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

Third space endoscopy pulmonary complications and chylothorax post peroral endoscopic myotomy

Third-space endoscopy (TSE) has emerged as an effective treatment modality for various gastrointestinal motility diseases and gastrointestinal tumors. TSE is based on the concept of working in the submucosa using a mucosal flap valve technique, which is the underlying premise for all TSE procedures; thus, some complications are shared across the spectrum of TSE procedures. Despite the high safety profiles of most TSE procedures, studies have reported various adverse events, including insufflation-related complications, bleeding, perforation, and infection. Although the occurrence rate of those complications is not very high, they sometimes result in critical conditions. No reports of chylous effusion following TSE procedures, particularly per-oral endoscopic myotomy, have been documented previously. We are presenting the first reported case of chylous pleural effusion after per-oral endoscopic myotomy. Additionally, we aim to present a comprehensive overview, discuss the existing data, and provide insights into pulmonary post-endoscopic complications in light of recent advancements in endoscopic procedures, especially TSE.

Peroral Endoscopic Myotomy: Short Versus Long Esophageal Myotomy for Achalasia Cardia: A Randomized Controlled Noninferiority Trial

BACKGROUND AND AIMS

The appropriate length of esophageal myotomy in peroral endoscopic myotomy (POEM) for achalasia cardia remains unclear. This study aimed to compare the outcome of short (≤3 cm) and long (≥6 cm) esophageal myotomy in patients with type I and II achalasia cardia.

METHODS

This single-blinded, randomized controlled noninferiority trial was conducted at a tertiary center between July 2021 and December 2021. Patients with achalasia types I and II were randomized into short (≤3 cm) and long (≥6 cm) esophageal myotomy groups. The primary outcome of the study was clinical success (Eckardt score ≤3) 1 year after the procedure. The secondary outcomes included a comparison of technical success, operating duration, occurrence of intraoperative adverse events, alterations in integrated relaxation pressure (IRP), change in barium column height after 5 minutes (1 mo), and gastroesophageal reflux disease (3 mo) between the groups.

RESULTS

Fifty-four patients were randomized into the short (n=27) or long (n=27) esophageal myotomy groups. Technical success rates were 100% (27/27) and 96.3% (26/27) in short myotomy (SM) and long myotomy (LM) groups, respectively. The clinical success rates were 96.3% (26/27) and 96.2% (25/26) in the SM and LM groups, respectively ( P =0.998). The mean (±SD) length of the esophageal myotomy was 2.75±0.36 cm in the SM and 6.69±1.35 cm in the LM groups ( P <0.001). The mean (±SD) procedure time for the SM and LM groups was 61.22±8.44 and 82.42±14.70 minutes ( P <0.001), respectively. The mean integrated relaxation pressure (IRP), Eckardt score, adverse events, reflux esophagitis, symptomatic gastroesophageal reflux disease, and esophageal acid exposure (>6%) did not differ significantly between the 2 groups following POEM treatment.

CONCLUSIONS

Short myotomy is noninferior to long myotomy in terms of clinical success, gastroesophageal reflux disease, and intraoperative adverse events at the short-term follow-up ( P >0.05). Short myotomy resulted in a reduced operative time ( P <0.05).

POEM for non-achalasia spastic oesophageal motility disorders

Non-achalasia oesophageal motility disorders (NAOMD) represent a heterogeneous group of rare diseases, including oesophagogastric junction outflow obstruction, distal oesophageal spasm, and hypercontractile oesophagus. Despite the differing aetiological, manometric and pathophysiological characteristics, these disorders are unified by similar clinical presentation, including dysphagia and chest pain. The management of these disorders remain a challenge for the clinician. Pharmacotherapy, botulinum toxin injection, endoscopic dilation, and laparoscopic Heller myotomy have been employed, with limited efficacy in the majority of patients. Currently, there are no controlled studies in literature that suggest which is the best management of these diseases. Since its introduction in clinical practice, PerOral Endoscopic Myotomy (POEM) has emerged as a very promising, minimally invasive and effective treatment for oesophageal achalasia. No longer after the first uses, POEM has been successfully used also for the management of selected patients with NAOMD, However, currently available data are limited by small study sample sizes and short-term follow-up.

Complications related to third space endoscopic procedures

Third space endoscopy (TSE) encompasses a breadth of procedures for the treatment of a variety of GI disorders. The widespread use of per-oral endoscopic myotomy (POEM) and its diversification to include extended indications and at locations other than the oesophagus has provided an insight into the potential complications encountered. The most common adverse events associated with POEM, the epitome of TSE procedures, include insufflation related injuries, bleeding, failure of mucosal barrier, infections, pain, blown out myotomy and gastroesophageal reflux disease. The purpose of this review is to highlight the pitfalls and to identify the risk factors that may lead to adverse events, and to recommend appropriate salvage interventions in the scope of the current evidence.

Single-Versus Multiple-Dose Antimicrobial Prophylaxis in Peroral Endoscopic Myotomy: A Randomized Controlled Study (SMAPP Trial)

Infections are uncommon after peroral endoscopic myotomy (POEM) procedure. However, prophylactic antibiotics are routinely administered for variable duration during peri-operative period. In this study, we aimed to determine the difference in the rate of infections between single (SD-A) and multiple doses (MD-A) antibiotic prophylaxis groups. The study was a prospective, randomized, non-inferiority trial conducted at a single tertiary care centre from Dec 2018 to Feb 2020. Eligible patients undergoing POEM were randomized into SD-A and MD-A groups. SD-A group received one dose of antibiotic (IIIrd gen cephalosporin) within 30-min of POEM. In the MD-A group, the same antibiotic was administered for a total of three days. Primary aim of the study was to determine the incidence of infections in the two groups. Secondary outcomes included incidence of fever (> 100 °F), inflammatory markers [erythrocyte sedimentation rate (ESR), c-reactive protein(CRP)], serum procalcitonin and adverse events related to antibiotics. (NCT03784365). 114 patients were randomized to SD-A (57) and MD-A (57) antibiotic groups. Mean post-POEM CRP (0.8 ± 0.9 vs 1.5 ± 1.6), ESR (15.8 ± 7.8 20.6 ± 11.7) and procalcitonin (0.05 ± 0.04 0.29 ± 0.58) were significantly higher after POEM (p = 0.001). Post-POEM inflammatory markers (ESR, CRP and procalcitonin) were similar in both the groups. Fever on day-0 (10.5% vs 14%) and day-1 (1.7% vs 3.5%) was detected in similar proportion of patients. Post-POEM infections were recorded in 3.5% (1.7% vs 5.3%, p = 0.618). Single dose of antibiotic is non-inferior to multiple dose antibiotic prophylaxis. Elevation of inflammatory markers and fever after POEM represents inflammation and does not predict infection after POEM.

Per-Oral Endoscopic Myotomy-Induced Gastroesophageal Reflux Disease and Review of the Efficacy of Proton Pump Inhibitors as a Management Strategy: Review of the Literature

Per-oral endoscopic myotomy (POEM) is a minimally invasive procedure that is very effective in the treatment of achalasia, a rare esophageal motility disorder. POEM has become the first-line treatment for achalasia, with high success rates reported in the literature. However, a known complication of POEM is gastroesophageal reflux disease (GERD). The exact cause and risk factors of post-POEM GERD are not fully understood; however, a number of factors have played a role in its development. The management of post-POEM GERD is mainly by conservative measures, such as lifestyle changes and medications, like proton pump inhibitors (PPI), which are often the first-line method of treatment. However, surgical procedures, such as fundoplication, may be necessary in some patients. This literature review will discuss the effectiveness of the use of PPIs as a management strategy for post-POEM GERD, the factors that lead to PPI-resistant GERD, and other management strategies utilized in these cases.

Repeat peroral endoscopic myotomy with simultaneous submucosal and muscle dissection as a salvage option for recurrent achalasia

BACKGROUND

For recurrent achalasia after initial peroral endoscopic myotomy (POEM) failure, repeat POEM (Re-POEM) has been reported as a treatment option. However, severe esophageal interlayer adhesions caused by previous procedures impede the successful establishment of a submucosal tunnel and lead to aborted Re-POEM procedures. Our team previously described POEM with simultaneous submucosal and muscle dissection (POEM-SSMD) as a feasible solution for achalasia with severe interlayer adhesions.

AIM

To investigate the effectiveness and safety of Re-POEM with simultaneous submucosal and muscle dissection (Re-POEM-SSMD).

METHODS

A total of 1049 patients with achalasia who underwent successful endoscopic myotomy at the Digestive Endoscopic Center of Chinese PLA General Hospital from December 2014 to May 2022 were reviewed. Patients with recurrent achalasia who experienced initial POEM clinical failure were retrospectively included in this study. The primary endpoint was retreatment clinical success, defined as an Eckardt score ≤ 3 during the postretreatment follow-up and no need for additional treatment. Procedure-related adverse events, changes in manometric lower esophageal sphincter (LES) pressure and reflux complications, as well as procedure-related parameters, were recorded.

RESULTS

Sixteen patients underwent Re-POEM (9 patients) or Re-POEM-SSMD (7 patients) successfully at a median of 45.5 mo (range, 4-95 mo) after initial POEM. During a median follow-up period of 31 mo (range, 7-96 mo), clinical success (Eckardt score ≤ 3) was achieved in 8 (88.9%) and 6 (85.7%) patients after Re-POEM and Re-POEM-SSMD, respectively (P = 0.849). The median Eckardt score dropped from 4 (range, 3-8) at preretreatment to 1 (range, 0-5) at postretreatment in the Re-POEM group (P = 0.025) and from 5 (range, 2-8) to 2 (range, 0-4) in the Re-POEM-SSMD group (P < 0.001). The mean manometric LES pressure decreased from 23.78 ± 9.04 mmHg to 11.45 ± 5.37 mmHg after Re-POEM (P < 0.001) and from 26.80 ± 7.48 mmHg to 11.05 ± 4.38 mmHg after Re-POEM-SSMD (P < 0.001). No serious adverse events were recorded in both groups.

CONCLUSION

In conclusion, Re-POEM-SSMD appears to be a safe and effective salvage therapy for recurrent achalasia with severe interlayer adhesions.

Technical details and outcomes of peroral endoscopic myotomy with fundoplication: the first U.S. experience (with video)

BACKGROUND AND AIMS

Peroral endoscopic myotomy (POEM) is an established endoscopic treatment for achalasia; however, post-POEM rates of GERD remain a significant cause of concern. Single-session POEM with fundoplication (POEM-F) to treat achalasia was recently described to reduce post-POEM GERD. This study aims to report the technical feasibility, safety, and early outcomes of the first U.S. cohort of POEM-F.

METHODS

We retrospectively reviewed all patients with achalasia treated with POEM-F at our center. The primary endpoint was technical success, defined as the successful completion of all steps of the POEM-F procedure.

RESULTS

Six patients (mean age, 50 ± 4.8 years; 1 woman) underwent POEM-F for achalasia. Technical success was achieved in all patients (6/6), and no major immediate or delayed (up to 30 days postprocedure) adverse events were seen. At the 1-month follow-up visit, the mean Eckardt score decreased from 8.8 ± 1.1 to .3 ± .5. The GERD health-related quality of life and reflux symptom index scores obtained at the 1-month follow-up, with patients on proton pump inhibitors, were 2.3 ± 3.7 and 2.2 ± 2.5, respectively.

CONCLUSIONS

This first case series on POEM-F in the United States suggests that POEM-F is feasible and safe with excellent short-term outcomes.

Safety and Efficacy of the Supine Position with the Right Shoulder Raised versus the Left Lateral Position in Peroral Endoscopic Myotomy for Achalasia: A Large-Sample Retrospective Study

BACKGROUND

The correct surgical position is very important in the treatment of peroral endoscopic myotomy (POEM) for achalasia, which can make the procedure safer and more efficient. Currently, there are two commonly used positions: the supine position with the right shoulder raised and the left lateral position. This study aims to evaluate the differences in the safety and efficacy of these two positions.

METHODS

We conducted a retrospective study of 702 patients with achalasia undergoing POEM from December 2010 to December 2020. These patients were divided into the supine position with the right shoulder raised group (n = 579) and the left lateral position group (n = 123). The efficacy of POEM and adverse events were analyzed.

RESULTS

The clinical characteristics were similar in both groups, and there were no significant differences between the two groups in the Eckardt score change, lower esophageal sphincter (LES) basal pressure or residual pressure after POEM (all p > 0.05). The mean operative time in the supine position with the right shoulder raised group was significantly shorter than that in the left lateral position group (43.5 min vs. 54.6 min, respectively, p < 0.001). In addition, the differences between the two groups in terms of gas-related complications, such as pneumoperitoneum, pneumomediastinum, and subcutaneous emphysema were statistically significant (all p < 0.05).

CONCLUSIONS

The efficacy of POEM was comparable between the two groups. However, the supine position with the right shoulder raised significantly reduced the operative time and the rate of procedure-related adverse events, especially gas-related complications.

Short versus long esophageal myotomy during peroral endoscopic myotomy: A systematic review and meta-analysis of comparative trials

BACKGROUND

: Peroral endoscopic myotomy (POEM) is an established modality of treatment for achalasia cardia. Considerable variations exist in the technique of POEM with respect to the length and orientation of the myotomy. In this systematic review and meta-analysis, we compared the outcomes of short versus long myotomy during POEM.

METHODS

: We searched multiple databases from January 2010 to March 2021 to identify studies reporting on POEM. We selected studies that reported on comparative outcomes of POEM using short versus long myotomy. We performed a comparative analysis of clinical success, procedural duration, gastroesophageal reflux disease (GERD), and adverse events with short and long myotomy in POEM by meta-analysis.

RESULTS

: A total of 521 patients from five studies in which 241 patients were treated with short and 280 patients with long myotomy approaches were analyzed. The pooled rate for clinical success gave an odds ratio (OR) of 1.27 (95% confidence interval [CI] 0.50-3.26; I2 = 0; P = 0.62); for hospital stay OR 0.22 (95% CI - 0.03 to 0.46; I2 = 0; P = 0.08); for GERD by esophagogastroduodenoscopy (EGD) OR 0.58 (95% CI 0.31-1.07; I2 = 0; P = 0.08), and for adverse events OR 0.67 (95% CI 0.29-1.53; I2 = 51; P = 0.34). Abnormal esophageal acid exposure was less frequent with OR 0.45 (95% CI 0.22-0.90; P = 0.02; I2 = 0) and the procedure duration was significantly shorter in the short myotomy group with OR - 0.76 (95% CI - 1.00 to - 0.52; I2 = 43; P =0.001).

CONCLUSION

: Short myotomy and long myotomy in POEM seem comparable with each other in terms of clinical success and adverse events. Short myotomy is associated with significantly shorter procedural duration and possibly reduced esophageal acid exposure compared with long myotomy.

Impedance planimetry values for predicting clinical response following peroral endoscopic myotomy

BACKGROUND

There is growing interest in developing impedance planimetry as a tool to enhance the clinical outcomes for endoscopic and surgical management of achalasia. The primary aim of this study was to determine whether impedance planimetry measurements can predict clinical response and reflux following peroral endoscopic myotomy (POEM).

METHODS

A multicenter cohort study of patients with achalasia undergoing POEM was established from prospective databases and retrospective chart reviews. Patients who underwent impedance planimetry before and after POEM were included. Clinical response was defined as an Eckardt score of ≤ 3. Tenfold cross-validated area under curve (AUC) values were established for the different impedance planimetry measurements associated with clinical response and reflux development.

RESULTS

Of the 290 patients included, 91.7 % (266/290) had a clinical response and 39.4 % (108/274) developed reflux following POEM. The most predictive impedance planimetry measurements for a clinical response were: percent change in cross-sectional area (%ΔCSA) and percent change in distensibility index (%ΔDI), with AUCs of 0.75 and 0.73, respectively. Optimal cutoff values for %ΔCSA and %ΔDI to determine a clinical response were a change of 360 % and 272 %, respectively. Impedance planimetry values were much poorer at predicting post-POEM reflux, with AUCs ranging from 0.40 to 0.62.

CONCLUSION

Percent change in CSA and distensibility index were the most predictive measures of a clinical response, with a moderate predictive ability. Impedance planimetry values for predicting reflux following POEM showed weak predictive capacity.

Population trends in achalasia diagnosis and management: a changing paradigm

The Chicago Classification of esophageal motility disorders improved the differentiation of achalasia subtypes and tailored treatment. Heller myotomy (HM) and pneumatic dilation are two established treatments for achalasia. Peroral endoscopic myotomy (POEM) has become a third definitive option and is on the rise. Using the National Inpatient Sample (NIS) database, we evaluated patients hospitalized with achalasia and associated surgical and endoscopic interventions from 2013 to 2017 and compared patients undergoing HM versus POEM. The NIS database was queried to include patients with achalasia. Patients who underwent HM, POEM (only 2017 due to lack of distinct procedure code in 2013), pneumatic dilation, or esophagectomy were identified. Adverse events during the hospitalization were also queried using diagnosis codes. From 2013 to 2017, patients hospitalized with achalasia increased from 16 850 to 19 485. There were reductions in the number of esophageal dilations (10.6-5.4%, P < 0.001) and HM (18.7-13.1%, P < 0.001). In 2017, 580 POEMs were performed. Compared with patients undergoing HM in 2017, patients who had POEM had higher mean age > 64 (P = 0.004), Charlson comorbidity index (P < 0.001), disease severity (P < 0.001), and likelihood of mortality (P < 0.001). There were no differences in length of stay, mortality, or total costs between the HM and POEM groups. Patients hospitalized with achlasia increased from 2013 to 2017, possibly due to the growth and accessibility of high-resolution esophageal manometry. As expertise in POEM increases, the number of POEM performed is anticipated to rise with possible further reductions in other treatment modalities for achalasia.

Comparison of Short Versus Long Esophageal Myotomy in Cases With Idiopathic Achalasia: A Randomized Controlled Trial

BACKGROUND/AIMS

Per-oral endoscopic myotomy (POEM) is an established treatment for achalasia. The technique of POEM is still evolving and the impact of length of esophageal myotomy on the outcomes of POEM is not known. In this study, we aim to compare the outcomes of short (3 cm) versus long (6 cm and above) esophageal myotomy in patients undergoing POEM for achalasia cardia.

METHODS

Consecutive patients with idiopathic achalasia (type I and II) were randomized to receive short (3 cm) or long esophageal myotomy (≥ 6 cm). Both groups were compared for clinical success, operative time, adverse events, and gastroesophageal reflux disease (GERD).

RESULTS

Seventy-one consecutive patients with type I and II achalasia underwent POEM with short (n = 34) or long (n = 37) esophageal myotomy techniques. Mean length of esophageal myotomy in short and long groups was 2.76 ± 0.41 and 7.97 ± 2.40, respectively (P < 0.001). Mean operative time was significantly shorter in short myotomy group (44.03 ± 13.78 minutes and 72.43 ± 27.28 minutes, P < 0.001). Clinical success was comparable in both arms at 1-year (Eckardt score 0.935 ± 0.929 vs 0.818 ± 0.983, P = 0.627). Improvement in objective parameters including integrated relaxation pressure and barium column height at 5 minutes was similar in both groups. GERD was detected in 50.88% patients with no significant difference in short and long myotomy groups (44.44% vs 56.67%, P = 0.431).

CONCLUSIONS

A short esophageal myotomy is non-inferior to long myotomy with regards to clinical success, adverse events, and GERD in cases with type I and II achalasia. Reduced operating duration favors short esophageal myotomy in these patients.

Long-term outcomes of per-oral endoscopic myotomy in achalasia patients with a minimum follow-up of 4 years: a multicenter study

Background and study aims  Per-oral endoscopic myotomy (POEM) is associated with a short-term clinical response of 82 % to 100 % in treatment of patients with achalasia. Data are limited on the long-term durability of the clinical response in these patients. The aim of this study was to determine the long-term outcomes of patients undergoing POEM for management of achalasia. Methods  This was a retrospective multicenter cohort study of consecutive patients who underwent POEM for management of achalasia. Patients had a minimum of 4 years follow-up. Clinical response was defined by an Eckardt score ≤ 3. Results  A total of 146 patients were included from 11 academic medical centers. Mean (± SD) age was 49.8 (± 16) years and 79 (54 %) were female. The most common type of achalasia was type II, seen in 70 (47.9 %) patients, followed by type I seen in 41 (28.1 %) patients. Prior treatments included: pneumatic dilation in 29 (19.9 %), botulinum toxin injection in 13 (8.9 %) and Heller myotomy in seven patients (4.8 %). Eight adverse events occurred (6 mucosotomies, 2 pneumothorax) in eight patients (5.5 %). Median follow-up duration was 55 months (IQR 49.9-60.6). Clinical response was observed in 139 (95.2 %) patients at follow-up of ≥ 48 months. Symptomatic reflux after POEM was seen in 45 (32.1 %) patients, while 35.3 % of patients were using daily PPI at 48 months post POEM. Reflux esophagitis was noted in 16.8 % of patients who underwent endoscopy. Conclusion  POEM is a durable and safe procedure with an acceptably low adverse event rate and an excellent long-term clinical response.

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.

Jackhammer esophagus with and without esophagogastric junction outflow obstruction demonstrates altered neural control resembling type 3 achalasia

BACKGROUND

Esophageal hypercontractility can manifest with and without esophagogastric junction (EGJ) outflow obstruction. We investigated clinical presentations and motility patterns in patients with esophageal hypercontractile disorders.

METHODS

Esophageal HRM studies fulfilling Chicago Classification 3.0 criteria for jackhammer esophagus (distal contractile integral, DCI >8000 mmHg.cm.s in ≥ 20% swallows) with (n = 30) and without (n = 83) EGJ obstruction (integrated relaxation pressure, IRP > 15 mm Hg) were retrospectively reviewed from five centers (4 in Europe, 1 in US). Single swallows (SS) and multiple rapid swallows (MRS) were analyzed using HRM software tools (IRP, DCI, distal latency, DL); MRS: SS DCI ratio >1 defined contraction reserve. Comparison groups were achalasia type 3 (n = 72, positive control for abnormal inhibition and EGJ obstruction) and healthy controls (n = 18). Symptoms, HRM metrics, and MRS contraction reserve were analyzed within jackhammer subgroups and comparison groups.

KEY RESULTS

The esophageal smooth muscle was excessively stimulated at baseline in jackhammer subgroups, with lack of augmentation following MRS identified more often compared with controls (P = .003) and type 3 achalasia (P = .07). Consistently abnormal inhibition was identified in type 3 achalasia (47%), and to a lower extent in jackhammer with obstruction (37%, P = .33), jackhammer esophagus (28%, P = .01), and controls (11%, P < .01 compared with type 3 achalasia). Perceptive symptoms (heartburn, chest pain) were common in jackhammer esophagus (P < .01 compared with type 3 achalasia), while transit symptoms (dysphagia) were more frequent with presence of EGJ obstruction (P ≤ .01 compared with jackhammer without obstruction).

CONCLUSIONS AND INFERENCES

The balance of excessive excitation and abnormal inhibition defines clinical and manometric manifestations in esophageal hypercontractile disorders.

Safety and efficacy of using a short tunnel versus a standard tunnel for peroral endoscopic myotomy for Ling type IIc and III achalasia: a retrospective study

BACKGROUND AND AIMS

Peroral endoscopic myotomy (POEM) for patients with Ling type IIc and III achalasia is associated with a high rate of adverse events. Decreasing the lengths of the tunnel and myotomy may be an effective method for reducing this rate. This study aimed to assess the safety and efficacy of using a short tunnel versus a standard tunnel for POEM.

METHOD

We conducted a retrospective study of 126 patients with Ling type IIc and III achalasia undergoing POEM from January 2013 to December 2016. These patients were divided into a short tunnel group (n = 63) and a standard tunnel group (n = 63). The clinical efficacy of the procedure, operative time, length of the tunnel, length of myotomy and rates of adverse events were analyzed.

RESULTS

The preoperative features were similar in both groups. No significant differences were found between the two groups in Eckardt score change, lower esophageal sphincter (LES) basal pressure or residual pressure after POEM (all p > 0.05). The mean lengths of the tunnel and myotomy were 7.6 cm and 4.8 cm, respectively, in the short tunnel group and 11.8 cm and 9.2 cm, respectively, in the standard tunnel group. The mean operative time of the short tunnel group was significantly shorter than that of the standard tunnel group (39.5 min vs. 48.2 min, respectively, p = 0.001). A significant difference was observed in the rates of procedure-related adverse events between the two groups (9.5% vs. 33.3%, p = 0.001).

CONCLUSION

The efficacy of the procedure was comparable between the two groups. However, the short tunnel significantly reduced the operation time and the rates of procedure-related adverse events.

Clinical and endoscopic predictors for intraprocedural mucosal injury during per-oral endoscopic myotomy

BACKGROUND AND AIMS

Mucosal injury (MI) is one of the most common perioperative adverse events of per-oral endoscopic myotomy (POEM). Severe undertreated MI may lead to contamination of the tunnel and even mediastinitis. This study explored the characteristics, predictors, and management approaches of intraoperative MI.

METHODS

A retrospective review of the prospectively collected database at a large tertiary referral endoscopy unit was conducted for all patients undergoing POEM between August 2010 and March 2016. MI was graded according to the difficulty of repair (I, easy to repair; II, difficult to repair). The primary outcomes were the incidence and predictors of intraoperative MI. Secondary outcomes were MI details and the corresponding treatment.

RESULTS

POEM was successfully performed in 1912 patients. A total of 338 patients experienced 387 MIs, for an overall frequency of 17.7% (338/1912). Type II MI was rare, with a frequency of 1.7% (39/1912). Major adverse events were more common in patients with MI than in those without MI (6.2% vs 2.5%, P < .001). On multivariable analysis, MI was independently associated with previous Heller myotomy (odds ratio [OR], 2.094; P = .026), previous POEM (OR, 2.441; P = .033), submucosal fibrosis (OR, 4.530; P < .001), mucosal edema (OR, 1.834; P = .001), and tunnel length ≥13 cm (OR, 2.699; P < .001). Previous POEM (OR, 5.005; P = .030) and submucosal fibrosis (OR, 12.074; P < .001) were significant predictors of type II MI. POEM experience >1 year was a protective factor for MI (OR, .614; P = .042) and type II MI (OR, .297; P = .042).

CONCLUSIONS

MI during POEM is common, but type II injury is rare. Previous POEM and submucosal fibrosis were significant predictors of type II mucosal injury. POEM experience after the learning curve reduces the risk of MI.

Peroral endoscopic myotomy is effective and safe in non-achalasia esophageal motility disorders: an international multicenter study

BACKGROUND AND STUDY AIMS

The efficacy of per oral endoscopic myotomy (POEM) in non-achalasia esophageal motility disorders such as esophagogastric junction outflow obstruction (EGJOO), diffuse esophageal spasm (DES), and jackhammer esophagus (JE) has not been well demonstrated. The aim of this international multicenter study was to assess clinical outcomes of POEM in patients with non-achalasia disorders, namely DES, JE, and EGJOO, in a large cohort of patients.

PATIENTS AND METHODS

This was a retrospective study at 11 centers. Consecutive patients who underwent POEM for EGJOO, DES, or JE between 1/2014 and 9/2016 were included. Rates of technical success (completion of myotomy), clinical response (symptom improvement/Eckardt score ≤ 3), and adverse events (AEs, severity per ASGE lexicon) were ascertained .

RESULTS

Fifty patients (56 % female; mean age 61.7 years) underwent POEM for EGJOO (n = 15), DES (n = 17), and JE (n = 18). The majority of patients (68 %) were treatment-naïve. Technical success was achieved in all patients with a mean procedural time of 88.4 ± 44.7 min. Mean total myotomy length was 15.1 ± 4.7 cm. Chest pain improved in 88.9 % of EGJOO and 87.0 % of DES/JE ( P  = 0.88). Clinical success was achieved in 93.3 % of EGJOO and in 84.9 % of DES/JE ( P  = 0.41) with a median follow-up of 195 and 272 days, respectively. Mean Eckardt score decreased from 6.2 to 1.0 in EGJOO ( P  < 0.001) and from 6.9 to 1.9 in DES/JE ( P  < 0.001). A total of 9 (18 %) AEs occurred and were rated as mild in 55.6 % and moderate in 44.4 %.

CONCLUSION

POEM is effective and safe in management of non-achalasia esophageal motility disorders, which include DES, JE, and EGJOO.

POEM for Achalasia

In 2008, a new treatment modality for esophageal achalasia was introduced—peroral endoscopic myotomy (POEM). POEM is a procedure performed endoscopically, which allows transection of the muscular fibers of the distal esophagus and of the lower esophageal sphincter. The procedure is therefore similar to a laparoscopic Heller myotomy without a fundoplication. Short-term studies have shown that POEM is very effective in relieving dysphagia and regurgitation, but concerns have been raised about the incidence of post-POEM gastroesophageal reflux. Prospective and randomized trials will be needed to determine the role of this new procedure in the treatment algorithm of esophageal achalasia.

An international multicenter study evaluating the clinical efficacy and safety of per-oral endoscopic myotomy in octogenarians

BACKGROUND AND AIMS

Per-oral endoscopic myotomy (POEM) for achalasia is particularly appealing in the elderly because it is minimally invasive. However, data in patients aged ≥80 years are scarce. The aim of this study was to assess the clinical outcome of POEM in octogenarians.

METHODS

This was a multicenter retrospective study at 8 centers. Consecutive octogenarians with achalasia who underwent POEM between 2010 and 2016 were included. Rates of technical success (completion of myotomy), clinical response (Eckardt score ≤3), and adverse events (severity graded as per American Society for Gastrointestinal Endoscopy lexicon) were assessed.

RESULTS

A total of 76 patients (47.4% female, mean age 84 years) underwent POEM for treatment of achalasia: type I, 17.1%; type II, 35.5%; type III, 17.1%; and unspecified, 30.3%. Overall, 41.1% were treatment naïve, whereas others had previous botulinum toxin injection and/or pneumatic dilation. The mean (± standard deviation [SD]) age-adjusted Charlson comorbidity index score was 6.2 ± 2.4, with the majority of patients having American Society of Anesthesiologists Physical Status Classification System (ASA) scores of II/III. Technical success was 93.4%, with a median follow-up of 256 days. Fourteen adverse events occurred in 11 patients (14.5%). There were 3 inadvertent mucosotomies, 6 cases of symptomatic capnoperitoneum and/or capnomediastinum, 2 esophageal leaks, 1 cardiac arrhythmia, and 2 other). The severities of these adverse events were mild (78.6%), moderate (14.3%), and severe (7.1%). Clinical success was achieved in 90.8% of patients, with a mean (± SD) Eckardt score reduction from 7.0 ± 2.3 to 0.8 ± 0.1 (P < .001), a median follow-up of 256 days, and interquartile range of 66 to 547.

CONCLUSION

Although the rate of technical success may be somewhat lower and the rate of adverse events slightly higher than previously reported, our data suggest that POEM in octogenarians is safe and effective, supporting its role as a primary modality for achalasia in this patient population.

Advanced Therapeutic Gastrointestinal Endoscopy in Children - Today and Tomorrow

Gastrointestinal (GI) endoscopy plays an indispensable role in the diagnosis and management of various pediatric GI disorders. While the pace of development of pediatric GI endoscopy has increased over the years, it remains sluggish compared to the advancements in GI endoscopic interventions available in adults. The predominant reasons that explain this observation include lack of formal training courses in advanced pediatric GI interventions, economic constraints in establishing a pediatric endoscopy unit, and unavailability of pediatric-specific devices and accessories. However, the situation is changing and more pediatric GI specialists are now performing complex GI procedures such as endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography for various pancreatico-biliary diseases and more recently, per-oral endoscopic myotomy for achalasia cardia. Endoscopic procedures are associated with reduced morbidity and mortality compared to open surgery for GI disorders. Notable examples include chronic pancreatitis, pancreatic fluid collections, various biliary diseases, and achalasia cardia for which previously open surgery was the treatment modality of choice. A solid body of evidence supports the safety and efficacy of endoscopic management in adults. However, additions continue to be made to literature describing the pediatric population. An important consideration in children includes size of children, which in turn determines the selection of endoscopes and type of sedation that can be used for the procedure.

Current Status of Peroral Endoscopic Myotomy

Peroral endoscopic myotomy (POEM) has been established as an optional treatment for achalasia. POEM is an endoluminal procedure that involves dissection of esophageal muscle fibers followed by submucosal tunneling. Inoue first attempted to use POEM for the treatment of achalasia in humans. Expanded indications of POEM include classic indications such as type I, type II, type III achalasia, failed prior treatments, including Botulinum toxin injection, endoscopic balloon dilation, laparoscopic Heller myotomy, and hypertensive motor disorders such as diffuse esophageal spasm, jackhammer esophagus. Contraindications include prior radiation therapy to the esophagus and prior extensive esophageal mucosal resection/ablation involving the POEM field. Most of the complications are minor and self-limited and can be managed conservatively. As POEM emerged as the main treatment for achalasia, various adaptations to tunnel endoscopic surgery have been attempted. Tunnel endoscopic surgery includes POEM, peroral endoscopic tumor resection, gastric peroral endoscopic pyloromyotomy. POEM has been widely accepted as a treatment for all types of achalasia, even for specific cases such as achalasia with failed prior treatments, and hypertensive motor disorders.

Outcomes of anterior myotomy versus posterior myotomy during POEM: a randomized pilot study

BACKGROUND AND STUDY AIMS

 Peroral endoscopic myotomy (POEM) can be performed via an anterior or posterior approach, depending on the operator's preference. Data are lacking on comparative outcomes of both approaches.

PATIENTS AND METHODS

 This is a pilot randomized study comparing endoscopic anterior and posterior myotomy during POEM in patients with Achalasia cardia (AC). Patients were randomized into 2 groups (n = 30 in each group); anterior myotomy group (AG) and posterior myotomy group (PG) and were followed at 1, 3 and 6 months after POEM.

RESULTS

 Technical success was achieved in 100 % of cases in both groups and total operative time was comparable (AG - 65 ± 17.65 minutes versus PG - 61.2 ± 16.67; P  = 0.38); Mucosotomies were more frequent in AG (20 % vs 3.3 %; P  = 0.02). Difference in other perioperative adverse events (AE) including insufflation-related AE and bleeding in both groups were statistically insignificant. At 1-month follow-up Eckardt score AG 0.57 ± 0.56 vs PG 0.53 ± 0.71; ( P  = 0.81), mean LES pressure AG 11.93 ± 6.36 vs PG 11.77 ± 6.61; ( P  = 0.59) and esophageal emptying on timed barium swallow at 5 minutes AG 1.32 ± 1.08 cm vs PG 1.29 ± 0.79 cm; ( P  = 0.09) were comparable in both groups. At 3 months, Eckardt score (0.52 ± 0.59 vs 0.63 ± 0.62; P  = 0.51) was similar in both groups. Incidence of esophagitis on EGD was comparable in both groups (24 % vs 33.3 %; P  = 0.45), however, pH metry at 3 months showed significantly more esophageal acid exposure in posterior group (2.98 % ± 4.24 vs 13.99 % ± 14.48; P  < 0.01). At 6 months clinical efficacy and LES pressures were comparable in both groups.

CONCLUSION

 Anterior and posterior approaches to POEM seem to have equal efficacy. However, the occurrence of mucosotomies was higher in the anterior myotomy group and acid exposure was higher with the posterior myotomy approach during POEM.

Comparison of outcomes of laparoscopic Heller myotomy versus per-oral endoscopic myotomy for management of achalasia

Achalasia is a rare disorder that has several treatment options. The gold standard of treatment is a surgical myotomy called a laparoscopic Heller myotomy (LHM). More recently, an endoscopic myotomy has become an option as well, called per-oral endoscopic myotomy (POEM). An achalasia registry was queried for patients undergoing either LHM or POEM at Baylor University Medical Center at Dallas. Patient demographics, preoperative and postoperative data points, and Eckardt scores were collected. The patients were further stratified into their follow-up intervals, immediate postoperative and long-term follow-up, to assess surgical success. A subset analysis was done for success of treatment for patients who had redo surgery versus those undergoing the procedure for the first time. There were 12 patients in the POEM group and 11 patients in the LHM group. Both groups demonstrated mean lower esophageal sphincter pressures with failure to relax. Procedure length and hospital length of stay were similar between the two groups. There were three adverse events in each group, but none altered the patient's postoperative clinical course. Eckardt scores, used to assess success of the surgery, were 82% for POEM patients and 66% for LHM patients after 6 months. The outcomes for POEM and LHM in our early experience are similar to those reported in the literature for high-volume centers managing achalasia.

Adverse events during and after per-oral endoscopic myotomy: prevention, diagnosis, and management

Per-oral endoscopic myotomy (POEM) has surfaced as an effective endoscopic treatment modality for achalasia cardia (AC). Promising results in short- and mid-term follow-up studies have increased the use of POEM for the management of AC. POEM can be safely performed in an endoscopy suit, and major adverse events (AEs) are uncommon. AEs encountered during POEM or during the perioperative period principally include insufflation-related AEs, mucosal injuries, bleeding, pain, and aspiration pneumonia. Most insufflation-related AEs do not require an active intervention and therefore should not be considered as AEs in the true sense. When management of AEs is required, most intraoperative AEs can be managed at the same time without untoward consequences. Occurrences of AEs lessen after completion of the learning curve. However, experience alone does not ensure "zero" incidence of AEs, and early recognition remains essential. Postoperative AEs, like leaks, delayed bleeding, and delayed mucosal perforations, may pose special challenges for diagnosis and management. There is no standardized classification system for grading the severity of AEs associated with POEM, resulting in wide variation in their reported occurrences. Uniform reporting of AEs is not only crucial to comprehensively analyze the safety of POEM but also for comparison with other established treatment modalities like Heller's myotomy. GERD is an important long-term AE after POEM. Unlike the perioperative AEs, little is known regarding the intraoperative or patient-related factors that influence the occurrence of post-POEM GERD. Large prospective studies with long-term follow-up are required to determine the procedural factors associated with GERD after POEM.

Peroral Endoscopic Myotomy in Children: First Experience With a New Triangular Knife

OBJECTIVES

Peroral endoscopic myotomy (POEM) is a novel treatment modality for achalasia cardia. The procedure is technically challenging and time consuming. Recently, a new triangle tip knife (TTJ) has been introduced, which is equipped with water jet facility. In the present study, we analyzed the feasibility, safety, and efficacy of POEM in children with new triangle tip knife.

METHODS

We retrospectively evaluated the data of children (18 years or younger) who underwent POEM using TTJ knife at our institution. All POEM procedures were performed under general anesthesia in an endoscopy suite. Technical feasibility, safety, efficacy, and procedure duration were assessed.

RESULTS

Ten children (4 boys, 6 girls) with mean age of 14.2 ± 2.74 (9-18) years, underwent POEM with TTJ knife. The subtypes of achalasia cardia were type I (4), type II (5), and type III (1). Two children had prior treatment with pneumatic balloon dilatation. POEM was performed via anterior route in majority of children (70%). Mean operating time was 47.6 ± 19.74 (30-98) minutes with no significant difference between anterior and posterior approaches to POEM (48.57 ± 24.01 vs 45.3 ± 3.51; P < 0.05). Four gas-related adverse events were encountered including capnoperitoneum and retroperitoneal carbon dioxide in 2 children each. Clinical success was noticed in 9 children with significant reduction in Eckardt score at 1 month after POEM (6.7 ± 1.49 vs 0.3 ± 0.48; P = 0.0001).

CONCLUSIONS

POEM can be efficiently performed with new triangle knife equipped with water jet technique. Integration of water jet reduces procedure duration and technical difficulty with POEM.

Outcome of peroral endoscopic myotomy in achalasia cardia: Experience with a new triangular knife

BACKGROUND AND AIM

Peroral endoscopic myotomy (POEM) is a technically demanding procedure. Recently, a new triangular knife with integrated water jet function (TTJ) has been introduced. The present study was aimed to analyze and compare the operating time, efficacy, and adverse events (AEs) between the conventional (TT knife) and new knife (TTJ).

PATIENTS AND METHODS

All patients with achalasia cardia (AC) who underwent POEM between August 2015 and November 2016 were analyzed retrospectively. Operating time (OT), technical success, and AEs were assessed and compared between TT and TTJ knife.

RESULTS

A total of 193 patients with AC underwent POEM during the specified period. Both groups had equivalent number of different subtypes of AC (I, II, and III). There was no difference in technical success between the two groups (TT, 99% vs TT, 98.9%). OT was significantly less in the TTJ group as compared to TT group (53.8 ± 15.2 vs 66.26 ± 19.2; P = 0.0001). On subanalysis, OT taken for submucosal tunneling was significantly less with TTJ knife (34.6 ± 10.1 vs 45.83 ± 14.80), whereas OT was similar for myotomy and clipping in both the groups. Significantly fewer use of coagulation forceps and exchanges of accessories were required in TTJ knife group (2.92 ± 1.77 vs 10.5 ± 3.58; P = 0.0001). There were no major AEs. Minor AEs were noted in 21.5% and 31% of patients in TTJ and TT knife groups, respectively.

CONCLUSION

New triangular knife reduces procedure time and technical difficulty with POEM. POEM is an efficacious treatment for achalasia and can be safely executed in an endoscopy unit.

Efficacy and Safety of Peroral Endoscopic Myotomy for Treatment of Achalasia After Failed Heller Myotomy

BACKGROUND & AIMS

In patients with persistent symptoms after Heller myotomy (HM), treatment options include repeat HM, pneumatic dilation, or peroral endoscopic myotomy (POEM). We evaluated the efficacy and safety of POEM in patients with achalasia with prior HM vs without prior HM.

METHODS

We conducted a retrospective cohort study of 180 patients with achalasia who underwent POEM at 13 tertiary centers worldwide, from December 2009 through September 2015. Patients were divided into 2 groups: those with prior HM (HM group, exposure; n = 90) and those without prior HM (non-HM group; n = 90). Clinical response was defined by a decrease in Eckardt scores to 3 or less. Adverse events were graded according to criteria set by the American Society for Gastrointestinal Endoscopy. Technical success, clinical success, and rates of adverse events were compared between groups. Patients were followed up for a median of 8.5 months.

RESULTS

POEM was technically successful in 98% of patients in the HM group and in 100% of patients in the non-HM group (P = .49). A significantly lower proportion of patients in the HM group had a clinical response to POEM (81%) than in the non-HM group (94%; P = .01). There were no significant differences in rates of adverse events between the groups (8% in the HM group vs 13% in the non-HM group; P = .23). Symptomatic reflux and reflux esophagitis after POEM were comparable between groups.

CONCLUSIONS

POEM is safe and effective for patients with achalasia who were not treated successfully by prior HM. Although the rate of clinical success in patients with prior HM is lower than in those without prior HM, the safety profile of POEM is comparable between groups.

Comprehensive Analysis of Adverse Events Associated With Per Oral Endoscopic Myotomy in 1826 Patients: An International Multicenter Study

OBJECTIVES

The safety of peroral endoscopic myotomy (POEM) is still debated since comprehensive analysis of adverse events (AEs) associated with the procedure in large multicenter cohort studies has not been performed. To study (1) the prevalence of AEs and (2) factors associated with occurrence of AEs in patients undergoing POEM.

METHODS

Patients who underwent POEM at 12 tertiary-care centers between 2009 and 2015 were included in this case-control study. Cases were defined by the occurrence of any AE related to the POEM procedure. Control patients were selected for each AE case by matching for age, gender, and disease classification (achalasia type I and II vs. type III/spastic esophageal disorders).

RESULTS

A total of 1,826 patients underwent POEM. Overall, 156 AEs occurred in 137 patients (7.5%). A total of 51 (2.8%) inadvertent mucosotomies occurred. Mild, moderate, and severe AEs had a frequency of 116 (6.4%), 31 (1.7%), and 9 (0.5%), respectively. Multivariate analysis demonstrated that sigmoid-type esophagus (odds ratio (OR) 2.28, P=0.05), endoscopist experience <20 cases (OR 1.98, P=0.04), use of a triangular tip knife (OR 3.22, P=0.05), and use of an electrosurgical current different than spray coagulation (OR 3.09, P=0.02) were significantly associated with the occurrence of AEs.

CONCLUSIONS

This large study comprehensively assessed the safety of POEM and highly suggests POEM as a relatively safe procedure when performed by experts at tertiary centers with an overall 7.5% prevalence of AEs. Severe AEs are rare. Sigmoid-type esophagus, endoscopist experience, type of knife, and current used can be considered as predictive factors of AE occurrence.

Anesthesia in per-oral endoscopic myotomy: A large tertiary care centre experience

BACKGROUND AND OBJECTIVES

Per-oral endoscopic myotomy (POEM) is safe and efficacious for the management of achalasia cardia (AC). POEM is usually performed under general anesthesia in an endoscopy suite or operating theatre. The current study was conducted with the aim to analyse anesthetic management of patients with AC who underwent POEM at our institution.

METHODS

We retrospectively analysed the data of patients with AC who underwent POEM at our institution from January 2013 to September 2016. All cases were performed in an endoscopy suite under supervision of an anesthesia management team. Pre-procedure endoscopic evacuation of esophagogastric contents was done in all cases. Management strategies used for gas-related adverse events and outcomes were assessed.

RESULTS

Four hundred and eighty patients (median age 40 years, range 4-77 years) underwent POEM during the study period. The sub-types of AC were type I (163), type II (297), and type III (20). POEM was successfully completed in 97.5% patients. Gas-related events were noted in 30.6% cases including-capno-thorax in 1%, capno-peritoneum in 12.3%, retroperitoneal air in 16.5%, capno-mediastinum in 0.2%, and capno-pericardium in 0.4% patients. Significant rise in end tidal CO2 (> 45) and peak airway pressure were observed in 8.1% and 5.4% cases, respectively. Drainage was required in 12.3% patients. There was no occurrence of aspiration during or after POEM.

CONCLUSIONS

POEM could be safely performed in an endoscopy suite under supervision of an expert anesthesia management team. Gas-related adverse events were common during POEM and could be managed with a standardized approach.

Long-term outcomes of per-oral endoscopic myotomy in patients with achalasia with a minimum follow-up of 2 years: an international multicenter study

BACKGROUND AND AIMS

Per-oral endoscopic myotomy (POEM) has shown promising safety and efficacy in short-term studies. However, long-term follow-up data are very limited. The aims of this study were to assess (1) clinical outcome of patients with a minimum post-POEM follow-up of 2 years and (2) factors associated with long-term clinical failure after POEM.

METHODS

A retrospective chart review was performed that included all consecutive patients with achalasia who underwent POEM with a minimum follow-up of 2 years at 10 tertiary-care centers. Clinical response was defined by a decrease in Eckardt score to 3 or lower.

RESULTS

A total of 205 patients (45.8% men; mean age, 49 years) were followed for a median of 31 months (interquartile range, 26-38 months). Of these, 81 patients (39.5%) had received previous treatment for achalasia before POEM. Clinical success was achieved in 98% (185/189), 98% (142/144), and 91% (187/205) of patients with follow-up within 6 months, at 12 months, and ≥24 months, respectively. Of 185 patients with clinical response at 6 months, 11 (6%) experienced recurrent symptoms at 2 years. History of previous pneumatic dilation was associated with long-term treatment failure (odds ratio, 3.41; 95% confidence interval, 1.25-9.23). Procedure-related adverse events occurred in 8.2% of patients and only 1 patient required surgical intervention. Abnormal esophageal acid exposure and reflux esophagitis were documented in 37.5% and 18% of patients, respectively. However, these rates are simply a reference number among a very selective group of patients.

CONCLUSIONS

POEM is safe and provides high initial clinical success and excellent long-term outcomes. Among patients with confirmed clinical response within 6 months, 6% had recurrent symptoms by 2 years.

Early adverse events of per-oral endoscopic myotomy

BACKGROUND AND AIMS

The recently developed technique of per-oral endoscopic myotomy (POEM) has been shown to be effective for the therapy of esophageal motility disorders. Limited information is available about POEM adverse events (AEs).

METHODS

POEM was performed on 241 patients (58% male; mean age, 47.4 ± 16.4 years) under general anesthesia over 61 months. The main outcome was the rate of intra- and post-procedural AEs. Post-procedural checks comprised clinical and laboratory examinations and endoscopy, with further follow-ups performed at 3, 6, and 12 months.

RESULTS

Of the 241 procedures, 238 were successfully completed (mean procedure time, 100.2 ± 39.5 min). Reasons for abortion were excessive submucosal fibrosis preventing submucosal tunneling. Three patients had severe procedural-related AEs (SAE rate, 1.2%); 1 case of pneumothorax required intra-procedural drainage, and 2 patients had delayed SAEs (1 ischemic gastric cardia perforation and 1 hemothorax, both leading to surgery). The overall rate of minor AEs was 31.1%, mainly prolonged intra-procedural bleeding (>15 min hemostasis) and defects of the mucosa overlying the tunnel; none led to clinically relevant signs or symptoms. Patients experiencing any AE had a significantly prolonged hospital stay (P = .037) and a trend toward prolonged procedure time (P = .094). Neck/upper thoracic emphysema and free abdominal air were noted in 31.5% and 35.7%, respectively (95.3% drained), but without relevant sequelae.

CONCLUSIONS

POEM has a low rate of SAEs; minor AEs are more frequent but lack a consistent definition. Therefore, based on our experience and literature analysis, we suggest a classification of AEs for POEM. (Clinical trials registration number: NCT01405417.).

Peroral endoscopic myotomy: procedural complications and pain management for the perioperative clinician

Achalasia refers to the lack of smooth muscle relaxation of the distal esophagus. Although nonsurgical treatments such as pneumatic dilatation of the distal esophagus and botulinum toxin injections have been performed, these procedures have limited duration. Similarly, surgical treatment with Heller myotomy is associated with complications. At our institution, we perform the peroral endoscopic myotomy (POEM) in qualified patients. Briefly, POEM involves endoscopic creation of a mid-esophageal submucosal bleb, creation of a submucosal tunnel with the endoscope, and then a distal myotomy, resulting in relaxation of the distal esophagus. The aim of our study is to document perioperative pain and associated pain management for our initial patients undergoing POEM and to review the literature for perioperative complications of this procedure. Therefore, anesthetic and pain management for our initial eleven patients undergoing POEM were reviewed. Patient demographics, pre-POEM pain medication history, perioperative pain medication requirements, and post-POEM pain scores were examined. We found post-POEM pain was usually in the mild–moderate range; a combination of medications was effective (opioids, nonsteroidal anti-inflammatory drugs, acetaminophen). Our literature search revealed a wide frequency range of complications such as pneumoperitoneum and subcutaneous emphysema, with rare serious events such as capnopericardium leading to cardiac arrest. In conclusion, our experience with POEM suggests pain and can be managed adequately with a combination of medications; the procedure appears to be safe and reasonable to perform in an outpatient endoscopy unit.

Peroral endoscopic myotomy achieves similar clinical response but incurs lesser charges compared to robotic heller myotomy

BACKGROUND/AIM

Several uncontrolled studies comparing peroral endoscopic myotomy (POEM) and Heller myotomy have demonstrated equivalent short-term efficacy and safety. However, no data exists rergarding the cost of POEM and how it compares to that of robotic Heller myotomy (RHM). The primary aim of this study was to compare the inpatient charges incurred in patients who underwent POEM or RHM for the treatment of achalasia.

PATIENTS AND METHODS

A retrospective single center review was conducted among 52 consecutive POEM patients (2012-2014) and 52 consecutive RHM patients (2009-2014). All RHM procedures included a Toupet fundoplication and were performed via a transabdominal approach. All POEM procedures were performed by a gastroenterologist in the endoscopy unit. Clinical response was defined by improvement of symptoms and decrease in Eckardt stage to ≤I. All procedural and facility charges were obtained from review of the hospital finance records.

RESULTS

There was no difference between POEM and RHM with regards to age, gender, symptom duration, achalasia subtype, manometry findings, or Eckardt symptom stage. There was no significant difference in the rate of adverse events (19.2% vs 9.6%, P = 0.26) or the length of stay (1.9 vs. 2.3, P = 0.18) between both groups. Clinical response rate of patients in the POEM groups was similar to that in the RHM group (94.3% vs. 88.5%, P = 0.48). POEM incurred significantly less total charges compared to LHM ($14481 vs. $17782, P = 0.02).

CONCLUSIONS

POEM when performed in an endoscopy unit was similar in efficacy and safety to RHM. However, POEM was associated with significant cost savings ($3301/procedure).

Is POEM the Answer for Management of Spastic Esophageal Disorders? A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Spastic esophageal disorders (SEDs) include spastic achalasia (type III), diffuse esophageal spasm (DES), and nutcracker/jackhammer esophagus (JH). Per-oral endoscopic myotomy (POEM) has demonstrated efficacy and safety in the treatment of achalasia. Recently, POEM has been indicated for the treatment of SEDs. We conducted a systematic review and meta-analysis to determine the clinical success and safety of POEM in SEDs.

METHODS

We searched several databases from 01/01/2007 to 01/10/2016 to identify studies (with five or more patients) on POEM for the treatment of SEDs. Weighted pooled rates (WPRs) for clinical success and adverse events (AEs) were calculated for all SEDs. Clinical success was defined as Eckardt scores of ≤3 and/or improvement in severity of dysphagia based on achalasia disease-specific health-related quality of life questionnaire. The WPRs for clinical success and AEs were analyzed using fixed- or random-effects model based on heterogeneity. The proportionate difference in clinical success and post-procedure adverse event rates among individual types of SEDs was also calculated.

RESULTS

A total of eight observational studies with 179 patients were included in the final analysis. Two studies were of good quality and six were of fair quality based on the National Institutes of Health quality assessment tool. The WPR with 95% confidence interval (CI) for cumulative clinical success of POEM in all SEDs was 87% (78, 93%), I ² = 37%. The total number of patients for individual disorders, i.e., type III achalasia, JH, and DES, was 116, 37, and 18, respectively. The WPRs for clinical success of POEM for type III achalasia, DES, and JH were 92, 88, and 72%, respectively. Proportion difference of WPR for clinical success was significantly higher for type III achalasia in comparison with JH (20%, P = 0.01). The WPR with 95% CI for AEs of POEM in all SEDs was 14% (9, 20%), I ² = 0%. The WPRs for post-procedure adverse events for type III achalasia, DES, and JH were 11, 14, and 16%, respectively. There was no difference in safety of POEM among individual SEDs.

CONCLUSION

POEM is an effective and safe therapeutic modality for the treatment of spastic esophageal disorders.