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

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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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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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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Anterior versus posterior approach in peroral endoscopic myotomy (POEM): a systematic review and meta-analysis

Endoscopy ◽

10.1055/a-1090-0788 ◽

2020 ◽

Vol 52 (04) ◽

pp. 251-258 ◽

Cited By ~ 5

Author(s):

Babu P. Mohan ◽

Andrew Ofosu ◽

Saurabh Chandan ◽

Daryl Ramai ◽

Shahab R. Khan ◽

...

Keyword(s):

Adverse Events ◽

Clinical Success ◽

Meta Analysis ◽

Peroral Endoscopic Myotomy ◽

Procedure Time ◽

Comparative Efficacy ◽

Total Procedure Time ◽

Endoscopic Myotomy ◽

The Individual ◽

Total Procedure

Abstract Background Peroral endoscopic myotomy (POEM) is increasingly being used as the endoscopic treatment option for achalasia. Data are limited as to the comparative efficacy of anterior vs. posterior myotomy. Methods We searched multiple databases from inception to August 2019 to identify studies reporting on POEM. We selected studies that reported on the outcomes of POEM, along with information on myotomy approach. We performed a comparative analysis of clinical success, gastroesophageal reflux disease (GERD), and adverse events with anterior and posterior myotomy in POEM by meta-analysis. Results 1247 patients from 18 studies were analyzed: 623 patients (11 cohorts) were treated via anterior myotomy and 624 patients (12 cohorts) via posterior myotomy. The pooled rate for clinical success gave an odds ratio (OR) of 1.02 (95 % confidence interval [CI] 0.52 – 2.0; I 2 0; P = 0.9); for GERD by esophagogastroduodenoscopy (EGD) was OR 1.02 (95 %CI 0.62 – 1.68; I 2 0; P = 0.9), and for GERD by pH was OR 0.98 (95 %CI 0.59 – 1.63; I 2 34; P = 0.9). The individual pooled rates of clinical success at 12 months and > 12 months, GERD (by symptoms, EGD, pH), and adverse events (mild, moderate, severe) were comparable. The pooled total procedure time with anterior myotomy was 82.7 minutes (95 %CI 69.0 – 96.4; I 2 98) and with posterior myotomy was 62.1 minutes (95 %CI 48.5 – 75.7; I 2 90). Conclusion Anterior and posterior myotomy in POEM seem comparable to each other in terms of clinical success, GERD, and adverse events. The total procedure time with posterior myotomy seems to be shorter than with anterior myotomy.

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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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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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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 (POEM) vs pneumatic dilation (PD) in treatment of achalasia: A meta-analysis of studies with ≥ 12-month follow-up

Endoscopy International Open ◽

10.1055/a-1483-9406 ◽

2021 ◽

Vol 09 (07) ◽

pp. E1097-E1107

Author(s):

Andrew Ofosu ◽

Babu P. Mohan ◽

Yervant Ichkhanian ◽

Maen Masadeh ◽

John Febin ◽

...

Keyword(s):

Clinical Success ◽

Meta Analysis ◽

Balloon Dilation ◽

Final Analysis ◽

Peroral Endoscopic Myotomy ◽

Pneumatic Dilation ◽

Type I ◽

Eckardt Score ◽

Endoscopic Myotomy

Abstract Background and study aims Peroral endoscopic myotomy (POEM) is increasingly being used as the preferred treatment option for achalasia. The aim of this systematic review and meta-analysis was to compare the efficacy and safety of POEM versus pneumatic balloon dilation (PD). Methods We performed a comprehensive review of studies that reported clinical outcomes of POEM and PD for the treatment of achalasia. Measured outcomes included clinical success (improvement of symptoms based on a validated scale including an Eckardt score ≤ 3), adverse events, and post-treatment gastroesophageal reflux disease (GERD). Results Sixty-six studies (6268 patients) were included in the final analysis, of which 29 studies (2919 patients) reported on POEM and 33 studies (3050 patients) reported on PD and 4 studies (299 patients) compared POEM versus PD. Clinical success with POEM was superior to PD at 12, 24, and 36 months (92.9 %, vs 76.9 % P = 0.001; 90.6 % vs 74.8 %, P = 0.004; 88.4 % vs 72.2 %, P = 0.006, respectively). POEM was superior to PD in type I, II and III achalasia (92.7 % vs 61 %, P = 0.01; 92.3 % vs 80.3 %, P = 0.01; 92.3 %v 41.9 %, P = 0.01 respectively)Pooled OR of clinical success at 12 and 24 months were significantly higher with POEM (8.97; P = 0.001 & 5.64; P = 0.006). Pooled OR of GERD was significantly higher with POEM (by symptoms: 2.95, P = 0.02 and by endoscopic findings: 6.98, P = 0.001). Rates of esophageal perforation (0.3 % vs 0.6 %, P = 0.8) and significant bleeding (0.4 % vs 0.7 %, P = 0.56) were comparable between POEM and PD groups. Conclusions POEM is more efficacious than PD in the treatment of patients with achalasia during short-term and long-term follow-up, albeit with higher risk of abnormal esophageal acid exposure.

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Management of Patients after Failed Peroral Endoscopic Myotomy: a Multicenter Study

Endoscopy ◽

10.1055/a-1312-0496 ◽

2020 ◽

Author(s):

Yervant Ichkhanian ◽

Daniella Assis ◽

Pietro Familiari ◽

Michael B Ujiki ◽

Baily Su ◽

...

Keyword(s):

Clinical Success ◽

Management Strategies ◽

Laparoscopic Heller Myotomy ◽

Peroral Endoscopic Myotomy ◽

Pneumatic Dilation ◽

Eckardt Score ◽

Endoscopic Myotomy ◽

Excellent Safety Profile ◽

International Multicenter

Background and Aims: Although Peroral Endoscopic Myotomy (POEM) is highly effective for the management of achalasia, clinical failures may occur. The optimal management of patients who fail POEM is not well known. This study aims to compare the outcomes of different management strategies in patients who had failed POEM. Patients and Methods: This is an international, multicenter, retrospective study at 16 tertiary centers between 1/2012 and 11/2019. All patients who underwent POEM and experienced persistent or recurrent symptoms (Eckardt score (ES) > 3) were included. The primary outcome was to compare the rate of clinical success (ES ≤ 3) between different management strategies. Results: A total of 99 patients (50 (50.5%) males, mean age 51.4 (16.2) yrs.) experienced clinical failure during the study period with a mean ES of 5.5 (0.2). A total of 29 (32.2%) patients were managed conservatively and 70 (71%) underwent re-treatment [repeat POEM 33 (33%), pneumatic dilation (PD) 30 (30%), and laparoscopic Heller myotomy (LHM) 7 (7.1%)]. During a median follow-up of 10 (IQR: 3-20) months, clinical success was highest in patients who underwent repeat POEM (25/33 (76%), mean ES 2.1 (2.1)), followed by PD (18/30 (60%), mean ES 2.8 (2.3)), and LHM (2/7 (29%), 4 (1.8)) (p=0.12). A total of 11 (37.9%, mean ES 4 (1.8)) patients in the conservative achieved clinical success. Conclusion: This study comprehensively assessed an international cohort of patients who underwent management of failed POEM. Repeat POEM and PD achieved acceptable clinical success with excellent safety profile.

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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.

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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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