Peroral endoscopic myotomy (POEM) for esophageal achalasia

Long-term outcomes of peroral endoscopic myotomy for Chicago classification type I vs type III achalasia in treatment-naive patients

The efficacy of peroral endoscopic myotomy (POEM) for achalasia has potential associations with Chicago classification by high-resolution manometry (HRM). Type II achalasia demonstrates the best response to POEM of all subtypes, while there remain controversies between type I and type III. Moreover, previous treatment history might cause discrepancy in direct comparison. We aimed to compare the clinical outcome of POEM for type I vs type III in treatment-naive patients. In total, 82 patients with type I or type III achalasia (45 type I, 37 type III) from February 2015 to December 2018 were enrolled and POEM was carried out as the initial treatment. Clinical success, change of Eckardt scores and HRM parameters were analyzed and compared between type I and type III group. About, 43 (95.6%) patients and 34 (91.9%) patients in type I and type III group acquired the clinical success (P = 0.821). Eckardt score and HRM results after POEM treatment decreased significantly in either group (P<0.01). Compared to type III group, higher reduction rates of Eckardt score (type I vs type III, 78.6 vs 66.9%, P = 0.034) and basal LES pressure (type I vs type III, 58.9 vs 40.4%, P = 0.040) were observed in type I group. Type I achalasia patients showed better response to POEM with more favorable clinical remission in Eckardt score and HRM outcomes than type III.

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.

New diagnostic and therapeutic procedures applied in pediatric esophageal achalasia in a pediatric tertiary center: A case series

Achalasia is an esophageal motor disorder that is rare in children. While the condition is uncommon, it is especially difficult to diagnose in pediatric patients; however, the ability to form a diagnosis has progressed markedly with the advent of esophageal high-resolution manometry (HRM). The aim of the present study was to highlight particularities of the diagnosis, based on esophageal HRM, as well as the treatment of achalasia in children. The current study analyzed cases of achalasia from a single pediatric tertiary center, Clinical Emergency Hospital for Children (Cluj-Napoca, Romania). The clinical data and the results of the investigations of seven children with achalasia, the first children to be evaluated using esophageal HRM in the center, were reported. The patients were aged between 11 and 18 years. All the patients were newly diagnosed with achalasia, except for one. The duration of symptoms was between 4 months and 2 years in the newly diagnosed patients. All the patients were assessed with conventional esophageal manometry and/or esophageal HRM. A multidisciplinary team contributed to the diagnosis and the management of achalasia. A total of 4 children diagnosed with type II achalasia were treated with peroral endoscopic myotomy (POEM) and 3 of the patients were treated with pneumatic dilations. Overall, achalasia is a rare but challenging condition in children. A diagnosis starts with a clinical suspicion based on swallowing disorders and upper digestive endoscopy, and is confirmed by esophageal HRM. Therapy should be adapted to the type of achalasia, the age of the children and the severity. In the present study, a relatively recent treatment option, POEM, was applied in pediatric patients with minor immediate adverse events. The report of these cases adds to the limited experience of using HRM and POEM in children with achalasia.

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.

East versus West: Comparisons and Implications in Adaptation to Practice

Endoscopic submucosal dissection (ESD) is the preferred strategy for the resection of large superficial neoplasia throughout the gastrointestinal tract in Asian countries. The transition of ESD to the West has been slower because of various regional and training differences. Nonetheless, over the past couple of decades, the steady growth of ESD mentors in the West and the introduction of viable training pathways and dedicated devices and accessories have led to the increasing adoption of ESD and other third space endoscopic procedures.

Is peroral endoscopic myotomy the new gold standard for achalasia therapy?

Our review focuses on critical analysis of the literature to determine whether peroral endoscopic myotomy (POEM) is poised to replace laparoscopic Heller myotomy (LHM) as the new "gold standard" for achalasia therapy. POEM matches or exceeds the efficacy of LHM. The difference in objective gastroesophageal reflux disease (GERD) between POEM and LHM is modest at best and dissipates with time. Post-POEM GERD can be easily managed medically in most patients without long-term GERD sequelae or the need for surgical fundoplication. Emerging POEM technique modifications can further decrease GERD. Endoscopic antireflux procedures such as transoral incisionless fundoplication (TIF) or POEM + F (POEM + fundoplication) can be used in the rare cases of medication-refractory GERD, but their long-term efficacy remains in question. In this comprehensive review, we summarize the current status of POEM with emphasis on GERD evaluation, prevention, treatment, and comparative data vs. LHM. Based on this analysis, it appears that POEM is indeed the new gold standard in the therapy of achalasia.

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.

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.

The Journey from Endoscopic Submucosal Dissection to Third Space Endoscopy

With the advent of endoscopic submucosal dissection, a variety of endoscopic devices including knives and high-frequency electrosurgical unit have become available. In addition, the concept of natural orifice transluminal endoscopic surgery pushed flexible endoscopic surgery ahead. In this review, the birth of peroral endoscopic myotomy and its expansion into the field of submucosal endoscopy are reviewed.

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.

GERD after Peroral Endoscopic Myotomy: Assessment of Incidence and Predisposing Factors

BACKGROUND

Peroral endoscopic myotomy (POEM) is an effective intervention for achalasia, but GERD is a major postoperative adverse event. This study aimed to characterize post-POEM GERD and identify preoperative or technical factors impacting development or severity of GERD.

STUDY DESIGN

This is a retrospective review of patients who underwent POEM at our institution. Favorable outcome was defined as postoperative Eckardt score of 3 or less. Subjective GERD was defined as symptoms consistent with reflux. Objective GERD was based on a DeMeester score greater than 14.7 or Los Angeles grade C or D esophagitis. Severe GERD was defined as a DeMeester score greater than 50.0 or Los Angeles grade D esophagitis Preoperative clinical and objective data and technical surgical elements were compared between those with and without GERD. Multivariate logistic analysis was performed to identify factors associated with each GERD definition.

RESULTS

A total of 183 patients underwent POEM. At a mean ± SD follow-up of 21.7 ± 20.7 months, 93.4% achieved favorable outcome. Subjective, objective, and severe objective GERD were found in 38.8%, 50.5%, and 19.2% of patients, respectively. Of those with objective GERD, 24.0% had no reflux symptoms. Women were more likely to report GERD symptoms (p = 0.007), but objective GERD rates were similar between sexes (p = 0.606). The independent predictors for objective GERD were normal preoperative diameter of esophagus (odds ratio [OR] 3.4; p = 0.008) and lower esophageal sphincter (LES) pressure less than 45 mmHg (OR 1.86; p = 0.027). The independent predictors for severe objective GERD were LES pressure less than 45 mmHg (OR 6.57; p = 0.007) and obesity (OR 5.03; p = 0.005). The length of esophageal or gastric myotomy or indication of procedure had no impact on the incidence or severity of GERD.

CONCLUSION

The rate of pathologic GERD after POEM is higher than symptomatic GERD. A nonhypertensive preoperative LES is a predictor for post-POEM GERD. No modifiable factors impact GERD after POEM.

Natural Orifice Transanal Endoscopic Rectopexy for Complete Rectal Prolapse: Prospective Evolution of a New Technique and Short-term Outcomes

BACKGROUND

Endoluminal surgery for the management of rectal prolapse remains largely experimental.

OBJECTIVE

To evaluate the evolution and short-term outcomes of a new endoluminal technique for the management of complete rectal prolapse.

DESIGN

This was a prospective study.

SETTINGS

This study was conducted at a single tertiary care teaching center.

PATIENTS

A total of 29 patients were included. The first 12 patients underwent the procedure with our initial technique, and the last 17 patients were subjected to the new modified procedure. The follow-up duration was 3 years for the older technique and 26 months for the newer technique.

INTERVENTION

This technique involves: 1) ventral "suture" rectopexy: rectum is fixed anteriorly to the anterior abdominal wall using percutaneously placed sutures. 2) Posterior rectum is fixed to the sacral promontory using tackers through a submucosal tunnel.

MAIN OUTCOME MEASURES

Safety, recurrence, functional outcomes, morbidity, and mortality were the main outcome measures.

RESULTS

There were improvements in constipation and incontinence scores, anal manometric pressures, anorectal angle, anorectal descent, and quality of life postoperatively in both groups. In patients undergoing the modified procedure, there was a significant decrease in duration of surgery (220 ± 48.89 vs 110 ± 12.51 min), shortened hospital stay (4.6 ± 1.71 vs 2.6 ± 0.65 d), decreased recurrence (25% vs 5.8%), and complications (surgical-site infection and retrorectal abscess).

LIMITATIONS

Short follow-up, small sample size, and single-center study were the limitations.

CONCLUSION

This is a novel endoluminal technique for treating rectal prolapse obviating perirectal dissection, abdominal incisions, or a mesh. This can now be performed under complete endoscopic and fluoroscopic vision. It avoids general anesthesia and therefore can be an alternative for patients with comorbid conditions in whom the standard abdominal procedure may not be well tolerated. Larger randomized multicentric studies with longer follow-ups are warranted. See Video Abstract at http://links.lww.com/DCR/C59.

RECTOPEXIA ENDOSCPICA TRANSANAL POR ORIFICIO NATURAL PARA EL PROLAPSO RECTAL COMPLETO EVOLUCIN PROSPECTIVA DE UNA NUEVA TCNICA Y RESULTADOS A CORTO PLAZO

ANTECEDENTES:La cirugía endoluminal para el tratamiento del prolapso rectal ha permanecido en gran parte experimental.OBJETIVO:Este estudio tiene como objetivo evaluar la evolución y los resultados a corto plazo de una nueva técnica endoluminal para el manejo del prolapso rectal completo.DISEÑO:Estudio prospectivo.ÁMBITOS:Único centro docente de tercer nivel de atención.PACIENTES:Se incluyeron un total de 29 pacientes (19 hombres y 10 mujeres) con prolapso rectal completo. Los primeros 12 pacientes fueron sometidos al procedimiento con nuestra técnica anteriormente descrita y los últimos 17 pacientes fueron sometidos al nuevo procedimiento modificado. La duración del seguimiento es de 3 años para la técnica más antigua y de 26 meses para la técnica más nueva.INTERVENCIÓN:Esta técnica implica: A) Rectopexia de "sutura" ventral: el recto se fija anteriormente a la pared abdominal anterior mediante suturas colocadas percutáneamente. B) El recto posterior se fija al promontorio sacro mediante grapas a través de un túnel submucoso.PRINCIPALES MEDIDAS DE RESULTADO:Seguridad, recurrencia, resultados funcionales, morbilidad y mortalidad.RESULTADOS:Hubo mejorías en las puntuaciones de estreñimiento (ODS) e incontinencia (SMIS), presiones manométricas anales (reposo y contracción), ángulo anorrectal, descenso anorrectal y calidad de vida post operatoria en ambos grupos. En los pacientes sometidos al procedimiento modificado hubo una significativa disminución en la duración de la cirugía (220 + 48,89 vs 110 + 12,51 minutos), acortamiento de la estancia hospitalaria (4,6 + 1,71 vs 2,6 + 0,65 días), disminución de la recurrencia (25% vs 5,8%) y complicaciones (infecciónes del sitio quirúrgico y abscesos retrorrectales).LIMITACIONES:Seguimiento corto, tamaño de muestra pequeña, estudio de un solo centro.CONCLUSIÓNES:La rectopexia endoscópica transanal por orificio natural (NOTER) es una novedosa técnica endoluminal para el tratamiento del prolapso rectal que evita la disección perirrectal, las incisiones abdominales o la fijación de una malla. Este procedimiento puede realizar hoy día bajo visión completa endoscópica y fluoroscópica. Evita la anestesia general y, por lo tanto, puede ser una alternativa para pacientes con condiciones comórbidas donde el procedimiento abdominal estándar puede no ser bien tolerado. Se justifican estudios multicéntricos aleatorios más grandes con un seguimiento más prolongado para validar aún más esta nueva técnica. Consulte Video Resumen en http://links.lww.com/DCR/C59. (Traducción-Dr Osvaldo Gauto).

Evolving field of third-space endoscopy: Derivatives of peroral endoscopic myotomy

Third-space endoscopy, also known as submucosal endoscopy, allows for a wide range of therapeutic interventions within the submucosal layer and even into the muscular or subserosal layers of the gastrointestinal lumen. The technical development of peroral endoscopic myotomy (POEM) for achalasia has revolutionized the field of therapeutic endoscopy and the method has been continuously refined and modified. Although POEM has been applied to treat primary achalasia, it shows a favorable clinical response in other esophageal motility disorders and as a salvage treatment after previously failed intervention. Gastroesophageal reflux after POEM has drawn considerable attention and there have been major advancements in its prevention and management. POEM has led to advantageous derivatives such as peroral endoscopic tumor resection or submucosal tunneling endoscopic resection for resection of subepithelial lesions, Zenker POEM for hypopharyngeal diverticula, diverticular POEM for epiphrenic esophageal diverticula, and gastric POEM for refractory gastroparesis. These techniques have a similar concept, which constitutes submucosal tunneling with a mucosal flap valve and secure mucosal incision closure. The submucosal tunneling technique is widely accepted and continues to evolve. This study aimed to review in detail the indications, outcomes, and technical variations in POEM and explore several emerging submucosal tunneling procedures. This review will benefit future studies by providing a summary of recent developments in this field.

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.

Clinical study of submucosal tunneling endoscopic resection and endoscopic submucosal dissection in the treatment of submucosal tumor originating from the muscularis propria layer of the esophagus

Herein, we aimed to evaluate the clinical value and safety of transendoscopic submucosal tunnel tumor resection (STER) and endoscopic submucosal dissection (ESD) for the resection of esophageal submucosal intrinsic muscle tumors. We retrospectively analyzed the clinical data of 68 patients with esophageal submucosal intrinsic muscle tumors treated with STER (STER group, n = 38, March 2018 to January 2020) or ESD (ESD group, n = 30, January 2017 to January 2020) at the First People's Hospital of Lianyungang to compare the treatment efficacy, hospitalization time and costs, and postoperative complications between the 2 groups. All 68 cases were of single lesions. The mean operative duration was shorter in the STER group (53.39 ± 11.57 min) than in the ESD group (68.33 ± 18.52 min, P < .05). The postoperative hospital stay duration was significantly shorter in the STER group (5.86 ± 1.01 days; P < .05) than in the ESD group (8.2 ± 3.4 days, P < .05). The mean hospitalization cost was significantly lower in the STER group than in the ESD group (12,468.8 + 4966.8 yuan vs 17,033.3 ± 4547.2 yuan; P < .05). Only 1 case of intraoperative perforation occurred in ESD group. There were no other complications in both groups. The wound healed in both groups, and no residual or recurrent tumors were detected during the follow-up period. Both STER and ESD can be used for the treatment of esophageal intrinsic muscular layer (MP) tumors, and STER is safer and more efficient for lesions with a diameter <3.5 cm.

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.

Fundoplication in laparoscopic Heller's cardiomyotomy for achalasia

BACKGROUND

Laparoscopic Heller's cardiomyotomy (LHC) is the preferred treatment of achalasia. It improves dysphagia by dividing muscles of the lower oesophageal sphincter, but this intervention can result in debilitating gastro-oesophageal reflux symptoms in some patients. To prevent these reflux symptoms, most surgeons add a fundoplication to Heller's cardiomyotomy, but there is no consensus regarding this or the type of fundoplication which is best suited for the purpose.

OBJECTIVES

To assess how the addition of a fundoplication affects postoperative reflux and dysphagia in people undergoing LHC and compare the different types of fundoplications used in combination with LHC to determine which is better at controlling reflux without worsening the dysphagia.

SEARCH METHODS

We searched three databases (CENTRAL, MEDLINE and Embase) on 31 October 2021 and trial registers to identify all published and unpublished randomised controlled trials (RCTs) in any language, comparing different fundoplications used in combination with LHC to treat achalasia. We also included RCTs where LHC with a fundoplication is compared with LHC without any fundoplication.

SELECTION CRITERIA

We only included RCTs which recruited adult participants with achalasia undergoing LHC with minimal hiatal dissection. We excluded non-randomised studies or studies involving paediatric participants. We also excluded studies where the procedure was done by open surgery and where circumferential hiatal dissection of the oesophagus was carried out, unless it was necessary to reduce a hiatus hernia or to facilitate a Toupet or Nissen fundoplication.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified studies to be included, assessed risk of bias using the Cochrane RoB 1 tool, and extracted the data. We calculated the risk ratio (RR) with 95% confidence interval (CI) using both fixed-effect and random-effect models with Review Manager (RevMan) software.

MAIN RESULTS

We included eight studies in this review, with a total of 571 participants with an average age of 45 years (range 33.5 to 50). LHC without any fundoplication was performed in 65 (11.3%) participants, 298 (52.1%) had Dor fundoplication, 81 (14.1%) had Toupet fundoplication, 72 (12.6%) had Nissen's fundoplication, and 55 (9.6%) participants had angle of His accentuation. Three studies with a total of 143 participants compared LHC + Dor to LHC without fundoplication. We found that the evidence is very uncertain as to whether the addition of a Dor fundoplication made any difference to the outcome of postoperative pathological acid reflux (RR 0.37, 95% CI 0.07 to 1.89; I2 = 56%; 2 studies, 97 participants; very low-certainty evidence) and uncertain for severe postoperative dysphagia (RR 3.00, 95% CI 0.34 to 26.33; I2 = 0%; 3 studies, 142 participants; low-certainty evidence). Three studies with 174 participants compared LHC + Dor to LHC + Toupet. The evidence suggests that there may be little to no difference in the outcomes of postoperative pathological acid reflux (RR 0.75, 95% CI 0.23 to 2.43; I2 = 60%; 3 studies, 105 participants; low-certainty evidence) and severe postoperative dysphagia (RR 0.78, 95% CI 0.19 to 3.15; I2 = 0%; 3 studies, 123 participants; low-certainty evidence) between the two interventions, but the certainty of the evidence is low. One study with 138 participants compared LHC + Dor to LHC + Nissen. Nissen fundoplication caused increased severe postoperative dysphagia (RR 0.19, 95% CI 0.04 to 0.83; 1 study, 138 participants; high-certainty evidence) when compared to Dor fundoplication. This study did not show a difference in postoperative pathological acid reflux (RR 4.72, 95% CI 0.23 to 96.59; 1 study, 138 participants; low-certainty evidence), but the certainty of evidence is low. One study with 110 participants compared LHC + Dor with LCH + angle of His accentuation, and reported that severe postoperative dysphagia was similar between the two interventions (RR 1.56, 95% CI 0.27 to 8.95; 1 study, 110 participants; moderate-certainty evidence), with moderate certainty of evidence. This study did not report on postoperative pathological acid reflux.

AUTHORS' CONCLUSIONS

When LHC was performed with minimal hiatal dissection, we were very uncertain whether the addition of a Dor fundoplication made a difference in controlling postoperative reflux, and we were uncertain if it increased the risk of severe postoperative dysphagia. There may be little to no difference in the outcomes of postoperative pathological acid reflux or severe dysphagia between Dor and Toupet fundoplications when used in combination with LHC, but the certainty of the evidence is low. Nissen (total) fundoplication used in combination with LHC for achalasia increased the risk of severe postoperative dysphagia. The angle of His accentuation and Dor fundoplication had a similar effect on severe postoperative dysphagia when combined with LHC, but their effect on postoperative pathological acid reflux was not reported.

Impact of antibiotic prophylaxis and conditioning modalities in per-oral endoscopic myotomy for esophageal motor disorders

BACKGROUND AND AIMS

No recommendation regarding antibiotic prophylaxis and preparation modalities are available for patients with esophageal motor disorders who benefit from Per-Oral Endoscopic Myotomy (POEM). The aim of our study was to evaluate their impact on the POEM's safety.

PATIENTS AND METHODS

This study was a comparative and multicentric retrospective analysis of a database prospectively collected. Patients over 18 years old with esophageal motor disorders confirmed by prior manometry, who underwent POEM were included. The primary endpoint was the occurrence of adverse events, as classified by Cotton, based on whether or not antibiotic prophylaxis was administered.

RESULTS

A total of 226 patients (median age 52.9 ± 19.12 years [18-105], 116 women [51.3%]) were included. The indication for POEM was mainly type 2 achalasia (n = 135, 60.3%). Antibiotic prophylaxis was administered to 170 patients (75.2%) during 3.93 ± 3.46 days [1-21]. The overall adverse events rate was 9.3% (n = 21). Antibiotic prophylaxis was associated with the occurrence of adverse events (p = .003), but had no impact on their severity (p = .238). Antibiotic prophylaxis didn't influence the effectiveness of POEM (1 [0-4] vs 1 [0-9], p = .231). The use of a liquid diet in the 48 h prior to the procedure was significantly associated with a lower adverse events rate (3.1% vs 6.19%, p = .0002).

CONCLUSION

The antibiotic prophylaxis during POEM does not prevent adverse events, had no impact on their severity and the efficacy of the procedure. A liquid diet before the procedure should be systematically proposed.

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.

Virtual disease landscape using mechanics-informed machine learning: Application to esophageal disorders

Esophageal disorders are related to the mechanical properties and function of the esophageal wall. Therefore, to understand the underlying fundamental mechanisms behind various esophageal disorders, it is crucial to map mechanical behavior of the esophageal wall in terms of mechanics-based parameters corresponding to altered bolus transit and increased intrabolus pressure. We present a hybrid framework that combines fluid mechanics and machine learning to identify the underlying physics of various esophageal disorders (motility disorders, eosinophilic esophagitis, reflux disease, scleroderma esophagus) and maps them onto a parameter space which we call the virtual disease landscape (VDL). A one-dimensional inverse model processes the output from an esophageal diagnostic device called the functional lumen imaging probe (FLIP) to estimate the mechanical "health" of the esophagus by predicting a set of mechanics-based parameters such as esophageal wall stiffness, muscle contraction pattern and active relaxation of esophageal wall. The mechanics-based parameters were then used to train a neural network that consists of a variational autoencoder that generated a latent space and a side network that predicted mechanical work metrics for estimating esophagogastric junction motility. The latent vectors along with a set of discrete mechanics-based parameters define the VDL and formed clusters corresponding to specific esophageal disorders. The VDL not only distinguishes among disorders but also displayed disease progression over time. Finally, we demonstrated the clinical applicability of this framework for estimating the effectiveness of a treatment and tracking patients' condition after a treatment.

Peroral Endoscopic Myotomy for the Treatment of Esophageal Diverticula: A Systematic Review and Meta-analysis

BACKGROUND

There is limited evidence on the efficacy of peroral endoscopic myotomy (POEM) in patients with esophageal diverticula.

AIMS

This meta-analysis aimed to assess the efficacy and safety profile of POEM in patients with Zenker (ZD) and epiphrenic diverticula.

METHODS

With a literature search through August 2020, we identified 12 studies (300 patients) assessing POEM in patients with esophageal diverticula. The primary outcome was treatment success. Results were expressed as pooled rates and 95% confidence intervals.

RESULTS

Pooled rate of technical success was 95.9% (93.4%-98.3%) in ZD patients and 95.1% (88.8%-100%) in patients with epiphrenic diverticula. Pooled rate of treatment success was similar for ZD (90.6%, 87.1%-94.1%) and epiphrenic diverticula (94.2%, 87.3%-100%). Rates of treatment success were maintained at 1 year (90%, 86.4%-97.4%) and 2 years (89.6%, 82.2%-96.9%) in ZD patients. Pooled rate of symptom recurrence was 2.6% (0.9%-4.4%) in ZD patients and 0% in patients with epiphrenic diverticula. Pooled rates of adverse events and severe adverse events were 10.6% (4.6%-16.6%) and 3.5% (0%-7.4%) in ZD and 8.4% (0%-16.8%) and 8.4% (0%-16.8%) in epiphrenic diverticula, respectively.

CONCLUSION

POEM represents an effective and safe therapy for the treatment of esophageal diverticula.

Per Oral Endoscopic Myotomy (POEM) for pediatric achalasia: Institutional experience and outcomes

BACKGROUND

The surgical treatment of achalasia by both laparoscopic and endoscopic approaches has been recognized as the definitive management in children. Despite reported low volumes in many centers, there has been an increasing worldwide experience with endoscopic approaches to pediatric achalasia. The aim of this study is to report our institutional experience with per oral endoscopic myotomy (POEM) as first-line or revisional therapy for achalasia.

METHODS

An IRB approved retrospective review of all patients who underwent operative procedures for achalasia, specifically with the POEM technique, from July 2015 to September 2021. Data including demographics, intra-operative details, pre and post operative Eckardt scores, complications, outcomes, and follow-up were obtained.

RESULTS

During the study period, a total of 43 children underwent 46 operations for achalasia including POEM and laparoscopic Heller myotomy (LHM). Operations included 37 POEMS (33 primary POEMS; 3 POEMS after failed LHM; and 1 POEM after failed POEM). Additionally, 9 LHM operations including, 4 primary LHM; 3 attempted POEMS converted to LHM; 1 attempted POEM after failed LHM converted to redo LHM; and 1 LHM after failed POEM. In the POEM group (n = 37), based on the high resolution esophageal manometry findings Chicago Classification types at diagnosis were as follows: 9 patients were type I (24.3%); 25 patients were type II (67.6%); 2 patients were type III (5.9%) and 1 patient was unknown type (2.7%). Sixteen children (43.2%) had prior endoscopic treatment of achalasia prior to POEM [Pneumatic Balloon Dilatation (PBD), and/or Botox injection (BTI)],), while prior operative intervention occurred in 4 patients (10.8%), 3 LHM and 1 POEM. Age at operation was 2-18 years (mean ± SD age: 11.6 ± 4.5 years). Weight at operation 11.8-100.7 kg (mean ± SD kg; 39 ± 19.9 kg). Range of baseline Eckardt score was 4-10 (mean ± SD: 6.73 ± 1.5). Operative time was 64-359 min (mean ± SD minutes: 138.1 ± 62.2 min). Intraoperative complications occurred in 16 patients (43.2%) but did not require reoperation during index admission including: 4 mucosotomy (11.8%); 9 pneumothoraces (24.3%); 2 pneumomediastinum (5.4%); 10 pneumoperitoneum (27%); 0 sub-mucosal tunnel bleeding (0%); 0 open conversion/death (0%). Post operative complications included: 5 recurrent dysphagia (13.5%); 0 esophageal leak (0%); 3 GERD (8.1%); 1 failed POEM (2.7%). Median length of stay was 2 days (mean ± SD days: 2.4 ± 0.9 day). Follow-up ranged from 1 to 74 months (median 15 months), mean follow-up 22.6 months ± 20 months. Post POEM Eckardt score was 0.6 ± 0.9. Five patients required a single PBD post POEM (13.5%) and 1 patient required a repeat myotomy (LHM) after POEM (2.7%) for a 16.2% reintervention rate. Subsequent normalization of Eckardt scores (≤ 3) and symptomatic relief was achieved in all patients (100%).

CONCLUSIONS

POEM as first-line therapy for pediatric achalasia, or as a secondary procedure after failed prior myotomy or POEM, in our experience is safe and effective. We have shown equivalent results to our own prior experience with LHM. Long-term follow-up will be performed to monitor for recurrent symptoms, adequate physical growth, and general development.

LEVEL OF EVIDENCE

II.

Water-jet vs traditional triangular tip knife in peroral endoscopic myotomy for esophageal dysmotility: A systemic review and meta-analysis

BACKGROUND

Peroral endoscopic myotomy is an increasingly used less invasive modality to treat esophageal dysmotility. Recently, triangular tip knife with integrated water jet function has been introduced to mitigate multiple instrument exchanges.

AIM

To compare traditional triangular tip knife and water jet knife in terms of procedural success, duration, instrument exchanges, coagulation forceps use, and adverse events.

METHODS

We conducted a systemic review and meta-analysis with two authors independently in electronic databases (PubMed, Embase, and Cochrane Library) from inception through May 2021. In addition, we conducted a relevant search by Reference Citation Analysis (RCA) (https://www.referencecitationanalysis.com). A fixed-effects model was used to calculate weighted mean, odds ratio (OR), and confidence intervals (CI).

RESULTS

We included 7 studies involving 558 patients. Triangular knife and water jet knife were similar in odds of procedural success with ratio of 4.78 (95%CI = 0.22-102.47) and odds of clinical success with ratio of 0.93 (95%CI = 0.29-2.97), respectively. Water jet knife had fewer instrument exchanges compared to triangular knife (2.21, 95%CI = 1.98-2.45 vs 11.9, 95%CI = 11.15-12.70) and usage of coagulation forceps (1.75, 95%CI = 1.52-1.97 vs 2.63, 95%CI = 2.37-2.89). Adverse events were higher in triangular knife group (OR: 2.30, 95%CI = 1.35-3.95).

CONCLUSION

Peroral endoscopic myotomy using water jet knife is comparable in terms of procedural success to triangular tip knife. Water jet knife also required shorter procedural duration, less instrument exchanges, coagulation devices, and overall adverse events.

Efficacy of endoscopic clip closure for nonperforated muscle layer exposure during esophageal endoscopic submucosal dissection

Exposure of the muscle layer during endoscopic submucosal dissection (ESD) in the esophagus can lead to complications such as fever and pain. Although closure with endoscopic clips is widely used when perforation is a major complication, its value when the exposed muscle layer is not perforated is unclear. Data for 104 lesions in 104 patients who underwent esophageal ESD between 2008 and 2020 were retrospectively analyzed. Patients with multiple tumors, those who experienced procedure-related adverse events such as aspiration pneumonitis, perforation during ESD, or delayed bleeding, and those in whom the muscle layer was not exposed were excluded. The clinical course of inflammation after ESD in patients in whom the muscle layer was exposed was examined according to whether endoscopic clips were used for closure. A significantly greater number of patients had a temperature ≤ 37.5°C in the clip closure group than in the nonclip closure group (≤37.5°C/≥37.6°C, 47/14 vs. 25/18, respectively, P = 0.040). Furthermore, significantly more patients in the clip closure group had a white blood cell count ≤10,000/μL (≤10,000/μL/>10,000/μL, 51/10 vs. 21/22, P < 0.001) and a C-reactive protein level < 1.0 mg/dL (<1.0 mg/dL/≥1.0 mg/dL, 40/21 vs. 36/7, P = 0.040) in the 24 hour post-ESD. The results were not changed after propensity score matching. Closure with endoscopic clips reduces inflammation after esophageal ESD with nonperforated muscle layer exposure. Even if there is no obvious perforation during ESD, closure of the exposed muscle layer with endoscopic clips may contribute to the clinical course post-ESD.

Clinical and financial outcomes of per-oral endoscopic myotomy compared to laparoscopic heller myotomy for treatment of achalasia

BACKGROUND

Previous studies analyzing short-term outcomes for per-oral endoscopic myotomy (POEM) have shown excellent clinical response rates and shorter operative times compared to laparoscopic Heller myotomy (LHM). Despite this, many payors have been slow to recognize POEM as a valid treatment option. Furthermore, comparative studies analyzing long-term outcomes are limited. This study compares perioperative and long-term outcomes, cost-effectiveness, and reimbursement for POEM and LHM at a single institution.

METHODS

Adult patients who underwent POEM or LHM between 2014 and 2021 and had complete preoperative data with at least one complete follow up, were retrospectively analyzed. Demographic data, success rate, operative time, myotomy length, length of stay, pre- and postoperative symptom scores, anti-reflux medication use, cost and reimbursement were compared.

RESULTS

58 patients met inclusion with 25 undergoing LHM and 33 undergoing POEM. There were no significant differences in preoperative characteristics. Treatment success (Eckardt ≤ 3) for POEM and LHM was achieved by 88% and 76% of patients, respectively (p = 0.302). POEM patients had a shorter median operative time (106 min. vs. 145 min., p = 0.003) and longer median myotomy length (11 cm vs. 8 cm, p < 0.001). All LHM patients had a length of stay (LOS) ≥ 1 day vs. 51.5% for POEM patients (p < 0.001). Both groups showed improvements in dysphagia, heartburn, regurgitation, Eckardt score, GERD HRQL, RSI, and anti-reflux medication use. The improvement in dysphagia score was greater in patients undergoing POEM (2.30 vs 1.12, p = 0.003). Median hospital reimbursement was dramatically less for POEM ($3,658 vs. $14,152, p = 0.002), despite median hospital costs being significantly lower compared to LHM ($2,420 vs. $3,132, p = 0.029).

RESULTS

POEM is associated with a shorter operative time and LOS, longer myotomy length, and greater resolution of dysphagia compared to LHM. POEM costs are significantly less than LHM but is poorly reimbursed.

Evaluation of the safety profile of endoscopic pyloromyotomy by G-POEM: a French multicenter study

BACKGROUND

Gastric per oral endoscopic esophageal myotomy (G-POEM) is a promising procedure to treat refractory gastroparesis. The safety profile of G-POEM is an important topic because gastroparesis is a functional pathology, with a procedure whose effectiveness is between 50 and 65% depending on the studies.

OBJECTIVES

We present this retrospective multicenter study, with the aim of establishing a safety profile, focusing on serious adverse events (AEs).

DESIGN

This was a multicenter observational cohort study conducted in five French expert centers.

METHODS

All patients who underwent G-POEM for refractory gastroparesis between 2015 and 2021 were included for analysis. AEs were classified into per endoscopic, early postoperative, and late postoperative, up to 1 month. Their severity was assessed using Dindo-Clavien and American Society for Gastrointestinal Endoscopy classification. The primary objective was to evaluate the rate of G-POEM severe AEs. Secondary objectives were to document other postoperative AEs, and to identify predictive factors.

RESULTS

In all, 217 patients were included: 81 men and 136 women, mean age 52 ± 17 years. The average procedural time was 44 ± 14 min (12-78). The average hospital stay was 3.7 ± 2.3 days. The AEs rate classified as Clavien-Dindo ⩾3 was 0.4% (one delayed bleeding requiring blood transfusion and endoscopic management). There were no deaths or patients admitted to intensive care unit. The rates of mucosotomy and capnoperitoneum were 3.7 and 1.8%, respectively, without clinical consequences. Most patients (81.5%) did not experience any AE. Three cases of dumping syndrome occurred, quickly managed by dietary measures.

CONCLUSION

Our study confirms the safety of G-POEM with less than 0.5% of serious AEs, medically managed. This outcome makes this a procedure to have a good benefit-risk ratio.

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.

Risks of refractory chest pain after peroral endoscopic myotomy in achalasia-related esophageal motility disorders: short-term results from a multicenter study in Japan

BACKGROUND AND AIMS

The etiology of chest pain in achalasia-related esophageal motility disorders and the frequency and risk factors of persistent chest pain after peroral endoscopic myotomy (POEM) remain unclear.

METHODS

A multicenter cohort study including 14 hospitals was conducted to elucidate the characteristics of patients with chest pain and the efficacy of POEM.

RESULTS

Consecutive cases of achalasia-related esophageal motility disorders included 2294 (64.2%) and 1280 (35.8%) patients with and without chest pain, respectively. Among the 2107 patients with chest pain who underwent POEM, we observed complete remission in 1464 patients (69.5%) and nonremission in 643 patients (30.5%), including a partial response in 619 patients (29.4%) and resistance in 24 patients (1.1%). Multivariate analysis revealed that advanced age (odds ratio [OR], .28), male sex (OR, .70), prior treatment (OR, 1.39), and sigmoid type (OR, .65) were related to the prevalence of chest pain. Long disease duration (OR, .69) and esophageal dilation (OR, .79) were related to decreased severity. POEM improved patients' quality of life that was hindered by chest pain. Early onset (OR, 1.45), advanced age (OR, .58), male sex (OR, .79), prior treatment (OR, 1.37), and posterior myotomy (OR, 1.42) were associated with nonremission after POEM; high-resolution manometry (HRM) findings and myotomy length showed no statistical significance on pain etiology and persistence after POEM.

CONCLUSIONS

The prevalence and severity of chest pain were dependent on age, sex, disease duration, prior treatment, and esophageal morphology rather than HRM findings. The efficacy of POEM is satisfactory; however, residual pain was often observed. Excessively long myotomy can be avoided, and anterior myotomy may be recommended.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Peroral endoscopic myotomy vs laparoscopic myotomy and partial fundoplication for esophageal achalasia: A single-center randomized controlled trial

BACKGROUND

Achalasia is a rare benign esophageal motor disorder characterized by incomplete relaxation of the lower esophageal sphincter (LES). The treatment of achalasia is not curative, but rather is aimed at reducing LES pressure. In patients who have failed noninvasive therapy, surgery should be considered. Myotomy with partial fundoplication has been considered the first-line treatment for non-advanced achalasia. Recently, peroral endoscopic myotomy (POEM), a technique that employs the principles of submucosal endoscopy to perform the equivalent of a surgical myotomy, has emerged as a promising minimally invasive technique for the management of this condition.

AIM

To compare POEM and laparoscopic myotomy and partial fundoplication (LM-PF) regarding their efficacy and outcomes for the treatment of achalasia.

METHODS

Forty treatment-naive adult patients who had been diagnosed with achalasia based on clinical and manometric criteria (dysphagia score ≥ II and Eckardt score > 3) were randomized to undergo either LM-PF or POEM. The outcome measures were anesthesia time, procedure time, symptom improvement, reflux esophagitis (as determined with the Gastroesophageal Reflux Disease Questionnaire), barium column height at 1 and 5 min (on a barium esophagogram), pressure at the LES, the occurrence of adverse events (AEs), length of stay (LOS), and quality of life (QoL).

RESULTS

There were no statistically significant differences between the LM-PF and POEM groups regarding symptom improvement at 1, 6, and 12 mo of follow-up (P = 0.192, P = 0.242, and P = 0.242, respectively). However, the rates of reflux esophagitis at 1, 6, and 12 mo of follow-up were significantly higher in the POEM group (P = 0.014, P < 0.001, and P = 0.002, respectively). There were also no statistical differences regarding the manometry values, the occurrence of AEs, or LOS. Anesthesia time and procedure time were significantly shorter in the POEM group than in the LM-PF group (185.00 ± 56.89 and 95.70 ± 30.47 min vs 296.75 ± 56.13 and 218.75 ± 50.88 min, respectively; P = 0.001 for both). In the POEM group, there were improvements in all domains of the QoL questionnaire, whereas there were improvements in only three domains in the LM-PF group.

CONCLUSION

POEM and LM-PF appear to be equally effective in controlling the symptoms of achalasia, shortening LOS, and minimizing AEs. Nevertheless, POEM has the advantage of improving all domains of QoL, and shortening anesthesia and procedure times but with a significantly higher rate of gastroesophageal reflux.

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.

Peroral Endoscopic Myotomy (POEM) in Children: A State of the Art Review

Esophageal achalasia is a relatively rare disease in children that has been treated with balloon dilatation, botulinum toxin injection, and Heller myotomy. Peroral endoscopic myotomy (POEM) is another treatment that has been successfully employed to treat adults with achalasia for over a decade and has been increasingly used in children. This State of the Art Review from the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Endoscopy Committee reviews the current literature in pediatric POEM including the technique, success rate, complications as well as training guidelines. Though there is limited data, POEM in children has shown encouraging success rates and with further study may become the mainstay of pediatric achalasia 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.

Evolution and evidence-based adaptations in techniques for peroral endoscopic myotomy for achalasia

Achalasia is an esophageal motility disorder characterized by impaired lower esophageal sphincter (LES) relaxation and failed peristalsis. Common clinical manifestations include dysphagia to solid and liquid foods, chest pain, regurgitation, and weight loss, resulting in significant morbidity and healthcare burden. Historically, surgical Heller myotomy and pneumatic dilation were the first-line therapeutic options for achalasia. This convention was shaken in 2009 when Inoue and colleagues introduced an endoscopic approach to dissect the muscle fibers of the LES, known as peroral endoscopic myotomy (POEM). Since incorporation of POEM into standard practice, the overall myotomy technique has remained unchanged; however, adaptations in the thickness and length of myotomy have evolved. Full-thickness myotomy is recognized to have similar clinical success and faster procedure times compared with selective circular muscle myotomy. Although myotomy length for type 1 and type 2 achalasia has classically been >6 cm, recent studies demonstrated similar outcomes with reduction of myotomy length to <3 cm. Length of myotomy for type 3 achalasia has been tailored to treat the entire length of spastic muscle segment, and the modality to gauge the optimal thickness and length of myotomy in this group has yet to be established. In addition to changes in POEM technique, the postoperative management of POEM has also changed, favoring reduced postprocedure imaging, antibiotic use, and hospitalizations.

Triple A syndrome-related achalasia treated by per-oral endoscopic myotomy: Three case reports

BACKGROUND

Triple A syndrome is a rare autosomal recessive disease characterized by adrenocorticotropic hormone-resistant adrenal insufficiency, alacrima and achalasia. In the last 5 years, per-oral endoscopic myotomy (POEM) has proved highly successful in treating primary achalasia over the long term, but its long-term performance has not been certified by achalasia related to Triple A syndrome.

CASE SUMMARY

Triple A syndrome is a rare autosomal recessive disease characterized by adrenocorticotropic hormone-resistant adrenal insufficiency, alacrima and achalasia. In the past 5 years, POEM has proved highly successful in treating primary achalasia over the long term, but its long-term performance has not been certified by achalasia related to Triple A syndrome. Eckardt scores and esophageal manometry improved significantly during the 2 years following POEM; however, grade-A reflux esophagitis recurred in 66.7% of patients in 12 mo post-procedure.

CONCLUSION

Based on these case studies, POEM is efficacious and safe for a treatment of achalasia associated with Triple A syndrome.

Esophageal Achalasia: From Laparoscopic to Robotic Heller Myotomy and Dor Fundoplication

Objective:

Laparoscopic Heller myotomy and Dor fundoplication has become the gold standard in treating esophageal achalasia and robotic surgical platform represents its natural evolution. The objective of our study was to assess durable long-term clinical outcomes in our cohort.

Methods and Procedures:

Between June 1, 1999 and June 30, 2019, 111 patients underwent minimally invasive treatment for achalasia (96 laparoscopically and 15 robotically). Fifty-two were males. Mean age was 49 years (20 – 96). Esophageal manometry confirmed the diagnosis. Fifty patients underwent pH monitoring study, with pathologic reflux in 18. Preoperative esophageal dilation was performed in 76 patients and 21 patients received botulin injection. Dysphagia was universally present, and mean duration was 96 months (5 – 480).

Results:

Median operative time was 144 minutes (90 – 200). One patient required conversion to open approach. Four mucosal perforations occurred in the laparoscopic group and were repaired intraoperatively. Seven patients underwent completion esophageal myotomy and added Dor fundoplication. Upper gastrointestinal series was performed before discharge. Median hospital stay was 39 hours (24 – 312). Median follow up was 157 months (6 – 240), and dysphagia was resolved in 94% of patients. Seven patients required postoperative esophageal dilation.

Conclusions:

Minimally invasive Heller myotomy and Dor fundoplication are feasible. The operation is challenging, but excellent results hinge on the operative techniques and experience. The high dexterity, three-dimensional view, and the ergonomic movements of robotic surgery allow application of all the technical elements, achieving the best durable outcome for the patient. Robotic surgery is the natural evolution of minimally invasive treatment of esophageal achalasia.