Page 158 - Read Online

de Moura et al. PBD and POEM in dilated megaesophagus

The first publication on POEM was by Inoue et al. [21] in reflux. Moreover, the formation of adhesions between
2010 with 17 patients. The mean myotomy was 8 cm, 6 the submucosal layer and the longitudinal musculature
cm from the esophageal part and 2 cm from the gastric after POEM may make it challenging if surgical revision
portion, with a significant decrease in the pressure is necessary for recurrence or persistent dysphagia
of the lower esophageal sphincter (52.4 to 19.9 mm). after POEM.
There was no recurrence of dysphagia with a short
follow-up of 5 months. CLINICAL PRACTICE

Initial published experience in humans [22] with non- At Clinicas Hospital University of São Paulo, one of
sigmoid megaesophagus is more encouraging despite the most experienced centers that treat patients with
a relatively short-term follow-up (3 years). The largest achalasia caused by Chagas disease, the endoscopic
series case [22] of 500 patients had Eckardt et al. [12] treatment through the pneumatic dilatation of the
score decreasing from 6.0 ± 3.0 to 1.0 ± 2.0 and lower cardia or POEM is indicated in degrees I and II based
esophageal sphincter (LES) pressures from 25.4 ± 17.1 on Ferreira-Santos classification.
to 13.4 ± 5.9 mmHg with a mean follow-up of 3 years
post-POEM. Gastroesophageal reflux was seen in In grade III, the option for POEM is questionable and
16.8% of patients at two months and 21.3% at 3-year in grade IV, dilation is indicated only with the intention
follow-up. to preparing the patient (providing greater nutritional
intake) for surgical treatment.
The most recent meta-analysis [23] involved 2,373
patients with a clinical success of 98 % after the From the surgical point of view, Heller’s cardiomyotomy
procedure. On one hand, the mean Eckardt et al. [12] is indicated in degrees I, II and III, whereas in grade IV
score decreased from 6.9 ± 0.15 pre-operatively to esophagectomy is the preferred technique.
1.0 ± 0.08 within 12 months of treatment. In addition,
there were significant decreases in the average lower At present, both gastroenterologists and surgeons
esophageal sphincter pressure, integrated relaxation do not know which modality of treatment is better to
pressure and the average heights of the barium patients with degrees II, comparing POEM, PBD and
column following a timed barium esophagogram after Heller’s cardiomyotomy and I.
the procedure. On the other hand, a mean follow-
up of 8 months post-procedure shows symptomatic At our institution, the first line treatment to patients
gastroesophageal reflux in 8.5 % and esophagitis on degree I is PBD. In degrees II and III, patients up to
esophagogastroduodenoscopy in 13 %.
70-year-old without high-risk comorbidities are referred
to POEM or Heller and in degree IV esophagectomy as
Only a few papers [24] have been published about
POEM for sigmoid-shaped esophagus. The dilated and the preferred technique. However, if the patient does not
tortuous esophagus lumen may make the endoscopic have surgical conditions, PBD is performed to provide
dissection and separation of tissue more challenging greater nutritional intake and to relieve symptoms.
and time consuming. The largest population was The botulinum toxin is not currently available at our
published by Hu et al. [25] with 32 patients and follow-up institution.
of 2 years with an efficacy of 96%. The Eckardt et al. [12]
scale decreased from 7.8 to 1.4 and the LES pressure CONCLUSION
from 37.9 to 12.9 mmHg. No serious complications were
observed. However, the most common complication In conclusion, in spite of promising results, POEM
was clinical reflux with an average of 25.8% of the requires significant qualifications, and because it is
patients. a recent procedure, lacks reproducibility. Long-term
results and randomized clinical trials before validating
Recent studies have shown that POEM results in the use of POEM in routine clinical practice for the
better improvement of dysphagia and reduction of LES treatment of esophageal achalasia.
pressure and lower complication rates compared to
PBD. In relation to balloon dilatation of the cardia, even with
variable durability mainly in advanced megaesophagus,
However, recent studies have shown that it is still widely used in older patients, with a higher
gastroesophageal reflux is more common in POEM, surgical risk, and in many cases in patients already
ranging from 15% to 35% in some studies, and submitted to Heller’s surgery who persist or develop
myotomy in the posterior wall is more susceptible to dysphagia.

Mini-invasive Surgery ¦ Volume 1 ¦ December 28, 2017 151