Peroral Endoscopic Myotomy Research Articles

Concomitant peroral endoscopic myotomy and gastric peroral endoscopic myotomy for persistent dysphagia and iatrogenic gastroparesis after laparoscopic fundoplication

Concomitant peroral endoscopic myotomy and gastric peroral endoscopic myotomy for persistent dysphagia and iatrogenic gastroparesis after laparoscopic fundoplication

Underwater coagulation using hybrid knife in peroral endoscopic myotomy for achalasia.

Underwater coagulation using hybrid knife in peroral endoscopic myotomy for achalasia.

Peroral endoscopic myotomy is an effective treatment for achalasia combined with hiatal hernia.

To explore the feasibility of peroral endoscopic myotomy (POEM) in patients with achalasia and hiatal hernia. We performed a retrospective review of 2136 patients with achalasia between January 2016 and December 2022. Patients with achalasia and hiatal hernia were assigned into study group, and matched patients with achalasia but no hiatal hernia were assigned into control group. The preoperative baseline information, procedure-related adverse events (AEs) and follow-up data were compared between the two groups. Hiatal hernia was identified in 56/1564 (3.6%) patients with achalasia. All of these patients underwent POEM with success. The preoperative baseline characteristics were similar between the study and control group. The study group presented with a similar rate of mucosal injury (12.5% vs 16.1, P = 0.589), pneumothorax (3.6% vs 1.8%, P = 1.000), pleural effusion (8.9% vs 12.5%, P = 0.541) and major AEs (1.8% vs 1.8%, P = 1.000) compared with the control group. As for the follow-up data, no significant differences were observed in clinical success (96.4% vs 92.9%, P = 0.679; 93.6% vs 94.0%, P = 1.000; 86.5% vs 91.4%, P = 0.711) clinical reflux (25.0% vs 19.6%, P = 0.496; 31.9% vs 26.0%, P = 0.521; 35.1% vs 31.4%, P = 0.739) and proton pump inhibitor usage (17.9% vs 16.1%, P = 0.801; 29.8% vs 24.0%, P = 0.520; 32.4% vs 25.7%, P = 0.531) between the study group and control group at 1-year, 2-year and 3-year follow-ups. POEM is a safe and effective treatment for achalasia combined with hiatal hernia.

Experience in Peroral Endoscopic Myotomy in a Center in Bogotá, Colombia, Between 2018 and 2022

Experience in Peroral Endoscopic Myotomy in a Center in Bogotá, Colombia, Between 2018 and 2022

Management of recurrence after peroral endoscopic myotomy and submucosal tunneling endoscopic septum division.

Management of recurrence after peroral endoscopic myotomy and submucosal tunneling endoscopic septum division.

Muscle resection biopsy during peroral endoscopic myotomy in a patient with achalasia

Watch a video of this article.

Gastric peroral endoscopic myotomy mucosotomy closure using a novel hand suturing device.

Gastric peroral endoscopic myotomy mucosotomy closure using a novel hand suturing device.

Peroral Endoscopic Myotomy in Patients with Type III Achalasia and Non Achalasia Esophageal Motility Disorders.

Background : Achalasia is a disease characterized by dysphagia, regurgitation, chest pain, and weight loss. It is now classified into three subtypes according to the Chicago classification. Type III achalasia is characterized by lower esophageal sphincter obstruction with premature or spastic distal esophageal contractions. The aim of this study is to evaluate the efficiency of peroral endoscopic myotomy (POEM) in patients with type III achalasia as well as non achalasia esophageal motility disorders. Methods : This pilot prospective observational study was carried out on 12 patients aged from 18 to 75 years old, both sexes, with achalasia type III and non-achalasia esophageal motility disorders. Follow up after 3 months of Peroral Endoscopic Myotomy was evaluated by Eckardt score. Results : There is significant decrease in mean Eckardt score after Peroral Endoscopic Myotomy (9.83 vs 1.17, P < 0.001) as t-test showed (t-test 13.23 with 95% CI 7.23- 10.11). Thus, the effect of POEM on reducing Eckardt score is statistically significant. During the operative procedure, the average length of myotomy measured 20.42 cm, with a mean operative duration of 55.33 minutes. Following a mean follow-up period of 15.83 months, the mean Eckardt score decreased to 1.17. Bleeding occurred during the procedure in three cases (25%), while mucosal injury was observed in only one case. Additionally, one case experienced postoperative chest infection. Conclusions : Peroral Endoscopic Myotomy is safe and effective intervention in the management of achalasia type III as well as non-achalasia esophageal motility disorders

Peroral endoscopic myotomy using a novel thin therapeutic scope.

Peroral endoscopic myotomy using a novel thin therapeutic scope.

Endoscopic therapies for bariatric surgery complications.

The aim of this review is to present the current state of the field, highlight recent developments, and describe the clinical outcomes of endoscopic therapies for bariatric surgery complications. The field of interventional endoscopy now presents a range of minimally invasive procedures for addressing postbariatric complications. Lumen-opposing metal stents have emerged as a reliable solution for managing gastrojejunal strictures following Roux-en-Y gastric bypass, whether with or without associated leaks. Additionally, they serve as a conduit for performing endoscopic retrograde cholangiopancreatography (ERCP) post-RYGB via EUS-directed ERCP (EDGE). Gastric peroral endoscopic myotomy, originally designed for gastroparesis, has demonstrated effectiveness in treating postgastric sleeve stenosis, particularly the challenging helical stenosis cases. Furthermore, innovative endoscopic antireflux techniques are showing encouraging outcomes in addressing gastroesophageal reflux disease (GERD) following sleeve gastrectomy. Additionally, several modifications have been proposed to enhance the efficacy of transoral outlet reduction (TORe), originally developed to treat weight regain due to gastrojejunal anastomotic issues post-RYGB. Endoscopic management of bariatric surgery complications is continuously evolving. The development of new techniques and devices allows endoscopists to provide novel, minimally invasive alternatives that were not possible in the near past. Many techniques, however, are limited to expert centers because they are technically demanding, and specialized training in bariatric endoscopy is still required.

Modified peroral endoscopic myotomy technique with retrograde on-demand myotomy for achalasia: a retrospective cohort study (with video).

Although myotomy is crucial in peroral endoscopic myotomy (POEM) surgeries, its optimum length remains controversial. Herein, we propose a modified POEM with new method of tailoring myotomy length aim to evaluate the safety, efficacy, and clinical outcomes of this modified POEM compared with standard POEM in type I or II achalasia. Seventy-five patients with type I or II achalasia who underwent POEM at the First Hospital of Jilin University between January 2018 and December 2022 were retrospectively analyzed. According to the myotomy approach, these patients were divided into the retrograde on-demand myotomy (RDM, n = 34), with myotomy beginning on gastric side and length tailored by determining the degree of lower esophageal sphincter (LES) distention, and standard myotomy (SM, n = 41) groups. The baseline data, myotomy length, operation time, clinical success rate, adverse event rate, and reflux-related adverse events were compared and analyzed. The median myotomy length in the RDM group was significantly shorter than that in the SM group (6 vs. 8cm, respectively; p < 0.001). Moreover, the median myotomy time in the RDM group was significantly shorter than that in the SM group (10 vs. 16min, respectively; p < 0.001). POEM was successfully performed in all the patients. At the 2-year follow-up, high clinical success rates were observed in both the RDM and SM groups (92.0% vs. 93.3%, respectively; p = 1.000). The incidence of intraoperative adverse events and postoperative reflux-related adverse events was low and comparable in both groups. RDM POEM is a safe and effective method for patients with type I or II achalasia. Furthermore, it has a shorter myotomy length and operation time than standard POEM technique.

Manometric profile of patients presented with dysphagia – A hospital-based descriptive study

Objectives: The prevalence of dysphagia is 16–22%. Achalasia is characterised by impaired relaxation of the lower oesophageal sphincter (LES) and absent oesophageal peristalsis. Minimally invasive procedures, endoscopic pneumatic balloon dilatation (PD) and peroral endoscopic myotomy (POEM) are treatments of choice. We aimed to assess the manometric profile of patients presented with dysphagia and pre- and post-LES pressure and integrated relaxation pressure (IRP) of patients who underwent PD and POEM. Materials and Methods: One hundred and twenty-nine patients presented with dysphagia underwent high resolution oesophageal manometry (HREM). Manometric parameters: IRP, LES and pattern of motility were noted. According to Chicago classification 4.0, those who are diagnosed with achalasia underwent PD (17) and POEM (15). Statistical analysis was performed using the Statistical Package for the Social Sciences version 28. Pre- and post-procedure values (IRP and basal LES) were compared using the Wilcoxon signed-rank test. Results: Out of 129 patients with dysphagia, 57 had increased IRP and 75 had simultaneous motility. The mean LES pressure and IRP were found to be 28 ± 19.82 and 17 ± 14.04 mmHg, respectively. On analysis, of patients who underwent procedures PD (17) and POEM (15), a statistically significant decrease in IRP was observed in patients with post POEM compared to post PD status (P = 0.005 and 0.017, respectively). Reduced basal LES pressure was observed in patients with post-POEM status compared to post-PD status, which was not statistically significant. Conclusion: About 44% of patients presented with dysphagia were diagnosed with achalasia cardia. POEM procedure was found to be more effective compared to pneumatic dilatation.

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.

A new through-the-scope clip with anchor prongs is safe and successful for a variety of endoscopic uses.

Background and study aims Endoscopic through-the-scope clips (TTSC) are used for hemostasis and closure. We documented the performance of a new TTSC with anchor prongs. Patients and methods We conducted a prospective case series of the new TTSC in 50 patients with an indication for endoscopic clipping at three hospitals in the United States and Canada. Patients were followed for 30 days after the index procedure. Outcomes included defect closure and rate of serious adverse events (SAEs) related to the device or procedure. Results Fifty patients had 56 clipping procedures. Thirty-four procedures were clipping after endoscopic mucosal resection (EMR) in the colon (33) or stomach (1), 16 after polypectomy, two for hemostasis of active bleeding, and one each for fistula closure, per-oral endoscopic myotomy mucosal closure, or anchoring a feeding tube. Complete defect closure was achieved in 32 of 33 colon EMR defects and 21 of 22 other defects. All clips were placed per labeled directions for use. In 41 patients (82.0%), prophylaxis of delayed bleeding was reported as an indication for endoscopic clipping. There were three instances of delayed bleeding. There were no device-related SAEs. The only technical difficulty was one instance of premature clip deployment. Conclusions A novel TTSC with anchor prongs showed success in a range of defect closures, an acceptable safety profile, and low incidence of technical difficulties.

Electrosurgery in Gastrointestinal Endoscopy: Bench to Bedside

AbstractElectrosurgical generator units (ESUs) are instrumental in modern therapeutic gastrointestinal (GI) endoscopy, converting household alternating current into high-frequency current to generate thermal energy within tissues. This review elucidates the essentials of electrosurgery, exploring the thermal effects on tissue, current resistance, voltage, current density, duty cycle, crest factor, and the distinctions between monopolar and bipolar circuitry. The concept of duty cycle, the proportion of time electrical current is delivered, and crest factor, the ratio of peak to root mean square voltage, are essential while comparing differently named modes across various commercially available ESUs. This article discusses the practical applications of electrosurgery in therapeutic GI endoscopy procedures, including endoscopic sphincterotomy, polypectomy, endoscopic mucosal resection, endoscopic submucosal dissection, and peroral endoscopic myotomy. It outlines recommended modes and settings for ESUs across various procedures, emphasizing the balance between cutting and coagulation to achieve optimal outcomes while minimizing adverse effects. The review further addresses special considerations for the use of grounding pads and the management of patients with implanted cardiac devices during electrosurgical procedures. This article concludes with a call for a deeper understanding of electrosurgical principles and their application in GI endoscopy to ensure patient safety and procedural success, backed by references to relevant literature and detailed tables summarizing electrosurgical modes and settings for various therapeutic interventions.

Heller Cardiomyotomy in end stage of achalasia with mega esophagus: Results in five cases

Achalasia is a motility disorder of esophagus with poor emptying and, characterised by a lack of peristalsis and impaired relaxation of the lower esophageal sphincter with high LES pressure,diameter of esophsgous can increase, and some patients progress to develop end-stage achalasia as megaesophagus or sigmoid esophagus and significant form dilation and tortuosity.These omplications occurs in between 5% and 20% of patients with acha­lasia. This group of patients if untreated are at risk of aspiration, aspiration pneumonia, and malnutrition. The management of this type of achalasia, aims to palliate symptoms by improving esophagus emptying and reducing the pressure gradient. In this group of patients, pneumatic dilatation (PD), surgical myotomy, or peroral endoscopic myotomy (POEM) may be less or not effective. Esophagectomy for the treatment of end-stage achalasia remains a controversial topic and has been recommended by some authors. We describe 5 patients with end-stage achalasia who was been successfully managed with laparotomy heller cardiomyotomy . In 4,12,18,24 months follow- up the condition of patients was good.

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.

The Impact of Pyloric Directed Therapy for Gastroparesis

Gastroparesis presents with nausea, early satiety, vomiting, bloating, distention, and abdominal pain and is diagnosed by documenting delayed passage of contents from the stomach to the intestines in the absence of mechanical obstruction. Several factors contribute to gastroparesis pathophysiology. Pylorospasm, or increased pyloric contractility, is present in many patients and may be a target for therapy of cases of refractory gastroparesis when medical management is insufficient. Pylorus-directed interventions including botulinum toxin injections, pneumatic balloon dilation, stenting, surgical pyloroplasty, and gastric per-oral endoscopic myotomy are increasingly employed to treat selected patients with gastroparesis who are unresponsive to medications.

Peroral endoscopic myotomy with diverticulotomy using a double tunnel technique: finding your way to an elusive lower esophageal sphincter in spastic achalasia and epiphrenic diverticulum

Peroral endoscopic myotomy with diverticulotomy using a double tunnel technique: finding your way to an elusive lower esophageal sphincter in spastic achalasia and epiphrenic diverticulum

Prognostic value of preoperative intragastric meal distribution in gastric emptying scintigraphy for long-term success of gastric peroral endoscopic myotomy in gastroparesis

Background and aimsGastric emptying scintigraphy (GES) is the gold standard for the diagnosis of gastroparesis. However, data are lacking regarding the prognostic value of pre-operative intragastric meal distribution during GES, in patients undergoing gastric peroral endoscopic myotomy (GPOEM) for gastroparesis. This study investigated the association of GES morphologic parameters and the long-term clinical success of G-POEM. MethodsThis retrospective study included patients who underwent G-POEM for refractory gastroparesis in a tertiary center with preoperative GES data. Intragastric meal distribution was measured using the proximal to distal count ratio (PDCR) at 0, 1, 2 and 4 hours (h), and the retention index (RI) was calculated. Clinical success was defined as a decrease of at least 50% in the post-G-POEM Gastroparesis Cardinal Symptom Index (GCSI) total score. ResultsIn total, 77 patients were included with a mean follow-up of 40.14 months. Clinical success was observed in 54.55% of patients. The RI was not associated with clinical success. Only PDCR at 0h (PDCR0) was associated with clinical success. In univariate analysis, the median PDCR0 was 6.0 (IQR 5.59) in patients with clinical success and 4.29 (IQR 4.51) in patients with clinical failure (p=0.019). In multivariate analysis, PDCR0 > 5.25 was associated with clinical success (HR = 4.36 [1.55;12.26], p=0.00524). ConclusionsThis study suggests that in patients with gastroparesis, High PDCR0 value (suggestive for a preferential fundic meal distribution) during preoperative GES is associated with long-term clinical response to G-POEM.