Introduction

Upper dysphagia is a swallowing disorder associated with underlying pathology in the mouth, throat, or esophagus. Cricopharyngeal achalasia (CA) may cause upper dysphagia and its diagnosis is not well established. In case of CA, endoscopic myotomy of upper esophageal sphincter (C-POEM) may be offered to relieve symptoms.

Aims & Methods

We present our experience in diagnosing and managing upper dysphagia with suspicion on CA in patients referred to our center between May 2022 and April 2024. The patients with Zenker diverticulum or organic stricture were not enrolled. All patients underwent X-ray examination, high-resolution manometry and endoscopy. In patients with suspected CA, botulinum toxin injection (100 IU) was administered into the upper esophageal sphincter. After botulinum toxin injection, the follow up visits were scheduled 1, 5 and 12 months after the procedure. In case of a positive effect of the injection, C-POEM (endoscopic myotomy of cricopharyngeal muscle) was considered after the effect of botulinum toxin had vaned. FOSS Function Outcome Swallowing Score and Dakkak and Bennett score of dysphagia were used to assess the severity of the symptoms. The score systems are listed in the table.

Results

Ten patients (4 males, 6 female) were referred to our center with long term upper esophageal dysphagia and considered eligible for botulinum toxin injection. The mean age was 69.7 years (ranges 30, 85), mean duration of symptoms was 8.6 years (SD ± 11) Three patients were unable to swallow safely and PEG tube had to be placed for nutritional support. Aetiologies of dysphagia were cervical injury (n=2), radiotherapy (n=2) and previous neurosurgery (n=1) or idiopathic dysphagia.
All patients underwent botulinum toxin injection. One patient developed vocal cord paresis one week after the injection and her condition improved after corticoid administration. No other adverse events of botulinum toxin were observed.
Improvement of dysphagia occurred in 7 patients after botulinum toxin injection while no change in symptoms was present in 3 patients. One month after the procedure mean
FOSS Function Outcome Swallowing Score improved from 3.3 to 1.56 (p = 0.015) and Dakkak and Bennett score of dysphagia from 2.7 to 1.33 (p=0.012). Two patients received successful C-POEM, the remaining patients will be offered C-POEM once a recurrence of symptoms will occur.
Three patients without effect of botulinum toxin injection were considered endoscopically incurable and referred back to neurology or otorhinolaryngology departments.

Conclusion

Botulinum toxin injection may be effective in treating upper dysphagia caused by a spasm of cricopharyngeal muscle and may serve as a useful selection tool for endoscopic myotomy.

Introduction

Gastric peroral endoscopic myotomy (G-POEM) is an emerging endoscopic technique for the treatment of refractory gastroparesis, particularly benefiting patients with pylorospasm. It is considered a safe procedure with a low risk of adverse events when performed by experienced endoscopists. Our aim was to perform a comprehensive analysis of all adverse events associated with G-POEM.

Aims & Methods

We performed a retrospective analysis of prospectively collected data from all patients who underwent G-POEM for gastroparesis at our centers (Prague, Brno) between November 2017 and April 2025. All procedures were performed by a single endoscopist (JM). The primary outcome was procedure-related adverse events rate and severity occurring during the perioperative and early postoperative period. Adverse events were categorized as follows: deviations from the expected peri and postoperative course were defined as "undesirable events." Undesirable events that met the criteria of the Clavien Dindo surgical classification (C-D) were considered "true adverse events".

Results

Out of 70 procedures, no true adverse or undesirable events occurred in 51 procedures (72.9%). Perioperatively, the following undesirable events occurred in 18 patients: : gastric (4; 5.7%) and duodenal mucosal injuries (2; 2.8%), major bleeding during the procedure treated endoscopically (1; 1.4%), serosal perforation (10; 14.3%), capnoperitoneum requiring puncture (3; 4.3%), and subcutaneous emphysema (1; 1.4%). In the early postoperative period, adverse events occurred in 3 patients: one patient complained of significant abdominal pain necessitating analgetics, subsequently, a small leak from the pyloric region to the subhepatic region was described on CT and gastroscopy confirmed ulceration at the tunnel site. The patient responded well to treatment with intravenous proton pump inhibitors. In two other cases, both involving patients with diabetic gastroparesis, decompensation of diabetes occurred during the hospital stay post-procedure. The following “undesirable” events were considered true adverse events according to the C-D classification: serosal perforation (10; C-D I), leak requiring prolonged hospitalization (1; C-D IIIa) and diabetes decompensation (2; C-D II). These complications occurred in 13 procedures (18.6%).
The mean duration of hospitalization after the procedure was 2 days (range 1-7). Three months after the procedure, 1 patient developed mild dumping syndrome, which was successfully treated conservatively.

Conclusion

G-POEM is a safe procedure. The rate of true adverse events according to Clavien-Dindo classification is low and severe AEs occurs rarely.

Introduction

Peroral endoscopic myotomy (POEM) is considered a standard method for achalasia treatment with excellent long term treatment success. However, the benefits of POEM are tempered by the risk of post-POEM reflux complications.

Aims & Methods

The aim of this retrospective analysis of prospectively collected data was to assess the long-term post-POEM reflux. Data from all consecutive patients who underwent POEM between December 2012 and April 2023 were analyzed. The patients assessed symptoms at 3 and 12 months after the procedure and every year thereafter. The patients underwent upper GI endoscopy, high-resolution manometry (HRM) and 24-hour pH monitoring 3 months after the procedure; endoscopy was then repeated at 2-3 years and at 6 year follow-up. Reflux esophagitis, reflux parameters measured by 24h pH monitoring (off PPIs), reflux symptoms and the use of proton pump inhibitors (PPIs) were the principal outcomes.

Results

A total of 539 POEM procedures (20x re-POEM) were performed in 519 patients. Three months after the procedure, 390 patients underwent 24h pH monitoring with abnormal acid exposure in 178 of them (45.6% [95% CI: 40.7, 50.6]). Reflux esophagitis was present in 181/463 patients (39.1% [95% CI: 34.7, 43.6]; LA C/D in 20 patients, 4.3%) at 3 months, in 94/263 patients (35.7% [95% CI: 30.2, 41.7]; LA C/D in 5 patients, 1.9%) at 24-36 months and in 18/88 patients (20.5% [95% CI: 13.3, 30]; LA C/D in 0 patients) 6 years after procedure. Follow- up questionnaires were completed in 185, 161 and 106 patients 48, 60, 72 months after the procedure and 34.6%, 35.7% and 34.4% of patients claimed occasional heartburn and 18.1%, 20.4% and 19.6% experienced occasional regurgitation of gastric content. However, only the minority (under 2% of the patients at 48, 60, 72 months) experienced the symptoms on daily basis. PPIs were administered to 53.3%, 48.4% and 54.3% of patients at 48, 60 and 72 months after POEM with majority of them (80%) taking PPIs on daily basis. We also investigated whether there were any differences in patients with and without PPIs. In patients with PPIs, there were less cases of reflux esophagitis 3 months after POEM (32.4% vs. 43.5%). More patients with PPIs experienced post-POEM heartburn (42.3% vs. 25.9%) at 48 months and at 60 months (48.7% vs. 25.4%). There were no significant differences in terms of pathological reflux on 24-hour pH monitoring and in the occurrence of severe esophagitis between patients with vs. without PPIs. Regarding severe reflux complications, there were no new cases of Barrett's esophagus and esophageal adenocarcinoma. One patient developed peptic stricture, which was successfully treated with balloon dilation. The outcomes were not different among patients who underwent anterior (60%) vs. posterior myotomy (40%).

Conclusion

The rate of post-POEM reflux esophagitis decreases over time, however approximately 50% of patients require long-term antisecretory treatment. Even if the risk of reflux complications is low, patients after POEM should remain under long-term surveillance.

Introduction

We previously reported 6 months results of a prospective, randomized and sham-controlled trial comparing endoscopic pyloromyotomy (G-POEM) with a sham procedure in patients with gastroparesis (GREG, 1). G-POEM was superior to a sham procedure in terms of both symptoms improvement and gastric emptying rate. Moreover, cross-over G-POEM, which was performed after a sham procedure was effective in 75% of patients. All patients have been prospectively followed according to an original protocol. Here, we report the long-term results. Unblinding of patients occurred 6 months after the originally allocated procedure (G-POEM or sham).

Aims & Methods

In GREG trial, G-POEM has been compared to a sham procedure in patients with refractory and severe gastroparesis (gastroparesis cardinal symptom index (GCSI) > 2.3, duration of symptoms of at least 6 months, with no adequate response to conservative measures). Patients randomized to the sham group with persistent symptoms were offered cross-over G-POEM. Symptoms were assessed in all enrolled patients (including those with a sham procedure only) at 12, 24 and 36 months, gastric emptying study and upper GI endoscopy were repeated at 12 months only in patients who underwent G-POEM (either primary or cross-over). The main outcomes were proportion of patients with treatment success and recurrences. Kaplan-Meier curve has been constructed to analyze the long-term effects.

Results

From a total of 41 randomized patients with gastroparesis (17 diabetic, 13 postsurgical, 11 idiopathic; 46% male), 33 patients received G-POEM (21 primary, 12 cross-over). Among these, median follow-up was 24 months and treatments success rates evolved from 72% (95% CI: 59%-90%) at 6 months to 67% (95% CI 52%-85%) at 12 months, 64% (49%-82%) at 24 months and 36 months. The corresponding numbers for diabetic, postsurgical and idiopathic gastroparesis at 36 months were 71% (51%-100%), 36% (17%-80%) and 78% (55%-100%). Overall, 3 patients (2 diabetic, 1 postsurgical) with previous treatment success experienced a recurrence of symptoms, however none of these patients required further intervention yet. One female patient with a primary treatment failure underwent redo G-POEM with treatment success (post-surgical etiology). Median gastric retention at 4 hours did not change between 3- and 12-months follow-up (6.7% to 10.0%). Seven patients underwent a sham procedure only, 4 achieving treatment success at 6 months. There were no symptomatic recurrencies up to 36 months follow-up. Among three “only sham” patients without a treatment success, one patient died from other reason and two patients who initially refused cross-over G-POEM decided to undergo this procedure later (one with treatment success, one is scheduled).

Conclusion

Endoscopic pyloromyotomy leads to a sustained improvement in approximately two thirds of patients with refractory GP and the rate of recurrencies is low. Diabetic and idiopathic GP showed a trend towards a higher long-term effect compared to postsurgical GP. Significant improvement of symptoms after sham procedure was infrequent but long-lasting.

References

Martinek J, Hustak R, Mares J, et al. Endoscopic pyloromyotomy for the treatment of severe and refractory gastroparesis: a pilot, randomised, sham-controlled trial. Gut 2022;71:2170–8.

Introduction

Gastroparesis (GP) is defined as symptomatic delayed gastric emptying. The most frequent etiologies are diabetes mellitus, after esophageal or gastric surgery and about a third of patients have idiopathic GP. The gastric emptying study by using a scintigraphy scintigraphy (GES) is considered as a principal diagnostic method. Endoscopic pyloromyotomy (G-POEM) is a method improving symptoms in about 60-70% of patients with GP. Its effect on gastric emptying remains controversial.

Aims & Methods

We performed a retrospective single-center analysis to assess the clinical efficicacy of G-POEM based on GES parameters. Between 2016 – 2024, a total of 72 patients with GP (confirmed by scintigraphy) underwent G-POEM and were later invited for clinical as well as scintigraphic assessment after 3, 12 and 36 months. Of these patients, 4 were excluded for missing data, incomplete follow-up data or non-standard testing meal. GES was always performed using the standardized 4 hours protocol with the standard testing meal mixed with 99Tc-DTPA. For this study, all GES were reanalyzed and the following parameters were established : residual activity after 2 hours, residual activity after 4 hours, biological halftimes of ingested activity and proximal-to-distal count ratio for time 0 (PDCR0).

Results

Mean value of GCSI before G-POEM was 3.1 and decreased to 1.6, 1.0 and 0.7 after 3, 12 and 36 months. Median value of GES after 2 hours was 60.2% before G-POEM and 38%, 32.6% and 24.2% after 3, 12 and 36 months. Median value of GES after 4 hours was 21.9% before G-POEM and 7.8%, 6.5% and 3.9% after 3, 12 and 36 months. Correlation index was weakly positive for GCSI and GES after 4 hours only for the first follow-up visit and negative for all remaining visits.
The residual activity after 2 hours and residual activity after 4 hours decreased after G-POEM during all follow-up visits (p<0,001). Mean decrease of residual activity after 4 hours was 12.89%, 15.13% and 6.7% after 3, 12 and 36 months.
Biological halftime also decreased after the procedure with statistically significant results with the mean halftime before G-POEM being 150 min and 86 min, 78.4 min and 65.8 min after 3, 12 and 36 months.
There was a difference between the diabetic and non-diabetic groups, with higher residual activity after 2 hours [median 29.6% before G-POEM, 9.0% after 3 months (p<0.001) and 11.0% after 12 months (p=0.005)] and 4 hours [median 64.8% before G-POEM, 39.4% after 3 months (p<0.001) and 37.7% after 12 months (p=0.012)] respectively in patients with diabetes.
The predictive value of PDCR0 for treatment success after G-POEM was only calculated for the first follow-up visit but was not statistically proved (p=0,712).

Conclusion

In our group of patients there is a weak correlation between the decrease of GCSI and GES early after G-POEM. The decrease in GES parameters tends to be lower in patients with diabetes compared to non-diabetic patients. Based on our data, predicting clinical success of G-POEM using PDCR0 cannot be recommended.

Introduction

Thoracic surgeries have been the traditional therapeutic approach for esophageal giant subepithelial lesions (g-SELs). Due to the rapid development of endoscopic techniques, increased reports on endoscopic resection (ER) of g-SELs have emerged in recent years.

Aims & Methods

We aimed to summarize the experience of our center on ER of esophageal g-SELs, and also develop a nomogram model to predict the procedural difficulty. 75 patients with g-SELs treated with ER at Zhongshan Hospital were included in the training set. Clinicopathological features, procedure-related characteristics, postprocedural outcomes and follow-up data were gathered and analyzed. A predictive nomogram model for procedural difficulty was proposed based on the risk factors identified by multivariable logistic regression analysis. Internal and external validation were conducted to verify the model performance.

Results

Of the 75 cases, the en bloc resection rate was 93.3%. Intraoperative and postoperative adverse events occurred in 7(9.3%) and 13(17.3%) patients, respectively. No recurrence or metastasis was observed. 32(42.7%) patients underwent a difficult procedure. A younger age, maximal tumor diameter ≥ 8 cm, irregular shape and extraluminal growth pattern were independent risk factors of a difficult procedure, while adopting submucosal tunneling endoscopic resection (STER) as the ER method was inversely correlated with procedural difficulty. The nomogram model showed good discrimination, with the area under the receiver-operating characteristics curve (AUC) of 0.858 and 0.827 of the training and validation set. Calibration curves and Hosmer-Lemeshow tests (P =0.524 of the training set and 0.413 of the validation set) also achieved favorable results.

Conclusion

ER serves as a promising therapeutic option for esophageal g-SELs. A younger age, large tumor size, irregular shape and extraluminal growth may indicate increased ER difficulty, while a STER procedure tends to be of lower difficulty. Our nomogram model performs well to predict ER difficulty for esophageal g-SELs.

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.