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j.gie.2017.05.031

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Letters to the Editor
DISCLOSURE
Dr Elfant is a consultant for Boston Scientific. All other
authors disclosed no financial relationships relevant to
this publication.
The authors thank David L. Diehl, MD, FACP, FASGE,
and Katie A. Propst, MD, for their thorough review of the
manuscript.
Shaffer R. S. Mok, MD, MBS
Henry C. Ho, MD
Paurush Shah, MD
Milan Patel, MD
John P. Gaughan, MS, PhD, MBA
Adam B. Elfant, MD, FACG
Department of Medicine
Division of Gastroenterology and Liver Diseases
Cooper Medical School of Rowan University
MD Anderson Cancer Center at Cooper
Mount Laurel, New Jersey, USA
REFERENCES
1. Buxbaum J, Yu CY. Indomethacin and lactated Ringer’s hydration to
prevent post-ERCP pancreatitis: right combination but wrong volume.
Gastrointest Endosc 2017;86:925-6.
2. Mok SRS, Ho HC, Shah P, et al. Lactated Ringer’s solution in
combination with rectal indomethacin for prevention of post-ERCP
pancreatitis and readmission: a prospective randomized, doubleblinded, placebo-controlled trial. Gastrointest Endosc 2017;85:
1005-13.
3. Wu BU, Hwang JQ, Gardner TH, et al. Lactated Ringer’s solution reduces
systemic inflammation compared with saline in patients with acute
pancreatitis. Clin Gastroenterol Hepatol 2011;9:710-7.
4. Wan J, Ren Y, Zhu Z, et al. How to select patients and timing for rectal
indomethacin to prevent post-ERCP pancreatitis: a systematic review
and meta-analysis. BMC Gastroenterol 2017;17:43.
5. Buxbaum J, Yan A, Yeh K, et al. Aggressive hydration with lactated
Ringer’s solution reduces pancreatitis after endoscopic retrograde
cholangiopancreatography. Clin Gastroenterol Hepatol 2014;12:
303-7.e1.
In this study, the response to PBD (20%) was inferior
to the response to re-POEM (63%) or LHM (45%). The
difference did not reach statistical significance because of
the small sample size. However, it provides strength to
the concept that cutting may fare better than stretching.2
In the present study, the response to PBD was very low
(20%). PBD was performed with 30-mm to 35-mm balloons
in most of the cases. A 40-mm balloon was used in only 4
patients subsequently. Graded dilation (30 to 35 to 40 mm)
is the standard of PBD, and anything less is likely to give a
suboptimal response.3 In addition, the subtypes of
achalasia in patients who underwent PBD were not
described. Type I and type III achalasia do not respond
well to PBD,4 which constituted 56% of the patients in
this study. Therefore, it would be useful to stratify the
results of retreatment (PBD or LHM) according to the
subtypes of achalasia.
The response to re-POEM was also inferior to that in
previously published data (85% to 100%).5,6 The approach
to primary POEM and re-POEM (anterior or posterior
POEM, partial or full-thickness myotomy) and the proportion of cases performed during the learning curve (primary
and re-POEM), need clarification as well. Incomplete
myotomy during or after the learning curve can affect
the results. If the response to primary POEM was suboptimal because of an incomplete myotomy, a good response
can be expected with future myotomy (Heller’s or
endoscopic). This may be the case in patients with no
initial response or early relapse after POEM (n Z 16,
37% in the present study). By contrast, some patients do
not respond or experience relapse even after adequate
myotomy; ie, refractory achalasia in the true sense.
DISCLOSURE
All authors disclosed no financial relationships
relevant to this publication.
Zaheer Nabi, MD, DNB
D. Nageshwar Reddy, MD, DM
Mohan Ramchandani, MD, DM
Asian Institute of Gastroenterology
Hyderabad, India
http://dx.doi.org/10.1016/j.gie.2017.06.020
Retreatment after failure of per-oral
endoscopic myotomy: Does “cutting”
fare better than “stretching”?
To the Editor:
REFERENCES
We read the article with great interest in which the
authors demonstrated the relative efficacies of repeated
per-oral endoscopic myotomy (re-POEM), laparoscopic
Heller’s myotomy (LHM), and pneumatic balloon dilation
(PBD) after the failure of primary POEM.1 Although the
sample size was small (n Z 34), the authors should be
congratulated for their efforts.
1. van Hoeij FB, Ponds FA, Werner Y, et al. Management of recurrent
symptoms after per-oral endoscopic myotomy in achalasia. Gastrointest
Endosc. Epub 2017 June 11.
2. Yaghoobi M, Mayrand S, Martel M, et al. Laparoscopic Heller’s myotomy
versus pneumatic dilation in the treatment of idiopathic achalasia: a
meta-analysis of randomized, controlled trials. Gastrointest Endosc
2013;78:468-75.
3. Boeckxstaens GE, Annese V, des Varannes SB, et al. Pneumatic dilation
versus laparoscopic Heller’s myotomy for idiopathic achalasia. N Engl J
Med 2011;364:1807-16.
www.giejournal.org
Volume 86, No. 5 : 2017 GASTROINTESTINAL ENDOSCOPY 927
Letters to the Editor
4. Pratap N, Kalapala R, Darisetty S, et al. Achalasia cardia subtyping by
high-resolution manometry predicts the therapeutic outcome of pneumatic balloon dilatation. J Neurogastroenterol Motil 2011;17:48-53.
5. Li QL, Yao LQ, Xu XY, et al. Repeat peroral endoscopic myotomy: a
salvage option for persistent/recurrent symptoms. Endoscopy 2016;48:
134-40.
6. Tyberg A, Seewald S, Sharaiha RZ, et al. A multicenter international registry of redo per-oral endoscopic myotomy (POEM) after failed POEM.
Gastrointest Endosc 2017;85:1208-11.
http://dx.doi.org/10.1016/j.gie.2017.05.031
Response:
We thank Dr Reddy and colleagues1 for their interest in
our article “Management of recurrent symptoms after
per-oral endoscopic myotomy in achalasia.”2 Those
authors point out that the response to pneumatic
dilation (PD) after failed per-oral endoscopic myotomy
(POEM) was low in our study, and we entirely agree.
Only 20% of the patients responded to PD. The authors
of the letter suggest this was due to our dilation scheme
of using 30 and 35 mm, not using 40 mm. However, we
think that further dilation up to 40 mm would probably
not have added much to the efficacy.
We recently could not find any effect of further dilation
up to 40 mm in a group of achalasia patients with recurrent
symptoms after Heller’s myotomy: a situation rather
similar to failed POEM.3 Furthermore, dilation with 30 to
35 mm is currently recommended by the ACG guideline4
and has been used in large international randomized
trials5 and many other studies, all reporting good efficacy
in therapy-naïve patients.6 A subsequent dilation up to
40 mm is recommended only in patients with partial but
not sufficient response or recurrent symptoms,4 whereas
it seems to have no additional value after failure of
35 mm.7,8 It is correct indeed that our low response rate
to PD could have been influenced by achalasia subtypes.
Three patients with type 3 achalasia underwent dilation after failed POEM, and pneumatic dilation failed in all of
them. However, what we think is more important is the effect of previous treatment.
It is generally acknowledged that retreatment has a
lower efficacy than primary treatment in new achalasia patients. This accounts for all types of retreatment in achalasia, including PD or repeated POEM after failed POEM.9
Therefore, the response rate to repeated POEM cannot
be compared with the efficacy of POEM in treatmentnaïve patients.1 In our study, we always performed a
full-thickness myotomy, and we ruled out the effect of
the learning curve. The two studies with high efficacy of
repeated POEM referred to by Dr Reddy and colleagues
have a very short follow-up duration of only 3 to 6 months
in most patients, and they defined clinical success as an
Eckardt score below 3 after 3 months. In our experience,
928 GASTROINTESTINAL ENDOSCOPY Volume 86, No. 5 : 2017
however, a larger number of patients experience recurrent
symptoms after more than 3 months.10,11
In summary, (1) retreatment of achalasia patients after
failed POEM is less effective than primary treatment in
these patients, regardless of the type of retreatment, and
(2) the preferred pneumatic dilation scheme is 30 and
35 mm, and 40 mm only in patients with partial but not
sufficient response.
DISCLOSURE
All authors disclosed no financial relationships
relevant to this publication.
Froukje B. van Hoeij, MD
Albert J. Bredenoord, MD, PhD
Department of Gastroenterology and Hepatology
Academic Medical Center
Amsterdam, the Netherlands
REFERENCES
1. Nabi Z, Reddy DN, Ramchandani M. Retreatment after failure of
per-oral endoscopic myotomy: Does “cutting” fare better than “stretching”? Gastrointest Endosc 2017;86:927-8.
2. van Hoeij FB, Ponds FA, Werner Y, et al. Management of recurrent
symptoms after per-oral endoscopic myotomy in achalasia. Gastrointest Endosc. Epub 2017 May 3.
3. Saleh CM, Ponds FA, Schijven MP, et al. Efficacy of pneumodilation in
achalasia after failed Heller myotomy. Neurogastroenterol Motil
2016;28:1741-6.
4. Vaezi MF, Pandolfino JE, Vela MF. ACG clinical guideline: diagnosis and
management of achalasia. Am J Gastroenterol 2013;108:1238-49.
5. Moonen A, Annese V, Belmans 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;65:732-9.
6. Smeets FG, Masclee AA, Keszthelyi D, et al. Esophagogastric junction
distensibility in the management of achalasia patients: relation to
treatment outcome. Neurogastroenterol Motil 2015;27:1495-503.
7. Vaezi MF, Richter JE, Wilcox CM, et al. Botulinum toxin versus pneumatic dilatation in the treatment of achalasia: a randomised trial.
Gut 1999;44:231-9.
8. Mikaeli J, Bishehsari F, Montazeri G, et al. Pneumatic balloon dilatation in achalasia: a prospective comparison of safety and efficacy
with different balloon diameters. Aliment Pharmacol Ther 2004;20:
431-6.
9. Werner YB, Costamagna G, Swanstrom 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.
10. Li QL, Yao LQ, Xu XY, et al. Repeat peroral endoscopic myotomy: a
salvage option for persistent/recurrent symptoms. Endoscopy
2016;48:134-40.
11. Tyberg A, Seewald S, Sharaiha RZ, et al. A multicenter international
registry of redo per-oral endoscopic myotomy (POEM) after failed
POEM. Gastrointest Endosc 2017;85:1208-11.
http://dx.doi.org/10.1016/j.gie.2017.06.023
www.giejournal.org
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