Type II achalasia is associated with a comparably favorable outcome following per oral endoscopic myotomy

Summary Per oral endoscopic myotomy (POEM) is a safe and effective treatment for esophageal motility disorder in treatment-naïve patients as well as salvage therapy. Though type II achalasia, compared to other subtypes, is reported to have a more favorable outcome with pneumatic dilation (PD) or Heller myotomy (HM), it is unclear whether achalasia subtype predicts symptom response to POEM. We aimed to evaluate whether type II achalasia is associated with a comparably favorable outcome following POEM. We performed a retrospective review of patients with esophageal motility disorder who were referred for POEM from April 2014 to June 2017. The main outcome was clinical success based on Eckardt score ≤3 and its association with subtype and safety. A total of 63 patients (mean age 51 years [SD 15]; 63% male) underwent a total of 68 POEMs with median of 263 days follow-up. Of these, 45 (71.3%) patients were type II achalasia. In all, 29 (46%) patients were treatment-naïve and 34 (54%) patients had previous endoscopic or surgical therapy including botulinum toxin injection in 16 (25%), PD in 10 (16%), both botulinum toxin injection and PD in 8 (13%) and HM in 3 (5%). Technical success was 100% and clinical success was achieved in 51 (81%) patients. The rate of clinical success was higher in patients with type II achalasia compared to the other subtypes (88.9% vs. 61.1% [P = 0.028]) and type II achalasia patients required fewer redo POEM (2.2% vs. 22.2% [P = 0.021]). Multivariate logistic regression analysis demonstrated the positive prediction of clinical success for type II achalasia following POEM (P = 0.046). As observed with PD and HM, type II achalasia was associated with a favorable clinical outcome following POEM.

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Per-oral endoscopic dual myotomy for the treatment of achalasia

Esophagus ◽

10.1007/s10388-021-00863-9 ◽

2021 ◽

Author(s):

Xianglei Yuan ◽

Zhe Feng ◽

Yanshi Zhao ◽

Xianhui Zeng ◽

Liansong Ye ◽

...

Keyword(s):

Adverse Events ◽

Clinical Success ◽

Mucosal Injury ◽

Single Session ◽

Eckardt Score ◽

Endoscopic Myotomy ◽

Favorable Safety ◽

Per Oral ◽

Disease Questionnaire

Abstract Background Repeat per-oral endoscopic myotomy is occasionally performed for persistent/recurrent symptoms in patients with achalasia, and yields favorable outcomes. We investigated a novel technique, per-oral endoscopic dual myotomy (dual-POEM), where a second myotomy was performed during a single session to augment the efficacy and avoid repeat interventions. The aim of this study was to evaluate its feasibility, safety and efficacy. Methods Consecutive patients diagnosed with achalasia who underwent dual-POEM (1/2018–5/2019) were prospectively collected and retrospectively analyzed. Patients with baseline Eckardt score ≥ 9, ≥ 10 years of symptoms, and/or having prior interventions other than myotomy received dual-POEM. The primary outcome was clinical success (Eckardt score ≤ 3). Secondary outcomes were procedure-related adverse events, change in lower esophageal sphincter (LES) pressure, and reflux complications. Results Seventeen patients received dual-POEM. Procedure-related adverse events were observed in 2 (11.8%) patients (mucosal injury and pneumonitis). Both were minor in severity. During a median follow-up of 33 months (interquartile range, IQR [31,35]; range, 19–36), clinical success was achieved in 16 (94.1%) patients. The median Eckardt score decreased from 9 (IQR [8, 11.5]; range 7–12) to 1 (IQR [1, 2]; range 0–4) (P < 0.001), and LES pressure decreased from 25.8 mmHg (IQR [21.7, 33.5]; range 17.7–46.3) to 7.4 mmHg (IQR [6.3, 10.4]; range 2.2–12.6) (P < 0.001). Seven (41.2%) patients developed postprocedural reflux either by gastroesophageal reflux disease questionnaire or esophagitis endoscopically, all successfully treated with proton pump inhibitors. Conclusion Dual-POEM preliminarily demonstrated high efficacy with a favorable safety profile in patients with achalasia with predictors of treatment failure.

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Gastric per-oral endoscopic myotomy (G-POEM) for refractory gastroparesis: results from an international prospective trial

Gut ◽

10.1136/gutjnl-2020-322756 ◽

2021 ◽

pp. gutjnl-2020-322756 ◽

Cited By ~ 1

Author(s):

Kia Vosoughi ◽

Yervant Ichkhanian ◽

Petros Benias ◽

Larry Miller ◽

A Aziz Aadam ◽

...

Keyword(s):

Gastric Emptying ◽

Clinical Success ◽

Short Form ◽

Prospective Trial ◽

Safe Procedure ◽

Per Oral Endoscopic Myotomy ◽

Standard Medical Therapy ◽

Endoscopic Myotomy ◽

Per Oral ◽

Cardinal Symptom

ObjectiveAlthough gastric per-oral endoscopic myotomy (G-POEM) is considered a promising technique for the management of refractory gastroparesis, high-quality evidence is limited. We prospectively investigated the efficacy and safety of G-POEM in unselected patients with refractory gastroparesis.DesignIn five tertiary centres, patients with symptomatic gastroparesis refractory to standard medical therapy and confirmed by impaired gastric emptying were included. The primary endpoint was clinical success, defined as at least one score decrease in Gastroparesis Cardinal Symptom Index (GCSI) with ≥25% decrease in two subscales, at 12 months. GCSI Score and subscales, adverse events (AEs) and 36-Item Short Form questionnaire of quality of life were evaluated at baseline and 1, 3, 6 and 12 months after G-POEM. Gastric emptying study was performed before and 3 months after the procedure.ResultsOf 80 enrolled patients, 75 patients (94%) completed 12-month follow-up. Clinical success at 12 months was 56% (95% CI, 44.8 to 66.7). GCSI Score (including subscales) improved moderately after G-POEM (p<0.05). In a regression model, a baseline GCSI Score >2.6 (OR=3.23, p=0.04) and baseline gastric retention >20% at 4 hours (OR=3.65, p=0.03) were independent predictors of clinical success at 12 months, as was early response to G-POEM at 1 month after therapy (OR 8.75, p<0.001). Mild procedure-related AEs occurred in 5 (6%) patients.ConclusionG-POEM is a safe procedure, but showed only modest overall effectiveness in the treatment of refractory gastroparesis. Further studies are required to identify the best candidates for G-POEM; unselective use of this procedure should be discouraged.Trial registration numberClinicalTrials.gov Registry NCT02732821.

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Pilot prospective study on formal training in per-oral endoscopic myotomy (POEM) during advanced endoscopy fellowship

Endoscopy International Open ◽

10.1055/a-1610-8962 ◽

2021 ◽

Vol 09 (12) ◽

pp. E1890-E1899

Author(s):

Salmaan Jawaid ◽

Peter V. Draganov ◽

Hiroyuki Aihara ◽

Mouen A. Khashab ◽

Dennis Yang

Keyword(s):

Prospective Study ◽

Cognitive Skills ◽

Assessment Tool ◽

Clinical Success ◽

Independent Practice ◽

Per Oral Endoscopic Myotomy ◽

Core Curricula ◽

Eckardt Score ◽

Endoscopic Myotomy ◽

Per Oral

Abstract Background and study aims Gastroenterology societies have recently proposed core curricula for training in per-oral endoscopic myotomy (POEM) based on expert opinion with limited data on its applicability for advanced endoscopy fellowship (AEF) trainees. We prospectively evaluated the feasibility of a structured POEM training curriculum during a dedicated AEF and the trainee’s performance during independent practice. Methods This was a single-center prospective study evaluating a trainee’s performance of POEM using a structured assessment tool (POEMAT) to assess core cognitive and technical skills. The trainee’s performance was then prospectively assessed during the first 12 months of independent practice. Results The trainee, who had not prior background in submucosal endoscopy, first observed 22 POEM cases followed by 35 hands-on procedures during his advanced endoscopy fellowship. Based on the POEMAT, submucosal entry and mucosal incision closure were the most challenging technical aspects, while cognitive skills were uniformly attained early in training. Overall, the trainee was able to cross the threshold for competence in his POEMAT performance score in 15 of his last 18 cases (83.3 %). The trainee performed 16 POEMs (baseline mean Eckardt 7.2) in his first 12 months of independent practice. Mean procedural time was 79.8 minutes (interquartile range: 67–94 minutes minutes) with no adverse events. Clinical success (Eckardt score < 3) was achieved in 100 % of the cases at a median follow-up of 20 weeks. Conclusions Results from this pilot study support the adoptability of the recently proposed core curricula for POEM training within the context of a dedicated AEF and provide a potential blueprint for future studies of performance in POEM among trainees.

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TP6.2.14 Outcome of POEM (Per-oral endoscopic myotomy) for achalasia

British Journal of Surgery ◽

10.1093/bjs/znab362.042 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Annabelle White ◽

Woochan Hwang ◽

Alekhaya Kotta ◽

Daniel Beasley ◽

Katarina Chow ◽

...

Keyword(s):

Clinical Success ◽

Pneumatic Dilatation ◽

Demeester Score ◽

First Line Therapy ◽

Eckardt Score ◽

Operative Endoscopy ◽

Endoscopic Myotomy ◽

Oesophageal Achalasia ◽

Per Oral

Abstract Aims Laparoscopic Heller’s myotomy (LHM) has been the surgical gold standard for treatment of oesophageal achalasia. Peroral endoscopic myotomy (POEM) has been proposed as an alternative technique. The aim of this study was to assess the safety and efficacy of POEM for achalasia in our unit. Methods We have operated on 202 patients for oesophageal achalasia since 2005: 107 had LHM, 86 had POEM, and 9 had an oesophagectomy. We assessed the clinical outcome of POEM comparing pre- and postoperative endoscopic, radiologic and manometric findings, as well as Eckardt-, GERD- and DsQoL score for achalasia. All follow-up patients were offered endoscopy. Results Data were completed for the first 45 POEM patients. The average age was 45 years. 18 patients (40%) had prior achalasia treatment. The median hospital stay was 2 days (2-5). There was no mortality, but 4 patients (9%) had post-operative complications. The median follow-up was 24 months (12-49). Clinical success (Eckardt score ≤ 3) was achieved in 39 patients (87%). Thirteen patients (29%) were taking PPIs for chest symptoms. Eleven of these underwent pH studies of whom only 1 had a DeMeester score > 14.5. Of the 24 patients who had post-operative endoscopy, 40% was diagnosed with oesophagitis grade A, yet only 5 of them were symptomatic. Conclusions POEM appears to be safe and effective and warrants consideration as first-line therapy in expert achalasia centres. Longer term randomized studies comparing the outcomes of POEM with LHM and pneumatic dilatation will determine its place in the treatment of achalasia.

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Outcomes of Peroral Endoscopic Myotomy After Previously Failed Botulinum Toxin Injection and/or Pneumatic Dilation

The American Journal of Gastroenterology ◽

10.14309/00000434-201710001-00813 ◽

2017 ◽

Vol 112 ◽

pp. S453

Author(s):

Sarah Z. Maher ◽

Jayakrishna Chintanaboina ◽

Eric Pauli ◽

Jennifer L. Maranki ◽

Abraham Mathew

Keyword(s):

Botulinum Toxin ◽

Botulinum Toxin Injection ◽

Peroral Endoscopic Myotomy ◽

Pneumatic Dilation ◽

Endoscopic Myotomy

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A128 JACKHAMMER ESOPHAGUS – A META-ANALYSIS OF PATIENT DEMOGRAPHICS, DISEASE PRESENTATION, MANOMETRY DATA AND TREATMENT OUTCOMES

Journal of the Canadian Association of Gastroenterology ◽

10.1093/jcag/gwz047.127 ◽

2020 ◽

Vol 3 (Supplement_1) ◽

pp. 148-149

Author(s):

G Wahba ◽

M Bouin

Keyword(s):

Treatment Outcomes ◽

Clinical Success ◽

Clinical Success Rate ◽

Motility Disorder ◽

Symptom Improvement ◽

Morbidly Obese ◽

Esophageal Motility Disorder ◽

Patient Demographics ◽

Pooled Data ◽

Clinical Series

Abstract Background Jackhammer esophagus (JE) is a newly described esophageal motility disorder characterized by the presence of distal esophageal hypercontractility. However, there is limited data on JE and this entity remains misunderstood. Aims To systematically review the published clinical data on JE and present pooled data on patient demographics, disease presentation, manometry parameters and treatment outcomes from the available literature. Methods We performed a systematic review of clinical series on JE (based on the latest Chicago Classification criteria (v3.0)) through MEDLINE, EMBASE and Web of Science. Patient data from included studies were then extracted and random-effects meta-analyses were performed to calculate and compare pooled data. Results Thirty-seven studies met inclusion criteria reporting on at least one pooled variable. The pooled prevalence of JE was 1.97% [95% CI: 1.39%-2.78%] amongst patients referred for high resolution manometry (HRM) based on eleven studies reporting this data (Figure 1). The mean age at diagnosis was 60.8 years [95% CI: 57.1–64.4] and 65% [95% CI: 58%-72%] of patients were female. JE was significantly more prevalent in post-lung transplant patients and morbidly obese patients undergoing HRM (23.99% [95% CI: 9.00%-38.97%] and 5.18% [95% CI: 1.76%-14.3%] respectively). Dysphagia was the most common presentation of JE (64% [95% CI: 52%-77%]) followed by gastroesophageal reflux disease (GERD) (46% [95% CI: 26%-67%]), regurgitation (39% [95% CI: 10%-67%] and heartburn (34% [95% CI: 22%-45%]). The pooled mean distal contractile integer (DCI) of all ten standard HRM swallows was 9,535 mmHg●s●cm [95% CI: 6,978–12,093] and the pooled mean integrated relaxation pressure (IRP) was 13.9 mmHg [95% CI: 8.2–19.7]. Endoscopic treatment as a whole was more successful than medical treatment in achieving clinical symptom improvement (79% [95% CI: 74%-85%] vs. 63% [95% CI: 47%-79%]; p=0.012). The pooled clinical success rate of peroral endoscopic myotomy (POEM) specifically was 82% [95% CI: 75%-90%]. Conclusions JE is a new motility disorder most commonly presenting with dysphagia. High clinical suspicion is important because the diagnosis can only be made through HRM and treatment outcomes are generally satisfactory. Funding Agencies None

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