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

David Albers; Thomas Frieling; Dani Dakkak; Rita Kuhlbusch-Zicklam; Ulrich Töx; Mathis Gittinger; Brigitte Schumacher

doi:10.1055/a-0668-2605

Zeitschrift für Gastroenterologie, Table of Contents

Z Gastroenterol 2018; 56(11): 1337-1342
DOI: 10.1055/a-0668-2605

Originalarbeit

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

Die Perorale Endoskopische Myotomie (POEM) ist eine effektive Behandlung des nicht-kardialen Thoraxschmerzes durch hyperkontraktile Ösophagusmotilitätsstörungen: Ergebnisse der POEM-HYPE-Studie

David Albers

¹Department of Internal Medicine and Gastroenterology, Elisabeth-Krankenhaus Essen, Essen, Germany

,

Thomas Frieling

²Department of Internal Medicine and Gastroenterology, Helios Klinikum Krefeld, Krefeld, Germany

,

Dani Dakkak

¹Department of Internal Medicine and Gastroenterology, Elisabeth-Krankenhaus Essen, Essen, Germany

,

Rita Kuhlbusch-Zicklam

²Department of Internal Medicine and Gastroenterology, Helios Klinikum Krefeld, Krefeld, Germany

,

Ulrich Töx

³Department of Gastroenterology, University of Cologne, Germany

,

Mathis Gittinger

¹Department of Internal Medicine and Gastroenterology, Elisabeth-Krankenhaus Essen, Essen, Germany

,

Brigitte Schumacher

¹Department of Internal Medicine and Gastroenterology, Elisabeth-Krankenhaus Essen, Essen, Germany

› Author Affiliations

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

Full Text

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