Case of early Barrett cancer following peroral endoscopic myotomy

The evolution of the treatment of esophageal achalasia. Chronicle of a 35-year journey

Over the last few decades, significant improvement has been made in both the evaluation and treatment of esophageal achalasia. The Chicago classification, today in version 4.0, is now the standard for diagnosis of achalasia, providing a classification into 3 subtypes with important therapeutic and prognostic implications. Therapy, which was at first mostly limited to pneumatic dilatation, today includes minimally invasive surgery and peroral endoscopic myotomy, allowing for a more tailored approach to patients and better treatment of recurrent symptoms. This review chronicles my personal experience with achalasia over the last 35 years, describing the progress made in the treatment of patients with achalasia.

Peroral Endoscopic Myotomy for Achalasia in Older Adults: A Retrospective Analysis of 39 Cases with a Minimum Follow-Up of 5 Years

Peroral endoscopic myotomy (POEM) has demonstrated favorable short-term safety and efficacy in older adults, while a comprehensive understanding of the long-term outcomes were vague. We aimed to evaluate clinical outcomes in older adults' 5-year postop after undergoing POEM to treatment achalasia. Older adults from a single hospital who received POEM between January 2010 and January 2017 were analyzed. Older persons were reached to evaluate their symptoms at present and encouraged repeat examinations for objective follow-up. The clinical success, POEM-related indicators, POEM-related adverse events, and quality of life were assessed. Thirty-nine older adults with a mean age of 70.82 ± 4.72 who underwent POEM were studied at a mean 84.23 ± 25.06 month follow-up. The preoperative diagnosis was achalasia type I in 7 older adults, achalasia type II in 26 older adults, and achalasia type III in 2 older adults. Sixteen older adults had prior treatment and 21 older adults suffered from comorbidities. The median operative time was 50 (25-120) minutes, and perioperative adverse events were recorded in four older adults. The current Eckardt scores were significantly lower than that before POEM (2.08 ± 2.12 vs. 6.58 ± 1.78, P < 0.001). Besides, long-term clinical success was gained in 66.7% of older adults. Three older adults received postop treatment for symptom recurrence. Ultimately, 80.6% of old adults expressed satisfaction with POEM, while 27.8% of older adults suffered from symptomatic reflux. In conclusion, POEM can provide symptomatic improvement in a large proportion of older adults with achalasia at 5-year postop.

Update on the Diagnosis and Treatment of Achalasia

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

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

BACKGROUND AND AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Technical details and outcomes of peroral endoscopic myotomy with fundoplication: the first U.S. experience (with video)

BACKGROUND AND AIMS

Peroral endoscopic myotomy (POEM) is an established endoscopic treatment for achalasia; however, post-POEM rates of GERD remain a significant cause of concern. Single-session POEM with fundoplication (POEM-F) to treat achalasia was recently described to reduce post-POEM GERD. This study aims to report the technical feasibility, safety, and early outcomes of the first U.S. cohort of POEM-F.

METHODS

We retrospectively reviewed all patients with achalasia treated with POEM-F at our center. The primary endpoint was technical success, defined as the successful completion of all steps of the POEM-F procedure.

RESULTS

Six patients (mean age, 50 ± 4.8 years; 1 woman) underwent POEM-F for achalasia. Technical success was achieved in all patients (6/6), and no major immediate or delayed (up to 30 days postprocedure) adverse events were seen. At the 1-month follow-up visit, the mean Eckardt score decreased from 8.8 ± 1.1 to .3 ± .5. The GERD health-related quality of life and reflux symptom index scores obtained at the 1-month follow-up, with patients on proton pump inhibitors, were 2.3 ± 3.7 and 2.2 ± 2.5, respectively.

CONCLUSIONS

This first case series on POEM-F in the United States suggests that POEM-F is feasible and safe with excellent short-term outcomes.

Role of functional luminal imaging probe in the management of postmyotomy clinical failure

BACKGROUND AND AIMS

A small percentage of patients with esophageal dysmotility disorders (EDDs) fail to improve or relapse after management by laparoscopic Heller myotomy (LHM) and peroral endoscopic myotomy (POEM). In this study, we aimed to describe the role of functional luminal imaging probe (FLIP) in identifying patients who might benefit from lower esophageal sphincter (LES)-directed retreatment.

METHODS

This was a retrospective study at 6 tertiary care centers (United States, 4; Europe, 1; Asia, 1) between January 2015 and April 2021 involving patients with prior failed myotomy. The primary outcome was the impact of the use of FLIP on the management of patients with prior failed myotomy.

RESULTS

One hundred twenty-three patients (62 women [50%]; mean age, 53 ± 21.1 years) who underwent LHM (n = 53, 43%) or POEM (n = 70, 57%) for the management of achalasia (n = 98) or other EDDs (n = 25) had clinical failure at a median time of 10.8 months (interquartile range, .8-17.3) postprocedure. Twenty-nine patients had apposing "abnormal" diagnoses in terms of integrated relaxation pressure (IRP) >15 mm Hg on HRM and distensibility index (DI) <2.8 mm²/mm Hg on FLIP, with ultimate change in management noted in 15 patients (10 directed toward conservative management, 5 directed toward LES-directed retreatment). The impact of FLIP on both diagnosis and management was noted in 15 of 29 patients (52%). In the subgroup analysis of 44 patients who underwent LES-directed retreatment, clinical success was highest among patients with both abnormal IRP and DI (21/25 [84%]) versus patients with only abnormal IRP (8/14 [57%]) or only abnormal DI (3/5 [60%], P = .04), with DI at 40-mL distension volume on FLIP identified as an independent predictor of clinical success (odd ratio, 1.51; 95% confidence interval, 1.02-2.1; P = .03).

CONCLUSIONS

The finding of this study further suggests the important role of using FLIP in addition to HRM in evaluating patients with clinical failure postmyotomy.

Laparoscopic Heller Myotomy with Dor Fundoplication: An Operation that has Withstood the Test of Time

BACKGROUND

Achalasia is a primary esophageal motility disorder characterized by aperistalsis and defective relaxation of the lower esophageal sphincter in response to swallowing. Patients' symptoms include dysphagia, regurgitation, weight loss, chest pain and aspiration. The disease is idiopathic, and the goal of treatment is to eliminate the resistance determined by the abnormal lower esophageal sphincter, therefore allowing passage of the ingested food from the esophagus into the stomach. Three effective treatment modalities are available today-pneumatic dilatation, peroral endoscopic myotomy, and laparoscopic Heller myotomy with a partial fundoplication.

METHODS

We described the technique to perform a laparoscopic Heller myotomy and a Dor fundoplication.

RESULTS

Five steps to perform a laparoscopic Heller myotomy and a Dor fundoplication were described.

CONCLUSIONS

The surgical approach is favored in many centers as it is very effective in relieving symptoms, while avoiding pathologic gastroesophageal reflux in most patients.

Esophageal Achalasia: Pros and Cons of the Treatment Options

Achalasia is a primary esophageal motility disorder of unknown origin. The goal of treatment is to reduce the resistance caused by a lower esophageal sphincter that fails to relax and is frequently hypertensive. Many treatment options are available to achieve this goal. In this review, we discuss the pros and cons of each therapeutic approach.

Gastroesophageal Reflux after Peroral Endoscopic Myotomy: Myth or Reality?

Peroral endoscopic myotomy (POEM) is an accepted treatment for achalasia cardia (AC), and results are comparable to those of laparoscopic Heller myotomy (LHM). In recent years, several reports have confirmed higher incidence of gastroesophageal reflux (GER) following POEM. This review evaluates the current evidence regarding post-POEM GER, critically examines the potential contributing factors responsible for GER, limitations of the current available functional testing, and precautions and preventive measures, and provides future directions for research. Factors conclusively contributing to increased post-POEM GER include injury to the sling fibers of the lower esophageal sphincter, length of gastric myotomy > 2 cm, and others. Historically, these same factors have been implicated for development of GER after surgical (laparoscopic) myotomy. Although less invasive, optimal technique of POEM may be important to control post-POEM GER. Most post-POEM GER occurs during the immediate post-POEM period, is mild, and is easily treatable using proton-pump inhibitors. GER incidence plateaus at 2 years and is comparable to that after LHM. Patients should therefore be prescribed proton-pump inhibitors for at least 2 years. Antireflux procedures (ARPs) are infrequently required in these patients as the incidence of refractory GER is low. Novel ARPs have been recently described and are currently under evaluation. Conclusive diagnosis of GER is a clinical challenge. Most patients are asymptomatic, and GER is diagnosed only on abnormal esophageal acid exposure (EAE). Studies have demonstrated that current measures to diagnose GER are inadequate, inaccurate, and cannot differentiate between true GER and abnormal EAE due to food fermentation in the distal esophagus. The Lyon Consensus criteria should be implemented for confirmation of diagnosis of GER. Finally, the review recommends an evidence-based clinical algorithm for evaluation and management of post-POEM GER and provides guidelines for future research in this field.

Single-session endoscopic fundoplication after peroral endoscopic myotomy (POEM+F) for prevention of post gastroesophageal reflux - 1-year follow-up study

BACKGROUND

Peroral endoscopic myotomy (POEM) is an established treatment for achalasia cardia; however, post-POEM gastroesophageal reflux (GER) remains a significant problem. Concomitant endoscopic fundoplication following POEM (POEM + F) was recently described to reduce post-POEM GER. This single-center study reports short-term outcomes of POEM + F.

METHODS

This was a retrospective analysis of a prospectively maintained database of patients undergoing POEM + F. Abstracted data included demographics, achalasia type, pre-POEM Eckardt score, prior therapy, follow-up. Follow-up assessment was 3-monthly for 1 year and included post-POEM Eckardt score, GerdQ score, wrap integrity and esophagitis on esophagogastroduodenoscopy, and pH studies. GER was defined according to Lyon Consensus.

RESULTS

25 patients underwent POEM + F (mean age 40.1 years [standard deviation (SD) 13.7]; 12 females). POEM + F was technically successful in 23/25 (92.0 %). Significant dysphagia improvement was seen in all 25 patients (mean pre- and post-POEM Eckardt scores 8.21 [SD 1.08] and 0.1 [SD 0.3], respectively; P = 0.001). Mean total procedure and fundoplication times were 115.6 (SD 27.2) minutes and 46.7 (SD 12.4) minutes, respectively; times reduced significantly after the initial five cases. Median follow-up was 12 months (interquartile range [IQR] 9-13). Intact wrap was seen in 19/23 (82.6 %). GER (abnormal esophageal acid exposure time [EAET]) was seen in 2/18 (11.1 %) and there was one reported GerdQ > 8. Borderline GER (asymptomatic grade A esophagitis, normal EAET) was identified in 4/22 (18.2 %). Three (12.0 %) minor delayed adverse events occurred but required no intervention. CONCLUSIONS : POEM + F was safe and reproducible. At 12 months' follow-up, incidence of post-POEM + F GER was low and acceptable.

Long-term Outcomes of Per-oral Endoscopic Myotomy in Spastic Esophageal Motility Disorders: A Large, Single-Center Study

BACKGROUND AND AIMS

Spastic esophageal motility disorders (SEMD) are a rare group of motility disorders including type III achalasia, distal esophageal spasm (DES), and Jackhammer esophagus (JHE). Limited data suggest that per-oral endoscopic myotomy (POEM) may be effective in these disorders. In this study, we aimed to evaluate the long-term outcomes of POEM in SEMD.

METHODS

The data of patients with SEMD who underwent POEM (January 2013 to December 2019) were analyzed, retrospectively. The following outcomes were recorded: POEM procedure details, technical and clinical success, adverse events, and gastroesophageal reflux disease (GERD). Clinical success was classified as immediate (<1 y), short-term (1 to 3 y), medium term (3 to 5 y), and long-term (>5 y).

RESULTS

A total of 1115 POEM procedures were performed during the study period for achalasia and nonachalasia spastic motility disorders. POEM was performed for SEMD in 74 (6.6%) patients including type III in 53, DES in 11, and JHE in 10 patients. Technical success was achieved in all the patients. The median follow-up for the entire group was 47.5 months (range: 2 to 77 mo). Clinical success at short-term (1 to 3 y) and long-term follow-up (>5 y) was attained in 85.2% and 82.6% patients, respectively. There was no significant difference in the clinical success between type III achalasia and JHE/DES. Mild and moderate adverse events were recorded in 21 (28.4%) cases. GERD was detected in 23 (56.1%) patients with 24-hour pH study. Erosive esophagitis and symptomatic GERD were found in 36 (48.6%) and 16 (21.6%) patients, respectively.

CONCLUSIONS

POEM is a safe, effective, and durable treatment modality for spastic motility disorders of the esophagus. However, GERD is found in about half of the patients mandating close monitoring after POEM.

Single session per oral endoscopic myotomy and trans oral incisionless fundoplication - can we prevent reflux in patients with achalasia?

Background and study aims  The rate of gastroesophageal reflux disease (GERD) after per oral endoscopic myotomy (POEM) is concerning. Endoscopic anti-reflux methods, such as Trans Oral Incisionless Fundoplication (TIF), are crucial for the long-term success of POEM, especially if they can be performed in the same session. Methods  We completed a proof-of-concept canine pilot study (n = 6) to assess safety and feasibility of POEM and TIF in a single session (POEM-TIF). Subsequently, POEM-TIF was also performed in patients with achalasia (n = 5). Herein, we report on the safety, technical and clinical success of the first-in-human cases with symptom follow-up at 1, 3 and 6 months and pH testing at 6 months. Results  POEM was completed successfully in six canines (3 anterior and 3 posterior myotomies), followed by TIF in the same session. Necropsy and extensive testing demonstrated no evidence of mucosal injury and no leaks. The reconstructed valve was 220 to 240 degrees, 3 to 4 cm in length, and resulted in concomitant esophageal lengthening (2-5 cm). Using similar principles, the first-in-human cases were performed without intraprocedural or delayed adverse events. pH testing at 6 months showed that four of five patients had no evidence of GERD (DeMeester > 14.72), and in one case, there was evidence of esophagitis. Conclusions  Single session POEM-TIF appears to be safe and feasible. Early clinical human data suggests that it may be able to reduce post POEM GERD, however the additional secondary benefits such as lengthening and straightening of the esophagus, may prove to be equally important for the long-term success of POEM.

Insights into the endoscopic management of esophageal achalasia

Achalasia is a primary esophageal motility disorder characterized by the loss of inhibitory neurons in the myenteric plexus, resulting in impaired relaxation of the esophagogastric junction. Achalasia is an incurable disease, and the treatment modalities are aimed at disruption of the esophagogastric junction and vary widely from pharmacological to endoscopic to surgical. Traditional endoscopic therapy includes pneumatic dilation, botulinum toxin injection, and peroral endoscopic myotomy. This review aims to provide an overview of the endoscopic management of achalasia, while focusing on the utilization of peroral endoscopic myotomy and other novel approaches.

Outcomes of anterior versus posterior peroral endoscopic myotomy 2 years post-procedure: prospective follow-up results from a randomized clinical trial

BACKGROUND

Peroral endoscopic myotomy (POEM) is considered a primary treatment modality for achalasia. It can be performed using either the anterior or posterior approach. A previous randomized clinical trial (RCT) showed that the posterior approach was noninferior to the anterior approach at 1 year post-POEM in terms of clinical success, rate of adverse event, and risk of gastroesophageal reflux disease (GERD). The aim of this post-RCT study was to compare outcomes at ≥ 2 years post-POEM.

METHODS

Patients who previously completed the 1-year follow-up were contacted and their Eckardt, dysphagia, and GERD questionnaire (GERDQ) scores and frequency of proton pump inhibitor use were recorded. Clinical success was defined as an Eckardt score < 3.

RESULTS

150 patients were initially randomized and 138 completed the 1-year follow-up. Of the 138, 111 (anterior group 54, posterior group 57) also completed ≥ 2 years of follow-up, with an overall clinical success decrease from 89 % to 82 %. At ≥ 2 years post-POEM, clinical success was achieved in 46/54 (85 %) and 45/57 (79 %) in the anterior and posterior groups, respectively (P = 0.43). A similar decrease in clinical success was noted in both groups at ≥ 2 years (anterior: 90 % to 85 %; posterior 89 % to 79 %; P = 0.47). GERDQ score was 6 (interquartile range 6 - 8; P = 0.08) in both treatment groups.

CONCLUSIONS

The anterior and posterior POEM techniques remained equally effective at 2 years and decreases in efficacy were similar between the two approaches over time. GERD outcomes were also similar in both groups during medium-term follow-up.

Achalasia and esophageal cancer: a large database analysis in Japan

BACKGROUND

Achalasia has been reported to be associated with esophageal cancers (ECs). However, owing to the rarity of achalasia, details of achalasia-related ECs are not well investigated.

METHOD

The incidence of ECs in Japanese patients with achalasia and achalasia-related esophageal motility disorders (EMDs) was estimated, and risk factors for achalasia-related ECs were determined. Characteristics of ECs and treatment courses were also analyzed.

RESULTS

Between 2010 and 2019, 2714 Japanese patients with achalasia and achalasia-related EMDs were recorded in 7 high-volume centers; 24 patients (21 men, 3 women) developed ECs. The incidence of ECs was estimated at 0.078 and 0.28 per 100 person-years from the onset and the diagnosis of disease, respectively. Kaplan-Meier estimate suggested that, in addition to a long history of achalasia, advanced age, male sex, and regular alcohol consumption were statistically significant risk factors for EC development. A prevalence of 40 ECs (12.5% multiple lesions, and 22.7% metachronal lesions) was also noted, predominantly distributed over the thoracic esophagus. All were histologically diagnosed as squamous cell carcinoma. Superficial ECs were successfully treated with endoscopic treatment in all cases, except one. Achalasia-related Barret esophagus was extremely rare, and Barret adenocarcinoma was not detected in our cohort.

CONCLUSION

The high relative risk of ECs was clarified in Japanese achalasia patients, although the absolute risk remained low. Therefore, surveillance endoscopy may be recommended in limited patients with several aforementioned risk factors determined. Superficial cancer can be treated with endoscopic treatment. Multiple and metachronal ECs should be screened.

Gastroesophageal reflux after per-oral endoscopic myotomy is frequently asymptomatic, but leads to more severe esophagitis: A case-control study

Background and aim

The incidence of gastroesophageal reflux disease (GERD) is high after per‐oral endoscopic myotomy (POEM). GERD after POEM may be qualitatively different from GERD in patients without motility disorders. In this study, we aimed to analyze and compare different aspects of GERD between patients with post‐POEM GERD and nonachalasia GERD.

Methods

The data of patients with GERD after POEM (January 2018 to June 2019) were compared with that of a control group (nonachalasia GERD group), which included patients presenting with typical reflux symptoms without associated major motility disorders. Patients with lower esophageal sphincter pressure lower than 10 mmHg were excluded from the study. GERD was evaluated at 3 months after POEM. Esophageal acid exposure time higher than 4.2% was used to define GERD. The primary outcome of the study was comparison of GERD‐related quality of life and reflux symptom severity between the two groups. In addition, the severity of erosive esophagitis and reflux‐symptom association were also recorded in the two groups.

Results

A total of 100 patients were included in the study, with 50 patients in each group (post‐POEM GERD vs. controls). The baseline parameters were comparable between the two groups. Median interquartile range of GERD‐related quality of life score was significantly lower in the post‐POEM group (11 [0–23.3] versus 34 [24–44]; p < 0.001). The post‐POEM GERD group had significantly lower median heartburn (6.0 [0–16.3] versus 15.5 [7.5–24.8]; p = 0.001) and regurgitation scores (0 [0–6.0] versus 20.0 [12.3–25.0]; p < 0.001). Erosive esophagitis was more frequent in the post‐POEM group (28 [56%] versus 10 [20.4%], p = 0.001). Only three (6%) patients in the post‐POEM group had a positive reflux‐symptom association as compared with 28 (56%) patients in the control group (p < 0.001).

Conclusion

In selected patients with pH positive GERD after POEM, the symptoms are milder and reflux‐symptom association is poor in spite of more severe esophagitis as compared with controls.

What is known

Gastroesophageal reflux disease (GERD) after per‐oral endoscopic myotomy (POEM) is common and subclinical

Data on GERD related quality of life and reflux‐symptom association after POEM is limited.

What is new here

Reflux symptoms after POEM are milder and have poor association with reflux episodes

Triviality of symptoms despite high acid exposure and severe esophagitis suggests esophageal hyposensitivity

Surgical management of achalasia

Esophageal achalasia is a primary esophageal motility disorder characterized by lack of peristalsis and by incomplete or absent relaxation of the lower esophageal sphincter in response to swallowing. The cause of the disease is unknown. The goal of treatment is to eliminate the functional outflow obstruction at the level of the gastroesophageal junction, therefore allowing emptying of the esophagus into the stomach. They include the laparoscopic Heller myotomy with partial fundoplication, pneumatic dilatation, and peroral endoscopic myotomy. Esophagectomy is considered as a last resort for patients who have failed prior therapeutic attempts. In this evidence and experience-based review, we will illustrate the technique and results of the surgical treatment of esophageal achalasia and compare it to the other available treatment modalities.

Antireflux Surgery for Gastroesophageal Reflux Refractory to Medical Treatment After Peroral Endoscopic Myotomy

Background: Between 1995 and 2010, the laparoscopic Heller myotomy (LHM) was considered in most centers the treatment of choice for esophageal achalasia. The technique evolved over time, and the initial thoracoscopic approach was abandoned in favor of LHM with the addition of a fundoplication, due to the high incidence of postoperative reflux. Recently, a new endoscopic technique has been adopted in the treatment of achalasia-peroral endoscopic myotomy (POEM), which has slowly become the preferred treatment modality in many centers. While POEM is as effective as LHM in relieving symptoms, it has been associated with a very high rate of pathological reflux, development of strictures, Barrett's esophagus, and adenocarcinoma. In addition, many patients still complain of heartburn and regurgitation even when treated with high doses of proton pump inhibitors. Methods: We described 3 cases of achalasia patients with reflux symptoms refractory to medical treatment after POEM who underwent laparoscopic antireflux surgery. Results: The operations were completed laparoscopically despite presence of mediastinal adhesions, probably secondary to micro-leaks during POEM. All patients had resolution of their symptoms. Conclusions: This is the first report that describes patients who developed severe heartburn and regurgitation refractory to medical treatment following POEM, who eventually underwent a laparoscopic partial fundoplication with resolution of their symptoms. Our experience shows that post-POEM reflux is a serious concern, especially when refractory to medical treatment. We feel that this is a worrisome problem that will require frequent surgical interventions in the future.

Third Space Endoscopy: Lessons Learnt From a Decade of Submucosal Endoscopy

The field of third space endoscopy (TSE), also called 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. Since the first description of per-oral endoscopic myotomy (POEM) for the treatment of achalasia cardia 10 years ago, this field has expanded rapidly. Several new procedures, submucosal tunneling endoscopic resection, gastric-POEM, Zenker POEM, per-rectal endoscopic myotomy, diverticular POEM, and recanalization for complete esophageal obstruction (per-oral endoscopic tunneling for restoration of the esophagus), have been performed. All TSE procedures employ a similar technique-after a mucosal incision, a submucosal tunnel is created, a myotomy is performed, or a subepithelial tumor is resected distal to the site of mucosal incision, after which the mucosal incision is closed. Potential indications for TSE include resection of subepithelial tumors in the esophagus, gastroesophageal junction, or stomach; refractory gastroparesis; Zenker diverticulum; Hirschsprung disease or other forms of megacolon; and recanalization for complete esophageal obstruction. Data are currently available for POEM, submucosal tunneling endoscopic resection, and gastric-POEM, although mainly in the form of retrospective studies, and randomized trials and long-term follow-up data are limited. Submucosal endoscopy has an excellent safety profile with very few intraoperative adverse events, the majority being related to insufflation, although bleeding, perforation, and sepsis have been reported. TSE procedures require special training and have demonstrated a learning curve.

The Treatment of Esophageal Achalasia: At the Intersection Between Innovation and Patient's Care

Innovation is of critical importance for the progress of medicine in general, and of surgery in particular. The introduction of minimally invasive surgery 30 years ago determined a revolution in the way we treat surgical diseases today, as most operations are now performed avoiding large incisions, with a consequent decrease in postoperative pain, shorter hospital stay, and a faster return to daily activities. However, for any innovation to become standard of care, the following criteria must be met: (1) Is it feasible? (2) Is it safe? (3) Does it offer clinical advantages to patients and the health care system? The treatment of esophageal achalasia represents an example of an innovation-per oral endoscopic myotomy-that although feasible and safe has become the standard of care without clear proof that it improves patients' outcome and provides an advantage for the health care system. The review of the treatment of esophageal achalasia during the past 30 years will shed light on this controversial dichotomy-innovation versus patient's care.