The Canadian POEM Experience: The First 50 Patients

Abstract Background and Aims Peroral endoscopic myotomy (POEM) has emerged as a less invasive technique for performing myotomy in patients with achalasia. This study aims to assess the safety and efficacy of POEM in a Canadian tertiary care center. Methods All consecutive patients who underwent POEM between March 2016 and May 2018 at a tertiary center were included. The primary outcome of the study was clinical success rate of POEM defined as a post-POEM Eckardt score ≤3 at ≥3 months. Adverse events were recorded according to the Clavien-Dindo grading system. Results A total of 50 consecutive patients underwent 51 POEM procedures with a mean procedure length of 85.6 ± 29.6 min. Post-POEM Eckardt scores of ≤3 at ≥3 months was achieved in 98% of patients. The incidence of pathologic reflux post-poem was 23%. The median length of hospital stay was 1 day. No major adverse events occurred. Interpretation POEM is a safe and effective procedure for the treatment of achalasia. At a median follow-up of 19.5 months, 98% of patients had sustained clinical response (Eckardt score ≤3).

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A195 THE CANADIAN POEM EXPERIENCE. THE FIRST 50 PATIENTS

Journal of the Canadian Association of Gastroenterology ◽

10.1093/jcag/gwz047.194 ◽

2020 ◽

Vol 3 (Supplement_1) ◽

pp. 66-68

Author(s):

M Rai ◽

M Woo ◽

R Bechara

Keyword(s):

Adverse Events ◽

Lower Esophageal Sphincter ◽

Symptom Relief ◽

Tertiary Care ◽

Clinical Success Rate ◽

Enteric Neurons ◽

Invasive Technique ◽

Eckardt Score ◽

Tertiary Center ◽

Esophageal Sphincter

Abstract Background Achalasia is a disorder of esophageal motility characterized by a loss of enteric neurons resulting in impaired relaxation of the lower esophageal sphincter and absence of esophageal peristalsis. There are no current treatments that allow for regeneration of the enteric neurons. Interventions focus primarily on lowering the LES pressure to provide symptom relief and improve quality of life. Peroral endoscopic myotomy (POEM) has emerged as a less invasive technique for performing myotomy in patients with achalasia. Aims This study aims to assess the safety and efficacy of POEM in a Canadian tertiary care center. Methods All consecutive patients who underwent POEM between March 2016 and May 2018 at a tertiary center were included. The primary outcome of the study was clinical success rate of POEM defined as a post-POEM Eckardt score ≤ 3 at ≥ 3 months. Adverse events were recorded according to the Clavien-Dindo grading system. Results A total of 50 consecutive patients underwent 51 POEM procedures with a mean procedure length of 85.6±29.6 minutes. Post-POEM Eckardt scores of ≤ 3 at ≥ 3 months was achieved in 98% of patients. The incidence of pathologic reflux post-poem was 23%. The median length of hospital stay was 1 day (range 1–2 days). No major adverse events occurred. Conclusions POEM is a safe and effective procedure for the treatment of achalasia. At a median follow up of 19.5 months, 98% of patients had sustained clinical response (Eckardt score ≤ 3). Stages of POEM. a) Injection and mucosal incision, b) submucosal tunneling c) completed tunnel, view from just above the lower esophageal sphincter (main), gastric side (right upper) and esophageal side (right lower) d) myotomy e[i]) completed myotomy f) closure with hemostatic clips. Funding Agencies None

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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.

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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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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.

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Outcomes of peroral endoscopic myotomy in patients with achalasia and prior bariatric surgery: A multicenter experience

Diseases of the Esophagus ◽

10.1093/dote/doab044 ◽

2021 ◽

Author(s):

S Bomman ◽

J S Klair ◽

M Ashat ◽

R El Abiad ◽

H Gerke ◽

...

Keyword(s):

Bariatric Surgery ◽

Clinical Success ◽

Botulinum Toxin Injection ◽

Clinical Success Rate ◽

Peroral Endoscopic Myotomy ◽

Pneumatic Dilation ◽

Type I ◽

Eckardt Score ◽

Endoscopic Myotomy ◽

The Mean

Summary Peroral endoscopic myotomy (POEM) in patients with achalasia who are status post bariatric surgery may be technically challenging due to postsurgical scarring and altered anatomy. The aim of the study was to assess the efficacy and safety of POEM for achalasia in patients with prior bariatric surgery. A review of prospectively maintained databases at three tertiary referral centers from January 2015 to January 2021 was performed. The primary outcome of interest was clinical success, defined as a post-treatment Eckardt score ≤ 3 or improvement in Eckardt score by ≥ 1 when the baseline score was <3, and improvement of symptoms. Secondary outcomes were adverse event rates and symptom recurrence. Sixteen patients status post Roux-en-Y gastric bypass (n = 14) and sleeve gastrectomy (n = 2) met inclusion criteria. Indications for POEM were achalasia type I (n = 2), type II (n = 9), and type III (n = 5). POEM was performed either by anterior or posterior approach. The pre-POEM mean integrated relaxation pressure was 26.2 ± 7.6 mm Hg. The mean total myotomy length was 10.2 ± 2.7 cm. The mean length of hospitalization was 1.4 ± 0.7 days. Pre- and postprocedure Eckardt scores were 6.1 ± 2.1 and 1.7 ± 1.8, respectively. The overall clinical success rate was 93.8% (15/16) with mean follow-up duration of 15.5 months. One patient had esophageal leak on postprocedure esophagram and managed endoscopically. Dysphagia recurred in two patients, which was successfully managed with pneumatic dilation with or without botulinum toxin injection. POEM appears to be safe and effective in the management of patients with achalasia who have undergone prior bariatric surgery.

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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.

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Peroral endoscopic myotomy for the treatment of achalasia patients with Roux-en-Y gastric bypass anatomy

Endoscopy ◽

10.1055/a-0656-5530 ◽

2018 ◽

Vol 51 (04) ◽

pp. 342-345 ◽

Cited By ~ 6

Author(s):

Omid Sanaei ◽

Peter Draganov ◽

Rastislav Kunda ◽

Dennis Yang ◽

Mouen Khashab

Keyword(s):

Gastric Bypass ◽

Clinical Success ◽

Length Of Hospital Stay ◽

Peroral Endoscopic Myotomy ◽

Tunnel Length ◽

Submucosal Tunnel ◽

Eckardt Score ◽

Exposure Testing ◽

Endoscopic Myotomy ◽

The Mean

Abstract Background The outcome of peroral endoscopic myotomy (POEM) in patients with prior Roux-en-Y gastric bypass (RYGB) is not known and some experts have recommended against its performance in this patient population because of the risk of postoperative regurgitation. The aim of this study was to report on the outcomes of POEM in patients with RYGB anatomy. Methods Patients with RYGB anatomy who underwent POEM for the treatment of achalasia at three tertiary centers were included. POEM was performed in standard fashion using the anterior or posterior approach. Clinical response was defined by a decrease in Eckardt score to ≤ 3. Results of esophageal acid exposure testing/pH-impedance and manometric testing after POEM were reported when available. Results A total of 10 achalasia patients with prior RYGB surgery underwent POEM. All procedures were technically successful with anterior myotomy performed in seven patients. The mean submucosal tunnel length and myotomy length were 12.9 cm and 11.1 cm, respectively. The mean procedure time was 72 minutes and mean length of hospital stay was 1.5 days. Clinical success was achieved in all 10 patients with a significant decrease in Eckardt score from 6.5 to 1 (P < 0.001). None of the patients experienced post-procedural regurgitation. Post-procedural pH testing was obtained in six patients and was normal in all of them. Conclusions This study suggests the feasibility, safety, and efficacy of POEM in patients with prior RYGB surgery. The risk of gastroesophageal reflux disease in these patients seems to be minimal after POEM.

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Role of peroral endoscopic myotomy in geriatric patients with achalasia: a systematic review and meta-analysis

Digestive Diseases ◽

10.1159/000516024 ◽

2021 ◽

Author(s):

Chunyu Zhong ◽

Sixiu Liu ◽

Huifang Xia ◽

Shali Tan ◽

Muhan Lü ◽

...

Keyword(s):

Systematic Review ◽

Adverse Events ◽

Geriatric Patients ◽

Clinical Success ◽

Meta Analysis ◽

Peroral Endoscopic Myotomy ◽

Cochrane Library ◽

Eckardt Score ◽

Endoscopic Myotomy

Background: Peroral endoscopic myotomy (POEM) is a particularly attractive intervention for achalasia. Presently, POEM has been reported to be effective and safe for achalasia in geriatric patients. Herein, this systematic review was conducted to explore the role of POEM in geriatric patients with achalasia. Method: PubMed, Embase and Cochrane Library were searched to identify studies evaluating the clinical outcome of POEM in geriatric patients with achalasia during January 2009 to October 2020. The primary outcomes were technical and clinical success. Secondary outcomes included postoperative Eckardt score, lower esophageal sphincter (LES) pressure, adverse events and clinical reflux. Results: There were seven studies with a total of 469 geriatric patients, pooled technical success of POEM treatment was 98.1% [95% confidence interval (CI), 95.1%-99.3%], and the pooled clinical success was 92.5% (95% CI, 89.3%-94.8%). After POEM, the Eckardt score significantly decreased by 6.09 points (95% CI, 5.44-6.74, P<0.00001), and the LES pressure significantly reduced by 13.53 mmHg (95% CI, 5.14-21.91, P=0.002). The pooled adverse events rate was 9.0% (95% CI, 4.3%-17.9%) and the post-POEM clinical reflux rate was 17.4% (95% CI, 12.9%-23.2%). Conclusions: Our current study demonstrated that POEM was an effective and safe technique for achalasia in geriatric patients.

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Feasibility of Using an Led-Probe in Third-Space Endoscopy: A Clinical Study

10.21203/rs.2.20562/v2 ◽

2020 ◽

Author(s):

Oscar Victor Hernández Mondragón ◽

Raul Antonio Zamarripa Mottu ◽

Omar Michell Solórzano Pineda ◽

Raul Antonio Gutierrez Aguilar ◽

Luis Fernando Garcia Contreras

Keyword(s):

Clinical Success ◽

Care Center ◽

Tertiary Care ◽

Third Space ◽

Peroral Endoscopic Myotomy ◽

Gastric Emptying Scintigraphy ◽

Submucosal Tunnel ◽

Average Patient ◽

Endoscopic Myotomy ◽

Integrated Relaxation Pressure

Abstract Background and aims: Third-space endoscopy is a novel, safe, and effective method for treating different gastrointestinal conditions. However, several failed endoscopic procedures are attributed to incomplete myotomy. Lighting devices are used to prevent organic injuries. We aimed to investigate the feasibility of using a hand-made LED-probe (LP) in third-space procedures.Patients and Methods: This prospective study was conducted in a tertiary-care center in Mexico between December 2016 and January 2019. We included peroral endoscopic myotomy (POEM) and gastric peroral endoscopic myotomy(G-POEM) procedures. Pseudoachalasia, peptic ulcer, normal gastric emptying scintigraphy (GES) and prepyloric tumors were excluded. LP was used to guide or confirm procedures. Clinical and procedural characteristics were recorded and analyzed.Results: Seventy third-space procedures were included (42POEM,28G-POEM), with an average patient age of 46.7±14.3 and 43.7±10.1 years, respectively. For the POEM and G-POEM groups, respectively, 18/42(42.9%) and 13/28(46.7%) patients were males; median procedure times were 50 (interquartile range[IQR]: 38-71) and 60(IQR: 48-77) min, median LP placement times were 5(IQR: 4-6) and 6(IQR: 5-7) min, mild adverse events occurred in 4(9.4%) and 4(14.2%) of cases, and clinical success at 6 months occurred in 100% and 85.7% of cases. Integrated relaxation pressure (IRP) improved from 27.3±10.8 to 9.5±4.1 mmHg (p<0.001); retention percentage at 4 hours also improved. LP was successfully placed and adequate myotomy confirmed including 14.2% and 17.8% of POEM and G-POEM difficult patients. Conclusions: Using an LP is promising and allows guiding during third-space procedures either for submucosal tunnel creation or myotomy confirmation, with excellent safety and efficacy in clinical practice.

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POEM: Five Years of Experience in a Single East European Center

Journal of Gastrointestinal and Liver Diseases ◽

10.15403/jgld-2676 ◽

2020 ◽

Vol 29 (3) ◽

pp. 323-328

Author(s):

Cristian Tefas ◽

Carina Boroș ◽

Lidia Ciobanu ◽

Teodora Surdea-Blaga ◽

Alina Tanțău ◽

...

Keyword(s):

Success Rate ◽

Clinical Success ◽

Therapeutic Option ◽

Clinical Success Rate ◽

Additional Treatment ◽

Esophageal Motility Disorder ◽

East European ◽

Eckardt Score ◽

Endoscopic Myotomy ◽

One Year

Background and Aims: Achalasia is an esophageal motility disorder with many available therapies. Peroral endoscopic myotomy (POEM) is a therapeutic alternative to surgical myotomy, harboring significant potential short term advantages. Our aim was to analyze a single-series POEM’s learning curve, safety and efficiency over short, medium and long-terms in an East European Center. Methods: This observational, prospective study was carried out in the Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania. Patients with symptomatic achalasia (Eckardt score>3) and pre-op evaluations consistent with the diagnosis of achalasia were included. All POEMs were performed by a highly skilled endoscopist. All patients were allowed to eat 48 hours after POEM. An esophagography was performed in all patients to exclude any leakage. The patients were asked to return for follow-up at established intervals: 1 month, 6 months, 12 months, and annually thereafter. Results: 136 patients were included with an average duration of symptomatology of 36.75 months. The procedure was technically successful in all patients, while a clinical success rate was achieved in 87.5% (n=119) of patients after one POEM session. The success rate was 92.64% after 6 months, 91.17% after one year, 88.9% after 2 years, and 87.5% after 3 years or more; 12.5% of patients required additional treatment. Eighteen patients (13.23%) presented major early complications. Gastroesophageal reflux disease was encountered in 16 patients immediately after POEM and in 22 patients at subsequent follow-ups. Conclusion: POEM is a safe and effective minimally invasive therapeutic option which can substitute surgical myotomy, having a high success rate and a low rate of adverse events in short, medium and long-term.

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