Abstract
INTRODUCTION:Peroral endoscopic myotomy (POEM) may result in a distended distal esophagus, referred to as a blown-out myotomy (BOM), the relevance of which is uncertain. The aim of this study was to investigate the prevalence, risk factors, and associated symptoms of BOM after achalasia treatment.METHODS:A data set of the locally treated patients in a randomized controlled trial comparing POEM with pneumatic dilation (PD) was analyzed. A BOM is defined as a >50% increase in esophageal diameter at its widest point in the distal esophagus between the lower esophageal sphincter and 5 cm above.RESULTS:Seventy-four patients were treated in our center, and 5-year follow-up data were available in 55 patients (32 patients [58%] randomized to POEM, 23 [42%] PD). In the group initially treated with POEM, the incidence of BOM increased from 11.5% (4/38) at 3 months, to 21.1% (8/38) at 1 year, 27.8% (10/36) at 2 years, and 31.3% (10/32) at 5 years. None of the patients treated with PD alone developed a BOM. Patients who developed a BOM had a higher total Eckardt score and Eckardt regurgitation component compared with patients who underwent POEM without BOM development (3 [2.75-3.25] vs 2 [1.75-3], P = 0.032, and 1 [0.75-1] vs 0 [0-1], P = 0.041). POEM patients with a BOM more often report reflux symptoms (85% [11/13] vs 46% [2/16], P = 0.023) and had a higher acid exposure time (24.5% [8-47] vs 6% [1.2-18.7], P = 0.027).DISCUSSION:Thirty percent of the patients treated with POEM develop a BOM, which is associated with a higher acid exposure, more reflux symptoms, and symptoms of regurgitation.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 1983-1989 |
| Number of pages | 7 |
| Journal | American Journal of Gastroenterology |
| Volume | 119 |
| Issue number | 10 |
| DOIs | |
| State | Published - Oct 1 2024 |
Funding
Potential competing interests: T.K., F.P., and B.B. have no financial or personal competing interests. P.F. received consultancy fees from Olympus and Cook Medical. J.E.P.: Sandhill Scientific/Diversatek (Consulting, Speaking, Grant), Takeda (Speaking), Astra Zeneca (Speaking), Medtronic (Speaking, Consulting, Patent, License), Torax (Speaking, Consulting), Ironwood (Consulting). A.B. received research funding from Nutricia, SST, Thelial, Sanofi, Dr. Falk Pharma, and received speaker and/or consulting fees from Laborie, Medtronic, Dr. Falk Pharma, Calypso Biotech, Alimentiv, Regeneron/Sanofi, AstraZeneca. Study Highlights WHAT IS KNOWN It is hypothesized that the development of a BOM is the result of a weakness in the esophageal wall at the point of the myotomy and persistent residual contractions as appropriate to achalasia. Over time, the stress will lead to deformation of the esophageal wall and lead to widening of the distal esophagus and formation of a pseudo-diverticulum. This hypothesis is supported by the fact that an epiphrenic diverticulum is very often secondary to an esophageal motility disorder and associated with a congenital weakness of the esophageal wall. The pseudo-diverticulum will have impaired emptying, cause delayed clearance, and induce regurgitation. Based on this mechanism, a reduction of outflow stress by lowering esophageal pressure or making the weak spot (myotomy site) less weak may be able to prevent/reduce the development of a BOM and reduce symptoms. Perhaps, reducing the vulnerability of the esophageal wall can be achieved by reducing the length of the myotomy or performing a selective circular myotomy instead of a full-Thickness myotomy. A figure explaining this hypothesis is shown in Supplementary Figure 1 (see Supplementary Digital Content 1, We did find that a more narrow esophageal caliber before treatment is associated with a higher rate of BOM development. It can be hypothesized that patients with a wider caliber of the esophagus are in a more chronic state of achalasia where the esophageal body is already dilated/decompensated and the esophageal body muscle is weak. Patients with a narrow caliber of the esophagus may have more powerful residual contractions. Over time, it is more likely in these patients to develop a BOM at the myotomy side due to the powerful residual contractions (more stress over time on the esophageal wall).
Keywords
- achalasia
- blownout myotomy
- POEM
ASJC Scopus subject areas
- Hepatology
- Gastroenterology