Introduction

Since 2010, per oral endoscopic myotomy (POEM) has become an important part of the treatment for achalasia. This technique involves myotomy of the lower esophageal sphincter and can be performed using various technical modalities, some of which have already been studied (such as different myotomy lengths and anterior versus posterior approach). The aim of this study is to compare the impact of the depth of myotomy (selective inner layer myotomy (SIM) vs full-thickness myotomy (FTM)) on the outcomes of patients treated with POEM for achalasia.

Aims & Methods

This was a retrospective, observational, bi-centric study conducted in two tertiary center between October 2018 and September 2022. Patients were divided into two groups: SIM and FTM. The primary endpoint was clinical efficacy at 6 months, while secondary endpoints were postoperative parameters (such as pain, length of hospital stay, complications) and gastroesophageal reflux disease (GERD) parameters (esophagitis at 6 months, heartburn, and pH-metry).

Results

Out of the 166 patients who underwent POEM, 158 were included in the study (33 in the FTM group and 125 in the SIM group). The clinical efficacy rates at 6 and 12 months were similar in both groups, with 84% and 70% in the SIM group versus 90% and 80% in the FTM group, respectively (p=0.57 and p=0.74). However, more opioid analgesics were consumed in the FTM group compared to the SIM group (45% vs 21%, p<0.01). The length of hospitalization was longer in the FTM group than in the SIM group (2.94 ± 2.33 vs 2.17 ±2.62, p<0.001). The rate of esophagitis at 6 months was comparable (16% in the SIM group vs 12% in the FTM group, p=0.73). There was no significant difference in terms of pyrosis at 6 or 12 months between the SIM and FTM groups (18.5% vs 3.8%, p=0.07 and 27% vs 12.5%, p=0.35, respectively).

Conclusion

There was no significant difference in terms of clinical efficacy and GERD occurrence between FTM and SIM. However, full-thickness myotomy was associated with more postoperative pain and a longer length of hospital stay. Therefore, selective internal myotomy should be preferred over full-thickness myotomy.

Introduction

Timed barium esophagogram (TBE) is widely used to evaluate esophageal clearance (EC) after peroral endoscopic myotomy (POEM) in achalasia. However, high-resolution impedance manometry (HRiM) offers a dynamic, radiation-free alternative, potentially more accurate and reflective of true esophageal function.

Aims & Methods

To compare EC assessed by HRiM (EC_HRiM) and TBE (EC_TBE) after POEM for achalasia, and to evaluate their diagnostic performance, reproducibility, and predictive value for long-term clinical success, with external validation.
We conducted a monocentric prospective study between October 2020 and September 2023. Patients undergoing POEM were assessed pre- and post-procedure using Eckardt score, HRiM, and TBE. Treatment failure was defined by an Eckardt score >3 at 12 months. EC impairment was defined as a residual column height >5 cm at 5 minutes. In parallel, we validated our findings in an independent cohort. Statistical correlations and diagnostic performance were analyzed using Spearman, Pearson, ICC, and ROC curve analyses.

Results

In the primary cohort (n=104; 65% male; median age 62; 75% with type II achalasia; 30% had prior treatment, mainly dilation), 97 patients completed the 12-month follow-up, with a POEM success rate of 90%. EC significantly improved post-POEM on both modalities (HRiM: −8.9 cm; TBE: −4.9 cm; p<0.001). Interobserver reproducibility of EC measurement was higher for HRiM (ICC =0.98) than for TBE (ICC=0.93) (p<0.001). EC_HRiM correlated more strongly with clinical outcomes (Spearman r = 0.68) than EC_TBE (r = 0.37). In univariate analysis, significant predictors of failure were EC_HRiM (p<0.001), 3-month Eckardt score (p<0.001), and EC_TBE (p<0.001). The most discriminative thresholds were EC_HRiM < 0 cm and EC_TBE < 9 cm. Diagnostic performance of HRiM at this threshold was: Se = 66%, Sp = 82%, PPV = 30%, NPV = 95%. For TBE, the same values were: Se = 100%, Sp = 59%, PPV = 19%, NPV = 100%.
In the external validation cohort (median age: 66.5 years; 55.7% male; 50.8% with type II achalasia), the 12-month failure rate was 14.8%. Diagnostic performance of HRiM for predicting clinical FAILURE in this cohort showed: sensitivity 55.6%, specificity 82.7%, PPV 35.7%, and NPV 91.5%, confirming its utility in real-world settings.

Conclusion

HRiM is a reliable, reproducible tool for assessment of esophageal clearance post-POEM and shows stronger correlation with clinical outcomes than TBE. Its predictive value was confirmed in an external validation cohort, supporting its potential as a new standard in achalasia management.

Disclosure

None

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

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 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

Outcome after treatment of achalasia is usually assessed by the Eckardt score (ES). The timed barium esophagogram (TBE) is used to objectively assess esophageal clearance after treatment. High-resolution manometry with impedancemetry (HRiM) provides information on esophageal clearance of liquids in addition to motility parameters. The aim of this study was to compare esophageal clearance determined by HRiM and TBE in patients with achalasia treated by POEM.

Aims & Methods

Consecutive patients treated with POEM had pre and post-POEM assessment with ES, TBE, and HRiM. Treatment failure was defined by an ES > 3 at 3 months post-POEM. Incomplete esophageal clearance (IEC) was defined by the presence of an esophageal stasis > 2 cm at 5 minutes in HRiM and/or TBE. All of the data available pre and post-POEM at 3 months was pooled for analysis. The correlation between ES, TBE and HRiM was evaluated by Spearman's method.

Results

Fifty patients with a median age of 65 years (23-84) were included in this study (85% with type 2 achalasia). The clinical response rate at 3 months was 94%. TBEM/HRiM results were available in (29/33) pre-POEM patients and (43/46) post-POEM patients at 3 months. Overall, an IEC was found in 91% on TBE and in 50.8% on HRiM. The correlation between the ES and IEC in HRiM and TBE were respectively 0.66 and 0.31. The correlation between esophageal clearance values between TBE and HRIM was low (r=0.375). At 3 months after POEM, IEC was present in 90.7% and 21.7% for TBE and HRiM, respectively (p<0.001). In univariate and multivariate analysis, only IEC in HRiM was significantly associated with ES > 3 (RR = 17.0 (p < 0.001)). The HRiM AUC was 0.872 vs. 0.707 for the TBE (p<0.001). The diagnostic performance of HRiM to predict an ES > 3 was Se: 85%; Sp: 77%; PPV: 74%; NPV: 87% vs. Se: 95%; Sp: 11%; PPV: 42%; NPV: 83% for the TBE. Data at one year will be available for the presentation.

Conclusion

In achalasia, the evaluation of esophageal clearance by HRiM is better correlated with ES than TBE and may be a relevant criterion for pre and post-therapeutic evaluation. Additional studies are underway to validate the relevance of this parameter more specifically in the evaluation of treatments for esophageal achalasia.

References

1. Lin Z, Nicodème F, Lin CY, Mogni B, Friesen L, Kahrilas PJ, et al. Parameters for quantifying bolus retention with high-resolution impedance manometry. Neurogastroenterol Motil. 2014 Jul;26(7):929–36.
2. Conchillo JM, Selimah M, Bredenoord AJ, Samsom M, Smout AJPM. Assessment of oesophageal emptying in achalasia patients by intraluminal impedance monitoring. Neurogastroenterol Motil. 2006 Nov;18(11):971–7.
3. Cho YK, Lipowska AM, Nicodème F, Teitelbaum EN, Johnston ER, Gawron A, et al. Assessing Bolus Retention in Achalasia using High Resolution Manometry with Impedance: A Comparator Study with Timed Barium Esophagram. 2015;15.
4. de Oliveira JM, Birgisson S, Doinoff C, Einstein D, Herts B, Davros W, et al. Timed barium swallow: a simple technique for evaluating esophageal emptying in patients with achalasia. Am J Roentgenol. 1997 Aug;169(2):473–9.
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Introduction

Per-oral endoscopic myotomy (POEM) has been widely employed as a treatment for esophageal motility disorders since 2008, exhibiting an efficacy rate of approximately 80-90% and a safety rate of 90%. Nevertheless, approximately 10% of patients remain symptomatic after treatment, with limited data available on second-line strategies. Our aim was to determine the validity of redoPOEM as a second line therapy after POEM failure.

Aims & Methods

We conducted a retrospective multicenter study involving 15 French expert centers, including all patients who underwent redoPOEM up to the end of September 2023. Patients were classified as experiencing primary failure if their Eckardt score exceeded 3 at 3 months post-procedure, and as experiencing secondary failure if their Eckardt score exceeded 3 at the last follow-up or if additional treatment was necessary. Safety was assessed using the AGREE classification, with events of grade II or higher considered significant.

Results

Ninety-one patients were included in the study, 44% were female, the average age was 54.6 ± 18.0 years. Patients were followed for a mean duration of 22 months (range 3,5 – 69,5 months). The mean Eckardt score before redoPOEM was 5.8 ± 2.0. No technical failure was reported. At the 3-month follow-up, 79% of patients had achieved clinical success, with an average Eckardt score of 2.05 ± 2.0. Long-term success was observed in 60.5% of all patients, and among those who had achieved clinical success at the 3-month mark, the long-term success rate was 77%. Additionally, 25% of the patients required a complementary treatment, such as botulinum toxin injections, endoscopic dilation or Heller myotomy. A low Eckardt score before redoPOEM was associated with clinical success at the 3-month follow-up in univariate analysis, whereas an Eckardt score of 5 or higher before redoPOEM appeared to be a risk factor for primary failure. Multivariate analysis did not show any predictive factors of failure. The safety rate was 90%, with no reported deaths within one month following the procedure. Nine patients experienced grade II or higher adverse event: four patients were treated with antibiotics for pneumonia or mucosal breach without further complications, while four others underwent a new endoscopy due to mucosal breach, with covered esophageal stents or hemostatic clips used to manage the situation. One patient experienced multiorgan failure.

Conclusion

RedoPOEM proves to be an effective strategy for managing patients who experience primary failure or symptomatic relapse following a POEM. It demonstrates promising efficacy and safety outcomes, supported by the largest cohort reported to date for redoPOEM. Further research is warranted to compare redoPOEM with Heller myotomy and endoscopic dilation as second-line treatments for esophageal motility disorders.