CASE REPORT
Atrial Fibrillation as an Unexpected Complication After Peroral Endoscopic Myotomy (POEM): A Case Report Abdulaziz M. Saleem, MD,* Hooman Hennessey, MD,w Daniel von Renteln, MD,z and Melina C. Vassiliou, MD, MEd, FRCSC, FACS*
Abstract: Peroral endoscopic myotomy (POEM) is an entirely endoscopic approach for the treatment of achalasia. This new procedure has been shown to be safe, effective, and associated with only minor complications in the postoperative period. This case report describes the development of atrial fibrillation after POEM secondary to direct compression from a hematoma in the submucosal tunnel. To our knowledge, this is the first report of a delayed hematoma after POEM. This procedure is still novel, and it is important to continue to share information about potential complications and long-term results. This report also includes several interesting radiographic images to illustrate what occurred. Finally, we provide a brief review of the literature on complications that have been described after POEM. Key Words: peroral endoscopic myotomy, achalasia, complications
(Surg Laparosc Endosc Percutan Tech 2014;24:e196–e199)
A
chalasia is an uncommon neuromuscular disorder of the esophagus of unknown etiology with an incidence of 1.63/100,000 cases per year.1 It is characterized by aperistalsis, failure of the lower esophageal sphincter (LES) to relax, and, in some cases, hypertension of the LES. The treatment options are medical, endoscopic, and surgical. All are aimed at relaxing or mechanically opening up the LES to allow food into the stomach, mostly by gravity. In 2007, an innovative, entirely endoscopic, and incisionless myotomy was developed. It was first described in the animal model,2 and then successfully reported in humans not long after by Professor Inoue of Japan.3 Since that time, many centers throughout the world have introduced POEM with similar excellent results, providing evidence for safety and effectiveness in relieving symptoms of dysphagia. As with any new procedure, ongoing collection of data is crucial in understanding the range of potential complications and the long-term outcomes. Herein, we report a unique complication that developed after a POEM procedure. The patient presented here was included in a recently published international multicenter prospective study of 70 Received for publication May 2, 2014; accepted July 22, 2014. From the *Department of General Surgery, McGill University Health Centre; wDepartment of Diagnostic Radiology, McGill University Health Centre, Montreal General Hospital; and zDepartment of Gastroenterology, Centre Hospitalier de l’Universite´ de Montre´al, Montre´al, QC, Canada. A.M.S. is a scholar from the department of General Surgery, King Abdulaziz University, Jeddah, Saudi Arabia. The author declares no conflicts of interest. Reprints: Melina C. Vassiliou, MD, MEd, FRCSC, FACS, Department of Surgery, McGill University, 1650 Cedar Ave., L9-313, Montreal, QC, Canada H3G 1A4 (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
e196 | www.surgical-laparoscopy.com
patients with achalasia.4 This report describes the conditions around this complication in much more detail.
CASE REPORT A 75-year-old gentleman was referred to our esophageal clinic having suffered from dysphagia with solids and liquids for the past 7 years. He was otherwise in good health, had no history of cardiac disease, and was not taking any medications. Esophagogastroduodenoscopy (EGD) demonstrated a dilated esophagus with some retained food and liquid, and a tight LES without any evidence of mucosal abnormalities. Biopsies of the esophagus were normal. A barium swallow showed the characteristic bird’s beak appearance at the esophagogastric junction. High-resolution esophageal manometry revealed an LES pressure of 21 mm Hg with a residual pressure of 18 mm Hg, and complete absence of peristaltic activity in the smooth muscle, compatible with achalasia (Type II—Chicago classification). His preoperative Eckardt score was 6. All of the potential treatment options were offered to the patient, including medical, endoscopic, and surgical. At our institution, we are conducting an IRB-approved study for the introduction of POEM, and this option was also offered to the patient. The patient opted for POEM. Preoperative electrocardiogram and laboratory studies were normal.
THE PROCEDURE POEM was introduced at our institution under an IRBapproved study and as part of a multicenter trial including several European centers. The endoscopist performing POEM at our institution observed several POEM procedures in Germany with a group that learned directly from Professor Inoue. Several procedures were then performed in the animal laboratory, and the first 4 procedures performed at our institution were proctored and performed in partnership with a Professor from Germany who had extensive experience with the procedure. POEM was performed in a standard manner under general anesthesia using CO2 insufflation, as has been previously described.5 The myotomy was 10 cm in length and no intraoperative complications occurred. The patient’s immediate postoperative course was uneventful. He was discharged on postoperative day 2 and reported greatly improved symptoms with very little pain. As per protocol, he underwent a contrast swallowing study on the first postoperative day, which did not demonstrate any evidence of leak, with good flow of contrast through the LES. He presented to the emergency department on postoperative day 19 complaining of fatigue, weakness, and chest discomfort. He did not report any dysphagia at this time, and his Eckardt score was 2. Electrocardiography revealed new-onset atrial fibrillation. A chest x-ray was performed demonstrating a “double right heart border,” and splaying of the carina by >90 degrees, findings typically seen in patients with left atrial enlargement and
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 5, October 2014
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 5, October 2014
FIGURE 1. A chest x-ray showing a “double right heart border” demonstrating the contour of the right atrium (blue arrow) and medially a second contour (yellow arrow), which would be the expected left atrium, which was not the case and splaying of the carina by >90 degrees (red curve).
cardiomegaly that were not present 1 month prior (Fig. 1). Given the chest x-ray findings, new onset of atrial fibrillation, and recent POEM procedure, a computed tomography (CT) scan of the thorax with intravenous and oral contrast was performed. The CT of the thorax revealed a 7.6 6.0 6.8 cm fluid-filled collection in the mediastinum, adjacent to the esophagus in the submucosal tunnel (Fig. 2). The hematoma was causing a local mass effect resulting in splaying of the carina, local extrinsic compression of the left atrium and stretching of the pulmonary veins. These CT findings are consistent with the patient’s clinical presentation of new-onset arrhythmia. A lesion found in this location explains the double contour of the right heart boarder on initial plain radiographs in addition to the paroxysmal abnormal electrical activity found on electrocardiography, which was presumed to be the result of irritation from the mass effect on the left atrium and pulmonary veins, areas of known ectopic electrical foci. The patient was admitted to the intensive care unit for close monitoring. An EGD was performed revealing an intact esophageal mucosa, without any evidence of hematoma or mass effect intraluminally. He was started on a low-dose b-blocker for rate control. Given the recent hematoma and low CHADS 2 score (score = 1), he was not anticoagulated. His rate converted to normal sinus rhythm within hours of admission. At 3 months, a repeat chest CT scan showed that the mediastinal hematoma had decreased in size. And EGD was performed and the patient had LA class B esophagitis at the gastroesophageal (GE) junction and mild gastritis. Biopsies of the stomach were positive for H. pylori for which the patient was treated. High-resolution esophageal manometry demonstrated a decrease in residual LES pressures to 7.4 mm Hg (from 18 mm Hg), and his Eckardt score was 0, both indicating successful treatment of his achalasia. The patient was treated for the esophagitis with a proton pump inhibitor.
DISCUSSION POEM is a novel, endoscopic technique for the treatment of achalasia. Since Inoue et al3 reported its safety and r
2014 Lippincott Williams & Wilkins
Atrial Fibrillation After POEM
effectiveness in humans, many groups have reported similar results with minimal complications.4 We have reported the case of a patient who underwent POEM complicated by a large mediastinal hematoma, which compressed the left atrium and stretched the pulmonary veins potentially being the cause for new-onset atrial fibrillation. This type of complication after POEM has not been reported before. In our patient, the mediastinal hematoma was managed conservatively and did not require further intervention. Many studies have shown that POEM is associated with minimal postoperative complications. In a prospective study by Ro¨sch et al including 16 patients who underwent POEM, they reported a 94% clinical success rate without major complications.5 One patient had a Forrest III superficial ulcer at the cardia of the stomach, and also required pneumatic balloon dilatation to relieve his persistent symptoms. Intraoperatively, 56% of patients had fullthickness dissection into the peritoneal cavity at the cardia, and 81% had full-thickness dissection of the muscle into the mediastinum. One patient had a small mucosal perforation at the GE junction that was successfully clipped.5 Kudo et al from Japan reported 105 patients who underwent POEM. One patient developed peritonitis, which was managed with antibiotics. Pneumo-mediastinum developed in several patients as detected by CT scan, which was managed conservatively, and 1 patient developed a pneumothorax, which was treated with a chest tube.6 Another study from China included 119 patients who underwent POEM.7 Postoperatively, the most common complications were asymptomatic subcutaneous emphysema, which developed in 55.5% of the cases. Other complications included mediastinal emphysema (29.4%), pneumothorax (25.2%), pleural effusion (48.7%), mild lung inflammation, and segmental atelectasis (49.6%). One patient (0.8%) had significant hematemesis on postoperative day 1, which required urgent endoscopy that revealed blood clots in the submucosal tunnel without any identifiable source. This was managed with a 3-cavity tube into the stomach and the lower part of the esophagus to compress the bleeding spot. One patient had an esophageal stenosis, which was treated by esophageal dilatation. During follow-up, 1 patient had difficulty eating after 1 week from surgery. Gastroscopy showed accumulated food caused by cracking of the tunnel’s opening, with formation of a submucosal sinus. That was managed endoscopically by resecting the mucosa overlying the sinus.7 Mucosal perforation at the cardia has also been reported and managed with fibrin sealant or endoscopic clips without any major complications.8 Although not reported in humans, mediastinal sepsis and leak at the myotomy site are potential serious complications after POEM and have been seen in animal models.9 This patient was included in a recently published international multicenter prospective study that included 70 patients with achalasia. The treatment success rate in this trial was 97% at 3 months follow-up.4 Interestingly, the success rate dropped to 88.5% and 82.4% at 6 and 12 months followup, respectively. Complication rates in addition to the one that occurred in this patient were low, including clip dislocation at mucosal closure (4%), mucosal injury through electrocautery (4%), perforation into mediastinum (1%), and bleeding requiring intervention (1%). The incidence of GE reflux was 33%, 30%, and 37% at 3, 6, and 12 months followup, respectively. Long-term results showed excellent symptom control with unchanged Eckardt score. www.surgical-laparoscopy.com |
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Surg Laparosc Endosc Percutan Tech
Volume 24, Number 5, October 2014
FIGURE 2. Computed tomography scan of the chest showing the mediastinal hematoma (black asterisk), compressing the pulmonary vein (blue arrows) and the left atrium (red arrow).
The occurrence of a hematoma in the submucosal tunnel after POEM is rare, and it occurred in 1 patient (0.8%) in one of the largest reported series of POEM.7 That patient presented with hematemesis on postoperative day 1, which could indicate the possibility of postoperative bleeding after dissection of the submucosal tunnel. However, our patient developed a contained hematoma that exerted a mass effect on the surrounding vital structures, which presented 19 days after surgery. Although it was likely a similar mechanism, because of the secure closure of the submucosal tunnel, blood did not escape from the submucosal tunnel to manifest as hematemesis, and instead increased slowly in size, until he became symptomatic. With appropriate training and well-selected patients, POEM is an effective and safe technique for the treatment
e198 | www.surgical-laparoscopy.com
of achalasia with encouraging initial results. Although the incidence of reported complications is low, these results should be interpreted with caution, given that the published work to date has been performed primarily in tertiary, large-volume centers, by top experts in the field, and these results may not be generalizable. Long-term studies are needed to determine the effectiveness of the procedure and to determine what the incidence of complications is.
REFERENCES 1. Sadowski DC, Ackah F, Jiang B, et al. Achalasia: incidence, prevalence and survival. A population-based study. Neurogastroenterol Motil. 2010;22:e256–e261. r
2014 Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 5, October 2014
2. Pasricha PJ, Hawari R, Ahmed I, et al. Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy. 2007;39:761–764. 3. Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010;42:265–271. 4. Von Renteln D, Fuchs KH, Fockens P, et al. Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study. Gastroenterology. 2013;145: 309–311, e303. 5. von Renteln D, Inoue H, Minami H, et al. Peroral endoscopic myotomy for the treatment of achalasia: a prospective single center study. Am J Gastroenterol. 2012;107:411–417.
r
2014 Lippincott Williams & Wilkins
Atrial Fibrillation After POEM
6. Inoue H, Tianle KM, Ikeda H, et al. Peroral endoscopic myotomy for esophageal achalasia: technique, indication, and outcomes. Thorac Surg Clin. 2011;21:519–525. 7. Ren Z, Zhong Y, Zhou P, et al. Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases). Surg Endosc. 2012;26:3267–3272. 8. Li H, Linghu E, Wang X. Fibrin sealant for closure of mucosal penetration at the cardia during peroral endoscopic myotomy (POEM). Endoscopy. 2012;44(suppl 2 UCTN):E215–E216. 9. Abu Gazala M, Khalaila A, Shussman N, et al. Transesophageal endoscopic myotomy for achalasia: recognizing potential pitfalls before clinical application. Surg Endosc. 2012;26:681–687.
www.surgical-laparoscopy.com |
e199
Atrial Fibrillation as an Unexpected Complication After Peroral Endoscopic Myotomy (POEM): A Case Report Abdulaziz M. Saleem, MD,* Hooman Hennessey, MD,w Daniel von Renteln, MD,z and Melina C. Vassiliou, MD, MEd, FRCSC, FACS*
Abstract: Peroral endoscopic myotomy (POEM) is an entirely endoscopic approach for the treatment of achalasia. This new procedure has been shown to be safe, effective, and associated with only minor complications in the postoperative period. This case report describes the development of atrial fibrillation after POEM secondary to direct compression from a hematoma in the submucosal tunnel. To our knowledge, this is the first report of a delayed hematoma after POEM. This procedure is still novel, and it is important to continue to share information about potential complications and long-term results. This report also includes several interesting radiographic images to illustrate what occurred. Finally, we provide a brief review of the literature on complications that have been described after POEM. Key Words: peroral endoscopic myotomy, achalasia, complications
(Surg Laparosc Endosc Percutan Tech 2014;24:e196–e199)
A
chalasia is an uncommon neuromuscular disorder of the esophagus of unknown etiology with an incidence of 1.63/100,000 cases per year.1 It is characterized by aperistalsis, failure of the lower esophageal sphincter (LES) to relax, and, in some cases, hypertension of the LES. The treatment options are medical, endoscopic, and surgical. All are aimed at relaxing or mechanically opening up the LES to allow food into the stomach, mostly by gravity. In 2007, an innovative, entirely endoscopic, and incisionless myotomy was developed. It was first described in the animal model,2 and then successfully reported in humans not long after by Professor Inoue of Japan.3 Since that time, many centers throughout the world have introduced POEM with similar excellent results, providing evidence for safety and effectiveness in relieving symptoms of dysphagia. As with any new procedure, ongoing collection of data is crucial in understanding the range of potential complications and the long-term outcomes. Herein, we report a unique complication that developed after a POEM procedure. The patient presented here was included in a recently published international multicenter prospective study of 70 Received for publication May 2, 2014; accepted July 22, 2014. From the *Department of General Surgery, McGill University Health Centre; wDepartment of Diagnostic Radiology, McGill University Health Centre, Montreal General Hospital; and zDepartment of Gastroenterology, Centre Hospitalier de l’Universite´ de Montre´al, Montre´al, QC, Canada. A.M.S. is a scholar from the department of General Surgery, King Abdulaziz University, Jeddah, Saudi Arabia. The author declares no conflicts of interest. Reprints: Melina C. Vassiliou, MD, MEd, FRCSC, FACS, Department of Surgery, McGill University, 1650 Cedar Ave., L9-313, Montreal, QC, Canada H3G 1A4 (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
e196 | www.surgical-laparoscopy.com
patients with achalasia.4 This report describes the conditions around this complication in much more detail.
CASE REPORT A 75-year-old gentleman was referred to our esophageal clinic having suffered from dysphagia with solids and liquids for the past 7 years. He was otherwise in good health, had no history of cardiac disease, and was not taking any medications. Esophagogastroduodenoscopy (EGD) demonstrated a dilated esophagus with some retained food and liquid, and a tight LES without any evidence of mucosal abnormalities. Biopsies of the esophagus were normal. A barium swallow showed the characteristic bird’s beak appearance at the esophagogastric junction. High-resolution esophageal manometry revealed an LES pressure of 21 mm Hg with a residual pressure of 18 mm Hg, and complete absence of peristaltic activity in the smooth muscle, compatible with achalasia (Type II—Chicago classification). His preoperative Eckardt score was 6. All of the potential treatment options were offered to the patient, including medical, endoscopic, and surgical. At our institution, we are conducting an IRB-approved study for the introduction of POEM, and this option was also offered to the patient. The patient opted for POEM. Preoperative electrocardiogram and laboratory studies were normal.
THE PROCEDURE POEM was introduced at our institution under an IRBapproved study and as part of a multicenter trial including several European centers. The endoscopist performing POEM at our institution observed several POEM procedures in Germany with a group that learned directly from Professor Inoue. Several procedures were then performed in the animal laboratory, and the first 4 procedures performed at our institution were proctored and performed in partnership with a Professor from Germany who had extensive experience with the procedure. POEM was performed in a standard manner under general anesthesia using CO2 insufflation, as has been previously described.5 The myotomy was 10 cm in length and no intraoperative complications occurred. The patient’s immediate postoperative course was uneventful. He was discharged on postoperative day 2 and reported greatly improved symptoms with very little pain. As per protocol, he underwent a contrast swallowing study on the first postoperative day, which did not demonstrate any evidence of leak, with good flow of contrast through the LES. He presented to the emergency department on postoperative day 19 complaining of fatigue, weakness, and chest discomfort. He did not report any dysphagia at this time, and his Eckardt score was 2. Electrocardiography revealed new-onset atrial fibrillation. A chest x-ray was performed demonstrating a “double right heart border,” and splaying of the carina by >90 degrees, findings typically seen in patients with left atrial enlargement and
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 5, October 2014
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 5, October 2014
FIGURE 1. A chest x-ray showing a “double right heart border” demonstrating the contour of the right atrium (blue arrow) and medially a second contour (yellow arrow), which would be the expected left atrium, which was not the case and splaying of the carina by >90 degrees (red curve).
cardiomegaly that were not present 1 month prior (Fig. 1). Given the chest x-ray findings, new onset of atrial fibrillation, and recent POEM procedure, a computed tomography (CT) scan of the thorax with intravenous and oral contrast was performed. The CT of the thorax revealed a 7.6 6.0 6.8 cm fluid-filled collection in the mediastinum, adjacent to the esophagus in the submucosal tunnel (Fig. 2). The hematoma was causing a local mass effect resulting in splaying of the carina, local extrinsic compression of the left atrium and stretching of the pulmonary veins. These CT findings are consistent with the patient’s clinical presentation of new-onset arrhythmia. A lesion found in this location explains the double contour of the right heart boarder on initial plain radiographs in addition to the paroxysmal abnormal electrical activity found on electrocardiography, which was presumed to be the result of irritation from the mass effect on the left atrium and pulmonary veins, areas of known ectopic electrical foci. The patient was admitted to the intensive care unit for close monitoring. An EGD was performed revealing an intact esophageal mucosa, without any evidence of hematoma or mass effect intraluminally. He was started on a low-dose b-blocker for rate control. Given the recent hematoma and low CHADS 2 score (score = 1), he was not anticoagulated. His rate converted to normal sinus rhythm within hours of admission. At 3 months, a repeat chest CT scan showed that the mediastinal hematoma had decreased in size. And EGD was performed and the patient had LA class B esophagitis at the gastroesophageal (GE) junction and mild gastritis. Biopsies of the stomach were positive for H. pylori for which the patient was treated. High-resolution esophageal manometry demonstrated a decrease in residual LES pressures to 7.4 mm Hg (from 18 mm Hg), and his Eckardt score was 0, both indicating successful treatment of his achalasia. The patient was treated for the esophagitis with a proton pump inhibitor.
DISCUSSION POEM is a novel, endoscopic technique for the treatment of achalasia. Since Inoue et al3 reported its safety and r
2014 Lippincott Williams & Wilkins
Atrial Fibrillation After POEM
effectiveness in humans, many groups have reported similar results with minimal complications.4 We have reported the case of a patient who underwent POEM complicated by a large mediastinal hematoma, which compressed the left atrium and stretched the pulmonary veins potentially being the cause for new-onset atrial fibrillation. This type of complication after POEM has not been reported before. In our patient, the mediastinal hematoma was managed conservatively and did not require further intervention. Many studies have shown that POEM is associated with minimal postoperative complications. In a prospective study by Ro¨sch et al including 16 patients who underwent POEM, they reported a 94% clinical success rate without major complications.5 One patient had a Forrest III superficial ulcer at the cardia of the stomach, and also required pneumatic balloon dilatation to relieve his persistent symptoms. Intraoperatively, 56% of patients had fullthickness dissection into the peritoneal cavity at the cardia, and 81% had full-thickness dissection of the muscle into the mediastinum. One patient had a small mucosal perforation at the GE junction that was successfully clipped.5 Kudo et al from Japan reported 105 patients who underwent POEM. One patient developed peritonitis, which was managed with antibiotics. Pneumo-mediastinum developed in several patients as detected by CT scan, which was managed conservatively, and 1 patient developed a pneumothorax, which was treated with a chest tube.6 Another study from China included 119 patients who underwent POEM.7 Postoperatively, the most common complications were asymptomatic subcutaneous emphysema, which developed in 55.5% of the cases. Other complications included mediastinal emphysema (29.4%), pneumothorax (25.2%), pleural effusion (48.7%), mild lung inflammation, and segmental atelectasis (49.6%). One patient (0.8%) had significant hematemesis on postoperative day 1, which required urgent endoscopy that revealed blood clots in the submucosal tunnel without any identifiable source. This was managed with a 3-cavity tube into the stomach and the lower part of the esophagus to compress the bleeding spot. One patient had an esophageal stenosis, which was treated by esophageal dilatation. During follow-up, 1 patient had difficulty eating after 1 week from surgery. Gastroscopy showed accumulated food caused by cracking of the tunnel’s opening, with formation of a submucosal sinus. That was managed endoscopically by resecting the mucosa overlying the sinus.7 Mucosal perforation at the cardia has also been reported and managed with fibrin sealant or endoscopic clips without any major complications.8 Although not reported in humans, mediastinal sepsis and leak at the myotomy site are potential serious complications after POEM and have been seen in animal models.9 This patient was included in a recently published international multicenter prospective study that included 70 patients with achalasia. The treatment success rate in this trial was 97% at 3 months follow-up.4 Interestingly, the success rate dropped to 88.5% and 82.4% at 6 and 12 months followup, respectively. Complication rates in addition to the one that occurred in this patient were low, including clip dislocation at mucosal closure (4%), mucosal injury through electrocautery (4%), perforation into mediastinum (1%), and bleeding requiring intervention (1%). The incidence of GE reflux was 33%, 30%, and 37% at 3, 6, and 12 months followup, respectively. Long-term results showed excellent symptom control with unchanged Eckardt score. www.surgical-laparoscopy.com |
e197
Saleem et al
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 5, October 2014
FIGURE 2. Computed tomography scan of the chest showing the mediastinal hematoma (black asterisk), compressing the pulmonary vein (blue arrows) and the left atrium (red arrow).
The occurrence of a hematoma in the submucosal tunnel after POEM is rare, and it occurred in 1 patient (0.8%) in one of the largest reported series of POEM.7 That patient presented with hematemesis on postoperative day 1, which could indicate the possibility of postoperative bleeding after dissection of the submucosal tunnel. However, our patient developed a contained hematoma that exerted a mass effect on the surrounding vital structures, which presented 19 days after surgery. Although it was likely a similar mechanism, because of the secure closure of the submucosal tunnel, blood did not escape from the submucosal tunnel to manifest as hematemesis, and instead increased slowly in size, until he became symptomatic. With appropriate training and well-selected patients, POEM is an effective and safe technique for the treatment
e198 | www.surgical-laparoscopy.com
of achalasia with encouraging initial results. Although the incidence of reported complications is low, these results should be interpreted with caution, given that the published work to date has been performed primarily in tertiary, large-volume centers, by top experts in the field, and these results may not be generalizable. Long-term studies are needed to determine the effectiveness of the procedure and to determine what the incidence of complications is.
REFERENCES 1. Sadowski DC, Ackah F, Jiang B, et al. Achalasia: incidence, prevalence and survival. A population-based study. Neurogastroenterol Motil. 2010;22:e256–e261. r
2014 Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 5, October 2014
2. Pasricha PJ, Hawari R, Ahmed I, et al. Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy. 2007;39:761–764. 3. Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010;42:265–271. 4. Von Renteln D, Fuchs KH, Fockens P, et al. Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study. Gastroenterology. 2013;145: 309–311, e303. 5. von Renteln D, Inoue H, Minami H, et al. Peroral endoscopic myotomy for the treatment of achalasia: a prospective single center study. Am J Gastroenterol. 2012;107:411–417.
r
2014 Lippincott Williams & Wilkins
Atrial Fibrillation After POEM
6. Inoue H, Tianle KM, Ikeda H, et al. Peroral endoscopic myotomy for esophageal achalasia: technique, indication, and outcomes. Thorac Surg Clin. 2011;21:519–525. 7. Ren Z, Zhong Y, Zhou P, et al. Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases). Surg Endosc. 2012;26:3267–3272. 8. Li H, Linghu E, Wang X. Fibrin sealant for closure of mucosal penetration at the cardia during peroral endoscopic myotomy (POEM). Endoscopy. 2012;44(suppl 2 UCTN):E215–E216. 9. Abu Gazala M, Khalaila A, Shussman N, et al. Transesophageal endoscopic myotomy for achalasia: recognizing potential pitfalls before clinical application. Surg Endosc. 2012;26:681–687.
www.surgical-laparoscopy.com |
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