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 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

Per-Oral Endoscopic Myotomy (POEM) was introduced in clinical practice few years ago, and quickly become one of the first line treatments of esophageal motility disorders. We report on the outcomes of the first 1000 patients treated with POEM in a single tertiary referral center during 11 years.

Aims & Methods

The first 1000 patients treated with POEM between May 2011 and September 2022 were identified from a prospective database and included in this study.
Demographics, clinical and technical aspects and follow-up data were collected and analysed. After treatment, patients underwent a regular follow-up, after 6 month, 2 years, 5 years and 10 years. Additional follow-up visits were performed, if clinically indicated. Timed Barium Esophagram, EGD, and esophageal manometry were performed before endoscopic treatment and during post-operative follow-up; a 24-hour esophageal pH monitoring study was performed 6 months after POEM.
Clinical failure was defined by and Eckardt score > 3 and by the need for additional treatments.

Results

Mean age of patients was 51.5 years; 36 patients were younger than 18 years and 157 older than 70 years. Four-hundred ninety-eight patients were male. One hundred seventy-seven patients had received previous treatments for achalasia (110 pneumodilation, 46 surgical myotomy; 21 botulinum toxin injection).
A total of 141 patients had a type I achalasia, 626 a type II, 111% a type III, 30 non-achalasia spastic esophageal motility disorders; in 92 patients achalasia type were not adequately classified. A sigmoid-type esophagus was present in 45 patients.
Mean symptoms duration before POEM was 24±64.6 months.
POEM was technically successful in 979 patients.
The median length of myotomy was 8.0 cm (range 4-22 cm) in the esophagus and 3.1 cm (range 0-7 cm) in the stomach. An anterior myotomy was performed in the 83% of patients. Mean operative time was 50.4 minutes (11–180 minutes).
Length of hospital stay was a mean of 2.5 days (range 1 to 48 days) after POEM.
Mild or moderate complications occurred in 28 patients (2.8%) and were managed conservatively. Severe complications occurred in 2 patients and required prolongation of hospital stay and other interventional treatment. There were no perioperative deaths in our series.
A mean follow-up of 30.4 months (3–130 months) was available for 93.8% of patients. Overall clinical success rate (Eckardt score ≤ 3) was 95.1%. Clinical success was 97.3%, 95.2%, 90.8% and 82% after 6 months, 2 years, 5 years and 10 years, respectively.
Thirty-three patients (70.2 %) with clinical failure underwent pneumodilation (78.8% with persisting clinical benefits); 5 patients (10.6% underwent surgery), one (2.1%) underwent re-POEM.
Clinical success was 93.4% in achalasia-patients and 83.3% in those with spastic motility disorders (p=0.1742).
An altered esophageal pH-study was documented in 32.6% patients; esophagitis rate was 34% (88% grade A/B; 12% grade C/D). At the date of the last follow-up, 38% of patients was receiving daily proton-pump inhibitors for gastroesophageal reflux. Two patients underwent antireflux surgery. Non cases of post-operative Barrett esophagus were identified.

Conclusion

Our results confirm the efficacy of POEM in a large cohort of patients. Benefits of POEM seem durable; adverse events are rare and no specific mortality was reported. Prevalence of GERD is relatively high, but well controlled by medications in the vast majority of patients.

Introduction

Peroral endoscopic myotomy (POEM) has become a standard endoscopic treatment for patients with achalasia, with many studies reporting on its long-term effectiveness. However, the impact of a patient’s previous surgical history on the long-term outcomes of POEM remains unknown.

Aims & Methods

This study aims to compare the long-term efficacy of POEM in achalasia patients with and without prior surgical interventions. A single center, retrospective review was conducted on achalasia patients who underwent POEM between January 2016 to December 2020. Clinical, demographic, radiographic, endoscopic, and manometric data were collected. Patients with less than two years of follow-up without noted failure were excluded. The analysis compared outcomes between first-time POEM patients (naïve POEM) and those undergoing POEM following failed surgical treatments (redo POEM). The primary outcome was the clinical success rate, defined as an Eckardt Score of 3 or less at final follow-up and no need for additional interventions. Secondary endpoints included the prevalance of postoperative gastroesophageal reflux disesase (GORD), the necessity for acid suppression medications, and additional interventions for achalasia.

Results

Data were collected on 47 naïve POEM and 26 redo POEM patients. After excluding 17 naïve POEM patients and 8 redo POEM patients who did not meet the criteria for long-term follow-up, a total of 30 naïve POEM patients and 18 redo POEM patients were analyzed. In the redo POEM group, 77.8% (14/18) of the patients underwent Heller myotomy with Dor fundoplication, while the surgical details for the remaining patients were unknown. The median length of symptoms was 5 (IQR 3-10) years for naïve patients and 6 (IQR 1.2-17.5) years for redo patients (p=0.29). According to the Chicago classification v4.0, the achalasia subtypes in the naïve POEM group were Type I in 9 patients (30%), Type II in 12 (40%), Type III in 3 (10%), and other types in 6 (20%). For the redo POEM group, subtypes were Type I in 9 patients (50%), Type III in 2 (11.1%), and unspecified in 7 (38.9%). Barium esophagram revealed no significant differences in the maximum diameter between the groups (naïve POEM 45.8 ± 21.4 mm vs. redo POEM 44.9 ± 15.4 mm, p=0.89). Long-term success rates were 76.7% (23/30) in naïve POEM and 83.3% (15/18) in redo POEM, with no significant difference between the groups (p=0.72). Postoperative GORD was noted in 63.3% (19/30) in the naïve POEM versus 67% (12/18) in the redo POEM (p=0.06), with newly prescribed acid suppression medication in 23.3% (7/18) and 55.6% (10/18), respectively (p=0.02). Additional interventions for achalasia were required in 10% (3/30) in the naïve POEM versus 11.1% (2/18) in the redo POEM, with no significant difference between the groups (p=1.0). In the naïve POEM group, one patient required a second POEM, another was hospitalized due to achalasia recurrence, and a third underwent Heller myotomy with Dor fundoplication. In the redo POEM group, one patient underwent endoscopic balloon dilatation, and another required esophagectomy.

Conclusion

POEM is an effective long-term treatment for achalasia, demonstrating similar success rates in patients undergoing either their first or redo POEM procedures. The overall efficacy and safety profiles support POEM as a recommended treatment for managing achalasia regardless of prior surgical treatment failures.

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.

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

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.