Clinical Endoscopy

Review

Role of endoscopy in patients with achalasia: So Young Han, Young Hoon Youn; Clin Endosc 2023;56(5):537-545. Published online June 2, 2023; DOI: https://doi.org/10.5946/ce.2023.001

Achalasia is an esophageal motility disorder characterized by impaired lower esophageal sphincter relaxation and peristalsis of the esophageal body. With the increasing prevalence of achalasia, interest in the role of endoscopy in its diagnosis, treatment, and monitoring is also growing. The major diagnostic modalities for achalasia include high-resolution manometry, esophagogastroduodenoscopy, and barium esophagography. Endoscopic assessment is important for early diagnosis to rule out diseases that mimic achalasia symptoms, such as pseudo-achalasia, esophageal cancer, esophageal webs, and eosinophilic esophagitis. The major endoscopic characteristics suggestive of achalasia include a widened esophageal lumen and food residue in the esophagus. Once diagnosed, achalasia can be treated either endoscopically or surgically. The preference for endoscopic treatment is increasing owing to its minimal invasiveness. Botulinum toxins, pneumatic balloon dilation, and peroral endoscopic myotomy (POEM) are important endoscopic treatments. Previous studies have demonstrated excellent treatment outcomes for POEM, with >95% improvement in dysphagia, making POEM the mainstay treatment option for achalasia. Several studies have reported an increased risk of esophageal cancer in patients with achalasia. However, routine endoscopic surveillance remains controversial owing to the lack of sufficient data. Further studies on surveillance methods and duration are warranted to establish concordant guidelines for the endoscopic surveillance of achalasia.

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Case of Concomitant Endoscopic Treatment of Achalasia with Superficial Esophageal Cancer
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Case Report

Two-Stage Peroral Endoscopic Myotomy for Sigmoid-Type Achalasia: Hak Su Kim, Hee Kyung Kim, Weon Jin Ko; Clin Endosc 2020;53(2):232-235. Published online July 16, 2019; DOI: https://doi.org/10.5946/ce.2019.067

Abstract PDF Supplementary Material PubReader ePub: Peroral endoscopic myotomy (POEM) has been recently considered as the first treatment option for achalasia. The standard POEM procedures are often successful in most patients, but sometimes technical challenges are encountered. We report a new technique that is divided between two tunneling sites in the esophagus for sigmoid-type achalasia. A 40-year-old male patient with dysphagia for 10 years was diagnosed with a sigmoid-shaped esophagus at our hospital. We devised a two-stage myotomy technique to treat sigmoidtype achalasia. The myotomy was first performed in the upper part of the greater flexion area and then in the lower part of the flexion. We termed this method “two-stage POEM”, which was successfully performed without any complications. This new POEM method can also be used to improve symptoms in patients with achalasia who have a structural deformity that may result in a high change of treatment failure.

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Original Article

Retention Esophagitis as a Significant Clinical Predictor of Progression to Esophageal Cancer in Achalasia: Haewon Kim, Hyojin Park, HeeSeung Choi, Yooju Shin, Hyunsung Park, Young Hoon Youn, Jie-Hyun Kim; Clin Endosc 2018;51(2):161-166. Published online March 6, 2018; DOI: https://doi.org/10.5946/ce.2017.087

Abstract PDF Supplementary Material PubReader ePub

Background
/Aims: Chronic liquid and/or food stasis caused by retention esophagitis (RE) in achalasia is a notable endoscopic finding because of the presence of a thickened or whitish esophageal mucosa and histologically altered squamous hyperplasia. We aimed to identify the clinical features of RE associated with achalasia and to clarify the clinical definition of RE in achalasia as a precancerous lesion identified by analyzing biomarker expressions.
Methods
From 2006 to 2015, we retrospectively reviewed 37 patients with achalasia without previous treatment. Among them, 21 patients had diagnostic findings of RE (RE+) and 16 patients had no diagnostic findings of RE (RE–). Immunohistochemical staining of p53, p16, and Ki-67 was performed on the endoscopic biopsy tissues from the patients with achalasia and 10 control patients with non-obstructive dysphagia.
Results
The symptom duration and transit delay were significantly longer in the RE+ group than in the RE– group. We found particularly high p53 positivity rates in the RE+ group (p<0.001). The rate of p16 expression was also significantly higher in the RE+ group than in the other two groups (p=0.003).
Conclusions
A high p53 expression rate was more frequently found in the RE+ group than in the other two groups. RE could be a meaningful clinical feature of achalasia for predicting esophageal carcinogenesis.

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Development and Validation of Serum Markers as Noninvasive Diagnostic Methods for Achalasia
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Ali Soroush, Arash Etemadi, Julian A. Abrams
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Shreya Chablaney, Rita M. Knotts
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Evaluation of Gastroesophageal Reflux Disease 1 Year after Esophageal Atresia Repair: Paradigms Lost from a Single Snapshot?
Renato Tambucci, Sara Isoldi, Giulia Angelino, Filippo Torroni, Simona Faraci, Francesca Rea, Erminia Francesca Romeo, Tamara Caldaro, Luciano Guerra, Anna Chiara Iolanda Contini, Monica Malamisura, Giovanni Federici di Abriola, Paola Francalanci, Andrea
The Journal of Pediatrics.2021; 228: 155. CrossRef
Endoscopic Surveillance in Idiopathic Achalasia
Olive Ochuba, Sheila W Ruo, Tasnim Alkayyali, Jasmine K Sandhu, Ahsan Waqar, Ashish Jain, Christine Joseph, Kosha Srivastava, Sujan Poudel
Cureus.2021;[Epub] CrossRef
Histopathological Analysis of Esophageal Mucosa in Patients with Achalasia
Bong Eun Lee, Gwang Ha Kim, Nari Shin, Do Youn Park, Geun Am Song
Gut and Liver.2021; 15(5): 713. CrossRef
Eosinophilic esophagitis in esophageal atresia: Tertiary care experience of a “selective” approach for biopsy sampling
Renato Tambucci, Francesca Rea, Giulia Angelino, Monica Malamisura, Maurizio Mennini, Carla Riccardi, Giovanni Farello, Laura Valfré, Luigi Dall’Oglio, Jonathan E. Markowitz, Alessandro G. Fiocchi, Paola De Angelis
World Allergy Organization Journal.2020; 13(4): 100116. CrossRef
Achalasia and associated esophageal cancer risk: What lessons can we learn from the molecular analysis of Barrett's–associated adenocarcinoma?
K. Nesteruk, M.C.W. Spaander, I. Leeuwenburgh, M.P. Peppelenbosch, G.M. Fuhler
Biochimica et Biophysica Acta (BBA) - Reviews on Cancer.2019; 1872(2): 188291. CrossRef
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Focused Review Series: Endoscopy in Children

Advanced Therapeutic Gastrointestinal Endoscopy in Children – Today and Tomorrow: Zaheer Nabi, Duvvur Nageshwar Reddy; Clin Endosc 2018;51(2):142-149. Published online December 12, 2017; DOI: https://doi.org/10.5946/ce.2017.102

Abstract PDF PubReader ePub

Gastrointestinal (GI) endoscopy plays an indispensable role in the diagnosis and management of various pediatric GI disorders. While the pace of development of pediatric GI endoscopy has increased over the years, it remains sluggish compared to the advancements in GI endoscopic interventions available in adults. The predominant reasons that explain this observation include lack of formal training courses in advanced pediatric GI interventions, economic constraints in establishing a pediatric endoscopy unit, and unavailability of pediatric-specific devices and accessories. However, the situation is changing and more pediatric GI specialists are now performing complex GI procedures such as endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography for various pancreatico-biliary diseases and more recently, per-oral endoscopic myotomy for achalasia cardia. Endoscopic procedures are associated with reduced morbidity and mortality compared to open surgery for GI disorders. Notable examples include chronic pancreatitis, pancreatic fluid collections, various biliary diseases, and achalasia cardia for which previously open surgery was the treatment modality of choice. A solid body of evidence supports the safety and efficacy of endoscopic management in adults. However, additions continue to be made to literature describing the pediatric population. An important consideration in children includes size of children, which in turn determines the selection of endoscopes and type of sedation that can be used for the procedure.

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Journal of Pediatric Gastroenterology and Nutrition.2020; 70(5): 681. CrossRef
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Case Reports

Double-Scope Peroral Endoscopic Myotomy (POEM) for Esophageal Achalasia: The First Trial of a New Double-Scope POEM: Hee Jin Hong, Ga Won Song, Weon Jin Ko, Won Hee Kim, Ki Baik Hahm, Sung Pyo Hong, Joo Young Cho; Clin Endosc 2016;49(4):383-386. Published online March 15, 2016; DOI: https://doi.org/10.5946/ce.2015.108

Abstract PDF PubReader ePub

With the accumulation of clinical trials demonstrating its efficacy and safety, peroral endoscopic myotomy (POEM) has emerged as a less invasive treatment option for esophageal achalasia compared with laparoscopic Heller myotomy. However, the difficulty in determining the exact extent of myotomy, a critical factor associated with the success and safety of the procedure, remains a limitation. Although the various endoscopic landmarks and ancillary techniques have been applied, none of these has been proven sufficient. As a solution for this limitation, the double-scope POEM technique with a second endoscope to assure the exact length of the submucosal tunnel has been applied since 2014. Before double-scope POEM was introduced, the second endoscope was applied only to confirm the accuracy of the procedure. In the present study, we performed double-scope POEM in the treatment of esophageal achalasia through a novel procedure of simultaneous application of the second endoscope to assist in the conventional POEM procedure.

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Ahmed Tawheed, Ibrahim Halil Bahcecioglu, Mehmet Yalniz, Mohamed El-Kassas
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Peroral Endoscopic Myotomy (POEM) in Children: A State of the Art Review
Ali A. Mencin, Amrita Sethi, Monique T. Barakat, Diana G. Lerner
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Per-oral endoscopic myotomy (POEM) for a sigmoid type of achalasia: short-term outcomes and changes in the esophageal angle
Shota Maruyama, Yusuke Taniyama, Tadashi Sakurai, Makoto Hikage, Chiaki Sato, Kai Takaya, Takuro Konno, Takeshi Naitoh, Michiaki Unno, Takashi Kamei
Surgical Endoscopy.2020; 34(9): 4124. CrossRef
Characteristics of a Subset of Achalasia With Normal Integrated Relaxation Pressure
Eunju Kim, In Kyung Yoo, Dong Keon Yon, Joo Young Cho, Sung Pyo Hong
Journal of Neurogastroenterology and Motility.2020; 26(2): 274. CrossRef
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Oscar Víctor Hernández Mondragón, Raúl Zamarripa Mottú, Omar Solórzano Pineda, Raúl Alberto Gutierrez Aguilar, Luís Fernando García Contreras
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Anastassios C. Manolakis, Haruhiro Inoue, Akiko Ueno, Yuto Shimamura
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Treatment of Achalasia with Per-Oral Endoscopic Myotomy: Analysis of 50 Consecutive Patients
Erica D. Kane, David J. Desilets, Donna Wilson, Marc Leduc, Vikram Budhraja, John R. Romanelli
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Two penetrating vessels as a novel indicator of the appropriate distal end of peroral endoscopic myotomy
Shinwa Tanaka, Fumiaki Kawara, Takashi Toyonaga, Haruhiro Inoue, Robert Bechara, Namiko Hoshi, Hirohumi Abe, Yoshiko Ohara, Tsukasa Ishida, Yoshinori Morita, Eiji Umegaki
Digestive Endoscopy.2018; 30(2): 206. CrossRef

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Extragastroesophageal Malignancy-Associated Secondary Achalasia: A Rare Association of Pancreatic Cancer Rendering Alarm Manifestation: Hong Min Kim, Ji Min Chu, Won Hee Kim, Sung Pyo Hong, Ki Baik Hahm, Kwang Hyun Ko; Clin Endosc 2015;48(4):328-331. Published online July 24, 2015; DOI: https://doi.org/10.5946/ce.2015.48.4.328

Abstract PDF PubReader ePub

Secondary achalasia or pseudoachalasia is a rare esophageal motor abnormality, which mimics primary achalasia; it is not easily distinguishable from idiopathic achalasia by manometry, radiological examination, or endoscopy. Although the majority of reported pseudoachalasia cases are associated with neoplasms at or near the esophagogastric (EG) junction, other neoplastic processes or even chronic illnesses such as rheumatoid arthritis can lead to the development of pseudoachalasia, for example, mediastinal masses, gastrointestinal (GI) tumors of the liver and biliary tract, and non-GI malignancies. Therefore, even if a patient presents with the typical findings of achalasia, we should be alert to the possibility of other GI malignancies besides EG tumors. For instance, pancreatic cancer was found in the case reported here; only four such cases have been reported in the literature. A 47-year-old man was admitted to our center with a 3-month history of dysphagia. His endoscopic and esophageal manometric findings were compatible with primary achalasia. However, unresponsiveness to diverse conventional achalasia treatments led us to suspect secondary achalasia. An active search led to a diagnosis of pancreatic mucinous cystadenocarcinoma invading the gastric fundus and EG junction. This rare case of pseudoachalasia caused by pancreatic carcinoma emphasizes the need for suspecting GI malignancies other than EG tumors in patients refractory to conventional achalasia treatment.

Citations

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Delayed Presentation of Malignancy-Associated Pseudoachalasia of the Gastric Cardia
Clive J Miranda, Farhan Azad, Ross R Moyer, Sasikanth N Ravi, Gina M Sparacino
Cureus.2024;[Epub] CrossRef
Is it necessary to perform a morphological assessment for an esophageal motility disorder? A retrospective descriptive study
Sofya Latrache, Chloe Melchior, Charlotte Desprez, Sabrina Sidali, Julien Recton, Olivier Touchais, Elise van der Eecken, Fabien Wuestenberghs, Cloe Charpentier, Anne Marie Leroi, Guillaume Gourcerol
Clinics and Research in Hepatology and Gastroenterology.2021; 45(6): 101633. CrossRef
When a Late Metastasis Is Hard to Swallow
Catarina Negrão, Rita Sismeiro, Margarida Monteiro, Filipa G Pereira, Marta Jonet
Cureus.2021;[Epub] CrossRef
Development of pseudoachalasia following magnetic sphincter augmentation (MSA) with restoration of peristalsis after endoscopic dilation
Katrin Schwameis, Shahin Ayazi, Ali H. Zaidi, Toshitaka Hoppo, Blair A. Jobe
Clinical Journal of Gastroenterology.2020; 13(5): 697. CrossRef
Burkitt’s Lymphoma of the Gastrohepatic Omentum: A Malignant Presentation of Pseudoachalasia
Eric Omar Then, Andrew Ofosu, Prashanth Rawla, Tagore Sunkara, Sriharsha Dadana, Andrea Culliford, Vinaya Gaduputi
Case Reports in Gastrointestinal Medicine.2019; 2019: 1. CrossRef

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Esophageal Cancer in Esophageal Diverticula Associated with Achalasia: Ah Ran Choi, Nu Ri Chon, Young Hoon Youn, Hyo Chae Paik, Yon Hee Kim, Hyojin Park; Clin Endosc 2015;48(1):70-73. Published online January 31, 2015; DOI: https://doi.org/10.5946/ce.2015.48.1.70

Abstract PDF PubReader ePub

The simultaneous occurrence of achalasia and esophageal diverticula is rare. Here, we report the case of a 68-year-old man with multiple esophageal diverticula associated with achalasia who was later diagnosed with early esophageal cancer. He initially presented with dysphagia and dyspepsia, and injection of botulinum toxin to the lower esophageal sphincter relieved his symptoms. Five years later, however, the patient presented with worsening of symptoms, and esophagogastroduodenoscopy (EGD) was performed. The endoscopic findings showed multifocal lugol-voiding lesions identified as moderate dysplasia. We decided to use photodynamic therapy to treat the multifocal dysplastic lesions. At follow-up EGD 2 months after photodynamic therapy, more lugol-voiding lesions representing a squamous cell carcinoma in situ were found. The patient ultimately underwent surgery for the treatment of recurrent esophageal multifocal neoplasia. After a follow-up period of 3 years, the patient showed a good outcome without symptoms. To manage premalignant lesions such as achalasia with esophageal diverticula, clinicians should be cautious, but have an aggressive approach regarding endoscopic surveillance.

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Advanced squamous cell carcinoma in an asymptomatic, large, epiphrenic esophageal diverticulum
Tomoaki Yoshida, Satoru Hashimoto, Ken-ichi Mizuno, Hiroshi Ichikawa, Junji Yokoyama, Hajime Umezu, Shuji Terai
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Aina KUNITOMO, Eiji HIGAKI, Tetsuya ABE, Takahiro HOSOI, Seiji ITO, Yasuhiro SHIMIZU
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Imaging in the Evaluation of Endoscopic or Surgical Treatment for Achalasia
Diego Palladino, Andrea Mardighian, Marilina D’Amora, Luca Roberto, Francesco Lassandro, Claudia Rossi, Gianluca Gatta, Mariano Scaglione, Guglielmi Giuseppe
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Original Articles

Peroral Endoscopic Myotomy for Treatment of Achalasia: Initial Results of a Korean Study: Byung Hoo Lee, Kwang Yeun Shim, Su Jin Hong, Gene Hyun Bok, Jun-Hyung Cho, Tae Hee Lee, Joo Young Cho; Clin Endosc 2013;46(2):161-167. Published online March 31, 2013; DOI: https://doi.org/10.5946/ce.2013.46.2.161

Abstract PDF PubReader ePub

Background/Aims

Achalasia is a rare esophageal motility disorder. Recently, a novel endoscopic technique, peroral endoscopic myotomy (POEM), was introduced as an alternative treatment for achalasia. We report the results and short term outcomes of POEM for patients with achalasia.

Methods

POEM was performed in 13 patients with achalasia. The procedure consisted of creating a submucosal tunnel followed by endoscopic myotomy of circular muscle bundles. The mucosal entry was closed by conventional hemostatic clips. A validated clinical symptom score (Eckardt score) and high resolution manometry were used to evaluate the outcomes.

Results

Both the clinical score of achalasia, as well as the resting lower esophageal sphincter (LES) pressure, were significantly reduced after POEM. Mean posttreatment Eckardt score was 0.4±0.7, compared to 6.4±1.9 prior to the treatment (p=0.001). The mean pretreatment and posttreatment LES pressure was 30.3 and 15.3 mm Hg, respectively (p=0.007). Following POEM, symptomatic relief from dysphagia without reflux symptoms was observed in all patients (13/13). No serious complications related to POEM were encountered.

Conclusions

Based upon our initial experience, the authors believe that POEM is a feasible, safe, and effective treatment and may possibly substitute established treatments of refractory achalasia.

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Peroral Endoscopic Myotomy for Treating Achalasia in an Animal Model: A Feasibility Study: Byoung Wook Bang, Young Chul Choi, Hyung Gil Kim, Kye Sook Kwon, Yong Woon Shin, Don Haeng Lee, Joon Mee Kim; Clin Endosc 2013;46(1):54-58. Published online January 31, 2013; DOI: https://doi.org/10.5946/ce.2013.46.1.54

Abstract PDF PubReader ePub

Background/Aims

Laparoscopic Heller myotomy with antireflux procedure is considered to be a standard treatment for achalasia. Recently, peroral endoscopic myotomy (POEM) was developed and performed on patients with achalasia. However, there is no report on POEM use in South Korea. The aim of this study was to evaluate the technical feasibility of POEM in a porcine model.

Methods

POEM was performed on two mini pigs. We performed upper endoscopy under general anesthesia. A submucosal tunnel was created and the circular muscle layer was incised using several knives. The mucosal entry was closed using resolution clips. We performed a follow-up endoscopy and sacrificed the pigs 2 weeks after the POEM. The myotomy site was evaluated grossly and histologically.

Results

POEM was successfully performed on the two mini pigs. No injuries to any abdominal or mediastinal structures occurred. Two weeks after the POEM, the esophageal mucosa healed without any endoscopic evidence of complications. Necropsy revealed that the circular muscle layer was completely lost and replaced with fibrotic tissue.

Conclusions

We found that POEM is a technically feasible method which can be performed on an animal model. However, to ensure safe use on patients with achalasia, further studies on technical methods and long-term follow-up examinations are required.

Citations

Citations to this article as recorded by

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Miotomía endoscópica peroral, experiencia in vivo : imprescindible para desarrollo de la técnica en humanos
A. Peñaloza-Ramírez, J. Suárez-Correa, J. Báez-Blanco, C. Sabogal-Gómez, H. Kuan-Casas, C. Sánchez-Pignalosa, P. Aponte-Ordóñez
Revista de Gastroenterología de México.2018; 83(2): 86. CrossRef
In vivo experience with peroral endoscopic myotomy: An essential activity for developing the technique in humans
A. Peñaloza-Ramírez, J. Suárez-Correa, J. Báez-Blanco, C. Sabogal-Gómez, H. Kuan-Casas, C. Sánchez-Pignalosa, P. Aponte-Ordóñez
Revista de Gastroenterología de México (English Edition).2018; 83(2): 86. CrossRef
Factors predicting the technical difficulty of peroral endoscopic myotomy for achalasia
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Sakai P
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Eun Young Kim, Kwang An Kwon, Il Ju Choi, Ji Kon Ryu, Ki Baik Hahm
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Training for peroral endoscopic myotomy
Daniel von Renteln, Melina C. Vassiliou, Thomas Rösch
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Dennis Yang, Mihir S. Wagh
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Su Jin Hong
Clinical Endoscopy.2013; 46(1): 1. CrossRef

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Review

Endoscopic Treatment of Primary Esophageal Motility Disorders: Joon Seong Lee, M.D., Ph.D.; Korean J Gastrointest Endosc 2011;42(6):341-348. Published online June 21, 2011

Abstract PDF: Treatment of primary esophageal motility disorders, particularly achalasia, has developed enormously. The proven treatments for these patients include mostly endoscopic methods. Currently, pneumatic dilatation and laparoscopic myotomy with partial fundoplication are both useful for treating achalasia. A young man with high lower esophageal sphincter pressure might be best indicated for a laparoscopic myotomy with fundoplication, whereas an older patient with a high risk for surgery or vigorous achalasia may for a candidate for an endoscopic botulinum toxin injection. Pneumatic balloon dilatation is the choice of treatment for other
case
s of achalasia. The best treatment option for a nonachalasia spastic motor disorder of the esophagus may be endoscopic injection of botulinum toxin. In the future, endoscopic injection of neuronal stem cells could be the best treatment option for achalasia.

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