Success Of Peroral Endoscopic Myotomy Research Articles

The third space for endoscopic treatment of motility disorders of the gastrointestinal tract.

Over the last few decades, we have seen the further advancement and progress of the field of interventional and therapeutic endoscopy, bringing us to undiscovered areas of the gut's lumen. The development of peroral endoscopic myotomy (POEM) created a breakthrough in the field of therapeutic endoscopy by bringing us to the so-called "third space," which is an artificially created space in the submucosal layer. The rise of third space endoscopy brought us novel and fundamental aspects into therapeutic endoscopy by paving the way to interventions throughout the gastrointestinal (GI) tract. With the success of POEM, the same third space principles have become the foundation for the development of other third space endoscopic techniques for the management of motility disorders of the GI tract, giving rise to a number of POEM offshoots. Since motility disorders of the GI tract are commonly encountered in clinical practice, the development of third space endoscopic interventions to address these disorders was seemingly timely, providing patients optimal care. In this chapter, we would like to offer a closer look and provide the readers a general overview of POEM and other POEM-based techniques which have been developed for the management of motility disorders of the GI tract.

POEM: clinical outcomes beyond 5 years.

The short-term success of peroral endoscopic myotomy (POEM) is well documented but the durability of the operation is questioned. The aim of this study was to evaluate the clinical outcomes of the POEM procedure for esophageal motility disorders in a large cohort in which all patients had at least 5years of follow-up. All patients from a single center who underwent a POEM between October 2010 and September 2014 were followed for long-term clinical outcomes. Postoperative Eckardt symptom scores of short term and ≥ 5years were collected through phone interview. Clinical success was defined as an Eckardt score < 3. Overall success was defined as Eckardt score < 3 and freedom from additional interventions. Of 138 patients, 100 patients were available for follow-up (mean age 56, 52% male). The indication for operation was achalasia in 94. The mean follow-up duration was 75months (range: 60-106months). Dysphagia was improved in 91% of patients. Long-term overall success was achieved in 79% of patients (80% of achalasia patients, 67% of DES patients). Preoperative mean Eckardt score was 6. At 6months, it was 1, and at 75months, it was 2 (p = 0.204). Five-year freedom from intervention was 96%. Overall, 7 patients had additional treatments: 1 balloon dilation (35mm), 4 laparoscopic Heller myotomy, and 2 redo POEM at a mean of 51months post-POEM. Ninety-three percent expressed complete satisfaction with POEM. A multitude of studies has shown the early benefits of POEM. Here, we show that nearly 80% of patients report clinical success with no significant decrement in symptom scores between their short- and long-term follow-up. Clearly POEM is an effective option for achalasia with durable long-term treatment efficacy.

Gastric Per Oral Pyloromyotomy for Post-Vagotomy-Induced Gastroparesis Following Esophagectomy

BackgroundFollowing the success of per-oral endoscopic myotomy (POEM) for achalasia, application of this minimally invasive skillset has broadened to other disease processes. Since 2013, gastric per-oral pyloromyotomy (GPOP) has become an increasingly accepted therapy for refractory gastroparesis. Although it does not treat the underlying etiology of the disease, pyloromyotomy has demonstrated measurable improvements in gastric emptying scintigraphy, nausea, and quality of life. Gastroparesis is a common complication of esophagectomy due to the inherent vagotomy that occurs during creation of the gastric conduit. Fifteen to 30% of post-esophagectomy patients develop gastroparesis with a large portion of them reporting symptoms refractory to medical therapy, botox injection, and endoscopic dilation. Therefore, GPOP may have the potential to offer symptomatic relief to a significant population of debilitated post-esophagectomy patients. Materials and MethodsThe procedure was recorded using standard operating room equipment. Materials utilized included high-definition single-channel gastroscope, therapeutic overtube, clear endoscopic cap, triangle tip (TT) knife, ERBE energy source, endoscopic clips, sclerotherapy needle, methylene blue with epinephrine, and CO2 insufflator. ResultsWe present a video of GPOP for a 71-year-old male with post-vagotomy-induced gastroparesis after esophagectomy. His pre-operative course was significant for persistent nausea and vomiting, diet intolerance, 20 lb weight loss, and frequent hospitalizations for aspiration pneumonia. Post-operatively, the patient recovered well and was discharged home on post-operative day 1 on a liquid diet. At 3-week follow-up, his nausea, vomiting, and PO intolerance had improved. At 6-month follow-up, he had no recent admissions for aspiration pneumonia and his pylorus remained widely patent on EGD. ConclusionsGPOP status post-esophagectomy presented multiple challenges: difficulty maintaining field of view and insufflation, establishing tension and counter tension for the mucosotomy, and a limited working space. With care and patience, endoscopists trained to perform POEM may apply their skillset to help a large population of patients suffering with post-esophagectomy gastroparesis.

Clinical outcomes of per-oral endoscopic tumor resection for submucosal tumors in the esophagus and gastric cardia.

The clinical success of per-oral endoscopic myotomy (POEM) has led to the development of a new field of 'submucosal endoscopy'. This study aimed to evaluate the safety, efficacy, and limitations of per-oral endoscopic tumor resection (POET) in the management of submucosal tumors (SMTs) in the esophagus and the gastric cardia. POET was performed in 47 patients from January 2011 to December 2017. The indication for POET was SMTs≤30mm in minor axis diameter. Patient and tumor characteristics (age, gender, tumor location, size, and histology), operative and clinical results of POET (procedure time and completion rate, en bloc resection rate, length of hospitalization, adverse events and tumor recurrence) were analyzed retrospectively. POET was successfully completed in 43 patients (91.5%) without any major adverse events (Clavien-Dindo IIIb-IV). Four patients required conversion to an open surgical procedure due to suboptimal visualization during POET. Four patients underwent piecemeal resection of their SMTs including GISTs. Median follow-up was 44months (10-96months), during that time, there were no incidences of tumor recurrence. Tumors that had a minor axis diameter>30mm or a tumor mass index (TMI) [major axis diameter (mm)×minor axis diameter (mm)] >1000 had a high likelihood of being converted to surgical resection. POET is a safe and effective treatment for SMTs. However, in patients where the minor axis diameter is>30mm or the TMI>1000, surgical excision should be considered. Furthermore, application of POET for SMTs with malignant potential should be carefully considered to ensure optimal oncologic outcomes.

New endoscopic classification of esophageal mucosa in achalasia: A predictor for submucosal fibrosis.

Background/Aim:In this study, we aim to investigate the predicting ability of one new endoscopic classification of esophageal mucosa in achalasia (EMIA) for submucosal fibrosis (SMF) affecting the success of peroral endoscopic myotomy (POEM).Patients and Methods:The endoscopic and clinical data of achalasia patients undergoing POEM from 2012 to 2016 were investigated retrospectively. According to the endoscopic images or videos, EMIA and SMF grades were recorded. The relation between EMIA and SMF gradings was assessed by Spearman's rank correlation, and the predictive factors of SMF were identified by logistic regression analysis.Results:A total of 568 achalasia patients who underwent POEM were enrolled. For EMIA classification, there were 40 (7.0%), 373 (65.7%), 139 (24.5%), 14 (2.5%), 1 (0.2%), and 1 (0.2%) case (s) for grades a, b, c, d, e1, and f4, respectively. POEM procedures were aborted in 16 patients, and 93.8% (15/16) were due to severe SMF. Because grades e and f were rare and the related SMF was obvious, these two grading cases were excluded from the following analysis. Correlation between EMIA and SMF gradings was significant (Spearman r = 0.62, P < 0.01). Multivariate logistic analysis, including age, sex, disease duration, Ling classification, previous treatment, and EMIA classification, demonstrated that the EMIA classification (grades c to d) was an independent predictor for advanced SMF (odds ratio = 26.547, 95% confidence interval: 15.809–44.578, P < 0.01).Conclusions:The new endoscopic EMIA classification is an independent predictor of advanced SMF during POEM. The classification may be used for assessment of the difficulty and success of POEM.

221 Success of Peroral Endoscopic Myotomy (POEM) Feasible in Spastic Esophageal Disorders (Excluding Achalasia) With Failed Medical Therapy? a Meta-Analysis and Systematic Review

221 Success of Peroral Endoscopic Myotomy (POEM) Feasible in Spastic Esophageal Disorders (Excluding Achalasia) With Failed Medical Therapy? a Meta-Analysis and Systematic Review

Tu1956 A Meta-Analysis and Systematic Review of Prospective Studies: Technical and Clinical Success of Peroral Endoscopic Myotomy (POEM) in Treating Adult Patients With Achalasia

Tu1956 A Meta-Analysis and Systematic Review of Prospective Studies: Technical and Clinical Success of Peroral Endoscopic Myotomy (POEM) in Treating Adult Patients With Achalasia

Tu1303 Success of Peroral Endoscopic Myotomy (Poem) in Treating Adult Patients With Achalasia: A Meta-Analysis and Systematic Review

Tu1303 Success of Peroral Endoscopic Myotomy (Poem) in Treating Adult Patients With Achalasia: A Meta-Analysis and Systematic Review

Peroral endoscopic myotomy for Jackhammer esophagus: to cut or not to cut the lower esophageal sphincter.

Background and study aims: With the success of peroral endoscopic myotomy (POEM) in treatment of achalasia, its successful application to other spastic esophageal motility disorders such as Jackhammer esophagus has been noted. The question of whether the lower esophageal sphincter (LES) should be included in the myotomy for Jackhammer esophagus is a topic of current debate. Here, we report our experience and results with four patients with Jackhammer esophagus treated with POEM. The clinical and manometric results are presented and their potential implications are discussed. Patients and methods: Between January 2014 and July 2015, four patients underwent POEM for treatment of Jackhammer esophagus at our center. Manometry was performed prior to and after POEM. All patients met the Chicago classification criteria for Jackhammer esophagus and received a barium esophagram and endoscopic examination before having POEM. Results: All patients had uneventful procedures without any intraoperative or post-procedure complications. Patients in which the LES was included during POEM had resolution or significant improvement in symptoms. One patient in whom the LES was preserved had resolution of chest pain but developed significant dysphagia and regurgitation. Subsequently this individual received a repeat POEM which included the LES, resulting in symptom resolution. Conclusions: POEM is a suitable treatment for patients with Jackhammer esophagus. Until there are larger-scale randomized studies, we speculate that based on our clinical experience and physiologic and manometric observations, obligatory inclusion of the LES is justified to reduce the risk of symptom development from iatrogenic ineffective esophageal motility or subsequent progression to achalasia.