Introduction

Peroral endoscopic myotomy has become the mainstay of treatment of achalasia. Oral feeding has been initiated if no submucosal leak of the contrast fluid was detected on the X-ray contrast study which was performed the following day after the procedure. However, as major adverse events are rare, and in case of their occurrence, are rarely asymptomatic, it has become unclear whether routine X-ray contrast study is necessary. In our center we have been performing POEM procedures since 2015 and initially routinely performed X-ray contrast study. However,during the course of time it has become unavailable and we were forced to initiate oral feeding diet based on our clinical decision. We adopted a protocol of the initiation of oral liquids on the 2 nd postoperative day (or later in case of suspected complication). We therefore compared these two strategies in terms of periprocedural and postprocedural complications rate and the length of the hospital stay.

Aims & Methods

This is a retrospective analysis of the single high-volume center. We evaluated (1) the rate of peri- and postprocedural complications and (2) length of the hospital stay in patients hospitalized for POEM for esophageal achalasia in 2015-2023. We separately evaluated the “X-ray subgroup” (oral feeding was initiated after X-ray that was performed the day after the procedure) and the “clinical decision subgroup” (oral feeding was initiated on the 2 nd postoperative day).

Results

We analyzed a total number of 274 POEM procedures (129 males, 145 females), mean age was 52,3±16 years. 102 patients (37.2%) received X-ray contrast study after the procedure, in 169 patients (62.8%) the initiation of oral feeding was based on clinical decision. The mean time of the hospital stay was 7.2±2.9 vs. 6.5±1.4 days in the X-ray group and in the clinical decision group, resp. (p<0.004).
In the X-ray group we detected complications in 8 patients (7.7%). 5 were periprocedural (mucosal perforation or aspiration during intubation), were solved during the procedure and did not lead to the extension of the hospital stay. There were postprocedural complications in 3 patients. In one case submucosal leak was detected on X-ray contrast study the following day after the procedure due to loosened clip in the mucosal entry and was solved by placing additional clips. In one case patient presented with bleeding from the mucosal entry after discharge. In one case the patient developed mediastinitis that led to the extension of the hospital stay. In the clinical decision group we detected complications in 10 patients (5.9 %), 9 of them were periprocedural (mucosal perforation or aspiration during intubation), 8 of which were solved during the procedure by endoscopic clipping and did not lead to the extension of the hospital stay, 1 required surgery. In one case of postprocedural complication perforation with pleural effusion was detected on CT scan and required
surgical intervention that led to the extension of the hospital stay.

Conclusion

Our analysis shows that severe complications after POEM are rare. In the X-ray subgroup there was only single postprocedural event in which X-ray was helpful in its early detection (1%). In the clinical decision subgroup there was also only single event that could have been identified on the X-ray (0.6%). The length of the hospital stay in the clinical judgement group was significantly shorter than in the X-ray group. This can be attributed to the improvement of overall experience with the management of the POEM patients as X-ray contrast has become unavailable after performing c.a. 100 POEM procedures.

References

Weusten, Bas L A M et al. “Endoscopic management of gastrointestinal motility disorders - part 1: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.” Endoscopy vol. 52,6 (2020): 498-515. doi:10.1055/a-1160-5549

Introduction

Gastric peroral endoscopic myotomy (G-POEM) is an emerging endoscopic technique for the treatment of refractory gastroparesis, particularly benefiting patients with pylorospasm. It is considered a safe procedure with a low risk of adverse events when performed by experienced endoscopists. Our aim was to perform a comprehensive analysis of all adverse events associated with G-POEM.

Aims & Methods

We performed a retrospective analysis of prospectively collected data from all patients who underwent G-POEM for gastroparesis at our centers (Prague, Brno) between November 2017 and April 2025. All procedures were performed by a single endoscopist (JM). The primary outcome was procedure-related adverse events rate and severity occurring during the perioperative and early postoperative period. Adverse events were categorized as follows: deviations from the expected peri and postoperative course were defined as "undesirable events." Undesirable events that met the criteria of the Clavien Dindo surgical classification (C-D) were considered "true adverse events".

Results

Out of 70 procedures, no true adverse or undesirable events occurred in 51 procedures (72.9%). Perioperatively, the following undesirable events occurred in 18 patients: : gastric (4; 5.7%) and duodenal mucosal injuries (2; 2.8%), major bleeding during the procedure treated endoscopically (1; 1.4%), serosal perforation (10; 14.3%), capnoperitoneum requiring puncture (3; 4.3%), and subcutaneous emphysema (1; 1.4%). In the early postoperative period, adverse events occurred in 3 patients: one patient complained of significant abdominal pain necessitating analgetics, subsequently, a small leak from the pyloric region to the subhepatic region was described on CT and gastroscopy confirmed ulceration at the tunnel site. The patient responded well to treatment with intravenous proton pump inhibitors. In two other cases, both involving patients with diabetic gastroparesis, decompensation of diabetes occurred during the hospital stay post-procedure. The following “undesirable” events were considered true adverse events according to the C-D classification: serosal perforation (10; C-D I), leak requiring prolonged hospitalization (1; C-D IIIa) and diabetes decompensation (2; C-D II). These complications occurred in 13 procedures (18.6%).
The mean duration of hospitalization after the procedure was 2 days (range 1-7). Three months after the procedure, 1 patient developed mild dumping syndrome, which was successfully treated conservatively.

Conclusion

G-POEM is a safe procedure. The rate of true adverse events according to Clavien-Dindo classification is low and severe AEs occurs rarely.

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

Peroral Endoscopic Myotomy (POEM) is an effective treatment for esophageal motility disorders, particularly achalasia. POEM also demonstrated a good safety and efficacy profile in patients with prior treatment failure (PTF). However, long-term data of POEM for this selective group have been underexplored. This study aims to compare long-term outcomes of POEM in patients with and without PTF.

Aims & Methods

This is a retrospective analysis of a prospectively maintained cohort of patients who underwent POEM for esophageal motility disorders at a single high-volume center between March 2012 and March 2024. Patients who had completed at least 6 months of follow-up were included. Baseline data included demographics, type of esophageal motility disorder, esophageal shape, and pre-POEM Eckardt score (ES). Procedural data included procedural time, adverse events and length of hospitalization. Follow-up data included clinical failure (defined as ES ≥ 4), gastroesophageal reflux disease (GERD) symptoms, erosive esophagitis > B grade at esophagogastroduodenoscopy (EGD) and acid exposure time (AET) > 6% at pH-impedance monitoring. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression to identify factors associated with clinical failure. A 1:1 PSM without replacement was performed, and weighted regression analyses were used to evaluate outcomes.

Results

595 patients underwent POEM during the study period. A total of 564 patients (median age 57 years, 57.3% male) with at least 6 months of follow-up after POEM for esophageal motility disorders (12.7% achalasia I, 76.6% achalasia II, 6.4% achalasia III, 4.2% other non-achalasia disorders) were included in the analysis. One-hundred eight (19.1%) patients had undergone previous treatments (37% Heller myotomy, 39% pneumatic balloon dilation, 15% POEM, 9% Botulinum toxin injection). No significant difference was observed in terms of median procedural time (70 minutes (IQR 55;85) vs 71 minutes (IQR 56;86)) and adverse events (4.6% vs 1.8%) between primary POEM patients and those with PTF (P = ns). Globally, over a median follow-up of 36 months (range 6-60), 72 (12.7%) clinical failures were reported. After matching, 130 patients (65 per group) were analyzed for clinical failure. In the matched cohort, clinical failure occurred more frequently in PTF patients compared to controls (24.6% vs 10.8%). In a weighted Cox regression model, PTF was associated with a significantly higher risk of clinical failure (HR 2.20; 95% CI 1.05–5.36; p = 0.04). Regarding reflux-related outcomes, no statistically significant differences were observed between groups after matching: clinical reflux (38.2% vs 30.3%, p = 0.41), severe esophagitis (34.2% vs 24.7%, p = 0.29), and pathological AET >6% (45.9% vs 45.9%, p = 1.00).

Conclusion

POEM remains a highly effective, safe and durable treatment option for esophageal motility disorders with optimal long-term outcomes. However, patients with PTF undergoing POEM had a significantly higher risk of clinical failure. These findings highlight the need for closer monitoring and potential enhanced interventions for these patients.

Introduction

Untreated symptomatic achalasia leads to decreased caloric intake due to adjustment of the composition of the diet to impaired esophageal emptying. Peroral endoscopic myotomy (POEM) provides reversion of normal eating pattern with consequent weight gain. We performed in-depth analysis of the metabolomic composition of blood plasma before POEM and the composition of the gained tissue mass 3 months after POEM using nuclear magnetic resonance spectroscopy and bioimpedance scale.

Aims & Methods

Consecutive patients with symptomatic untreated achalasia were included in the study. At the first visit (hospital admission due to POEM procedure), we evaluated Eckardt score, obtained blood metabolomics using nuclear magnetic resonance (NMR) spectroscopy and nutrition-related parameters obtained using bioimpedance scale (body weight, muscle and fat weight). At the second visit 3 months after the POEM procedure, the same NMR metabolomic and nutritional parameters were obtained.

Results

43 patients (22M/21F) were included in the study. The symptoms significantly improved 3 months after the POEM procedure (Eckardt score 6.86±1,92 vs. 0,71±0,77, p<0.0001). The average overall weight gain was 5,58±5,05 kg, average fat gain was 1,77±3,33 kg and average muscle gain was 1,33±4,78kg. We also determined the difference in the muscle and fat contribution to the weight of the patient (pre and post POEM, expressed in %). We performed correlation analyses between the amount of amino acids before POEM and the gain of the muscle weight and fat weight. We observed that the individual levels of branched chain amino acids (valine, leucine, isoleucine) (BCAA), their keto acids (ketovaline, ketoleucine, ketoisoleucine) and levels of glutamine, histidine and lysine before POEM were positively correlated with the % of muscle gain (p values in range 0.03-0.0004) and inversely correlated with the % of fat gain (p values in range 0.01-0.00001, Pearson correlation).

Conclusion

Our analysis revealed that post POEM muscle mass gain is directly correlated to the amount of proteogenic amino acids in circulation before the intervention. The level of BCAA before POEM showed consistent positive correlation to the increase of the muscle mass 3 months after POEM. This finding could further serve as a guidance for nutrition strategies in patients with yet untreated achalasia and also in the broader spectrum of patients with impaired caloric intake. We suggest that achalasia could serve as a study model for metabolic changes related to restored normal dietary pattern. Supported by VEGA 1/0060/23.

Disclosure

Nothing to disclose.

Introduction

Red dichromatic imaging (RDI) is a next-generation image enhancement technique which works by employing green, amber and red wavelengths. The blood vessels in the deeper tissues absorb the amber light because of strong affinity with hemoglobin. Even though red light can penetrate deep into the tissue, it is weakly absorbed by hemoglobin. RDI enhances the visibility of deep blood vessels and bleeding sources. Hence it leads to early identification of bleeding sources and quicker hemostasis. RDI enhances the contrast between diluted blood and highly concentrated blood, thereby clearly visualizing the bleeding source. Bleeding during POEM is not very uncommon(0.5-0.7%). Early recognition of bleeding points and quicker hemostasis help in decreasing complications. The utility of RDI in the peroral endoscopic myotomy is not studied so far to our knowledge.

Aims & Methods

To assess the reduction in total procedural time using Red dichromatic imaging (RDI) compared to white light imaging in achieving haemostasis during POEM. To identifying avascular mucosal site by identifying and avoiding deep blood vessels using RDI, use of RDI in comparison with white light imaging (WLI) in achieving haemostasis, ease of mucosal entry by using RDI when compared to WLI and psychological stress experienced by endoscopists during haemostasis treatment.
A single centre prospective, randomized study conducted at tertiary referral centre. Patient with achalasia cardia who are undergoing POEM procedure are randomized into two groups- Group 1- Patient undergoing POEM using novel GF 1500 UGI Scope (RDI) and Group 2- patient undergoing procedure using regular white light endoscope. In group 1, RDI mode 2 was used for mucosal injection and incision and RDI mode 1 was used for identifying and controlling bleeding during the procedure.

Results

Achalasia cardia patients(n=103) undergoing POEM procedure where enrolled in this study, with 52 subjects in RDI Group and 51 subjects in WLI group. The mean age in the RDI group was 49.01± 14.78 years and in WLI group was 46.68± 15.58 years (p=0.32). The Eckardt score improved significantly in the both groups and adverse events where similar in both the groups. The total hemostasis time was significantly better (p=0.02) in the RDI group (7.9±12.02 sec) compared to WLI group (18.92±25.89 sec). Therefore the total procedural time was significantly quicker (p=0.02) in the RDI group when compared to the WLI group. However there was no significant advantage (p=0.18) of RDI over WLI in preventing mucosal entry point bleed. The RDI group had significant advantage in parameters like ease of entry (p=0.0001) and stress encountered by the operator (p=0.028).

Conclusion

Bleeding during POEM procedure can be daunting for even an experienced endoscopist and RDI can be helpful in this regard. The total hemostasis time, total procedural time, ease of submucosal entry and stress of the operator is seen to be significantly better using novel RDI. Hence RDI helps in early identification of bleeding sources and quicker hemostasis during POEM.

References

1. Maehata T, Fujimoto A, Uraoka T, Kato M, Horii J, Sasaki M, Kiguchi Y, Akimoto T, Nakayama A, Ochiai Y, Goto O. Efficacy of a new image-enhancement technique for achieving hemostasis in endoscopic submucosal dissection. Gastrointestinal Endoscopy. 2020 Sep 1;92(3):667-74.
2. Hirai Y, Fujimoto A, Matsutani N, Murakami S, Nakajima Y, Miyanaga R, Nakazato Y, Watanabe K, Kikuchi M, Yahagi N. Evaluation of the visibility of bleeding points using red dichromatic imaging in endoscopic hemostasis for acute GI bleeding (with video). Gastrointestinal Endoscopy. 2022 Apr 1;95(4):692-700.
3. Anudeep KV, Ramchandani M, Inavolu P, Nabi Z, Reddy DN. Red dichromatic imaging in peroral endoscopic myotomy: a novel image-enhancing technique. VideoGIE. 2021 May 1;6(5):203-6.

Introduction

Gastric peroral endoscopic myotomy (G-POEM) has proven to be an effective technique for treating refractory gastroparesis^1,2. However, data on the long-term outcomes of the technique remain limited. We present findings from a multicenter study with over one year of follow-up.

Aims & Methods

In this retrospective study, patients undergoing G-POEM for refractory gastroparesis at two Italian centers from March 2019 to October 2024 were included. Primary endpoints were clinical success rates at 1 and 2 years. Secondary endpoints included factors associated with long-term clinical success (CS), changes in Gastric Emptying Study (GES) results, and Body Mass Index (BMI). CS was defined as a ≥1-point improvement in the Gastroparesis Cardinal Symptom Index (GCSI) and a 25% reduction in two symptom subscales.

Results

A total of 56 patients underwent G-POEM (median age 61 years [IQR 25: 45.8 - IQR 75: 71.5], 57.1% female, and 60.8% with idiopathic gastroparesis).
Technical success was achieved in 54 out of 56 cases (96.4%). Only two adverse events were recorded (3.5%, both grade 1 according to the AGREE classification). The median length of myotomy was 3.00 cm (IQR 25: 3.00 - IQR 75: 5.00). Single-layer myotomy was performed in 12 patients (21.4%), while 42 patients (78.6%) underwent full-thickness myotomy.
CS rates were 70.0% (35/50 patients) at 3 months, 66.7% (31/45 patients) at 6 months, 64.9% (24/37 patients) at 12 months, and 57.1% (16/28) at 24 months, with a significant change over time (𝑄=25.36, p<0.001). Among patients with CS at 12 months, 4 experienced symptoms relapse at 24 months, while 1 patient achieved success at 24 months despite not having CS at 12 months. There were no differences in success rates based on the etiology of gastroparesis (Table 1)
In multivariate regression logistic, age (OR = 1.27, p=0.02) and baseline GCSI (OR = 1.45, p=0.03) were significant predictors of CS at 1 year.
Among patients with CS at two years, there was no significant difference between pre-procedure and post-procedure BMI (median follow-up time 1091 days)(22.6 vs 22.0, p=0.40) or between pre- and post-procedure GES t ½ (median follow-up time 901 days)(174 vs 101 min, p=0.078).

Table 1: Clinical success subgroup analysis

Conclusion

The efficacy of G-POEM decreases over time, reaching approximately 60% at two years. Long-term clinical success does not correlate with changes in BMI or GES parameters. Further studies are needed to better understand factors influencing long-term outcomes of G-POEM and to optimize patient selection.

References

1. Mandarino FV, Vespa E, Barchi A, et al. Precision Endoscopy in Peroral Myotomies for Motility Disorders of the Upper Gastrointestinal Tract: Current Insights and Prospective Avenues-A Comprehensive Review. Life (Basel). 2023;13(11):2143. Published 2023 Oct 31. doi:10.3390/life13112143
2. Mandarino FV, Testoni SGG, Barchi A, et al. Gastric emptying study before gastric peroral endoscopic myotomy (G-POEM): can intragastric meal distribution be a predictor of success?. Gut. 2023;72(5):1019-1020. doi:10.1136/gutjnl-2022-327701