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

Background and study aims: With the success of peroral endoscopic myotomy (POEM) in treatment of achalasia, its successful application to other spastic esophageal motility disorders such as Jackhammer esophagus has been noted. The question of whether the lower esophageal sphincter (LES) should be included in the myotomy for Jackhammer esophagus is a topic of current debate. Here, we report our experience and results with four patients with Jackhammer esophagus treated with POEM. The clinical and manometric results are presented and their potential implications are discussed.

Patients and methods: Between January 2014 and July 2015, four patients underwent POEM for treatment of Jackhammer esophagus at our center. Manometry was performed prior to and after POEM. All patients met the Chicago classification criteria for Jackhammer esophagus and received a barium esophagram and endoscopic examination before having POEM.

Results: All patients had uneventful procedures without any intraoperative or post-procedure complications. Patients in which the LES was included during POEM had resolution or significant improvement in symptoms. One patient in whom the LES was preserved had resolution of chest pain but developed significant dysphagia and regurgitation. Subsequently this individual received a repeat POEM which included the LES, resulting in symptom resolution.

Conclusions: POEM is a suitable treatment for patients with Jackhammer esophagus. Until there are larger-scale randomized studies, we speculate that based on our clinical experience and physiologic and manometric observations, obligatory inclusion of the LES is justified to reduce the risk of symptom development from iatrogenic ineffective esophageal motility or subsequent progression to achalasia.

• References

• 1 Jung KW, Jung HY, Yoon IJ et al. New diagnostic criteria for nutcracker esophagus using conventional water-perfused manometry: a comparison between nutcracker esophagus with and without gastroesophageal reflux disease. Journal of gastroenterology and hepatology 2010; 25: 1239-1243
• 2 Roman S, Tutuian R. Esophageal hypertensive peristaltic disorders. Neurogastroenterology and motility: the official journal of the European Gastrointestinal Motility Society 2012; 24: 32-39
• 3 Kahrilas PJ, Bredenoord AJ, Fox M et al. The Chicago Classification of esophageal motility disorders, v3.0. Neurogastroenterology and motility: the official journal of the European Gastrointestinal Motility Society 2015; 27: 160-174
• 4 Roman S, Pandolfino JE, Chen J et al. Phenotypes and clinical context of hypercontractility in high-resolution esophageal pressure topography (EPT). Am J Gastroenterol 2012; 107: 37-45
• 5 Valdovinos MA, Zavala-Solares MR, Coss-Adame E. Esophageal hypomotility and spastic motor disorders: current diagnosis and treatment. Curr Gastroenterol Rep 2014; 16: 421
• 6 Patti MG, Gorodner MV, Galvani C et al. Spectrum of esophageal motility disorders: Implications for diagnosis and treatment. Archives of Surgery 2005; 140: 442-449
• 7 Ellis Jr FH. Esophagomyotomy for noncardiac chest pain resulting from diffuse esophageal spasm and related disorders. The American journal of medicine 1992; 92: 129s-131s
• 8 Coss-Adame E, Erdogan A, Rao SS. Treatment of esophageal (noncardiac) chest pain: an expert review. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association 2014; 12: 1224-1245
• 9 Khashab MA, Saxena P, Kumbhari V et al. Peroral endoscopic myotomy as a platform for the treatment of spastic esophageal disorders refractory to medical therapy (with video). Gastrointestinal endoscopy 2014; 79: 136-139
• 10 Almansa C, Hinder RA, Smith CD et al. A comprehensive appraisal of the surgical treatment of diffuse esophageal spasm. Journal of gastrointestinal surgery: official journal of the Society for Surgery of the Alimentary Tract 2008; 12: 1133-1145
• 11 Herbella FA, Tineli AC, Wilson Jr JL et al. Surgical treatment of primary esophageal motility disorders. Journal of gastrointestinal surgery: official journal of the Society for Surgery of the Alimentary Tract 2008; 12: 604-608
• 12 Kuribayashi S, Iwakiri K, Kawada A et al. Variant parameter values-as defined by the Chicago Criteria-produced by ManoScan and a new system with Unisensor catheter. Neurogastroenterology and motility: the official journal of the European Gastrointestinal Motility Society 2015; 27: 188-194
• 13 Inoue H, Minami H, Kobayashi Y et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
• 14 Paterson WG, Beck IT, Da Costa LR. Transition from nutcracker esophagus to achalasia. A case report. Journal of clinical gastroenterology 1991; 13: 554-558
• 15 Fontes LH, Herbella FA, Rodriguez TN et al. Progression of diffuse esophageal spasm to achalasia: incidence and predictive factors. Diseases of the esophagus: official journal of the International Society for Diseases of the Esophagus / ISDE 2013; 26: 470-474
• 16 Patti MG, Pellegrini CA, Arcerito M et al. Comparison of medical and minimally invasive surgical therapy for primary esophageal motility disorders. Archives of surgery (Chicago, Ill: 1960) 1995; 130: 609-615 ; discussion 615-606
• 17 Badillo R, Francis D, DeVault K. Formation of large esophageal diverticulum after peroral endoscopic myotomy. Gastrointestinal endoscopy 2015; DOI: 10.1016/j.gie.2015.05.020.
• 18 Werner YB, Costamagna G, Swanstrom LL et al. Clinical response to peroral endoscopic myotomy in patients with idiopathic achalasia at a minimum follow-up of 2 years. Gut 2015; DOI: 10.1136/gutjnl-2014-308649.
• 19 Bechara R, Ikeda H, Inoue H. Peroral endoscopic myotomy: an evolving treatment for achalasia. Nat Rev Gastroenterol Hepatol 2015; 12: 410-426
• 20 Familiari P, Greco S, Gigante G et al. Gastroesophageal reflux disease after peroral endoscopic myotomy: Analysis of clinical, procedural and functional factors, associated with gastroesophageal reflux disease and esophagitis. Digestive Endoscopy 2016; 28: 33-41