Peroral endoscopic myotomy for management of cricopharyngeal bars (CP-POEM): a retrospective evaluation

Abstract Background Cricopharyngeal bars (CPBs) are a unique etiology of oropharyngeal dysphagia. Symptomatic patients are managed with endoscopic dilation or surgical myotomy. Cricopharyngeal peroral endoscopic myotomy (CP-POEM) is an emerging technique for the management of dysphagia due to CPBs. This study evaluated technical success, clinical success, adverse events, and long-term recurrence following CP-POEM. Methods Consecutive patients who underwent POEM for management of CPBs between May 2015 and December 2020 at four tertiary care centers were included. Primary outcome was clinical success (defined as improvement of dysphagia score to ≤ 1). Secondary outcomes were technical success, rate and severity of adverse events, procedure duration, and symptom recurrence. Results 27 patients (mean age 69 years; 10 female) underwent CP-POEM during the study period. The most common presenting symptoms at the time of index procedure were dysphagia (26; 96.3 %) and regurgitation (20; 74.1 %). Clinical and technical success were achieved in all patients. Mild/moderate adverse events occurred in two patients (7.4 %). CP-POEM significantly reduced the median dysphagia score. Conclusions CP-POEM was a safe and effective treatment for symptomatic CPBs. Although symptom recurrence was low, long-term outcome data are needed. CP-POEM should be considered as a management option for symptomatic CPBs at centers with POEM expertise.

Download Full-text

Advanced achalasia: good candidate for peroral endoscopic myotomy

Diseases of the Esophagus ◽

10.1093/dote/doaa097 ◽

2020 ◽

Author(s):

Shaotian Qiu ◽

Ningli Chai ◽

Yaqi Zhai ◽

Xiangyao Wang ◽

Yan Wang ◽

...

Keyword(s):

Adverse Events ◽

Clinical Success ◽

Laparoscopic Heller Myotomy ◽

Peroral Endoscopic Myotomy ◽

Symptom Duration ◽

Technical Success ◽

Technical Success Rate ◽

Eckardt Score ◽

Endoscopic Myotomy ◽

Favorable Safety

SUMMARY Peroral endoscopic myotomy (POEM) has been increasingly accepted as the first-line treatment of achalasia. However, laparoscopic Heller myotomy or esophagectomy still remains as the mainstay treatment for advanced achalasia featured with megaesophagus and/or sigmoid-shaped esophagus. Although the efficacy of POEM for advanced achalasia with sigmoid-shaped esophagus has been described, little is known about the role of POEM for patients with megaesophagus. The aim of our study is to evaluate the efficacy and safety of POEM for advanced achalasia with megaesophagus. Patients who received initial examinations and underwent POEM in our hospital from June 2013 to December 2018 were identified and data were retrospectively analyzed. The advanced achalasia was defined as megaesophagus with a diameter of ≥6 cm. The primary outcome was clinical success. The secondary outcomes were technical success and adverse events. A total of 112 patients (50 females, 44.6%) were included with a mean age of 44.8 years. The median symptom duration was 6.5 years (IQR:3.0–13.0 years). Modified POEM techniques were used in 27.7% (31/112) of patients. Technical success rate was 99.1% (112/113) per procedure. Clinical success was seen in 93.1% patients with median Eckardt score decreasing from 8.0 to 1.0 (P < 0.001) during a median 31.0 months of follow-up. The mean LES pressure decreased from 29.5 mmHg to 14.2 mmHg after POEM (P < 0.05). Procedure-related adverse events occurred in 8.9% patients. Reflux disease was observed postoperatively in 26.7% of patients. POEM is also indicated for patients with advanced achalasia with a favorable safety and efficacy.

Download Full-text

The Effect of Peroral Endoscopic Myotomy in Achalasia Patients with Prior Endoscopic Intervention: A Systematic Review and Meta-Analysis

Digestive Surgery ◽

10.1159/000512627 ◽

2021 ◽

pp. 1-13

Author(s):

Chunyu Zhong ◽

Bowen Ni ◽

Sixiu Liu ◽

Shali Tan ◽

Muhan Lü ◽

...

Keyword(s):

Adverse Events ◽

Randomized Clinical Trials ◽

Clinical Success ◽

Meta Analysis ◽

Clinical Success Rate ◽

Peroral Endoscopic Myotomy ◽

Technical Success ◽

Endoscopic Intervention ◽

Eckardt Score ◽

Endoscopic Myotomy

Background: Peroral endoscopic myotomy (POEM) has been reported to be effective in achalasia patients with prior failed endoscopic intervention (PFI). We performed this meta-analysis to compare and summarize the clinical outcome of POEM in patients with or without prior endoscopic intervention. Method: We searched relevant studies published up to March 2020. Meta-analysis for technical success, clinical success, Eckardt score, lower esophageal sphincter (LES) pressure, clinical reflux, and adverse event were conducted based on a random-effects model. Results: Eight studies enrolling 1,797 patients who underwent POEM were enrolled, including 1,128 naïve achalasia patients and 669 patients with PFI. In the PFI group, the pooled estimated rate of technical success was 97.7% (95% confidence interval [CI], 95.8–98.8%), the pooled clinical success rate was 91.0% (95% CI, 88.0–93.4%), and the pooled adverse events rate was 23.5% (95% CI, 10.6–44.1%). The Eckardt score significantly decreased by 5.95 points (95% CI, 5.50–6.40, p < 0.00001) and the LES pressure significantly reduced by 19.74 mm Hg (95% CI, 14.10–25.39, p < 0.00001) in the PFI group. There were no difference in the technical success, clinical success, and adverse events rate between the treatment-naïve group and PFI group, with a risk ratio of 1.0 (95% CI, 0.99–1.01, p = 0.89), 1.02 (95% CI, 0.98–1.06, p = 0.36), and 0.88 (95% CI, 0.67–1.16, p = 0.38), respectively. Conclusions: POEM is an effective and safe treatment for achalasia patients with prior endoscopic intervention. Randomized clinical trials are needed to further verify the efficiency and safety of the POEM in those patients.

Download Full-text

Transoral Incisionless fundoplication for reflux after peroral endoscopic myotomy: a crucial addition to our arsenal

Endoscopy International Open ◽

10.1055/a-0584-6802 ◽

2018 ◽

Vol 06 (05) ◽

pp. E549-E552 ◽

Cited By ~ 17

Author(s):

Amy Tyberg ◽

Anthony Choi ◽

Monica Gaidhane ◽

Michel Kahaleh

Keyword(s):

Adverse Events ◽

Case Series ◽

Acid Exposure ◽

Peroral Endoscopic Myotomy ◽

Technical Success ◽

Post Procedure ◽

First Case ◽

Endoscopic Myotomy ◽

Small Cohort

Abstract Introduction Increased esophageal acid exposure is seen in a large percentage of patients with achalasia who undergo peroral endoscopic myotomy (POEM). Endoscopic transoral fundoplication (TIF) is a novel endoscopic technique for the management of patients with chronic gastroesophageal reflux (GERD). We present the first case series evaluating the role of TIF post-POEM. Methods Consecutive patients 18 years or older from our academic institution who underwent a POEM procedure and subsequently underwent TIF for symptomatic reflux or regurgitation between December 2014 and June 2017 were included. The primary outcome was discontinuation of proton-pump inhibitor (PPI) use and healing of esophagitis (when initially present) on post-procedure esophagogastroduodenoscopy (EGD). Technical success was defined as successful completion of the endoscopic fundoplication. Adverse events (AEs) were recorded for all patients. Results Five patients were included (60 % male, average age 55 ± 14 years). Technical success was achieved in 100 % of patients. Discontinuation of PPI use was achieved in 5/5 patients (100 %). Three patients had esophagitis pre-procedure and all were noted to have resolution of inflammation on post-procedure EGD. No adverse events were noted. Mean follow-up time was 27 months (range 5 – 34 months). Conclusion TIF post-POEM appears feasible, safe, and efficacious in improving symptoms and esophagitis, decreasing long-term risks of acid exposure, and decreasing risks of long-term PPI use in patients post-POEM in this small cohort of patients. Larger studies are needed to confirm these initial findings.

Download Full-text

One-year results of gastric peroral endoscopic myotomy for refractory gastroparesis: a French multicenter study

Endoscopy ◽

10.1055/a-1205-5686 ◽

2020 ◽

Author(s):

Olivier Ragi ◽

Jérémie Jacques ◽

Julien Branche ◽

Sarah Leblanc ◽

Geoffroy Vanbiervliet ◽

...

Keyword(s):

Success Rate ◽

Multicenter Study ◽

Clinical Success ◽

Clinical Success Rate ◽

Peroral Endoscopic Myotomy ◽

Gastric Retention ◽

Endoscopic Myotomy ◽

Cardinal Symptom

Abstract Background: Data on the long-term outcomes of gastric peroral endoscopic myotomy (G-POEM) for refractory gastroparesis are lacking. We report the results of a large multicenter long-term follow-up study of G-POEM for refractory gastroparesis. Methods: This was a retrospective multicenter study of all G-POEM operations performed in seven expert French centers for refractory gastroparesis with at least 1 year of follow-up. The primary endpoint was the 1-year clinical success rate, defined as at least a 1-point improvement in the Gastroparesis Cardinal Symptom Index (GCSI). Results: 76 patients were included (60.5 % women; age 56 years). The median symptom duration was 48 months. The median gastric retention at 4 hours (H4) before G-POEM was 45 % (interquartile range [IQR] 29 % – 67 %). The median GCSI before G-POEM was 3.6 (IQR 2.8 – 4.0). Clinical success was achieved in 65.8 % of the patients at 1 year, with a median rate of reduction in the GCSI score of 41 %. In logistic regression analysis, only a high preoperative GCSI satiety subscale score was predictive of clinical success (odds ratio [OR] 3.41, 95 % confidence interval [CI] 1.01 – 11.54; P = 0.048), while a high rate of gastric retention at H4 was significantly associated with clinical failure (OR 0.97, 95 %CI 0.95 – 1.00; P = 0.03). Conclusions: The results confirm the efficacy of G-POEM for the treatment of refractory gastroparesis, as evidenced by a 65.8 % clinical success rate at 1 year. Although G-POEM is promising, prospective sham-controlled trials are urgently needed to confirm its efficacy and identify the patient populations who will benefit most from this procedure.

Download Full-text

Long-term outcome of peroral endoscopic myotomy for esophageal achalasia in patients with previous Heller myotomy

Surgical Endoscopy ◽

10.1007/s00464-016-5267-1 ◽

2016 ◽

Vol 31 (6) ◽

pp. 2596-2601 ◽

Cited By ~ 21

Author(s):

Helle Ø. Kristensen ◽

Jakob Kirkegård ◽

Daniel Willy Kjær ◽

Frank Viborg Mortensen ◽

Rastislav Kunda ◽

...

Keyword(s):

Heller Myotomy ◽

Esophageal Achalasia ◽

Peroral Endoscopic Myotomy ◽

Term Outcome ◽

Long Term Outcome ◽

Endoscopic Myotomy

Download Full-text

Feasibility of Speedboat RS2 with bipolar radiofrequency energy for peroral endoscopic myotomy in patients with achalasia (with video)

Endoscopy International Open ◽

10.1055/a-1165-0087 ◽

2020 ◽

Vol 08 (08) ◽

pp. E998-E1001

Author(s):

Gaurav Patil ◽

Anki Dalal ◽

Amit P. Maydeo

Keyword(s):

Peroral Endoscopic Myotomy ◽

Symptom Duration ◽

Radiofrequency Energy ◽

Technical Success ◽

Novel Device ◽

Bipolar Radiofrequency ◽

Gastrointestinal Lesions ◽

Endoscopic Myotomy ◽

Long Term Studies

Abstract Background During peroral endoscopic myotomy (POEM), use of traditional instruments leads to an increase in overall time of procedure due to constant exchange of instruments. Speedboat-RS2 (Creo-Medical, UK) is a novel device which has shown promising results for endoscopic submucosal dissection of gastrointestinal lesions, but its feasibility, and safety for POEM is unexplored. Methods Data from patients who had undergone POEM for achalasia cardia utilizing Speedboat-RS2 was reviewed. Results Two patients with mean age of 46 years and mean symptom duration of 3 years were included. Both patients had type II achalasia diagnosed on esophageal manometry. One patient underwent anterior myotomy and the other posterior approach. Submucosal tunneling (~15 cm) was achieved in a mean of 20 minutes, myotomy (~ 9 cm) in 8 minutes and the entire procedure was completed in a mean of 30 minutes with 100 % technical success. Both patients were discharged the day after the procedure without any immediate adverse events. At 6 weeks, endoscopy was uneventful and the patients were asymptomatic. Conclusions Early experience shows that Speedboat-RS2 is feasible for performing POEM with good safety profile. Submucosal tunneling was relatively quick and coagulation was effective. Long term studies with a larger patient cohort are warranted.

Download Full-text

Impact of prior treatment on long-term outcome of peroral endoscopic myotomy in pediatric achalasia

Journal of Pediatric Surgery ◽

10.1016/j.jpedsurg.2019.07.010 ◽

2020 ◽

Vol 55 (8) ◽

pp. 1552-1555 ◽

Cited By ~ 2

Author(s):

Zaheer Nabi ◽

Mohan Ramchandani ◽

Santosh Darisetty ◽

Rama Kotla ◽

D. Nageshwar Reddy

Keyword(s):

Peroral Endoscopic Myotomy ◽

Prior Treatment ◽

Term Outcome ◽

Long Term Outcome ◽

Endoscopic Myotomy

Download Full-text

Peroral Endoscopic Myotomy for Esophageal Achalasia in Portugal: Outcomes of the First Prospective Series

GE Portuguese Journal of Gastroenterology ◽

10.1159/000511528 ◽

2020 ◽

pp. 1-8

Author(s):

Rui Mendo ◽

Pedro Barreiro ◽

José Rodrigues ◽

Catarina Félix ◽

Catarina O'Neill ◽

...

Keyword(s):

Adverse Events ◽

Clinical Success ◽

Peroral Endoscopic Myotomy ◽

Successful Outcome ◽

Consecutive Series ◽

Procedure Time ◽

Short Term ◽

Invasive Treatment ◽

Eckardt Score ◽

Endoscopic Myotomy

Background: Peroral endoscopic myotomy (POEM) is an innovative achalasia treatment procedure that involves myotomy of the lower esophageal sphincter through a submucosal tunneling approach, combining the efficacy of surgical myotomy with the benefit of being a less invasive treatment. At this time, no data are available of POEM in Portugal. This study aimed to examine the safety and short-term outcomes of POEM in a Portuguese center. Methods: Fifty POEM were performed on 49 consecutive patients at our institution between January 2017 and January 2020. A prospective study of a consecutive series of patients was conducted, including procedure time, myotomy location and length, adverse events and clinical success. An Eckardt score of ≤3 after POEM was deemed as a successful outcome. Gastroesophageal reflux disease (GERD) was evaluated based on symptoms and on upper endoscopy, which was performed at 3–6 months postoperatively to check for reflux esophagitis. Results: POEM was successfully completed in all cases: 70% (n = 35) were naïve and 30% (n = 15) had previous treatments. The mean procedure time was 73.4 ± 22.6 min (range 45–125 min). There were no major adverse events. Minor adverse events were rare (8%), and there was no perioperative mortality. The Eckardt score significantly decreased from 6.9 ± 2.4 preoperatively to 0.5 ± 1.0 postoperatively (p < 0.05). Overall clinical success was documented in 98, 98 and 95.2% at 1, 3 and 6 months, respectively. These short-term outcomes after POEM were independent of previous treatments. Symptomatic GERD was seen in 22.4% of patients. Conclusions: Our results confirm the safety and excellent short-term efficacy of POEM in a Portuguese center. This supports POEM as one of the first-line achalasia therapies in Portugal when performed by experienced operators.

Download Full-text

Efficacy and Safety of Peroral Endoscopic Myotomy for Sigmoid-Type Achalasia: A Systematic Review and Meta-Analysis

Frontiers in Medicine ◽

10.3389/fmed.2021.677694 ◽

2021 ◽

Vol 8 ◽

Author(s):

Jin Xu ◽

Chunyu Zhong ◽

Shu Huang ◽

Xinyi Zeng ◽

Shali Tan ◽

...

Keyword(s):

Adverse Events ◽

Fixed Effects ◽

Clinical Success ◽

Meta Analysis ◽

Peroral Endoscopic Myotomy ◽

Therapeutic Modality ◽

Current Evidence ◽

Cochrane Library ◽

Efficacy And Safety ◽

Endoscopic Myotomy

Background: The efficacy and safety of peroral endoscopic myotomy (POEM) in the treatment of sigmoid-type achalasia is unknown. This meta-analysis aims to explore the clinical outcomes of POEM for sigmoid-type achalasia.Method: We searched all relevant studies published up to September 2020 in PubMed, Embase, and Cochrane library databases. Meta-analyses for clinical success, Eckardt score, angle of esophageal tortuosity, diameter of esophagus, lower esophageal sphincter (LES) pressure, integrated relaxation pressure (IRP), adverse events, and gastroesophageal reflux diseases were performed based on random or fixed-effects models as needed.Results: We found a total of eight studies that provided data on 248 patients. Overall, the pooled clinical success was achieved in 211 sigmoid-type achalasia patients [90.4%; 95% confidence interval (CI), 85.5%−93.8%]. The pre- and post-POEM Eckardt scores, angle of esophageal tortuosity, diameter of esophageal, LES pressure, and IRP were significantly improved (All p < 0.05). The pooled adverse events rate was 13.0% (95% CI, 3.6%−37.4%). The pooled objective confirmation of reflux rate was 41.5% (95% CI, 26.5%−58.3%), and symptomatic reflux rate was 12.5% (95% CI, 8.3%−18.4%).Conclusions: Our current evidence indicated that POEM is an effective and safe therapeutic modality for the treatment of sigmoid-type achalasia.

Download Full-text