Ahmed Sharata

Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure.

Background:Esophageal achalasia is most commonly treated with laparoscopic myotomy or endoscopic dilation. Per-oral endoscopic myotomy (POEM), an incisionless selective myotomy, has been described as a less invasive surgical treatment. This study presents 6-month physiological and symptomatic outcomes after POEM for achalasia. Methods:Data on single-institution POEMs were collected prospectively. Pre- and postoperative symptoms were quantified with Eckardt scores. Objective testing (manometry, endoscopy, timed-barium swallow) was performed preoperatively and 6 months postoperatively. At 6 months, gastroesophageal reflux was evaluated by 24-hour pH testing. Pre-/postmyotomy data were compared using paired nonparametric statistics. Results:Eighteen achalasia patients underwent POEMs between October 2010 and October 2011. The mean age was 59 ± 20 years and mean body mass index was 26 ± 5 kg/m2. Six patients had prior dilations or Botox injections. Myotomy length was 9 cm (7–12 cm), and the median operating time was 135 minutes (90–260). There were 3 intraoperative complications: 2 gastric mucosotomies and 1 full-thickness esophagotomy, all repaired endoscopically with no sequelae. The median hospital stay was 1 day and median return to normal activity was 3 days (3–9 days). All patients had relief of dysphagia [dysphagia score ⩽ 1 (“rare”)]. Only 2 patients had Eckardt scores greater than 1, due to persistent noncardiac chest pain. At a mean follow-up of 11.4 months, dysphagia relief persisted for all patients. Postoperative manometry and timed barium swallows showed significant improvements in lower esophageal relaxation characteristics and esophageal emptying, respectively. Objective evidence of gastroesophageal reflux was seen in 46% patients postoperatively. Conclusions:POEM is safe and effective. All patients had dysphagia relief, 83% having relief of noncardiac chest pain. There is significant though mild gastroesophageal reflux postoperatively in 46% of patients in 6-month pH studies. The lower esophageal sphincter shows normalized pressures and relaxation.

Peroral endoscopic esophageal myotomy: defining the learning curve

BACKGROUND Peroral endoscopic myotomy (POEM) is an endoscopic alternative to laparoscopic esophageal myotomy. It requires a demanding skill set that involves both advanced endoscopic skills and knowledge of surgical anatomy and complication management. OBJECTIVE Determine the learning curve for POEM. DESIGN Prospective cohort study. SETTING Tertiary-care teaching hospital. PATIENTS The study involved the first 40 consecutive patients undergoing the POEM procedure under a prospective institutional review board protocol (research.gov #NCT01399476, 1056). INTERVENTION Peroral endoscopic myotomy for esophageal motility disorders. MAIN OUTCOME MEASUREMENTS Length of procedure (LOP) and technical errors (inadvertent mucosotomy). RESULTS A total of 40 patients underwent POEM. The mean LOP was 126 ± 41 minutes. The mean myotomy length was 9 cm (range, 6-20 cm). The LOP per centimeter myotomy and variability decreased as our experience progressed. The means (± standard deviation) of the LOP per centimeter myotomy were as follows: first cohort, 16 ± 4 minutes; second, 17 ± 5 minutes; third, 13 ± 3 minutes; fourth, 15 ± 2 minutes; and fifth, 13 ± 4 minutes. The incidence of inadvertent mucosotomy also decreased with increasing experience, to 8, 6, 4, 0, and 1, respectively. These minor complications were repaired intraoperatively with clips. There were 7 patients with capnoperitonium and another with bilateral capnothoraces that were associated with hemodynamic instability but resolved by Veress needle decompression. Two patients required endoscopy in the early postoperative period: self-limited hematemesis in one and radiologic evidence of leakage at the mucosotomy site in another. LIMITATIONS Nonrandomized study. CONCLUSION Mastery of operative technique in POEM is evidenced by a decrease in LOP, variability of minutes per centimeter of myotomy, and incidence of inadvertent mucosotomies and plateaus in about 20 cases for experienced endoscopists. The learning curve can be shortened with very close supervision and/or proctoring.

Partial Anterior vs Partial Posterior Fundoplication Following Transabdominal Esophagocardiomyotomy for Achalasia of the Esophagus Meta-regression of Objective Postoperative Gastroesophageal Reflux and Dysphagia

OBJECTIVES To review transabdominal esophagocardiomyotomy (surgical treatment of achalasia) of the esophagus and to compare outcomes of partial anterior vs partial posterior fundoplication. DATA SOURCES An electronic search was conducted among studies published between January 1976 and September 2011 using the keywords achalasia, myotomy, antireflux surgery, and fundoplication. STUDY SELECTION Prospective studies of transabdominal esophagocardiomyotomy were selected. DATA EXTRACTION Outcomes selected were recurrent or persistent postoperative dysphagia and an abnormal 24-hour pH test result. Studies were divided into the following 3 groups: myotomy only, myotomy with anterior fundoplication, and myotomy with posterior fundoplication. Studies were weighted by the number of patients and by the follow-up duration. Event rates were calculated using meta-regression of the log-odds with the inverse variance method. DATA SYNTHESIS Thirty-nine studies with a total of 2998 patients were identified. The odds of postoperative dysphagia were 0.06 (95% CI, 0.03-0.12) for myotomy only, 0.11 (95% CI, 0.09-0.14) for myotomy with anterior fundoplication, and 0.06 (95% CI, 0.04-0.08) for myotomy with posterior fundoplication. The odds of a postoperative abnormal 24-hour pH test result were 0.37 (95% CI, 0.12-1.08) for myotomy only, 0.16 (95% CI, 0.11-0.24) for myotomy with anterior fundoplication, and 0.18 (95% CI, 0.13-0.25) for myotomy with posterior fundoplication. The increased odds of postoperative dysphagia in the group undergoing myotomy with anterior fundoplication compared with the group undergoing myotomy with posterior fundoplication were statistically significant (P < .001). However, the incidence of a postoperative abnormal 24-hour pH test result was statistically similar. CONCLUSION Partial posterior fundoplication when combined with an esophagocardiomyotomy may be associated with significantly lower reintervention rates for postoperative dysphagia, while providing similar reflux control compared with partial anterior fundoplication.

Technique of per-oral endoscopic myotomy (POEM) of the esophagus (with video)

BackgroundPer-Oral Endoscopic Myotomy (POEM) is becoming an acceptable alternative to laparoscopic cardiomyotomy for esophageal motility disorders. The aim of this video is to provide key technical steps to completing this procedure.MethodEach patient underwent diagnostic investigations including high resolution manometry (HRM), esophageogastroduodenoscopy (EGD), and timed-barium swallow for primary esophageal motility disorders preoperatively. Patients undergoing POEM procedures are preoperatively prepared by taking Nystatin swish-and-swallow for 3 days, 24 h of clear liquid diet, and 12 h of NPO. Preoperative antibiotics are given. Under general anesthesia and with the patient in the supine position, endoscopy with CO2 insufflation is prepared. Special endoscopic instruments and electrocautery settings are required to perform the POEM procedure, as illustrated in the slides. POEM is performed in six key/critical steps: (1) diagnostic endoscopy; (2) taking measurements; (3) esophageal mucosotomy creation; (4) submucosal tunneling; (5) selective circular myotomy of the anterior lower esophageal sphincter; and (6) closure of the mucosotomy. According to our protocol, all patients get an esophogram the next morning after surgery prior to discharge. The patient receives objective testing (HRM with 24 PH Impedance test, EGD, and timed-barium swallow) 6 months postoperatively.ConclusionIn six key steps, POEM can be accomplished as described in the video.

Peroral endoscopic myotomy as salvation technique post‐Heller: International experience

Treatment for achalasia has traditionally been Heller myotomy (HM). Despite its excellent efficacy rate, a number of patients remain symptomatic post‐procedure. Limited data exist as to the best management for recurrence of symptoms post‐HM. We present an international, multicenter experience evaluating the efficacy and safety of post‐HM peroral endoscopic myotomy (POEM).

Subxyphoid Thyroidectomy A Feasibility Study

Objective. The cultural desire to avoid cervical incisions and increasing concern for cosmetic outcomes has motivated surgeons to develop alternative approaches to thyroid surgery. The Direct Drive Endoscopic System (DDES) platform combines a flexible endoscope with a pair of separately controlled articulating instruments through a single, flexible, access system. We hypothesized that the DDES platform would permit single-incision minimally invasive thyroid lobectomy without robotic assistance. Methods. This is a single-cadaver feasibility study. A single, 2.2-cm subxyphoid incision was used for access. The platform’s 55-cm flexible sheath was secured to the operating table rails and introduced into the subcutaneous space. A flexible pediatric endoscope was simultaneously introduced with 2 interchangeable 4-mm instruments. Blunt dissection and electrocautery were used to create the tunnel in the otherwise free central plane. The thyroid was dissected using a superior to inferior technique while maintaining the critical steps of traditional thyroid surgery. A Veress needle introduced through the lateral neck provided additional retraction. Results. The total operating time was 2.5 hours. The subcutaneous tunnel was safe and accommodated the DDES well. Visualization was adequate. Graspers, scissors, and hook cautery were used to complete the lobectomy. The ergonomics, articulation, and strength of the instrumentation were sufficient. Conclusions. Subxyphoid thyroidectomy is technically possible and avoids the difficulties inherent to a transaxillary approach while still avoiding cosmetically unappealing cervical scars. Continued technological refinement will only expand the therapeutic possibilities of flexible endoscopy while minimizing the physical insult to patients and maximizing aesthetics for patients.

Endoscopic Tools and Techniques for Fistula and Leaks

Since the first attempts at intestinal anastomoses, leaks and fistulas have been a constant problem. In particular, the rising prevalence of morbid obesity and corresponding increase in the volume of bariatric surgery have led to a mounting experience with associated gastrointestinal anastomotic complications. Anastomotic or staple-line leaks after gastrointestinal surgery are relatively uncommon complications, but quite morbid and potentially lethal.

Long-term outcomes following POEM for non-achalasia motility disorders of the esophagus

BackgroundOptimal treatment for symptomatic patients with non-achalasia motility disorders (NAD) such as diffuse esophageal spasm, esophagogastric junction outlet obstruction, and hypercontractile disorder is not well established. POEM has been offered to these patients since it is a less invasive and less morbid procedure but long-term outcomes remain undetermined. The aim of this study was to assess long-term outcomes of POEM for patients with NAD.MethodsRecords of 40 consecutive patients undergoing POEM for NAD from May 2011 to January 2016 at a single center were retrospectively reviewed. Preoperative and 6-month postoperative symptom scores, high-resolution manometry, pH testing, and timed barium swallow (TBS) data were collected. Patients were contacted by phone to obtain long-term symptom assessment. Symptoms were assessed using a standardized symptom questionnaire with scores for symptoms graded according to frequency and the Eckardt score.ResultsTen percent had minor complications with no postoperative sequelae. 90% of patients had significant improvement in their mean Eckardt scores (5.02 vs. 1.12, p < 0.001) at early follow-up. Improvements in chest pain (1.02–0.36, p = 0.001) and dysphagia (2.20 vs. 0.40, p = 0.001) were seen. Significant improvements in manometric pressures and esophageal emptying on TBS were observed across groups. 38% (10/26) of patients had a postoperative pH score > 14.72. Long-term (median 48 months) symptom scores were obtained from 29 (72.5%) patients. 82% of patients (24/29) had sustained symptom improvement. A small increase in the dysphagia scores was reported in the long-term follow-up compared to the immediate postoperative period (0.36–0.89, p = 0.046).ConclusionsChest pain and dysphagia are effectively palliated with POEM in patients with non-achalasia disorders of the esophagus. Significant improvements are durable in long-term follow-up. Despite earlier reports by our group suggesting possible inferior outcomes from POEM for this difficult group of patients, this study is far more encouraging. POEM should be considered in the treatment of patients with non-achalasia disorders of the esophagus.