Discordance between high-resolution manometry, esophagoscopy and contrast esophagogram in determining landmarks for per-
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and Other Interventional Techniques
Discordance between high‑resolution manometry, esophagoscopy and contrast esophagogram in determining landmarks for per‑oral endoscopic myotomy in spastic esophageal disorders: a word of caution Luis Serrano1 · Adham R. Saad1 · Christoper DuCoin1 · John W. Jacobs1 · Joel E. Richter1 · Vic Velanovich2 Received: 29 May 2020 / Accepted: 29 September 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Background Myotomy length for per-oral endoscopic myotomy (POEM) is standardized for type I and II achalasia. However, for type III achalasia, jackhammer esophagus, diffuse esophageal spasms and esophagogastric junction outflow obstruction, there is no standard. Determining myotomy length based on the high-pressure zone found during high-resolution manometry (HRM) and spastic length found during esophagography may be used to determine adequate myotomy length without excess muscle destruction. Methods The records of patients who have undergone POEM procedures at our institution had the following data gleaned: age, sex, esophageal spastic diagnosis, length of high-pressure zone and lower esophageal sphincter (LES) position by HRM, length of spastic esophagus by esophagography, position of the z-line by esophagoscopy and length of myotomy performed. Outcomes were assessed based on patient symptomatic improvement and need for re-intervention. Results 71 patients were evaluated for POEM, with 67 completing POEM. There was an average difference in LES position by HRM and z-line position by esophagoscopy of 3.9 ± 3.0 cm. There was an average difference in high-pressure zone by HRM and spastic length by esophagography of 4.9 ± 3.2 cm. Overall, with a median of 20 months follow-up, 74% achieved long-term symptomatic improvement, with 17 patients requiring re-intervention. Conclusions Discordance among HRM, esophagography and esophagoscopy can be significant. Caution should be employed with using these methods to determine myotomy length in POEM. Keywords Achalasia · Spastic esophageal disorders · High-resolution manometry · Esophagography · Esophagoscopy · Peroral endoscopic myotomy Spastic esophageal motility disorders are a rare group of diseases causing dysphagia, chest pain, regurgitation and perceived heartburn. The pathophysiology of these disorders is related to esophageal muscle dysfunction of the lower esophageal sphincter (LES) and esophageal body. Esophageal motility disorders are primarily diagnosed with * Vic Velanovich [email protected] 1
Divisions of General Surgery and Gastroenterology, Joy McCann Culverhouse Center for Swallowing Disorders, The University of South Florida, Tampa, FL, USA
Division of General Surgery, The University of South Florida, 5 Tampa General Circle, Suite 740, Tampa, FL 33606, USA
2
high-resolution manometry (HRM) which evaluates pressures generated by muscle function of the esophagus [1]. These disorders include achalasia (three types), diffuse esophageal spasm (DES), jackhammer esophagus, esophagogastric ou
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