Peroral endoscopic myotomy (POEM) for esophageal achalasia

Peroral endoscopic myotomy for the treatment of achalasia: a clinical comparative study of endoscopic full-thickness and circular muscle myotomy

BACKGROUND

A circular muscle myotomy preserving the longitudinal outer esophageal muscular layer is often recommended during peroral endoscopic myotomy (POEM) for achalasia. However, because the longitudinal muscle fibers of the esophagus are extremely thin and fragile, and completeness of myotomy is the basis for the excellent results of conventional surgical myotomy, this modification needs to be further debated. Here, we retrospectively analyzed our prospectively maintained POEM database to compare the outcomes of endoscopic full-thickness and circular muscle myotomy.

STUDY DESIGN

According to the myotomy depth, 103 patients with full-thickness myotomy were assigned to group A, while 131 patients with circular muscle myotomy were assigned to group B. Symptom relief, procedure-related parameters and adverse events, manometry outcomes, and reflux complications were compared between groups.

RESULTS

The mean operation times were significantly shorter in group A compared with group B (p = 0.02). There was no increase in any procedure-related adverse event after full-thickness myotomy (all p < 0.05). During follow-up, treatment success (Eckardt score ≤ 3) persisted for 96.0% (95 of 99) of patients in group A and for 95.0% (115 of 121) of patients in group B (p = 0.75). There were no statistically significant differences in pre- and post-treatment D-value of symptom scores and lower esophageal sphincter pressures between groups (both p > 0.05). The overall clinical reflux complication rates were also similar (21.2% vs 16.5%, p = 0.38).

CONCLUSIONS

Short-term symptom relief and manometry outcomes of each method were comparable. Full-thickness myotomy significantly reduced the procedure time but did not increase the procedure-related adverse events or clinical reflux complications.

Submucosal endoscopy with mucosal resection (SEMR): a new hybrid technique of endoscopic submucosal balloon dissection in the porcine rectosigmoid colon

BACKGROUND

We developed a technique, submucosal endoscopy with mucosal resection (SEMR) intended to make endoscopic submucosal dissection easier and safer. With this technique, the submucosal layer is balloon dissected in lieu of electrosurgical knife dissection. The aim of this study was to further evaluate SEMR in the porcine rectum and colon.

METHODS

Targeted sites in the rectum and the distal colon were marked by spot coagulation. Submucosal fluid cushions (SFC) were created followed by a circumferential mucosal incision. After isolation of the targeted mucosa, balloon dissection was initiated. The balloon catheter was inserted deep into SFC and the inflated balloon repeatedly pulled back toward the endoscope tip to disrupt the submucosa. Residual strands of submucosa were cut. Dissection difficulty scores (DDS) were used using a visual analogue scale ranging from 0 to 5 (failed). The entire study period was divided into three periods (first period, pigs 1-10; second period, pigs 11-20; third period, pigs 21-30).

RESULTS

Sixty lesions in 30 pigs were resected using SEMR. The en block resection rate was 95%. There were three incomplete resections, two as a result of an errant site location and one as a result of a floppy prototype balloon catheter tip. The median resected size, procedure time, and DDS were 6.0 cm, 25 min, and 1. All three failed cases occurred in first period. The procedure time in third period was significantly shorter than the second period (P = 0.0017). The DDS in first period was significantly higher than the second (P = 0.0024) and third (P = 0.0155) periods. Two perforations, one muscularis propria catheter perforation, and one mucosal perforation were observed (3.3%).

CONCLUSIONS

Large mucosal target sites in the rectum and distal colon could be safely removed en bloc by means of a hybrid technique, SEMR, with blunt submucosal balloon dissection.

Submucosal endoscopy with mucosal resection (SEMR): a new hybrid technique of endoscopic submucosal balloon dissection in the porcine rectosigmoid colon

BACKGROUND

We developed a technique, submucosal endoscopy with mucosal resection (SEMR) intended to make endoscopic submucosal dissection easier and safer. With this technique, the submucosal layer is balloon dissected in lieu of electrosurgical knife dissection. The aim of this study was to further evaluate SEMR in the porcine rectum and colon.

METHODS

Targeted sites in the rectum and the distal colon were marked by spot coagulation. Submucosal fluid cushions (SFC) were created followed by a circumferential mucosal incision. After isolation of the targeted mucosa, balloon dissection was initiated. The balloon catheter was inserted deep into SFC and the inflated balloon repeatedly pulled back toward the endoscope tip to disrupt the submucosa. Residual strands of submucosa were cut. Dissection difficulty scores (DDS) were used using a visual analogue scale ranging from 0 to 5 (failed). The entire study period was divided into three periods (first period, pigs 1-10; second period, pigs 11-20; third period, pigs 21-30).

RESULTS

Sixty lesions in 30 pigs were resected using SEMR. The en block resection rate was 95%. There were three incomplete resections, two as a result of an errant site location and one as a result of a floppy prototype balloon catheter tip. The median resected size, procedure time, and DDS were 6.0 cm, 25 min, and 1. All three failed cases occurred in first period. The procedure time in third period was significantly shorter than the second period (P = 0.0017). The DDS in first period was significantly higher than the second (P = 0.0024) and third (P = 0.0155) periods. Two perforations, one muscularis propria catheter perforation, and one mucosal perforation were observed (3.3%).

CONCLUSIONS

Large mucosal target sites in the rectum and distal colon could be safely removed en bloc by means of a hybrid technique, SEMR, with blunt submucosal balloon dissection.

The management of esophageal achalasia: from diagnosis to surgical treatment

The goal of this review is to illustrate our approach to patients with achalasia in terms of preoperative evaluation and surgical technique. Indications, patient selection and management are herein discussed. Specifically, we illustrate the pathogenetic theories and diagnostic algorithm with current up-to-date techniques to diagnose achalasia and its manometric variants. Finally, we focus on the therapeutic approaches available today: medical and surgical. A special emphasis is given on the surgical treatment of achalasia and we provide the reader with a detailed description of our pre and postoperative management.

Peroral endoscopic myotomy (POEM) is safe and effective in the setting of prior endoscopic intervention

OBJECTIVE

We aimed to determine the safety and feasibility of peroral endoscopic myotomy (POEM) in the setting of prior endoscopic interventions.

PATIENTS

This study involves 40 consecutive patients undergoing POEM.

INTERVENTION

POEM was performed for esophageal motility disorders, including achalasia, nutcracker with nonrelaxing lower esophageal sphincter (LES), hypertensive lower esophageal sphincter, and diffuse esophageal spasm.

MAIN OUTCOME MEASURES

Outcome measures include length of procedure (LOP), intraoperative complications, and dysphagia relief.

RESULTS

Forty patients, with a mean age of 54 ± 19 years, underwent POEM. The pre-POEM intervention group consisted of 12 patients (nine achalasia, two nutcracker with nonrelaxing LES, and one diffuse esophageal spasm) who also had previous endoscopic treatment, while the pre-POEM non-intervention group consisted of 28 patients (22 achalasia, 3 hypertensive LES, 2 nutcracker with nonrelaxing LES, and 1 diffuse esophageal spasm). Ten patients had botox injections and two patients had large caliber balloon dilations prior to POEM. The median preoperative Eckardt score was 5 in the pre-POEM intervention group vs 6 in the pre-POEM non-intervention group (p value = 0.4). There was no statistical difference in the mean LOP (134 ± 43 vs 131 ± 41, p = 0.8) or the incidence of intraoperative complications (17 vs 3 %, p = 0.2) between the two groups. There was also no difference in the 6-month postoperative median Eckardt scores between the two groups (1 vs 1, p = 0.4).

CONCLUSION

POEM is safe and effective even following preoperative endoscopic large caliber balloon dilations or botox injection. These interventions do not seem to contribute to increased adverse intraoperative or postoperative clinical outcomes.

Effect of peroral endoscopic myotomy on esophagogastric junction physiology in patients with achalasia

BACKGROUND

Pneumatic dilation and laparoscopic Heller myotomy improve parameters of esophageal function such as lower esophageal sphincter (LES) pressure, esophageal emptying, and esophagogastric junction (EGJ) distensibility.

OBJECTIVE

To evaluate the effect of peroral endoscopic myotomy (POEM) on esophagogastric function.

DESIGN

Prospective trial.

SETTING

Endoscopy department at a university hospital.

PATIENTS

All consecutive patients aged >17 years with achalasia and an Eckardt score of ≥3.

INTERVENTION

Before and 3 months after POEM, 10 consecutive patients underwent esophageal manometry, timed barium esophagograms, and EndoFLIP as well as an EGD.

MAIN OUTCOME MEASUREMENTS

Eckardt symptom score, LES resting pressure, centimeters of barium stasis, EGJ distensibility, and reflux esophagitis.

RESULTS

Compared with scores before POEM, patient symptom scores were significantly reduced (1, interquartile range [IQR 0-1] vs 8 [IQR 4-8]; P = .005). LES pressure decreased significantly (6.0 mm Hg [IQR 2.6-7.4] vs 19.0 mm Hg [IQR 13.0-28.0]; P = .008). Esophageal emptying increased significantly, and a 5-minute barium column measured 2.3 cm (IQR 0-3.2 cm) versus 10.1 cm (IQR 5.7-10.8 cm; P = .005). EGJ distensibility increased significantly (6.7 mm(2)/mm Hg [IQR 3.8-16.6] vs 1.0 mm(2)/mm Hg [IQR 0.4-2.3]; P = .02) at 50 mL. In 6 of 10 patients, reflux esophagitis was seen. Of these patients, 3 reported reflux symptoms.

LIMITATIONS

Small number of patients, short-term follow-up.

CONCLUSION

POEM improves esophagogastric function and suggests favorable long-term results based on Eckardt score, esophageal manometry, esophageal emptying, and EGJ distensibility. Long-term follow-up of larger series will determine whether the high rate of reflux esophagitis affects the clinical application of POEM.

Temporary endoscopic metallic stent for idiopathic esophageal achalasia

Idiopathic achalasia is a motor disorder of the esophagus of unknown etiology caused by loss of motor neurons determining an altered motility. It may determine severe symptoms such as progressive dysphagia, regurgitations, and pulmonary aspirations. Many therapeutic options may be offered to patients with achalasia, from surgery to endoscopic treatments such as pneumatic dilation, botulinum injection, peroral endoscopic myotomy, or endoscopic stenting. Recently, temporary placement of a stent was proposed by Cheng as therapy for achalasia disorders, whereas no Western authors have dealt with it up to date. The present study reports our preliminary experience in 7 patients with achalasia treated with a temporary stent. Partially covered self-expanding metallic stents (Micro-Tech, Nanjin, China) 80 mm long and 30 mm wide were placed under fluoroscopic control and removed after 6 days. Clinical follow-up was scheduled to check endoscopic success, symptoms release, and complications. The placement and the removal of the stents were obtained in all patients without complications. Mean clinical follow-up was 19 months. Five out of 7 patients referred total symptoms release and 2 experienced significant improvement of dysphagia. The procedure was not time consuming and was safe; no mild or severe complications were registered. In conclusion, our results may suggest a possible safe and effective endoscopic alternative treatment in patients with achalasia; however, further larger studies are necessary to confirm these promising, but very preliminary, data.

Tunneling endoscopic muscularis dissection for subepithelial tumors originating from the muscularis propria of the esophagus and gastric cardia

BACKGROUND AND AIMS

Endoscopic resection of esophageal or cardial subepithelial tumors (SETs) originating from the muscularis propria (MP) is rarely done due to the high risk of perforation, fistula formation, and secondary infection. The aim of this study was to evaluate the preliminary clinical feasibility and safety of tunneling endoscopic muscularis dissection (tEMD) for resection of SETs located in the esophagus and gastric cardia

METHODS

Twelve patients with SETs originating from the MP of the esophagus (n = 7) or cardia (n = 5) were treated by tEMD. The procedure included creation of a submucosal tunnel to reach the tumor, dissection of the tumor from the surrounding submucosal tissue and the unaffected MP layer, full-thickness resection of the tumor and affected MP, and subsequent closure of the tunnel mucosal entry with endoscopic clips.

RESULTS

The en bloc resection rate was 100 % (seven lesions affected the deep MP so complete MP resection was performed; five lesions affected the superficial MP for a partial MP resection). The average tumor size was 18.5 ± 6.9 (range 10-30) mm. The mean operating time was 78.3 ± 25.5 (range 50-130) min. The histological diagnoses were two gastrointestinal stromal tumors with very low risk, nine leiomyomas, and one schwannoma. Air leakage and effusion included subcutaneous and mediastinal emphysema in eight patients (66.7 %), pneumothorax in four (33.3 %), pneumoperitoneum in three (25.0 %), and small pleural effusion in two (16.7 %). All air leakage and effusion cases were resolved with conservative management. No patient developed delayed hemorrhage and chronic fistula after tEMD. During the mean follow-up time of 7.1 ± 4.3 (range 2-15) months, no tumor recurrence was found in any patient.

CONCLUSIONS

tEMD appears to be a feasible minimally invasive and effective treatment for patients with SETs originating from the MP layer of the esophagus and cardia.

Recent trends in the management of achalasia

Radical treatment for achalasia is currently unavailable. At present, most palliative procedures are designed improve the passage of food through the gastroesophageal junction and thereby alleviate symptoms. Drug therapy is of limited, transient effectiveness. Pneumatic dilation (PD) is considered superior to endoscopic botulinum toxin injection (EBTI). The mainstay of surgical treatment for achalasia is laparoscopic Heller myotomy (LHM) with fundoplication, currently considered superior to PD. Per oral endoscopic myotomy (POEM), a "state-of-the-art" procedure for minimally invasive surgery, holds great promise for the future management of achalasia. Definitive conclusions regarding the benefits and risks of currently available treatments for achalasia must await the accumulation of evidence from well-designed clinical trials.

Peroral endoscopic esophageal myotomy: defining the learning curve

BACKGROUND

Peroral endoscopic myotomy (POEM) is an endoscopic alternative to laparoscopic esophageal myotomy. It requires a demanding skill set that involves both advanced endoscopic skills and knowledge of surgical anatomy and complication management.

OBJECTIVE

Determine the learning curve for POEM.

DESIGN

Prospective cohort study.

SETTING

Tertiary-care teaching hospital.

PATIENTS

The study involved the first 40 consecutive patients undergoing the POEM procedure under a prospective institutional review board protocol (research.gov #NCT01399476, 1056).

INTERVENTION

Peroral endoscopic myotomy for esophageal motility disorders.

MAIN OUTCOME MEASUREMENTS

Length of procedure (LOP) and technical errors (inadvertent mucosotomy).

RESULTS

A total of 40 patients underwent POEM. The mean LOP was 126 ± 41 minutes. The mean myotomy length was 9 cm (range, 6-20 cm). The LOP per centimeter myotomy and variability decreased as our experience progressed. The means (± standard deviation) of the LOP per centimeter myotomy were as follows: first cohort, 16 ± 4 minutes; second, 17 ± 5 minutes; third, 13 ± 3 minutes; fourth, 15 ± 2 minutes; and fifth, 13 ± 4 minutes. The incidence of inadvertent mucosotomy also decreased with increasing experience, to 8, 6, 4, 0, and 1, respectively. These minor complications were repaired intraoperatively with clips. There were 7 patients with capnoperitonium and another with bilateral capnothoraces that were associated with hemodynamic instability but resolved by Veress needle decompression. Two patients required endoscopy in the early postoperative period: self-limited hematemesis in one and radiologic evidence of leakage at the mucosotomy site in another.

LIMITATIONS

Nonrandomized study.

CONCLUSION

Mastery of operative technique in POEM is evidenced by a decrease in LOP, variability of minutes per centimeter of myotomy, and incidence of inadvertent mucosotomies and plateaus in about 20 cases for experienced endoscopists. The learning curve can be shortened with very close supervision and/or proctoring.

Present and future advanced laparoscopic surgery

Modern laparoscopy, starting with Kurt Semm's insufflators and the first successful appendectomies, has only been around for approximately 30 years. Since those early successes, the technology has grown from the inception of basic laparoscopy to endoscopic surgery through natural orifices, and it continues to evolve by leaps and bounds with computer-assisted surgery and improved robotics in surgery. Without question, laparoscopy has revolutionized the way we perform standard surgery, especially relative to the techniques that had been used for hundreds of years. Despite the development of multiple novel technologies since the 1980s, very little has changed with regard to basic conceptualizations and practice of laparoscopy. In this review article, we will describe the highlights of recent advanced laparoscopic surgery procedures, their potential applications within the field of surgery, and how these advances may impact and improve future quality and patient outcomes.

Direct incision versus submucosal tunneling as a method of creating transgastric accesses for natural orifice transluminal endoscopic surgery (NOTES) peritoneoscopy: randomized controlled trial

AIM

The optimal approach for creating accesses for transgastric peritoneoscopy is still uncertain. The present study aims to assess the feasibility of carrying out transgastric submucosal tunnel (SMT) peritoneoscopy and to determine whether this approach improves or restricts access to various sectors within the peritoneal cavity.

METHODS

This was a randomized comparative study carried out in an in-vivo survival porcine model. Sixty-six beads in six swine were visualized and touched via gastrotomies created by either direct incision (DI) or SMT. The influence of the type of gastrotomy on improving or restricting access to particular sites within the peritoneal cavity for natural orifice transluminal endoscopic surgery (NOTES) peritoneoscopy was compared. The main outcome measurements were localization score of beads, overall procedural time, morbidities and mortalities.

RESULTS

A significantly higher mean (SD) localization score was observed in peritoneoscopies carried out in the DI group (P < 0.001). Both the visualization and the touching scores were significantly better with the DI technique, and the overall yield of NOTES peritoneoscopy with DI and SMT were 72.73% and 60.6%, respectively (P = 0.043). Significantly more beads that were not touched in the SMT group were located in the sub-phrenic area (P = 0.013). The overall procedural time was significantly shorter in the DI group (P = 0.004). No major morbidities or mortalities occurred in any procedures.

CONCLUSIONS

SMT resulted in lower visualization and touching scores for transgastric NOTES peritoneoscopy. Alternate methods to improve the diagnostic yield to the sub-phrenic area are required.

Euro-NOTES Status Paper: from the concept to clinical practice

BACKGROUND

The concept of natural orifice transluminal endoscopic surgery (NOTES) consists of the reduction of access trauma by using a natural orifice access to the intra-abdominal cavity. This could possibly lead to less postoperative pain, quicker recovery from surgery, fewer postoperative complications, fewer wound infections, and fewer long-term problems such as hernias. The Euro-NOTES Foundation has organized yearly meetings to work on this concept to bring it safely into clinical practice. The aim of this Euro-NOTES status update is to assess the yearly scientific working group reports and provide an overview on the current clinical practice of NOTES procedures.

METHODS

After the Euro-NOTES meeting 2011 in Frankfurt, Germany, an analysis was started regarding the most important topics of the European working groups. All prospectively documented information was gathered from Euro-NOTES and D-NOTES working groups from 2007 to 2011. The top five topics were analyzed.

RESULTS

The statements of the working group activities demonstrate the growing information and changing insights. The most important selected topics were infection issue, peritoneal access, education and training, platforms and new technology, closure, suture, and anastomosis. The focus on research topics changed over time. The principle of hybrid access has overcome the technical and safety limitations of pure NOTES. Currently the following NOTES access routes are established for several indications: transvaginal access for cholecystectomy, appendectomy and colon resections; transesophageal access for myotomy; transgastric access for full-thickness small-tumor resections; and transanal/transcolonic access for rectal and colon resections.

CONCLUSIONS

NOTES and hybrid NOTES techniques have emerged for all natural orifices and were introduced into clinical practice with a good safety record. There are different indications for different natural orifices. Each technique has been optimized for the purpose of finding a safe and realistic solution to perform the procedure according to the specific indication.

Partial recovery of peristalsis after myotomy for achalasia: more the rule than the exception

IMPORTANCE

Although successful treatment of achalasia depends on alleviating the obstruction at the esophagogastric junction, the postintervention contractile and pressurization pattern may also play a role in outcome.

OBJECTIVE

To determine whether myotomy that alleviates the esophagogastric junction outflow obstruction in achalasia might improve peristalsis.

DESIGN

Retrospective study from August 1, 2004, through January 30, 2012.

SETTING

Two tertiary care hospitals in Chicago and Lyon.

PATIENTS

We included 30 patients (18 male; mean age [range], 43 [17-78] years), of whom 8 had type 1 (26.6%), 17 had type 2 (56.7%), and 5 (16.7%) had type 3 achalasia according to the Chicago classification.

INTERVENTIONS

Esophageal high-resolution manometry before and after laparoscopic or endoscopic myotomy.

MAIN OUTCOMES MEASURE

The integrity of peristalsis, characterized as intact, weak contractions; frequent failed peristalsis; or premature contractions.

RESULTS

Although peristaltic fragments were evident only in patients with type 3 achalasia before treatment, intact, weak, or frequent failed peristalsis was encountered in 5 patients with type 1 (63%), 8 with type 2 (47%), and 4 with type 3 (80%) achalasia after myotomy. One patient with type 3 achalasia had distal esophageal spasm after treatment. In patients with a postmyotomy integrated relaxation pressure of less than 15 mm Hg, only 10 (40%) had persistent absent peristalsis. Panesophageal pressurization disappeared after myotomy in 16 of 19 patients. In the 5 patients with postmyotomy integrated relaxation pressure of more than 15 mm Hg, 4 had weak peristalsis and 1 had absent peristalsis.

CONCLUSIONS AND RELEVANCE

Reduction or normalization of the esophagogastric junction relaxation pressure achieved by myotomy in achalasia is associated with partial recovery of peristalsis in some patients, suggesting that the disease process progresses from the esophagogastric junction to the esophageal body. Whether the return of peristalsis is predictive of an improved therapeutic outcome requires further study.

Peroral Endoscopic Myotomy (POEM) in a Patient with Complete Heart Block-a Case Report

Achalasia cardia is the commonest esophageal motility disorder. Recently, a new endoscopic procedure-peroral endoscopic myotomy (POEM)-has emerged for treating this chronic and debilitating condition. It has shown comparable success rates in prospective studies with conventional Heller's myotomy with lesser rates of postoperative reflux. Literature regarding this procedure from India is scarce due to its limited availability. This case report illustrates the use of POEM in a patient with a permanent cardiac pacemaker and demonstrates its safety and efficacy in such a situation.

The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience

BACKGROUND

Per oral endoscopic myotomy (POEM) represents a Natural Orifice Transluminal Endoscopic Surgery (NOTES) approach to Heller myotomy. Even though we are now entering an exponential phase of growth with a large number of centers interested in POEM, published data to guide them are limited. As part of the July 2012 NOSCAR meeting, a conference was organized to review POEM and develop a consensus document. Authors SNS and TS who chaired the NOSCAR panel recognized the dearth of published data, which also may lag the rapid developments in POEM. Therefore, they undertook a survey of early POEM adopters around the world to rapidly obtain global, extensive, and current data on POEM. The raw survey data were made available to NOSCAR panel participants to assist with their presentations. We summarize the salient findings of the survey.

METHODS

A comprehensive POEM survey was created and tested. The final survey instrument consisted of 197 questions that covered all aspects of POEM, including operator discipline, prior training, patient selection, setting, technique preference, results, adverse events, regulatory requirements, and perspectives on the future. An automated online response collector was used.

RESULTS

The International Per Oral Endoscopic Myotomy Survey (IPOEMS) involved 16 expert centers, 7 in North America, 5 in Asia, 4 in Europe, including all high-volume centers (≥30 POEMs per center), as of July 2012. These centers had performed 841 POEMs. There were modest variations among centers in technique and periprocedural management, but all centers uniformly reported excellent efficacy and safety outcomes.

CONCLUSIONS

The international POEM survey provides a "global snapshot" of the experience of early adopters. The excellent outcomes over a large cumulative volume of procedures are in line with those of published small series and lend further support to the notion that POEM represents a paradigm shift in the treatment of achalasia.

The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience

BACKGROUND

Per oral endoscopic myotomy (POEM) represents a Natural Orifice Transluminal Endoscopic Surgery (NOTES) approach to Heller myotomy. Even though we are now entering an exponential phase of growth with a large number of centers interested in POEM, published data to guide them are limited. As part of the July 2012 NOSCAR meeting, a conference was organized to review POEM and develop a consensus document. Authors SNS and TS who chaired the NOSCAR panel recognized the dearth of published data, which also may lag the rapid developments in POEM. Therefore, they undertook a survey of early POEM adopters around the world to rapidly obtain global, extensive, and current data on POEM. The raw survey data were made available to NOSCAR panel participants to assist with their presentations. We summarize the salient findings of the survey.

METHODS

A comprehensive POEM survey was created and tested. The final survey instrument consisted of 197 questions that covered all aspects of POEM, including operator discipline, prior training, patient selection, setting, technique preference, results, adverse events, regulatory requirements, and perspectives on the future. An automated online response collector was used.

RESULTS

The International Per Oral Endoscopic Myotomy Survey (IPOEMS) involved 16 expert centers, 7 in North America, 5 in Asia, 4 in Europe, including all high-volume centers (≥30 POEMs per center), as of July 2012. These centers had performed 841 POEMs. There were modest variations among centers in technique and periprocedural management, but all centers uniformly reported excellent efficacy and safety outcomes.

CONCLUSIONS

The international POEM survey provides a "global snapshot" of the experience of early adopters. The excellent outcomes over a large cumulative volume of procedures are in line with those of published small series and lend further support to the notion that POEM represents a paradigm shift in the treatment of achalasia.

[New trends and concepts in diagnosis and treatment of achalasia]

The last 2 decades have witnessed a revolution in the treatment of esophageal achalasia. Nowadays, laparoscopic Heller myotomy with partial fundoplication is considered in most centers the primary treatment modality, while endoscopic treatment, i.e. pneumatic dilatation, is mainly reserved for the management of patients unfit for surgery or in case of surgical failure. Recently, a new approach to achalasia has been proposed: the peroral endoscopic myotomy (POEM), which combines the advantages of endoscopy and surgery. This article reviews the evolution of the diagnosis and treatment of esophageal achalasia during the last 20 years.

Transesophageal endoscopic myotomy (TEEM) for the treatment of achalasia: the United States human experience

BACKGROUND

From our early experience with NOTES, our group has acquired familiarity with transesophageal submucosal dissection and myotomy in swine model, which allowed us to perfect a model to perform purely endoscopic transesophageal myotomy (TEEM) for the treatment of achalasia and apply it into clinical practice. This study was designed to assess the safety, feasibility, and efficacy of TEEM in a series of patients with achalasia.

METHODS

Under institutional review board approval, patients were enrolled on our study, where TEEM was offered as an alternative to laparoscopic or robotic Heller myotomy. The inclusion criteria were patients with achalasia confirmed by esophageal manometry, between age 18 and 50 years, and ASA class 2 or lower. The exclusion criteria were pregnancy, prior esophageal surgery, immunosuppression, coagulopathies, and severe medical comorbidities. The procedures were performed under general anesthesia, with the patient in supine position on positive pressure ventilation. With a GIF-180 (Olympus, Tokyo, Japan) positioned at 10 cm above the GEJ, a mucosotomy was performed at the 2 o'clock position, and a submucosal space was developed caudally creating a controlled submucosal tunnel extending 2 cm distal to the GEJ. Upon completion of this tunnel the gastroesophageal lumen was inspected for mucosal integrity. The scope was then reinserted into the submucosal tunnel and using a triangle-tip knife, myotomy was performed starting at 5 cm above the GEJ and ending at 2 cm below the GEJ. During this process the circular muscle layer of the esophagus was carefully divided with preservation of the longitudinal layer. At the end of the procedure, the mucosal incision was closed longitudinally with endoscopic clips and surgical glue.

RESULTS

Five patients underwent TEEM, with no perioperative complication. All patients reported significant improvement of their dysphagia immediately after the procedure. On the first postoperative day, all barium swallows showed disappearance of the classical bird beak taper, rapid emptying of contrast into the stomach, and absence of leaks. All patients were discharged on the second postoperative day on liquid diet. Two patients reported transient heartburn, which were well controlled with medications. The average preoperative GERD-HRQL was 20, which improved to 11.3 at 7 days postoperative and 2 at 30 days postoperative. To date, three patients have already returned for their 6-month follow-up, reporting adequate swallowing and low LES pressures on esophageal manometry (their mean preoperative LES resting pressure was 36.46 mmHg and residual pressure was 43.16 mmHg, whereas the 6-month follow-up mean LES resting pressure was 10.06 mmHg and residual pressure was 0.43 mmHg).

CONCLUSIONS

TEEM seems to be safe, feasible, and effective for the treatment of patients with achalasia. Long-term data are still necessary for wide-spread utilization of this novel technique.

Recent developments in gastric endoscopic submucosal dissection: towards the era of endoscopic resection of layers deeper than the submucosa

With technical advances in endoscopic submucosal dissection (ESD), several variations of endoscopic procedure derived from ESD and fusion procedures of endoscopy and laparoscopy for upper gastrointestinal submucosal tumor and cancer have recently been developed. The former includes endoscopic muscularis dissection (EMD), submucosal endoscopic tumor resection (SET), endoscopic submucosal tunnel dissection (ESTD) and endoscopic full-thickness resection (EFTR), and the latter includes laparoscopic and endoscopic cooperative surgery (LECS), laparoscopy-assisted endoscopic full-thickness resection (LAEFR), and laparoscopic lymphadenectomy without gastrectomy following ESD. In the present article, recent developments in gastric ESD and advanced procedures derived from ESD are discussed.

Management of achalasia

Achalasia is a rare motility disorder of the esophagus characterized by the absence of peristalsis and defective relaxation of the lower esophageal sphincter. Patients present at all ages with dysphagia and regurgitation as main symptoms. The diagnosis is suggested by barium swallow and endoscopy and confirmed by manometry. Because there is no curative treatment for achalasia, treatment is confined to disruption of the lower esophageal sphincter to improve bolus passage. The most successful therapies are pneumodilation and laparoscopic Heller myotomy, with comparable short-term clinical rates of success. The prognosis of achalasia patients is good, but re-treatment is often necessary.

Esophageal dilation with integrated balloon imaging: initial evaluation in a porcine model

BACKGROUND

When treating achalasia, balloon dilation is often combined with fluoroscopy to allow the lower esophageal sphincter to be visualized as it is being dilated. We sought to evaluate a new balloon dilation technology, EsoFLIP, which allows the shape of the balloon to be visualized in a nonradiographic manner by using impedance planimetry electrodes located within the dilation balloon.

METHODS

Two pigs weighing 35 kg were used. The EsoFLIP balloon dilator was introduced under endoscopic visualization. Successive injections of 50, 60, 70 and 85 mL into the dilation balloon permitted dilations at increasing diameters to be achieved. Following each dilation fluid was withdrawn to leave 30 mL in the balloon and an EsoFLIP image was captured to track progressive dilation of the gastroesophageal junction (GEJ).

RESULTS

The EsoFLIP catheter was safely deployed in the two pigs and no complications were noted. For pig 1, during dilation, the measured balloon diameter at the waist was 24.1, 28.9, 29.2 and 30.0 mm for balloon dilation volumes of 50, 60, 70 and 85 mL respectively. For pig 2 the corresponding diameter at the waist was 22.8, 27.1, 28.5 and 29.4 mm. The GEJ diameter increased from 12.5 and 12.4 mm to 17.4 and 17.5mm for pigs 1 and 2 respectively. Distensibility of the GEJ in pig 1 increased from 2.3 mm(2)/mmHg before to 4.4 mm(2)/mmHg after dilation and in pig 2 from 4.4 to 9.6 mm(2)/mmHg. The GEJ substantively achieved its final diameter after the dilation using just 50 mL in the balloon.

CONCLUSIONS

We demonstrated technical feasibility and safety of the EsoFLIP dilator in a porcine model. Further studies in humans with achalasia remain to be conducted, which, besides demonstrating technical feasibility, should also evaluate the use of distensibility measurements taken during dilation to predict outcomes.

Endoscopic approaches to treatment of achalasia

Endoscopic therapy for achalasia is directed at disrupting or weakening the lower esophageal sphincter (LES). The two most commonly utilized endoscopic interventions are large balloon pneumatic dilation (PD) and botulinum toxin injection (BTI). These interventions have been extensively scrutinized and compared with each other as well as with surgical disruption (myotomy) of the LES. PD is generally more effective in improving dysphagia in achalasia than BTI, with the latter reserved for infirm older people, and PD may approach treatment results attained with myotomy. However, PD may need to be repeated. Small balloon dilation and endoscopic stent placement for achalasia have only been used in select centers. Per oral endoscopic myotomy is a newer endoscopic modality that will likely change the treatment paradigm for achalasia. It arose from the field of natural orifice transluminal endoscopic surgery and represents a scarless endoscopic approach to Heller myotomy. This is a technique that requires extensive training and preparation and thus there should be rigorous accreditation and monitoring of outcomes to ensure safety and efficacy.

Management of spastic disorders of the esophagus

The concept of esophageal spastic disorders encompasses spastic achalasia, distal esophageal spasm, and jackhammer esophagus. These are conceptually distinct in that spastic achalasia and distal esophageal spasm are characterized by a loss of neural inhibition, whereas jackhammer esophagus is associated with hypercontractility. Hypercontractility may also occur as a result of esophagogastric junction outflow obstruction or inflammation. The diagnosis of jackhammer esophagus as a primary motility disorder is based on the characteristic manometric findings after ruling out mechanical obstruction and eosinophilic esophagitis. Despite the differences in pathophysiology among the esophageal spastic disorders, their management is similar.

Peroral endoscopic myotomy for treatment of achalasia: initial results of a korean study

BACKGROUND/AIMS

Achalasia is a rare esophageal motility disorder. Recently, a novel endoscopic technique, peroral endoscopic myotomy (POEM), was introduced as an alternative treatment for achalasia. We report the results and short term outcomes of POEM for patients with achalasia.

METHODS

POEM was performed in 13 patients with achalasia. The procedure consisted of creating a submucosal tunnel followed by endoscopic myotomy of circular muscle bundles. The mucosal entry was closed by conventional hemostatic clips. A validated clinical symptom score (Eckardt score) and high resolution manometry were used to evaluate the outcomes.

RESULTS

Both the clinical score of achalasia, as well as the resting lower esophageal sphincter (LES) pressure, were significantly reduced after POEM. Mean posttreatment Eckardt score was 0.4±0.7, compared to 6.4±1.9 prior to the treatment (p=0.001). The mean pretreatment and posttreatment LES pressure was 30.3 and 15.3 mm Hg, respectively (p=0.007). Following POEM, symptomatic relief from dysphagia without reflux symptoms was observed in all patients (13/13). No serious complications related to POEM were encountered.

CONCLUSIONS

Based upon our initial experience, the authors believe that POEM is a feasible, safe, and effective treatment and may possibly substitute established treatments of refractory achalasia.

Human applications of submucosal endoscopy under conscious sedation for pure natural orifice transluminal endoscopic surgery

BACKGROUND

The submucosal endoscopy provide not only a reliable methods of access and closure for peritoneoscopy, but also an endoscopic working space for full-thickness resection. The aim of this study was to report the clinical outcome of submucosal endoscopy for pure natural orifice transluminal endoscopic surgery.

METHODS

We prospectively evaluated 10 patients who received submucosal endoscopies. The indications of submucosal endoscopy were transgastric peritoneoscopy (TGP) and endoscopic full-thickness resection (EFTR) of a gastric subepithelial tumor. All procedures were performed with a standard gastroscope under conscious sedation with the balanced propofol method in the endoscopic unit. After a 40 mm submucosal tunnel was created using an endoscopic submucosal dissection technique, (1) in TGP, balloon dilation of a serosal puncture and intraperitoneal exploration was performed; (2) in EFTR, a full-thickness incision and snaring resection was performed. Closure of the mucosal incision was performed by endoclips.

RESULTS

All cases were technically feasible. The mean times for creating the submucosal tunnel, main procedure (peritoneal exploration or resection), and closure were acceptable (10.44 ± 2.42 minutes, 18.80 ± 9.41 minutes, and 5.63 ± 2.17 minutes, respectively). The mean hospital stay was 3.8 ± 1.48 days. All TGPs were diagnostic (4 peritoneal carcinomatosis and 1 tuberculosis). En bloc and complete resections were possible in all EFTRs (3 gastrointestinal stromal tumors and 2 schwannomas; mean tumor size, 20.8 ± 3.27 mm). There were no procedure-related complications, such as significant bleeding or peritonitis.

CONCLUSIONS

Human applications of submucosal endoscopy under conscious sedation for pure NOTES were feasible and safe.

Comparison of perioperative outcomes between peroral esophageal myotomy (POEM) and laparoscopic Heller myotomy

BACKGROUND

Peroral esophageal myotomy (POEM) is a novel endoscopic operation for the treatment of achalasia. Few POEM outcome data exist, and no study has compared POEM with the surgical standard, laparoscopic Heller myotomy (LHM).

METHODS

Perioperative outcomes were compared between POEM and LHM performed in a nonrandomized fashion. Patients in both groups met the following eligibility criteria: diagnosis of achalasia, age 18-85, and absence of prior achalasia treatment.

RESULTS

Eighteen patients underwent POEM, and 55 patients underwent LHM. Operative times were shorter for POEM (113 vs. 125 min, p < .05), and estimated blood loss was less (≤10 ml in all cases vs. 50 ml, p < .001). Myotomy lengths, complication rates, and length of stay were similar. Pain scores were similar upon post-anesthesia care unit arrival and on postoperative day 1 but were higher at 2 h for POEM patients (3.5 vs. 2, p = .03). Narcotic requirements were similar, although fewer POEM patients received ketorolac. POEM patients' Eckardt scores decreased (median 1 postop vs. 7 preop, p < .001), and 16 (89 %) patients had a treatment success (score ≤3) at median 6-month follow-up. Six weeks after POEM, routine follow-up manometry and esophagram showed normalization of esophagogastric junction pressures and contrast column heights.

CONCLUSIONS

POEM and LHM appear to have similar perioperative outcomes. Further investigation is needed regarding long-term results after POEM.

Submucosal tunnelling endoscopic resection for the treatment of esophageal submucosal tumours originating from the muscularis propria layer: an analysis of 15 cases

BACKGROUND AND AIMS

The aim of this prospective study was to evaluate the feasibility of submucosal tunnelling endoscopic resection of esophageal tumours originating from the muscularis propria layer.

METHODS

Fifteen patients with esophageal submucosal tumours originating from the muscularis propria layer underwent submucosal tunnelling endoscopic resection between August 2011 and February 2012. The key steps were: (1) creating a submucosal tunnel from 5 cm above the tumour between the submucosal and muscular layers with a hook knife or hybrid knife; (2) dissecting the tumour by the technique of endoscopic submucosal dissection; (3) closing the mucosal incision site with clips after the tumour was removed.

RESULTS

Submucosal tunnelling endoscopic resection was successfully performed in all cases. The en bloc resection rate was 100%. The average tumour diameter was 1.8 cm (range 1.0-3.0 cm). During the procedure, perforation occurred in 3 patients, who recovered after conservative treatment. No residual tumour or tumour recurrence was detected during the follow-up period (mean: 3.5 months, range: 1-9 months). Pathological diagnoses of these tumours were leiomyomas (12/15) and gastrointestinal stromal tumours (3/15).

CONCLUSIONS

Submucosal tunnelling endoscopic resection is a feasible method for the treatment of small esophageal submucosal tumours originating from the muscularis propria layer.

Endoscopic submucosal dissection of large gastrointestinal stromal tumors in the esophagus and stomach

BACKGROUND AND AIM

Gastrointestinal stromal tumors (GISTs), the most common mesenchymal tumors of the digestive tract with potential for malignant transformation, are mainly treated by open surgery or laparoscopic resection. The aim of this retrospective study was to evaluate the clinical efficacy, safety, and feasibility of endoscopic submucosal dissection (ESD) for large-size (2-5 cm) GISTs in the esophagus and stomach.

METHODS

A total of 31 patients with large-size GISTs in the esophagus (6 patients) and stomach (25 patients) underwent ESD between September 2008 and December 2011. Demographics, clinical data, therapeutic outcomes, complications, pathological characteristics, risk classification, and follow-up outcomes were recorded.

RESULTS

ESD was successfully performed in 31 patients at age of 59.06 ± 7.23 years (range: 46-74). The mean time of the procedure was 70.16 ± 16.25 min (range: 40-105). Perforation for 2-10 mm occurred in six patients (19.35%) and was endoscopically repaired with clips or nylon bands, with no conversions to open surgery. Intraoperative bleeding occurred in three patients (9.68%) and was corrected with argon plasma coagulation or hot biopsy forceps. No mortalities occurred. The mean size of the resected tumors was 2.70 ± 0.72 cm (range: 2.0-5.0). Out of the 31 patients, 24 (77.42%) were at very low risk and 7 (22.58%) were at low risk. Positive rate of CD117, DOG-1, and CD34 were 83.87%, 12.90%, and 100%, respectively. A follow up for 14.29 ± 8.99 months (range: 3-39) showed no recurrence or metastasis.

CONCLUSIONS

ESD appears to be an effective, safe, and feasible treatment for large-size GISTs in the esophagus and stomach.

Endoscopy 20 years into the future

Gastrointestinal endoscopy has had a spectacular run in the last few decades with advances in technology that have redefined both gastroenterology and gastrointestinal surgery. Going forward, its contributions are likely to be even more meaningful as new procedures expand both the indications as well as the user base and contribute to bending the curve of healthcare costs. In this essay, I will describe some of what I believe to be the most important future developments with the greatest potential for impact across the spectrum of digestive disorders.

Peroral endoscopic myotomy for treating achalasia in an animal model: a feasibility study

Background/Aims

Laparoscopic Heller myotomy with antireflux procedure is considered to be a standard treatment for achalasia. Recently, peroral endoscopic myotomy (POEM) was developed and performed on patients with achalasia. However, there is no report on POEM use in South Korea. The aim of this study was to evaluate the technical feasibility of POEM in a porcine model.

Methods

POEM was performed on two mini pigs. We performed upper endoscopy under general anesthesia. A submucosal tunnel was created and the circular muscle layer was incised using several knives. The mucosal entry was closed using resolution clips. We performed a follow-up endoscopy and sacrificed the pigs 2 weeks after the POEM. The myotomy site was evaluated grossly and histologically.

Results

POEM was successfully performed on the two mini pigs. No injuries to any abdominal or mediastinal structures occurred. Two weeks after the POEM, the esophageal mucosa healed without any endoscopic evidence of complications. Necropsy revealed that the circular muscle layer was completely lost and replaced with fibrotic tissue.

Conclusions

We found that POEM is a technically feasible method which can be performed on an animal model. However, to ensure safe use on patients with achalasia, further studies on technical methods and long-term follow-up examinations are required.

Improvement of endocytoscopic findings after per oral endoscopic myotomy (POEM) in esophageal achalasia; does POEM reduce the risk of developing esophageal carcinoma? Per oral endoscopic myotomy, endocytoscopy and carcinogenesis

BACKGROUND

Per oral endoscopic myotomy (POEM) has been reported to be a new therapeutic option for esophageal achalasia. The possibility that POEM could reduce the risk of developing esophageal squamous cell carcinoma was evaluated.

METHODS

This was a single-centre, retrospective study. Fifteen consecutive patients with esophageal achalasia who underwent POEM in our institution between August 2010 and January 2012 were enrolled. Ultra-high magnification with endocytoscopy was performed, and both histopathological and immunohistochemical evaluations for Ki-67 and p53 were assessed before and 3 months after POEM.

RESULTS

POEM was successfully performed and effectively released the dysphagia symptom in all patients without severe complications. Subjective symptoms (mean Ekcardt score, before 7.4 vs. after 0.5, p<0.05) and manometric pressure studies (mean lower esophageal sphincter pressure), before 82.7 vs. after 22.9 mmHg, p<0.05) showed substantial improvement following POEM. The average numbers of esophageal epithelial nuclei before and after POEM on endocytoscopic images were 128.0 and 78.0, respectively (p<0.05). The mean Ki-67-positive ratio was 26.0 (median 25.4, range, 10.3-33.2) before and 20.7 (median 20.0, 13.1-29.9; p=0.07) after POEM, and the mean p53-positive ratio was 2.35 (median 2.61, 0.32-4.23) before and 0.97 (median 1.49, 0.32-1.56; p<0.05) after POEM. A significant positive correlation was seen between the number of nuclei and the Ki-67-positive ratio (p<0.05).

CONCLUSIONS

POEM appears to be an effective and less invasive treatment of choice against achalasia and may reduce the risk of esophageal carcinogenesis. Endocytoscopy can be useful for the assessment of esophageal cellular proliferation.

New endoscopic classification of achalasia for selection of candidates for peroral endoscopic myotomy

AIM

To propose a new endoscopic classification of achalasia for selecting patients appropriate for undergoing peroral endoscopic myotomy (POEM).

METHODS

We screened out the data of patients with achalasia examined from October 2000 to September 2011 at our Digestive Endoscopic Center with endoscopic pictures clear enough to reveal the morphology of middle and lower esophagus. After analyzing the correlation between the endoscopic morphology of the esophageal lumen and POEM, we proposed a new endoscopic classification (Ling classification) of achalasia according to three kinds of endoscopically viewed structures: multi-ring structure, crescent-like structure and diverticulum structure. There were three types based on the criteria of Ling classification: type I, smooth without multi-ring, crescent-like structure or diverticulum structure; type II, with multi-ring or crescent-like structure but without diverticulum structure; and type III, with diverticulum structure. Type II was classified into three subtypes: Ling II(a), Ling II(b) and Ling II(c); and type III also had three subtypes: Ling III(l), Ling III(r) and Ling III(lr). Two endoscopists made a final decision upon mutual agreement through discussion if their separately recorded characteristics were different.

RESULTS

Among the 976 screened patients with achalasia, 636 patients with qualified endoscopic pictures were selected for the analysis, including 405 males and 231 females. The average age was 42.7 years, ranging from 6 to 93 years. Type I was the most commonly observed type of achalasia, accounting for 64.5% (410/636), and type III was the least commonly observed type of achalasia, accounting for 2.8% (18/636). And type II accounted for 32.7% (208/636) and subtype of Ling II(a), Ling II(b) and Ling II(c) accounted for 14.6% (93/636), 9.9% (63/636) and 8.2% (52/636), respectively. And subtype of Ling III(l), Ling III(r) and Ling III(lr) accounted for 0.8% (5/636), 0.3% (2/636) and 1.7% (11/636), respectively.

CONCLUSION

A new endoscopic classification of achalasia is proposed that might help in determining the proper candidates for POEM.

Recent progress in treatment of achalasia

Achalasia is a rare primary esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter, absent or decreased esophageal peristaltic waves and synchronous contractions. As the exact pathogenesis of the disease remains unclear, treatment options focus on the alleviation of the functional obstruction caused by lower esophageal sphincter and prevention of gastroesophageal reflux disease at the same time. Treatment modalities include pharmacological therapy, interventional therapy, surgical treatment and spinal rotation massage. This article reviews the latest progress in treatment of achalasia, with particular emphasis on the evolution of main treatments which include endoscopic pneumatic dilation, Heller myotomy and per-oral endoscopic myotomy (POEM).

Achalasia

Endoscopic therapy for achalasia is centered on disrupting or weakening the lower esophageal sphincter. The three traditional treatment options for achalasia are surgical myotomy, pneumatic dilation, and botulinum toxin injection. Pneumatic dilation yields results that are generally better than botulinum toxin injection and may approach a clinical response comparable with surgery. Per oral endoscopic myotomy is a newer endoscopic modality that will likely change the treatment paradigm for achalasia.