Eckardt score was 0.93 and the late 1.40, with a mean improvement of 7.1 in early results and 6.63 in late results (p<0.05). CONCLUSIONS: POEM can be reproduced with an excellent safety profile, significant relief of symptoms and improvement in esophageal emptying, and in quality of life.

RESUMO RACIONAL: A acalasia é uma desordem da motilidade esofágica, com apresentação clínica de disfagia e regurgitação, uma condição crônica sem cura. As opções de tratamentos atuais visam reduzir o tônus do esfíncter esofagiano inferior (EEI) por meios farmacológicos, endoscópicos ou cirúrgicos, com o objetivo de aliviar os sintomas dos pacientes. A miotomia endoscópica peroral, sigla do inglês (POEM) é uma cirurgia endoscópica alternativa à cardiomiotomia a Heller (CH), em que a miotomia é realizada por via oral, por endoscopia, oferecendo eficácia comparável a miotomia cirúrgica, com relativa facilidade e mínima invasão, sem incisões externas. OBJETIVOS: Analisar a segurança do POEM analisando seus resultados, eventos adversos, complicações perioperatórias e suas principais formas de contorná-los, além de avaliar a eficácia do procedimento e a qualidade de vida pós-operatória, em curto prazo. MÉTODOS: Estudo qualitativo e quantitativo, observacional e transversal avaliando pacientes que realizaram o POEM em um centro de referência, entre dezembro de 2016 até dezembro de 2022, mantendo padrão técnico de preparo pré, peri e pós-operatório. RESULTADOS: Foram incluídos no estudo 94 pacientes e apenas 3 apresentaram complicações pós-operátorias. O escore de Eckardt médio precoce pós-operatório foi de 0,93 e o tardio de 1,40, com melhora média de 7,1 em resultados precoces e de 6,63 em resultados tardios (p<0,05). CONCLUSÕES: O POEM pode ser reproduzido com excelente perfil de segurança, alívio significativo dos sintomas e melhora do esvaziamento do esôfago, oferecendo melhora na qualidade de vida.

Management of symptoms recurrence after myotomy for achalasia. a practical approach / Manejo da recidiva de sintomas após miotomia para acalasia. uma abordagem prática

ABSTRACT BACKGROUND: Achalasia is an esophageal motility disorder, and myotomy is one of the most used treatment techniques. However, symptom persistence or recurrence occurs in 9 to 20% of cases. AIMS: This study aims to provide a practical approach for managing the recurrence or persistence of achalasia symptoms after myotomy. METHODS: A critical review was performed to gather evidence for a rational approach for managing the recurrence or persistence of achalasia symptoms after myotomy. RESULTS: To properly manage an achalasia patient with significant symptoms after myotomy, such as dysphagia, regurgitation, thoracic pain, and weight loss, it is necessary to classify symptoms, stratify severity, perform appropriate tests, and define a treatment strategy. A systematic differential diagnosis workup is essential to cover the main etiologies of symptoms recurrence or persistence after myotomy. Upper digestive endoscopy and dynamic digital radiography are the main tests that can be applied for investigation. The treatment options include endoscopic dilation, peroral endoscopic myotomy, redo surgery, and esophagectomy, and the decision should be based on the patient's individual characteristics. CONCLUSIONS: A good clinical evaluation and the use of proper tests jointly with a rational assessment, are essential for the management of symptoms recurrence or persistence after achalasia myotomy.

RESUMO RACIONAL: A acalasia é um distúrbio da motilidade esofágica e a miotomia é uma das técnicas de tratamento mais utilizadas. No entanto, a persistência ou recorrência dos sintomas ocorre em 9 a 20%. OBJETIVOS: Este estudo visa fornecer uma abordagem prática para o manejo da recorrência ou persistência dos sintomas de acalasia após miotomia. MÉTODOS: Foi realizada uma revisão crítica para reunir evidências para uma abordagem racional no manejo da recorrência ou persistência dos sintomas de acalasia após miotomia. RESULTADOS: Para o manejo adequado de um paciente com acalásia com sintomas significativos após miotomia, como disfagia, regurgitação, dor torácica e perda de peso, é necessário classificar os sintomas, estratificar a gravidade, realizar exames adequados e definir uma estratégia de tratamento. Uma investigação diagnóstica diferencial sistemática é essencial para cobrir as principais etiologias de recorrência ou persistência dos sintomas após a miotomia. A endoscopia digestiva alta e a radiografia digital dinâmica são os principais exames que podem ser aplicados para investigação. As opções de tratamento incluem dilatação endoscópica, POEM (miotomia endoscópica oral), remiotomia e esofagectomia, e a decisão deve ser baseada nas características individuais do paciente. CONCLUSÕES: Uma boa avaliação clínica e a utilização de exames adequados, juntamente com uma avaliação racional, são essenciais para o manejo da recorrência ou persistência dos sintomas após miotomia por acalasia.

Peroral endoscopic myotomy for the treatment of achalasia in the Unified Healthcare System (SUS): results of a short-term / Miotomia endoscópica peroral para o tratamento de acalásia no Sistema Único de Saúde (SUS): resultados de seguimento no curto-prazo

ABSTRACT Introduction: achalasia is a chronic disease. Since there is no curative treatment, diagnosed patients have pharmacological and/or surgical techniques available, aimed at minimizing the condition. POEM appears as a promising new type of palliative treatment with good rates of symptom improvement. Objective: evaluate the profile of POEM at the Clinical Hospital of the Federal University of Pernambuco (HC - UFPE) and correlate it with the world scenario. Methods: data collection was performed retrospectively from September 2017 to October 2019 with all patients undergoing POEM at the HC - UFPE. Sociodemographic, clinical, and hospital variables were evaluated before and three months after the procedure. Results: of 27 patients (52.41 ± 19.24 years old) who underwent the procedure, 66.7% had idiopathic etiology and 33.3% had etiology secondary to Chagas disease. 48% patients underwent previous procedures, of which seven used some type of medication for symptom control, two underwent pneumatic endoscopic dilation, and four underwent Heller cardiomyotomy with partial fundoplication. 62.5% of the evaluated patients had type II achalasia before the procedure. Seven (25.9%) patients presented the following adverse events: four presented bleeding, two pneumoperitoneum, and one both complications, all being treated conservatively. The Eckardt score reduced from 8.37 ± 1.45 to 0.85 ± 1.06 (p-value <0.001). Conclusion: clinical improvement of symptoms and the patient profile followed the worldwide trend, with emphasis on the etiology secondary to Chagas disease, endemic in Brazil. Gastroesophageal reflux remains the main post-operative symptom.

RESUMO Introdução: a acalasia é uma doença crônica. Por não haver tratamento curativo, os pacientes diagnosticados dispõem de técnicas farmacológicas e/ou cirúrgicas, visando minimizar o quadro. A POEM surge como um novo tipo de tratamento paliativo promissor com boas taxas de melhora dos sintomas. Objetivo: avaliar o perfil das POEM realizadas no Hospital das Clínicas da Universidade Federal de Pernambuco (HC - UFPE) e correlacioná-lo com o cenário mundial. Métodos: a coleta de dados foi realizada retrospectivamente no período de setembro de 2017 a outubro de 2019 com todos os pacientes submetidos a POEM no HC - UFPE. Variáveis sociodemográficas, clínicas e hospitalares foram avaliadas antes e três meses após o procedimento. Resultados: total de 27 pacientes (52,41 ± 19,24 anos) que realizaram o procedimento, 66,7% com etiologia idiopática e 33,3% com etiologia secundária à doença de Chagas. 48% tinham sido submetidos a procedimentos prévios, dos quais sete usaram algum tipo de medicamento para controle dos sintomas, dois foram submetidos à dilatação endoscópica pneumática e quatro à cardiomiotomia a Heller com fundoplicatura parcial. 62,5% dos pacientes avaliados tinham acalasia tipo ii antes do procedimento. Sete (25,9%) apresentaram eventos adversos: quatro sangramentos, dois pneumoperitônio e um ambas as complicações, todos foram tratados de forma conservadora. O escore de Eckardt reduziu de 8,37 ± 1,45 para 0,85 ± 1,06 (valor de p<0,001). Conclusão: melhora clínica e o perfil dos pacientes acompanhou a tendência mundial, destaque para a etiologia secundária à doença de Chagas, endêmica no Brasil. O refluxo gastroesofágico continua sendo o principal sintoma pós-operatório.

Abdominal esophagocardiectomy with esophagogastric anastomosis, with vagal preservation and construction of a spiral anti reflux valve in the treatment of advanced megaesophagus / Esofagocardiectomia abdominal com esofagogastro anastomose, com preservação vagal e construção de válvula antirrefluxo em espiral no tratamento do megaesôfago avançado

ABSTRACT Objective: present a new operative technique characterized by abdominal esophagocardiectomy, with esophagogastrus anastomosis, vagal preservation and spiral anti-reflux valve construction in the treatment of advanced megaesophagus in patients with severe systemic diseases, as well as its result in an initial group of 17 patients. Method: We selected 17 patients with advanced megaesophagus and comorbidities submitted to new technique. The following parameters were analyzed: age, sex, length of hospital stay, early and late complications, mortality, radiological/endoscopic aspects. Results: twelve male patients (70%) and five (30%) were operated on, with mean age of 51.5 years and mean hospital stay of 14.8 days. There was no mortality in the immediate intraoperative or postoperative period and there were no cases of postoperative fistula. During hospitalization there was one case of pulmonary atelectasis (5.8%), one of pleural effusion (5.8%), two of wall infection (11.7%) and one of urinary retention (5.8%). Discussion: We believe it to be an easy technique, made exclusively by the abdominal route, that is, without violating the thoracic cavity. Such a procedure would be beneficial in patients with advanced megaesophagus and important comorbidities, as well as in those with a history of previous surgeries. Conclusion: the technique described was easy to perform and safe, when performed by an experienced team, with low morbidity and mortality in patients with advanced megaesophagus and important comorbidities, which could increase your complications with more invasive and complex surgeries.

RESUMO Objetivo: apresentar uma nova técnica caracterizada por esofagocardiectomia abdominal com esofagogastro anastomose, preservação vagal e construção de válvula antirrefluxo em espiral no tratamento do megaesôfago avançado de pacientes com doenças sistêmicas graves, assim como seu resultado em grupo inicial de 17 pacientes. Método: foram selecionados 17 pacientes com megaesôfago avançado e comorbidades submetidos a nova técnica. Os seguintes parâmetros analisados foram: idade, sexo, tempo de permanência hospitalar, complicações precoces e tardias, mortalidade, aspectos radiológicos/endoscópicos. Resultados: foram operados 12 (70%) pacientes do sexo masculino e 5 (30%) do sexo feminino, com idade média foi de 51,5 anos e tempo de permanência hospitalar médio de 14,8 dias. Não houve mortalidade no intraoperatório ou pós-operatório imediato e não houve casos de fìstula. Durante a internação houve um caso de atelectasia pulmonar (5,8%), um de derrame pleural (5,8%), dois de infecção de parede (11,7%) e um de retenção urinária (5,8%). Discussão: acreditamos ser uma técnica de fácil realização, feita exclusivamente por via abdominal, ou seja, sem violar a cavidade torácica. Tal procedimento seria benéfico em pacientes com megaesôfago avançado e comorbidades importantes, assim como naqueles com história de cirurgias prévias. Conclusão: a técnica descrita mostrou-se de fácil execução e segura, quando realizada por equipe experiente, com baixa morbimortalidade em pacientes com megaesôfago avançado e comorbidades importantes, o que poderia aumentar suas complicações com cirurgias mais invasivas e complexas.

Comparison between double-tunnel and traditional peroral endoscopic myotomy for achalasia cardia / 中华消化内镜杂志

Objective:To evaluate the long-term efficacy of double-tunnel peroral endoscopic myotomy (POEM) and traditional POEM in the treatment of achalasia cardia.Methods:A randomized controlled trial was performed on the data of 30 patients with achalasia cardia, who underwent POEM in the First Affiliated Hospital of Nanjing Medical University from June 2018 to June 2019. The 30 consecutive patients were randomly assigned to double-tunnel POEM group (15 cases, a second tunnel was established opposite to the traditional one) and traditional POEM group (15 cases). Intraoperative information was recorded, and patients were followed up regularly to compare the efficacy and complications between the two groups.Results:Double-tunnel POEM and traditional POEM were all completed with technical success. There were no significant differences in the intraoperative complications (5/15 VS 4/15, P=1.000), hospitalization time or cost between the two groups. The follow-up time was 17.20±4.83 months and 15.33±4.67 months in the traditional POEM group and the double-tunnel POEM group, respectively. The Eckardt scores after surgery between the two groups had no significant difference [1.53 (2.00) VS 1.60 (3.00), Z=-0.363, P=0.744]. The symptom relief cases were both 14 in the two groups. The postoperative 4-second integrated relaxation pressure (4 s IRP) of the double-tunnel group (11.27±3.14 mmHg) was significantly lower than that of the traditional group (15.05±4.21 mmHg, t=2.794, P=0.009). There was no significant difference in postoperative gastroesophageal reflux disease questionnaire scores between the two groups (4.40±1.64 VS 4.20±1.42, t=0.357, P=0.724). Conclusion:Double-tunnel POEM has almost the same efficacy as the traditional POEM except for a lower post-POEM 4 sIRP.

Sintomas associados aos diferentes graus de megaesôfago na doença de Chagas / Symptoms associated with different degrees of megaesophagus in chagas disease

ABSTRACT BACKGROUND: Dysphagia is the most frequent digestive symptom in Chagas disease, although other symptoms are reported. These symptoms can be associated with the degree of radiological impairment of the esophagus and the duration of dysphagia. OBJECTIVE: This investigation aimed to assess the symptoms and the time of dysphagia related to the different degrees of megaesophagus in patients with Chagas disease. METHODS: A total of 29 patients aged 48 to 73 years participated in this investigation. All of them had dysphagia and a positive serum result for Chagas disease. They were submitted to the assessment of symptoms and radiological examination of the esophagus to assess the degree of megaesophagus, which ranged from I (mild change) to IV (intense change). Dysphagia was quantified with the Eating Assessment Tool (EAT-10). RESULTS: Twelve (41%) patients had megaesophagus degree I, 9 (31%) had degree II, and 8 (28%) had degrees III (6) and IV (2). The intensity of dysphagia was not related to the result of the radiological examination, with EAT-10 median of 5.5 for the degree I, 9.0 for degree II, and 5.5 for degrees III and IV (P>0.25). Choking (14%), regurgitation (21%), voice complaint (21%), weight loss (17%), and odynophagia (17%) were not related to the degree of megaesophagus. Voice changes and odynophagia were related to the patients' time of dysphagia. Likewise, the frequency of symptoms and EAT-10 values were related to the duration of dysphagia. CONCLUSION: The longer the patient had dysphagia, the more frequent were the symptoms reported by the patients. There was no relationship between the degrees of megaesophagus and the symptoms and intensity of dysphagia.

RESUMO CONTEXTO: Disfagia é o mais frequente sintoma digestivo da doença de Chagas; entretanto, outros sintomas podem ser referidos. Esses sintomas podem ser associados ao grau de comprometimento radiológico do esôfago e à duração da disfagia. OBJETIVO: Avaliar os sintomas e o tempo de disfagia relacionados com os diferentes graus de megaesôfago em pacientes com doença de Chagas. MÉTODOS: Participaram da investigação 29 pacientes com idades entre 48 e 73 anos, todos com disfagia e teste sorológico positivo para doença de Chagas. Eles foram submetidos à avaliação de sintomas e exame radiológico do esôfago para avaliar o grau de megaesôfago, que variou de I (alteração discreta) a IV (alteração intensa). Disfagia foi quantificada pelo método Eating Assessment Tool (EAT-10). RESULTADOS: Doze (41%) pacientes apresentaram grau I de megaesôfago, 9 (31%) grau II, e 8 (28%) graus III/IV. A intensidade da disfagia não foi relacionada com o resultado do exame radiológico, com a mediana do EAT-10 de 5,5 para o grau I, 9,0 para o grau II, e 5,5 para os graus III/IV (P>0,25). Engasgo (14%), regurgitação (21%), queixa vocal (21%), perda de peso (17%), e odinofagia (17%) não foram relacionados ao grau de megaesôfago. Houve relação entre alteração vocal e odinofagia com o tempo que os pacientes tinham disfagia. Houve relação entre frequência de sintomas e valores do EAT-10 com a duração da disfagia. CONCLUSÃO: Quanto mais longo o tempo que o paciente tem disfagia maior a frequência de sintomas referidos pelos pacientes. Não há relação entre graus de megaesôfago com os sintomas e a intensidade da disfagia.

Esofagitis eosinofílica y acalasia esofágica / Eosinophilic esophagitis and esophageal acalasia

Introducción: La esofagitis eosinofílica es una enfermedad emergente, caracterizada por infiltración del esófago por leucocitos eosinófilos. Sus principales síntomas son la disfagia y las frecuentes impactaciones de alimento en el esófago. Actualmente existen evidencias científicas que reconocen la enfermedad como causa posible de evolución no favorable en pacientes después de miotomía de Héller. Objetivo: Describir las evidencias biomoleculares que asocian la esofagitis eosinofílica y la acalasia esofágica. Métodos: Se realizó una revisión sistemática y crítica de las evidencias sobre los mecanismos biomoleculares asociados a la esofagitis eosinofílica y la acalasia esofágica. Se consultaron artículos publicados entre 2015 y 2020 e indexados en las bases de datos PubMed, SciELO, LILACS y Scopus. Análisis e integración de la información: Se discute sobre cuestiones medulares que han sido publicadas recientemente respecto al tema en cuestión. ¿Pueden coexistir la esofagitis eosinofílica y la acalasia esofágica? ¿Influye la esofagitis eosinofílica en el resultado del tratamiento de la acalasia esofágica? ¿Qué investigaciones serían necesarias para establecer la relación entre las dos enfermedades? Conclusiones: Los mecanismos celulares y biomoleculares desencadenados por la infiltración eosinofílica contextualizan la diferencia etiológica y fisiopatológica de la esofagitis eosinofílica y la acalasia esofágica, lo cual sustenta la evolución desfavorable posmiotomía de los pacientes y motiva la realización de estudios prospectivos y controlados con el fin de ofrecer una mejor calidad de vida(AU)

Introduction: Eosinophilic esophagitis is an emerging disease characterized by infiltration of the esophagus by eosinophilic leukocytes. Its main symptoms are dysphagia and frequent food impaction in the esophagus. Scientific evidence is now available that recognizes the disease as the possible cause of unfavorable evolution in patients undergoing Heller myotomy. Objective: Describe the biomolecular evidence associating eosinophilic esophagitis to esophageal achalasia. Methods: A systematic critical review was conducted of the evidence about biomolecular mechanisms associated to eosinophilic esophagitis and esophageal achalasia. The articles consulted were published in the databases PubMed, SciELO, LILACS and Scopus from 2015 to 2020. Data analysis and integration: A discussion is provided about crucial questions published recently concerning the study topic: Can eosinophilic esophagitis and esophageal achalasia coexist? Does eosinophilic esophagitis influence the result of esophageal achalasia treatment? What studies are required to establish the relationship between the two conditions? Conclusions: The cellular and biomolecular mechanisms triggered by eosonophilic infiltration contextualize the etiological and pathophysiological difference between eosinophilic esophagitis and esophageal achalasia. This explains the unfavorable post-myotomy evolution of patients and encourages the conduct of prospective controlled studies aimed at enhancing quality of life(AU)

Peroral endoscopic myotomy in a pediatric patient with refractory achalasia: a case report and review of the literature

A 15-year-old male patient presented with dysphagia, regurgitation, weight loss and retrosternal pain. The diagnosis of achalasia was made 4 years before. The esophagogram revealed severe esophagus dilatation and the classic "bird-beak" termination. A Heller myotomy plus fundoplication and endoscopic balloon dilatation were conducted four months previously. Nevertheless, the symptoms persisted and the last high-resolution manometry study still showed achalasia type II. The patient underwent a peroral endoscopic esophageal myotomy (POEM). POEM is a feasible and safe procedure for experienced and properly- equipped health care delivery centers and could be used as a rescue treatment in refractory achalasia. We present the youngest patient with achalasia in our region who had a successful response to rescue POEM.

Un paciente varón de 15 años, con el diagnóstico de acalasia realizado 4 años antes, acudió a evaluación por presentar disfagia, regurgitación, pérdida de peso y dolor restroesternal. El esofagograma baritado evidenció una dilatación severa del esófago y la terminación clásica en "pico de pájaro". El paciente había sido sometido a una miotomía de Heller más fundoplicatura y posteriormente a una dilatación esofágica con balón 4 meses atrás. Sin embargo, los síntomas persistían y la última manometría de alta resolución reveló acalasia tipo II. Finalmente, se realizó una miotomía endoscópica por vía oral (POEM); el cual es un procedimiento seguro y accesible en centros experimentados y debidamente equipados, pudiendo ser una adecuada opción de tratamiento en casos de acalasia refractaria. Presentamos el caso del paciente más joven en nuestra región con acalasia con una respuesta exitosa a un POEM de rescate.

Surgical treatment of relapsed megaesophagus / Tratamento cirúrgico do megaesôfago recidivado

ABSTRACT Objective: to analyze the surgical treatment of patients with recurrent megaesophagus followed at the esophageal-stomach-duodenal outpatient clinic of the Hospital de Clínicas - UNICAMP. Methods: a retrospective study, from 2011 to 2017, with 26 patients with Chagas or idiopathic megaesophagus, surgically treated, and who recurred with dysphagia. Clinical, endoscopic and radiographic aspects were assessed and correlated with the performed surgical procedures. Results: 50% had dysphagia for liquids, 69% regurgitation, 65.3% heartburn, 69.2% weight loss and 69.2% had Chagas disease. In addition, 38.4% had megaesophagus stage 1 and 2 and 61.5% stage 3 and 4. Regarding the reoperations, 53% of them underwent Heller-Pinotti surgery by laparoscopy, Serra-Dória in 30.7% and esophageal mucosectomy in 7.9%. In 72% of the reoperations there were no postoperative complications, and 80% of the patients had a good outcome, with reduction or elimination of dysphagia. Among the reoperated patients undergoing the laparoscopic Heller-Pinotti technique, three reported little improvement of dysphagia in the postoperative period and among those who underwent Serra-Dória surgery, 100% had no dysphagia. It was observed that, when the time between the first procedure and the reoperation was longer, the better the surgical result was, with statistical significant decreased dysphagia (p=0.0013, p<0.05). Conclusions: there was a preference to perform laparoscopic re-miotomy and, as a second option, Serra-Dória surgery, for patients with recurrent megaesophagus. Esophagectomy or esophageal mucosectomy were reserved for more severe patients.

RESUMO Objetivo: analisar o tratamento cirúrgico dos pacientes com megaesôfago recidivado acompanhados no ambulatório de cirurgia de esôfago-estômago-duodeno do Hospital de Clínicas da UNICAMP. Métodos: estudo restrospectivo no período de 2011 a 2017, com 26 pacientes portadores de megaesôfago chagásico ou idiopático, tratados cirurgicamente e que evoluíram com recidiva da disfagia. Foram avaliados aspectos clínicos, endoscópicos e radiográficos, sendo correlacionados com os procedimentos cirúrgicos realizados. Resultados: 50% apresentava disfagia para líquidos, 69% regurgitação, 65,3% pirose, 69,2% perda de peso e 69,2% era chagásico. Além disso, 38,4% apresentavam megaesôfago estágio 1 e 2 e 61,5% estágio 3 e 4. Quanto às reoperações, em 53% foi realizada a cirurgia de Heller-Pinotti videolaparoscópica, seguida de Serra-Dória em 30,7% e mucosectomia esofágica em 7,9%. Em 72% das reoperações não houve complicações pós-operatórias e 80% tiveram evolução satisfatória com redução ou ausência da disfagia. Dentre os pacientes reoperados pela técnica de Heller-Pinotti videolaparoscópica, três referiram pouca melhora da disfagia no pós-operatório. Dentre os pacientes submetidos à cirurgia de Serra-Dória, 100% tiveram evolução satisfatória da disfagia. Foi observado nos pacientes com o tempo entre a primeira cirurgia e a reoperação mais longo, um melhor resultado cirúrgico com diminuição da disfagia, com relevância estatística (p=0,0013, p<0,05). Conclusão: houve preferência nas reoperações de megaesôfago pela realização de re-miotomia por videolaparoscopia e, como segunda opção, a cirurgia de Serra-Dória. A esofagectomia ou mucosectomia esofágica foram reservadas para os casos mais avançados.

Clinical features of different subtypes of esophageal achalasia / 中华全科医师杂志

Esophageal achalasia is a rare digestive disease. The pathogenesis of achalasia is still elusive. The main symptoms of achalasia are dysphagia, regurgitation, chest pain and weight loss. Three subtypes are defined in the Chicago Classification 3.0, and each subtype has unique clinical features and treatment consideration. This article will review the clinical features of three subtypes of esophageal achalasia.

Calidad de vida y evolución clínica después de miotomía de Heller con fundoplicatura de Dor / Quality of Life and Clinical Evolution after Heller Myotomy plus Dor fundoplication

RESUMEN Introducción: La miotomía de Heller laparoscópica es considerada en la actualidad el tratamiento de elección para el alivio de la disfagia. Se ha demostrado que gracias a ella se logra una baja incidencia de reflujo gastroesofágico y una mejoría evidente de la calidad de vida Objetivo: Evaluar la calidad de vida y evolución clínica de los pacientes después de la miotomía de Heller con fundoplicatura de Dor. Método: Estudio observacional descriptivo longitudinal prospectivo mediante la aplicación del cuestionario de índice de calidad de vida gastrointestinal a pacientes operados de acalasia esofágica desde enero del 2010 hasta diciembre del 2017 en el Centro Nacional de Cirugía de Mínimo Acceso. Se aplicó un cuestionario en el preoperatorio y al año de operados. Análisis estadístico: Porcentajes para variables cualitativas, media ± desviación estándar o mediana y rango según corresponda para las cuantitativas, para la comparación de los resultados del cuestionario se emplearon pruebas de hipótesis de comparación de medias, con nivel de significación estadística α= 0,05. Resultados: Fueron incluidos en el estudio 101 pacientes. Las edades oscilaban entre 18 y 78 años con una media de 47 años. El tiempo medio de evolución de los síntomas fue de 62 meses, con una media de 3,3 en la escala de disfagia y una presión de reposo del esfínter esofágico inferior (mmHg) 38,7 ± 16,8, se obtuvo un GIQLI inicial de 85,3 ± 20,4 que aumentó al año a 131,6 ± 10,5 Conclusiones: La miotomía de Heller con fundoplicatura de Dor, mejora la calidad de vida de los pacientes con acalasia esofágica con una evolución clínica excelente(AU)

ABSTRACT Introduction: Laparoscopic Heller myotomy is now considered the treatment of choice for the relief of dysphagia. It has been shown that thanks to it a low incidence of gastroesophageal reflux and evident improvement in the quality of life is achieved. Objective: To evaluate the quality of life and clinical evolution of patients after Heller myotomy plus Dor fundoplication. Method: Prospective, longitudinal, descriptive, observational study carried out by applying the Gastrointestinal Quality of Life Index (GIQLI) questionnaire to patients operated on for esophageal achalasia, from January 2010 to December 2017, at the National Center for Minimum Access Surgery. The questionnaire was applied preoperatively and one year after surgery. Statistical analysis: Percentages for qualitative variables, mean and standard deviation, or median and range, as appropriate for quantitative variables. For the comparison of the results of the questionnaire, we used tests of hypothesis of comparison of means, with statistical significance level of 0.05. Results: The ages ranged between 18 and 78 years, with an average of 47 years. The mean time of evolution of symptoms was 62 months, with an average of 3.3 on the dysphagia scale and a resting pressure of the lower esophageal sphincter (mmHg) 38.7±16.8. An initial gastrointestinal quality of life index of 85.3±20.4 was obtained, which increased to 131.6±10.5 per year. Conclusions: Heller myotomy plus Dor fundoplication improves the quality of life of patients with esophageal achalasia and guarantees an excellent clinical evolution(AU)

Agreement between upper endoscopy and esophagography in the diagnosis of megaesophagus in Chagas disease

Abstract INTRODUCTION The diagnosis and classification of megaesophagus can be challenging in patients with Chagas disease. The present study aimed to evaluate the agreement between upper endoscopies and esophagographies for the diagnosis and classification of megaesophagus in Chagas disease. METHODS: A cross-sectional study of 50 patients with Chagas disease with upper digestive symptoms was undertaken. Esophagography and upper endoscopy exams were performed to compare diagnoses. Statistical analysis included sensitivity and specificity used to evaluate the diagnostic accuracy of upper endoscopies, and measures of agreement: linearly weighted Kappa (κw) and Cohen`s classical Kappa (κ) coefficients with 95% confidence intervals (95% CI). RESULTS: Twenty-three patients (46%) were diagnosed with megaesophagus by esophagography. The upper endoscopy sensitivity and specificity for megaesophagus diagnosis were 100% and 33.3%, respectively. Regarding megaesophagus classifications, there was a substantial agreement between the two exams (κw = 0.622; 95% CI: 0.498 to 0.746). Within megaesophagus groups, agreement for group I was slight (κ = 0.096; 95% CI: 0.000 to 0.403); for group II, substantial (κ = 0.703; 95% CI: 0.456 to 0.950); and for groups III and IV, inconclusive (κ = 0.457; 95% CI: 0.000 to 0.967; κ = 0.540; 95% CI: 0.035 to 1.000, respectively). CONCLUSIONS Upper endoscopy has a high sensitivity, but a low specificity to diagnose megaesophagus. Agreement between the two exams varies depending on the megaesophagus grade. Thus, upper endoscopy can be used in the diagnostic workup of a possible Chagas disease megaesophagus, but all identified cases should undergo esophagography.

Miotomía endoscópica por vía oral (POEM) en un paciente pediátrico para tratamiento de la acalasia esofágica / Per oral endoscopic myotomy in a pediatric patient with achalasia

INTRODUCCIÓN: La acalasia es el trastorno motor primario más frecuente del esófago. Su incidencia reportada es baja, aún más en pacientes pediátricos. La miotomía de Heller laparoscópica corresponde al estándar actual de tratamiento. Durante los últimos años la miotomía endoscópica por vía oral (POEM) se ha posicionado como una alternativa terapéutica segura y tan efectiva como el Heller para la acalasia esofágica. OBJETIVO: Describir la técnica de POEM y reportar el primer caso pediátrico en nuestro país. CASO CLÍNICO: Paciente de 11 años, previamente sano, que se presentó con disfagia ilógica progresiva y baja de peso. El estudio concluyó una acalasia tipo II. Fue sometido a POEM y cursó un postoperatorio sin incidentes. A un año de la intervención se ha documentado resolución de la sintomatología, seguimiento endoscópico y manométrico sin complicaciones. CONCLUSIONES: El caso descrito corresponde al primer POEM en un paciente pediátrico en nuestro país. La acalasia esofágica es infrecuente en pediatría y el POEM ha demostrado éxito clínico y seguridad comparables a la miotomía de Heller laparoscópica en el corto y mediano plazo. El seguimiento a largo plazo permitirá determinar su rol definitivo en el tratamiento de pacientes pediátricos con acalasia esofágica.

INTRODUCTION: Achalasia is the most common primary motor disorder of the esophagus. Its reported incidence is low, even more in pediatric patients. Laparoscopic Heller myotomy is the current stan dard of treatment. During the last years, per-oral endoscopic myotomy (POEM) has been positioned as a safe and effective therapeutic alternative as the Heller procedure for esophageal achalasia. OBJECTIVE: To describe the POEM technique and report the first pediatric case in our country. CLINICAL CASE: 11-year-old patient, previously healthy, who presented with progressive dysphagia for solids and liquids and weight loss. The study concluded a type II achalasia. The patient underwent a POEM and had a postoperative course without incidents. One year after the intervention, symptomatic, endoscopic and manometric resolution have been documented. CONCLUSIONS: The described case is the first POEM in a pediatric patient in our country. Esophageal achalasia is uncommon in pediatrics and POEM has demonstrated clinical success and safety comparable to laparoscopic Heller myotomy in short and medium term. Long-term follow-up will determine its definitive role in the treatment of pediatric patients with esophageal achalasia.

Acalasia, una visión actual / Achalasia, a current view

La palabra 'acalasia' es un neologismo de origen griego, acuñado por el médico inglés Sir Edwin Cooper en 1913, y significa: sin calidad de relajación. La acalasia es una enfermedad que se manifiesta clínicamente por disfagia para sólidos y para líquidos, regurgitación esofágica, dolor retroesternal, tos, broncoaspiración, neumonía, acidez estomacal y pérdida de peso. Su fisiopatología corresponde a la ausencia de peristalsis esofágica e insuficiente relajación del esfínter esofágico inferior. Estas anormalidades motoras se deben a la pérdida de las neuronas mientéricas que coordinan la peristalsis esofágica y la relajación del esfínter esofágico inferior. Fue descrita por primera vez por Sir Thomas Willis en 1674. Aunque actualmente se considera idiopática, se han comenzado a considerar como posibles causas las alteraciones autoinmunitarias y la predisposición genética; además, las infecciones por virus herpes y por virus herpes zóster se han implicado como causas probables. Su incidencia anual oscila entre 0,3 y 1,63 por 100.000 personas en adultos, con una prevalencia anual de 10 en 100.000 habitantes. Afecta por igual a los dos sexos, y el grupo etario más afectado es el de 30 a 60 años. El diagnóstico se sospecha por los síntomas que presenta el paciente, de los cuales la disfagia es el más importante. Se confirma por medio de la endoscopia de las vías digestivas altas, el esofagograma y la manometría de alta resolución. El tratamiento sigue siendo paliativo y se puede orientar por el subtipo de acalasia, según la clasificación de Chicago. Los mejores resultados se obtienen mediante las técnicas de dilatación neumática, miotomía laparoscópica de Heller y, más recientemente, mediante la miotomía endoscópica peroral (Per-Oral Endoscopic Myotomy, POEM), descrita por Haruhiro Inoue en Japón en el año 2008. Aún faltan estudios prospectivos aleatorizados con seguimiento a largo plazo para determinar cuál es la mejor técnica. Se presenta una revisión actualizada del tema

The word achalasia is a neologism of Greek origin, coined by the English physician Sir Edwin Cooper in 1913, and means no quality of relaxation. Achalasia is a disease clinically manifested by dysphagia with both solids and liquids, esophageal regurgitation, retrosternal pain, cough, bronchial aspiration, pneumonia, heartburn and weight loss. Physiopathologically it corresponds to the loss of esophageal peristalsis and to an insufficient relaxation of the lower esophageal sphincter (LES). These motor abnormalities are due to the loss of myenteric neurons that coordinate esophageal peristalsis and relaxation of the LES. First described by Sir Thomas Willis in 1674, and although it is currently considered idiopathic, it has begun to be considered as possible causes autoimmune components and genetic predisposition; viral infections by herpes and chickenpox zoster have also been implicated as probable causes. Its incidence ranges from 0.3 to 1.63 per 100,000 adults, with a prevalence of 10 in 100,000 inhabitants per year. It affects equally any gender, and the age group between 30 and 60 years is the most affected. The diagnosis is suspected based on the symptomatology, with dysphagia being the most important symptom. It is confirmed with the performance of endoscopy of the upper digestive tract, esophagogram and high resolution manometry. The treatment remains palliative, and may be guided by the subtype of achalasia, according to the Chicago classification. The best results are obtained by the techniques of pneumatic dilation, Heller's laparoscopic myotomy, and more recently by the POEM technique (per oral endoscopic myotomy), described in 2008 in Japan by Haruhiro Inoue. There is still a lack of prospective randomized studies with long-term follow-up that determine which is the best technique. An updated review of the subject is presented

Practice guideline of peroral endoscopic myotomy of achalasia: Zhongshan experience / 中华胃肠外科杂志

Peroral endoscopic myotomy (POEM) is a novel clinical technique developed in 2010, and has been widely accepted for treating achalasia and esophageal motility disorders, because of its minimal invasiveness and good efficacy. Zhongshan Hospital has published the practice guideline (the "Zhongshan experience") of peroral endoscopic myotomy of achalasia (v1.2018) based on experience combined with literatures. (1) Preoperative evaluation includes clinical symptom assessment, gastroscopy, high-resolution manometry and upper gastrointestinal radiography. (2) Absolute indication is idiopathic achalasia, and age is no longer a contraindication. (3) The criteria include the medical centers with legal qualifications and the operators with over 5 years of clinical experience in gastroenterological surgery or gastroenterology and more than 30 cases of esophageal endoscopic submucosal dissection (ESD). (4) The length of the myotomy is 8 to 10 cm. The recommended location of the myotomy is the anterior or posterior wall. Whether a full-thickness or circular muscle myotomy is chosen is based on patient′s condition. (5) If pleural effusion, atelectasis or pneumothorax occurs, CT examination is recommended during the postoperative period. If patients presents with symptoms such as vomiting and high fever, endoscopic examination and upper gastrointestinal radiography should be performed. (6) Major adverse events include mucosal injury, perforation, bleeding, pneumothorax and pleural effusion. (7) The Eckardt score system and endoscopic examination are used for evaluating the effectiveness after POEM.

Opioid Treatment and Excessive Alcohol Consumption Are Associated With Esophagogastric Junction Disorders

BACKGROUND/AIMS: The influence of external factors such as opioids and alcohol has been extensively investigated for various segments of the gastrointestinal tract. However, the association between their use and the development of esophagogastric junction outflow obstruction disorders (EGJOODs) is unknown. Therefore, the aim of this study is to analyze prevalence and clinical relevance of opioids and alcohol intake in patients with EGJOODs. METHODS: In this single-center, retrospective study, we reviewed clinical and pharmacological data of 375 consecutive patients who had undergone high resolution impedance manometry for EGJOODs. EGJOODs were classified according to the Chicago classification version 3.0 and to recently published normal values for test meals. Demographics, manometric data, and symptoms were compared between different groups using Pearson's chi-squared test, Fisher's exact test, and multivariate analysis. A P < 0.05 was considered significant. RESULTS: EGJOOD was found in 30.7% (115/375) of all analyzed patients. The prevalence of opioids (14.8% vs 4.2%, P = 0.026) was significantly higher in patients with EGJOODs compared to patients without EGJOODs. Additionally, excessive alcohol consumption (12.2% vs 3.5%, P = 0.011) was associated with EGJOODs. Excessive alcohol consumption was especially frequent in the non-achalasia esophagogastric junction outflow obstruction subgroup (16.2%) and opioid use in the achalasia type III subgroup (20.0%). CONCLUSIONS: We found a significant association between EGJOODs and opioid as well as excessive alcohol consumption. This underlines the importance of detailed history taking regarding medication and ethanol consumption in patients with dysphagia. Further prospective studies on mechanisms undelaying esophagogastric junction dysfunction due to opioids or alcohol are warranted.

Clinical value of repeated peroral endoscopic myotomy for persistent/recurrent achalasia / 中华消化内镜杂志

Objective@#To evaluate the feasibility, safety and efficacy of repeated peroral endoscopic myotomy (Re-POEM) as a make-up therapy after POEM failure.@*Methods@#Thirty-three patients with persistent/recurrent symptoms after first POEM (Eckardt symptom score≥4) were selected from a database of a total of 2 516 consecutive patients with achalasia. The main outcome measures was Eckardt score during follow-up; the secondary outcome measures were procedure-related adverse events, changes in manometric lower esophageal sphincter (LES) pressure, and reflux symptoms before and after Re-POEM.@*Results@#All patients successfully underwent Re-POEM in mean 18.6 months (ranging 3-55 months) after their first POEM procedures. The mean symptom score before Re-POEM was 5.5 (ranging 4-8). Mean operation time was 45.1 minutes (ranging 28-64 minutes). Submucosal tunnel infection occurred in 1 patient who recovered with conservative treatment. During a mean follow-up period of 36.6 months (ranging 12-58 months), symptom relief was achieved in all patients. Eckardt score reduced to 1.3 (ranging 0-3), significantly different from that before (P<0.001). Mean LES pressure also declined from 26.0 mmHg (1 mmHg=0.133 kPa) to 9.6 mmHg after Re-POEM (P<0.001). The incidence of gastroesophageal reflux of Re-POEM was 33.3% (11/33).@*Conclusions@#Re-POEM appears safe and effective as a make-up option after POEM failure.