Effect of Peroral Endoscopic Myotomy vs Pneumatic Dilation on Symptom Severity and Treatment Outcomes Among Treatment-Naive Patients With Achalasia: A Randomized Clinical Trial

Update on the Diagnosis and Treatment of Achalasia

Achalasia is a rare disease of the esophagus with impaired relaxation of the lower esophageal sphincter and aperistalsis. The etiology is unknown but speculations include a viral or autoimmune etiology. All specialists dealing with swallowing and esophageal diseases should recognize the classic symptoms of dysphagia for solids/liquids, regurgitation, and choking, especially at night. High-resolution manometry is critical for the diagnosis with endoscopy and barium esophagram having a supportive role. The disease cannot be cured but most can return to near normal swallowing and a regular diet with appropriate therapy. Treatment includes smooth muscle relaxants, botulinum toxin injections to the lower sphincter, pneumatic dilation, Heller myotomy, and peroral endoscopic myotomy. One treatment does not fit all and a tailored approach through a multidiscipline team will give the best long-term outcomes.

Pathogenesis, clinical manifestations, diagnosis, and treatment progress of achalasia of cardia

Achalasia cardia, type of esophageal dynamic disorder, is a relatively rare primary motor esophageal disease characterized by the functional loss of plexus ganglion cells in the distal esophagus and lower esophageal sphincter. Loss of function of the distal and lower esophageal sphincter ganglion cells is the main cause of achalasia cardia, and is more likely to occur in the elderly. Histological changes in the esophageal mucosa are considered pathogenic; however, studies have found that inflammation and genetic changes at the molecular level may also cause achalasia cardia, resulting in dysphagia, reflux, aspiration, retrosternal pain, and weight loss. Currently, the treatment options for achalasia focus on reducing the resting pressure of the lower esophageal sphincter, helping to empty the esophagus and relieve symptoms. Treatment measures include botulinum toxin injection, inflatable dilation, stent insertion, and surgical myotomy (open or laparoscopic). Surgical procedures are often subject to controversy owing to concerns about safety and effectiveness, particularly in older patients. Herein, we review clinical epidemiological and experimental data to determine the prevalence, pathogenesis, clinical presentation, diagnostic criteria, and treatment options for achalasia to support its clinical management.

Training in esophageal peroral endoscopic myotomy (POEM) on an ex vivo porcine model: learning curve study and training strategy

BACKGROUND

Peroral endoscopic myotomy (POEM) is a very effective treatment for achalasia. However, training remains non-standardized. We evaluated a training curriculum, including ex vivo cases, followed by patients' cases under expert supervision. The objective was to establish a learning curve of POEM.

MATERIALS AND METHODS

Four operators having completed advanced endoscopy fellowship were involved. They had already observed > 30 cases performed by experts. They performed 30 POEMs standardized (tunnel and myotomy lengths) procedures on ex vivo porcine model. Procedural times, number/volume of injections, mucosal and serous perforations, and myotomy length were collected. The learning curve was assessed using dissection speed (DS) and a dedicated performance score (PS), including learning rate (LR) and learning plateau (LP).

RESULTS

The operators completed all cases within 4 months (median of 3.5 cases/week). The mean procedural time was 43.3 min ± 14.4. Mean myotomy length was 70.0 mm ± 15.6 mm. Dissection speed averaged 1.78 mm/min ± 0.78. Using DS and PS as parameter, the LR was reached after 12.2 cases (DS = 2.0 mm/min) and 10.4 cases, respectively. When comparing the LP and the plateau phase, the DS was slower (1.3 ± 0.5 mm/min versus 2.1 ± 0.54 mm/min, p < 0.005) and perforations were decreased: 0.35 ± 0.82 in LP vs. 0.16 ± 0.44 in PP. Following this training, all operators performed 10 supervised cases and are competent in POEM.

CONCLUSION

The association of observed cases and supervised ex vivo model training is effective for starting POEM on patients. The learning curve is 12 cases to reach a plateau.

Gastric Peroral Endoscopic Pyloromyotomy for Infants With Congenital Hypertrophic Pyloric Stenosis

INTRODUCTION

Congenital hypertrophic pyloric stenosis (CHPS), the most common infantile disease requiring surgical intervention, is routinely treated with open or laparoscopic pyloromyotomy. Recently, gastric peroral endoscopic pyloromyotomy (G-POEM) has been used for adult gastroparesis. We aimed to evaluate the efficacy and safety of G-POEM in treating infantile CHPS.

METHODS

We reviewed data from 21 G-POEM-treated patients at 3 tertiary children's endoscopic centers in China between January 2019 and December 2020. Clinical characteristics, procedure-related parameters, perioperative management, and follow-up outcomes were summarized.

RESULTS

G-POEM was performed successfully in all patients. The median operative duration was 49 (14-150) minutes. The submucosal tunnels were successfully established along the greater curvature of the stomach in 19 cases, and 2 cases were switched to the lesser curvature because of difficulty. No perioperative major adverse events occurred. Minor adverse events included inconsequential mucosal injury in 5 cases and unsatisfactory closure of the mucosal incision in 1 case. Upper gastrointestinal contrast radiography in all patients showed smooth passage of the contrast agent through the pylorus on postoperative day 3. The growth curves of the patients reached normal levels 3 months after the procedure. No recurrent clinical symptoms occurred in any patient during the median follow-up period of 25.5 (14-36) months.

DISCUSSION

G-POEM is feasible, safe, and effective for infants with CHPS, with satisfactory clinical responses over a short-term follow-up. Further multicenter studies should be performed to compare the long-term outcomes of this minimally invasive technique with open or laparoscopic pyloromyotomy.

Long-term Outcome of Peroral Endoscopic Myotomy in Esophageal Motility Disorders: A Systematic Review and Meta-analysis

BACKGROUND AND AIM

Peroral endoscopic myotomy (POEM) is an established treatment for achalasia. In this systematic review and meta-analysis, we aimed to analyze the mid and long-term outcomes of POEM in esophageal motility disorders.

METHODS

Literature search was performed in databases including PubMed, Embase, Cochrane databases, and Google scholar from January 2010 to May 2021. The primary objective of the study was the clinical success (Eckardt score ≤3 or <4) at mid-term (30 to 60 mo) and long-term (>60 mo) follow-up after POEM. Secondary objectives included post-POEM gastroesophageal reflux (GER) as evaluated by symptoms, increased esophageal acid exposure, and reflux esophagitis.

RESULTS

Seventeen studies with 3591 patients were included in the review. Subtypes of motility disorders were type I (27%), type II (54.5%), type III (10.7%), distal esophageal spasm/Jackhammer esophagus (2%), and esophagogastric junction outflow obstruction (17.5%). Pooled mean follow-up duration was 48.9 months (95% CI, 40.02-57.75). Pooled rate of clinical success at mid-term follow-up was 87% (95% CI, 81-91; I2 , 86%) and long-term was 84% (95% CI, 76-89; I2 , 47%). In nonachalasia motility disorders (esophagogastric junction outflow obstruction, distal esophageal spasm, and Jackhammer esophagus), pooled rate of clinical success was 77% (95% CI, 65-85; I2 , 0%). GER as estimated by symptoms was 23% (95% CI, 19-27; I2 , 74%), erosive esophagitis was 27% (95% CI, 18-38%; I2 , 91%), and increased esophageal acid exposure was 41% (95% CI, 30-52; I2 , 88%).

CONCLUSION

POEM is a durable treatment option in cases with achalasia. One-fourth of patients suffer from erosive GER in the long-term and success rates are lower in nonachalasia esophageal motility disorders.

Systematic Review of Treatment of Patients with Achalasia: Heller Myotomy, Pneumatic Dilation, and Peroral Endoscopic Myotomy

BACKGROUND

The aim of this systematic review is to assess all comparative randomized controlled trials evaluating Heller myotomy, pneumatic dilation, and peroral endoscopic myotomy.

STUDY DESIGN

Achalasia is an esophageal motility disorder associated with degeneration of the myenteric plexus; it causes significant symptoms and impacts patient quality of life (QOL). The optimal treatment for patients with achalasia and the impact of these interventions on QOL remain unclear. PubMed, Embase, Scopus, and Cochrane were searched from inception to April 2020. Randomized controlled trials that compared the 3 interventions were included. Primary outcome was QOL at 12 to 36 months after the operation. Secondary outcomes included reintervention, dysphagia, leak/perforation, and GERD recurrence.

RESULTS

Nine publications of 6 studies were included. Of the 9 publications, there was no significant difference in QOL at 12 to 36 months except for one study in which QOL was significantly higher in patients who underwent Heller myotomy as opposed to pneumatic dilation at 3 years; however, at 5 years there was no difference. Pneumatic dilation was associated with the highest rates of dysphagia recurrence and reintervention, but peroral endoscopic myotomy had the lowest.

CONCLUSIONS

The treatment of achalasia should be chosen in accordance with patient goals. After any of the 3 interventions, QOL appears to be similar. However, peroral endoscopic myotomy may be associated with the lowest rates of perforation/leak, dysphagia, and reintervention and may be the lowest risk option. However, there are barriers to widespread use due to challenges in training and adoption.

Advances in the Diagnosis and Management of Achalasia and Achalasia-Like Syndromes: Insights From HRM and FLIP

High-resolution manometry, Chicago Classification v4.0, the functional lumen imaging probe, Panometry, and peroral endoscopic myotomy (POEM) are all now integral parts of the landscape for managing achalasia or, more precisely, achalasia-like syndromes. This narrative review examines the impact of these innovations on the management of achalasia-like syndromes. High-resolution manometry was the disruptive technology that prompted the paradigm shift to thinking of motility disorders as patterns of obstructive physiology involving the esophagogastric junction and/or the distal esophagus rather than as siloed entities. An early observation was that the cardinal feature of achalasia-impaired lower esophageal sphincter relaxation-can occur in several subtypes: without peristalsis, with pan-esophageal pressurization, with premature (spastic) distal esophageal contractions, or even with preserved peristalsis (esophagogastric junction outlet obstruction). Furthermore, there being no biomarker for achalasia, no manometric pattern is perfectly sensitive or specific for 'achalasia' and there is also no 'gold standard' for the diagnosis. Consequently, complimentary physiological testing with a timed barium esophagram or functional lumen imaging probe are employed both to improve the detection of patients likely to respond to treatments for 'achalasia' and to characterize other syndromes also likely to benefit from achalasia therapies. These findings have become particularly relevant with the development of a minimally invasive technique for performing a tailored esophageal myotomy, POEM. Now and in the future, optimal achalasia management is to render treatment in a phenotype-specific manner, that is, POEM calibrated in a patient-specific manner for obstructive physiology including the distal esophagus and more conservative strategies such as a short POEM or pneumatic dilation for obstructive physiology limited to the lower esophageal sphincter.

Successful Design and Implementation of a POEM Program for Achalasia in an Integrated Healthcare System

BACKGROUND

Per Oral Endoscopic Myotomy (POEM) is a minimally invasive treatment for achalasia with results comparable to laparoscopic Heller myotomy (LHM). Studies have described the development of proficiency for endoscopists learning to perform POEM, and societies have defined educational and technical objectives for advanced endoscopy fellows in training. However, there is limited guidance on the organizational strategy and educational plan necessary to develop an achalasia service with POEM expertise.

AIMS

We aim to outline the steps for design and implementation of a successful POEM program.

METHODS

We reported our experience developing a multi-disciplinary clinical program for POEM and the steps taken to achieve procedural proficiency. We also reported our technical success (successful tunneling into the gastric cardia and myotomy of LES muscle fibers) and clinical success (post-procedure Eckardt score ≤ 3) at 3-6 months and 12 months post-procedure. Adverse events were classified per the ASGE lexicon for endoscopic adverse events.

RESULTS

After creating a multi-disciplinary clinical program for achalasia and completing procedural proficiency for POEM, our technical success rate was 100% and clinical success rate 90% for the first 41 patients. One adverse event (2.4%) occurred, moderate in severity per the American Society of Gastrointestinal Endoscopy (ASGE) lexicon for adverse endoscopic events.

CONCLUSION

In this study, we outlined the steps involved to establish a POEM service in a large integrated healthcare system. Prior competency in interventional endoscopy, procedural training models, POEM observation and education, proctorship, and interdisciplinary patient care are recommended.

Periprocedural safety profile of peroral endoscopic myotomy (POEM)-a retrospective analysis of adverse events according to two different classifications

BACKGROUND

Peroral endoscopic myotomy (POEM) is nowadays a standard method for treatment of achalasia; nevertheless, it remains an invasive intervention with corresponding risk of adverse events (AEs). The classification and grading of AEs are still a matter of discussion. The aim of our retrospective study was to assess the occurrence of all "undesirable" events and "true" adverse events in patients undergoing POEM and to compare the outcomes when either Clavien-Dindo classification (CDC) or American Society of Gastrointestinal Endoscopy (ASGE) lexicon classification applied.

METHODS

This was a retrospective analysis of prospectively managed database of all patients who had undergone POEM between December 2012 and August 2018. We assessed the pre-, peri-, and early-postoperative (up to patient's discharge) undesirable events (including those not fulfilling criteria for AEs) and "true" AEs according the definition in either of the classifications.

RESULTS

A total of 231 patients have successfully undergone 244 POEM procedures (13 × re-POEM). Twenty-nine procedures (11.9%) passed uneventfully, while in 215 procedures (88.1%), a total of 440 undesirable events occurred. The CDC identified 27 AEs (17 minor, 10 major) occurring in 23/244 (9.4%) procedures. The ASGE lexicon identified identical 27 AEs (21 mild or moderate, 6 severe or fatal) resulting in the severity distribution of AEs being the only difference between the two classifications. Only the absence of previous treatment was found to be a risk factor [p = 0.047, OR with 95% CI: 4.55 (1.02; 20.25)] in the combined logistic regression model.

CONCLUSION

Undesirable events are common in patients undergoing POEM but the incidence of true AEs is low according to both classifications. Severe adverse events are infrequent irrespective of the classification applied. CDC may be more appropriate than ASGE lexicon for classifying POEM-related AEs given a surgical nature of this procedure.

[Therapy of esophageal motility disorders]

Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2020 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.

Expanding the role of pneumatic dilation for nonachalasia patients: a comparative study

BACKGROUND AND AIMS

Treatment options for nonachalasia obstructive disorders of the esophagogastric junction (EGJ) are limited. The aim of this study was to assess the treatment efficacy of pneumatic dilation (PD) for the disorders of EGJ outflow obstruction (EGJOO) and postfundoplication EGJ obstruction (PF-EGJO) and to assess attitudes regarding training in PD.

METHODS

This was a 2-part study. The main study was a prospective, single-center study comparing treatment outcomes after PD in patients with EGJOO and PF-EGJO, defined using manometry criteria, versus achalasia. Treatment success was defined as a post-PD Eckardt score (ES) of ≤2 at the longest duration of follow-up available. In a substudy, a 2-question survey was sent to 78 advanced endoscopy fellowship sites in the United States regarding training in PD.

RESULTS

Of the 58% of respondents to the advanced endoscopy program director survey, two-thirds reported no training in PD at their program. The primary rationale cited was lack of a clinical need for PD. Sixty-one patients (15 achalasia, 32 EGJOO, and 14 PF-EGJO) were included in the main study with outcomes available at a mean follow-up of 8.8 months. Overall, mean ES decreased from 6.30 to 2.89 (P < .0001), and a mean percentage of improvement in symptoms reported by patients was 55.3%. ES ≤2 was achieved by 33 of 61 patients (54.1%).

CONCLUSIONS

PD is an effective treatment for the nonachalasia obstructive disorders of the EGJ. There may be a current gap in training and technical expertise in PD.

Achalasia

Approaches to achalasia include non-operative and operative techniques with Heller Myotomy and Per-Oral Endoscopic Myotomy (POEM) at the forefront of palliative strategies. Given the diverse subtypes and the time-dependent failure pattern for achalasia, there is no standard approach. We elect for a POEM for type III achalasia, poor functional status, hostile abdomen, and salvage after the previous myotomy. A Heller myotomy is elected over a POEM for type II achalasia, presence of diverticulum, and hiatal hernia. As long-term outcomes become available, an optimal customized strategy will become clearer.

Role of Endoscopy in Motility Disorders of Upper Gastrointestinal Tract

Gastrointestinal motility disorders have a wide range of symptoms and affect patients' quality of life. With the advancement of endoscopy, the diagnostic and therapeutic roles of endoscopy in motility disorders is becoming more significant. Endoscopy is necessary to rule out possible organic diseases in patients with suspected motility disorders and provide significant clues for their diagnosis. Moreover, interventional endoscopy may be a primary or alternative treatment option for selected patients with motility disorders, and it is becoming a promising field as new therapeutic applications are developed and utilized for various motility disorders. This review may provide suitable indications for the use of endoscopy in diagnosing and treating motility disorders of the upper gastrointestinal tract.

Peroral endoscopic myotomy: is it better to perform it in naive patients or as second-line therapy? Results of an open-label-controlled study in 105 patients

BACKGROUND

Whether Peroral Endoscopic Myotomy (POEM) can be proposed as a second-line treatment in patients with achalasia remains to be confirmed in real-life series.

OBJECTIVE

This study aimed to compare the efficacy, feasibility and safety of POEM between treatment-naïve patients and patients who had prior endoscopic or surgical therapies for achalasia.

METHODS

All consecutive patients who underwent a POEM procedure for achalasia in our centre from June 2015 to September 2018 were included in this retrospective study. They were classified into treatment-naïve patients (POEM1) and patients who had at least one previous endoscopic and/or surgical treatment for achalasia (POEM2).

RESULTS

A total of 105 patients were included, 52 in the POEM1 group and 53 in the POEM2 group. Clinical success (defined as an Eckardt score ≤ 3) at 6 months was observed in 93% of POEM1 patients and 84% of POEM2 patients (p = 0.18). Technical success rate was not significantly different between the two groups (100% vs 96%, respectively; p = 0.50). No significant difference was noted in terms of adverse event rate (19% vs 19%, respectively; p = 1.00). Post-procedure pain occurred in 12% of treatment-naive and 9% of non-naïve patients (p = 0.76). The median length of hospital stay was 3 days in both groups (p = 0.17). Symptomatic gastroesophageal reflux occurred in 25% of POEM1 patients and 16% of POEM2 patients (p = 0.24).

CONCLUSION

Efficacy, feasibility and safety of POEM are not different between treatment-naïve and non-naïve patients. POEM is a valuable second-line approach in patients with persistent symptoms of achalasia after surgical or endoscopic treatments.

Third-space endoscopy: the final frontier

Over the years, our growing experience with endoscopic submucosal dissection along with technological advances has solidified our comfort and knowledge on working in the submucosa, also referred to as the "third space." Per-oral endoscopic myotomy (POEM) was the first prototype third-space endoscopy (TSE) procedure, demonstrating the feasibility and clinical utility of endoscopic esophagogastric myotomy via submucosal tunneling. The launch of POEM accelerated the evolution of TSE from a vanguard concept to an expanding field with a wide range of clinical applications. In this review, we discuss the status and future directions of multiple TSE interventions.

Achalasia: Current therapeutic options

Achalasia is an esophageal motor disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and absent peristalsis in the smooth muscle esophageal body. As a result, patients typically experience dysphagia, regurgitation, chest pain, and weight loss. Over the past 10-15 years, there has been a resurgence of interest in the evaluation of therapies for achalasia. Unfortunately, little progress in the development of effective pharmacological treatments has been made. Botulinum toxin injection provides some relief of symptoms in many patients but requires periodic reinjection that may provide progressively less benefit over time. There are now three well-established, safe, and effective therapies for the treatment of achalasia: pneumatic dilation (PD), laparoscopic Heller myotomy (LHM), and peroral endoscopic myotomy (POEM) which can lead to marked symptom improvement in most patients. Each treatment has a specific constellation of risks, benefits, and recurrence rate. The first-line treatment used will depend on patient preference, achalasia subtype, and local expertise. The recent impressive advances in both the art and science of achalasia therapy are explored with a comprehensive review of the various treatment modalities and comparative controlled clinical trials. In addition, key technical pearls of the procedural treatments are demonstrated.

From Chicago classification v3.0 to v4.0: Diagnostic changes and clinical implications

BACKGROUND

The Chicago Classification (CC) used to define esophageal motility disorders in high-resolution manometry (HRM) has evolved over time. Our aim was to compare the frequency of motility disorders diagnosed with the last two versions (CCv3.0 and CCv4.0) and to evaluate symptoms severity according to the diagnoses.

METHODS

From June to December 2020, patients who underwent esophageal HRM with swallows in supine and sitting positions were included. HRM studies were retrospectively analyzed using CCv3.0 and CCv4.0. Symptoms severity and quality of life were assessed with validated standardized questionnaires.

KEY RESULTS

Among the 130 patients included (73 women, mean age 52 years), motility disorder diagnoses remained unchanged in 102 patients (78%) with both CC. The 3 patients with esophago-gastric junction outflow obstruction (EGJOO) with CCv3.0 were EGJOO, ineffective esophageal motility (IEM) and normal with CCv4.0. Twenty-four out of 63 IEM diagnosed with the CCv3.0 (38%) turned into normal motility with the CCv4.0. Whatever the CC used, brief esophageal dysphagia questionnaire score was significantly higher in patients with EGJ relaxation disorders compared to those with IEM (25 (0-34) vs 0 (0-19), p = 0.01). Gastro-Esophageal Reflux disease questionnaire (GERD-Q) score was higher in patients with IEM with both CC compared to those who turned to normal with CCv4.0.

CONCLUSIONS AND INFERENCES

While motility disorders diagnoses remained mainly unchanged with both CC, IEM was less frequent with CCv4.0 compared to CCv3.0. The higher GERD-Q score in IEM patients with CCv4.0 suggests that CCv4.0 might identify IEM more likely associated with GERD.

Major adverse events related to endoscopic or laparoscopic procedures in achalasia. A systematic review and meta-analysis

INTRODUCTION AND AIMS

Surgical or endoscopic treatments play an essential role in the management of achalasia. The probability of adverse events in the performance of said treatments is a relevant aspect, when establishing the risk-benefit balance. The present study aimed to establish the association between serious adverse events and the performance of those procedures, in adult patients with achalasia.

MATERIALS AND METHODS

A systemic search of randomized and nonrandomized clinical trials, retrospective cohorts, and cases series on adult patients with achalasia that underwent laparoscopic Heller myotomy (LHM), peroral endoscopic myotomy (POEM), or endoscopic balloon dilation, that reported serious adverse events, was carried out on the Medline, CENTRAL, and EBSCO databases. Serious adverse events were defined as: death at 30 days, Clavien-Dindo grade III or higher classification, esophageal or gastric perforation, pneumothorax, mucosal tear, leakage, emphysema, pneumonia, and chest pain. The methodology included the PRISMA guidelines for reporting systematic reviews.

RESULTS

Thirty-five studies were found that reported information on 1,276 patients that underwent POEM, 5,492 that underwent LHM, and 10,346 that underwent endoscopic balloon dilation. The proportions of adverse events for the three techniques were 3.6, 4.9, and 3.1%, respectively.

DISCUSSION AND CONCLUSIONS

The 3 therapeutic interventions evaluated had similar proportions of adverse events. There were few reports of death at 30 days as an outcome and the lack of standardization in reporting adverse events in the studies analyzed was prominent.

Effectiveness and complication of achalasia treatment: A systematic review and network meta-analysis of randomized controlled trials

Achalasia(AC) is an esophageal motility disorder characterized by decreased esophageal motility and impaired relaxation of lower esophageal sphincter(LES). The treatment of achalasia is continuously improved for the development of technology, but each treatment has its own advantages and disadvantages. This article was to compare the efficacy and complication of different treatment on AC. PUBMED/MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials were searched for eligible studies. A random-effects model within a Bayesian framework was applied to compare treatment effects as odds ratio (OR) with their corresponding 95% credible interval (CI), also OR was applied to compare complication with 95% CI. The surface under the cumulative ranking area (SUCRA) was calculated to make the ranking of the treatments for outcomes. Twenty-seven randomized controlled trials (RCTs) were eligible. According to SUCRA ranking, anterior peroral endoscopic myotomy (APOEM) (SUCRA = 84.6%) might have the highest probability to be the best treatment for dysphagia remission in AC patients, followed by POEM (SUCRA = 78.4%). For gastroesophageal reflux disease (GERD) assessment, the corresponding SUCRA values indicated that botulinum toxin(BT) (SUCRA = 18.3%) might have lowest GERD incidence rate and POEM ranked the worst (SUCRA = 69.8%).. APOEM might have the highest probability to be the best therapeutic strategy for dysphagia remission in a short-term of follow-up, but the GERD incidence rate was high. BT injection might have the lowest probability to treat dysphagia, but the risk of GERD was the lowest. In the future, more RCTs with higher qualities are needed to make head-to-head comparison between 2 or more treatments.

Achalasia, from diagnosis to treatment

INTRODUCTION

Achalasia is an uncommon esophageal motility disorder and is characterized by alterations of the motility of the esophageal body in conjunction with altered lower esophageal sphincter (LES) relaxation. The clinical presentation of patients with achalasia may be complex; however, the most frequent symptom is dysphagia. The management of patients with achalasia is often challenging, due to the heterogeneous clinical presentation.

AREAS COVERED

The diagnosis and management of achalasia has significantly improved in the last years due to the growing availability of high-resolution manometry (HRM) and the implementation in the therapeutic armamentarium of new therapeutic endoscopic procedures. Traditional therapeutic strategies include botulinum toxin injected to the LES and pneumatic balloon dilation. On the other hand, surgical treatments contemplate laparoscopic Heller myotomy and, less frequently, esophagectomy. Furthermore, in the last few years, per oral endoscopic myotomy (POEM) has been proposed as the main endoscopic therapeutic alternative to the laparoscopic Heller myotomy.

EXPERT OPINION

Diagnosis and treatment of achalasia still represent a challenging area. However, we believe that an accurate up-front evaluation is, nowadays, necessary in addressing patients with achalasia for a more accurate diagnosis as well as for the best treatment options.

A Look into the Future of Endoscopic Submucosal Dissection and Third Space Endoscopy: The Role for Robotics and Other Innovation

Endoscopic resection has been widely applied especially in endoscopic submucosal dissection and third space endoscopy (TSE). Flexible endoluminal robotics allow performance of endoscopic submucosal dissection with exposure of the submucosal plane for precise dissection using two robotic arms. The introduction of TSE revolutionized the horizon of therapeutic endoscopy to the submucosal space beneath and beyond the mucosa. Advantages of TSE include avoidance of full thickness incision in gastrointestinal tract through the submucosal tunneling for performance of peroral endoscopic myotomy and submucosal tunneling endoscopic resection. In future, robotic-driven devices should be developed to enhance performance of complex endoluminal procedures and TSE.

Submucosal endoscopy: the present and future

Submucosal endoscopy or third-space endoscopy utilizes the potential space between the mucosal and muscularis layers of the gastrointestinal tract to execute therapeutic interventions for various diseases. Over the last decade, endoscopic access to the submucosal space has revolutionized the field of therapeutic endoscopy. Submucosal endoscopy was originally used to perform endoscopic myotomy in patients with achalasia cardia, and its use has grown exponentially since. Currently, submucosal endoscopy is widely used to resect subepithelial tumors and to manage refractory gastroparesis and Zenker's diverticulum. While the utility of submucosal endoscopy has stood the test of time in esophageal motility disorders and subepithelial tumors, its durability remains to be established in conditions such as Zenker's diverticulum and refractory gastroparesis. Other emerging indications for submucosal endoscopy include esophageal epiphrenic diverticulum, Hirschsprung's disease, and esophageal strictures not amenable to conventional endoscopic treatment. The potential of submucosal endoscopy to provide easy and safe access to the mediastinum and peritoneal spaces may open doors to novel indications and rejuvenate the interest of endoscopists in natural orifice transluminal endoscopic surgery in the future. This review focuses on the current spectrum, recent updates, and future direction of submucosal endoscopy in the gastrointestinal tract.

Indications and Outcomes of Per Oral Endoscopic Myotomy from Mouth to Anus

Third space endoscopy or submucosal endoscopy using a mucosal flap valve allows secure access to the submucosal and deeper layers of the gastrointestinal tract without the risk of a full-thickness perforation. This allows the performance of submucosal tunneling and myotomy for spastic segments of the gastrointestinal tract. Per oral endoscopic myotomy (POEM) has been described for the treatment of achalasia cardia and other spastic esophageal disorders and is widely implemented. Endoscopic pyloromyotomy (G-POEM) has been performed for the treatment of refractory gastroparesis. Z-POEM for Zenker's diverticulum, D-POEM for epiphrenic diverticulum, and per-rectal endoscopic myotomy for treatment of Hirschsprung's disease are described..

Updates in the Field of Submucosal Endoscopy

Submucosal endoscopy (third-space endoscopy) can be defined as an endoscopic procedure performed in the submucosal space. This procedure is novel and has been utilized for delivery to the submucosal space in a variety of gastrointestinal diseases, such as a tumor, achalasia, gastroparesis, and subepithelial tumors. The main submucosal endoscopy includes peroral endoscopic myotomy, gastric peroral endoscopic myotomy, Zenker peroral endoscopic myotomy, submucosal tunneling for endoscopic resection, and endoscopic submucosal tunnel dissection. Submucosal endoscopy has been used as a viable alternative to surgical techniques because it is minimally invasive in the treatment and diagnosis of gastrointestinal diseases and disorders. However, there is limited evidence to prove this. This article reviews the current applications and evidence regarding submucosal endoscopy while exploring the possible future clinical applications in this field. As our understanding of these procedures improves, the future of submucosal endoscopy could be promising in the fields of diagnostic and therapeutic endoscopy.

Risk factors for clinical failure of peroral endoscopic myotomy in achalasia

The recent development of per oral endoscopic myotomy (POEM) has been a game changer in the management of patients with achalasia. However, approximately 1 in 10 patients will not experience clinical success. The aim of this mini-review is to describe the current state of knowledge about the risk factors associated with POEM failure for the treatment of achalasia. Suspected risk factors are detailed into pre-, intra-, and post-procedural factors and put into perspective. Pre-procedural factors have been described, such as pre-treatment Eckardt score, previous treatments for achalasia, sigmoid type esophagus, significant esophageal dilatation, non-type II achalasia, young age and long duration of symptoms. An intra-procedural factor, mucosal injury during POEM, has also been associated with POEM failure. The occurrence of post-POEM GERD was identified as a controversial post-procedural factor associated with failure. The presumed mechanisms of POEM failure are incomplete myotomy or ineffective LES disruption, as confirmed by high-resolution manometry. However, when manometry confirms a significant decrease in LES pressure, it is likely that either impaired peristalsis or a morphologic abnormality such as extreme esophageal dilatation or severe tortuosity, which are not treated by POEM, should be suspected. Notably, a recently described adverse effect of POEM is the formation of a pseudo-diverticulum at the site of the myotomy (blown out myotomy). We finally stress the importance of performing a complete workup in case of POEM failure as different mechanisms of POEM failure should lead to different management.

Peroral endoscopic myotomy versus pneumatic dilation in treatment-naive patients with achalasia: 5-year follow-up of a randomised controlled trial

BACKGROUND

2-year follow-up data from our randomised controlled trial showed that peroral endoscopic myotomy is associated with a significantly higher efficacy than pneumatic dilation as initial treatment of therapy-naive patients with achalasia. Here we report therapeutic success rates in patients treated with peroral endoscopic myotomy compared with pneumatic dilation at the 5-year follow-up.

METHODS

We did a multicentre, randomised controlled trial in six hospitals in the Netherlands, Germany, Italy, Hong Kong, and the USA. Adults aged 18-80 years with newly diagnosed symptomatic achalasia (based on an Eckardt score >3) were eligible for inclusion. Patients were randomly assigned (1:1) to peroral endoscopic myotomy or pneumatic dilation using web-based randomisation with a random block size of 8 and stratification according to site. Randomisation concealment for treatment type was double blind until official study enrolment. Treatment was unmasked because of the different technical approach of each procedure. Patients in the pneumatic dilation group were dilated with a single series of 30-35 mm balloons. The need for subsequent dilations in the pneumatic dilation group, and the need for dilation after initial treatment in the peroral endoscopic myotomy group, was considered treatment failure. The primary outcome was therapeutic success (Eckardt score ≤3 in the absence of severe treatment-related complications and no need for retreatment). Analysis of the primary outcome was by modified intention to treat, including all patients randomly assigned to a group, excluding those patients who did not receive treatment or were lost to follow-up. Safety was assessed in all included patients. This study is registered at the Dutch Trial Registry, NTR3593, and is completed.

FINDINGS

Between Sept 21, 2012, and July 20, 2015, 182 patients were assessed for eligibility, 133 of whom were included in the study and randomly assigned to peroral endoscopic myotomy (n=67) or pneumatic dilation (n=66). 5-year follow-up data were available for 62 patients in the peroral endoscopic myotomy group and 63 patients in the pneumatic dilation group. 50 (81%) patients in the peroral endoscopic myotomy group had treatment success at 5 years, compared with 25 (40%) in the pneumatic dilation group, an adjusted absolute difference of 41% (95% CI 25-57; p<0·0001). Reasons for failure were no initial effect of treatment (one patient in the peroral endoscopic myotomy group vs 12 patients in the pneumatic dilation group) and recurrent symptoms causing treatment failure (11 patients in the peroral endoscopic myotomy group [seven patients between 2 and 5 years] vs 25 patients in the pneumatic dilation group [nine patients between 2 and 5 years]); one patient in the pneumatic dilation group had treatment failure due to an adverse event. Proton-pump inhibitor use (mostly daily) was significantly higher after peroral endoscopic myotomy than after pneumatic dilation among patients still in clinical remission (23 [46%] of 50 patients vs three [13%] of 24 patients; p=0·008). 5-year follow-up endoscopy of patients still in clinical remission showed reflux oesophagitis in 14 (33%) of 42 patients in the peroral endoscopic myotomy group (12 [29%] grade A or B, two [5%] grade C or D) and two (13%) of 16 patients in the pneumatic dilation group (two [13%] grade A or B, none grade C or D; p=0·19). No intervention-related serious adverse events occurred between 2 and 5 years after treatment. The following non-intervention-related serious adverse events occurred between 2 and 5 years: a stroke (one [2%]) in the peroral endoscopic myotomy group; and death due to a melanoma (one [2%]) and dementia (one [2%]) in the pneumatic dilation group.

INTERPRETATION

Based on this study, peroral endoscopic myotomy should be proposed as an initial treatment option for patients with achalasia. Although our study has shown that peroral endoscopic myotomy has greater long-term efficacy with a low risk of major treatment-related complications, this should not lead to abandonment of pneumatic dilation from clinical practice. Ideally, all treatment options should be discussed with treatment-naive patients with achalasia and a shared decision should be made.

FUNDING

Fonds NutsOhra and European Society of Gastrointestinal Endoscopy.

Mid-Term and Long-Term Outcomes of Peroral Endoscopic Myotomy for the Treatment of Achalasia: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Peroral endoscopic myotomy (POEM) achieves a satisfactory short-term clinical response in patients with achalasia. However, data on mid- and long-term clinical outcomes are limited. We aimed to assess the mid- and long-term efficacy and safety of POEM in achalasia patients.

METHODS

Using the pre-designed search strategy, we identified relevant studies that evaluated the efficacy and safety of POEM with a minimum of 2-year follow-up in the Embase, Cochrane, and PubMed databases from inception to January 2021. Primary outcome was pooled mid- and long-term clinical success rate based on the Eckardt score. Secondary outcome was pooled long-term reflux-related adverse events.

RESULTS

A total of 21 studies involving 2,698 patients were included. Overall, the pooled clinical success rates with 2-, 3-, 4-, and 5-year follow-ups were 91.3% (95% confidence interval [CI] 88.4-93.6%), 90.4% (95% CI 88.1-92.2%), 89.8% (95% CI 83.6-93.9%), and 82.2% (95% CI 76.6-86.7%), respectively. Besides, the pooled long-term clinical success rates for type I, II, and III achalasia were 86.1% (95% CI 80.9-90.1%; I² = 0%), 87.9% (95% CI 84.2-90.8%; I² = 48.354%), and 83.9% (95% CI 72.5-91.2%; I² = 0%), respectively. Moreover, the pooled incidence of symptomatic reflux and reflux esophagitis was 23.9% (95% CI 18.7-29.9%) and 16.7% (95% CI 11.9-23.1%), respectively.

CONCLUSIONS

POEM is associated with a long-term clinical success of 82.2% after 5 years of follow-up. Randomized control trials comparing POEM with laparoscopic Heller myotomy or pneumatic dilation with longer follow-up periods are needed to further demonstrate the long-term safety and efficacy of POEM.

Safety of same-day discharge after peroral endoscopic myotomy

There are limited data on the safety of same-day discharge (SDD) after peroral endoscopic myotomy (POEM). The aim of our study is to assess the frequency and relationship to POEM for emergency department (ED) visits and hospitalizations after SDD in these patients. We retrospectively identified consecutive patients between November 2019 and August 2021 who underwent POEM with SDD and at least 6 months follow-up. Criteria for SDD includes: (1) no serious procedure-related adverse event; (2) post-POEM esophagram without leak; (3) stable vital signs; (4) ability to take liquids orally; (5) pain controlled without IV analgesia; (6) adequate social support; (7) American Society of Anesthesiologists (ASA) class I-III. A causative relationship between POEM and ED visits and hospitalizations was assigned by consensus. Out of 185 POEMs performed, 78 (41.7%, 42M, mean 51±16 years) had SDD. Within 30 days of POEM, 8 ED visits occurred in 7/78 (9%) patients and 2 (25%) were considered related to POEM; hospitalization was required in 3 (38%). After 30 days, 11 ED visits occurred in 10/78 (12.8%) patients and 1 (9%) was considered related to POEM; hospitalization was required in 5 (45%). In this study of consecutive SDD patients after POEM, 3/19 (16%) ED visits and 2/8 (25%) hospitalizations within 6 months were considered related to the procedure. Therefore, eligible patients who follow and fulfill a strict protocol after POEM may be safely discharged the same day.

OUTCOME OF PER ORAL ENDOSCOPIC MYOTOMY (POEM) IN SIGMOID ACHALASIA AT A MEDIAN FOLLOW UP OF 17 MONTHS

BACKGROUND

Advanced achalasia cardia (AC) represents the end stage in the natural history of AC. Role of per oral endoscopic myotomy (POEM) in this technically difficult subset is emerging.

METHODS

Retrospective review of the patients who had undergone POEM for advanced AC with sigmoid esophagus. We assessed the technical success, clinical success and adverse event rate. Pre and post POEM Eckardt score (ES), integrated relaxation pressure-4sec (IRP-4), lower oesophageal sphincter pressure (LESP) and height and width of barium column at 5 minutes were noted.

RESULTS

Of the 85 patients who underwent POEM for AC, 10 patients had advanced AC with sigmoid esophagus of which eight were sigmoid and two were advanced sigmoid. The clinical and technical success was 100% with significant reduction of ES, IRP-4, LESP and height and width of barium column at 5 minutes. One patient had a minor adverse event in the form of mucosal injury that was closed with hemoclips. At a median follow up of 17 months there was no recurrence.

CONCLUSION

Our study demonstrates POEM to be a safe and effective modality of treatment in this technically difficult subset of AC with sigmoid morphology.

Abdominal esophagocardiectomy with esophagogastric anastomosis, with vagal preservation and construction of a spiral anti reflux valve in the treatment of advanced megaesophagus

OBJECTIVE

present a new operative technique characterized by abdominal esophagocardiectomy, with esophagogastrus anastomosis, vagal preservation and spiral anti-reflux valve construction in the treatment of advanced megaesophagus in patients with severe systemic diseases, as well as its result in an initial group of 17 patients.

METHOD

We selected 17 patients with advanced megaesophagus and comorbidities submitted to new technique. The following parameters were analyzed: age, sex, length of hospital stay, early and late complications, mortality, radiological/endoscopic aspects.

RESULTS

twelve male patients (70%) and five (30%) were operated on, with mean age of 51.5 years and mean hospital stay of 14.8 days. There was no mortality in the immediate intraoperative or postoperative period and there were no cases of postoperative fistula. During hospitalization there was one case of pulmonary atelectasis (5.8%), one of pleural effusion (5.8%), two of wall infection (11.7%) and one of urinary retention (5.8%). Discussion: We believe it to be an easy technique, made exclusively by the abdominal route, that is, without violating the thoracic cavity. Such a procedure would be beneficial in patients with advanced megaesophagus and important comorbidities, as well as in those with a history of previous surgeries.

CONCLUSION

the technique described was easy to perform and safe, when performed by an experienced team, with low morbidity and mortality in patients with advanced megaesophagus and important comorbidities, which could increase your complications with more invasive and complex surgeries.

Risk factors and long-term course of gastroesophageal reflux disease after peroral endoscopic myotomy: A large-scale multicenter cohort study in Japan

BACKGROUND : Gastroesophageal reflux disease (GERD) and reflux esophagitis remain problems after peroral endoscopic myotomy (POEM). This study aimed to elucidate the risk factors and long-term course of reflux esophagitis and symptomatic GERD after POEM. METHODS : This multicenter cohort study involved 14 high volume centers. Overall, 2905 patients with achalasia-related esophageal motility disorders treated with POEM were analyzed for reflux esophagitis, severe reflux esophagitis (Los Angeles classification C or D), and symptomatic GERD. RESULTS : Reflux esophagitis was diagnosed in 1886 patients (64.9 %). Age ≥ 65 years (risk ratio [RR] 0.85), male sex (RR 1.11), posterior myotomy (RR 1.12), esophageal myotomy > 10 cm (RR 1.12), and gastric myotomy > 2 cm (RR 1.17) were independently associated with reflux esophagitis. Severe reflux esophagitis was diagnosed in 219 patients (7.5 %). Age ≥ 65 years (RR 1.72), previous treatments (RR 2.21), Eckardt score ≥ 7 (RR 0.68), sigmoid-type achalasia (RR 1.40), and esophageal myotomy > 10 cm (RR 1.59) were factors associated with severe reflux esophagitis. Proton pump inhibitors (PPIs) were more effective for reflux esophagitis at 5-year follow-up (P = 0.03) than after 1 year (P = 0.08). Symptomatic GERD was present in 458 patients (15.9 %). Symptom duration ≥ 10 years (RR 1.28), achalasia diagnosis (RR 0.68), integrated relaxation pressure ≥ 26 (RR 0.60), and posterior myotomy (RR 0.80) were associated with symptomatic GERD. The incidence of symptomatic GERD was lower at 5-year follow-up compared with that after 1 year (P = 0.04), particularly in PPI users (P < 0.001). CONCLUSIONS : The incidence of severe reflux esophagitis was low after POEM, but excessive myotomy for older patients with previous treatments should be avoided. Early phase symptomatic GERD is non-acid reflux dependent and the natural course is favorable, basically supporting conservative treatment.

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.

Cost-efficient snare-assisted peroral endoscopic myotomy in comparison of conventional endoscopic knife for treatment of achalasia: results of a randomized controlled trial

BACKGROUND

To date, the ideal endoscopic knife for peroral endoscopic myotomy (POEM) with good performance and cost-effectiveness is still under investigation. The present study was aimed to evaluate the efficacy, safety, and cost-effectiveness of snare-assisted POEM, compared with the conventional endoscopic knife approach.

METHODS

From May 2017 to December 2018, patients with achalasia presenting for POEM without previous endoscopic or surgical therapy were prospectively recruited in this randomized controlled trial. Patients were randomly allocated to receive POEM using either the snare (snare group) or HookKnife (conventional group). The primary outcome was clinical success (Eckardt score ≤ 3) at 12-month follow-up, powered for noninferiority with a margin of -15%. The secondary outcomes included adverse events (AEs), procedure-related parameters, clinical outcomes, and cost-effectiveness.

RESULTS

A total of 75 patients with similar baseline characteristics between the snare (N = 37) and conventional (N = 38) groups were included. Clinical success at 12-month follow-up was achieved in 94.6% of patients in the snare group and 92.1% of patients in the conventional group (difference, 2.5% [95% CI, -8.7% to 13.7%]; P < 0.001 for noninferiority). No severe AEs occurred in both groups. The use of snare is associated with comparable procedure time (40.6 minutes vs. 42.5 minutes, P = 0.337), a lower frequency of hemostatic forceps use (27.0% vs. 68.4%, P < 0.001), and lower hospital costs ($4271.1 vs. $5327.3, P < 0.001). The cost-effectiveness plane revealed that 96.9% of snare-assisted POEM procedures offered more cost-savings and health utility benefits.

CONCLUSIONS

The snare-assisted POEM was noninferior to the conventional endoscopic knife approach in terms of clinical efficacy, with comparable safety outcomes and cost-effective benefits.

Peroral Endoscopy Myotomy (POEM) for Esophageal Motility Disorders

PURPOSE OF REVIEW

This review aims to provide an overview of the current role of per oral endoscopic myotomy (POEM) in the management of primary esophageal motility disorders and treatment of Zenker's diverticulum.

RECENT FINDINGS

POEM has been shown to be an effective treatment for achalasia. Recent research has suggested that the length of myotomy may be tailored to the disease phenotype and that short myotomy may be equally effective compared to long myotomy. The role of intra-operative EndoFLIP has shown promise as a tool to assess of the adequacy of myotomy. Further research is needed to determine the role of POEM in other esophageal motility disorders and for treatment of Zenker's diverticulum. Per oral endoscopic myotomy has been shown to be an effective and durable treatment option for achalasia with additional potential roles for the treatment of other esophageal motility disorders and Zenker's diverticulum.

The Predictive Value of Intraoperative Esophageal Functional Luminal Imaging Probe Panometry in Patients With Achalasia Undergoing Peroral Endoscopic Myotomy: A Single-center Experience

Background/Aims

We evaluated the clinical significance and prognostic power of functional luminal imaging probe (FLIP) panometry in patients with achalasia treated with peroral endoscopic myotomy (POEM), and examined the clinical parameters associated with symptomatic improvement and the presence of contractility (POC) following POEM.

Methods

We reviewed the electronic medical records of patients with achalasia treated with FLIP panometry and POEM at a tertiary teaching hospital in Seoul, Republic of Korea. Follow-up examination was composed of esophageal manometry and questionnaires on symptoms. We analyzed the FLIP data by interpolating using the cubic spline method in MATLAB.

Results

We retrospectively analyzed 33 men and 35 women (mean age 52 ± 17 years), of whom 14, 39, and 15 patients were diagnosed with achalasia types I, II, and III, respectively. The FLIP panometry diagnoses were reduced esophagogastric junction opening (REO) with a retrograde contractile response (n = 43); REO with an absent contractile response (n = 5); REO with a normal contractile response (n = 11); and a retrograde contractile response (n = 9). Overall, the patients showed improvements in Eckardt scores following POEM from 6.48 ± 2.20 to 1.16 ± 1.15 (P < 0.01). Post-POEM symptomatic improvement was not significantly associated with any of the clinical parameters, including panometry diagnosis. Conversely, post-POEM POC was significantly associated with the presence of repetitive antegrade contractions and achalasia subtypes (both P < 0.01).

Conclusion

While FLIP panometry was not significantly associated with the clinical course of achalasia, FLIP panometry was associated with POC following POEM and may complement manometry in the functional evaluation of esophageal motility disorders.

Outcome of sequential dilatation in achalasia cardia patients: a prospective cohort study

BACKGROUND

Sequential increment of balloon diameter for endoscopic pneumatic dilatation is a protocol that is used for symptomatic relief in achalasia cardia. However, most of the studies evaluating its effectiveness are retrospective in nature. This study intended to look into the efficacy of the above protocol in a prospective fashion.

METHODS

Consecutive patients of achalasia cardia (n = 72) attending gastroenterology department were subjected to graded dilatation with 30, 35, and 40 mm pneumatic balloon and followed up (median 48 weeks; range: 4-96 weeks) with Eckardt score. Efficacy was assessed by proportion of patients achieving and maintaining clinical remission (Eckardt score ≤ 3) without requiring surgery during follow-up.

RESULT

Overall 91% of patients (60 out of 66 with follow-up data) remained symptom free without requirement of surgery. Proportion of type 3 achalasia patients was significantly higher in the group requiring surgery compared to those who did not (p = 0.005). Threshold of 12 mm Hg in 4-week post-dilatation integrated relaxation pressure noted to predict future requirement of surgery in type 3 achalasia patients with sensitivity and specificity of 75% and 85%, respectively. Major adverse events requiring in-patient management were 2.9% with perforation noted in 1.9%.

CONCLUSION

A sequential increment of balloon diameter for pneumatic dilatation in achalasia is an effective mode of therapy to achieve and maintain clinical remission in achalasia. The incidents of adverse events are low in this approach. Type 3 achalasia patients are more likely to require surgery despite sequential dilatation.

Predictors of Long-Term Outcomes, Recurrent Dysphagia, and Gastroesophageal Reflux After Per-oral Endoscopic Myotomy in Esophageal Motility Disorders

BACKGROUND

There is limited data on long-term outcomes of per-oral endoscopic myotomy (POEM). In this study, we aim to evaluate the efficacy of POEM in patients who completed a minimum follow-up of 5 years.

METHODS

Data of patients who underwent POEM and completed ≥ 5-year follow-up were analyzed, retrospectively. Primary outcome of study was clinical success (Eckardt ≤ 3) at ≥ 5 years after POEM. Secondary outcomes included predictors of dysphagia and symptomatic gastroesophageal reflux disease (GERD) on long-term follow-up.

RESULTS

Three hundred nineteen patients (males 182, mean age 40.5 ± 14.2 years) completed a median of 73-(60-89) month follow-up. Esophageal motility disorders included idiopathic achalasia (type I 26.6%, type II 60.8%, type III 5.6%) and Jackhammer esophagus or distal esophageal spasm (2.8%). POEM was technically successful in 307 (96.2%) patients. Long-term success was 92.6% (overall), 92.1% (type I), 94.7% (type II), 87.5% (type III), and 75% (Jackhammer esophagus/distal esophageal spasm). Symptomatic GERD and reflux esophagitis were detected in 28.9% and 35.3% patients, respectively. On multivariate analysis, young age and female gender were independent risk factors for recurrent dysphagia (p = 0.037) and symptomatic GERD after POEM (p = 0.025), respectively. Lower post-POEM lower esophageal sphincter pressure was an independent predictor for reflux esophagitis (p = 0.016).

CONCLUSION

POEM is an effective and durable treatment for achalasia and non-achalasia spastic motility disorders. Young patients and females may be at higher risk for recurrent dysphagia and symptomatic GERD, respectively.

New Applications for Submucosal Tunneling in Third Space Endoscopy: A Comprehensive Review

Third space endoscopy (TSE), a type of natural orifice transluminal endoscopic surgery, was first introduced a decade ago, and since then, has revolutionized the field of therapeutic endoscopy. TSE involves tunneling into the submucosal space between the intestinal mucosa and the muscularis propria. By accessing this "third space," endoscopists can perform minimally invasive myotomies, resections, and dissections while maintaining the mucosa and preventing full-thickness perforation. TSE procedures can be used to treat motility disorders as well as neoplasms throughout the gastrointestinal tract, which were traditionally conditions that would require open or laparoscopic surgery. The main TSE procedures include peroral endoscopic myotomy, gastric peroral endoscopic myotomy, Zenker peroral endoscopic myotomy, submucosal tunneling for endoscopic resection, endoscopic submucosal tunnel dissection, peroral endoscopic tunneling for restoration of the esophagus, and per-rectal endoscopic myotomy. Some of those procedures have now been accepted as viable alternative to surgical techniques due to their limited invasiveness, safety and cost. This review will explore the different techniques recently added to our arsenal while describing their potential efficacy and limitations.

Safety and effectiveness of sling fiber preservation POEM to reduce severe post-procedural erosive esophagitis

BACKGROUND

Peroral endoscopic myotomy (POEM) is standard treatment for achalasia. Gastroesophageal reflux disease (GERD) after POEM has been an important challenge since the early days of POEM implementation. The esophagogastric junction anti-reflux barrier consists of internal lower esophageal sphincter (LES) (i.e., intrinsic muscles of distal esophagus with sling fibers) and external LES (crural diaphragm and phrenoesophageal ligament anchors the distal esophagus to the crural diaphragm). During conventional POEM, the entire internal LES is unintentionally dissected. Preservation of the sling fiber may reduce post-POEM GERD, but its safety and effectiveness have been unclear. In this study, we investigated the safety and effectiveness of sling fiber preservation POEM (SP-POEM) for reducing severe post-procedural erosive esophagitis.

METHODS

We analyzed data of 236 patients who underwent POEM; of these, 203 patients underwent posterior myotomy without (Group 1) or with attempted (Group 2) sling fiber preservation. Group 1 (N = 79; sling fiber excision, N = 68) and Group 2 (N = 90; sling fiber preservation, N = 81) were compared. Post-procedural erosive esophagitis (Los Angeles classification) were assessed and the area (direction and length) of mucosal break was also investigated. The gastroesophageal flap valve was evaluated by Hill's classification.

RESULTS

Severe erosive esophagitis exceeding grade C (Los Angeles classification) occurred in 44.1% of patients (30/68) in Group 1 and in 18.5% of patients (15/81) in Group 2. In mapping of erosive esophagitis, mucosal breaks appeared widely in all directions in Group 1; they tended to be limited in Group 2 (especially in the 2 o'clock direction). Assessment using the Hill's classification showed that the gastroesophageal flap valve was preserved after SP-POEM.

CONCLUSION

SP-POEM is safe and effective, with a success rate of 90%. The rate of severe erosive esophagitis can be decreased by preserving sling fibers.

Effect of esophageal muscle fibrosis on prognosis of per-oral endoscopic myotomy (POEM) in achalasia patients

BACKGROUND AND AIMS

Although esophageal smooth muscle fibrosis of achalasia (AC) patients has been described, the role and mechanism remain unclear. The aim of this study was to evaluate the fibrosis in the distal esophageal muscle in patients with AC and explore its relationship with prognosis of per-oral endoscopic myotomy (POEM).

METHODS

Lower esophageal sphincter (LES) muscle from forty patients undergoing POEM for AC were obtained at the time of surgery. Control specimens consisted of similar muscle taken from distal esophagectomy for gastric tumors. The muscle fibrosis were assessed by Masson staining and confirmed by immunohistochemistry for collagen I and III. The total number of eosinophil within the myenteric propria were counted. In addition, clinical data were obtained through electronic medical records. Statistical comparison between groups were made.

RESULTS

A significantly higher proportion of fibrosis in AC as compared with controls (P = 0.000). Eosinophil count, TGF-β1, collagen I, and III were higher than those of control (P = 0.000, P = 0.001, P = 0.011, and P = 0.002, respectively). TGF-β1, collagen I, and III were positively correlated with eosinophil count (all P < 0.05). Furthermore, the proportion of severe LES fibrosis in patients who failed to respond to POEM two years after operation was higher than that in responders (P = 0.028). And, Eckardt score two years after POEM was also positively correlated with degree of fibrosis-related cytokines (all P < 0.05).

CONCLUSION

Smooth muscle fibrosis was prominent in lower part of esophagus of AC and positively correlated with severity of symptoms two years after POEM. The fibrosis might be relevant to eosinophil infiltration and TGF-β1. Further studies are required to more clearly delineate the mechanism of muscle fibrosis and its correlation with prognosis of therapy for this idiopathic disease.

Achalasia

Achalasia is a rare disorder of the oesophageal smooth muscle characterized by impaired relaxation of the lower oesophageal sphincter (LES) and absent or spastic contractions in the oesophageal body. The key pathophysiological mechanism is loss of inhibitory nerve function that probably results from an autoimmune attack targeting oesophageal myenteric nerves through cell-mediated and, possibly, antibody-mediated mechanisms. Achalasia incidence and prevalence increase with age, but the disorder can affect all ages and both sexes. Cardinal symptoms consist of dysphagia, regurgitation, chest pain and weight loss. Several years can pass between symptom onset and an achalasia diagnosis. Evaluation starts with endoscopy to rule out structural causes, followed by high-resolution manometry and/or barium radiography. Functional lumen imaging probe can provide complementary evidence. Achalasia subtypes have management and prognostic implications. Although symptom questionnaires are not useful for diagnosis, the Eckardt score is a simple symptom scoring scale that helps to quantify symptom response to therapy. Oral pharmacotherapy is not particularly effective. Botulinum toxin injection into the LES can temporize symptoms and function as a bridge to definitive therapy. Pneumatic dilation, per-oral endoscopic myotomy and laparoscopic Heller myotomy can provide durable symptom benefit. End-stage achalasia with a dilated, non-functioning oesophagus may require oesophagectomy or enteral feeding into the stomach. Long-term complications can, rarely, include oesophageal cancer, but surveillance recommendations have not been established.

Comparison of functional lumen imaging probe and high-resolution manometry to assess response after peroral endoscopic myotomy

BACKGROUND AND AIMS

Outcomes after peroral endoscopic myotomy (POEM) are assessed clinically by the Eckardt score (ES) or objectively by high-resolution manometry (HRM) and functional lumen imaging probe (FLIP). This study compared HRM and FLIP to evaluate clinical response after POEM.

METHODS

This was a single tertiary center retrospective study of consecutive patients who underwent POEM for treatment-naive achalasia and with ≥6 months of follow-up. Baseline and follow-up testing in all patients included ES, HRM, and FLIP of the esophagogastric junction (EGJ). A normal post-POEM (or normalized) EGJ distensibility index (EGJ-DI) >2.8 mm²/mm Hg, maximum EGJ diameter (MxEGJD) ≥14 mm, and integrated relaxation pressure (IRP) <15 mm Hg were compared with a clinical response, defined as ES ≤3.

RESULTS

Eighty-seven patients (58% men, mean age 51 ± 17 years) were included. Overall clinical response by ES, IRP, MxEGJD, and EGJ-DI were 97.7%, 86.2%, 75.9%, and 92.0%, respectively. The sensitivity of a normal IRP (87.1% [95% confidence interval {CI}, 78.0-93.4]) was similar to the sensitivity of a normal MxEGJD (75.3% [95% CI, 64.7-84.0], P = .053) and normal EGJ-DI (91.8% [95% CI, 83.8%-96.6%], P = .39) after POEM to predict clinical response. However, the sensitivity of a normal post-POEM EGJ-DI was superior to a normal post-POEM MxEGJD (P = .001) to predict clinical response. There was no difference in the area under the curve of a normal MxEGJD or EGJ-DI to predict a normal IRP (P = .956) after POEM.

CONCLUSIONS

Normal FLIP metrics ≥6 months after POEM for achalasia show good to excellent sensitivity but are equivalent to a normalized IRP by HRM to predict clinical response by ESs. FLIP may be used as an alternative to HRM to assess lower esophageal sphincter response to POEM in these patients. (Clinical trial registration number: NCT02770859.).

POEM, GPOEM, and ZPOEM

Our tripartite narrative review discusses Peroral Endoscopic Myotomy (POEM), gastric POEM (GPOEM) and POEM for Zenker's diverticula (ZPOEM). POEM is the prototypical procedure that launched the novel "3rd space endoscopy" field of advanced endoscopy. It revolutionized achalasia therapy by offering a much less invasive version of the prior gold standard, the laparoscopic Heller myotomy (HM). We review in detail indications, outcomes, technique variations and comparative data between POEM and HM particularly with regard to the hotly debated issue of GERD. We then proceed to discuss two less illustrious but nevertheless important offshoots of the iconic POEM procedure: GPOEM for gastroparesis and ZPOEM for the treatment of hypopharyngeal diverticula. For GPOEM, we discuss the rationale of pylorus-directed therapies, briefly touch on GPOEM technique variations and then focus on the importance of proper patient selection and emerging data in this area. On the third and final part of our review, we discuss ZPOEM and expound on technique variations including our "ultra-short tunnel technique". Our review emphasizes that, despite the superiority of endoscopy over surgery for the treatment of hypopharyngeal diverticula, there is no clear evidence yet of the superiority of the newfangled ZPOEM technique compared to the conventional endoscopic myotomy technique practiced for over two decades prior to the advent of ZPOEM.

Achalasia Cardia: Balloon, Tunnel, or Knife?

Achalasia cardia is a rare esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter during swallowing and aperistalsis of the esophageal smooth muscles. The treatment approaches to achalasia include nonsurgical treatment with medications (nitrates, calcium channel blockers), endoscopic treatment (balloon pneumatic dilation [PD], botulinum toxin injection [BTI], peroral endoscopic myotomy [POEM]), and surgery (laparoscopic Heller's myotomy [LHM]). The subtype of achalasia (the Chicago Classification) governs the ideal treatment. For the commonly encountered achalasia subtype I and II, PD, LHM, and POEM all have similar efficacy. However, for type III achalasia, POEM seems to be the best line of treatment. Among high-risk elderly patients or those with comorbidities, BTI is preferred. The choice of treatment should be minimally invasive therapy with good short-term and sustained long-term effects with negligible adverse events. POEM seems to be evolving as a first-line therapy among the available therapies. Here, we review the treatment options among achalasia cardia patients with special attention to post-POEM gastroesophageal reflux disease and its management.

Efficacy and safety of peroral endoscopic myotomy in 100 older patients

BACKGROUND

Peroral endoscopic myotomy (POEM) is a standard treatment for achalasia. Several reports have described the efficacy and safety of POEM for elderly patients, but none has reported the efficacy and safety of POEM in a large number of elderly patients for > 3 years postoperatively. In this study, we examined the safety and outcome of POEM for 3 years postoperatively in 100 elderly patients.

METHODS

One hundred consecutive patients aged > 65 years who underwent POEM from September 2011 to March 2020 were included in this study. In analysis 1, we retrospectively investigated the safety and efficacy of POEM in all patients. In analysis 2, the efficacy and safety of POEM were statistically compared between two groups: the early elderly (65-74 years of age, 55 patients) and late elderly (≥ 75 years of age, 45 patients).

RESULTS

The technical success rate of POEM was 100%. In analysis 1, the 3-month, 1-year, 2-year, and 3-year efficacies of POEM (Eckardt score of ≤ 3) were 100% (92/92 cases), 100% (91/91 cases), 97.8% (88/90 cases), and 100% (92/92 cases), respectively. Procedure-related adverse events occurred in 11% of patients, but none was fatal. Two late elderly patients developed aspiration pneumonia due to delirium and underwent long-term hospitalization. In analysis 2, there were no significant differences in the efficacy and safety of POEM between the two age groups.

CONCLUSIONS

POEM is effective and safe for elderly patients. However, precautions are needed regarding the risk of adverse events associated with delirium when POEM is performed in elderly patients.

Peroral endoscopic longer vs shorter esophageal myotomy for achalasia treatment: A systematic review and meta-analysis

BACKGROUND

Peroral endoscopic myotomy (POEM) has been demonstrated to be safe and effective in the treatment of achalasia. Longer myotomy is the standard POEM procedure for achalasia but when compared with shorter myotomy, its effectiveness is not as well known.

AIM

To compare the clinical effectiveness of longer and shorter myotomy.

METHODS

PubMed, EmBase, Cochrane Library, web of science and clinicaltrials.gov were queried for studies comparing shorter and longer POEM for achalasia treatment. The primary outcome was clinical success rate. Secondary outcomes comprised of operative time, adverse events (AEs) rate, gastroesophageal reflux disease (GERD) and procedure-related parameters. The Mantel-Haenszel fixed-effects model was primarily used for the analysis. Publication bias was assessed.

RESULTS

Six studies were included in this analysis with a total of 514 participants. During the follow-up period of 1-28.7 mo, longer and shorter myotomy in treating achalasia showed similar excellent effectiveness [overall clinical success (OR = 1, 95%CI: 0.46-2.17, P = 1, I²: 0%; subgroup of abstract (OR = 1.19, 95%CI: 0.38 to 3.73; P = 0.76; I²: 0%); subgroup of full text (OR = 0.86 95%CI: 0.30 to 2.49; P = 0.78; I²: 0%)]. Shorter myotomy had significantly reduced mean operative time compared with the longer procedure. There were no statistically significant differences in AEs rates, including GERD (overall OR = 1.21, 95%CI: 0.76-1.91; P = 0.42; I²: 9%; subgroup of abstract OR = 0.77, 95%CI: 0.40-1.47; P = 0.43; I²: 0%; subgroup of full text OR = 1.91, 95%CI: 0.98-3.75; P = 0.06; I²: 0%), hospital stay (overall MD = -0.07, 95%CI: -0.30 to 0.16; P = 0.55; I²: 24%; subgroup of abstract MD = 0.20, 95%CI: -0.25 to 0.65; P = 0.39; I²: 0; subgroup of full text MD = -0.16, 95%CI: -0.42 to 0.10; P = 0.23; I²: 42%), and major bleeding (overall OR = 1.25, 95%CI: 0.58-2.71; P = 0.56; I²: 0%) between the two procedures. These differences remained statistically non-significant in all sensitivity analyses.

CONCLUSION

POEM was effective in treating achalasia. Shorter and longer myotomy procedures provided similar therapeutic effects in terms of long-term effectiveness. In addition, shorter myotomy reduced the operative time.