Introduction

Untreated symptomatic achalasia leads to decreased caloric intake due to adjustment of the composition of the diet to impaired esophageal emptying. Peroral endoscopic myotomy (POEM) provides reversion of normal eating pattern with consequent weight gain. We performed in-depth analysis of the metabolomic composition of blood plasma before POEM and the composition of the gained tissue mass 3 months after POEM using nuclear magnetic resonance spectroscopy and bioimpedance scale.

Aims & Methods

Consecutive patients with symptomatic untreated achalasia were included in the study. At the first visit (hospital admission due to POEM procedure), we evaluated Eckardt score, obtained blood metabolomics using nuclear magnetic resonance (NMR) spectroscopy and nutrition-related parameters obtained using bioimpedance scale (body weight, muscle and fat weight). At the second visit 3 months after the POEM procedure, the same NMR metabolomic and nutritional parameters were obtained.

Results

43 patients (22M/21F) were included in the study. The symptoms significantly improved 3 months after the POEM procedure (Eckardt score 6.86±1,92 vs. 0,71±0,77, p<0.0001). The average overall weight gain was 5,58±5,05 kg, average fat gain was 1,77±3,33 kg and average muscle gain was 1,33±4,78kg. We also determined the difference in the muscle and fat contribution to the weight of the patient (pre and post POEM, expressed in %). We performed correlation analyses between the amount of amino acids before POEM and the gain of the muscle weight and fat weight. We observed that the individual levels of branched chain amino acids (valine, leucine, isoleucine) (BCAA), their keto acids (ketovaline, ketoleucine, ketoisoleucine) and levels of glutamine, histidine and lysine before POEM were positively correlated with the % of muscle gain (p values in range 0.03-0.0004) and inversely correlated with the % of fat gain (p values in range 0.01-0.00001, Pearson correlation).

Conclusion

Our analysis revealed that post POEM muscle mass gain is directly correlated to the amount of proteogenic amino acids in circulation before the intervention. The level of BCAA before POEM showed consistent positive correlation to the increase of the muscle mass 3 months after POEM. This finding could further serve as a guidance for nutrition strategies in patients with yet untreated achalasia and also in the broader spectrum of patients with impaired caloric intake. We suggest that achalasia could serve as a study model for metabolic changes related to restored normal dietary pattern. Supported by VEGA 1/0060/23.

Disclosure

Nothing to disclose.

Introduction

Peroral endoscopic myotomy has become the mainstay of treatment of achalasia. Oral feeding has been initiated if no submucosal leak of the contrast fluid was detected on the X-ray contrast study which was performed the following day after the procedure. However, as major adverse events are rare, and in case of their occurrence, are rarely asymptomatic, it has become unclear whether routine X-ray contrast study is necessary. In our center we have been performing POEM procedures since 2015 and initially routinely performed X-ray contrast study. However,during the course of time it has become unavailable and we were forced to initiate oral feeding diet based on our clinical decision. We adopted a protocol of the initiation of oral liquids on the 2 nd postoperative day (or later in case of suspected complication). We therefore compared these two strategies in terms of periprocedural and postprocedural complications rate and the length of the hospital stay.

Aims & Methods

This is a retrospective analysis of the single high-volume center. We evaluated (1) the rate of peri- and postprocedural complications and (2) length of the hospital stay in patients hospitalized for POEM for esophageal achalasia in 2015-2023. We separately evaluated the “X-ray subgroup” (oral feeding was initiated after X-ray that was performed the day after the procedure) and the “clinical decision subgroup” (oral feeding was initiated on the 2 nd postoperative day).

Results

We analyzed a total number of 274 POEM procedures (129 males, 145 females), mean age was 52,3±16 years. 102 patients (37.2%) received X-ray contrast study after the procedure, in 169 patients (62.8%) the initiation of oral feeding was based on clinical decision. The mean time of the hospital stay was 7.2±2.9 vs. 6.5±1.4 days in the X-ray group and in the clinical decision group, resp. (p<0.004).
In the X-ray group we detected complications in 8 patients (7.7%). 5 were periprocedural (mucosal perforation or aspiration during intubation), were solved during the procedure and did not lead to the extension of the hospital stay. There were postprocedural complications in 3 patients. In one case submucosal leak was detected on X-ray contrast study the following day after the procedure due to loosened clip in the mucosal entry and was solved by placing additional clips. In one case patient presented with bleeding from the mucosal entry after discharge. In one case the patient developed mediastinitis that led to the extension of the hospital stay. In the clinical decision group we detected complications in 10 patients (5.9 %), 9 of them were periprocedural (mucosal perforation or aspiration during intubation), 8 of which were solved during the procedure by endoscopic clipping and did not lead to the extension of the hospital stay, 1 required surgery. In one case of postprocedural complication perforation with pleural effusion was detected on CT scan and required
surgical intervention that led to the extension of the hospital stay.

Conclusion

Our analysis shows that severe complications after POEM are rare. In the X-ray subgroup there was only single postprocedural event in which X-ray was helpful in its early detection (1%). In the clinical decision subgroup there was also only single event that could have been identified on the X-ray (0.6%). The length of the hospital stay in the clinical judgement group was significantly shorter than in the X-ray group. This can be attributed to the improvement of overall experience with the management of the POEM patients as X-ray contrast has become unavailable after performing c.a. 100 POEM procedures.

References

Weusten, Bas L A M et al. “Endoscopic management of gastrointestinal motility disorders - part 1: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.” Endoscopy vol. 52,6 (2020): 498-515. doi:10.1055/a-1160-5549

Introduction

Eosinophilic esophagitis is a chronic, immune-mediated inflammatory disease of esophagus characterized by a significant mucosal eosinophilia. However, the definite cause of this disease remains unknown. One of the most probable etiology factors is an abnormal response of immune system to various types of ingested food. Therefore, one of the treatment options is the so called 6-food elimination diet. This diet represents a therapeutic method of choice especially in patients who could not be treated by standard immunosuppressive medications such as corticosteroids. The 6 food groups that are mostly associated with food allergies are: eggs, dairy products, seafood/shellfish, nuts, wheat, and soy. Although widely used, there is surprisingly lack of data evaluating its effect on metabolomic profile of the patients and their well-being despite its strict dietary regime.

Aims & Methods

The aim of this study was to evaluate possible changes in metabolomic and anthropometric parameters in healthy individuals pre and after 4 weeks of elimination diet.
We performed a prospective single center study on healthy volunteers (age >18 years). For metabolomic analysis of blood plasma and urine the method of NMR (Nuclear Magnetic Resonance) was used. Anthropometric analysis was performed by bioelectrical impedance. All volunteers also filled validated questionnaires considering various aspects of patient well-being (WHOQOL-BREF, PROMIS-10 and PHQ-15). The statistical analysis was processed by unparametric tests (Mann-Whitney U-test) for comparison of equality of medians and unparametric paired Wilcoxon-signed-rank test.

Results

Fifteen (15) healthy volunteers without any previous dietary restrictions participated in this study (12 women with median age 35,5 years and 3 men with median age 41 years). Evaluation of blood plasma metabolomic profile shows significant increase of acetate, succinate, creatine, and creatinine at the end of the four weeks period of the course of the diet. The urine metabolomic profile shows significant decrease of dimethylamine. Importantly, no statistically significant changes were observed in the levels of essential aminoacids. No relevant differences were observed considering anthropometric parameters (BMI, percentage of fat and muscle mass) and in the questionnaires assessing quality of life.

Conclusion

The results of presented study shows that the 6-food elimination diet have only minor effect on the metabolomic profile of healthy volunteers. This further suggest its good safety profile for the treatment of eosinophilic esophagitis. In addition, presented data point out that this diet does not significantly lower the quality of life of patients which could result to good adherence to the diet in short term course.

Clinical Case Summary

Achalasia is a rare esophageal motility disorder in children, with an estimated incidence of 0.02–0.11 per 100,000. The condition leads to failure of lower esophageal sphincter (LES) relaxation and absence of peristalsis, often resulting in feeding difficulties, vomiting, and growth retardation. Conventional treatments such as pneumatic balloon dilatation (PD) are often ineffective in very young children due to technical limitations and high recurrence rates. Peroral endoscopic myotomy (POEM) has emerged as a minimally invasive alternative, but data in the pediatric population, particularly in children under 3 years, are limited.
We present a 2-year-old boy with persistent vomiting, dysphagia, and failure to thrive. He weighed only 8 kg and had undergone two unsuccessful PD attempts. POEM was performed under general anesthesia using pediatric-modified technique: a 10-cm submucosal tunnel and 8-cm myotomy (5 cm selective, 3 cm full-thickness) were completed. Intraprocedural pneumoperitoneum was managed via Veress needle decompression. No complications occurred, and the child was discharged after 7 days. One month postoperatively, he gained 2 kg and achieved symptom resolution. Follow-up at 3 and 6 months showed continued weight gain and an Eckardt score improvement from 10 to 1.
This case highlights that POEM is feasible, effective, and safe even in very young and underweight children. It supports the expansion of POEM into earlier pediatric age groups, offering a durable alternative when conventional therapies fail.

References

1. Zhong C, Tan S, Huang S, et al. Clinical outcomes of peroral endoscopic myotomy for achalasia in children: A systematic review and meta-analysis. Dis Esophagus. 2021;34(4):1–11. doi:10.1093/dote/doaa112
2. Maselli R, Inoue H, Misawa M, et al. Peroral endoscopic myotomy (POEM) in a 3-year-old girl with severe growth retardation, achalasia, and Down syndrome. Endoscopy. 2012;44(Suppl 2):285–8. doi:10.1055/s-0032-1306696
3. Duman S, Yurci A, Cho JY. Peroral Endoscopic Myotomy (POEM) in a 19-Month-Old Girl with Primary Achalasia. J Dig Endosc. 2023;14(02):112–114. doi:10.1055/s-0043-1768544
4. Familiari P, Marchese M, Gigante G, et al. Peroral endoscopic myotomy for the treatment of achalasia in children. J Pediatr Gastroenterol Nutr. 2013;57(6):794–797. doi:10.1097/MPG.0b013e3182a80b13

Introduction

Peroral endoscopic myotomy (POEM) has become the mainstay of treatment of oesophageal achalasia in adult patients and recently also gained acceptance as effective therapy of achalasia in paediatric population. Here we retrospectively reviewed prospectively collected children with achalasia that had been treated with POEM at our institution.

Aims & Methods

Patients that were hospitalized in the Paediatric Clinic for POEM procedure from 11/2017 to 05/2023 were included. All patients had achalasia confirmed by high resolution manometry (HRM). We evaluated their symptoms in terms of duration and intensity (Eckardt score) and the integrated relaxation pressure (IRP) obtained by HRM before POEM. 3 months after POEM during the follow-up visit we determined Eckardt score, IRP and the presence of reflux oesophagitis on upper endoscopy. When finalizing the abstract we conducted a brief telephone survey to determine Eckardt score and presence of reflux symptoms.

Results

10 patients (6 boys and 4 girls), mean age 11.5 (5-18) years were included. 9 of these patients received POEM as their first therapy for achalasia, 1 patient had been previously treated surgically via thoracotomy. The median of the duration of symptoms was 8.5 (range 1-36) months. All patients were diagnosed with type I achalasia according to Chicago classification. Eckardt score decreased significantly 3 months after POEM (7.38±1.68 vs. 0.63±1.06 before and after POEM, respectively, p<0.0001) and sustained unchanged (0.4±0.66) during the median follow-up of 21.5 months (range 1-60 months). IRP also significantly decreased after the intervention (46.5±11.1 mmHg vs. 3.8±5.68 mmHg; before and after POEM, respectively, p=0.0001). Complications occurred in 2 patients. Pleuropneumonia in one patient led to extension of hospital stay and was solved conservatively. Upper GI bleeding occurred in one patient 2 weeks after discharge, was self-limited without any obvious source found. Follow-up endoscopy was performed off PPI therapy and revealed mild esophagitis (LA A) in 2 patients that also reported mild heartburn.

Conclusion

POEM represents an effective therapy for achalasia in paediatric population in mid-term follow-up as it significantly improves symptom and provides effective decrease of the IRP. Although in our case series no severe heartburn or reflux esophagitis occurred, more data with longer follow up are needed to prove either long-term safety with regard to the reflux issue and the need for long term PPI therapy in these patients. Supported by VEGA 1/0060/23.

Introduction

Since 2010, per oral endoscopic myotomy (POEM) has become an important part of the treatment for achalasia. This technique involves myotomy of the lower esophageal sphincter and can be performed using various technical modalities, some of which have already been studied (such as different myotomy lengths and anterior versus posterior approach). The aim of this study is to compare the impact of the depth of myotomy (selective inner layer myotomy (SIM) vs full-thickness myotomy (FTM)) on the outcomes of patients treated with POEM for achalasia.

Aims & Methods

This was a retrospective, observational, bi-centric study conducted in two tertiary center between October 2018 and September 2022. Patients were divided into two groups: SIM and FTM. The primary endpoint was clinical efficacy at 6 months, while secondary endpoints were postoperative parameters (such as pain, length of hospital stay, complications) and gastroesophageal reflux disease (GERD) parameters (esophagitis at 6 months, heartburn, and pH-metry).

Results

Out of the 166 patients who underwent POEM, 158 were included in the study (33 in the FTM group and 125 in the SIM group). The clinical efficacy rates at 6 and 12 months were similar in both groups, with 84% and 70% in the SIM group versus 90% and 80% in the FTM group, respectively (p=0.57 and p=0.74). However, more opioid analgesics were consumed in the FTM group compared to the SIM group (45% vs 21%, p<0.01). The length of hospitalization was longer in the FTM group than in the SIM group (2.94 ± 2.33 vs 2.17 ±2.62, p<0.001). The rate of esophagitis at 6 months was comparable (16% in the SIM group vs 12% in the FTM group, p=0.73). There was no significant difference in terms of pyrosis at 6 or 12 months between the SIM and FTM groups (18.5% vs 3.8%, p=0.07 and 27% vs 12.5%, p=0.35, respectively).

Conclusion

There was no significant difference in terms of clinical efficacy and GERD occurrence between FTM and SIM. However, full-thickness myotomy was associated with more postoperative pain and a longer length of hospital stay. Therefore, selective internal myotomy should be preferred over full-thickness myotomy.

Introduction

Gastroesophageal reflux is responsible for various extresophageal symptoms that are commonly labelled as laryngopharyngeal reflux (LPR). These mostly include cough, throat clearing, globus sensation and hoarseness. The pathophysiological link between reflux and symptoms likely includes direct effect of the refluxate on the upper airways epithelium and reflex that is initiated by stimulation of the afferent nociceptive fibres in the distal esophagus by acidic gastroesophageal reflux. Arguably, the relationship between reflux and laryngopharyngeal symptoms might involve other, yet not well explored mechanisms. In our previous research we found that LPR patients have impaired mucociliary clearance of the respiratory epithelium of the upper airways. This could contribute to the inflammation persistence and the presence of symptoms. We therefore aimed to determine whether any parameter of the reflux burden as detected by 24-hour pH/impedance correlates with ciliary beat frequency (CBF), the major quantifiable aspect of mucociliary clearance.

Aims & Methods

Consecutive patients with LPR confirmed by off PPI 24-hour pH/impedance had a sample of the ciliated epithelium obtained from the nose using a cytology brush. Nasal CBF was analysed using a digital high‐speed video microscope and the dedicated software application Ciliary Analysis (NI LabVIEW). Healthy volunteers without either esophageal or extraesophageal reflux symptoms served as a control group. Both patients’ and healthy volunteers’ group were without any airway inflammation at least 3 months prior to the evaluation and were at least 10 days of PPI therapy. Maximal, minimal, and the median value of the CBF (Hz) was obtained. We performed correlation analyses between the acid exposure time (AET), number of reflux episodes, mean nocturnal baseline impedance (MNBI) in all impedance segments (Z1-Z6) and CBF values.

Results

32 patients with LPR confirmed by 24-hour pH/impedance that had positive reflux symptom index (RSI>13) were included in the final analysis. Of them, 12 patients had confirmed by positive acid exposure time (AET>6%) and/or abnormal number of reflux episodes (>80). Firstly, we confirmed our previous observations that LPR patients had lower CB frequency (median value) compared to the healthy individuals (6,37±2,17 vs. 10,9±1,9; p<0.0001). Separate analysis of patients with proven GERD showed no CBF difference from the remaining (pH negative patients) (6,26±2,53 vs. 6,43±1,94; p=0,42). Secondly, we performed correlation analysis between AET/number of reflux episodes and CBF. We found no significant correlation between reflux burden and median value of CBF (N=32, R=-0.18, p=NS and R=0.05, p=NS for AET and number of refluxes, resp.). Thirdly, we performed correlation analyses between CBF and MNBI values of all impedance segments. Indeed, correlation analysis between median CBF and MNBI Z1-Z6 showed no significant correlations (N=32, R=-0.16, 0.09, 0.28, 0.01, 0.14 for Z1, Z2, Z3, Z4, Z5, Z6, resp., resulting in p=NS in all segments).

Conclusion

pH positive LPR patients had no difference in CBF values from the remaining (pH negative) patients. Reflux burden in the esophagus as determined by pH recording does not seem to be related to ciliary beat frequency. We observed no significant correlation between the MNBI values in any impedance segment and the median CBF value. Further research should be performed to determine the putative mechanism between the impairment of CBF and reflux.
Supported by: VEGA 1/0060/23