Acalasia o hipertrofia del músculo Cricofaríngeo: opciones de tratamiento

La disfagia alta es un síntoma frecuente de consulta al otorrinolaringólogo o gastroenteròlogo. Los diagnósticos diferenciales son trastornos de la deglución por daño neurològico, anillos esofágicos superiores, globus faríngeo, neoplasia, disfagia lusoria y trastornos motores inespecífico y otras más raras aún. Hay escasa literatura actualizada en pacientes adultos. El diagnóstico se basa en el estudio radiológico baritado, endoscopia y complementariamente con manometría. Las opciones de tratamiento son motivo de discusión, dada la poca evidencia disponible. En este artículo se presentan los resultados observados en una cohorte de 10 pacientes con diagnóstico confirmado de acalasia del cricofaríngeo sometidos a dilatación endoscópica (7 pacientes) o miotomía quirúrgica por cervicotomía (3 pacientes). Se evaluó evolución de la disfagia, complicaciones post procedimiento y resultados a largo plazo. No hubo complicaciones mayores, la disfagia mejoro en ambos grupos, en el grupo de dilatación se complementó el tratamiento con dilataciones periódicas en 2 pacientes. No hubo diferencias significativas en los 2 grupos estudiados. Conclusión: ambas opciones terapéuticas presentan buenos resultados en el tratamiento de estos pacientes.

Dysphagia at cervical level is a frequent symptom causing visit to otolaryngologist or gastroenterologist. The differential diagnoses are swallowing disorders due to neurological damage, upper esophageal rings, pharyngeal globus, neoplasia, non-specific motor disorders and other even rarer ones. There is little updated literature in adult patients. The diagnosis is based on the barium radiological study, endoscopy and complementary manometry. Treatment options are a matter of discussion, given the little evidence available. This paper presents the results observed in a cohort of 10 patients with a confirmed diagnosis of cricopharyngeal achalasia who underwent endoscopic dilation (7 patients) or surgical myotomy by cervicotomy (3 patients). The evolution of dysphagia, post-procedure complications and long-term results were evaluated. There were no major complications, dysphagia improved in both groups, in the dilation group the treatment was supplemented with periodic dilations in 2 patients. There were no significant differences in the 2 groups studied. Conclusion: both therapeutic options present good results in the treatment of these patients.

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.

Divertículo de Zenker / Zenker's Diverticulum

Introducción: Los divertículos de Zenker son los más frecuentes del esófago. El tratamiento quirúrgico más utilizado es la diverticulectomía con miotomía cricofaríngea abierta. Objetivo: Describir un paciente con diagnóstico de divertículo de Zenker cuya presentación fue la disfagia e infecciones respiratorias recurrentes. Presentación del caso: Describimos el caso de una paciente de 73 años con disfagia alta e infecciones respiratorias recurrentes, con el diagnóstico de divertículo de Zenker, a quien se le realiza diverticulectomía más miotomía. Conclusiones: El divertículo de Zenker o divertículo yuxtaesfinteriano faringoesofágico es una entidad de baja prevalencia que se presenta en pacientes entre los 50 y 70 años, predominantemente en los de sexo masculino. La radiografía contrastada del tracto digestivo superior y endoscopia determinan el diagnóstico en su mayoría y la diverticulectomía más cricomiotomía es la técnica más empleada(AU)

Introduction: Zenker's diverticula are the most frequent diverticula of the esophagus. The most commonly used surgical treatment is diverticulectomy with open cricopharyngeal myotomy. Objective: To describe a patient with a diagnosis of Zenker's diverticulum and whose presentation was dysphagia and recurrent respiratory infections. Case presentation: We describe the case of a 73-year-old female patient with high dysphagia and recurrent respiratory infections, with the diagnosis of Zenker's diverticulum, and who underwent diverticulectomy plus myotomy. Conclusions: Zenker's diverticulum or pharyngoesophageal juxtasphincteric diverticulum is a low-prevalence condition that occurs in patients between 50 and 70 years of age, predominantly in males. Contrast radiography of the upper digestive tract and endoscopy determine the diagnosis in the majority of cases, while diverticulectomy plus cricomyotomy is the most commonly used technique(AU)

Z-POEM: ¿Procedimiento ideal para el tratamiento del divertículo de Zenker? / Z-POEM: Ideal procedure for the treatment of Zenker's diverticulum?

Introducción. El divertículo de Zenker es una patología poco frecuente, caracterizada por la presencia de disfagia, halitosis, tos y pérdida de peso, que afectan la calidad de vida de los pacientes. El tratamiento es quirúrgico y las técnicas han evolucionado de forma permanente. El objetivo de este estudio fue evaluar la mejoría de la disfagia en pacientes a quienes se les realizó la técnica de miotomía endoscópica peroral (Z-POEM). Métodos. Estudio descriptivo de una serie de 23 pacientes con divertículo de Zenker diagnosticado por endoscopia y esofagograma, tratados entre mayo de 2018 y noviembre de 2021 en diferentes instituciones de la ciudad de Bogotá, D.C., Colombia, mediante una miotomía endoscópica del cricofaríngeo con la técnica de Z-POEM. Resultados. La mayoría de los pacientes fueron adultos mayores, de sexo masculino. Los síntomas más frecuentes correspondieron a disfagia y regurgitación. El tamaño promedio del divertículo fue de tres centímetros. La estancia hospitalaria fue de un día. Un paciente presentó disfagia postoperatoria en relación con los clips y otro presentó un absceso mediastinal, el cual fue resuelto de manera endoscópica. Actualmente, todos los pacientes se encuentran asintomáticos y no han presentado recurrencia. Conclusiones. El tratamiento endoscópico mínimamente invasivo mediante la miotomía endoscópica peroral (Z-POEM) en el paciente con divertículo de Zenker es una alternativa segura y eficaz, con buenos resultados y poca morbilidad

Introduction. Zenker's diverticulum is a rare pathology characterized by the presence of dysphagia, halitosis, cough, and weight loss, which affect the patients' quality of life. The treatment is surgical and the techniques have evolved permanently. The objective of this study was to evaluate the improvement of dysphagia in patients who underwent peroral endoscopic myotomy technique (Z-POEM). Methods. Descriptive study of a series of 23 patients with Zenker's diverticulum diagnosed by endoscopy and esophagram, treated between May 2018 and November 2021 at different institutions in Bogotá, Colombia, by means of an endoscopic cricopharyngeal myotomy with the Z-POEM technique. Results. Most of patients were older males. The most frequent symptoms corresponded to dysphagia and regurgitation. The average size of the diverticulum was three centimeters. The hospital stay was one day. One patient presented postoperative dysphagia related to the clips and another presented a mediastinal abscess which was resolved endoscopically. Currently, all patients are asymptomatic and have not presented recurrence. Conclusions. Minimally invasive endoscopic treatment by peroral endoscopic myotomy (Z-POEM) in patients with Zenker's diverticulum is a safe and effective alternative, with good results and low morbidity

Diagnóstico y manejo actual de la acalasia / Diagnosis and current management of achalasia

Introducción. La acalasia es un trastorno motor del esófago poco común, de etiología no clara, caracterizado por la pérdida de relajación del esfínter esofágico inferior, pérdida del peristaltismo normal, regurgitación y disfagia. Métodos. Se realizó una revisión narrativa de la literatura en revistas científicas y bases de datos en español e inglés, con el fin de presentar información actualizada en lo referente al diagnóstico y tratamiento de esta patología. Resultado. Se presenta la actualización de los criterios de los trastornos motores esofágicos según la clasificación de Chicago (CCv4.0) para el diagnóstico de acalasia y sus subtipos de acuerdo con los nuevos criterios, así como los tratamientos actuales. Conclusión. La acalasia es un trastorno esofágico multimodal, con manifestaciones de predominio gastrointestinal, por lo que su diagnóstico y abordaje terapéutico oportuno es esencial para mejorar la calidad de vida de los pacientes

Introduction. Achalasia is a rare motor disorder of the esophagus of unclear etiology, characterized by loss of lower esophageal sphincter relaxation, loss of normal peristalsis, regurgitation, and dysphagia. Methods. A narrative review of the literature in scientific journals and databases in Spanish and English was carried out, in order to present updated information regarding the diagnosis and treatment of this pathology. Result. The update of the Chicago esophageal motor disorders criteria (CCv4.0) is presented for the diagnosis of achalasia and its subtypes according to the new criteria, as well as current treatments. Conclusion. Achalasia is a multimodal esophageal disorder, with predominantly gastrointestinal manifestations, so its timely diagnosis and therapeutic approach is essential to improve the quality of life of patients.

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.

Esófago porcino: modelo ex vivo de entrenamiento laparoscópico para la miotomía de Heller y funduplicatura de Dor / Porcine esophagus: ex vivo laparoscopic training model for Heller's myotomy and Dor's funduplication

El dominio de procedimientos avanzados en laparoscopia es fundamental para los cirujanos, por ello el entrenamiento es imprescindible. La miotomía de Heller y funduplicatura de Dor requieren el desarrollo de habilidades y destrezas para realizar la cirugía de forma segura y eficaz, superar la curva de aprendizaje es un reto para el cirujano en formación, por lo que se propone el esófago porcino como modelo ex vivo de entrenamiento laparoscópico, con el fin de permitir desarrollar las habilidades necesarias y así llevar a cabo con éxito el procedimiento quirúrgico.Objetivo : Aplicar el esófago porcino como modelo ex vivo para el entrenamiento laparoscópico de la miotomía de Heller y funduplicatura de Dor.Métodos : Se realizó un estudio prospectivo, experimental y longitudinal, aplicado en un período de 17 semanas, en sesiones de 1 hora cada una, una sesión por semana.Resultados : Se llevaron a cabo 17 prácticas realizadas por el autor, evaluadas por cirujanos expertos, observando un aumento de la puntuación obtenida en la escala GOALS y disminución del tiempo de ejecución a medida que aumentaba el número de prácticas con una correlación altamente significativa, según la tau-B de Kendall (p=0,000).Conclusión : El modelo ex vivo permitió recrear la mayoría de los pasos quirúrgicos y demostró ser una herramienta útil y valiosa, disminuyendo el tiempo de ejecución del procedimiento y aumentando significativamente las habilidades laparoscópicas(AU)

Mastery of advanced procedures in laparoscopy is important for surgeons, therefore training is essential. Heller's myotomy and Dor's fundoplication require the development of abilities and skills to perform the surgery safely and effectively, overcoming the learning curve is a challenge for the surgeon in training, so the porcine esophagus is proposed as an ex vivo model of laparoscopic training in order to develop the necessary skills to successfully carry out the surgical procedure. Objective: To apply the porcine esophagus as an ex vivo model for laparoscopic training of Heller's myotomy and Dor's fundoplication. Methods: A prospective, experimental and longitudinal study was carried out, applied by the authors in a period of 17 weeks, in sessions of 1 hour each, one session per week. Results: 17 practices carried out by the author were carried out, evaluated by expert surgeons, observing an increase in the score obtained on the GOALS scale and a decrease in execution time as the number of practices with a high significant influence increase, according to Kendall's tau-B (p=0.000). Conclusion: The ex vivo model allowed recreating most of the surgical steps and stood out as a useful and valuable tool, decreasing the execution time of the procedure and significantly increasing laparoscopic skills(AU)

Efficacy of peroral endoscopic myotomy for esophageal diverticulum / 中华消化内镜杂志

Objective:To investigate the medium- and long-term efficacy of peroral endoscopic myotomy (POEM) for esophageal diverticulum and the risk factors for postoperative recurrence.Methods:A retrospective study was conducted on 31 cases of esophageal diverticulum who were treated by POEM in Zhongda Hospital, Southeast University from May 1st 2016 to August 1st 2019. The Eckardt score, the operative success rate, and the recurrence rate after the operation were observed and recorded. Multivariate logistic regression analysis was performed to explore the risk factors for postoperative recurrence.Results:POEM was successfully completed in all 31 patients, who were followed up for 30.6±11.1 months (20-63 months). The Eckardt score before the operation was 8.2±2.4, and was 1.4±0.7, 1.4±1.1, 1.3±1.1, and 1.3±0.9 at 1, 6, 12 and 24 months, respectively after the operation, which significantly decreased at all follow-up time points ( P<0.001). The success rates at 1, 6, 12, and 24 months after the operation were 96.8% (30/31), 90.3% (28/31), 90.3% (28/31) and 90.3% (28/31), respectively. Three patients suffered symptom relapse, with an overall recurrence rate of 9.7% (3/31). Logistic regression analysis showed that the disease duration ( P=0.038, OR=1.041, 95% CI: 1.002-1.080) and preoperative Eckardt score ( P=0.024, OR=2.299, 95% CI: 1.117-4.728) were risk factors for postoperative recurrence of POEM. Conclusion:POEM is safe and effective for esophageal diverticulum. Patients with long disease duration and high preoperative Eckardt score are associated with recurrence.

Clinical analysis of peroral endoscopic diverticulotomy for the treatment of esophageal epiphrenic diverticulum with esophagogastric junction outflow tract disorder / 中华消化杂志

Objective:To evaluate the safety and efficacy of combination of submucosal tunneling endoscopic septum division (STESD) and peroral endoscopic myotomy (POEM) for the treatment of esophageal epiphrenic diverticulum with esophagogastric junction (EGJ) outflow tract disorder.Methods:From October 2017 to August 2021, 6 patients with esophageal epiphrenic diverticulum complicated with EGJ outflow tract disorder receiving combination of STESD and POEM in the Endoscopic Center of the First Affiliated Hospital of Nanjing Medical University were enrolled. The clinical characteristics of the patients were retrospectively analyzed, which included the ratio of male to female, age, course of disease, length of diverticula, location, whether with multiple diverticula, type of EGJ outflow tract disorders, whether the endoscopic technique was successful (the completion of all steps under endoscopy, including tunnel establishment and diverticulum cristae, lower esophageal sphincter and cardia muscularis propria incision); operation time, changes in the severity of clinical symptoms before and after operation (including weight loss, dysphagia, retrosternal pain, and reflux assessed using the Eckardt score), intraoperative and postoperative complications, and follow-up, including whether achieved clinical success (complete or nearly complete improvement of dysphagia, vomiting after eating, retrosternal pain, regurgitation, weight loss, no need for repeat endoscopic intervention during follow-up) and adverse events. Descriptive methods were used for statistical analysis.Results:The male to female ratio of the 6 patients was 3 to 3, the median age was 69.2 years old, and the median disease course was 92.3 months. The median length of the diverticula was 47.5 mm. Diverticulum was located in the right wall of esophagus in 4 cases and in the left wall of esophagus in 2 cases, of which 1 patient was multiple diverticulum of esophagus. Achalasia was found in 5 cases, and EGJ outflow obstruction was found in 1 case. All the 6 patients successfully completed combination of STESD and POEM, and all achieved successful edoscopic technique. The operation time (range) was 55 min (40 to 70 min). Clinical symptom Eckardt score (range) before and after operation was 9.0 (7.0 to 11.0) and 1.3 (1.0 to 2.0), respectively. After operation the clinical symptom improved compared with that before operation. There were no delayed bleeding, perforation, infection, subcutaneous emphysema and other complications and severe adverse events. Six patients were all cured and discharged. Follow-up period was 1 to 50 months. The symptoms of dysphagia, vomiting after eating, retrosternal pain, regurgitation and weight loss were all significantly improved compared with those before operation. There were no severe adverse events and all achieved clinical success.Conclusions:Combination of STESD and POEM is safe and effective in the treatment of esophageal epiphrenic diverticulum with EGJ outflow tract disorder, and has good short-term and long-term effects.

Clinical observation of peroral endoscopic myotomy for mid-esophageal diverticulum in 7 cases / 中华消化内镜杂志

To investigate the effectiveness and safety of diverticular peroral endoscopic myotomy (D-POEM) for mid-esophageal diverticulum. Data of consecutive patients in the prospective database with mid-esophageal diverticulum who received D-POEM in West China Hospital, Sichuan University between April 2014 to September 2019 were collected. The modified Eckardt scoring system for mid-esophageal diverticulum was used to evaluate the severity of diverticular symptoms. The effectiveness and safety of D-POEM were evaluated in terms of clinical success, technical success, complications and recurrence. A total of 7 patients with mid-esophageal diverticulum were included. Clinical and technical success was achieved in all patients with operation time of 16-70 minutes. No serious complications (2 cases with minor complications) or recurrence occurred. The follow-up time was 2-16 months. The median modified Eckardt score decreased from 3 points before operation to 0 points after operation. It is preliminarily believed that D-POEM ensures a complete septotomy between normal esophageal lumen and esophageal diverticulum. It is a safe and effective technique for mid-esophageal diverticulum. The modified Eckardt scoring system is suitable for symptom evaluation before and after treatment of mid-esophageal diverticulum.

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.

Short-term outcomes and learning curve of the robot-assisted Heller-Dor myotomy for achalasia of cardia: A single-center retrospective study / 中国胸心血管外科临床杂志

@#Objective     To investigate short-term outcomes of robot-assisted Heller-Dor myotomy (RAHM-Dor) for achalasia of cardia and our learning curve experience. Methods     The clinical data and recent follow-up results of 42 patients who received RAHM-Dor from November 2015 to January 2020 in the Department of Thoracic Surgery of the First Affiliated Hospital of Nanchang University were retrospectively analyzed, including 20 males and 22 females with a mean age of 40.8±18.4 years. Results    Dysphagia was the most common symptom, followed by heartburn and regurgitation. The mean operation time was 122.8±23.9 min. The mean blood loss was 47.5±32.7 mL. Two patients suffered mucosal injury, and successfully repaired by suturing during surgery. There was no esophageal fistula, conversion to an open operation or perioperative death in this series. The median length of hospital stay was 8 (6, 9) d. In all patients, the Stooler and Eckardt scores of postoperative 1, 6 and 12 months decreased compared to those of pre-operation (P<0.001). Conclusion     RAHM-Dor is a safe and feasible avenue for the treatment of achalasia of cardia, and can achieve a satisfying short-term results. The learning curve shows a transition to the standard stage from the learning stage after 16-18 operations.

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.

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.

Long-term results and influencing factors of laparoscopic Heller myotomy for achalasia / 中华胸心血管外科杂志

Objective:To assess the long-term outcome and influencing factors of laparoscopic Heller myotomy plus Dor fundoplication(LHM+ Dor) for achalasia by a single operator.Methods:Fifty-four patients who underwent LHM+ Dor consecutively from January 2011 to December 2019 were retrospectively reviewed. Those who had already undergone surgical or endoscopic myotomy and who were complicated with cancer were ruled out. Symptom inquiry and esophagogram were conducted both before and after surgery for assessing surgical results. Esophagoscopy, esophageal manometry and 24 h pH monitoring were performed before surgery, and the effects of these preoperative factors on the long-term outcome were analyzed.Results:All patients had dysphagia for average 6.5 years, ranging from 0.5-30.0 years. Intra-operative mucosal perforation occurred in 4(7.4%) patients, and there were no postoperative morbidity and mortality. At a median follow-up of 5.2 years, the morbidity of dysphagia decreased from 100% before surgery to 5.5% after surgery( P<0.001), Eckardt scores from 4.85±1.64 to 0.71±1.08( P=0.000). After surgery, 94.4% of patients had excellent and good relief of symptoms and good control of gastroesophageal reflux, the morbidity of heartburn being 3.7%. At 5 years after surgery, the probability of being symptoms free(Eckardt score≤1) was 91.7% in patients without preoperative night cough, compared to 54.6% in those with preoperative night cough( P=0.047). The probability was 92.3% in patients with grade Ⅰ and Ⅱ dilation of the esophagus and 79.0% in patients with grade Ⅲ and Ⅳ dilation( P=0.027). At multivariate analysis, heavier esophageal dilation was the independent predicator for poor symptom control after surgery. Conclusion:LHM+ Dor can be safely performed and durably relieve achalasia symptoms. Severe esophageal dilation before surgery is an independent predictor of a poor response to surgery.

Analysis of Efficacy, Safety and Influential Factors of Peroral Endoscopic Myotomy in Geriatric Patients With Achalasia / 胃肠病学

Background: Peroral endoscopic myotomy (POEM) is safe and effective in the treatment of achalasia (AC). However, there are few reports on application of POEM in the elderly, and is limited by small sample size and short follow-up. Aims: To evaluate the efficacy and safety of POEM and its influential factors on AC in geriatric patients. Methods: A total of 215 AC patients received POEM from November 2012 to December 2018 at the First Affiliated Hospital of Nanjing Medical University were enrolled, and were divided into elderly group (≥60 years old) and non-elderly group (0.05). The median follow-up was 42 (29, 60) months. The rate of treatment failure or recurrence in elderly group was significantly increased than that in non-elderly group (17.5% vs. 7.4%, P=0.047). However, there was no statistical difference in incidence of clinical reflux between the two groups (P>0.05). The postoperative efficacy was correlated with preoperative IRP in elderly patients (P=0.033). The propensity score matching results showed that no significant difference in prognosis was found between the two groups. Conclusions: POEM is safe and effective for elderly patients with AC. However, the efficacy is lower in elderly patients than that in non-elderly patients due to the long course of disease and lower preoperative IRP.

Safety and Outcome of Laparoscopic Heller’s Cardiomyotomy with Intraoperative Endoscopic Assessment and Dor’s Fundoplication in Primary Achalasia Cardia: A Single-center Prospective Study

Introduction: Achalasia cardia is a primary esophageal motility disorder of an unknown etiology, characterized by abnormal peristalsis of the esophageal body and the absence of relaxation of the lower esophageal sphincter. Laparoscopic Heller cardiomyotomy is the surgical procedure of choice for achalasia cardia. Aim: The aim of the study was to the immediate safety and long-term efficacy of laparoscopic Heller’s cardiomyotomy with intraoperative endoscopy and Dor’s anterior partial fundoplication in patients with achalasia cardia. Materials and Methods: In this prospective study, laparoscopic Heller’s myotomy with intraoperative endoscopy and anterior Dor’s fundoplication were performed in all achalasia cardia patients. Patients’ demographic, clinical features such as dysphagia grade and Eckardt score, intraoperative, post-operative parameters, and response to treatment on follow-up were analyzed. Results: In 14 patients, 10 were females (71%), the mean age was 37±14.96 years. Mean pre-operative modified Takita’s dysphagia grade was 2.93±0.73. Endoscopic classic findings and barium swallow bird beak sign were diagnostic in all cases. Preoperative Eckardt score was 8.93±1.44. Eckardt score at discharge was 0.43±0.51 and at 12th month was 0.21±0.43. On analysis, there was a significant improvement in pre-operative values of modified Takita’s dysphagia grade and Eckardt score to normal values postoperatively (P < 0.0001) and the durable effect was persistently observed in 3rd and 6th, 9th, and 12th-month follow-up. Conclusion: Laparoscopic Heller’s myotomy with intraoperative endoscopy and Dor’s fundoplication are safe and effective with significant improvement in post-operative Takita’s dysphagia score and Eckardt score.