Per-oral endoscopic myotomy: Hope at the end of the tunnel

Abstract

Achalasia is a primary oesophageal motor disorder with absence f peristalsis usually associated with defective relaxation of the ower oesophageal sphincter (LES) [1]. This condition results n dysphagia, regurgitation, pain, undernutrition and potential ulmonary complications. Achalasia is also associated with an ncreased risk of oesophageal squamous cell carcinoma. Because chalasia may be refractory to systemic (calcium channel blockrs) and local (botulinum toxin injection) pharmacological agents, echanical disruption of the LES is currently the best long-term herapeutic option [1]. A recent meta-analysis showed that pneuatic dilation has clinical success rate of 88%, 70% and 29% after , 5 and 10 years, respectively, with a perforation rate of 2%. aparoscopic Heller myotomy, usually combined with an antireflux rocedure, shows 77–100% success rates after 3 years, but these ecline over time. A prospective, randomized, multicenter Euroean trial comparing graded pneumatic dilation to laparoscopic eller myotomy in 201 patients concluded similar therapeutic sucess rates in the 2 groups (reduction in the Eckardt score of below after 2 years in 86% and 90%, respectively). Either treatment can herefore be proposed as initial therapy [1]. Peroral endoscopic myotomy (POEM) has recently been introuced as a new treatment for achalasia. Briefly, POEM is a three-step rocedure. Step one is the creation of a submucosal oesophageal unnel to reach the LES. Step two consists in the precise cutting f the circular muscle bundles over a 7 cm oesophageal and 2 cm astric length. Step three is the clip closure of the entry point of he submucosal tunnel. From a technical point of view, POEM is at he merging of Natural Orifice Translumental Endoscopic Surgery NOTES) and endoscopic submucosal dissection. POEM developed rom a proof-of-concept series of experiments on transoesophageal OTES where investigators aimed to access the mediastinum using submucosal endoscopy with a mucosal flap safety valve technique 2]. Inoue et al., from Yokohama, Japan, reported on the first clinical eries of POEM including 17 patients: a 100% clinical success rate hat correlated well with significant reduction in LES pressure in all atients. No complication was noted. The median length of stay was ve days [3]. Since that initial study, there is now a rapidly growing