Outcomes Of Peroral Endoscopic Myotomy Research Articles

Sex/Gender Differences in Esophageal Motility Disorders

Esophageal motility disorders are relatively rare and are attributed to an imbalance between the excitatory and inhibitory nerves that innervate the esophagus. These disorders include achalasia, distal esophageal spasms, and jackhammer esophagus. The prevalence of achalasia is equal in men and women; however, lower esophageal hypermotility disorders are slightly more common in women. Women with achalasia experience chest pain more frequently, whereas men tend to have high lower esophageal sphincter pressure. Additionally, women with achalasia respond better to pneumatic balloon dilatation than men. However, research on sex and gender differences in the outcomes of peroral endoscopic myotomy remains insufficient. Future studies should investigate the differences in outcomes, complications, and long-term effects to ensure optimal treatment in men and women with esophageal motility disorders. This research will be useful to develop sex-tailored treatments for esophageal motility disorders.

ThP3.5 - A systematic review of comparing the outcomes of per-oral endoscopic myotomy vs pneumatic dilation in patients diagnosed with achalasia

Abstract Objective The objective of this meta-analysis is to compare the success rate of per-oral endoscopic myotomy (POEM) versus pneumatic dilation (PD) for patients with achalasia. Methods Studies reporting success rates and symptoms in patients undergoing POEM versus PD were selected from medical electronic databases and meta-analysis was conducted by following the guidelines of the Cochrane Collaboration using statistical software RevMan version 5. Results Four studies on 319 patients reporting success rates and Eckardt scores were included. In the random effect model analysis, the success rate [odds ratio (OR) 6.22, 95%, CI (3.23, 11.97), Z = 5.47, p = 0.00001] favoured the PD and there was no heterogeneity (Tau2 = 0; Chi2 = 1.29, df = 2 (P = 0.53; I2 = 0 %) among included studies. Eckardt scores [mean difference -0.36, 95%, CI (-0.76, 0.03), Z = 1.79, p = 0.07] suggesting the achalasia symptoms severity was also similar in both interventions. There was moderate heterogeneity (Tau2 = 0.10; Chi2 = 7.47, df = 3 (P = 0.06; I2 = 60 %) among the included studies. Conclusion The POEM seems to be more successful when compared to the PD for patients with achalasia. On comparison of Eckardt score, there was no statistical difference seen between the two groups.

Clinical outcomes of peroral endoscopic myotomy with and without septotomy for management of epiphrenic diverticula: an international multicenter experience (with video)

There are few data favoring the need for septotomy at the time of peroral endoscopic myotomy (POEM) or if POEM alone is sufficient. Our aim was to compare POEM outcomes with and without septotomy (POEM+S or POEM-S) in patients with symptomatic epiphrenic diverticula (ED) and an underlying motility disorder. This was an international, multicenter retrospective study involving 21 centers between January 2014 and January 2023. Patients with ED and an underlying motility disorder who underwent POEM were included. The primary outcome was clinical success (Eckardt score [ES]≤3 or a 1-point drop in ES for patients with baseline ES<3) without the need for repeat surgical/endoscopic interventions during follow-up. A total of 85 patients (mean age, 64.29 ± 17.1 years; 32 [37.6%] female) with ED and underlying motility disorder underwent POEM+S (n= 47) or POEM-S (n= 38). Patients in the POEM+S group had a significantly higher mean pre-POEM ES (7.3 ± 2.1 vs 5.8 ± 2; P= .002). The most common indication for POEM was achalasia (51% in the POEM+S cohort and 51.8% in the POEM-S cohort; P= .7). A posterior approach was favored in the POEM+S group (76.6% vs 52.6%; P= .02). A similar rate of technical success was seen in both groups (97.9% vs 100%; P= .1). The rate of adverse events was similar between the 2 cohorts (4.2% vs 8.1%; P= .6). The median length of hospital stay after POEM-S was significantly longer compared with POEM+S (2 days [interquartile range (IQR), 1-4 days] vs 1 day [IQR, 1-2 days]; P= .005). Clinical success was equivalent between the 2 groups (83% vs 86.8%; P= .6) at a median follow-up duration of 8 months (IQR, 3-19 months). In patients with ED and an underlying motility disorder, both POEM+S and POEM-S are equally safe and effective, with similar procedure duration and a low recurrence rate at short-term follow-up. Future comparative prospective studies with long-term follow-up are required to validate these findings.

Peroral endoscopic myotomy for spastic esophageal dysmotility among opioid users: a multicenter propensity score matching study

Opioid-induced esophageal dysfunction (OIED) often presents as spastic esophageal disorders (SEDs) and esophagogastric junction outflow obstruction (EGJOO). The aim of this study was to evaluate and compare clinical outcomes of peroral endoscopic myotomy (POEM) for SEDs and EGJOO among opioid users and nonusers. This propensity score (PS) matching study included consecutive opioid users and nonusers who underwent POEM for SEDs and EGJOO between January 2018 and September 2022. The following covariates were used for the PS calculation: age, sex, duration of symptoms, Eckardt score, type of motility disorder, and length of myotomy during POEM. Clinical response was defined as a post-POEM Eckardt score≤3. A total of 277 consecutive patients underwent POEM during the study period. PS matching resulted in the selection of 64 pairs of patients strictly matched 1:1 (n= 128) with no statistically significant differences in demographic, baseline, or procedural characteristics or in the parameters considered for the PS between the 2 groups. Clinical response to POEM was significantly lower among opioid users (51 of 64 [79.7%]) versus nonusers (60 of 64 [93.8%]) (P= .03) at a median follow-up of 18 months. Among opioid users, higher opioid dose (>60 morphine milligram equivalents per day) was associated with a higher likelihood of failure to respond to POEM (odds ratio, 4.59; 95% confidence interval, 1.31-3.98; P= .02). Clinical response to POEM for SEDs and EGJOO is significantly lower among opioid users versus nonusers. There was a dose-relationship between opioids and response to POEM, with higher daily opioid usage associated with a higher likelihood of treatment failure.

Achalasia phenotypes and prediction of peroral endoscopic myotomy outcomes using machine learning.

High-resolution manometry (HRM) and esophagography are used for achalasia diagnosis; however, achalasia phenotypes combining esophageal motility and morphology are unknown. Moreover, predicting treatment outcomes of peroral endoscopic myotomy (POEM) in treatment-naïve patients remains an unmet need. In this multicenter cohort study, we included 1824 treatment-naïve patients diagnosed with achalasia. In total, 1778 patients underwent POEM. Clustering by machine learning was conducted to identify achalasia phenotypes using patients' demographic data, including age, sex, disease duration, body mass index, and HRM/esophagography findings. Machine learning models were developed to predict persistent symptoms (Eckardt score ≥3) and reflux esophagitis (RE) (Los Angeles grades A-D) after POEM. Machine learning identified three achalasia phenotypes: phenotype 1, type I achalasia with a dilated esophagus (n = 676; 37.0%); phenotype 2, type II achalasia with a dilated esophagus (n = 203; 11.1%); and phenotype 3, late-onset type I-III achalasia with a nondilated esophagus (n = 619, 33.9%). Types I and II achalasia in phenotypes 1 and 2 exhibited different clinical characteristics from those in phenotype 3, implying different pathophysiologies within the same HRM diagnosis. A predictive model for persistent symptoms exhibited an area under the curve of 0.70. Pre-POEM Eckardt score ≥6 was the greatest contributing factor for persistent symptoms. The area under the curve for post-POEM RE was 0.61. Achalasia phenotypes combining esophageal motility and morphology indicated multiple disease pathophysiologies. Machine learning helped develop an optimal risk stratification model for persistent symptoms with novel insights into treatment resistance factors.

Healthcare Utilization, Costs and Other Outcomes of Peroral Endoscopic Myotomy (POEM) Versus Heller Myotomy in the Inpatient Management of Achalasia in The United States: A 2016 to 2020 Nationwide Study

Introduction: Per-Oral Endoscopic Myotomy (POEM) is the recommended first-line treatment for all achalasia subtypes due to its minimally invasive nature. We aim to evaluate the trends of utilization, costs, and outcomes (mortality and complications) of POEM versus Heller Myotomy (HM) in U.S. hospitals. Methods: This is a retrospective study of individuals admitted with a primary diagnosis of achalasia. Data was obtained from Nationwide Inpatient Sample databases from the years 2016 to 2020 using ICD-10 codes. We assessed the therapeutic procedures employed, the trends and outcomes associated with POEM versus HM in terms of hospital utilization, mortality, morbidity, and the baseline characteristics of our study population. Results: A total of 26 880 adult individuals were diagnosed with achalasia. Of these, 11% underwent POEM, while 59% underwent HM. POEM rates increased from 6% to 10% of achalasia admissions, while HM decreased from 49% to 41% during the study period. No significant differences in total hospital charges or length of stay were observed between the 2 procedures. Regarding procedural complications, HM was associated with significantly reduced odds of pneumonia (adjusted Odds Ratio [aOR] = 0.09, 95% CI: 0.02-0.41), pneumoperitoneum (aOR = 0.11, 95% CI: 0.03-0.36), and pneumomediastinum (aOR = 0.21, 95% CI: 0.06-0.68), with no difference in the odds of esophageal perforation (aOR = 1.33, 95% CI: 0.27-6.48) and sepsis (aOR = 2.04, 95% CI: 0.22-18.40). Conclusion: While HM rates are currently declining in the U.S., POEM usage appears to be increasing. Despite being a less invasive measure than HM, POEM remains underutilized in the U.S.

Short-term Outcome of Peroral Endoscopic Myotomy Performed by the Same Endoscopist on Achalasia and Nonachalasia Esophageal Motility Disorders.

Peroral endoscopic myotomy (POEM) is a relatively new but increasingly therapeutic option for achalasia. In recent years, POEM has been used for nonachalasia esophageal motility disorders (NAEMDs), such as diffuse esophageal spasm, esophagogastric junction outlet obstruction, and hypercontractile disorder, with some clinical success. No studies thus far compare the outcomes of these two groups. We perform the first head-to-head comparison of outcomes after POEM in patients with achalasia and NAEMD. A retrospective analysis of all patients undergoing POEM at one university hospital by a single expert endoscopist from July 2021 to December 2022 was performed. All patients were symptomatic, and the presence of esophageal motility disorders was confirmed using multiple diagnostic modalities. These patients were then divided into 2 groups, achalasia and NAEMD, based on the underlying diagnosis. Statistical analysis of different clinical outcomes, including effectiveness and safety, was performed. Thirty-seven patients (mean age: 59.55, females: 22) underwent POEM in the study period. Twenty patients had achalasia and 17 patients had NAEMD. The median myotomy length was 5.5 cm for the achalasia group and 10 cm for the NAEMD group. This excluded patients with esophagogastric junction outlet obstruction in which the median myotomy length was 3 cm. The procedure time, the duration of hospital stays, the rates of same-day discharge, and complications were similar between the two. Short-term outcomes of POEM for the two groups were similar with improvement in 94% of patients in the achalasia group and 93.75% in the NAEMD group. Contrary to prior observations, our study highlights that POEM is equally effective in achieving clinical improvement in patients with NAEMD as achalasia over 6 months of follow-up. In addition, POEM has a comparable safety profile in both patient groups making it a feasible therapeutic option for these debilitating and challenging disorders.

Outcomes of Per-Oral Endoscopic Myotomy in the Treatment of Esophageal Achalasia: Over One Hundred Cases in a Single Tertiary Center

Objective: To study the outcomes and complications of per-oral endoscopic myotomy (POEM) in patients with esophageal achalasia. Materials and Methods: This retrospective observational study reviewed the medical records of esophageal achalasia patients who underwent POEM between March 2013 and September 2022. One hundred and eight cases were included. Results: A total of 108 consecutive patients were included in this study and classified into 4 groups: 30 (27.8%) as type I; 53 (49.1%) as type II; 5 (4.6%) as type III; and 20 (18.5%) as unspecified due to unsuccessful catheter placement across the esophagogastric junction. The mean patient age was 46.10+16.59, 77 (71.3%) patients were female. Ten (9.3%) of the patients had undergone prior treatment, including balloon dilation, POEM, Heller myotomy, and nitroglycerine. Technical success was achieved in 106 (98.1%) cases, clinical success was evaluated only in 88 patients who follow up more than 6 month and the median follow-up time was 20.50 months (range 6-110 months). The clinical success was accomplished in 82 (93.2%), and 26 (24.1%) patients experienced perioperative complications which were significantly associated with anterior myotomy and probably operator learning curve. One patient (1.1%) had recurrent symptoms at 24-month follow up. Gastroesophageal reflux disease (GERD) was found in 19 (21.6%) patients, all of whom responded well to proton pump inhibitors (PPIs). Conclusion: POEM is effective and safe in long-term treatment of achalasia. Although the incidence of symptomatic GERD was slightly high, the cases were not severe and were well controlled with medication.

44. LONG-TERM OUTCOMES OF PERORAL ENDOSCOPIC MYOTOMY FOR PATIENTS WITH ACHALASIA: A SINGLE-CENTRE STUDY

Abstract Background and study aims: The short-term outcomes of Peroral endoscopic myotomy (POEM) for achalasia are well described, however, there is limited long-term data in the literature. This study aims to retrospectively assess the long-term outcomes of the POEM in a Canadian tertiary care centre. Methods All patients who underwent POEM for treatment of Achalasia with minimum follow-up of at least 4 years at a tertiary care centre were enrolled in this study. The primary outcome of the study was clinical success defined as a post-POEM Eckardt score ≤ 3 at ≥48 months. Secondary outcomes included changes in body mass index (BMI), incidence of gastroesophageal reflux disease (GERD), adverse events and length of hospital stay. Result Thirty-eight patient (aged 53.9 ± 17.9) underwent POEM, with a median follow-up period of 61 months (48–79). The mean Eckardt score was significantly reduced from 7.7 ± 1.9 to 1.2 ± 0.6 (P &amp;lt; 0.001). All patients achieved post-POEM Eckardt scores of ≤3 at ≥48 months. BMI increased from 27.4 ± 6.5 pre-POEM to 29.4 ± 6.7 (P &amp;lt; 0.003) post-POEM. Twelve (31.5%) patients developed pathologic reflux. Conclusion POEM is an effective and safe procedure for achalasia with durable long-term outcomes. Larger series with longer follow-up are required to confirm these results.

Comparing clinical outcomes of peroral endoscopic myotomy for achalasia between Eastern and Western countries: a systematic review and meta-analysis.

Peroral endoscopic myotomy (POEM) has revolutionized the therapeutic strategy for achalasia with promising results. We conducted this meta-analysis to compare clinical outcomes between Eastern and Western countries. A comprehensive literature search was conducted in PubMed, EMBASE, Web of Science and Cochrane Library databases to query for studies that assessed the efficacy of POEM for achalasia. All articles published from inception to December 31, 2021 were included. The primary outcome was the pooled clinical success rate. The secondary outcomes included the pooled technical success rate, incidence of adverse events, procedure time and hospital stay. Eighteen Eastern studies involving 5962 patients and 11 Western studies involving 1651 patients were included. The pooled clinical success rate and technical success rate for POEM was equal in the Eastern studies compared to Western studies. The pooled incidence of procedure adverse events for POEM was a little lower in the Eastern studies compared to Western studies (6.6% vs. 8.7%). Similarly, the incidence of reflux-related adverse events was lower in Eastern studies than that in Western studies. The pooled procedure time of POEM was shorter in Eastern studies compared to Western studies (61minutes vs. 80minutes), while the length of hospital stay was longer in Eastern studies compared to Western studies (5.8days vs. 2.4days). Overall, Eastern countries have the similar POEM outcomes compared to Western countries. However, Eastern countries still need to do more to reduce the length of hospital stay.

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

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. 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. 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%). 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.

Comments on: "Long-term outcomes of peroral endoscopic myotomy for achalasia: a systematic review and meta-analysis".

See also: Long-term outcomes of peroral endoscopic myotomy for achalasia: a systematic review and meta-analysisEndoscopy 2023; 55(02): 167-175DOI: 10.1055/a-1894-0147 See also: Reply to Zhang et al.Endoscopy 2023; 55(03): 298-298DOI: 10.1055/a-1931-4364

The Differential Outcomes of Peroral Endoscopic Myotomy and Pneumatic Dilatation Upon Subtypes of Achalasia Indicate Pathophysiological Differences in Morphological Change of Esophageal Body

The Differential Outcomes of Peroral Endoscopic Myotomy and Pneumatic Dilatation Upon Subtypes of Achalasia Indicate Pathophysiological Differences in Morphological Change of Esophageal Body

Mid-Term and Long-Term Outcomes of Peroral Endoscopic Myotomy for the Treatment of Achalasia: A Systematic Review and Meta-Analysis.

Peroral endoscopic myotomy (POEM) achieves a satisfactory short-term clinical response in patients with achalasia. However, data on mid- and long-term clinical outcomes are limited. We aimed to assess the mid- and long-term efficacy and safety of POEM in achalasia patients. Using the pre-designed search strategy, we identified relevant studies that evaluated the efficacy and safety of POEM with a minimum of 2-year follow-up in the Embase, Cochrane, and PubMed databases from inception to January 2021. Primary outcome was pooled mid- and long-term clinical success rate based on the Eckardt score. Secondary outcome was pooled long-term reflux-related adverse events. A total of 21 studies involving 2,698 patients were included. Overall, the pooled clinical success rates with 2-, 3-, 4-, and 5-year follow-ups were 91.3% (95% confidence interval [CI] 88.4-93.6%), 90.4% (95% CI 88.1-92.2%), 89.8% (95% CI 83.6-93.9%), and 82.2% (95% CI 76.6-86.7%), respectively. Besides, the pooled long-term clinical success rates for type I, II, and III achalasia were 86.1% (95% CI 80.9-90.1%; I2 = 0%), 87.9% (95% CI 84.2-90.8%; I2 = 48.354%), and 83.9% (95% CI 72.5-91.2%; I2 = 0%), respectively. Moreover, the pooled incidence of symptomatic reflux and reflux esophagitis was 23.9% (95% CI 18.7-29.9%) and 16.7% (95% CI 11.9-23.1%), respectively. POEM is associated with a long-term clinical success of 82.2% after 5years of follow-up. Randomized control trials comparing POEM with laparoscopic Heller myotomy or pneumatic dilation with longer follow-up periods are needed to further demonstrate the long-term safety and efficacy of POEM.

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

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

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

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. 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. 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 (106min. vs. 145min., p = 0.003) and longer median myotomy length (11cm vs. 8cm, p < 0.001). All LHM patients had a length of stay (LOS) ≥ 1day 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). 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.

Long-term outcomes of peroral endoscopic myotomy for achalasia: a systematic review and meta-analysis.

The long-term outcomes of esophageal peroral endoscopic myotomy (POEM) are still unknown. We searched electronic databases (MEDLINE/PubMed, EMBASE, Scopus) for studies assessing outcomes after POEM for esophageal achalasia with a minimum median follow-up duration of 36 months. Pooled rates of clinical success and postoperative reflux were calculated and compared with the same values at 12/24/36 months when available. Subgroup analyses were performed to explore the interstudy heterogeneity. From 1528 initial records, 11 studies (2017-2021) were included. A total of 2342 patients (age 48.1 [SD 6.8] years; 50.1 % males) with a median follow-up of 48 months (interquartile range 45-60) were analyzed. The pooled clinical success rate was 87.3 % (95 %CI 83.6 %-91.0 %; I2 = 73.1 %). The symptomatic reflux pooled rate was 22.0 % (95 %CI 14.4 %-29.5 %; I2 = 92.7 %). Three cases of peptic strictures and one Barrett's esophagus were reported. The pooled rate of severe adverse events was 1.5 % (95 %CI 0.5 %-2.5 %; I2 = 52.8 %). Long-term clinical efficacy of POEM persisted in 87 % of patients with achalasia. Post-POEM symptomatic reflux remained stable over time. The risk for Barrett's esophagus and peptic strictures appeared minimal.

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.

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.

Predictors of Long-Term Outcomes, Recurrent Dysphagia, and Gastroesophageal Reflux After Per-oral Endoscopic Myotomy in Esophageal Motility Disorders

BackgroundThere is limited data on long-term outcomes of per-oral endoscopic myotomy (POEM). In this study, we aim to evaluate the efficacy of POEM in patients who completed a minimum follow-up of 5 years. MethodsData of patients who underwent POEM and completed ≥ 5-year follow-up were analyzed, retrospectively. Primary outcome of study was clinical success (Eckardt ≤ 3) at ≥ 5 years after POEM. Secondary outcomes included predictors of dysphagia and symptomatic gastroesophageal reflux disease (GERD) on long-term follow-up. ResultsThree hundred nineteen patients (males 182, mean age 40.5±14.2 years) completed a median of 73-(60–89) month follow-up. Esophageal motility disorders included idiopathic achalasia (type I 26.6%, type II 60.8%, type III 5.6%) and Jackhammer esophagus or distal esophageal spasm (2.8%). POEM was technically successful in 307 (96.2%) patients. Long-term success was 92.6% (overall), 92.1% (type I), 94.7% (type II), 87.5% (type III), and 75% (Jackhammer esophagus/distal esophageal spasm). Symptomatic GERD and reflux esophagitis were detected in 28.9% and 35.3% patients, respectively. On multivariate analysis, young age and female gender were independent risk factors for recurrent dysphagia (p = 0.037) and symptomatic GERD after POEM (p = 0.025), respectively. Lower post-POEM lower esophageal sphincter pressure was an independent predictor for reflux esophagitis (p = 0.016). ConclusionPOEM is an effective and durable treatment for achalasia and non-achalasia spastic motility disorders. Young patients and females may be at higher risk for recurrent dysphagia and symptomatic GERD, respectively.