Clinical efficacy of segmented peroral endoscopic myotomy for the treatment of achalasia

177 Variables Associated With Clinical Failure After PerOral Endoscopic Myotomy (POEM): a Case Control Study

Etiological treatment of esophageal achalasia are absent. None of the currently available treatment methods can restore normal esophageal peristalsis and the functionality of the lower esophageal sphincter, thereby alleviating dysphagia and other symptoms of achalasia. Therapeutic procedures currently used for the effective treatment of achalasia of the esophagus are represented by laparoscopic Heller's myotomy and endoscopic balloon dilatation of the esophagus. According to the literature, Heller's myotomy is considered as a method of choice in children, since it provides more reliable results in comparison with pneumatic expansion during prolonged observation. Peroral endoscopic myotomy (POEM) is a new endoscopic method for the treatment of esophageal achalasia, first reported by P. Pasricha in experiment, and then H. Inoue performed this operation in adult patients. There are only a few studies on the use of POEM in children and adolescents. Existing studies have demonstrated the feasibility of this procedure in children, low level of complications and excellent results with short-term observation. Several studies have reported high efficacy in the use of POEM in children, ranging from 90% to 100%. Reports of the occurrence of complications after POEM in children are sporadic and are represented by the formation of subcutaneous emphysema, carboperitoneum, retroperitoneum and mediastinal emphysema. Obviously, detailed studies with longer observation are required before the role of POEM in the treatment of esophageal achalasia in children can be established. If preliminary results are confirmed, POEM can be a real alternative to Heller's myotomy in pediatric patients. This study is intended to explore the potential and safety of the use of POEM for the treatment of achalasia in children based on a review of existing data in the scientific literature.

Per oral endoscopic myotomy (POEM) has recently emerged as a viable option relative to the classic approach of laparoscopic Heller myotomy (LHM) for the treatment of esophageal achalasia. In this cost-utility analysis of POEM and LHM, we hypothesized that POEM would be cost-effective relative to LHM. A stochastic cost-utility analysis of treatment for achalasia was performed to determine the cost-effectiveness of POEM relative to LHM. Costs were estimated from the provider perspective and obtained from our institution's cost-accounting database. The measure of effectiveness was quality-adjusted life years (QALYs) which were estimated from direct elicitation of utility using a visual analog scale. The primary outcome was the incremental cost-effectiveness ratio (ICER). Uncertainty was assessed by bootstrapping the sample and computing the cost-effectiveness acceptability curve (CEAC). Patients treated within an 11-year period (2004-2016) were recruited for participation (20 POEM, 21 LHM). During the index admission, the mean costs for POEM ($8630±$2653) and the mean costs for LHM ($7604±$2091) were not significantly different (P=0.179). Additionally, mean QALYs for POEM (0.413±0.248) were higher than that associated with LHM (0.357±0.338), but this difference was also not statistically significant (P=0.55). The ICER suggested that it would cost an additional $18,536 for each QALY gained using POEM. There was substantial uncertainty in the ICER; there was a 48.25% probability that POEM was cost-effective at the mean ICER. At a willingness-to-pay threshold of $100,000, there was a 68.31% probability that POEM was cost-effective relative to LHM. In the treatment of achalasia, POEM appears to be cost-effective relative to LHM depending on one's willingness-to-pay for an additional QALY.

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

Efficacy of surgical or endoscopic treatment of idiopathic achalasia: a systematic review and network meta-analysis

INTRODUCTION: Peroral endoscopic myotomy (POEM) is a relatively new innovate technique that has been shown to be an effective treatment for achalasia. Despite studies demonstrating its effectiveness as a less invasive therapy, POEM is still not as widely implemented as the traditional Heller myotomy for the treatment of achalasia. We aimed to explore the barriers that may impact implementation of POEM and to assess the regional perception of POEM amongst gastroenterologists in an urban setting. METHODS: An Internal Review Board (IRB) approved our 21-question multiple-choice survey that was developed by a panel of specialists that included a POEM trained advanced endoscopist. This was sent via email to 208 physicians practicing in the Philadelphia area. Some questions allowed for responders to select all answers that applied. RESULTS: Forty-five physicians (45/208, 21.6%) completed our online survey. Of the total 45 responders, 82.2% were male and 68.9% were practicing at an academic medical center. Approximately 73% of responders had treated anywhere from 5 to 50 patients diagnosed with achalasia during their career. Only 11% have treated over 50 patients with achalasia. In assessing what therapies these gastroenterologists have prescribed in the treatment of achalasia, the majority of responders prescribed botulinum toxin injections (86.4%) and endoscopic dilation (standard and pneumatic) (70%). In addition, 72.7% recommended surgical myotomy (laproscopic or open) while only 27.3% prescribed POEM. In fact, 69.8% of responders had never prescribed POEM even though 95.6% would consider POEM for the treatment of achalasia and 78.6% of responders believed POEM will gain acceptance as a main form of therapy. Nearly a quarter (24.4%) of responders were unaware of a program that performed POEM in the area. CONCLUSION: Although the vast majority of gastroenterologists surveyed considered POEM an acceptable therapy for the treatment of achalasia (95.6%), a significantly smaller portion of physicians had actually recommended it themselves (27.3%). A fairly significant percentage of responders were unaware of a local POEM program, which may have served as a barrier to their implementation of this therapy. Future studies will be to compare our current data to that in 18 months after establishment of a POEM program at a local academic hospital.

Objective To compare the advantage and disadvantage of peroral endoscopic myotomy (POEM) and pneumatic dilation (PD) for the treatment of achalasia of cardia (AC). Methods Patients with confirmed AC undergoing endoscopic therapy in Southwest Hospital, Third Military Medical University between January 2011 and September 2014 were divided into POEM treatment group (n=56) and PD treatment group (n=30), according to the decision of the patients and their families. Postoperative improvement of clinical symptoms, changes in the maximum esophageal diameter, complications, hospital stay, and inpatient expenses were compared between the two groups. Results No significant differences were observed in general preoperative data between the two groups, including gender, age, body mass index (BMI), maximum esophageal diameter, Eckardt score and disease duration (all P>0.05). The Eckardt score showed a significant decrease in 1, 6, and 12 months after operation compared to the pre-operation score in both groups (P 0.05). Six months after operation, the response rate between the two groups was no significantly different[93% (52/56) VS 80% (24/30), χ2=0.115, P=0.076], but the maximum esophageal diameter of the POEM group was smaller than that of the PD group (25.39±7.12 mm VS 32.12±9.99 mm, t=3.612, P=0.001). Twelve months after operation, the Eckardt score of the POEM group was lower than that of the PD group (0.44±0.85 score VS 1.26±1.74 score, t=2.940, P=0.004), and the response rate was higher in the POEM group[93% (52/56) VS 80% (24/30), χ2=0.115, P=0.076]. The incidence of pneumatic complications was 32% (18/56) in the POEM group, but none occurred in the PD group (χ2=12.195, P=0.000). The hospital stay of the POEM group and the PD group was 12.33±4.13 days and 6.50±2.28 days, respectively (W=616, P=0.000). The inpatient expense of the POEM group and the PD group was 8 013.283±4 322.695 yuan, and 1 571.018±1 590.193 yuan, respectively (W=505, P=0.000). Conclusion Both POEM and PD showed good short-term efficacy for AC. POEM is more effective, and its treatment outcome lasts longer, whereas PD has more widely indications because it is easier to operate with less complications, shorter hospital stay, and lower costs.Trail registration Chinese clinical trial registry, ChiCTR-OOC-15005889. Key words: Endoscopic therapy; Peroral endoscopic myotomy; Pneumatic dilation; Achalasia; Eckardt score

Per oral endoscopic myotomy (POEM) represents a Natural Orifice Transluminal Endoscopic Surgery (NOTES) approach to Heller myotomy. Even though we are now entering an exponential phase of growth with a large number of centers interested in POEM, published data to guide them are limited. As part of the July 2012 NOSCAR meeting, a conference was organized to review POEM and develop a consensus document. Authors SNS and TS who chaired the NOSCAR panel recognized the dearth of published data, which also may lag the rapid developments in POEM. Therefore, they undertook a survey of early POEM adopters around the world to rapidly obtain global, extensive, and current data on POEM. The raw survey data were made available to NOSCAR panel participants to assist with their presentations. We summarize the salient findings of the survey. A comprehensive POEM survey was created and tested. The final survey instrument consisted of 197 questions that covered all aspects of POEM, including operator discipline, prior training, patient selection, setting, technique preference, results, adverse events, regulatory requirements, and perspectives on the future. An automated online response collector was used. The International Per Oral Endoscopic Myotomy Survey (IPOEMS) involved 16 expert centers, 7 in North America, 5 in Asia, 4 in Europe, including all high-volume centers (≥30 POEMs per center), as of July 2012. These centers had performed 841 POEMs.There were modest variations among centers in technique and periprocedural management, but all centers uniformly reported excellent efficacy and safety outcomes. The international POEM survey provides a "global snapshot" of the experience of early adopters. The excellent outcomes over a large cumulative volume of procedures are in line with those of published small series and lend further support to the notion that POEM represents a paradigm shift in the treatment of achalasia.

Peroral Endoscopic Myotomy (POEM) is a safe treatment for esophageal achalasia with comparable safety to Heller myotomy plus fundoplication and pneumatic dilatation (PD). More data comparing POEM to Heller Myotomy plus fundoplication and pneumatic dilation are available since the previous Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guideline published on this topic in 2021. This guideline provides an update to the evidence-based guideline from SAGES published in 2021. It is intended to support clinicians, surgeons, and patients in decisions about the use of POEM for the treatment of achalasia. The panel agreed on 3 recommendations for adults with achalasia. A conditional recommendation for the use of POEM over PD was issued. Conditional recommendations included the option of using either POEM with appropriate use of proton pump inhibitors (PPIs) or HM with fundoplication to treat achalasia. POEM was favored over HM with fundoplication for achalasia subtype III. No new literature was found for children, and the previous recommendation from 2021 should be referred to for this population. POEM is a safe and effective treatment for achalasia in adults. It demonstrates greater efficacy than PD, though there are specific situations where PD may be the more appropriate choice. POEM has previously been compared to Heller myotomy, but this comparison is less relevant to modern surgical practice. Shifting the paradigm, POEM plus appropriate use of PPIs should be compared to Heller plus fundoplication. This reflection of current practice allows for a conditional recommendation for either approach in the treatment of achalasia subtypes 1 and 2, and for a preference of POEM for subtype 3.

Sa1458 PerOral Endoscopic Myotomy for the Treatment of Achalasia: a Systematic Review

Introduction. The interest in achalasia has signifi cantly increased with the advent of new methods for the diagnosis and treatment of this disease. New methods are introduced several years earlier abroad than in Russia, prospective randomized trials are conducted more often, based on the results of which clinical recommendations are established. Therefore, the authors of this article provide an extensive review of foreign literature devoted to the diagnosis and treatment of achalasia, which refl ects not only current trends, but also those areas to which researchers of past years paid attention.Results. Traditional and new diagnostic methods (timed barium swallow and high-resolution manometry) are described. The Chicago classifi cation of esophageal motility disorders version 3.0 is given. The whole spectrum of treatment of esophageal achalasia — conservative and surgical methods with analysis of immediate and long-term results, including the comparison of these methods and with the combined use of several techniques in one patient is presented. The complex problem of choosing a treatment method for the end-stage achalasia is considered. For key points in diagnosing and treating the disease, clinical guidelines on achalasia published in 2020 (European Guideline on Achalasia — UEG and ESNM recommendations) are presented.Conclusion. Esophageal achalasia is a chronic disease, for the treatment of which there is still no consensus. Balloon pneumatic dilation, peroral endoscopic myotomy and laparoscopic Heller myotomy with fundoplication are safe and highly eff ective and can be recommended for the treatment of achalasia. Currently, there is a gradual transition to a less invasive initial treatment of the end-stage achalasia, but large multicenter and randomized clinical trials are necessary to obtain fi nal data on various treatment options.

Peroral endoscopic myotomy (POEM) is an evolving therapeutic modality for achalasia. We aim to determine efficacy of POEM for the treatment of achalasia and compare it with laparoscopic Heller's myotomy (LHM). Systematic review and meta-analyses was conducted on 19 studies using POEM for achalasia. Pubmed, Medline, Cochrane, and Ovid databases, were searched using the terms 'achalasia', 'POEM', 'peroral endoscopic myotomy', 'per oral endoscopic myotomy', and 'per-oral endoscopic myotomy'. Reduction in Eckhart's score and lower esophageal sphincter (LES) pressure were the main outcome measures. A total of 1,045 patients underwent POEM in 29 studies. Ninety patients undergoing POEM was compared with 160 undergoing LHM in five studies. Nineteen and 14 studies, respectively, evaluated for Eckhart's score and LES pressure. There was significant reduction in Eckhart's score and LES pressure with effect sizes of -7.95 (p<0.0001) and -7.28 (p<0.0001), respectively. There was significant heterogeneity among the studies [(Q=83.06; I (2)=78.33%; p<0.0001) for Eckhart's score and (Q=61.44; I (2)=75.68%; p<0.0001) for LES pressure]. There were no differences between POEM and LHM in reduction in Eckhart's score, post-operative pain scores and analgesic requirements, length of hospital stay, adverse events, and symptomatic gastroesophageal reflux/reflux esophagitis. Operative time was significantly lower for POEM. POEM is effective for achalasia and has similar outcomes as LHM. Multicenter randomized trials need to be conducted to further compare the efficacy and safety of POEM between treatment naïve achalasia patients and those who failed treatment.

Clinical efficacy and safety of peroral endoscopic myotomy for esophageal achalasia: A multicenter study in Taiwan

To compare different therapeutic modalities and determine their role in the treatment of esophageal achalasia. The last 3 decades have seen a significant improvement in the diagnosis and treatment of esophageal achalasia. Conventional manometry has been replaced by high-resolution manometry, which has determined a more precise classification of achalasia in three subtypes, with important treatment implications. Therapy, while still palliative, has evolved tremendously. While pneumatic dilatation was for a long time the main choice of treatment, this approach slowly changed at the beginning of the nineties when minimally invasive surgery was adopted, initially thoracoscopically and then laparoscopically with the addition of partial fundoplication. And in 2010, the first report of a new endoscopic technique - peroral endoscopic myotomy (POEM) - was published, revamping the interest in the endoscopic treatment of achalasia. This review focuses particularly on the comparison of POEM and laparoscopic Heller myotomy (LHM) with partial fundoplication as primary treatment modality for esophageal achalasia. Based on the available data, we believe that LHM with partial fundoplication should be the primary treatment modality in most patients. POEM should be selected when surgical expertise is not available, for type III achalasia, for the treatment of recurrent symptoms, and for patients who had prior abdominal operations that would make LHM challenging and unsafe.

Since peroral endoscopic myotomy (POEM) emerged in 2010 as a treatment for achalasia, more than 7,000 procedures have been performed in the world. The main indication for POEM continues to be achalasia, which is a rare esophageal motility disorder characterized by impaired lower esophageal sphincter relaxation and aperistalsis. POEM has also been applied in other types of primary esophageal motility disorders. Short-term outcomes indicate that POEM has comparable results to laparoscopic Heller myotomy in terms of efficacy and safety. Studies show decrease in Eckardt scores after POEM as a reflection of symptomatic relief. Now, a decade after its introduction, long-term data have emerged for POEM and demonstrates that POEM remains effective and safe. Both POEM and laparoscopic Heller myotomy are associated with postinterventional gastroesophageal reflux disease (GERD). Antireflux mechanisms are disrupted during the procedures. However, the rate of GERD is higher after POEM than with laparoscopic Heller myotomy. Laparoscopic Heller myotomy is commonly performed with a partial fundoplication to reduce antireflux, but POEM is not typically combined with an antireflux procedure. Further studies should examine the long-term effects of postinterventional GERD.