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Endoscopy 2013; 45(03): 161-166
DOI: 10.1055/s-0032-1326203
Original article
© Georg Thieme Verlag KG Stuttgart · New York

Peroral endoscopic remyotomy for failed Heller myotomy: a prospective single-center study

P. H. Zhou   *
Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
,
Q. L. Li   *
Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
,
L. Q. Yao
Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
,
M. D. Xu
Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
,
W. F. Chen
Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
,
M. Y. Cai
Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
,
J. W. Hu
Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
,
L. Li
Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
,
Y. Q. Zhang
Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
,
Y. S. Zhong
Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
,
L. L. Ma
Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
,
W. Z. Qin
Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
,
Z. Cui
Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
› Author Affiliations
Further Information

Publication History

submitted 06 July 2012

accepted after revision 26 December 2012

Publication Date:
06 February 2013 (online)

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Commentaire de travail de P. H. Zhou et al., pp. 161Endoscopy 2013; 45(03): 327-327
DOI: 10.1055/s-0032-1309590

Background and study aims: Recurrence/persistence of symptoms occurs in approximately 20 % of patients after Heller myotomy for achalasia. Controversy exists regarding the therapy for patients in whom Heller myotomy has failed. The aim of the current study was to evaluate the efficacy and feasibility of peroral endoscopic myotomy (POEM), a new endoscopic myotomy technique, for patients with failed Heller myotomy.

Patients and methods: A total of 12 patients with recurrence/persistence of symptoms after Heller myotomy, as diagnosed by established methods and an Eckardt score of ≥ 4, were prospectively included. The primary outcome was symptom relief during follow-up, defined as an Eckardt score of ≤ 3. Secondary outcomes were procedure-related adverse events, lower esophageal sphincter (LES) pressure on manometry, reflux symptoms, and medication use before and after POEM.

Results: All 12 patients underwent successful POEM after a mean of 11.9 years (range 2 – 38 years) from the time of the primary Heller myotomy. No serious complications related to POEM were encountered. During a mean follow-up period of 10.4 months (range 5 – 14 months), treatment success was achieved in 11/12 patients (91.7 %; mean score pre- vs. post-treatment 9.2 vs. 1.3; P < 0.001). Mean LES pressure was 29.4 mmHg pre-treatment and 13.5 mmHg post-treatment (P < 0.001). One patient developed mild reflux symptoms and required intermittent medication with proton pump inhibitors.

Conclusions: POEM seems to be a promising new treatment for failed Heller myotomy resulting in short-term symptom relief in > 90 % of cases. Previous Heller myotomy may make subsequent endoscopic remyotomy more challenging, but does not prevent successful POEM.

* Both authors contributed equally to this work


 

  • References

  • 1 Eckardt AJ, Eckardt VF. Treatment and surveillance strategies in achalasia: an update. Nat Rev Gastroenterol Hepatol 2011; 8: 311-319
    CrossrefPubMedGoogle Scholar
  • 2 Campos GM, Vittinghoff E, Rabl C et al. Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis. Ann Surg 2009; 249: 45-57
    CrossrefPubMedGoogle Scholar
  • 3 Miller DL, Allen MS, Trastek VF et al. Esophageal resection for recurrent achalasia. Ann Thorac Surg 1995; 60: 922-925
    CrossrefPubMedGoogle Scholar
  • 4 Zaninotto G, Costantini M, Portale G et al. Etiology, diagnosis, and treatment of failures after laparoscopic Heller myotomy for achalasia. Ann Surg 2002; 235: 186-192
    CrossrefPubMedGoogle Scholar
  • 5 Guardino JM, Vela MF, Connor JT et al. Pneumatic dilation for the treatment of achalasia in untreated patients and patients with failed Heller myotomy. J Clin Gastroenterol 2004; 38: 855-860
    CrossrefPubMedGoogle Scholar
  • 6 Iqbal A, Tierney B, Haider M et al. Laparoscopic re-operation for failed Heller myotomy. Dis Esophagus 2006; 19: 193-199
    CrossrefPubMedGoogle Scholar
  • 7 Duffy PE, Awad ZT, Filipi CJ. The laparoscopic reoperation of failed Heller myotomy. Surg Endosc 2003; 17: 1046-1049
    CrossrefPubMedGoogle Scholar
  • 8 Gockel I, Junginger T, Eckardt VF. Persistent and recurrent achalasia after Heller myotomy: analysis of different patterns and long-term results of reoperation. Arch Surg 2007; 142: 1093-1197
    CrossrefPubMedGoogle Scholar
  • 9 Rakita S, Villadolid D, Kalipersad C et al. Outcomes promote reoperative Heller myotomy for symptoms of achalasia. Surg Endosc 2007; 21: 1709-1714
    CrossrefPubMedGoogle Scholar
  • 10 Inoue H, Minami H, Kobayashi Y et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 von Renteln D, Inoue H, Minami H et al. Peroral endoscopic myotomy for the treatment of achalasia: a prospective single center study. Am J Gastroenterol 2012; 107: 411-417
    CrossrefPubMedGoogle Scholar
  • 12 Zhou PH, Yao LQ, Zhang YQ et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia: 205 cases report. Gastrointest Endosc 2012; 75 : AB132-AB133
    PubMedGoogle Scholar
  • 13 Eckardt VF. Clinical presentations and complications of achalasia. Gastrointest Endosc Clin N Am 2001; 11: 281-292
    CrossrefPubMedGoogle Scholar
  • 14 Pandolfino JE, Kwiatek MA, Nealis T et al. Achalasia: a new clinically relevant classification by high-resolution manometry. Gastroenterology 2008; 135: 1526-1533
    CrossrefPubMedGoogle Scholar
  • 15 Gockel I, Junginger T, Bernhard G et al. Heller myotomy for failed pneumatic dilation in achalasia: how effective is it?. Ann Surg 2004; 239: 371-377
    CrossrefPubMedGoogle Scholar
  • 16 Gorecki PJ, Hinder RA, Libbey JS et al. Redo laparoscopic surgery for achalasia: is it feasible?. Surg Endosc 2002; 16: 772-776
    CrossrefPubMedGoogle Scholar
  • 17 James DR, Purkayastha S, Aziz O et al. The feasibility, safety and outcomes of laparoscopic re-operation for achalasia. Minim Invasive Ther Allied Technol 2012; 21: 161-167
    CrossrefPubMedGoogle Scholar
  • 18 Petersen RP, Pellegrini CA. Revisional surgery after Heller myotomy for esophageal achalasia. Surg Laparosc Endosc Percutan Tech 2010; 20: 321-325
    CrossrefPubMedGoogle Scholar
  • 19 Patti MG, Molena D, Fisichella PM et al. Laparoscopic Heller myotomy and Dor fundoplication for achalasia: analysis of successes and failures. Arch Surg 2001; 136: 870-875 ; discussion 875-877
    CrossrefPubMedGoogle Scholar
  • 20 Pasricha PJ, Hawari R, Ahmed I et al. Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy 2007; 39: 761-764
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Hungness ES, Teitelbaum EN, Santos BF et al. Comparison of perioperative outcomes between peroral esophageal myotomy (POEM) and laparoscopic Heller myotomy. J Gastrointest Surg 2012; DOI: 10.1007/s11605-012-2030-3.
    PubMedGoogle Scholar
  • 22 Xu MD, Cai MY, Zhou PH et al. Submucosal tunneling endoscopic resection: a new technique for treating upper GI submucosal tumors originating from the muscularis propria layer (with videos). Gastrointest Endosc 2012; 75: 195-199
    CrossrefPubMedGoogle Scholar
  • 23 Li QL, Yao LQ, Zhou PH et al. Submucosal tumors of the esophagogastric junction originating from the muscularis propria layer: a large study of endoscopic submucosal dissection (with video). Gastrointest Endosc 2012; 75: 1153-1158
    CrossrefPubMedGoogle Scholar
  • 24 Ren Z, Zhong Y, Zhou P et al. Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases). Surg Endosc 2012; 26: 3267-3272
    CrossrefPubMedGoogle Scholar
  • 25 Wang L, Li YM. Recurrent achalasia treated with Heller myotomy: a review of the literature. World J Gastroenterol 2008; 14: 7122-7126
    CrossrefPubMedGoogle Scholar
  • 26 Oelschlager BK, Chang L, Pellegrini CA. Improved outcome after extended gastric myotomy for achalasia. Arch Surg 2003; 138: 490-495 (discussion 495-497)
    CrossrefPubMedGoogle Scholar
  • 27 Hulselmans M, Vanuytsel T, Degreef T et al. Long-term outcome of pneumatic dilation in the treatment of achalasia. Clin Gastroenterol Hepatol 2010; 8: 30-35
    CrossrefPubMedGoogle Scholar