Peroral Esophageal Myotomy Research Articles

Long-Term Outcomes of Pneumatic Balloon Dilation versus Peroral Endoscopic Myotomy in Type I and II Achalasia Patients: A Propensity Score-Matched Analysis

Peroral esophageal myotomy (POEM) shows higher efficacy than pneumatic balloon dilation (PBD) for type I and II achalasia over 2 years. However, long-term durability beyond 5 years remains under investigated. This study aimed to assess the long-term efficacy of PBD versus POEM. This retrospective comparative study examined treatment-naïve achalasia patients who underwent either PBD or POEM. Cohort balance was achieved through propensity score (PS) matching based on age, sex, Eckardt's score, and Charlson's comorbidity index. The primary outcome was the time-to-second intervention. Secondary outcomes included treatment failure, Eckardt's score, number of intervention sessions, weight gain, and adverse events. Of the 127 patients, 67 underwent PBD and 60 underwent POEM, with an average follow-up of 7 years (IQR 5-10 years). After PS matching, 100 patients with 1:1 matching were included in the analysis. Baseline characteristics, including clinical, endoscopic, and manometric attributes, were comparable between groups. The POEM group had a significantly longer time-to-second intervention than the PBD group (hazard ratio 0.139, 95% CI 0.048-0.405) and underwent more endoscopic sessions (p< 0.001 by linear marginal model analysis) within the first 2 years. Beyond 2 years, subsequent interventions were comparable between groups. There were no differences in the Eckardt score or weight gain. Hospital stays were shorter in the PBD group (2 vs. 4 days; p < 0.001). POEM patients had more adverse events, including perforation. POEM demonstrated greater long-term durability than PBD, but PBD was associated with shorter hospital stays and fewer adverse events.

Comparison of the Clinical Efficacy, Safety, and Postoperative Outcomes Between Peroral Esophageal Myotomy and Laparoscopic Heller's Myotomy With Fundoplication: A Systematic Review.

Achalasia, a neurodegenerative disease caused by the progressive destruction of ganglion cells in the myenteric plexus, is accompanied by incomplete relaxation of the lower esophageal sphincter. Laparoscopic Heller's myotomy (LHM) coupled with fundoplication has been the gold standard procedure for achalasia. Peroral esophageal myotomy (POEM) has recently gained popularity as it is minimally invasive, has fewer adverse events, and has excellent short-term outcomes. So, we aimed to compare the clinical efficacy, safety, and postoperative outcomes between LHM and POEM. We did a systematic review by following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA)guidelines for 2020 and exploring research databases such as PUBMED and PMC Central, Google Scholar, and Research Gate. After appropriate screenings, articles relevant to the review were scrutinized based on the eligibility criteria. Quality assessment tools such as the Newcastle-Ottawa Scale (NOS) and theassessment of multiple systematic reviews(AMSTAR) were used to finalize the articles. A total of 11 articles (seven observational studies, two RCTs, and two systematic reviews) were included in the review after a quality check. The study included 2127 patients, classified into 981 for POEM and 1146 for LHM, who had undergone treatment for achalasia. Most of the studies had a follow-up of ≤ two years. Comparing efficacy, POEM had similar results to LHM in terms of Eckardt scores. However, abnormal DeMeester scores were found in POEM. Adverse events were significantly higher in LHM when compared to POEM in terms of safety. Peroral esophageal myotomy also stood out as having a shorter procedure time, a shorter hospital stay, and lesser odds of being a clinical failure. As for postoperative outcomes, despite treatment with proton pump inhibitors, LHM was more effective in preventing the development of esophagitis compared to POEM due to partial fundoplication.Postoperative reflux and the development of esophagitis remain certain with POEM and need to be followed up with more studies with longer follow-ups. However, POEM still stands as a better choice compared to LHM in terms of efficacy and safety.

423. DYSPHAGIA AND RE-INTERVENTION AFTER MYOTOMY FOR ACHALASIA: A MATTER OF TECHNIQUE, OR A MATTER OF TIME?

Abstract Background Achalasia is an incurable neurodegenerative disease of the esophagus. Palliative treatment includes disruption of the lower esophageal sphincter via multiple techniques, including open Heller myotomy (OHM), laparoscopic Heller myotomy (LHM), and per-oral esophageal myotomy (POEM). There is a paucity of data comparing long-term outcomes between OHM, LHM, and POEM. We sought to evaluate the relationship of these methods with clinical outcome parameters using our institution’s experience. Methods Patients greater than 3 years removed from myotomy for achalasia were studied. Post-operative Eckardt Symptom (ES) score and daily proton pump inhibitor (PPI) usage was recorded. Patients underwent timed barium esophagram (TBE) as clinically indicated. Retention was defined as a persistent column &amp;gt;5 cm at 5 minutes. Post-operative interventions included Savary dilation, Botox injection, pneumatic dilation, surgical myotomy, and esophagectomy. Groups were stratified by surgery type (OHM, LHM, POEM) and by time since surgery (3–6 years, 6–10 years, &amp;gt;10 years). A logistic regression analysis was performed examining the relationship of surgery type, time, symptomatic/objective outcomes, and post-operative interventions. Results 172 patients had long-term data available. Mean follow up was 7.8 years (3.1–19.5 years). Nearly one-third of patients had a post-operative intervention (31%, 53/172). On regression analysis, OHM was associated with a higher risk of intervention (OR 9.4, p &amp;lt; 0.05). Barium retention was significantly associated with LHM (OR 15.9, p &amp;lt; 0.05) and the 3–6 year post-operative period (OR 11.1, p &amp;lt; 0.05). PPI usage was not associated with surgery type, but was associated with the 3–6 year post-operative period (OR 3.2, p &amp;lt; 0.05). There was no significant association of dysphagia with surgery type or time. Conclusion Post-operative barium retention and interventions are associated with specific myotomy techniques, but not time. PPI usage is associated with the early post-operative period, but not technique. Neither myotomy technique nor time alone are sufficient to predict risk of abnormal ES or dysphagia.

Peroral esophageal myotomy for esophageal motility disorders

The concept of third space endoscopy first described in 2007, was adapted and performed in humans in 2010 by Inoue et al. in a group of patients with esophageal achalasia (EA). Since then, esophageal endoscopic myotomy (E-POEM), has been performed in more than 10,000 patients worldwide up to now. Safety and efficacy have been confirmed at early, mid and long-term evaluations, in different gastrointestinal diseases including achalasia, refractory gastroparesis, and other esophageal motility disorders (EMD). Nowadays, this treatment has shown to be not only an excellent option, but also with its excellent outcomes, the first option in certain clinical scenarios such as type III achalasia. Thus, the minimal invasive nature of POEM gives us multiple advantages compared with the classical treatments that includes pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM), including not only clinical aspects but also economical. High resolution manometry (HRM) has substantially redefined the actual approach of esophageal motility disorders with the major changes in instrumental use, diagnostic algorithms, and therapeutics. The previous Chicago's classification V 3.0 clearly improved our knowledge about pathophysiology of spastic esophageal motor disorders, however, with its recent update (Chicago V 4.0), multiple changes in diagnosis and treatment are expected. In the present article, we aimed to review and analyze the most important aspects about the results of E-POEM in the management of EMD according to the view of the new Chicago's classification V 4.0.

483. UTILITY OF ENDOLUMINAL FUNCTIONAL LUMEN IMAGING IN DIAGNOSIS OF ESOPHAGEAL DYSFUNCTION FOLLOWING BARIATRIC SURGERY

Abstract We present the case of a 46-year-old male with medically complicated class III obesity who presented with new-onset and persistent dysphagia after undergoing a successful laparoscopic Roux-en-Y gastric bypass surgery. An esophagogastroduodenoscopy was unrevealing, however, further workup with the endoluminal functional lumen imaging probe (EndoFLIP) device was suggestive of esophageal dysmotility with decreased distensibility index of the GE junction and absent/disorganized secondary esophageal peristalsis. Thorough chart review was performed to elicit details of the case presentation. Further, a literature review was performed to supplement background knowledge and discussion. We present a case of symptomatic esophageal dysphagia in a post-procedural bariatric surgery patient with normal EGD yet positive findings on functional lumen imaging, consistent with the newly described entity termed Post Obesity Surgery Esophageal Dysfunction (POSED). POSED is defined by aperistalsis and increased intragastric pressure seen after bariatric surgery. It is thought to occur due to a high-pressure gastric zone created in the noncompliant postoperative stomach after Roux-en-Y gastric bypass, or an increased esophageal afterload by a restrictive laparoscopic sleeve gastrectomy. No treatment guidelines exist, though options include botulinum toxin, dilation, and per-oral esophageal myotomy. This case provides further insight into the role that functional lumen imaging has in the bariatric patient, as it may be able to more accurately detect patients who will develop esophageal dysmotility following bariatric surgery, or perhaps even those who may be predisposed prior to undergoing intervention for weight loss.

The Reflux Symptoms Before and After Peroral Endoscopic Myotomy of Chinese Patients With Achalasia.

Background/AimsAchalasia is a rare disease, but the incidence is increasing recently. Peroral esophageal myotomy (POEM) is an effective treatment. Regurgitation is a common symptom before and after POEM. Our aim is to investigate the factors related to preoperative and postoperative reflux symptoms.MethodsOur study was retrospective. The achalasia patients diagnosed by high-resolution manometry and gastroscopy were divided into reflux group and non-reflux group before and after POEM, respectively. General information, symptoms, POEM information, and manometric results were compared.Results(1) Ninety-six of 130 patients had reflux symptoms before POEM. The lower esophageal sphincter pressure (LESP) in the reflux group was significantly higher than the non-reflux group (P = 0.023), while integrated relaxation pressure (IRP) was similar. The reflux group had longer esophagus than the non-reflux group (P = 0.006). Reflux symptoms were not related to subtypes of achalasia. (2) Twenty-five of 84 patients had reflux symptoms after POEM. Postoperative Eckardt scores, LESP, and 4-second IRP (4sIRP) were significantly lower than the preoperative values (P < 0.001). The preoperative values and POEM information were similar between the postoperative 2 groups and there was no significant difference in the presence of preoperative reflux symptoms between 2 groups. The postoperative LESP and 4sIRP were similar between the 2 groups, however, the postoperative UESP was significantly higher in the reflux group than the non-reflux group (P = 0.042). The non-reflux group had more declines in Eckardt scores and LESP than the reflux group.ConclusionsThe reflux symptoms of achalasia patients without treatment were mainly due to food retention. The postoperative reflux symptoms were not the sign of the excessive relaxation of lower esophageal sphincter.

Peroral endoscopic myotomy in a pediatric patient with refractory achalasia: a case report and review of the literature

A 15-year-old male patient presented with dysphagia, regurgitation, weight loss and retrosternal pain. The diagnosis of achalasia was made 4 years before. The esophagogram revealed severe esophagus dilatation and the classic “bird-beak” termination. A Heller myotomy plus fundoplication and endoscopic balloon dilatation were conducted four months previously. Nevertheless, the symptoms persisted and the last high-resolution manometry study still showed achalasia type II. The patient underwent a peroral endoscopic esophageal myotomy (POEM). POEM is a feasible and safe procedure for experienced and properly- equipped health care delivery centers and could be used as a rescue treatment in refr e present the youngest patient with achalasia in our region who had a successful response to rescue POEM.

Type II achalasia. What can be hidden behind panesophageal pressurization?

The aimwas to investigate features of manometric pattern of type II achalasia.Materials and methods: High-resolution esophgeal manometry (HRM) was performed in 250 patients with achalasia. In 154 cases patients underwent peroral esophageal myotomy (POEM).Results: We found that poor results after POEM showed patients with high preoperative esophageal pressurization (&gt;80 mm Hg). The poorest result after POEM we observed in patient with short additional increase of panesophageal pressure (up to 95 mm Hg) withing the contour of panesophageal pressurization.

Surgical Management of Esophageal Achalasia in Pediatrics: A Systematic Review

There are no evidence-based guidelines on the surgical management of esophageal achalasia (OA) in children. This can be a challenging condition with significant physical and psychological morbidity. Our aim was to identify the most common management modalities and their outcomes. A systematic review was performed through a literature search of health care databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, aiming at identifying pediatric series discussing the diagnosis and management of OA. Duplicates, case series with < 9 patients, and follow-up of < 1 year were excluded. The included papers were analyzed for diagnostic methods, primary treatment method, complications, follow-up duration, outcome measures recorded, and outcome. Data from 33 papers for 742 children treated for OA was analyzed. Eleven mentioned multiple management modalities. In summary, 25 described Heller's esophagomyotomy (HM), 13 esophageal dilatation (EOD), and 6 peroral esophageal myotomy (POEM). Mean follow-up was 43.7 months (12-180). Outcome measures were heterogeneous. However, analysis of reported success showed a mean success of 78% for HM (p = 1.79 × 10-7), 44.9% for EOD (p = 0.24), and 99.3% for POEM (p = 0.001). Reported complications were 12.8% for HM, 5% for EOD, and 24.4% for POEM. Further interventions were required for 10.9% of HM, 62.3% of EOD, and 0.01% of POEM patient groups. Methods of diagnosis and measures of successful outcomes were heterogeneous, limiting the strength of evidence. HM showed superior short-term success rates to EOD. POEM is a promising modality but requires investment in equipment and training. Information about sustainability of response and long-term outcomes is lacking.

Per-oral endoscopic myotomy for achalasia.

Symptoms in patients with achalasia are produced by outflow obstruction at the level of the lower esophageal sphincter (LES). As a consequence of neural destruction the LES does not undergo normal swallow-induced relaxation. In addition, the esophageal body loses normal peristaltic function and esophageal emptying is on the basis of gravity. All therapies for achalasia are palliative in that normal LES or esophageal body function cannot be restored. The efficacy of any therapy for achalasia is directly related to its ability to reduce the outflow obstruction at the LES. The three main treatment options are pneumatic dilatation, laparoscopic myotomy and partial fundoplication and per-oral endoscopic myotomy or per-oral esophageal myotomy (POEM). Details of the procedures and outcomes will be discussed.

Efficacy and safety of peroral esophageal myotomy vs laparoscopic Heller’s myotomy for treatment of achalasia: a meta-analysis

Efficacy and safety of peroral esophageal myotomy <i>vs</i> laparoscopic Heller’s myotomy for treatment of achalasia: a meta-analysis

How to Effectively Use High-Resolution Esophageal Manometry

How to Effectively Use High-Resolution Esophageal Manometry

Managing Esophageal Dysphagia in the Elderly

Esophageal dysphagia in the elderly is a common clinical problem. Achalasia is a disease in which there is loss of ganglion in the myenteric plexus of the lower esophageal sphincter resulting in incomplete relaxation of that muscle causing a functional obstruction to outflow. Treatment is aimed at reducing sphincter pressure allowing for gravity and the oral portion of the swallow to propel the bolus through the esophagus. Pneumatic dilatation, Heller myotomy (laparoscopic), and the newest procedure peroral endoscopic esophageal myotomy (POEM) are all reasonable options for effective treatment even in the elderly. The choice depends on the decision of the patient, subtype of achalasia, local expertise, and fitness for surgery. Patients over 45 with type 2 achalasia respond exceptionally well to pneumatic dilation, and we recommend consideration of this technique if expertise is available. POEM has achieved excellent short-term results and if local expertise exists, it should be strongly considered especially in patients with type 3 achalasia. Type 1 achalasia may respond slightly better to myotomy, either Heller or POEM. Proton pump inhibitors remain the treatment of choice for GERD and should not be avoided in the elderly for fear of adverse reactions. While none of the FDA warnings nor concern for chronic renal failure or dementia can be dismissed, much more research is needed before we accept that PPIs are truly causal. Surgery for GERD in patients over 65 is as effective as in the young and should be considered in appropriate candidates. Eosinophilic esophagitis, while not common in the elderly, frequently results in clinically important dysphagia. PPIs, topical oral steroids, and dietary interventions are all used individually and together to improve symptoms. PPIs remain first line and are required twice daily for at least 8weeks as an initial trial. Dilation with either balloons or polyvinyl dilators are highly effective in patients with rings and focal strictures, can be performed safely, and limit the number of medications an elderly patient needs to take.

Mo1031 Is Peroral Esophageal Myotomy (POEM) Comparable to Laparoscopic Heller's Myotomy for Achalasia: A Systematic Review and Meta-analysis of the Current Literature

Mo1031 Is Peroral Esophageal Myotomy (POEM) Comparable to Laparoscopic Heller's Myotomy for Achalasia: A Systematic Review and Meta-analysis of the Current Literature

Surgery or Peroral Esophageal Myotomy for Achalasia: A Systematic Review and Meta-Analysis.

To date very few studies with small sample size have compared peroral esophageal myotomy (POEM) with the current surgical standard of care, laparoscopic Heller myotomy (LHM), in terms of efficacy and safety, and no recommendations have been proposed.To investigate the efficacy and safety of POEM compared with LHM, for the treatment of achalasia.The databases of Pubmed, Medline, Cochrane, and Ovid were systematically searched between January 1, 2005 and January 31, 2015, with the medical subject headings (MeSH) and keywords “achalasia,” “POEM,” “per oral endoscopic myotomy,” and “peroral endoscopic myotomy,” “laparoscopic Heller myotomy” (LHM), “Heller myotomy.”All types of study designs including adult patients with diagnosis of achalasia were selected. Studies that did not report the comparison between endoscopic and surgical treatment, experimental studies in animal models, single case reports, technical reports, reviews, abstracts, and editorials were excluded.The total number of included patients was 486 (196 in POEM group and 290 in LHM group).There were no differences between POEM and LHM in reduction in Eckardt score (MD = −0.659, 95% CI: −1.70 to 0.38, P = 0.217), operative time (MD = −0.354, 95% CI: −1.12 to 0.41, P = 0.36), postoperative pain scores (MD = −1.86, 95% CI: −5.17 to 1.44, P = 0.268), analgesic requirements (MD = −0.74, 95% CI: −2.65 to 1.16, P = 0.445), and complications (OR = 1.11, 95% CI: 0.5–2.44, P = 0.796). Length of hospital stay was significantly lower for POEM (MD = −0.629, 95% CI: −1.256 to −0.002, P = 0.049). There was a trend toward significant reduction in symptomatic gastroesophageal reflux rate in favors of LHM compared to POEM group (OR = 1.81, 95% CI: 1.11–2.95, P = 0.017).All included studied were not randomized. Furthermore all selected studies did not report the results of follow-up longer than 1 year and most of them included patients who were both treatment naive and underwent previous endoscopic or surgical interventions for achalasia.POEM represents a safe and efficacy procedure comparable to the safety profile of LHM for achalasia at a short-term follow-up. Long-term clinical trials are urgently needed.

Is Peroral Esophageal Myotomy (POEM) Comparable to Laparoscopic Hellerʼs Myotomy for Achalasia?: A Systematic Review and Meta-analysis of the Current Literature

Introduction: Achalasia is a neuromuscular disorder with significant morbidity leading to more recent focus on advancing current treatment options. Per-oral endoscopic myotomy (POEM) is gaining attention among interventional gastroenterologists and gastrointestinal surgeons since 2010. Recent literature comparing POEM with laparoscopic Heller myotomy (LHM) for achalasia has been heterogeneous secondary to lower sample size and /or lack of randomized trials. The purpose of this meta-analysis was to assess the safety and efficacy between POEM and LHM. Methods: Literature were identified by searching the electronic databases of PubMed, the Cochrane Database of Systematic Reviews and gray literature from inception to May 25, 2015. For quality assurance purposes throughout the systematic review, multiple independent extractions were performed and the process was executed as per the standards of the Cochrane collaboration. Primary outcomes were operative time, mean change in Eckardt score. Secondary outcomes included days hospitalized and adverse events. Cochrane risk of bias tool was used to assess the methodological quality of included studies. All data were pooled under a random effects model. Overall quality of evidence was summarized using the GRADE method.The data were analyzed using Review Manager version 5.1 software. Results: Overall, six studies were identified that compared outcomes between LHM and POEM for a total of 468 patients. The LHM procedure appeared to have a longer operative time, in minutes, (MD=46.99, 95% CI: -7.93-101.92; p=0.09), but was not statistically significant. There was also no significant difference in the mean change in Eckardt Score (MD=0.33, 95% CI: -0.65-1.31; p=0.51), length of hospital stay, in days, (MD= -0.24, 95% CI: -1.43-0.95; p=0.69), or occurrence of any adverse event (OR=1.24, 95% CI: 0.39-3.89; p=0.72) between LHM and POEM. Conclusion: Based on limited literature, our meta-analysis shows POEM is a comparable intervention for achalasia treatment compared to LHM. However, future large randomized controlled trials with large sample size are warranted to verify these findings.

Association of High-Resolution Manometry Metrics with the Symptoms of Achalasia and the Symptomatic Outcomes of Peroral Esophageal Myotomy.

BackgroundHigh-resolution manometry (HRM) has improved the accuracy of manometry in detecting achalasia and has helped distinguish between clinically relevant subtypes. This study investigated whether HRM metrics correlate with the achalasia symptoms and symptomatic outcomes of peroral esophageal myotomy (POEM).MethodsOf the 30 patients who were enrolled, 25 were treated with POEM, 12 of who underwent HRM after 3 months. All the patients completed the Eckardt score questionnaires, and those who underwent POEM were followed up for about 6 months. Pearson correlation was used to assess the relationship between the HRM metrics and symptoms and outcomes.Key resultsThe integrated relaxation pressure (IRP) score positively correlated with the total Eckardt score, regurgitation score and weight loss score in all the patients, and with the weight loss score in type I achalasia. In 25 patients (10 patients, type I; 15 patients, type II) who underwent POEM, the total Eckardt scores and individual symptom scores significantly decreased after surgery. Changes in the Eckardt scores were similar between type I and type II. Further, the Eckardt scores and weight loss score changes were positively correlated with baseline IRP. Twelve patients (4 patients, type I; 8 patients, type II) underwent HRM again after POEM. IRP changed significantly after POEM, as did the DEP in type II. The IRP changes after POEM were positively correlated with the Eckardt score changes.Conclusions & InferencesIRP is correlated with the symptoms and outcomes of achalasia patients. Thus, HRM is effective for assessing the severity of achalasia and can predict the efficacy of POEM.

Measurement of Esophagogastric Junction Distensibility May Assist in Selecting Patients for Endoluminal Gastroesophageal Reflux Disease Surgery: Author's Reply.

TO THE EDITOR: We thank the author for his interest in our manuscript.1,2 During the transoral incisionless fundoplication (TIF) procedure, a retractor is anchored at the esophagogastric junction (EGJ) after which tension is applied to advance the EGJ caudally.3,4 Therefore, we agree that lengthening of the EGJ is a substantial mode of action of the TIF procedure. In addition, transmural placement of polypropylene fasteners creates an endoluminal fundoplication through permanent serosa-to-serosa or serosa-to-muscularis fusion with tightening of the distal esophagus, which decreases EGJ diameter and distensibility. 5,6 Therefore, we believe that EGJ distensibility can be an important parameter for evaluation of endoluminal gastroesophageal reflux disease (GERD) surgery like the TIF procedure, although we agree that the immediate decrease in EGJ distensibility after the TIF procedure might be the consequence of postoperative edema.7 It is important to note that consensus is lacking with regard to analysis of parameters obtained from EndoFLIP measurements. According to the most widely accepted approach, EGJ distensibility is assessed based on the narrowest cross sectional area and corresponding intra-bag pressure. Standardized methods to evaluate the change in EGJ length with the EndoFLIP technique are still to be defined. Therefore, we anticipate that development of more extensive biomechanical measures will result in more accurate interpretation of EndoFLIP data. In the present study, we used the EndoFLIP technique in the preoperative diagnostic work-up to predict postoperative outcome. Recent studies highlight that the EndoFLIP technique could be used as an intra-operative quality tool during either anti-reflux or achalasia surgery.8,9 Teitelbaum et al10 described that the EndoFLIP technique is able to guide laparoscopic Heller myotomy and peroral esophageal myotomy to obtain an ideal postoperative EGJ distensibility with regard to both postoperative achalasia and reflux symptoms. In addition, Perretta et al8 provided observational data about the change in EGJ distensibility and diameter during different stages of laparoscopic Nissen fundoplication. In the future, the EndoFLIP method could potentially be used during laparoscopic fundoplication to prevent creation of a hypercompetent valve with associated postoperative symptoms (eg, dysphagia or gas bloating).8 It therefore appears that the EndoFLIP technique has considerable potential as an intra-operative tool. On the other hand, currently available methodologies limit its role with regards to the assessment of EGJ distensibility in the preoperative diagnostic work-up or in post-procedure evaluation of patients undergoing endoluminal GERD surgery like TIF. Additional research is necessary to define the role of the EndoFLIP technique for both the preoperative work-up and tool for intraoperative calibration.

The effect of incremental distal gastric myotomy lengths on EGJ distensibility during POEM for achalasia.

During peroral esophageal myotomy (POEM) for the treatment of achalasia, the optimal distal gastric myotomy length is unknown. In this study, we used a functional lumen imaging probe (FLIP) to intraoperatively measure the effect of variable distal myotomy lengths on esophagogastric junction (EGJ) distensibility. EGJ distensibility index (DI) (minimum cross-sectional area divided by intrabag pressure) was measured with FLIP after each operative step. Each patient's myotomy was performed in four increments from proximal to distal: (1) an esophageal myotomy (from 6 cm proximal to the EGJ to 1 cm proximal to it), (2) a myotomy ablating the lower esophageal sphincter (LES) complex (from 1 cm proximal to the EGJ to 1 cm distal to it), (3) an initial gastric extension (from 1 cm distal to the EGJ to 2 cm distal), and (4) a final gastric extension (from 2 cm distal to the EGJ to 3 cm distal). Measurements were taken in 16 achalasia patients during POEM. POEM resulted in an overall increase in DI (pre 1.2 vs. post 7.2 mm(2)/mmHg, p < .001). Initial creation of the submucosal tunnel resulted in a threefold increase in DI (1.2 vs. 3.6 mm(2)/mmHg, p < .001). When the myotomy was then performed in a stepwise fashion from proximal to distal, the initial esophageal myotomy component had no effect on DI. Subsequent myotomy extension across the LES complex resulted in an increase in DI, as did the initial gastric myotomy extension (to 2 cm distal to the EGJ). The final gastric myotomy extension (to 3 cm distal) had no further effect. During POEM, creation of the submucosal tunnel prior to myotomy resulted in a marked improvement in EGJ physiology. Myotomy extension across the LES complex and to 2 cm onto the gastric wall resulted in the normalization of EGJ distensibility, whereas subsequent extension to 3 cm distal to the EGJ did not increase compliance further.

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

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