Peroral endoscopic dual myotomy (dual POEM) for achalasia with severe esophageal dilatation

Peroral endoscopic myotomy assisted with an elastic ring for achalasia with obvious submucosal fibrosis: A case report

BACKGROUND

Peroral endoscopic myotomy (POEM) is an established treatment option for esophageal achalasia. However, technical challenges and failures exist. Submucosal fibrosis is a rare cause of aborted POEM procedures.

CASE SUMMARY

We performed POEM with an elastic ring for achalasia with obvious submucosal fibrosis. The short-term outcome was excellent, surgery time was significantly shorter, and success rate was higher with POEM for achalasia with obvious submucosal fibrosis.

CONCLUSION

POEM performed with an elastic ring is a feasible and effective endoscopic treatment modality for achalasia with obvious submucosal fibrosis.

Per-oral endoscopic dual myotomy for the treatment of achalasia

BACKGROUND

Repeat per-oral endoscopic myotomy is occasionally performed for persistent/recurrent symptoms in patients with achalasia, and yields favorable outcomes. We investigated a novel technique, per-oral endoscopic dual myotomy (dual-POEM), where a second myotomy was performed during a single session to augment the efficacy and avoid repeat interventions. The aim of this study was to evaluate its feasibility, safety and efficacy.

METHODS

Consecutive patients diagnosed with achalasia who underwent dual-POEM (1/2018-5/2019) were prospectively collected and retrospectively analyzed. Patients with baseline Eckardt score ≥ 9, ≥ 10 years of symptoms, and/or having prior interventions other than myotomy received dual-POEM. The primary outcome was clinical success (Eckardt score ≤ 3). Secondary outcomes were procedure-related adverse events, change in lower esophageal sphincter (LES) pressure, and reflux complications.

RESULTS

Seventeen patients received dual-POEM. Procedure-related adverse events were observed in 2 (11.8%) patients (mucosal injury and pneumonitis). Both were minor in severity. During a median follow-up of 33 months (interquartile range, IQR [31,35]; range, 19-36), clinical success was achieved in 16 (94.1%) patients. The median Eckardt score decreased from 9 (IQR [8, 11.5]; range 7-12) to 1 (IQR [1, 2]; range 0-4) (P < 0.001), and LES pressure decreased from 25.8 mmHg (IQR [21.7, 33.5]; range 17.7-46.3) to 7.4 mmHg (IQR [6.3, 10.4]; range 2.2-12.6) (P < 0.001). Seven (41.2%) patients developed postprocedural reflux either by gastroesophageal reflux disease questionnaire or esophagitis endoscopically, all successfully treated with proton pump inhibitors.

CONCLUSION

Dual-POEM preliminarily demonstrated high efficacy with a favorable safety profile in patients with achalasia with predictors of treatment failure.

Peroral endoscopic myotomy for management of gastrointestinal motility disorder

Achalasia is a type of esophageal motility disorder, consisting of relaxation dysfunction of the lower esophagus and disturbed esophageal peristalsis. Related clinical symptoms include dysphagia, regurgitation, chest pain, and weight loss. Traditional treatment options include endoscopic botulinum toxin injection, endoscopic pneumatic dilation, and laparoscopic Heller’s myotomy. These therapies mainly relieve symptoms by reducing the pressure on the lower esophageal sphincter and reducing blood flow resistance at the esophagogastric junction. Based on endoscopic submucosal dissection and natural orifice transluminal endoscopic surgery, peroral endoscopic myotomy (POEM) is a purely endoscopic method of myotomy with minimal invasiveness and a low rate of adverse events when performed by experienced operators. Since then, numerous studies have shown the significant clinical efficacy and safety of POEM. The purpose of this article is to introduce different modified POEMs, special indications for different POEMs, and their advantages as well as disadvantages.

Application of MESNA in endoscopic submucosal dissection for esophageal diseases

With the development of digestive endoscopy, early esophageal carcinoma, esophageal leiomyoma, achalasia, and mediastinal lesions, which were previously treated by thoracoscopy or thoracotomy, may be treated by digestive endoscopy. Endoscopic submucosal dissection (ESD) can achieve en bloc resection of large gastrointestinal mucosal and submucosal lesions and has become the first-line treatment for early esophageal cancer and precancerous lesions without lymph node metastasis. Submucosal tunnel endoscopy has expanded endoscopic indications by establishing a submucosal tunnel, and it has been applied in esophageal lesions originating from the muscularis propia and even mediastinal tumors. An ideal submucosal fluid infusion may shorten dissection time during ESD or submucosal tunnel endoscopy. Selecting appropriate submucosal injection is one of the important factors for ESD success. Submucosal injections of sodium-2-mercaptoethanesulfonate can soften tissues and facilitate endoscopic submucosal dissection and is worthy of clinical promotion.