Introduction

POEM is an established treatment modality for achalasia cardia. Monopolar knives (MPK) are typically used for submucosal dissection as well as myotomy during POEM. More recently, a novel bipolar device (BPD) is commercially available for endoscopic dissection and resection procedures.

Aims & Methods

In this study, we aim to compare the performance of MPK with BPD during POEM. This is a prospective, multicenter cohort study including consecutive cases with achalasia cardia who underwent POEM using conventional MPK or a novel BPD from Dec 2019 to Jan 2023. The primary aim of the study was to evaluate the requirement for accessory exchange during POEM procedure. The secondary objectives included technical success, procedure time, adverse events, post-procedure pain and clinical success (Eckardt≤3). Post-operative pain scores were assessed on the day of procedure and first post-operative day using a standardized scale i.e. visual analog scale (VAS). The severity of pain was graded as mild (0-30), moderate (>30-70) and severe (>70).

Results

278 cases (40.9y, 162 males) with achalasia underwent POEM using either a monopolar knife (n=220) or bipolar device (n=58). All the procedures were performed by posterior route (5 O’clock). Median exchange of accessories was significantly lower in the BPD group [3 (2-8) vs 1 (1-2), p=0.001). The use of coagulation forceps for hemostasis or pre-coagulation was significantly less in the BPD group [1(0-6) vs 0(0-1), p=0.001]. There was no difference in technical success, procedure duration and adverse events between the two groups. Post-operative pain was significantly less in the BPD group [40(20-90) vs 40 (20-80), p=0.021]. The proportion of cases with moderate to severe post-operative pain was significantly higher in the MPK group (79.6% vs 56.9%, p=0.001). (Table 1)

Table 1. Comparison of technical and clinical outcomes between the two groups

	Monopolar knife (N=220)	Bipolar device (n-58)	p
Technical success (%)	220 (100)	57 (98.3)	0.209
Mean procedure time, min (SD)	52.5 (16.3)	50.9 (18.7)	0.523
Exchange of accessories, median (range)	3 (2-8)	1 (1-2)	0.001
Use of coagulation forceps, median (range)	1 (0-6)	0 (0-1)	0.001
Pain score, median (range)	40 (20-90)	40 (20-80)	0.021
Pain severity (%) Mild Moderate Severe	45 (20.5) 168 (76.4) 7 (3.2)	25 (43.1) 32 (55.2) 1 (1.7)	0.001 0.003 1.000
Adverse events (%) Mucosal injuries Capnoperitoneum Pleural effusion	18 (8.2) 5 13 0	6 (10.3) 1 4 1	0.602

Conclusion

The novel BPD is safe and effective for performing POEM procedures with the added advantage of minimum exchange of accessories and reduced post-operative pain as compared to MPK.

References

Nabi Z, Chavan R, Ramchandani M, Tsiamoulos Z, Basha J, Goud R, Darisetty S, Reddy N. Endoscopic submucosal dissection and tunneling procedures using a novel all-in-one bipolar device. Endosc Int Open. 2020 Oct;8(10):E1302-E1307.

Disclosure

Dr Zaheer Nabi and Mohan Ramchandani have consultant agreement with Creo Medical

Introduction

Per-oral endoscopic myotomy (POEM) is an established treatment modality for achalasia cardia. Submucosal fibrosis (SMF) is rare, but the most important reason for technical failure during POEM. Prediction of SMF may be crucial to improve technical outcomes with POEM.

Aims & Methods

In this study we aim to evaluate the predictors for SMF in cases with achalasia cardia.Consecutive patients with achalasia cardia who underwent POEM (Aug 2021 to October 2022) were included in the study, prospectively. Various factors were analysed for prediction of SMF including age, gender, stasis esophagitis, type of achalasia, duration of disease, lower esophageal sphincter pressure (LESP), height of barium column on barium esophagogram and severity of symptoms (Eckardt score). Esophageal mucosa was graded for the severity of stasis esophagitis (grade I to grade III) based on vascular pattern, mucosal thickening, ulceration and nodularity. SMF was graded (I minimal, II moderate, III severe) according to mucosal lift, difficulty in entry, density of SM fibers, separation of mucosa and muscle.

Results

240 patients (males 139, mean age 44.4±14.7 years) underwent POEM during the study period. The subtypes of achalasia included type I in 29, type II in 201, type III in 10. Median symptom duration was 24 (1-240) months and mean pre-POEM Eckardt score was 7.6±1.8. Majority (93.3%) of the patients were treatment naïve and underwent POEM via posterior route (91.2%). Stasis esophagitis was evident in 122 (50.8%) patients including grade I in 99 (41.3%), grade II in 16 (6.7%) and grade III in 7 (2.9%) patients. SMF was detected in 87 (36.3%) patients including grade I in 52 (21.7%), grade II in 30 (12.5%) and grade III in 5 (2.1%) patients. Mean age, duration of symptoms, width of esophagus and procedure duration were significantly higher in cases with submucosal fibrosis. (Table 1) Significantly higher proportion of patients with type I achalasia (62.1%) had SMF as compared to type II (33.8%) and type III achalasia (10%) [p=0.013]. On multivariate analysis, the presence of stasis esophagitis and width of esophagus on timed barium were predictors of significant (≥grade II) SMF.

Multivarient analysis	SMF (no or grade 1)	Significant SMF (grade 2 or 3)	p value
Age, mean+/-SD	44.5+/-14.5	44.0+/-15.9	0.859
Disease duration, months	36.3+/-43.9	43.9+/-53.1	0.035
Mean Eckardt score	7.8+/-1.9	7.1+/-1.4	0.060
Mean TBS height in cm	13.8+/-5.1	13.4+/-5.4	0.619
Mean TBS width in cm	4.6+/-1.7	6.1+/-3.5	0.001
Mean LES pressure, mmHg	24.3+/-10 3	26.9+/-15.1	0.198
Mean Integrated relaxation pressure, mmHg	26.6+/-13.7	27.2+/-13 9	0.791
Mean Myotomy length, cm	9.2+/-2.6	9.9+/-2.9	0.114
Mean Procedure time, min	40.8+/-17.7	58.2+/-24.1	0.001

Conclusion

Severe SMF (grade III) is uncommon in cases with achalasia cardia. The presence of stasis esophagitis and width of esophagus are predictors of SMF during POEM.

References

1. Wu QN, Xu XY, Zhang XC, Xu MD, Zhang YQ, Chen WF, Cai MY, Qin WZ, Hu JW, Yao LQ, Li QL. Submucosal fibrosis in achalasia patients is a rare cause of aborted peroral endoscopic myotomy procedures. Endoscopy. 2017 Aug;49(08):736-44.
2. Feng X, Linghu E, Chai N, Ding H. New endoscopic classification of esophageal mucosa in achalasia: A predictor for submucosal fibrosis. Saudi journal of gastroenterology: official journal of the Saudi Gastroenterology Association. 2018 Mar;24(2):122.

Disclosure

Nothing to disclose

Introduction

Per-oral endoscopic myotomy (POEM) is an established treatment for achalasia cardia. However, there are limited studies on the long-term outcomes of POEM in patients with failed Heller’s myotomy (HM).

Aims & Methods

Aims: In this study, we aimed to evaluate the long-term outcomes of POEM in cases with prior failed HM.
Methods: The data of all the patients with recurrence of symptoms after HM who underwent POEM (Sep 2013 to March 2023) was analyzed, retrospectively. Primary outcome was clinical success [Eckardt score (ES) <3]. Secondary outcomes included improvement of manometry parameters, barium emptying at five minutes and gastroesophageal reflux (esophagitis and increased esophageal acid exposure) after POEM.

Results

72 cases (45.9±13.4y, 43 males) with history of HM underwent POEM during the study period. The subtypes of achalasia were type 1 (40.3%), type 2 (37.5%), spastic motility disorders (2.8%) and unknown (19.4%). Prior treatment included HM in 48 (66.7%), HM plus pneumatic dilatation in 20 (27.8%), LHM plus pneumatic dilatation and Botox in 4 (5.5%). All the POEM procedures were performed by posterior route and technical success was achieved in all the cases. The mean length of myotomy was 10.7±3.3 cm and mean procedure duration was 59.1±25.9 min. There was significant improvement in ES (pre-POEM 6.5±1.8 vs post-POEM 0.7±0.7), LES pressures (31.7±12.5 vs 13.3±5.7 mmHg) and barium emptying (14.2±4.2 vs 2.4±3.1 cm) at 1-yr follow-up. At a median follow-up of 63-months (IQR 40-95), clinical success (ES<3) was documented in 58 (87.9%) patients. Reflux esophagitis and increased esophageal acid exposure were recorded in 28 (57.1%) and 11 (55%), respectively.

	Pre-POEM	Post-POEM	p
Mean Eckardt score	6.5±1.8	1y: 0.7±0.7 5y: 1.5±1	0.001
Mean LES pressure, mmHg	31.7±12.5	13.3±5.7	0.001
Barium height at 5-min, cm	14.2±4.2	2.4±3.1	0.001
Reflux esophagitis Grade A Grade B Grade C	-	28 (57.1%) 17 8 3
Increased esophageal acid exposure (>4%)	-	11 (55%)
PPI use (%)	24 (33%)	22 (37.9%)	0.482
Clinical success (5y)	-	58 (87.9%)	-

Conclusion

POEM is a durable treatment modality in cases with relapse of symptoms after Heller’s myotomy. Gastroesophageal reflux is common after POEM and should be systematically evaluated.

Disclosure

No disclosures

Introduction

Prophylactic wound closure after Endoscopic Submucosal Dissection (ESD) is suggested in high-risk patients to reduce delayed AEs (e.g. bleeding). The closure of large wounds can be challenging with standard endoscopic devices (e.g. endoclips) and dedicated devices are needed. Endoscopic Hand-Suturing (EHS) can be a therapeutic option to close extensive gastrointestinal defects. The current study presents the EHS experience from two Italian centers, aiming to assess the feasibility and clinical effectiveness of the EHS technique.

Aims & Methods

Data from two high-volume endoscopic Italian centers were retrospectively collected. Patients with an ESD wound closed using the SutuArt (Olympus Medical Systems, Tokyo, Japan) device were enrolled in the study (Figure1). Demographics, technical data, success rate, suturing speed, and AEs were recorded

Results

Between June 2023 and August 2024 10 patients were enrolled in the study, demographics in Table 1. All patients were at high-risk for delayed bleeding after gastric or colorectal ESD (figure2). The mean lesion size was 34mm (range 15-45). In all cases SutuArt (Olympus Medical Systems, Tokyo, Japan) needle holder with V-LOC 180, size 3-0 threads (Medtronic) were used. All procedures were performed by two expert endoscopists. ESD-wound closure was successfully achieved in 90% of cases. The mean suturing time was 42 min (range: 25–65 min, SD=23.3 min) meanwhile the mean ESD time was 86 minutes (range: 15–185min, SD=38min). Suturing significantly increased the total procedure time (120min Vs 86min, p<0.001). In one case, the wound closure failed due to suture breakage, resulting in needle entrapment within the mesorectum, with the impossibility of retrieving it. No other AEs were reported.

Conclusion

ESD-defects closure with EHS is feasible and safe with promising outcomes. However, this technique is significantly time-consuming. Probably extended training may be required for endoscopists performing suturing, and further studies are needed to assess the real-life applicability and the cost-effectiveness of this technique.

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).

	RDI (n=52)	WLI (n=51)	p value
Age (years)	49.01±14.78	46.68± 15.58	0.32
Male: Female	25:27	33:18	0.088
Total Procedural time	54.7±23.93	63.33±23.13	0.02
Total Hemostasis time	7.9±12.02	18.92±25.89	0.02
Easy of entry (Easy vs Difficult)	41/11	16/35	0.0001
Psychological stress (Nil or minimal vs moderate or high stress)	41/11	30/21	0.028
Procedure approach (Posterior vs anterior)	41/11	42/9	0.65
Type of Achalasia (I/II/IIIorNS)	5/43/4	1/42/8	0.135
Treatment Naive vs previous procedures for Achalasia	42/10	41/10	0.96

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

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