Esophageal Per-Oral Endoscopic Myotomy (E-POEM): Future Directions and Perspectives.

PURPOSE OF REVIEW: POEM is a mature procedure endorsed by societal guidelines as a first line therapy for achalasia and spastic esophageal disorders. Nonetheless, several questions remain, including expanding indications for POEM, periprocedural evaluation and management, and the optimal POEM technique to enhance clinical success while mitigating risk for reflux. RECENT FINDINGS: There is uncertainty regarding several technical aspects of the POEM myotomy; though aggregating evidence supports the use of real-time impedance planimetry to guide the myotomy. While post-POEM reflux remains a concerning long term sequela, there is an increasing focus on the potential role of endoscopic anti-reflux interventions. Lastly, with the widespread adoption of POEM, we continue to witness ongoing efforts to standardize post-procedural care and training in this procedure. POEM is no longer a novel but rather established procedure. Yet, this technique has continued to evolve, with the aim of optimizing treatment success while reducing adverse events and risk for post-procedural reflux.

Efficacy and safety of per-oral endoscopic myotomy in non-achalasia esophageal motility disorders: a systematic review and meta-analysis.

Per­oral endoscopic myotomy (POEM) is the preferred endoscopic modality for managing achalasia cardia. However, there are no recommendations on the role of POEM in non­achalasia esophageal dysmotility disorders (NAEMD), including esophagogastric junction outflow obstruction (EGJOO), distal esophageal spasm (DES), and hypercontractile esophagus (HE). The present systematic review and meta-analysis aimed to assess the safety and efficacy of POEM in the treatment of NAEMD. MEDLINE, Embase, and Scopus were searched from inception to August 2023 for studies analyzing the outcome of POEM in NAEMD. Clinical success and adverse events were the main outcomes assessed. The event rates and their 95% confidence interval were calculated using a random effects model. A total of 11 studies with 271 patients were included in the final analysis. The pooled clinical success rate with POEM in NAEMD was 86.9% (82.9-90.9). On subgroup analysis, the pooled clinical success rates of POEM in DES and EGJOO were 97.8% (90.9-100.0) and 92.7% (86.3-95.1), which were significantly higher than in HE 81.2% (73.5-88.8). Data from limited studies showed that the pooled rate of improvement in dysphagia and chest pain was 88.5% (83.0-93.9) and 87.4% (80.5-94.4). The pooled incidence of overall AEs and serious AEs was 12.6% (5.7-19.5) and 0.3% (0.0-1.9), respectively. On follow-up, the pooled incidence of new-onset heartburn was 18.7% (11.1-26.2). POEM is a safe and efficacious treatment modality for the management of NAEMD with a lower clinical success in patients with HE. Further large-scale studies are required to validate the findings of the present analysis.

Efficacy and safety of peroral endoscopic myotomy for pediatric achalasia: A nationwide study.

Achalasia, a rare esophageal motility disorder characterized by the inability of the lower esophageal sphincter to relax and loss of esophageal peristalsis, significantly impacts pediatric patient quality of life through symptoms like dysphagia, chest pain, and weight loss. This nationwide retrospective cohort study evaluates the efficacy and safety of peroral endoscopic myotomy (POEM) for pediatric achalasia in Mongolia, contributing to the limited global data on this minimally invasive treatment in children. Conducted between February 2020 and March 2022 at 2 tertiary centers, the study included symptomatic achalasia patients, treatment-naive or those with unsatisfactory outcomes from previous esophageal dilations. The POEM procedure was assessed for its impact on esophageal structure and function, symptom severity via the Eckardt score, and procedure-related safety, with outcomes measured at baseline, 3 days, and 12 months post-procedure. The study demonstrated notable post-procedure improvements across all measured outcomes: abnormal contraction length and esophageal width significantly reduced, underscoring the procedure's effectiveness. More precisely, the integrated relaxation pressure showed a significant improvement from a mean of 26.8 mm Hg (standard deviation [SD], 5.4 mm Hg) pre-procedure to 10.8 mm Hg (SD, 1.1 mm Hg) 12 months (P < .001). Similarly, Eckardt scores, which assess symptom severity, improved significantly from a pre-procedure mean of 7.0 (SD, 1.0) to a substantially lower score post-procedure (P < .001), reflecting enhanced patient quality of life and symptom alleviation. This study underscores POEM's role as an effective, minimally invasive option for pediatric achalasia management within the Mongolian population, offering significant symptomatic relief and improved esophageal function.

Gastroesophageal reflux following peroral endoscopic myotomy for achalasia: Bumps in the road to success.

Achalasia can significantly impair the quality of life. The clinical presentation typically includes dysphagia to both solids and liquids, chest pain, and regurgitation. Diagnosis can be delayed in patients with atypical presentations, and they might receive a wrong diagnosis, such as gastroesophageal reflux disease (GERD), owing to overlapping symptoms of both disorders. Although the cause of achalasia is poorly understood, its impact on the motility of the esophagus and gastroesophageal junction is well established. Several treatment modalities have been utilized, with the most common being surgical Heller myotomy with concomitant fundoplication and pneumatic balloon dilatation. Recently, peroral endoscopic myotomy (POEM) has gained popularity as an effective treatment for achalasia, despite a relatively high incidence of GERD occurring after treatment compared to other modalities. The magnitude of post-POEM GERD depends on its definition and is influenced by patient and procedure-related factors. The long-term sequelae of post-POEM GERD are yet to be determined, but it appears to have a benign course and is usually manageable with clinically available modalities. Identifying risk factors for post-POEM GERD and modifying the POEM procedure in selected patients may improve the overall success of this technique.

Safety and feasibility of same-day discharge for per-oral endoscopic myotomy.

AIMS: Per-oral endoscopic myotomy (POEM) is a recognised treatment for achalasia, with the accepted approach involving admission for imaging and dietary progression. However, recent publications suggest same-day discharge (SDD) may be possible, which could be time and cost-saving. We sought to investigate the safety of SDD following POEM. METHODS: Fifty consecutive POEMs at two referral centres in New Zealand were performed between 2020-2023. All patients were planned for early dietary introduction and were eligible for SDD if symptoms were managed. Analgesia was available in recovery and supplied at discharge. Imaging and endoscopy were performed only if there were clinical concerns. Rates of discharge clearance, discharge, complications and re-admission were analysed. RESULTS: All 50 POEMs were technically successful. A total of 41/50 (82%) received clearance for SDD. Additionally, 35/50 (70%) achieved discharge and 6/50 (12%) were observed overnight for social reasons, including lack of transport to the referring domicile. Of the patients not cleared for SDD, 7/9 (78%) were discharged within 24 hours, and the others after 48 and 72 hours. Procedural complications were recorded in three patients (6%), with one requiring endoscopic assessment and clipping. There were two re-admissions (4%), both lt;24-hour hospital stays, and managed medically. CONCLUSIONS: The majority of patients achieved same-day discharge clearance (82%) and 96% required less than 24 hours hospital stay. Complication and re-admission rates were low overall. We have demonstrated that POEM can be an SDD procedure facilitated by early dietary introduction and liberal analgesia, without the need for routine imaging or endoscopy.

POEM for non-achalasia spastic oesophageal motility disorders.

Non-achalasia oesophageal motility disorders (NAOMD) represent a heterogeneous group of rare diseases, including oesophagogastric junction outflow obstruction, distal oesophageal spasm, and hypercontractile oesophagus. Despite the differing aetiological, manometric and pathophysiological characteristics, these disorders are unified by similar clinical presentation, including dysphagia and chest pain. The management of these disorders remain a challenge for the clinician. Pharmacotherapy, botulinum toxin injection, endoscopic dilation, and laparoscopic Heller myotomy have been employed, with limited efficacy in the majority of patients. Currently, there are no controlled studies in literature that suggest which is the best management of these diseases. Since its introduction in clinical practice, PerOral Endoscopic Myotomy (POEM) has emerged as a very promising, minimally invasive and effective treatment for oesophageal achalasia. No longer after the first uses, POEM has been successfully used also for the management of selected patients with NAOMD, However, currently available data are limited by small study sample sizes and short-term follow-up.

Traditional septotomy or Z-POEM for Zenker's diverticulum.

Zenker's diverticulum (ZD), also known as a cricopharyngeal pouch, is a pulsion pseudodiverticulum located dorsally at the pharyngoesophageal junction. The pathophysiology of ZD involves cricopharyngeal spasm, incoordination, impaired upper esophageal sphincter opening, and structural changes in the cricopharyngeal muscle, leading to symptoms such as dysphagia, regurgitation of undigested food, foreign body sensation, halitosis, unintentional weight loss, and respiratory issues. Treatment for symptomatic ZD typically involves myotomy of the cricopharyngeal muscle. Endoscopic techniques, particularly flexible endoscopy septotomy (FES) and Zenker peroral endoscopic myotomy (Z-POEM), have become preferred options due to their minimally invasive nature. This review discusses the techniques and clinical outcomes of FES and Z-POEM, focusing on specific clinical scenarios to guide the choice between these methods. Additionally, the variability in FES techniques, the effectiveness of Z-POEM, and the impact of different diverticulum sizes on treatment outcomes are analyzed, providing a comprehensive overview of current therapeutic approaches for ZD.

Complications related to third space endoscopic procedures.

Third space endoscopy (TSE) encompasses a breadth of procedures for the treatment of a variety of GI disorders. The widespread use of per-oral endoscopic myotomy (POEM) and its diversification to include extended indications and at locations other than the oesophagus has provided an insight into the potential complications encountered. The most common adverse events associated with POEM, the epitome of TSE procedures, include insufflation related injuries, bleeding, failure of mucosal barrier, infections, pain, blown out myotomy and gastroesophageal reflux disease. The purpose of this review is to highlight the pitfalls and to identify the risk factors that may lead to adverse events, and to recommend appropriate salvage interventions in the scope of the current evidence.

Per oral endoscopic myotomy for achalasia.

Achalasia, characterized by impaired lower esophageal sphincter (LES) relaxation and failed peristalsis, stands out as the most widely recognized primary esophageal motility disorder. It manifests with dysphagia to solid and liquid foods, chest pain, regurgitation, and weight loss, leading to significant morbidity and healthcare burden. Traditionally, surgical Heller myotomy and pneumatic dilation were the primary therapeutic approaches for achalasia. However, in 2009, Inoue and colleagues introduced a groundbreaking endoscopic technique called peroral endoscopic myotomy (POEM), revolutionizing the management of this condition. This review aims to comprehensively examine the recent advancements in the POEM technique for patients diagnosed with achalasia, delving into critical aspects, such as the tailoring of the myotomy, the prevention of intraprocedural adverse events (AEs), the evaluation of long-term outcomes, and the feasibility of retreatment in cases of therapeutic failure.

Cricopharyngeal achalasia and upper oesophageal endoscopic myotomy (CP-POEM).

Cricopharyngeal achalasia (CPA), also known as cricopharyngeal bar, is a rare motor disorder affecting the upper oesophageal sphincter. This comprehensive literature review focuses on clinical aspects that can assist physicians in daily decision-making. The diagnosis of CPA is primarily based on symptoms of upper dysphagia and radiological identification of a posterior bar. However, the diagnostic process is not standardized and necessitates a multimodal approach, including radiological, endoscopic, and manometric studies performed by various specialists. Treatment options for CPA include botulinum toxin injection, endoscopic balloon dilatation, open or endoscopic surgery, and cricopharyngeal peroral endoscopic myotomy (CP-POEM). CP-POEM is the latest indication for POEM and has shown promising results with minimal adverse events, though high-quality evidence is still lacking.

The Impact of Early Nutrition Following Peroral Endoscopic Myotomy in Achalasia: A Tertiary Center Experience.

BACKGROUND/AIMS:  This retrospective single-center study aimed to assess the safety of early feeding in patients who met certain criteria following peroral endoscopic myotomy (POEM). MATERIALS AND METHODS:  Data from 100 patients who underwent POEM at our center between January and December 2022 were collected. Early feeding was defined as the introduction of clear liquid foods at 4 hours post procedure. At 4 and 24 hours, the pain was rated using the visual analog scale (VAS) in all patients. Patients without intraoperative complications (pneumoperitoneum requiring needle drainage, severe arterial bleeding requiring the use of hemostatic forceps, severe mucosal injury) and severe pain (VAS score > 6) and nausea-vomiting at the fourth postoperative hour were given the early feeding approach. In patients who did not meet these requirements, enteral feeding was initiated after 24 hours (late feeding). RESULTS:  Among the 100 patients, 50 patients were categorized early feeding. No patients had a control esophagogram. In the early and late enteral feeding groups, VAS scores were 4 (0-6) and 6 (1-8) (P< 001) at 4 hours and 1 (0-3) and 1 (0-6) (P = .043) at 24 hours, respectively. No severe complications were developed after early feeding. The median hospital stay in the early feeding group was 1 (1-3) day. There was no emergency readmission in any of early feeding patients. CONCLUSION:  Our study showed early feeding following POEM can be begun in achalasia patients who do not have intraoperative complications, severe pain, or nausea/vomiting.

Association of gastric myotomy length in peroral endoscopic myotomy (POEM) with gastro-esophageal junction distensibility measured by Endoluminal Functional Lumen Imaging Probe (EndoFLIP).

BACKGROUND: Endoluminal Functional Lumen Imaging Probe (EndoFLIP) is a device that measures gastro-esophageal junction (GEJ) distensibility. However, it is not demonstrated that GEJ distensibility increases proportionally with varying gastric myotomy length in peroral endoscopic myotomy (POEM). This study aimed to investigate the association between gastric myotomy length in POEM and intraoperative EndoFLIP findings. METHODS: This single-center, retrospective cohort study included patients who underwent POEM with intraoperative EndoFLIP from December 2019 to January 2023. Using EndoFLIP, minimal balloon diameter and its distensibility index (DI) were measured pre- and post-myotomy. Primary and secondary outcomes were the post-myotomy EndoFLIP findings at 30 ml and 40 ml volume fills. RESULTS: The study included 44 patients (mean age 53.1 years, 50% female). Chicago classification included achalasia type I (39%), II (41%), III (9%), hypercontractile esophagus (2%), and EGJOO (9%). The mean esophageal myotomy length was 7.5 ± 2.2 cm and gastric myotomy was 2.1 ± 0.6 cm. Simple linear regression analyses indicated that for each 1 cm increase in gastric myotomy length, the DI at 30 ml volume fill was estimated to increase by 2.0 mm2/mmHg (p < 0.05, R2 = 0.41), the minimal diameter at 30 ml volume fill was estimated to increase by 2.4 mm (p < 0.05, R2 = 0.48), and the minimal diameter at 40 ml volume fill was estimated to increase by 1.3 mm (p < 0.05, R2 = 0.09). CONCLUSIONS: This study demonstrates a significant linear relationship between gastric myotomy length and GEJ distensibility measured by EndoFLIP during POEM. These findings may be useful in clinical practice by enabling EndoFLIP to help calibrate a desired gastric myotomy length to achieve optimal DI and minimal diameter.

Esophageal impedance planimetry during per-oral endoscopic myotomy guides myotomy extent.

INTRODUCTION: Peroral endoscopic myotomy (POEM) is the standard treatment for achalasia. Functional luminal imaging probe (FLIP) technology enables objective measurement of lower esophageal sphincter (LES) geometry, with literature linking specific values to improved post-POEM outcomes. Our study assesses FLIP's intraoperative use in evaluating myotomy extent in real-time. METHODS: Retrospective data from all patients undergoing POEM with intraoperative FLIP measurements were extracted from June 2020 to January 2023. The primary endpoint was intraoperative FLIP measurements, management changes, and symptom improvement (Eckardt score). RESULTS: Fourteen patients (age 56 ± 14 years, BMI 28 ± 7 kg/m2) were identified. Most patients were female (64%). Predominantly, patients presented with type II achalasia (50%). FLIP measurements were taken before and after myotomy, demonstrating increases in mean distensibility index (DI) 1.6 ± 1. 4 to 5.4 ± 2.1 mm2/mmHg (p < 0.05) and mean diameter (Dmin) 6 ± 1.8 to 10.9 ± 2.3 mm (p < 0.05) at 50 ml balloon fill. Additional myotomy was performed in one patient when an inadequate increase in FLIP values were noted. Mean operative time was 98 ± 28 min, and there were no intraoperative complications. At the 30-day follow-up, median Eckardt score decreased from mean a preoperative score of 7 ± 2 to a post-operative mean of 2 ± 3, with 10 patients (78%) having a score ≤ 2. In total, four patients experienced symptom recurrence, with repeat FLIP values revealing a significant decrease in DI from 7 ± 2.2 post-POEM to 2.5 ± 1.5 at recurrence. FLIP technology identified LES pathology in 3 out of 4 (75%) patients, facilitating referral to LES-directed therapy. CONCLUSION: Our study adds to the literature supporting the use of FLIP technology during the POEM procedure, with most patients achieving ideal values after a standard-length myotomy. This suggests the potential benefits of shorter myotomies guided by FLIP to achieve comparable outcomes and reduce postoperative GERD risk. Collaborative standardization of study designs and outcome measures is crucial for facilitating prospective trials and cross-setting outcome comparisons.

Does preoperative symptom duration affect outcomes following per oral endoscopic myotomy (POEM)?

BACKGROUND: Per oral endoscopic myotomy (POEM) is a safe therapy for the treatment of achalasia. Long-term effects of untreated achalasia include worsening dysmotility and disruptions in esophageal anatomy, i.e., tortuosity and dilation. We hypothesize that long-standing achalasia prior to intervention will have worse outcomes following POEM than in patients with symptoms for shorter duration. METHODS: We retrospectively analyzed achalasia patients who underwent POEM at our institution from 2011 to 2023, categorizing them into symptom duration cohorts (< 1 year, 1-3 years, 4-10 years, > 10 years). Inclusion criteria comprised patients with documented achalasia diagnosis who received POEM treatment at our facility. Exclusion criteria encompassed individuals lacking data pertaining to achalasia diagnosis, the time frame before intervention, or those missing pre and postoperative Eckardt scores. POEM failure was defined as symptom recurrence, necessity for repeat intervention, or high postoperative Eckardt score. We compared demographic, preoperative, and postoperative outcomes across these cohorts, and employed multivariable logistic regression to explore the link between symptom duration and POEM response. RESULTS: During the study period, in our increased cohort 234 patients met inclusion criteria. 75 patients had symptoms for < 1 year, 78 patients had symptoms from 1 to 3 years, 47 patients had symptoms from 4 to 10 years, and 34 patients had symptoms > 10 years. Patient demographics such as age, sex, BMI, Charleson-Deyo-Comorbidity-Index, and diabetes did not differ amongst cohorts. High-resolution manometry data, including achalasia type, Median IRP, LES residual pressure, and Basal LES pressure did not differ between groups. Preoperative Eckardt scores ranged from 4 to 5 across groups (p 0.24). Patients endorsed an average of three total preoperative symptoms across groups (p 0.13). Patients with symptoms greater than 4 years had significantly more endoscopic interventions prior to POEM (37% vs, 68% p .001). There was no significant difference in post-procedure mean Eckardt scores between cohorts. All cohorts experienced the same number of post-POEM symptoms. Post-POEM manometric measurements remained consistent across cohorts. Similarly, there were no significant differences in terms of symptom recurrence, requirement for repeat interventions, or repeat POEM among the cohorts. Multivariable logistic regression analysis determined achalasia symptoms greater than a decade did not result in increased odds of having a higher postoperative Eckardt score, worse dysphagia, regurgitation, or weight loss. CONCLUSIONS: In this increased cohort, this data once again suggests that longer symptom duration is not associated with increased rates of POEM failure.

Transverse versus longitudinal mucosal incision during POEM for esophageal motility disorders: a randomized trial.

BACKGROUND: Longitudinal incision is the commonly used incision for entry into the submucosal space during peroral endoscopic myotomy (POEM) for esophageal motility disorders. Transverse incision is another alternative for entry and retrospective data suggest it has less operative time and chance of gas-related events. METHODS: This was a single-center, randomized trial conducted at a tertiary care hospital. Patients undergoing POEM for esophageal motility disorders were randomized into group A (longitudinal incision) and group B (transverse incision). The primary objective was to compare the time needed for entry into the submucosal space. The secondary objectives were to compare the time needed to close the incision, number of clips required to close the incision, and development of gas-related events. The sample size was calculated as for a non-inferiority design using Kelsey method. RESULTS: Sixty patients were randomized (30 in each group). On comparing the 2 types of incisions, there was no difference in entry time [3 (2, 5) vs 2 (1.75, 5) min, p = 0.399], closure time [7 (4, 13.5) vs 9 (6.75, 19) min, p = 0.155], and number of clips needed for closure [4 (4, 6) vs 5 (4, 7), p = 0.156]. Additionally, the gas-related events were comparable between the 2 groups (capnoperitoneum needing aspiration-5 vs 2, p = 0.228, and development of subcutaneous emphysema-3 vs 1, p = 0.301). CONCLUSION: This randomized trial shows comparable entry time, closure time, number of clips needed to close the incision, and gas-related events between longitudinal and transverse incisions. REGISTRATION NUMBER: CTRI/2021/08/035829.

The effect of per-oral endoscopic myotomy by achalasia subtype as measured by impedance planimetry.

BACKGROUND: Achalasia is an esophageal motility disorder with three subtypes based on manometry that can treated with per-oral endoscopic myotomy (POEM). With the advent of impedance planimetry (EndoFLIP®), we hypothesized the three achalasia subtypes would have different pre-POEM EndoFLIP® diameter and distensibility index (DI) measurements but would be similar after POEM. METHODS: A single-institution, retrospective review of consecutive POEM cases by a single surgeon-endoscopist team from 04/07/2017 to 08/28/2023. Patients with a diagnosis of achalasia were stratified into type 1, 2, or 3 based on pre-POEM manometry. Patient characteristics, Eckardt scores, and pre-and-post-POEM diameter and DI were compared by subtype with descriptive, univariate, and multivariable linear regression statistics. RESULTS: Sixty-four patients met inclusion criteria, of whom 9(14.1%) had Type 1, 36(56.3%) had Type 2, and 19(29.7%) had Type 3. There were no differences between Types with respect to median pre-POEM Eckardt scores (9[IQR:7-9) vs. 8[IQR:6-9] vs. 7[IQR:5-8], p = 0.148), median post-POEM Eckardt scores (0[IQR:0-1] vs. 0[IQR:0-0] vs. 0[IQR0-0.5], p = 0.112). EndoFLIP® data revealed variation in median pre-POEM diameter and DI between Subtypes (6.9[IQR:6-8.5] vs. 5.5[IQR:5-6.8] vs. 5[IQR:5-6.1], p = 0.025 and 1.8[IQR:1.3-3.2] vs. 0.9[IQR:0.6-1.6] vs. 0.6[IQR:0.5-0.8], p = 0.003, respectively), but not in the change in diameter or DI post-POEM (5.1[IQR:4.3-5.9] vs. 5.1[IQR:4.1-7.1] vs. 5.9[IQR:5-6.4], p = 0.217 and 3.9[IQR:2.5-4.7] vs. 3.4[IQR:2.4-4.7] vs. 2.7[IQR:2.3-3.7], p = 0.461, respectively). However, after adjusting for potentially confounding factors, pre- or post-POEM diameter and DI did not demonstrate statistically significant differences among subtypes. CONCLUSIONS: Achalasia subtypes did not demonstrate different pre-POEM diameters or DI as measured by EndoFLIP® nor are there differences after POEM completion. While achalasia subtypes may have slightly different pathophysiology based on manometry findings, similar pre- and post-POEM impedance planimetry findings, along with similar Eckardt scores, support the use of POEM in the treatment of any achalasia subtype.