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• W3136535191 abstract "Achalasia is the prototypical motor disorder of the esophagus, characterized by incomplete lower esophageal sphincter relaxation and absence of peristalsis resulting from damaged innervation.1Pandolfino J.E. Gawron A.J. Achalasia: a systematic review.JAMA. 2015; 313: 1841-1852Crossref PubMed Scopus (198) Google Scholar The clinical consequences of achalasia have been recognized for centuries, but the therapeutic realm has not yet evolved beyond relieving the functional obstruction, which then allows for the esophagus to empty, assisted by gravity and residual esophageal and hydrostatic pressure. Mechanical disruption of the lower esophageal sphincter is achieved by pneumatic dilation, Heller myotomy, or, more recently, peroral endoscopic myotomy (POEM), all with excellent short-term and to some degree long-term results.2Fisichella P.M. Patti M.G. From Heller to POEM (1914-2014): a 100-year history of surgery for achalasia.Gastrointest Surg. 2014; 18: 1870-1875Crossref PubMed Scopus (15) Google Scholar Unfortunately, these treatments are not foolproof, and long-term studies of patients with achalasia commonly demonstrate the need for adjunct procedures to maintain symptomatic and objective remission over decades.3Sawas T. Ravi K. Geno D.M. et al.The course of achalasia one to four decades after initial treatment.Aliment Pharmacol Ther. 2017; 45: 553-560Crossref Scopus (9) Google Scholar When symptoms recur, any of several factors may be at play, ranging from incomplete myotomy, peptic strictures, and severe deformity of the esophagus to, rarely, malignancy. Curiously, some patients have none of the above problems but still present with recurrent symptoms and objective evidence of impaired esophageal emptying despite a complete myotomy. In 1988, Rubesin et al4Rubesin S.E. Kennedy M. Levine M.S. et al.Distal esophageal ballooning following Heller myotomy.Radiology. 1988; 167: 345-347Crossref PubMed Scopus (5) Google Scholar reported on a phenomenon of “distal esophageal ballooning” after Heller myotomy in 23 patients with achalasia who underwent a postoperative esophagram within 30 days of the surgery. Nearly half of the patients experienced this radiologic feature, characterized by an outpouching along the myotomy incision with an average length of 6 cm and width of 4 cm. Although the authors hypothesized that this area could act as an area of stasis, symptoms were not experienced by their cohort. In this current study, Triggs et al5Triggs J.R. Krause A.J. Carlson D.A. et al.Blown-out myotomy: an adverse event of laparoscopic Heller myotomy and peroral endoscopic myotomy for achalasia.Gastrointest Endosc. 2021; 93: 861-868Abstract Full Text Full Text PDF Scopus (2) Google Scholar revisit this phenomenon of pseudodiverticulum formation at the myotomy site in a retrospective review of 129 patients with achalasia. These patients received a surgical (n = 65) or an endoscopic (n = 64) myotomy. No pseudodiverticula were seen in patients who received pneumatic dilation. “Distal esophageal ballooning” was re-termed “blown-out myotomy” (BOM) and defined as a wide-mouthed outpouching with ≤50% increase in esophageal diameter. The term “BOM” appears to highlight the hypothesis that residual muscle contraction in the esophageal body leads to the formation of this pseudodiverticulum over time, which appears unlikely to be the sole explanation on the basis of earlier data, where the timing between the myotomy and radiologic assessment was <30 days. The main findings of the study5Triggs J.R. Krause A.J. Carlson D.A. et al.Blown-out myotomy: an adverse event of laparoscopic Heller myotomy and peroral endoscopic myotomy for achalasia.Gastrointest Endosc. 2021; 93: 861-868Abstract Full Text Full Text PDF Scopus (2) Google Scholar were that (1) “distal esophageal ballooning” or “BOM” was associated with treatment failure in achalasia defined by an elevated Eckhart score, that (2) “BOM” occurs more frequently after Heller myotomy compared with POEM, and (3) “BOM” occurs more often in achalasia subtypes 2 and 3. The authors argue that BOM may be an important mechanism by which treatment failure in achalasia occurs despite adequate myotomy, even though in their own data the median integrated residual pressure (IRP) in patients with BOM was significantly higher than in those without (15.0 mm Hg vs 11.0 mm Hg). There was also a trend toward a greater proportion of patients with BOM having an IRP >15 mm Hg (ie, residual achalasia) compared with those without, albeit with a nonsignificant P value likely explainable by type II error. In addition to the higher IRP, the follow-up was longer in patients with BOM than in those without; both factors may be important with regard to increased symptom burden and treatment failure over time. The authors should be commended for reporting outcomes in a relatively large cohort of patients with achalasia and further exploring the significance of the presence of a pseudodiverticulum and how myotomy type and length might contribute. Unfortunately, the exact timing of the development of BOM, particularly after POEM, remains uncertain and unclear, but earlier data, from both the radiologic4Rubesin S.E. Kennedy M. Levine M.S. et al.Distal esophageal ballooning following Heller myotomy.Radiology. 1988; 167: 345-347Crossref PubMed Scopus (5) Google Scholar and the surgical literature,6Barker J.R. Franklin R.H. Heller's operation for achalasia of the cardia: a study of the early and late results.Br J Surg. 1971; 58: 466-468Crossref PubMed Scopus (18) Google Scholar suggest that this is an early phenomenon. This does not rule out that stasis of solid food and residual contractility in patients with type 2 and type 3 achalasia may further contribute to a poor clinical outcome over time, but clearly the pathophysiology of treatment failure in achalasia remains incompletely understood, and an elevated IRP may potentially play a significant role, producing symptoms of treatment failure among patients with achalasia. We do not yet fully grasp the pressure dynamics that lead to relapse of achalasia, but the authors nicely speculate this in Figure 3 of the article,5Triggs J.R. Krause A.J. Carlson D.A. et al.Blown-out myotomy: an adverse event of laparoscopic Heller myotomy and peroral endoscopic myotomy for achalasia.Gastrointest Endosc. 2021; 93: 861-868Abstract Full Text Full Text PDF Scopus (2) Google Scholar depicting an esophagus that gradually evolves from acting more like a common cavity with the stomach to eventually becoming “blown out” and not emptying. Overall, the study by Triggs et al5Triggs J.R. Krause A.J. Carlson D.A. et al.Blown-out myotomy: an adverse event of laparoscopic Heller myotomy and peroral endoscopic myotomy for achalasia.Gastrointest Endosc. 2021; 93: 861-868Abstract Full Text Full Text PDF Scopus (2) Google Scholar represents a step in the right direction for exploring factors that might be important and modifiable among patients with treatment failure after myotomy. Similar to many previous retrospective studies, it has generated rich hypothesis-generating data that will help shape future studies. For example, will tailoring the myotomy length in various subtypes of achalasia lead to improved long-term outcomes? Would follow-up assessment of residual esophageal motility and IRP over time predict who might be at risk for treatment failure and allow early intervention? Is a lower IRP needed from myotomy to prevent this adverse event, and will POEM, which may have a lower rate of pseudodiverticula, produce improved long-term outcomes? Unfortunately, large and robust multicenter studies, which constitute the ideal method of examining these hypotheses, are few and far between. Such trials are resource intensive and take a long time, perhaps more than a decade, to yield answers, but ultimately they will be what is needed. The author disclosed no financial relationships. Blown-out myotomy: an adverse event of laparoscopic Heller myotomy and peroral endoscopic myotomy for achalasiaGastrointestinal EndoscopyVol. 93Issue 4PreviewAlthough laparoscopic Heller myotomy (LHM) or peroral endoscopic myotomy (POEM) is highly effective, 10% to 20% of patients with achalasia remain symptomatic after treatment. In evaluating such patients, we have observed a pattern of failure associated with a pseudodiverticulum, or blown-out myotomy (BOM), in the distal esophagus. We aimed to assess risk factors and patient-reported outcomes associated with a BOM. Full-Text PDF" @default.
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• W3136535191 title "Pseudodiverticulum at the myotomy site in achalasia: Significant finding or overblown?" @default.
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• W3136535191 doi "https://doi.org/10.1016/j.gie.2020.09.007" @default.
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