Hiroki Sato1,2, Yohei Nishikawa3, Hirofumi Abe4, Hironari Shiwaku5, Junya Shiota6, Chiaki Sato7, Hiroyuki Sakae8, Masaki Ominami9, Yoshitaka Hata10, Hisashi Fukuda11, Ryo Ogawa12, Jun Nakamura13, Tetsuya Tatsuta14, Yuichiro Ikebuchi15, Hiroshi Yokomichi16, Shuji Terai1, Haruhiro Inoue3. 1. Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan. 2. Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, USA. 3. Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan. 4. Department of Gastroenterology, Kobe University Hospital, Hyogo, Japan. 5. Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan. 6. Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan. 7. Department of Surgery, Tohoku University Graduate School of Medicine, Miyagi, Japan. 8. Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan. 9. Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan. 10. Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. 11. Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan. 12. Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan. 13. Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan. 14. Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori, Japan. 15. Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori, Japan. 16. Department of Health Sciences, University of Yamanashi, Yamanashi, Japan.
Abstract
OBJECTIVES: Indications for peroral endoscopic myotomy (POEM) and endoscopic submucosal dissection (ESD) in patients with achalasia concomitant with esophageal carcinoma (EC) are unclear. This study aimed to clarify the role of POEM in cases of achalasia concomitant with EC and to elucidate the indications for ESD and efficient surveillance for EC. METHODS: We conducted a multicenter cohort study at 14 hospitals in Japan, including 3707 cases of achalasia-related esophageal motility disorders (EMDs). Factors contributing to EC risk, the characteristics of EC, and clinical outcomes of POEM/ESD were analyzed. RESULTS: In patients undergoing POEM, screening and surveillance endoscopy throughout a 1-year period resulted in diagnosis of 72.1% new EC cases. Of 62 patients with 123 ECs, 40.3% had multiple or metachronous lesions within 37.5 months. EC was predominantly observed in the middle thoracic esophagus (58.5%) and posteriorly (73.2%). POEM had comparable safety and efficacy in cases of concomitant EC even after ESD. Endoscopic en bloc resection was performed in 95.8% and 89.3% of ECs diagnosed before and after POEM, respectively (P = 0.351); however, ESD on the POEM-line was impaired by fibrosis. Multivariate analysis revealed risk factors for EC, including regular alcohol consumption, a history of smoking, advanced age, and extended disease duration. Alcohol intake and smoking had a synergistic effect on EC development. CONCLUSIONS: Screening and surveillance of POEM help in detecting EC. ESD is feasible in achalasia, although on the POEM-line is challenging. Surveillance endoscopy for EC is recommended for cases with specific risks and a history of ECs.
OBJECTIVES: Indications for peroral endoscopic myotomy (POEM) and endoscopic submucosal dissection (ESD) in patients with achalasia concomitant with esophageal carcinoma (EC) are unclear. This study aimed to clarify the role of POEM in cases of achalasia concomitant with EC and to elucidate the indications for ESD and efficient surveillance for EC. METHODS: We conducted a multicenter cohort study at 14 hospitals in Japan, including 3707 cases of achalasia-related esophageal motility disorders (EMDs). Factors contributing to EC risk, the characteristics of EC, and clinical outcomes of POEM/ESD were analyzed. RESULTS: In patients undergoing POEM, screening and surveillance endoscopy throughout a 1-year period resulted in diagnosis of 72.1% new EC cases. Of 62 patients with 123 ECs, 40.3% had multiple or metachronous lesions within 37.5 months. EC was predominantly observed in the middle thoracic esophagus (58.5%) and posteriorly (73.2%). POEM had comparable safety and efficacy in cases of concomitant EC even after ESD. Endoscopic en bloc resection was performed in 95.8% and 89.3% of ECs diagnosed before and after POEM, respectively (P = 0.351); however, ESD on the POEM-line was impaired by fibrosis. Multivariate analysis revealed risk factors for EC, including regular alcohol consumption, a history of smoking, advanced age, and extended disease duration. Alcohol intake and smoking had a synergistic effect on EC development. CONCLUSIONS: Screening and surveillance of POEM help in detecting EC. ESD is feasible in achalasia, although on the POEM-line is challenging. Surveillance endoscopy for EC is recommended for cases with specific risks and a history of ECs.