Difficult peroral endoscopic myotomy: definition and management strategies

Peroral endoscopic myotomy for complex achalasia and the POEM difficulty score: An update

Objectives

We present an update on the (peroral endoscopic myotomy (POEM) difficulty score [PDS] by introducing a novel knife with waterjet functionality.

Methods

This is a retrospective review of patients who underwent POEM between May 2018 and July 2023 at the Kingston Health Sciences Center. Demographic and procedural variables were compared using descriptive and inferential statistics.

Results

One hundred thirty-nine consecutive POEMs were included in the study. Seventy-four (56.7% male; aged 56.7 ± 16.5 years) complex achalasia (CA) and 65 (55.4% female; aged 47.3 ± 20.2 years) non-CA POEM procedures were performed. PDS correlates moderately with procedural efficiency with a correlation coefficient of 0.595 (Spearman's p < 0.001). The mean efficiency for non-CA was 3.3 ± 1.2 min/cm compared to CA as follows: type III 3.3 ± 1.3 min/cm; prior myotomy 5.3 ± 2.3 min/cm; ≧4 prior procedures 4.0 ± 1.7 min/cm; sigmoid type 5.2 ± 2.4 min/cm. The median PDS for non-CA was 1 (1-5). In comparison, the median PDS for CA is as follows: type III 3 (2-4); prior myotomy 4 (3-5); ≧4 prior procedures 3 (1.25-4); sigmoid type 3 (2-4). PDS excluding the presence of spastic contractions correlated better with procedural velocity, with a correlation coefficient of 0.645 (Spearman's p < 0.001).

Conclusions

PDS continues to moderately correlate with procedural efficiency using the novel knife. The presence of spastic contractions correlated poorly with procedural efficiency. Thus, it may be omitted in further studies.

Efficacy of a novel small-caliber therapeutic endoscope in peroral endoscopic myotomy for esophageal motility disorders: a propensity score matching analysis

BACKGROUND

EG-840TP is a novel small-caliber therapeutic endoscope with a large working channel. We aimed to evaluate the treatment outcomes of peroral endoscopic myotomy using EG-840TP compared to those using a conventional therapeutic endoscope (GIF-H290T).

METHODS

Patients who underwent peroral endoscopic myotomy for achalasia and non-achalasia esophageal motility disorders were enrolled between March 2021 and March 2023. Procedure times and other treatment outcomes were compared between patients treated with EG-840TP and GIF-H290T using propensity score matching analysis. In the subgroup analysis, patients were divided into subsets based on myotomy length, morphology, esophageal dilation, and operator skill, and the procedure time was compared between the matched groups.

RESULTS

A total of 154 patients were enrolled in this study, and 39 patients treated using each type of scope were matched. The EG-840TP group tended to have a shorter procedure time than the GIF-H290T group. There were no significant differences between the groups in terms of short-term clinical success or perioperative adverse events. In the subgroup analysis, the procedure time of the EG-840TP group was significantly shorter than that of the GIF-H290T group when patients had a straight esophagus (44 min vs. 54 min, p = 0.0015) and the operator was a non-expert (49 min vs. 64 min, p = 0.031).

CONCLUSIONS

POEM using EG-840TP showed procedure time, clinical success, and adverse events equivalent to those of a conventional therapeutic endoscope. However, EG-840TP potentially contributed to a shorter procedure time in patients with a straight esophagus or in non-expert operators than GIF-H290T.

Repeat peroral endoscopic myotomy: technical difficulty and risk factors

BACKGROUND AND AIMS

Repeat peroral endoscopic myotomy (Re-POEM) appears to be a promising salvage option for patients with persistent or recurrent symptoms after initial POEM, but it may be more technical challenging. Here we aim to evaluate the safety and technical difficulty of Re-POEM.

METHODS

Between July 2012 and October 2023, 158 achalasia patients underwent Re-POEM and were retrospectively enrolled. Another 2978 patients without prior myotomy were selected for the naive POEM group. After propensity score matching (PSM), procedure-related parameters were compared between the 2 groups. Univariable and multivariable analyses were performed to reveal risk factors for difficult Re-POEM (defined as procedure time ≥90 minutes).

RESULTS

With similar baseline characteristics between the 2 groups after PSM, the procedure time was comparable between Re-POEM and naive POEM groups (61.4 ± 27.0 vs 59.3 ± 29.9, P = .496). The Re-POEM group had a shorter esophageal myotomy length (7.0 ± 2.1 cm vs 8.2 ± 1.1 cm, P < .001) and longer gastric myotomy length (2.3 ± .6 cm vs 2.1 ± .4 cm, P = .017) compared with the naive POEM group. Mucosal injury in the Re-POEM group was slightly higher, which was not statistically significant (20.3% vs 13.9%, P = .135). No differences were found in the incidence of gas-related adverse events (AEs), major AEs, and technical difficulty. Multivariate analysis determined mucosal edema (odds ratio, 4.942; 95% confidence interval, 1.554-15.714; P = .007) and submucosal fibrosis (odds ratio, 3.817; 95% confidence interval, 1.333-10.931; P = .013) to be independent risk factors for difficult Re-POEM.

CONCLUSIONS

Re-POEM appears to be safe and feasible as a salvage option after initial POEM failure, with comparable procedure duration, incidence of AEs, and technical difficulty with naive POEM. Mucosal edema and submucosal fibrosis were associated with difficult Re-POEM.

Comparing clinical success and procedural difficulty between treatment-naïve and treatment-refractory patients with esophageal motility disorders during peroral endoscopic myotomy

BACKGROUND AND AIMS

Peroral endoscopic myotomy (POEM) can successfully treat patients with achalasia. Prior therapy with Botox (Allergan, Madison, NJ, USA) injections, pneumatic dilation (PD), and/or laparoscopic Heller myotomy (LHM) is believed to increase the difficulty of POEM procedures. We aimed to determine if prior treatment methods were associated with longer procedure times or lower clinical success.

METHODS

In this single-center retrospective study, consecutive patients who underwent POEM for achalasia between February 2017 and September 2021 were studied. Collected data were patient demographics, prior treatment, pre- and postprocedure Eckardt score (ES), distensibility indices (DIs), and procedure times. Primary outcomes were clinical success and procedure difficulty.

RESULTS

Of 95 patients (mean age, 55.6 years; 45% women), 25 patients underwent POEM for type I achalasia, 31 for type II achalasia, and 33 for spastic esophageal pathologies. Thirty-three patients (34.7%) were treated for achalasia before POEM with onabotulinumtoxinA injections (n = 18), PD (n = 17), and LHM (n = 3). There were no significant differences in post-treatment ESs or technical success between the 2 groups (P = .98 and P = .66, respectively). Multivariate analysis showed that prior treatment was associated with decreased case time and easier tunneling during POEM.

CONCLUSIONS

Prior treatment did not impact the clinical success rate of POEM and led to decreased case times and easier tunneling difficulty, likely because of persistent lower esophageal sphincter changes and differences in diagnostic indications. POEM should be considered for patients with treatment-refractory symptoms as a safe and feasible option. Further large-scale studies are needed to validate our findings.

A prediction model and nomogram for technical difficulty of peroral endoscopic myotomy

BACKGROUND AND AIMS

Peroral endoscopic myotomy (POEM) is a promising endoscopic technique for achalasia. We aimed to establish a regression model and develop a simple nomogram to predict the technical difficulty of POEM in a single center with large volume cases.

METHODS

3385 achalasia patients treated with POEM were included, and the technical difficulty was systemically evaluated. All of them were randomized into the training cohort (n = 1693) or internal validation cohort (n = 1692). Then, the prediction model and nomogram were proposed based on multivariate logistic regression analysis in the training cohort and assessed in the validation cohort.

RESULTS

Of 3385 patients, technical difficulty happened in 417 (12.32%) cases. In the training stage, six factors were weighted based on the β coefficient from the regression model, including age, disease duration, sigmoid esophagus, mucosal edema, submucosal fibrosis, and tunnel length. The patients were categorized into low-risk (< 0.1), medium-risk (0.1-0.25), and high-risk (> = 0.25) groups. Our score model performed satisfying discrimination with the areas under the receiver-operating characteristic curve (AUC) of 0.743 (95% confidence interval (CI), 0.701-0.785) and calibration with goodness of fit in the Hosmer-Lemeshow test (P = 0.088) in internal validation.

CONCLUSIONS

The prediction model and nomogram demonstrated good performance in predicting the technical difficulty of POEM.

Impact of modified techniques on outcomes of peroral endoscopic myotomy: A narrative review

Peroral endoscopic myotomy (POEM) is an established frontline treatment modality for achalasia cardia. Since its initial description, several modifications have been proposed to the technique of POEM. Broadly speaking, these modifications follow the basic principles of submucosal endoscopy, but incorporate variations in the POEM technique, including the difference in the orientation of myotomy (anterior or posterior), length of myotomy (short or long), and thickness of myotomy (selective circular or full thickness). Some of these modifications have been shown to reduce procedural duration without compromising the efficacy of the POEM procedure. More recently, several alterations have been reported that intend to reduce gastroesophageal reflux after POEM. These include preservation of sling fibers during posterior POEM and addition of NOTES fundoplication to the POEM procedure. Although some of the modified techniques have been compared with the conventional techniques in quality trials, randomized studies are awaited for others. The incorporation of some of these modifications will likely make POEM a technically easy and safer modality in near future. This review aims to discuss the current evidence with regard to the impact of modified techniques on the outcome of POEM.

Peroral Endoscopic Myotomy for Pediatric Achalasia: A Retrospective Analysis of 21 Cases With a Minimum Follow-Up of 5 Years

BACKGROUND

Peroral endoscopic myotomy (POEM) has shown promising short-term safety and efficacy in pediatric patients, while long-term outcomes are largely unknown. This study aimed to assess the clinical effects of POEM for pediatric achalasia who had a follow-up of at least 5 years.

METHODS

Pediatric patients from a single center who underwent a POEM between October 2011 and November 2016 were, respectively, collected and analyzed for long-term clinical outcomes. Patients were contacted to evaluate their current symptoms and encouraged repeat endoscopy and manometry. The clinical success, procedure-related parameters, adverse events, gastroesophageal reflux disease after POEM, and quality of life were evaluated.

RESULTS

A total of twenty-four patients who underwent POEM in our center were studied, with a mean age of 14.42 ± 2.65. Two of the 24 patients (8.3%) had previous treatment. The mean of the procedure time was 58.67 ± 19.10 min, 8.3% (2/24) of patients experienced perioperative adverse events. The current symptom scores were obtained from 21 patients at a mean follow-up of 92.57 months, the remainder were lost to follow-up after a mean of 38 months. Eckardt scores were significantly improved from preoperative baseline (preoperative 7.67 ± 1.62 vs. current 0.86 ± 1.28, P < 0.001). Long-term overall success was achieved in 95.8% of patients and none required retreatment for symptoms. 12.5% of patients were suffered from clinical reflux. 76.2% of patients expressed satisfaction with POEM. No severe adverse events were observed during the operation and the 5-years follow-up.

CONCLUSION

POEM resulted in successful symptomatic mitigation in a majority of pediatric patients after 5 years. A multi-center large-scale, prospective study is necessary for a confirmed conclusion.

Per-oral Endoscopic Myotomy and Other Applications of Third Space Endoscopy: Current Status and Future Perspectives

INTRODUCTION

The modification of NOTES (natural orifice transluminal endoscopic surgery) by mucosal safety flap has introduced us to the world of third space endoscopy (TSE). POEM (per-oral endoscopic myotomy) for achalasia cardia being its first vista, the realm expanded so that we can now remove en bloc a subepithelial/intramural tumor by POET (per-oral endoscopic tumor resection), perform G-POEM (gastric per-oral endoscopic myotomy) for refractory gastroparesis, restore esophageal continuity in complete obstruction by performing POETRE (per-oral endoscopic tunneling for the restoration of the esophagus), divide the septum in Zenker diverticulum completely with negligible risk of perforation by Z-POEM (Zenker per-oral endoscopic myotomy) and relieve constipation in Hirschsprung disease by PREM (per-rectal endoscopic myotomy). However, the real potential of TSE became evident with the introduction of POEM with fundoplication. TSE has opened the gates of the peritoneal cavity. Improved expertise and equipment will make the role of endoscopist complimentary to the surgeon with the dawn of a new field in therapeutic endoscopy.

AREAS COVERED

This review intends to comprehensively discuss the various aspects of POEM for achalasia studied so far followed by a brief discussion about other applications of TSE and the future perspectives in this exciting field.

Outcomes of peroral endoscopic myotomy in challenging achalasia patients: a long-term follow-up study

BACKGROUND

Peroral endoscopic myotomy (POEM) has been shown to be effective for achalasia patients. Our study aimed to analyze the clinical outcomes of POEM for challenging patients.

METHODS

We retrospectively enrolled 278 challenging achalasia patients who underwent POEM from January 2011 to July 2019. The outcomes of POEM such as procedure time, adverse events, and risk factors of adverse events were analyzed.

RESULTS

Of the 278 patients (134 males and 144 females) with a mean age of 47.0 years, 103, 223, 93, and 98 patients had prior treatment and were Ling classification IIc/III, submucosal fibrosis (SMF) classification 2/3, and esophageal mucosa in achalasia (EMIA) classification c/d/e/f, respectively. The mean procedure time was 45.9 min (range, 15-158 min). The mean length of the tunnel and myotomy were 10.1 cm (range, 7-17 cm) and 6.6 cm (range, 5-13 cm), respectively. The major adverse event rate was 14.1%, while the minor adverse event rate was 4.7%. SMF classification 2/3 was an independent risk factor for incomplete tunneling, adverse events, and procedure time ≥ 90 min. The mean follow-up time was 37.2 months (range 1-99 months). The mean Eckardt score and esophageal sphincter pressure were both significantly declined postoperatively. The clinical success rate was 95.6%.

CONCLUSION

POEM is safe and effective for challenging achalasia patients. SMF classification grade 2/3 was shown to be an independent risk factor for incomplete tunneling, adverse events, and procedure time ≥ 90 min. For these patients, POEM should be performed by experienced endoscopists, some cases are better served with traditional surgery, such as minimally invasive Heller with Dor fundoplication.

Feasibility of Speedboat RS2 with bipolar radiofrequency energy for peroral endoscopic myotomy in patients with achalasia (with video)

Background  During peroral endoscopic myotomy (POEM), use of traditional instruments leads to an increase in overall time of procedure due to constant exchange of instruments. Speedboat-RS2 (Creo-Medical, UK) is a novel device which has shown promising results for endoscopic submucosal dissection of gastrointestinal lesions, but its feasibility, and safety for POEM is unexplored. Methods  Data from patients who had undergone POEM for achalasia cardia utilizing Speedboat-RS2 was reviewed. Results  Two patients with mean age of 46 years and mean symptom duration of 3 years were included. Both patients had type II achalasia diagnosed on esophageal manometry. One patient underwent anterior myotomy and the other posterior approach. Submucosal tunneling (~15 cm) was achieved in a mean of 20 minutes, myotomy (~ 9 cm) in 8 minutes and the entire procedure was completed in a mean of 30 minutes with 100 % technical success. Both patients were discharged the day after the procedure without any immediate adverse events. At 6 weeks, endoscopy was uneventful and the patients were asymptomatic. Conclusions  Early experience shows that Speedboat-RS2 is feasible for performing POEM with good safety profile. Submucosal tunneling was relatively quick and coagulation was effective. Long term studies with a larger patient cohort are warranted.