Peroral endoscopic myotomy (POEM) is effective in treatment of noncardiac chest pain caused by hypercontractile esophageal motility disorders: results of the POEM-HYPE-Study

Abstract

Background Noncardiac chest pain (NCCP) is recurrent angina pectoris-like pain without evidence of coronary heart disease in conventional diagnostic evaluation. In gastroenterology, managing of patients with NCCP is ambiguous to detect gastroesophageal reflux and hypercontractile esophageal motility disorders. Recently, peroral endoscopic myotomy (POEM) was established as treatment option in achalasia. However, limited data exist on the effectivity of POEM in NCCP with hypercontractile esophageal motility disorders.

Material and methods In this prospective study (POEM-HYPE), we evaluated 14 patients with NCCP and hypercontractile esophageal motility disorders (type III achalasia, n = 7; hypercontractile esophagus, n = 6; distal esophageal spasm, n = 1). All patients underwent standardized diagnostic work-up including esophagogastroduodenoscopy with esophageal biopsies, high-resolution esophageal manometry, and combined intraluminal impedance and pH testing before and 3 weeks after POEM. A standardized symptom questionnaire was disposed before POEM, 3 weeks after, and every 6 months after the POEM.

Results After POEM, 12 patients showed significant symptom relief (pre-Eckardt score: 7.78 ± 1.47, 3 weeks post: 1.64 ± 1.44, 6 months: 2.0 ± 1.84 and 1.86 ± 1.89 after 15.0 ± 10.0 months post-intervention). High-resolution manometry showed significant reduction in integrated relaxation pressure (pre-POEM: 24.74 ± 18.9 mm Hg, post-POEM: 13.8 ± 16.5 mm Hg) and distal contractile integral (pre-POEM: 2880 ± 3700 mmHg*s*cm, post-POEM: 1109 ± 1042 mmHg*s*cm). One lesion of the submucosal tunnel occurred as a moderate adverse event and was handled endoscopically. The long-term clinical success rate was 85.7 %. No severe gastroesophageal reflux occurred after interventions. Two patients required secondary therapy with injection of botulinum toxin in the tubular esophagus and balloon dilation.

Conclusion The results suggest that POEM is an effective and safe therapeutic option for patients with NCCP and hypercontractile esophageal motility disorders.

Zusammenfassung

Hintergrund Nicht-kardiale Thoraxschmerzen (NCCP) sind rekurrierende Angina-pectoris-ähnliche Schmerzen, für deren Ursache sich durch konventionelle Untersuchungen keine koronare Herzerkrankung nachweisen lässt. In der Gastroenterologie ist die Diagnostik zum Nachweis einer gastroösophagealen Refluxerkrankung bzw. hyperkontraktilen Ösophagusmotilitätsstörung anspruchsvoll.

Material und Methode In dieser prospektiven Studie (POEM-HYPE) evaluierten wir 14 Patienten mit NCCP und hyperkontraktilen Ösophagusmotilitätsstörungen (Typ-III-Achalasie n = 7, hyperkontraktiler Ösophagus n = 6, distaler Ösophagusspasmus n = 1). Alle Patienten durchliefen eine standardisierte Diagnostik mit Ösophagogastroduodenoskopie mit Biopsien, hochauflösender Ösophagusmanometrie, kombinierter intraluminaler 24 Std. pH-Metrie-Impedanzmessung vor und 3 Wochen nach POEM. Ein standardisierter Symptome-Fragebogen wurde vor, 3 Wochen und alle 6 Monate nach POEM ausgefüllt.

Ergebnisse Nach POEM zeigten 12 Patienten eine signifikante Symptome-Verbesserung (prä-Eckardt-Score: 7,78  ± 1,47, post-3 Wochen: 1,64 ± 1,44, post-6 Monate: 2,0 ± 1,84 und 1,86 ± 1,89 nach 15,0 ± 10,0 Monaten nach POEM. Die hochauflösende Ösophagusmanometrie zeigte eine signifikante Reduktion des IRP (integrated relaxation pressure) (prä-POEM: 24,74 ± 18,9 mm Hg, post-POEM: 13,8 ± 16,5 mm Hg) und DCI (distal contractile integral) (prä-POEM: 2880 ± 3700 mmHg*s*cm, post-POEM: 1109 ± 1042 mmHg*s*cm). Eine Läsion des submukösen Tunnels trat als moderate Komplikation auf, die endoskopisch behandelt wurde. Die Langzeiterfolgsrate lag bei 85,7 %. Es trat kein schwerer gastroösophagealer Reflux nach Intervention auf. Bei zwei Patienten war eine sekundäre Behandlung durch Botulinumtoxin bzw. Ballondehnung notwendig.

Schlussfolgerung POEM ist eine effektive und sichere Behandlungsoption für Patienten mit NCCP und hyperkontraktilen Ösophagusmotilitätsstörungen.

Key words

noncardiac chest pain (NCCP) - hypercontractile esophageal motility disorder - peroral endoscopic myotomy (POEM) - endoscopic therapy - achalasia type III - Jackhammer esophagus - distal esophageal spasm

Schlüsselwörter

nicht-kardialer Thoraxschmerz (NCCP) - hyperkontraktile Ösophagusmotilitätsstörungen - perorale endoskopische Myotomie (POEM) - Achalasie Typ III - Jackhammer Ösophagus - distaler Ösophagusspasmus

• References

• 1 Frieling T. Differential diagnosis “non-cardiac chest pain”. Dtsch Med Wochenschr 2015; 140: 1166-1172
• 2 Frieling T, Bergdoldt G, Allescher HD. et al. Chest pain – not always the heart! Clinical impact of gastrointestinal diseases in non-cardiac chest pain. Z Gastroenterol 2015; 53: 120-124
• 3 Frieling T. Noncardiac chest pain (NCCP) in German chest pain units. Z Gastroenterol 2015; 53: 335-336
• 4 Kahrilas PJ, Bredenoord AJ, Fox M. et al. The Chicago Classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil 2015; 27: 160-174
• 5 Kahrilas PJ, Boeckxstaens G. The spectrum of achalasia: lessons from studies of pathophysiology and high-resolution manometry. Gastroenterology 2013; 145: 954-965
• 6 George N, Abdallah J, Maradey-Romero C. et al. Review article: the current treatment of non-cardiac chest pain. Aliment Pharmacol Ther 2016; 43: 213-239
• 7 Tuason J, Inoue H. Current status of achalasia management: a review on diagnosis and treatment. J Gastroenterol 2017; 52: 401-406
• 8 Bruno RR, Donner-Banzhoff N, Söllner W. et al. The interdisciplinary management of acute chest pain. Dtsch Arztebl Int 2015; 112: 768-779
• 9 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
• 10 Sifrim D, Holloway R, Silny J. et al. Acid, nonacid, and gas reflux in patients with gastroesophageal reflux disease during ambulatory 24-hour pH-impedance recordings. Gastroenterology 2001; 120: 1588-1598
• 11 Becker V, Bajbouj M, Waller K. et al. Clinical trial: persistent gastro-oesophageal reflux symptoms despite standard therapy with proton pump inhibitors – a follow-up study of intraluminal impedance guided therapy. Aliment Pharmacol Ther 2007; 26: 1355-1360
• 12 Shay S, Tutuian R, Sifrim D. et al. Twenty-four hour ambulatory simultaneous impedance and pH monitoring: a multicenter report of normal values from 60 healthy volunteers. Am J Gastroenterol 2004; 99: 1037-1043
• 13 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
• 14 Weingart W, Allescher HD. Nicht-kardialer Thoraxschmerz. Dtsch Med Wochenschr 2010; 135: 2135-2146
• 15 Fass R, Navarro-Rodriguez T. Noncardiac chest pain. J Clin Gastroenterol 2008; 42: 636-646
• 16 Storr M, Allescher HD, Rösch T. et al. Treatment of symptomatic diffuse esophageal spasm by endoscopic injections of botulinum toxin: a prospective study with long-term follow-up. Gastrointest Endosc 2001; 54: 754-759
• 17 Roman S, Kahrilas PJ. Management of spastic disorders of the esophagus. Gastroenterol Clin North Am 2013; 42: 27-43
• 18 Rohof WO, Salvador R, Annese V. et al. Outcomes of treatment for achalasia depend on manometric subtype. Gastroenterology 2013; 144: 718-725
• 19 Pratap N, Kalapala R, Darisetty S. et al. Achalasia cardia subtyping by high-resolution manometry predicts the therapeutic outcome of pneumatic balloon dilation. J Neurogastroneterol Motil 2011; 17: 48-53
• 20 Moonen A, Annese V, Belmas A. et al. Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut 2016; 65: 732-739
• 21 Leconte M, Douard R, Gaudric M. et al. Functional results after extended myotomy for diffuse esophageal spasm. Br J Surg 2007; 94: 113-118
• 22 Kahrilas PJ, Pandolfino JE. Treatments for achalasia in 2017: how to choose among them. Curr Opin Gastroenterol 2017; 33: 270-276
• 23 Fontes LH, Herbella FA, Rodriguez TN. et al. Progression of diffuse esophageal spasm to achalasia: incidence and predictive factors. Dis Esoph 2013; 26: 470-474
• 24 Paterson WG, Beck IT, Da Costa LR. Transition from nutcracker esophagus to achalasia. A case report. J Clin Gastroenterol 1991; 13: 554-558
• 25 Bechara R, Inoue H. POEM, the prototypical “new NOTES” procedure and first successful NOTES procedure. Gastrointest Endosc Clin N Am 2016; 26: 237-255
• 26 Frieling T, Wenzel G, Heise J. et al. Endoscopic anti-reflux procedures: what causes the clinical benefit?. Gastroenterology 2005; 129: 397-398
• 27 Sidhu AS, Triadafilopoulos G. Neuroregulation of lower esophageal sphincter function as treatment for gastroesophageal reflux disease. World J Gastroenterol 2008; 14: 985-990
• 28 Arts J, Sifrim D, Rutgeerts P. et al. Influence of radiofrequency energy delivery at the gastroesophageal junction (the Stretta procedure) on symptoms, acid exposure, and esophageal sensitivity to acid perfusion in gastroesophagal reflux disease. Dig Dis Sci 2007; 52: 2170-2177
• 29 Werner YB, Costamagna G, Swanström LL. et al. Clinical response to peroral endoscopic myotomy in patients with idiopathic achalasia at a minimum follow-up of 2 years. Gut 2016; 65: 899-906
• 30 Kashab MA, Messallam AA, Onimaru M. et al. International multicenter experience with peroral endoscopic myotomy for the treatment of spastic esophageal disorders refractory to medical therapy. Gastrointest Endosc 2015; 81: 1170-1177
• 31 Kumbhari V, Tieu AH, Onimaru M. et al. Peroral endoscopic myotomy (POEM) vs laparoscopic Heller myotomy (LHM) for the treatment of type III achalasia in 75 patients: a multicentre comparative study. Endosc Int Open 2015; 3: E195-E201
• 32 Cai MY, Zhou PH, Yao LQ. et al. Peroral endoscopic myotomy for idiopathic achalasia: randomized comparison of water-jet assisted versus conventional dissection technique. Surg Endosc 2014; 28: 1158-1165