Introduction

Per-oral endoscopic myotomy (POEM) for esophageal achalasia and related diseases is widely performed worldwide because of its effectiveness and low invasiveness. The Eckardt score is often used as a method to evaluate the therapeutic effect of POEM, but it is a subjective evaluation of the patient and has a drawback of poor objectivity. Conventional barium swallow can observe esophageal dynamics in real time, but it is a two-dimensional image evaluation, and it is difficult to adequately assess the esophageal volume and luminal area. High resolution manometry (HRM) also provides a detailed view of esophageal contractions but does not accurately assess esophageal dynamics.

Aims & Methods

To verify the effectiveness of POEM, we performed 4D analysis using 320-row area detector computed tomography (320-ADCT), adding time axis to the 3D image, and evaluated the steric movement of the esophagus. Images were created by sitting in a Fowler's position at approximately 45 degrees on a 320-ADCT table and taking continuous images for 10 seconds at the same time as the start of contrast swallowing.
Among patients who underwent POEM in our hospital from December 2020 to May 2022, 22 patients with disorders of EGJ outflow (achalasia and EGJOO) were included. 320-ACDT images were taken before and after POEM to assess the maximum esophageal diameter and esophageal lumen area at the lower esophageal sphincter (LES). Esophageal emptying was evaluated by calculating the time integral to the esophageal internal volume.

Results

The median age of the patients was 58 years (18 -87), with 11 males and 11 females. The disease was type I achalasia in nine patients, type II achalasia in eight, type III achalasia in one, and EGJOO in four. POEM was completed in all patients, and the median Eckardt scores decreased from 7 to 1 (p < 0.001). On HRM, integrated relaxation pressure (mmHg) decreased significantly from 30.5 to 9 and LES pressure (esleeve) (mmHg) decreased from 46.1 to 16.7 (p < 0.001). In the 320-ADCT images, the maximum esophageal diameter (mm) at the LES level significantly increased from 2.1 to 7.7 and the maximum esophageal area (mm²) from 2 to 23 before and after POEM (p < 0.001). The volume time integral (ml-s) decreased significantly from 602 to 82 (p < 0.001), indicating an improvement in esophageal emptying. In the comparison of esophageal type I achalasia and type II achalasia, the rate of decrease in volume time integral was significantly lower in type I achalasia (44% vs 85%, p = 0.027). When comparing patients with and without gastroesophageal reflux disease (GERD) after POEM, there was no difference in the length of the myotomy, but in patients with GERD, the amount of extension from resting to maximum at the LES level of the esophagus was significantly greater in both esophageal diameter (7 mm vs 4 mm, p = 0.048) and esophageal area (25 mm² vs 9 mm², p = 0.006).

Conclusion

The improvement of esophageal distensibility at LES level and esophageal emptying by POEM could be evaluated objectively by esophageal 4D analysis using 320-ADCT. The extent of esophageal distensibility at the LES level was also determined as a risk of post-POEM GERD. 4D analysis with 320-ADCT may be a new tool to assess esophageal motility.

Introduction

Per-oral endoscopic myotomy (POEM) is a leading therapeutic procedure for third space endoscopy (TSE) and has been the first choice for treatment of esophageal achalasia. TSE requires treatment in a narrow space. The recently launched thin therapeutic endoscope (EG-840TP, Fujifilm Medical) is expected to be useful for TSE including POEM.

Aims & Methods

To clarify the effectiveness of thin therapeutic endoscopy in POEM, we conducted a retrospective observational study of 66 patients who underwent POEM in our hospital between November 2019 and March 2024. Patient characteristics and outcomes were compared between 52 patients treated with a normal-diameter therapeutic endoscope (T group) and 14 patients treated with a thin therapeutic endoscope (TP group).

Results

The patients in T group were 26 males and 26 females, median age 61 years (18-88), 44 cases of esophageal achalasia (Type I/II/III: 28/15/1), 6 cases of EGJOO, and 2 cases of DES. The TP group included 7 men and 7 women, median age 60 years (13-81), 11 cases of esophageal achalasia type I, 2 cases of EGJOO, and 1 case of DES. Sigmoid type was 58% (n = 30) and 29% (n = 4) in the T/TP group, respectively, and was significantly more common in the T group. Treatment before POEM was balloon dilation 11/1, POEM1/1, and Heller-Dor5/0 in the T/TP group, all of which were not significantly different. There was no difference in the length of myotomy between the two groups in either the esophagus or stomach. The median treatment time in each group was 92 minutes in the T group and 107 minutes in the TP group, and there was no significant difference in the submucosal tunnel creation time. However, the myotomy time per cm was 2.5 min in the T group and 3.8 min in the TP group, which was significantly longer in the TP group (p<0.01). Clips required for entry closure were significantly less in the TP group (8 clips in the T group and 5 clips in the TP group) (p<0.01). Eckardt scores after POEM improved equally in the two groups, and the rates of adverse events and GERD after POEM did not differ between the two groups.

Conclusion

POEM using a thin therapeutic endoscope resulted in similar treatment outcome as conventional endoscopes. Although there was no difference in the treatment time, TP group required fewer clips to close the entry. The prolonged myotomy time in the TP group was considered to reflect the fact that the thin therapeutic endoscope made it easier to approach the muscle layer and more careful myotomy was performed. Although further investigation is needed, a thin therapeutic endoscope may be useful for TSE.

References

1. Inoue, H., et al. (2010). "Peroral endoscopic myotomy (POEM) for esophageal achalasia." Endoscopy 42(4): 265-271.
2. Shimamura, Y., et al. (2023). "Evolving field of third-space endoscopy: Derivatives of peroral endoscopic myotomy." Dig Endosc 35(2): 162-172.

Introduction

Achalasia is a primary motility disorder, which presented by dysphagia. The most effective treatment of the disease is surgical (peroral myotomy or laparoscopic myotomy). However, there are few studies which assess the changes in esophageal motility after surgery.

Aims & Methods

The aim of our study was evaluating the changes in esophageal manometry in patients with achalasia after peroral endoscopic myotomy (POEM).
Subjects and methods: 43 patients with achalasia were consequently observed before and 1 year after POEM. Females predominated (28 subjects). All patients examined endoscopically, then high resolution manometry (HRM) was performed by Solar™ GI (MMS/Laborie, Netherland). Achalasia was defined as described in Chicago Classification 4.0. Eight patients had I type of achalasia, 24 – II type and 11 – III type.

Results

The median Eckardt score was 7 on the start and 2 – after POEM in 35 patients (group A). However, 8 patients were dissatisfied with the surgery (4 pts with II type achalasia and 4 – III type). They continued to suffer from dysphagia and/or noncardiac chest pain (group B).
According to HRM the mean resting pressure of LES in group A reduced 2 folds from 39,1±2,7 mmHg to 18,9±1,4 mmHg. Also we revealed the dramatic decrease in integrated residual pressure (IRP) from 22,8±0,7 mmHg to 9,8±0,6 mmHg and DCI: from 1865,5±286,9 to 128,2±53,8. In a group B the mean resting pressure of LES reduced from 48,8±2,4 mmHg to 33,6±2,4 mmHg. The integrated residual pressure (IRP) decreased from 22,8±0,7 mmHg to 15,01±0,6 mmHg and DCI: from 2999,6±417,6 to 1038,1±107,7.
Even though, we didn’t observed the peristaltic waves in two groups before and after POEM as a normal manometric criteria: the consistent contraction of upper part of esophagus and then lower part of esophagus. Besides, HRM evaluated persisting spastic contraction in the middle and lower part of esophagus in patients with type III achalasia from group B. Two patients from group B with type II had good results in esophageal manometry.

Conclusion

The reduction of resting pressure, integrated resting pressure and distal contractile interval in several times can be accepted as criteria of POEM effectiveness. Besides, in patients with III type of achalasia we must assess the absence of spastic contraction as additional criteria of POEM satisfaction.

Introduction

Peroral endoscopic myotomy (POEM) has become the mainstay of treatment of oesophageal achalasia in adult patients and recently also gained acceptance as effective therapy of achalasia in paediatric population. Here we retrospectively reviewed prospectively collected children with achalasia that had been treated with POEM at our institution.

Aims & Methods

Patients that were hospitalized in the Paediatric Clinic for POEM procedure from 11/2017 to 05/2023 were included. All patients had achalasia confirmed by high resolution manometry (HRM). We evaluated their symptoms in terms of duration and intensity (Eckardt score) and the integrated relaxation pressure (IRP) obtained by HRM before POEM. 3 months after POEM during the follow-up visit we determined Eckardt score, IRP and the presence of reflux oesophagitis on upper endoscopy. When finalizing the abstract we conducted a brief telephone survey to determine Eckardt score and presence of reflux symptoms.

Results

10 patients (6 boys and 4 girls), mean age 11.5 (5-18) years were included. 9 of these patients received POEM as their first therapy for achalasia, 1 patient had been previously treated surgically via thoracotomy. The median of the duration of symptoms was 8.5 (range 1-36) months. All patients were diagnosed with type I achalasia according to Chicago classification. Eckardt score decreased significantly 3 months after POEM (7.38±1.68 vs. 0.63±1.06 before and after POEM, respectively, p<0.0001) and sustained unchanged (0.4±0.66) during the median follow-up of 21.5 months (range 1-60 months). IRP also significantly decreased after the intervention (46.5±11.1 mmHg vs. 3.8±5.68 mmHg; before and after POEM, respectively, p=0.0001). Complications occurred in 2 patients. Pleuropneumonia in one patient led to extension of hospital stay and was solved conservatively. Upper GI bleeding occurred in one patient 2 weeks after discharge, was self-limited without any obvious source found. Follow-up endoscopy was performed off PPI therapy and revealed mild esophagitis (LA A) in 2 patients that also reported mild heartburn.

Conclusion

POEM represents an effective therapy for achalasia in paediatric population in mid-term follow-up as it significantly improves symptom and provides effective decrease of the IRP. Although in our case series no severe heartburn or reflux esophagitis occurred, more data with longer follow up are needed to prove either long-term safety with regard to the reflux issue and the need for long term PPI therapy in these patients. Supported by VEGA 1/0060/23.

Introduction

The development of peroral endoscopic myotomy (POEM) has led to a paradigm shift in the treatment of esophageal motility disorders^1-5. Hiatal hernia (HH) has been reported in approximately 4-20% of patients with achalasia^6-8. Due to the altered position of the proximal stomach entering thoracic cavity, careful anatomical inspection at the completion of myotomy is essential to minimize the risk of adverse events⁷. Although two observational studies suggested that the presence of HH did not significantly affect clinical outcomes^9-10, these studies were limited by small sample sizes from single centers, with 13 and 56 cases of HH, respectively. Further study involving larger cohorts is needed to enable meaningful comparisons and to elucidate the impact of HH on POEM outcomes.

Aims & Methods

We hypothesized that the coexistence of a HH may be associated with adverse events, such as mediastinitis and esophageal perforation, or incomplete myotomy due to the technical challenges of approaching the esophagogastric junction^6-7. This retrospective cohort study aimed to compare outcomes between patients with and without HH undergoing POEM. Using the Nationwide Inpatient Sample in the United States from 2016 through 2022, we identified 6572 patients undergoing POEM for achalasia or non-achalasia spastic disorders. One-to-one propensity score matching was performed to compare adverse events, defined as any adverse event associated with an extended length of stay (>3 days), reintervention, 30-day mortality, and length of stay between the groups.

Results

	HH (n=1276)	Non-HH (n=1276)	P value
Adverse events	107 (8.4)	80 (6.3)	0.04
Infection (peritonitis, mediastinitis, sepsis)	62 (4.9)	42 (3.3)	0.04
Bleeding (gastrointestinal bleeding, hematoma)	32 (2.3)	26 (2.0)	0.49
Perforation (esophageal perforation, laceration)	9 (0.7)	8 (0.6)	0.52
Trauma (pneumothorax, injuries to other organs)	14 (1.1)	5 (0.4)	0.03
Reintervention	92 (7.2)	67 (5.3)	0.04
Pneumatic dilatation	88 (6.9)	67 (5.3)	0.08
Laparoscopic Heller myotomy	18 (1.4)	6 (0.5)	0.01
Second POEM	0 (0)	4 (0.3)	0.05

In the propensity score-matched analysis involving 1276 pairs, the HH group had significantly higher rates of adverse events (8.4% vs 6.3%; p = 0.04) and reintervention (7.2% vs 5.3%; p = 0.04) compared to the non-HH group (Table). The most common adverse events were infections, such as peritonitis and mediastinitis (4.9% vs 3.3%; p = 0.04). A longer length of stay (median: 4 vs 3 days; p < 0.01) was observed in the HH group. No significant difference in 30-day mortality was noted between the groups. On logistic regression analysis, HH (OR 1.33; 95% CI, 1.06–1.68) and achalasia (vs. non-achalasia spastic disorders; OR 1.54; 95% CI, 1.17–2.02) were associated with adverse events.

Conclusion

The risk of adverse events and reintervention were higher in the HH group. These findings highlight the need for tailored management in POEM for HH cases.

References

[1] Inoue H, et al. POEM for esophageal achalasia. Endoscopy. 2010;42:265-71.
[2] Ramchandani M, et al. Recent Advancements and Future Perspectives of POEM. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2024;22:1983-96.e2.
[3] Inoue H, et al. Statement for GERD after POEM from an international multicenter experience. Esophagus. 2020;17:3-10.
[4] Ponds FA, et al. Effect of POEM vs Pneumatic Dilation on Symptom Severity and Treatment Outcomes Among Treatment-Naive Patients With Achalasia: A Randomized Clinical Trial. Jama. 2019;322:134-44.
[5] Inoue H, et al. Clinical practice guidelines for POEM. Digestive endoscopy. 2018;30:563-79.
[6] Ushimaru Y, et al. Occult Hiatal Hernia in Achalasia Patients: Its Incidence and Treatment Options. Dig Surg. 2019;36:418-25.
[7] Fletcher PR. Acute hiatal hernia with oesophageal perforation following Heller's operation. Br J Surg. 1978;65:486-8.
[8] Sanei-Moghaddam A, et al. Cricopharyngeal myotomy for cricopharyngeus stricture in an inclusion body myositis patient with hiatus hernia: a learning experience. BMJ case reports. 2013;2013.
[9] Xu P, et al. Peroral endoscopic myotomy is an effective treatment for achalasia combined with hiatal hernia. Surgical endoscopy. 2024;38:4543-9.
[10] Tutuian G, et al. Achalasia and Hiatal Hernia: A Rare Association and a Therapeutic Challenge. J Neurogastroenterol Motil. 2023;29:455-9.

Disclosure

No disclosures for this study

Introduction

Per-oral endoscopic myotomy (POEM) has revolutionised achalasia treatment, nevertheless there is still a lack of technical standardization. No clear definition of “long”, “standard” or “short” POEM exists to date. With the exception of type III achalasia, there is evidence that myotomy limited to the lower esophageal sphincter (<6 cm) may be highly effective, time-saving and associated with less post-postoperative gastroesophageal reflux, yet it is common practice to use long myotomy in these patients.

Aims & Methods

We conducted a systematic review with meta-analysis to define current myotomy length standards during POEM. A literature search was performed on MEDLINE-Pubmed, Embase, Scopus, and Cochrane Library (from inception to December 2022). We included prospective, retrospective clinical studies and randomized controlled trials reporting technical details of POEM, in which no definite or comparative myotomy length was intentionally adopted thus representing a “standard” myotomy for the operator. The primary outcome was the pooled mean total myotomy length. Secondary outcomes included clinical success and reflux symptoms. Main exclusion criteria were: patient age < 18 years; studies providing achalasia diagnosis without high-resolution manometry, studies including patients with non-achalasia esophageal motility disorders, studies comparing different myotomy lengths or adopting pre-specified myotomy lengths, studies including type III achalasia patients only. Sub-group analyses were performed to explore heterogeneity across studies and to assess the impact of different subtypes, geography and time trends on the primary outcome.

Results

From initial 7,172 records, after exclusion criteria were applied, a total of 25 articles were included. Of those, 6 provided results on the primary outcome in separate subgroups and were therefore included as separate studies. Overall, 31 studies with a total 3023 patients were evaluated. The pooled mean of total myotomy length was 10.39 cm (95% CI 10.06-10.71; I² 99.3%). The pooled mean of esophageal and gastric myotomy length, provided by 17 studies, was 7.11 cm (95% CI 6.51-7.71; I² 99.8%) and 2.81 cm (95% CI 2.41-3-22; I² 99.8%) respectively. At the subgroup analysis for achalasia subtypes, pooled mean length in non-spastic achalasia (type I and II) was 10.17 cm (95% CI 9.91-10.43; I² 94.2%), while in type III attested at 14.02 cm (95% CI 10.59-17.44; I² 98.9%). Pooled mean myotomy length for studies conducted between 2014-2018 was 10.56 cm (95% CI 9.51-11.61; I² 99.0%) while studies between 2019-2022 showed a mean length of 10.3 cm (95% CI 9.99-10.61; I² 99.6%). No geographical difference was observed: in eastern countries mean length was 10.2 cm (95% CI 9.12-10.92; I² 98.9%), while in western countries was 10.95 cm (95% CI 9.83-12.07; I² 99.5%). At a median follow-up of 29 months, the pooled clinical success rate was 91% (95% CI 88.9%-93.2%; I² 67.2%), while the pooled rate of post-POEM clinical reflux was 26% (95% CI 21.0%-31.3%; I² 89.5%).

Conclusion

Our meta-analysis found that the pooled mean myotomy length during a "standard” POEM is 10.4 cm, remaining over 10 cm in non-spastic (type I and II) achalasia. The high heterogeneity across studies confirms that POEM technique needs further standardization. We found no time trend towards adopting short POEM, despite recent evidence supporting efficacy and safety of this approach.

Introduction

Peroral endoscopic myotomy (POEM) is emerging as a minimally invasive therapeutic option for achalasia. Data are limited in pediatric population.
To compare the efficacy and safety of POEM in pediatric and adult patients with achalasia.

Aims & Methods

A prospective study was conducted, including all patients who underwent POEM, since August/2022, in a tertiary centre. Patients aged under 18yo were included in the pediatric group and above 18yo in adult group. Procedural-related parameters, adverse advents, pre- and post-intervention clinical, manometric and radiologic outcomes were evaluated.

Results

41 patients were included, including three children (mean age: 14.3±1.2vs.51.8±19.1yo; male gender: 100%(n=3)vs.39.5%(n=15)). According to the Chicago classification v4.0, all three children had type II achalasia (adults: type I-5.3%(n=2), type II-89.4%(n=34), type III-5.3%(n=2)). No significant differences were observed between groups in relation to clinical symptoms (Eckardt score (ES): 7.6vs.0.9;ρ=0.23; average duration of symptoms: 21vs.19months;ρ=0,36), pre-POEM integrated relaxation pressure (IRP) (36.7vs.19.0;ρ=0,11), esophagogastric junction contractile integral (EGJ-CI) (105,3vs.91,2;ρ=0.72) and barium swallow study at 1/5 minutes (4.5/5.1vs.12.6/10.0;ρ=0,17/0.29) and post-POEM IRP (9.75vs.6.19;ρ=0.32), EGJ-CI (7vs25.20;ρ=0.30) and barium swallow study (3.45/2.20vs.2.65/1.43;ρ=0.57/0.56), evaluated at 4.3±1.3 and 8.5±2.1months of follow-up. Technical success was 100% in all groups with mean procedure time of 91.7±12.6minutes for children (vs.86.1±21.6 for adults;ρ=0.35). Clinical success was similar in both groups (ES: children-0±0 vs. adults-0.31±0.63;ρ=0.69). There were no significant differences between groups regarding intraprocedural complications (67%vs.66%;ρ=0.98), post-procedural complications or major adverse events. No mortality or need for surgery. Symptomatic gastroesophageal reflux disease (GERD), successfully treated with daily PPI, was only observed in 5(13.2%) adults (vs. 0% of pediatric patients;ρ=0.021).

Conclusion

POEM proved to be effective and safe for achalasia both in adults and pediatric patients, with no statistically significant differences regarding technical, clinical, manometric and imaging success or complications. Achalasia should be treated as early as possible, with apparently lower incidence of post-POEM GERD in pediatric patients.

References

1. Rui Mendo, Pedro Barreiro, José Rodrigues, Catarina Félix, Catarina O'Neill, Iala Carina, Joyce Chivia, Cristina Chagas; Peroral Endoscopic Myotomy for
Esophageal Achalasia in Portugal: Outcomes of the First Prospective Series. GE Port J Gastroenterol 30 April 2021; 28 (3): 162–169.