Severe submucosal fibrosis - the "Achilles' heel" of peroral endoscopic myotomy

Recent Advancements and Future Perspectives of Per Oral Endoscopic Myotomy

Per oral endoscopic myotomy (POEM) has emerged as a preferred approach for the treatment of idiopathic achalasia and various esophageal motility disorders, offering a minimally invasive alternative to traditional laparoscopic Heller's myotomy. Over the past decade, POEM has solidified its status as the primary therapeutic choice in these conditions through constant improvements. Its evolution has been marked by continuous progress, driven by the integration of innovative technologies and sophisticated techniques. Notable advancements in the techniques include the advent of shorter myotomies and sling fiber-preserving gastric myotomies. The introduction of novel image-enhanced endoscopic techniques, such as red dichromatic imaging and much safer bipolar devices, promises to enhance safety and reduce the technical demands of the POEM procedure. Furthermore, significant strides have been made in understanding gastroesophageal reflux (GERD) following POEM, enabling the differentiation of "true reflux" from acidification resulting from fermentation through manual pH tracing assessment. This distinction aids in identifying cases necessitating treatment with proton pump inhibitors. Other treatment strategies of post-POEM GERD have expanded to the incorporation of NOTES fundoplication and device-assisted fundoplication if the necessity arises. This comprehensive review delves into recent developments in POEM, encompassing technical variations, the assessment and management of post-POEM reflux, outcomes in special populations, and future prospects. By exploring these facets, we aim to provide a comprehensive overview of the current state of POEM, shedding light on its evolution and the promising directions it is poised to take in the field of third-space endoscopy.

Outcomes of Per-Oral Endoscopic Myotomy in Children: A Systematic Review and Meta-analysis

Per-oral endoscopic myotomy (POEM) is an established treatment modality in adult patients with achalasia cardia. There are limited data regarding the efficacy and safety of POEM in pediatric achalasia. In this systematic review and meta-analysis, we aimed to analyze the outcomes of POEM in children and adolescents with achalasia cardia. Literature search was performed in Embase, PubMed, and Cochrane database for studies evaluating the outcome of POEM in pediatric achalasia between January 2010 and March 2021. Primary objective of the study was clinical success (Eckardt ≤ 3). Secondary outcomes included technical success, procedure duration, adverse events , and gastroesophageal reflux after POEM. A total of 14 studies (419 children, 234 boys) were included in the review. The subtypes of achalasia were type I (30.6%), type II (63.8%), and type III (5.6%). Pooled rate of technical success was 97.1% (95% CI 94.5-98.5%; I² = 0). Pooled clinical success in intention to treat and per-protocol population was 88% (95% CI 84.4-90.9%; I² = 0) and 94.4% (95% CI 91.5-96.4%; I² = 0), respectively. Post-POEM, pooled mean reduction in Eckardt scores was 6.71 (95% CI 6.14 7.28; p < 0.001; I² = 81%). Pooled rate for overall adverse events was 12.9% (95% CI 7.4-21.7%; I² 64.5%), major adverse events was 4.2% (95% CI 2.4-7.4%), and erosive esophagitis was 26.3% (95% CI 17.5-37.7%; I² 51%). POEM is an effective procedure in children with achalasia. Future studies are required to determine the durability of response and comparative outcomes with other treatment modalities for achalasia.

Double tunnel technique reduces technical failure during POEM in cases with severe submucosal fibrosis

Background and study aims  Submucosal fibrosis (SMF) is one of the major reasons for technical failure during per-oral endoscopic myotomy (POEM). In this study, we aimed to evaluate the impact of double tunnel technique (DT-POEM) on the technical success of POEM in cases with severe SMF. Patients and methods  Data from patients with achalasia in whom SMF was encountered during POEM from Jan 2013 to Jan 2020 at our center were retrospectively evaluated. The technical success and adverse events (AEs) were analyzed and compared between cases with SMF who underwent POEM via single tunnel versus DT-POEM technique. Results  A total of 1,150 patients underwent POEM during the study period. There were 14 technical failures (1.2 %). SMF and severe SMF was found in 104 (9 %) and 21 (1.8 %) patients, respectively. The majority of patients (17, 80.9 %) with severe SMF had type I achalasia. Overall, technical failures occurred in 14 cases (1.2 %) and severe SMF resulted in the majority of the technical failures (10, 71.4 %). DT-POEM was utilized in 11 cases (52.4 %) with severe SMF. The median procedure time with DT-POEM was 150 minutes (85-210). There were no major AEs and DT-POEM was technically successful in all the patients. The technical success of POEM in cases with SMF improved after the adoption of the double tunnel technique (98.4 % vs 68.3 %, P  = 0.0001). Conclusions  Severe SMF is the most common reason for technical failure during POEM. DT-POEM improves the technical success rates of POEM in patients with severe SMF.