Per-oral endoscopic myotomy white paper summary

Two-Person Technique of Peroral Endoscopic Myotomy for Achalasia with an Advanced Endoscopist and a Thoracic Surgeon: Initial Experience

Background and Aims. We initiated peroral endoscopic myotomy (POEM) utilizing a two-person technique with combination of an advanced endoscopist and a thoracic surgeon with complementary skills. Our aim was to determine the feasibility and outcomes in initial 20 patients. Methods. In this observational study, main outcomes measured were therapeutic success in relieving symptoms (Eckardt score < 3), decrease in lower esophageal sphincter (LES) pressures, improvement in emptying on timed barium esophagogram (TBE), and complications. Results. POEM was successful in all 20 patients with a mean operative time of 140.1 + 32.9 minutes. Eckardt symptom scores decreased significantly at two-month follow-up (6.4 + 2.9 versus 0.25 + 0.45, p < 0.001). Both basal and residual LES pressures decreased significantly (28.2 + 14.1 mmHg versus 12.8 + 6.3 and 22.4 + 11.3 versus 6.3 + 3.4 mmHg, p = 0.025 and <0.001, resp.). Barium column height at 5 minutes on TBE reduced from 6.8 + 4.9 cm to 2.3 + 2.9 cm (p = 0.05). Two patients (10%) had mucosal perforations and one had delayed bleeding (5%). Conclusions. Two-person technique of POEM with combination of an advanced endoscopist and a thoracic surgeon is highly successful with low risk of complications.

Comprehensive analysis of efficacy and safety of peroral endoscopic myotomy performed by a gastroenterologist in the endoscopy unit: a single-center experience

BACKGROUND AND AIMS

The safety and efficacy of peroral endoscopic myotomy (POEM) when performed by gastroenterologists in the endoscopy unit are currently unknown. The aims of this study were to assess (1) the safety and efficacy of POEM in which all procedures were performed by 1 gastroenterologist in the endoscopy unit, and (2) the predictors of adverse events and nonresponse.

METHODS

All consecutive patients who underwent POEM at 1 tertiary center were included. Clinical response was defined by a decrease in the Eckardt score to 3 or lower. Adverse events were graded according to the American Society for Gastrointestinal Endoscopy lexicon's severity grading system.

RESULTS

A total of 60 consecutive patients underwent POEM in the endoscopy suite with a mean procedure length of 99 minutes. The mean length of submucosal tunnel was 14 cm and the mean myotomy length was 11 cm. The median length of hospital stay was 1 day. Among 52 patients with a mean follow-up period of 118 days (range 30-750), clinical response was observed in 48 patients (92.3%). There was a significant decrease in Eckardt score after POEM (8 vs 1.19, P < .0001). The mean lower esophageal sphincter pressure decreased significantly after POEM (29 mm Hg vs 11 mm Hg, P < .0001). A total of 10 adverse events occurred in 10 patients (16.7%): 7 rated as mild, 3 as moderate, and none as severe. Procedure length was the only predictor of adverse events (P = .01). pH impedance testing was completed in 25 patients, and 22 (88%) had abnormal acid exposure, but positive symptom correlation was present in only 6 patients. All patients with symptomatic reflux were successfully treated with proton pump inhibitors.

CONCLUSIONS

POEM can be effectively and safely performed by experienced gastroenterologists at a tertiary care endoscopy unit. Adverse events are infrequent, and most can be managed intraprocedurally. Post-POEM reflux is frequent but can be successfully managed medically.

The Per Oral Endoscopic Myotomy (POEM) technique: how many preclinical procedures are needed to master it?

BACKGROUND AND STUDY AIM

Per oral endoscopic myotomy (POEM) is a complex technique used in achalasia. Preclinical training is essential but little is known about the number of procedures needed. The aim of this study was to determine the number of procedures required to master POEM in an animal model.

PATIENTS AND METHODS

This prospective comparative study was conducted in two swine models at a single institution in Mexico City between November 2012 and October 2014: Group 1 (G1) = 30 ex vivo and Group 2 (G2) = 20 live swine models. POEM was mastered after finishing the five steps without complications. Time, characteristics, and complications were recorded. Velocity of tunnelization and myotomy (VTM) was determined. Ex vivo analysis was done in G1 immediately after finishing POEM and at day 30 in G2.

RESULTS

A total of 50 POEM were done in both groups (G1 = 30, G2 = 20). The mean times were 90.17 min (G1) and 89.50 min (G2) (P = 0.92). Myotomy was faster in G2 (21.10 vs 27.97 min; P = 0.009) with a slightly slower tunnelization (40.35 vs 41.13 min; P = 0.86). Myotomy was longer in G2 (9.25 vs 8.83 cm; P = 0.26). VTM between the groups was similar (G1 = 0.159 vs G2 = 0.157 cm/min; P = 0.925). Complications were: mucosotomy (G1 = 18 %, G2 = 8 %; P = 0.430), mediastinal perforation (G1 = 12 %, G2 = 8 %; P = 1.0), and perforation at the gastroesophageal junction (GEJ) level (G1 = 16 %, G2 = 4 %; P = 0.149). Seven models in G2 presented minor bleeding and there was one death not attributed to the procedure. Mastery was obtained after 26 cases.

CONCLUSIONS

We suggest that centers interested in learning POEM consider 26 procedures in animal models to master it before performing it in patients with achalasia.

Perspective on peroral endoscopic myotomy for achalasia: Zhongshan experience

Worldwide, peroral endoscopic myotomy (POEM) has achieved remarkable initial outcomes in the treatment of achalasia. In China, POEM has developed very quickly since the first case was performed in our center in August 2010. With experience, we have successfully performed POEM for special cases (such as pediatric patients, patients with sigmoid-type esophagus, and patients with recurrent symptoms after previous surgery) and have altered our technique to achieve long-term symptom remission and simplify the POEM procedure. These changes include posterior wall incision, full-thickness myotomy, a “push-and-pull” technique for myotomy, and water-jet assisted POEM. In this article, our experiences in POEM are summarized, including changes in technique, applications of the procedure, and the management of possible complications.

Evaluation of the need for routine esophagram after peroral endoscopic myotomy (POEM)

BACKGROUND

Peroral endoscopic myotomy (POEM) is a novel surgical option for the treatment of achalasia. Most centers perform a routine esophagram on postoperative day (POD) #1 to rule esophageal perforation and leaks. In this study, we sought to determine the clinical utility of routine contrast studies post-POEM.

METHODS

POEM was performed using an anterior submucosal tunnel and selective myotomy of the circular muscle layer. A routine contrast esophagram was obtained on POD #1. We conducted a retrospective review of the radiologists' interpretations of these studies and compared them to patient's clinical course.

RESULTS

Seventy-eight patients were included. Among these, two complications occurred. One patient was non-compliant with postoperative nil per os orders and developed epigastric pain suspicious for a leak that was demonstrated on esophagram. Another patient had subcutaneous emphysema on POD #1 esophagram, a finding that was also present on physical examination, without esophageal leakage. Another esophagram in an asymptomatic patient was suspicious for submucosal tunnel hematoma which prompted a return to the operating room with negative results. Overall, 56 patients had abnormal studies. POD #1 esophagram demonstrated a sensitivity of 100 % and specificity of 45 % in identifying clinically significant complications.

CONCLUSIONS

In this series, we found routine esophagram to have a high sensitivity but a very low specificity in detecting clinically significant complications. Routine esophagram after POEM may not be necessary.

A prospective analysis of GERD after POEM on anterior myotomy

Background

Peroral endoscopic myotomy (POEM) is an emerging, minimally invasive procedure capable of overcoming limitations of achalasia treatments, but gastroesophageal reflux disease (GERD) after POEM is of concern and its risk factors have not been evaluated. This prospective study examined GERD and the association of POEM with reflux esophagitis.

Methods

Achalasia patients were recruited from a single center. The pre- and postoperative assessments included Eckardt scores, manometry, endoscopy, and pH monitoring.

Results

Between September 2011 and November 2014, 105 patients underwent POEM; 70 patients were followed up 3 months after POEM. Postoperatively, significant reductions were observed in lower esophageal sphincter (LES) pressure [from 40.0 ± 22.8 to 20.7 ± 14.0 mmHg (P < 0.05)], LES residual pressure [from 22.1 ± 13.3 to 11.4 ± 6.6 mmHg (P < 0.05)], and Eckardt scores [from 5.7 ± 2.5 to 0.7 ± 0.8 (P < 0.05)]. Symptomatic GERD and moderate reflux esophagitis developed in 5 and 11 patients (grade B, n = 8; grade C, n = 3), respectively, and were well controlled with proton pump inhibitors. Univariate logistic regression analysis revealed integrated relaxation pressure was a predictor of ≥grade B reflux esophagitis. No POEM factors were found to be associated with reflux esophagitis.

Conclusion

POEM is effective and safe in treating achalasia, with no occurrence of clinically significant refractory GERD. Myotomy during POEM, especially of the gastric side, was not associated with ≥grade B (requiring medical intervention) reflux esophagitis. Extended gastric myotomy (2–3 cm) during POEM is recommended to improve outcomes.

Per oral endoscopic myotomy for the treatment of achalasia

Per oral endoscopic myotomy (POEM) represents the culmination of natural orifice transluminal endoscopic surgery (NOTES) research, and its most successful application to date. Over a thousand POEMs have been performed globally with remarkable results in terms of clinical efficacy and safety.

PURPOSE OF REVIEW

We examine the most recent literature concerning POEM since the last two comprehensive analyses [Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) White Paper, ASGE Preservation and Incorporation of Valuable endoscopic Innovations (PIVI)], and integrate this literature in the consensus POEM guidelines and perspective. These current works are largely centered on POEM operator learning curve, comparison of POEM and laparoscopic Heller myotomy (LHM) and extended application of POEM.

RECENT FINDINGS

POEM and LHM are comparable in terms of efficacy (diminished dysphagia and Eckardt score) and complications including GERD. POEM has been successfully performed in a wide variety of patients including children, those with prior achalasia therapy and those with spastic esophageal disorders.

SUMMARY

POEM has been validated as a treatment for achalasia. Issues remain regarding its longer term efficacy in comparison with LHM. Subsequent comparison trials are needed.

VIDEO ABSTRACT

http://links.lww.com/COG/A14.

Peroral endoscopic myotomy: an evolving treatment for achalasia

Peroral endoscopic myotomy (POEM) was first performed in Japan in 2008 for uncomplicated achalasia. With excellent results, it was adopted by highly skilled endoscopists around the world and the indications for POEM were expanded to include advanced sigmoid achalasia, failed surgical myotomy, patients with previous endoscopic treatments and even other spastic oesophageal motility disorders. With increased uptake and performance of POEM, variations in technique and improved management of adverse events have been developed. Now, 6 years since the first case and with >3,000 procedures performed worldwide, long-term data has shown the efficacy of POEM to be long-lasting. A growing body of literature also exists pertaining to the learning curve, application of novel technologies, extended indications and physiologic changes with POEM. Ultimately, this once experimental procedure is evolving towards becoming the preferred treatment for achalasia and other spastic oesophageal motility disorders.

Usefulness of peroral endoscopic myotomy for treating achalasia in children: experience from a single center

INTRODUCTION

Achalasia is a rare esophageal motility disorder in the pediatric population. Peroral endoscopic myotomy (POEM) has been demonstrated to be effective and safe for the treatment of achalasia as a novel endoscopic technique, but data involving its utility in pediatric patients are limited. We aimed to assess the safety and efficacy of POEM for pediatric patients with achalasia.

MATERIALS AND METHODS

Between July 2012 and August 2014, five consecutive pediatric patients (2 female and 3 male, with a median age of 15 years) with achalasia underwent POEM in our center. Diagnosis was based on symptoms, manometry, radiology and endoscopy. Preoperative and postoperative symptoms scores, and manometry outcomes were recorded and analyzed.

RESULTS

Procedure was performed successfully in all patients, and the median time required for the procedure was 50 min (range 40-90 min). There were no mortalities and no serious intraoperative and postoperative complications. The median length of myotomy was 8 cm (range 6-11 cm). During a median follow-up period of 18 months, treatment success (Eckardt score ≤3) was achieved in all patients. There was a significant improvement of symptoms relief, dysphagia score and lower esophageal sphincter pressure decrease after POEM. No patient developed gastroesophageal reflux disease.

CONCLUSION

Our study suggests that POEM is a safe and effective technique for treating pediatric achalasia. Further studies with long-term follow-up in large-volume pediatric patients are warranted to clearly define the durability of the procedure.

Peroral endoscopic myotomy

Peroral endoscopic myotomy (POEM) incorporates concepts of natural orifice translumenal endoscopic surgery and achieves endoscopic myotomy by utilizing a submucosal tunnel as an operating space. Although intended for the palliation of symptoms of achalasia, there is mounting data to suggest it is also efficacious in the management of spastic esophageal disorders. The technique requires an understanding of the pathophysiology of esophageal motility disorders as well as knowledge of surgical anatomy of the foregut. POEM achieves short term response in 82% to 100% of patients with minimal risk of adverse events. In addition, it appears to be effective and safe even at the extremes of age and regardless of prior therapy undertaken. Although infrequent, the ability of the endoscopist to manage an intraprocedural adverse event is critical as failure to do so could result in significant morbidity. The major late adverse event is gastroesophageal reflux which appears to occur in 20% to 46% of patients. Research is being conducted to clarify the optimal technique for POEM and a personalized approach by measuring intraprocedural esophagogastric junction distensibility appears promising. In addition to esophageal disorders, POEM is being studied in the management of gastroparesis (gastric pyloromyotomy) with initial reports demonstrating technical feasibility. Although POEM represents a paradigm shift the management of esophageal motility disorders, the results of prospective randomized controlled trials with long-term follow up are eagerly awaited.

Treatment of esophageal achalasia in children: Today and tomorrow

BACKGROUND

Esophageal achalasia (EA) is a rare esophageal motility disorder in children. Laparoscopic Heller myotomy (LHM) represents the treatment of choice in young patients. Peroral endoscopic myotomy (POEM) is becoming an alternative to LHM. The aim of this study is to evaluate the effectiveness, safety, and outcomes of POEM vs LHM in treatment of children with EA.

METHODS

Data of pediatric patients with EA, who underwent LHM and POEM from February 2009 to December 2013 in two centers, were collected.

RESULTS

Eighteen patients (9 male, mean age: 11.6 years; range: 2-17 years) were included. Nine patients (6 male, mean age: 10.7 years; range: 2-16 years) underwent LHM, and the other 9 (3 males, mean age: 12.2 years; range: 6-17 years) underwent POEM procedure. Mean operation time was shorter in POEM group compared with LHM group (62/149 minutes). Myotomy was longer in POEM group than in LHM group (11/7 cm). One major complication occurred after LHM (esophageal perforation). No clinical and manometric differences were observed between LHM and POEM in follow-up. The incidence of iatrogenic gastroesophageal reflux disease was low (1 patient in both groups).

CONCLUSIONS

Results of a midterm follow-up show that LHM and POEM are safe and effective treatments also in children. Besides, POEM is a mini-invasive technique with an inferior execution timing compared to LHM. A skilled endoscopic team is mandatory to perform this procedure.

Natural-orifice transluminal endoscopic surgery

BACKGROUND

Natural-orifice transluminal endoscopic surgery (NOTES) represents one of the most significant innovations in surgery to emerge since the advent of laparoscopy. A decade of progress with this approach has now been catalogued, and yet its clinical application remains controversial.

METHODS

A PubMed search was carried out for articles describing NOTES in both the preclinical and the clinical setting. Public perceptions and expert opinion regarding NOTES in the published literature were analysed carefully.

RESULTS

Two hundred relevant articles on NOTES were studied and the outcomes reviewed. A division between direct- and indirect-target NOTES was established. The areas with the most promising clinical application included direct-target NOTES, such as transanal total mesorectal excision and peroral endoscopic myotomy. The clinical experience with distant-target NOTES, such as for appendicectomy and cholecystectomy, showed feasibility; however, NOTES-specific morbidity was introduced and this represents an important limitation.

CONCLUSION

NOTES experimentation in the preclinical setting has increased substantially. There has also been a significant increase in the application of NOTES in humans in the past decade. Enthusiasm for NOTES should be tempered by the risk of incurring NOTES-specific morbidity. Surgeons should carefully consider patient preferences regarding this new minimally invasive option, as opinions are not unanimously supportive of NOTES. As technical limitations are overcome, the clinical application of NOTES is predicted to increase. It is paramount that, when this complex technique is performed on humans, it is applied judiciously by appropriately trained experts with outcomes recorded in a registry.

Per-oral endoscopic myotomy: Major advance in achalasia treatment and in endoscopic surgery

Per-oral endoscopic myotomy (POEM) represents a natural orifice endoscopic surgery (NOTES) approach to laparoscopy Heller myotomy (LHM). POEM is arguably the most successful clinical application of NOTES. The growth of POEM from a single center in 2008 to approximately 60 centers worldwide in 2014 with several thousand procedures having been performed attests to the success of POEM. Initial efficacy, safety and acid reflux data suggest at least equivalence of POEM to LHM, the previous gold standard for achalasia therapy. Adjunctive techniques used in the West include impedance planimetry for real-time intraprocedural luminal assessment and endoscopic suturing for challenging mucosal defect closures during POEM. The impact of POEM extends beyond the realm of esophageal motility disorders as it is rapidly popularizing endoscopic submucosal dissection in the West and spawning offshoots that use the submucosal tunnel technique for a host of new indications ranging from resection of tumors to pyloromyotomy for gastroparesis.

Peroral endoscopic myotomy for advanced achalasia with sigmoid-shaped esophagus: long-term outcomes from a prospective, single-center study

BACKGROUND

The sigmoid-shaped esophagus is considered to be the advanced stage of achalasia, in which the esophageal lumen is significantly dilated, swerved, and rotated. In consideration of the efficacy of peroral endoscopic myotomy (POEM) for early achalasia, it may also offer another option for the treatment of advanced achalasia with sigmoid-shaped esophagus. Our purpose was to evaluate the feasibility and long-term efficacy of POEM for patients with sigmoid-type achalasia.

METHODS

32 consecutive patients with sigmoid-type achalasia (S1 type in 29 patients and S2 type in 3 patients) were prospectively included. Primary outcome was symptom relief during follow-up, defined as an Eckardt score ≤3. Secondary outcomes were procedure-related adverse events, the resting lower esophageal sphincter (LES) pressure, clinical reflux complications, and procedure-related parameters.

RESULTS

All cases received POEM successfully. The mean operation time was 63.7 min (range 22-130 min). No serious complications related to POEM were encountered. During a mean follow-up period of 30.0 months (range 24-44 months), treatment success was achieved e in 96.8% of cases (mean score pre- vs. post-treatment 7.8 vs. 1.4; P < 0.001). Mean LES pressure also decreased from a mean of 37.9 to 12.9 mmHg after POEM (P < 0.001). One patient experienced only partial symptom relief and additional balloon dilations were carried out to relief the symptoms twice. The overall clinical reflux complication rate of POEM for sigmoid-type achalasia was 25.8%.

CONCLUSION

The 2-year outcomes of POEM for advanced achalasia with sigmoid-shaped esophagus were excellent, resulting in long-term symptom relief in over 96% cases and without serious complications. The morphological changes of esophagus may make subsequent endoscopic tunneling more challenging and time-consuming, but do not prevent successful POEM.