Retrograde myotomy: a variation in per oral endoscopic myotomy (POEM) technique

Peroral esophageal myotomy for esophageal motility disorders

The concept of third space endoscopy first described in 2007, was adapted and performed in humans in 2010 by Inoue et al. in a group of patients with esophageal achalasia (EA). Since then, esophageal endoscopic myotomy (E-POEM), has been performed in more than 10,000 patients worldwide up to now. Safety and efficacy have been confirmed at early, mid and long-term evaluations, in different gastrointestinal diseases including achalasia, refractory gastroparesis, and other esophageal motility disorders (EMD). Nowadays, this treatment has shown to be not only an excellent option, but also with its excellent outcomes, the first option in certain clinical scenarios such as type III achalasia. Thus, the minimal invasive nature of POEM gives us multiple advantages compared with the classical treatments that includes pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM), including not only clinical aspects but also economical. High resolution manometry (HRM) has substantially redefined the actual approach of esophageal motility disorders with the major changes in instrumental use, diagnostic algorithms, and therapeutics. The previous Chicago's classification V 3.0 clearly improved our knowledge about pathophysiology of spastic esophageal motor disorders, however, with its recent update (Chicago V 4.0), multiple changes in diagnosis and treatment are expected. In the present article, we aimed to review and analyze the most important aspects about the results of E-POEM in the management of EMD according to the view of the new Chicago's classification V 4.0.

Retrograde Myotomy as an Alternative to Antegrade Myotomy in Peroral Endoscopic Myotomy (POEM) for Achalasia Cardia - Is It Better?

BACKGROUND

Antegrade approach myotomy is usually performed in peroral endoscopic myotomy (POEM) for achalasia cardia. This study assessed the feasibility of retrograde approach as an alternative.

METHODS

This is a retrospective review of a prospectively maintained database of patients undergoing POEM, comparing the 2 techniques of antegrade myotomy (AM) and retrograde myotomy (RM). AM was performed by the conventional technique of proximal to distal myotomy while RM was from the distal end to proximal. The time required for myotomy, complications, and technical nuances were compared.

RESULTS

Of the 24 cases of POEM, 6 were done by RM and 18 by AM approach. The baseline characteristics, symptomatology, type of achalasia, and preprocedure Eckardt score were similar between the 2 technique arms. The median myotomy time for AM was 21 minute while for RM was 25 minute (P=0.07). Complication rates were similar.Technical issues during RM included: (1) difficulty in visualizing the depth of myotomy; (2) incomplete myotomy requiring back and forth scope adjustment; (3) need for antegrade movement for completion of myotomy; (4) difficulty visualizing the axis of myotomy; (5) added arm strain during posterior myotomy.

CONCLUSION

Our study did not find any additional benefit of RM compared with AM approach for POEM.

Updated Systematic Review of Achalasia, with a Focus on POEM Therapy

AIM

To systematically review clinical presentation, diagnosis, and therapy of achalasia, focusing on recent developments in high-resolution esophageal manometry (HREM) for diagnosis and peroral endoscopic myotomy (POEM) for therapy.

METHODS

Systematic review of achalasia using computerized literature search via PubMed and Ovid of articles published since 2005 with keywords ("achalasia") AND ("high resolution" or "HREM" or "peroral endoscopic myotomy" or "POEM"). Two authors independently performed literature searches and incorporated articles into this review by consensus according to prospectively determined criteria.

RESULTS

Achalasia is an uncommon esophageal motility disorder, usually manifested by dysphagia to solids and liquids, and sometimes manifested by chest pain, regurgitation, and weight loss. Symptoms often suggest more common disorders, such as gastroesophageal reflux disease (GERD), thus often delaying diagnosis. Achalasia is a predominantly idiopathic chronic disease. Diagnosis is typically suggested by barium swallow showing esophageal dilation; absent distal esophageal peristalsis; smoothly tapered narrowing ("bird's beak") at esophagogastric junction; and delayed passage of contrast into stomach. Diagnostic findings at high-resolution esophageal manometry (HREM) include: distal esophageal aperistalsis and integrated relaxation pressure (trough LES pressure during 4 s) > 15 mmHg. Achalasia is classified by HREM into: type 1 classic; type 2 compartmentalized high pressure in esophageal body, and type 3 spastic. This classification impacts therapeutic decisions. Esophagogastroduodenoscopy is required before therapy to assess esophagus and esophagogastric junction and to exclude distal esophageal malignancy. POEM is a revolutionizing achalasia therapy. POEM creates a myotomy via interventional endoscopy. Numerous studies demonstrate that POEM produces comparable, if not superior, results compared to standard laparoscopic Heller myotomy (LHM), as determined by LES pressure, dysphagia frequency, Eckardt score, hospital length of stay, therapy durability, and incidence of GERD. Other therapies, including botulinum toxin injection and pneumatic dilation, have moderately less efficacy and much less durability than POEM.

CONCLUSION

This comprehensive review suggests that POEM is equivalent or perhaps superior to LHM for achalasia in terms of cost efficiency, hospital length of stay, and relief of dysphagia, with comparable side effects. The data are, however, not conclusive due to sparse long-term follow-up and lack of randomized comparative clinical trials. POEM therapy is currently limited by a shortage of trained endoscopists.

Consensus on the digestive endoscopic tunnel technique

With the digestive endoscopic tunnel technique (DETT), many diseases that previously would have been treated by surgery are now endoscopically curable by establishing a submucosal tunnel between the mucosa and muscularis propria (MP). Through the tunnel, endoscopic diagnosis or treatment is performed for lesions in the mucosa, in the MP, and even outside the gastrointestinal (GI) tract. At present, the tunnel technique application range covers the following: (1) Treatment of lesions originating from the mucosal layer, e.g., endoscopic submucosal tunnel dissection for oesophageal large or circular early-stage cancer or precancerosis; (2) treatment of lesions from the MP layer, per-oral endoscopic myotomy, submucosal tunnelling endoscopic resection, etc.; and (3) diagnosis and treatment of lesions outside the GI tract, such as resection of lymph nodes and benign tumour excision in the mediastinum or abdominal cavity. With the increasing number of DETTs performed worldwide, endoscopic tunnel therapeutics, which is based on DETT, has been gradually developed and optimized. However, there is not yet an expert consensus on DETT to regulate its indications, contraindications, surgical procedure, and postoperative treatment. The International DETT Alliance signed up this consensus to standardize the procedures of DETT. In this consensus, we describe the definition, mechanism, and significance of DETT, prevention of infection and concepts of DETT-associated complications, methods to establish a submucosal tunnel, and application of DETT for lesions in the mucosa, in the MP and outside the GI tract (indications and contraindications, procedures, pre- and postoperative treatments, effectiveness, complications and treatments, and a comparison between DETT and other operations).

Per oral endoscopic myotomy: early experience and safety of a multispecialty approach

BACKGROUND

Per oral endoscopic myotomy (POEM) has gained increasing popularity for treating achalasia. A multidisciplinary approach may allow safe and early adoption of POEM into clinical practice.

MATERIALS AND METHODS

We performed a retrospective review of our initial POEM cases. All procedures were performed by a team of interventional gastroenterologist and thoracic surgeon. We analyzed demographics, comorbidities, achalasia subtypes, length of hospital stay, duration of surgery, morbidity, mortality, length of myotomy, preoperative and postoperative Eckardt scores.

RESULTS

Thirty-one consecutive patients underwent POEM during the 24-month period from January 2014 to December 2015. Eighteen patients (58%) had prior non-operative interventions. Average duration of follow-up was 9.6 months. Seventeen patients (66.8%) had follow-up of 12 months and longer. Average preoperative Eckardt score was 6.3 (3-10), median 6. Average postoperative Eckardt score was 1.4 (0-8), median 1, in 1 month and an average 2.2, median 1, in 1 year. Patients with type III achalasia were most refractory to treatment, while patients with type II had the best results. Average LOS was 1.3 days (1-5), median 1 day. Average DOS was 106 min (60-148), median 106. Average LOM was 13 cm (10-15), with median of 13 cm. We had one 30-day mortality secondary to coronary artery disease. Four patients had prior Heller myotomies and underwent a posterior myotomy during POEM, with outcomes similar to patients with no prior myotomy.

CONCLUSIONS

We demonstrated safety and efficiency of a multispecialty approach for achalasia with POEM with a low rate of complications.

Per Oral Endoscopic Myotomy for Achalasia: A Detailed Description of the Technique and Review of the Literature

Historically, the most robust outcomes in treatment of achalasia were seen with surgical myotomy. Per oral endoscopic myotomy (POEM) introduced an endoscopic method for creating a surgical myotomy. Thousands of cases of POEM have been performed; however, there is no standard technique, and the rates of clinical success and adverse events vary widely among centers. This article presents a detailed description of the POEM technique, including the rationale and potential pitfalls of the main variations, in the context of the international literature.

Clinical Effect of Endoscopic Pneumatic Dilation for Achalasia

Although pneumatic dilation is an accepted method for the treatment of achalasia, this therapy has high recurrence and complication rates, and prolonged follow-up studies on the parameters associated with various outcomes are rare. In this prospective 10-year follow-up study, a satisfactory therapeutic effect was achieved without serious complications. We report the therapeutic experience with pneumatic dilation, having aimed to evaluate the long-term clinical safety and efficacy of pneumatic dilation. In total, 35 consecutive patients with idiopathic achalasia who underwent pneumatic dilation were followed up at regular intervals in person or by a phone interview over a 10-year period. The mean duration of the follow-up was 43.03 ± 26.34 months (range 6-120 months). Remission was assessed by the dysphagia classification and symptom scores. Patients' clinical symptom scores were calculated before and at 6 to 36  months, 37 to 60  months, and >60  months after therapy. The influence of the patients' age, gender, and disease duration on the therapeutic effect was analyzed. The success rate of the operation was 97.2% (35/36), without massive hemorrhaging, perforation or other serious complications. Dysphagia after the therapy was significantly eased (P < 0.01). In total, 35 patients have been followed up for 6 to 36  months after therapy, 21 cases for 37 to 60  months, and 5 cases for >60  months, and the patients' symptom scores separately decreased significantly compared with the pretherapy scores (P < 0.01). For these patients, the 6 to 36  months remission rate was 85.7% (30/35), the 37 to 60  months rate was 61.9% (13/21), and the >60  months rate was 40% (2/5). The dilation effect had no relationship to the patient's age, gender, and disease duration (P > 0.05). The patients in 30 cases (85.7%) were successfully treated with a single dilation, in 4 cases (11.4%) with 2 dilations, and in 1 case (2.9%) with 3 dilations. These results suggest that endoscopic pneumatic dilation is an achalasia therapy with a good response; it is a simple and safe procedure with long-term clinical effectiveness. It is a preferred method in the treatment of achalasia.