Clinical Endoscopy

Review

Role of endoscopy in patients with achalasia: So Young Han, Young Hoon Youn; Clin Endosc 2023;56(5):537-545. Published online June 2, 2023; DOI: https://doi.org/10.5946/ce.2023.001

Achalasia is an esophageal motility disorder characterized by impaired lower esophageal sphincter relaxation and peristalsis of the esophageal body. With the increasing prevalence of achalasia, interest in the role of endoscopy in its diagnosis, treatment, and monitoring is also growing. The major diagnostic modalities for achalasia include high-resolution manometry, esophagogastroduodenoscopy, and barium esophagography. Endoscopic assessment is important for early diagnosis to rule out diseases that mimic achalasia symptoms, such as pseudo-achalasia, esophageal cancer, esophageal webs, and eosinophilic esophagitis. The major endoscopic characteristics suggestive of achalasia include a widened esophageal lumen and food residue in the esophagus. Once diagnosed, achalasia can be treated either endoscopically or surgically. The preference for endoscopic treatment is increasing owing to its minimal invasiveness. Botulinum toxins, pneumatic balloon dilation, and peroral endoscopic myotomy (POEM) are important endoscopic treatments. Previous studies have demonstrated excellent treatment outcomes for POEM, with >95% improvement in dysphagia, making POEM the mainstay treatment option for achalasia. Several studies have reported an increased risk of esophageal cancer in patients with achalasia. However, routine endoscopic surveillance remains controversial owing to the lack of sufficient data. Further studies on surveillance methods and duration are warranted to establish concordant guidelines for the endoscopic surveillance of achalasia.

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Sol Kim, Bo-In Lee
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Case of Concomitant Endoscopic Treatment of Achalasia with Superficial Esophageal Cancer
Myung-Hun Lee, Kyoungwon Jung, Jae Hyun Kim, Sung Eun Kim, Won Moon, Moo In Park, Seun Ja Park
The Korean Journal of Gastroenterology.2023; 82(5): 248. CrossRef

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Commentary

Peroral Endoscopic Myotomy, a Well-Established, Efficacious, and Safe Treatment Option for Achalasia: Is the History of Previous Treatment a Hurdle or Not?: Young Hoon Youn; Clin Endosc 2020;53(3):247-248. Published online May 29, 2020; DOI: https://doi.org/10.5946/ce.2020.120

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Original Articles

Retention Esophagitis as a Significant Clinical Predictor of Progression to Esophageal Cancer in Achalasia: Haewon Kim, Hyojin Park, HeeSeung Choi, Yooju Shin, Hyunsung Park, Young Hoon Youn, Jie-Hyun Kim; Clin Endosc 2018;51(2):161-166. Published online March 6, 2018; DOI: https://doi.org/10.5946/ce.2017.087

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Background
/Aims: Chronic liquid and/or food stasis caused by retention esophagitis (RE) in achalasia is a notable endoscopic finding because of the presence of a thickened or whitish esophageal mucosa and histologically altered squamous hyperplasia. We aimed to identify the clinical features of RE associated with achalasia and to clarify the clinical definition of RE in achalasia as a precancerous lesion identified by analyzing biomarker expressions.
Methods
From 2006 to 2015, we retrospectively reviewed 37 patients with achalasia without previous treatment. Among them, 21 patients had diagnostic findings of RE (RE+) and 16 patients had no diagnostic findings of RE (RE–). Immunohistochemical staining of p53, p16, and Ki-67 was performed on the endoscopic biopsy tissues from the patients with achalasia and 10 control patients with non-obstructive dysphagia.
Results
The symptom duration and transit delay were significantly longer in the RE+ group than in the RE– group. We found particularly high p53 positivity rates in the RE+ group (p<0.001). The rate of p16 expression was also significantly higher in the RE+ group than in the other two groups (p=0.003).
Conclusions
A high p53 expression rate was more frequently found in the RE+ group than in the other two groups. RE could be a meaningful clinical feature of achalasia for predicting esophageal carcinogenesis.

Citations

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Development and Validation of Serum Markers as Noninvasive Diagnostic Methods for Achalasia
Xingyu Jia, Songfeng Chen, Xun Hou, Qianjun Zhuang, Niandi Tan, Mengyu Zhang, Jinhui Wang, Xiangbin Xing, Yinglian Xiao
Clinical and Translational Gastroenterology.2024; 15(1): e00651. CrossRef
Non-Acid Fluid Exposure and Esophageal Squamous Cell Carcinoma
Ali Soroush, Arash Etemadi, Julian A. Abrams
Digestive Diseases and Sciences.2022; 67(7): 2754. CrossRef
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Shreya Chablaney, Rita M. Knotts
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Renato Tambucci, Sara Isoldi, Giulia Angelino, Filippo Torroni, Simona Faraci, Francesca Rea, Erminia Francesca Romeo, Tamara Caldaro, Luciano Guerra, Anna Chiara Iolanda Contini, Monica Malamisura, Giovanni Federici di Abriola, Paola Francalanci, Andrea
The Journal of Pediatrics.2021; 228: 155. CrossRef
Endoscopic Surveillance in Idiopathic Achalasia
Olive Ochuba, Sheila W Ruo, Tasnim Alkayyali, Jasmine K Sandhu, Ahsan Waqar, Ashish Jain, Christine Joseph, Kosha Srivastava, Sujan Poudel
Cureus.2021;[Epub] CrossRef
Histopathological Analysis of Esophageal Mucosa in Patients with Achalasia
Bong Eun Lee, Gwang Ha Kim, Nari Shin, Do Youn Park, Geun Am Song
Gut and Liver.2021; 15(5): 713. CrossRef
Eosinophilic esophagitis in esophageal atresia: Tertiary care experience of a “selective” approach for biopsy sampling
Renato Tambucci, Francesca Rea, Giulia Angelino, Monica Malamisura, Maurizio Mennini, Carla Riccardi, Giovanni Farello, Laura Valfré, Luigi Dall’Oglio, Jonathan E. Markowitz, Alessandro G. Fiocchi, Paola De Angelis
World Allergy Organization Journal.2020; 13(4): 100116. CrossRef
Achalasia and associated esophageal cancer risk: What lessons can we learn from the molecular analysis of Barrett's–associated adenocarcinoma?
K. Nesteruk, M.C.W. Spaander, I. Leeuwenburgh, M.P. Peppelenbosch, G.M. Fuhler
Biochimica et Biophysica Acta (BBA) - Reviews on Cancer.2019; 1872(2): 188291. CrossRef
Retention Esophagitis in Patients with Achalasia Requires Cancer Surveillance
Eun Jeong Gong, Do Hoon Kim
Clinical Endoscopy.2018; 51(2): 111. CrossRef

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Clinical Outcomes of Endoscopic Submucosal Dissection for Superficial Esophageal Squamous Neoplasms: Jung Soo Park, Young Hoon Youn, Jae Jun Park, Jie-Hyun Kim, Hyojin Park; Clin Endosc 2016;49(2):168-175. Published online February 12, 2016; DOI: https://doi.org/10.5946/ce.2015.080

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Background
/Aims: Endoscopic treatment has been broadly applied to superficial esophageal neoplasms. Endoscopic submucosal dissection (ESD) allows for high rates of en bloc resection, precise histological assessment, and low rates of local recurrence. The aim of this study was to evaluate the outcomes of ESD for superficial esophageal neoplasms.
Methods
We retrospectively reviewed 36 esophageal ESDs for superficial squamous neoplasms in 32 patients between March 2009 and August 2014 at Gangnam Severance Hospital.
Results
The median patient age was 64 years, and 30 men were included. The indications were early squamous cell carcinoma in 26 lesions, adenoma with high-grade dysplasia in five lesions, and low-grade dysplasia in five lesions. The en bloc resection and R0 resection rates were 97.2% (35 of 36) and 91.7% (33 of 36), respectively. Microperforation and post-ESD bleeding occurred in 5.6% (2 of 36) and 5.6% (2 of 36), respectively. Post-ESD esophageal strictures developed in five patients (13.9%). Five patients (15.6%) had an additional treatment after ESD (concurrent chemoradiation therapy in three, radiation therapy in one, and surgery in one patient). There was no disease-specific mortality during the median follow-up of 31 months.
Conclusions
Favorable clinical outcomes were observed in ESD for superficial esophageal squamous neoplasms. Esophageal ESD could be a good treatment option in terms of efficacy and safety.

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Case Reports

Endoscopic Submucosal Dissection for Recurrent or Residual Superficial Esophageal Cancer after Chemoradiotherapy: Two Cases: Changhyeok Hwang, Young Hoon Youn, Sung-eun Choi, Young Hak Jung, Hae Yeul Park, Jae Jun Park, Jie Hyun Kim, Hyojin Park; Clin Endosc 2015;48(6):553-557. Published online November 30, 2015; DOI: https://doi.org/10.5946/ce.2015.48.6.553

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We report two cases of endoscopic submucosal dissection (ESD) for recurrent or residual esophageal squamous cell carcinoma (ESCC) lesions after chemoradiotherapy for advanced esophageal cancer. Case 1 involved a 64-year-old man who had previously undergone chemoradiotherapy for advanced ESCC and achieved a complete response (CR) for 22 months, until metachronous recurrent superficial ESCC was detected on follow-up esophagogastroduodenoscopy (EGD). We performed ESD and found no evidence of recurrence for 24 months. Case 2 involved a 59-year-old man who had previously undergone chemoradiotherapy for advanced ESCC. He responded favorably to treatment, and most of the tumor had disappeared on follow-up EGD 4 months later. However, there were two residual superficial esophageal lugol-voiding lesions. We performed ESD, and he had a CR for 32 months thereafter. ESD can be considered a viable treatment option for recurrent or residual superficial ESCC after chemoradiotherapy for advanced esophageal cancer.

Citations

Citations to this article as recorded by

Clinical efficacy of endoscopic submucosal dissection in the treatment of early esophageal cancer and precancerous lesions
Yue Wu, Haihui Zhang, Bingxi Zhou, Shuangyin Han, Yanrui Zhang
Journal of Cancer Research and Therapeutics.2018; 14(1): 52. CrossRef

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Esophageal Cancer in Esophageal Diverticula Associated with Achalasia: Ah Ran Choi, Nu Ri Chon, Young Hoon Youn, Hyo Chae Paik, Yon Hee Kim, Hyojin Park; Clin Endosc 2015;48(1):70-73. Published online January 31, 2015; DOI: https://doi.org/10.5946/ce.2015.48.1.70

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The simultaneous occurrence of achalasia and esophageal diverticula is rare. Here, we report the case of a 68-year-old man with multiple esophageal diverticula associated with achalasia who was later diagnosed with early esophageal cancer. He initially presented with dysphagia and dyspepsia, and injection of botulinum toxin to the lower esophageal sphincter relieved his symptoms. Five years later, however, the patient presented with worsening of symptoms, and esophagogastroduodenoscopy (EGD) was performed. The endoscopic findings showed multifocal lugol-voiding lesions identified as moderate dysplasia. We decided to use photodynamic therapy to treat the multifocal dysplastic lesions. At follow-up EGD 2 months after photodynamic therapy, more lugol-voiding lesions representing a squamous cell carcinoma in situ were found. The patient ultimately underwent surgery for the treatment of recurrent esophageal multifocal neoplasia. After a follow-up period of 3 years, the patient showed a good outcome without symptoms. To manage premalignant lesions such as achalasia with esophageal diverticula, clinicians should be cautious, but have an aggressive approach regarding endoscopic surveillance.

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Advanced squamous cell carcinoma in an asymptomatic, large, epiphrenic esophageal diverticulum
Tomoaki Yoshida, Satoru Hashimoto, Ken-ichi Mizuno, Hiroshi Ichikawa, Junji Yokoyama, Hajime Umezu, Shuji Terai
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Locally Advanced Esophageal Cancer Arising from an Epiphrenic Diverticulum Treated by Curative Esophagectomy Combined with Adjacent Organs Resection
Aina KUNITOMO, Eiji HIGAKI, Tetsuya ABE, Takahiro HOSOI, Seiji ITO, Yasuhiro SHIMIZU
Nihon Rinsho Geka Gakkai Zasshi (Journal of Japan Surgical Association).2019; 80(11): 1999. CrossRef
Imaging in the Evaluation of Endoscopic or Surgical Treatment for Achalasia
Diego Palladino, Andrea Mardighian, Marilina D’Amora, Luca Roberto, Francesco Lassandro, Claudia Rossi, Gianluca Gatta, Mariano Scaglione, Guglielmi Giuseppe
Gastroenterology Research and Practice.2016; 2016: 1. CrossRef

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A Case of Postfundoplication Dysphagia without Symptomatic Improvement after Endoscopic Dilatation: Chanhee Kyung, Han Ho Jeon, Heewook Kim, Jie-Hyun Kim, Young Hoon Youn, Hyojin Park; Clin Endosc 2014;47(1):104-107. Published online January 24, 2014; DOI: https://doi.org/10.5946/ce.2014.47.1.104

Abstract PDF PubReader ePub: Laparoscopic fundoplication is a treatment option for gastroesophageal reflux disease refractory to medical treatment. When deciding whether or not to undergo surgery, patients with refractory gastroesophageal reflux disease and esophageal motility disorder need to fully understand the operative procedure, postoperative complications, and residual symptoms such as dysphagia, globus sensation, and recurrence of reflux. Herein, we report a case of a patient diagnosed with gastroesophageal reflux disease and aperistalsis who underwent Nissen (total, 360°) fundoplication after lack of response to medical treatment and subsequently underwent pneumatic dilatation due to unrelieved postoperative dysphagia and globus sensation.

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