Intraoperative distensibility measurement during laparoscopic Heller's myotomy for achalasia may reduce the myotomy length without compromising patient outcome

Our study aimed to assess whether intraoperative esophagogastric junction (EGJ) distensibility measurement using the EndoFLIP EF325 catheter (Crospon Ltd., Galway, Ireland) could potentially be used to guide laparoscopic Heller's myotomy (LHM), potentially modifying the operation outcome and comparing this clinically to our previous technique of gastroscopic assessment. Following a full diagnostic assessment with manometry and endoscopy patients with achalasia were divided into two groups. A retrospective cohort of patients operated on between 2007 and 2010 had a gastroscopy‐guided LHM (G‐LHM) with a standardized myotomy of 8 cm on the esophagus and 3 cm on the stomach. From 2010, patients were prospectively studied with an EndoFLIP‐guided LHM (E‐LHM). The length of the myotomy was dictated by intraoperative distensibility monitoring of the EGJ. All patients with achalasia recorded Urbach quality of life scoring preoperatively and 6 months postoperatively. A further group of normal laparoscopic control patients (E‐LC) without any esophageal pathology also underwent intraoperative EGJ distensibility monitoring. Thirty‐eight patients took part, 15 in the E‐LC group, 8 in G‐LHM group and 15 in the E‐LHM group. We revealed that patients with achalasia in the E‐LHM group had a significantly smaller EGJ cross‐sectional area and distensibility than the E‐LC group. Myotomy and fundoplication increased the distensibility of the EGJ to a value greater than normal control patients. Patients in the G‐LHM group had a standard myotomy of 11 cm; patients in the E‐LHM group had a variable length myotomy of 6 cm (IQR 5.0–6.0). In both G‐LHM and E‐LHM groups, there was a significant improvement in patient's quality of life with no significant difference between the groups. Our study has shown that the EndoFLIP system was effective at measuring distensibility changes during LHM. LHM significantly increases the distensibility of the EGJ and also significantly improves patient symptoms. E‐LHM may reduce the overall myotomy length, and this does not appear to compromise the clinical outcome.     

Submucosal tunnel endoscopy: Peroral endoscopic myotomy and peroral endoscopic tumor resection

Peroral endoscopic myotomy(POEM) is an innovative,minimally invasive, endoscopic treatment for esophageal achalasia and other esophageal motility disorders, emerged from the natural orifice transluminal endoscopic surgery procedures, and since the first human case performed by Inoue in 2008, showed exciting results in international level, with more than 4000 cases globally up to now. POEM showed superior characteristics than the standard 100-year-old surgical or laparoscopic Heller myotomy(LHM), not only for all types of esophageal achalasia [classical(Ⅰ), vigorous(Ⅱ), spastic(Ⅲ), Chicago Classification], but also for advanced sigmoid type achalasia(S1 and S2), failed LHM, or other esophageal motility disorders(diffuse esophageal spasm, nutcracker esophagus or Jackhammer esophagus). POEM starts with a mucosal incision, followed by submucosal tunnel creation crossing the esophagogastric junction(EGJ) and myotomy. Finally the mucosal entry is closed with endoscopic clip placement. POEM permitted relatively free choice of myotomy length and localization. Although it is technically demanding procedure, POEM can be performed safely and achieves very good control of dysphagia and chest pain. Gastroesophageal reflux is the most common troublesome side effect, and is well controllable with proton pump inhibitors. Furthermore, POEM opened the era of submucosal tunnel endoscopy, with many other applications. Based on the same principles with POEM, in combination with new technological developments, such as endoscopic suturing, peroral endoscopic tumor resection(POET), is safely and effectively applied for challenging submucosal esophageal, EGJ and gastric cardia tumors(submucosal tumors), emerged from muscularis propria. POET showed up to know promising results, however, it is restricted to specialized centers. The present article reviews the recent data of POEM and POET and discussed controversial issues that need further study and future perspectives.     

Distal Esophageal Spasm

Distal esophageal spasm (DES) is an uncommon esophageal motility disorder associated with dysphagia and/or chest pain. Its pathophysiology implies an impairment of esophageal inhibitory neural function. Using conventional manometry, DES was defined by the presence of simultaneous esophageal contractions. With the introduction of high-resolution manometry and esophageal pressure topography (EPT) in clinical practice, rapidly propagated contractions are nonspecific of esophageal spasm. Hence, a more physiological and clinically relevant definition was proposed. Distal latency (DL) measures the period of inhibition that precedes contraction in the distal esophagus immediately proximal to the esophagogastric junction (EGJ). Premature contractions, defined as reduced DL, appeared to be much more specific for DES in EPT. Premature contractions with normal EGJ relaxation constitute DES, while premature contractions with impaired EGJ relaxation are diagnostic of spastic achalasia. Because of the interaction between DES and gastroesophageal reflux disease, 24-h esophageal pH monitoring should also be considered in patient evaluation. Medical treatment of DES aims to compensate for the deficient inhibitory neural function. Sildenafil, which blocks nitric oxide degradation and thus prolongs esophageal muscle relaxation, is a promising treatment. Endoscopic injection of botulinum toxin in the esophageal muscle is also an interesting therapeutic option. Finally, extended surgical myotomy might be discussed in extreme cases after failure of other therapeutic options.     

Peroral endoscopic myotomy outcomes: Efficacy and gastroesophageal reflux disease

Achalasia is a well-defined neuromuscular disorder of esophageal swallowing function characterized by a nonrelaxing lower esophageal sphincter (LES) and aperistalsis of the esophageal body. Peroral endoscopic myotomy (POEM) is a flexible endoscopic approach to perform a selective circular myotomy of the distal esophagus and proximal stomach. More than a thousand cases have been performed worldwide. Most early reports on POEM focus on its feasibility and safety. Emerging long-term series have reported excellent subjective and objective outcomes of dysphagia relief for achalasia. With increasing experience, centers are expanding indications to end-stage achalasia and nonachalasia neuromuscular disorders such as diffuse esophageal spasm and nonrelaxing LES with hypertensive esophageal body contractions. The postoperative gastroesophageal reflux post-POEM is an issue that requires close objective follow-up, as the correlation of subjective reflux symptoms and objective testing in this setting is poor. Few series have indeed reported on equivalent excellent outcomes post-POEM as compared with a laparoscopic myotomy. This early experience with POEM has demonstrated the validity of this new technique in the management of benign disorders of esophageal swallowing. Refinements in technique and decreases in gastroesophageal reflux disease may make this procedure even more desirable, and potentially the first-line therapy in the management of spastic disorders of the esophagus.     

经口内镜全层肌切开术治疗重症贲门失弛缓症的临床应用

目的探讨经口内镜全层肌切开术治疗重症贲门失弛缓症的疗效与安全性。方法经口内镜全层肌切开术治疗64例重症（至少满足以下条件之一：Eckardt评分≥6分;食管直径≥6cm或S形食管）贲门失弛缓症患者,术后定期随访和复查,收集患者一般情况、症状评分、并发症、复发、内镜及X线钡餐检查结果等资料。结果64例患者均成功完成手术,平均操作时间55min,隧道长度平均14．1cm,肌切开长度平均10．6cm,全层肌切开范围为食管胃接合部上下6．0cm。术后患者症状均得到缓解;并发症发生率为9．4％（6／64）,其中气肿发生率为6．3％（4／64）。术后6个月,Eckardt评分较术前明显改善[（7．4±1．5）分比（0．6±0．8）分,P〈0．001],食管直径较术前明显减小[（59．7±13．0）mm比（31．4±3．3）mm,P〈0．001],贲门口直径较术前明显扩大[（15．6±10．1）mm比（33．4±8．9）mm,P〈0．01]。平均随访12．3个月,98．4％（63／64）有效;随访期内无复发病例。结论经口内镜下全层肌切开术可作为重症贲门失弛缓症患者的有效治疗手段,但临床应用时间尚短,其长期疗效及远期并发症仍有待于进一步随访评估。     

Functional analysis of long‐term outcome after Heller's myotomy for achalasia

Treatment of achalasia aims at reducing the pressure of the lower esophageal sphincter (LES) and palliate symptoms. Our objective in this study was to investigate functional changes of the esophagus after Heller myotomy and evaluate their influence on postoperative gastroesophageal reflux and esophageal morphologic changes. Between 1980 and 2003, 216 patients with achalasia underwent Heller myotomy, associated with anterior partial fundoplication (Dor fundoplication). Preoperative and long‐term outcome data were collected from these patients at our hospital. The objective was to analyze esophageal functional results after Heller myotomy in the long term. Results were classified as excellent, good, fair, or poor, according to Vantrappen and Hellemans’ modified classification. One‐year, 2‐year, 5‐year, 10‐year, and 20‐year postoperative follow‐up information was available in 100% of all patients, 91.7%, 85.1%, 60%, 52.6%, and 45.9%, respectively. There were no perioperative deaths. One year after the surgery, all patients had a significant reduction in symptoms of dysphagia and regurgitation. Five years, 10 years, 15 years, and 20 years after surgery, there were 77.2% of patients (142 in 184), 68.1%, 57.1%, and 54.5%, respectively, who were satisfied (excellent to good) with surgery. No esophageal peristalsis was demonstrated in patients during follow‐up. Contractile waves in the body of the esophagus were simultaneous. The difference in the distal esophageal amplitude, the LES relaxation rate, and LES pressures in the anterior wall and/ or two sides was significant (P < 0.05) when compared before and after operation. However, there was no significant difference in the LES length and LES pressure in the posterior side. The change of direction of the LES pressure and the relaxation of LES correlate with long‐term outcomes. Postoperative gastroesophageal reflux rates, including nocturnal reflux, increased with time. The percentage of patients whose esophageal diameter became normal or remained mildly increased with time in the first 10 years after surgery changed significantly. Myotomy is an effective way to palliate symptoms in patients with achalasia. Adequate myotomy can lead to reduction of LES pressure in two or three directions, which may facilitate esophageal emptying by gravity. Surgical intervention does not lead to the return of esophageal peristalsis. Functional damage of LES in patients with achalasia is irreversible.     

Return of esophageal peristalsis after Heller's myotomy for idiopathic achalasia

A 23-year-old male was diagnosed as having idiopathic achalasia on the basis of clinical, radiologic, endoscopic, and manometric evaluation. He underwent a Heller's myotomy with 180 degrees posterior fundoplication as an antireflux procedure, and he did well subsequently. On reexamination one month later, return of peristaltic activity throughout the body of the esophagus was shown on manometric studies. Two years after the operation, peptic esophagitis was diagnosed by esophagoscopy, and the acid reflux test confirmed the existence of gastroesophageal reflux. To our knowledge, this represents the first reported case of return of esophageal peristalsis in idiopathic achalasia after surgical myotomy.     

The effect of fundoplication on proliferative and anti-apoptotic activity of esophageal mucosa in gastroesophageal reflux disease: 4-year follow-up study

OBJECTIVE: The capacity of fundoplication to prevent esophageal adenocarcinoma is controversial. Development of cancer is associated with proliferation and anti‐apoptosis, for which little data exist as to their response to fundoplication. Therefore, we wanted to clarify the effect of fundoplication on the magnitude of Ki‐67 and B‐cell lymphoma 2 (Bcl‐2) during 48 months of follow up. METHODS: Ki‐67 and Bcl‐2 were assessed quantitatively from biopsies of the esophagogastric junction (EGJ) and from the distal and proximal esophagus of 20 patients with gastroesophageal reflux disease (GERD) treated by fundoplication. An upper gastrointestinal endoscopy was performed preoperatively and postoperatively at 6 months for 20 patients and 48 months for 16 patients, respectively. Ki‐67 and Bcl‐2 were compared to those of 7 controls. RESULTS: Compared to the preoperative level, Ki‐67 was elevated in the distal (P = 0.012) and proximal (P = 0.007) esophagus at 48 months. Compared to control values, Ki‐67 was lower at 6 months in the EGJ (P = 0.037) and the proximal esophagus (P = 0.003) and higher at 48 months in the distal esophagus (P = 0.002). Compared to control values, Bcl‐2 was lower at 6 months in the EGJ (P = 0.038). Correlations between Ki‐67 and Bcl‐2 were positive in the EGJ (P > 0.001) and in the distal (P = 0.001) and proximal esophagus (P = 0.013). CONCLUSION: Proliferative activity after fundoplication increased during long‐term follow up in the distal esophagus despite a normal fundic wrap and objective healing of GERD.     

A comprehensive analysis of partial peristalsis recovery after peroral endoscopic myotomy in patients with achalasia

Objective

To determine whether peroral endoscopic myotomy (POEM) improves esophageal peristalsis and to investigate the association between recovery of esophageal peristalsis after POEM and clinical features of the patients.

Methods

In this single-center retrospective study, data were collected from medical records of the patients with achalasia who underwent POEM between January 2014 and May 2016. Demographics data, high-resolution esophageal manometry parameters, Eckardt score, and gastroesophageal reflux disease questionnaire (GERD-Q) score were collected. Weak and fragmented contraction was defined as partial recovery of esophageal peristalsis based on the Chicago classification version 3.0. Logistic regression analysis was used to identify variables associated with the partial recovery of peristalsis after POEM.

Results

A total of 103 patients were enrolled. Esophageal contractile activity was observed in the distal two-thirds of the esophagus in 24 patients. The Eckardt score, integrated relaxation pressure, and lower esophageal sphincter (LES) resting pressure were significantly decreased after POEM. Multivariate analysis revealed that preprocedural LES resting pressure (P = 0.013) and preprocedural Eckardt score (P = 0.002) were related to the partial recovery of peristalsis after POEM. Symptoms of gastroesophageal reflux and reflux esophagitis after POEM were less frequent in those with partial recovery of peristalsis (both P < 0.05).

Conclusions

Normalization of esophagogastric junction relaxation pressure achieved by POEM is associated with the partial recovery of esophageal peristalsis in patients with achalasia. Preprocedural LES resting pressure and the Eckardt score are predictive of the recovery of esophageal peristalsis.     

Perimeter and Location of the Muscular Gastroesophageal Junction or ‘Cardia’ in Control Subjects and in Patients with Reflux Esophagitis or Achalasia

The location and perimeter of the true muscular gastroesophageal junction or cardia were determined during operation in 6 patients with achalasia, in 20 control subjects, and in 40 patients with reflux esophagitis. These two latter groups were submitted to highly selective vagotomy, owing to duodenal ulcer in the control subjects and as part of the surgical technique in reflux esophagitis patients. The careful dissection and isolation of the distal 5–6 cm of the esophagus and esophagogastric junction permitted us to measure the location and perimeter very precisely. There was a very close correlation between the distance incisors-beginning of gastroesophageal sphincter measured preoperatively and the distance incisors-cardia measured during surgery. The cardia could be clearly identified by external inspection corresponding to the limit between the longitudinal muscle layer of the esophagus and the serosal surface of the stomach. The perimeter of the cardia in the patients with reflux esophagitis was significantly larger than the perimeter of the control subjects (p<0.001). Intraoperative manometry demonstrated that the external limit of the cardia corresponded to the beginning of the gastroesophageal sphincter. Patients with achalasia had significantly smaller perimeter than controls or reflux esophagitis patients (p < 0.001).     

Long myotomy of the esophagus and gastric cardia with a complete fundic patch procedure for diffuse esophageal spasm

Under the hypothesis that the surgical management of diffuse esophageal spasm requires the elimination or reduction of episodes of dysphagia and chest pain and prevention of postoperative gastroesophageal reflux, long esophageal myotomy and fundoplication had been performed. However, there have been some cases with unsatisfactory results. We describe herein a new surgical procedure of long myotomy of the esophagus and gastric cardia with a complete fundic patch operation for the patient with diffuse esophageal spasm. The advantages of this procedure are to preserve the separation of each myotomized edge and to reinforce the wall of the surface of the myotomized mucosa in order to avoid the postoperative problems. Postoperative course of the patient with this procedure was satisfactory.     

Long-term outcome of esophageal myotomy for achalasia

AIM:Modified Heller‘s myotomy is still the first choice for achalasia and the assessment of surgical outcomes is usually made based on the subjective sensation of patients.This study was to objectively assess the long-term outcomes of esophageal myotomy for achalasia using esophageal manometry, 24-hour pH monitoring,esophageal scintigraphy and fiberoptic esophagoscopy.METHODS:From February 1979 to October 2000, 176 patients with achalasia underwent modified Heller‘s myotomy, including esophageal myotomy alone in 146 patients, myotomy in combination with Gallone or Dor antirefiux procedure in 22 and 8 patients, respectively. Clinical score,pressure of the lower esophageal sphincter (LES),esophageal clearance rate and gastroesophageal reflux were determined before and i to 22 years after surgery.RESULTS: After a median follow-up of 14 years, 84.5% of patients had a good or excellent relief of symptoms,and clinical scores as well as resting pressures of the esophageal body and LES were reduced compared with preoperative values (P&lt;0.001).However,there was no significant difference in DeMeester score between pre-and postoperative patients(P=0.51).Esophageal transit was improved in postoperative patients, but still slower than that in normal controls. The incidence of gastroesophageal reflux in patients who underwent esophageal myotomy alone was 63.6% compared to 27.3% in those who underwent myotomy and antirefiux procedure (P=-0.087). Three (1.7%) patients were complicated with esophageal cancer after surgery.CONCLUSION: Esophageal myotomy for achalasia can reduce the resting pressures of the esophageal body and LES and improve esophageal transit and dysphagia. Myotomy in combination with antireflux procedure can prevent gastroesophageal reflux to a certain extent,but further randomized studies should be carried out to demonstrate its efficacy.     

Barrett's Esophagus after Cardiomyotomy for Esophageal Achalasia

Heller's myotomy for esophageal achalasia was performed on 64 patients in the 24 yr up to 1988. After follow-up averaging 13 yr, 46 patients were reexamined with endoscopy, biopsy, and manometry. Barrett's metaplasia of the distal esophagus was found in four patients 6, 13, 20, and 23 yr after the myotomy. These four also underwent ambulatory 24-h pH monitoring. They had the lowest distal esophageal sphincter pressures (1–5 mm Hg), and all four had symptoms of gastroesophageal reflux and pathologic pH values (<4 in the distal esophagus for 32–62% of the total recording time). Because of heightened risk for the development of Barrett's metaplasia following cardiomotomy for esophageal achalasia, with increased liability to carcinoma of the esophagus, regular endoscopic surveillance of these patients is advisable.     

Treatment of idiopathic achalasia with per-oral esophageal myotomy

Achalasia is a rare esophageal motility disorder that necessitates the disruption of the lower esophageal sphincter. Patients with achalasia should be evaluated in a systematic, multidisciplinary fashion. Workup should include upper endoscopy, esophagography, and high-resolution manometry. The gold standard for surgical treatment is laparoscopic Heller myotomy with partial fundoplication. Per-oral esophageal myotomy is a novel endoscopic technique that has gained considerable traction over the past decade. The procedure includes the creation of a submucosal tunnel and a selective circular myotomy of the lower esophageal sphincter. Common intra-operative hazards include bleeding within the submucosal tunnel and capnoperitoneum. Significant complications are rare. Patients experience excellent dysphagia relief that is on par with laparoscopic Heller myotomy at moderate-term follow up. Post-operative gastroesophageal reflux disease occurs in greater than one-third of patients, and the vast majority of cases are readily controlled with an anti-secretory medication. Although data is sparse, there is a growing body of literature that supports the long-term durability of per-oral esophageal myotomy.     

Laparoscopic long myotomy and Dor fundoplication guided by perioperative endoscopic ultrasound

An 80-year-old man with diffuse esophageal spasm underwent high-resolution manometry perioperatively and postoperatively. Integrated relaxation pressure was normal, and distal latency and peristaltic waves had disappeared. Endoscopic ultrasound (EUS) revealed esophageal muscle layer thickening to more than 1 cm in an area spanning the esophagogastric junction to the oral side. Laparoscopic long myotomy (LM) was performed followed by Dor fundoplication. The patient was discharged with a good postoperative course. Perioperative EUS-guided LM via the transhiatal approach was useful in this case.     

The presence and mucin histochemistry of cardiac type mucosa at the esophagogastric junction

OBJECTIVES: Traditionally, the gastric cardia has been described as a native part of the stomach connecting to the esophagus. In recent literature, however, it is suggested that the cardia is an acquired lesion that develops due to gastroesophageal reflux disease. As a contribution to this debate, we evaluated the presence of cardiac mucosa at the esophagogastric junction (EGJ) in a random group of patients who presented at our endoscopy unit. METHODS: In 253 unselected patients, biopsies were taken from the EGJ. In order to prevent sampling error, we selected only those EGJ biopsies in which the squamocolumnar junction (SCJ) was present in the histological biopsy material. Fifty-five patients were excluded since the SCJ was located proximal to the EGJ in the esophagus. The type of columnar mucosa immediately distal to the SCJ, and its mucin histochemistry, were assessed. The columnar mucosa was categorized as purely cardiac, oxyntocardiac, or fundic mucosa. RESULTS: In 63 of the 198 patients, the SCJ was actually present in the EGJ biopsies. Purely cardiac mucosa was present in 39 (62%) biopsies and oxyntocardiac mucosa was present in 24 (38%) biopsies. Fundic mucosa was not seen directly adjacent to squamous epithelium. Acid mucins were present in 23 (37%) patients and they correlated with histological esophagitis and presence of H. pylori in the cardia. CONCLUSIONS:Cardiac mucosa was uniformly present adjacent to the squamous epithelium at the EGJ. This argues against the hypothesis that the gastric cardia is an acquired metaplastic lesion. The presence of acid mucins was frequently observed and could be a pathological condition as it was associated with histological esophagitis and the presence of H. pylori in the cardia.     

Specific esophagogram to assess functional outcomes after Heller's myotomy and Dor's fundoplication for esophageal achalasia

Esophageal emptying assessed at the ‘timed barium’ esophagogram correlates well with symptomatic outcomes after pneumatic dilation for esophageal achalasia, although 30% of patients with satisfactory outcome exhibit partial improvement in emptying. The aim of the study was to investigate any correlation of esophageal emptying to symptomatic response after laparoscopic Heller's myotomy and Dor's fundoplication. ‘Bread and barium’ (transit time of a barium opaque bread bolus) and ‘timed barium’ (height of esophageal barium column 5 minutes after ingestion of 200–250 mL of barium suspension) esophagogram was used to assess esophageal emptying in 73 patients with esophageal achalasia before 1 and 5 years (31 cases) after laparoscopic myotomy and anterior fundoplication. Symptoms assessment was based to a specific score. At 1‐year follow‐up, excellent and good symptomatic results were obtained in 95% of the cases. Esophageal maximum diameter, esophageal transit time, and esophageal barium column were significantly correlated to each other and to symptom score postoperatively (P < 0.001). Complete and partial (<90% and 50–90% postoperative reduction in barium column, respectively) emptying was seen in 55% and 31% of patients with excellent result. Patients with a pseudodiverticulum postoperatively had a more delayed esophageal emptying than those without. Symptomatic outcome and esophageal emptying did not deteriorate at 5‐year follow‐up. Esophageal emptying assessed by ‘barium and bread’ and ‘timed barium’ esophagogram correlated well with symptomatic outcome after laparoscopic myotomy for esophageal achalasia. Complete symptomatic relief does not necessarily reflect complete esophageal emptying. Outcomes do not deteriorate by time. Because of wide availability, esophagogram can be applied in follow‐up of postmyotomy patients in conjunction with symptomatic evaluation.     

Controversies in the treatment of gastroesophageal reflux and achalasia

The immense success of laparoscopic surgery as an effective treatment of gastroesophageal reflux disease (GERD) and achalasia has established minimal invasive surgery as the gold standard for these two conditions with lower morbidity and mortality, shorter hospital stay, faster convalescence, and less postoperative pain. One controversy in the treatment of GERD evolves around laparoscopic antireflux surgery (LARS) as the preferred treatment for Barrett's esophagus and the procedure's potential to reduce the risk of adenocarcinoma of the esophagus. GERD has also been associated with respiratory symptoms, asthma and laryngeal injury, and a second controversy prompts discussions about whether total or partial fundoplication is the more appropriate treatment for GERD. A new and promising alternative in the treatment of GERD is endoluminal therapy. Three types of this new treatment option will be discussed: radiofrequency energy delivered to the lower esophageal sphincter, the creation of a mechanical barrier at the gastroesophageal junction, and the direct endoscopic tightening of the lower esophageal sphincter. Laparoscopic surgery is discussed not only as a very effective treatment for GERD but also as permanent cure for achalasia. This review analyzes the three most important treatment options for achalasia: medications, pneumatic dilatation, and surgical therapy. Medications as the only true non-invasive option in the treatment of achalasia are not as effective as LARS because of their short half-life and variable absorption due to the poor esophageal emptying. The second treatment option, pneumatic dilatation, involves the stretching of the lower esophagus and is still considered the most effective non-surgical treatment for achalasia. Finally, surgical therapy for achalasia and the two major controversies concerning this laparoscopic treatment are discussed. The first involves the extent to which the myotomy is extended onto the stomach, and the second concerns the necessity and type of antireflux procedure to prevent GERD after myotomy. LARS and laparoscopic Heller myotomy are the agreed upon as the gold standards for surgical treatment of GERD and achalasia, respectively. In the hands of an experienced laparoscopic surgeon both are safe and effective treatments for patients with excellent subjective and objective long-term results with at least 90% patient satisfaction.     

Adenocarcinoma of the esophagogastric junction

Adenocarcinoma of the esophagogastric junction (EGJ) has increased rapidly in incidence in the latter half of the twentieth century. The increase in incidence has affected white men between the ages of 40 and 60 disproportionately. Understanding the etiology and improving treatment requires careful classification of EGJ tumors. A recent consensus conference recognized three types of EGJ adenocarcinomas: distal esophageal, cardia, and subcardia gastric. Distal esophageal adenocarcinomas are associated with Barrett's esophagus. Helicobacter pylori infection may play a role in some adenocarcinomas of the subcardia, but the association is unproven. Therapy for all types of EGJ tumors is surgical, but multimodal forms of treatment are commonly used because of the advanced stage at which these tumors often present. Several endoscopic options exist for primary therapy of early-stage tumors and for palliation.     

Peroral endoscopic myotomy

Peroral endoscopic myotomy(POEM) incorporates concepts of natural orifice translumenal endoscopic surgery and achieves endoscopic myotomy by utilizing a submucosal tunnel as an operating space. Although intended for the palliation of symptoms of achalasia, there is mounting data to suggest it is also efficacious in the management of spastic esophageal disorders. The technique requires an understanding of the pathophysiology of esophageal motility disorders as well as knowledge of surgical anatomy of the foregut. POEM achieves short term response in 82% to 100% of patients with minimal risk of adverse events. In addition, it appears to be effective and safe even at the extremes of age and regardless of prior therapy undertaken. Although infrequent, the ability of the endoscopist to manage an intraprocedural adverse event is critical as failure to do so could result in significant morbidity. The major late adverse event is gastroesophageal reflux which appears to occur in 20% to 46% of patients. Research is being conducted to clarify the optimal technique for POEM and a personalized approach by measuring intraprocedural esophagogastric junction distensibility appears promising. In addition to esophageal disorders, POEM is being studied in the management of gastroparesis(gastric pyloromyotomy) with initial reports demonstrating technical feasibility. Although POEM represents a paradigm shift the management of esophageal motility disorders, the results of prospective randomized controlled trials with long-term follow up are eagerly awaited.