Introduction

Per Oral Endoscopic Myotomy (POEM) is typically performed with diathermy and an ESD knife. Laser is an energy source used in urology for stone management and has also been reported for POEM¹. In this case series, we compared POEM using a novel 1920 nm super pulsed thulium fiber laser (POEM-L) to historical data of POEM performed with diathermy (POEM-D) at our center².

Aims & Methods

We aimed to evaluate the feasibility of a novel 1920nm super pulsed thulium fiber laser for POEM. Collected data from the first 10 patients with achalasia who underwent POEM-L at Haukeland University Hospital from February 2022 until March 2023 were analyzed. The patients were followed up with respect to acute and delayed complications and the efficiency of the treatment with Eckhart score (ES). The historical data on POEM-D were 84 patients treated from January 2014-2019. All POEM-L was performed under general anesthesia using a 365 or 550 micron 1920 nm super pulsed thulium fiber laser in combination with a 4,5-7 Fr triple-lumen cannula for fiber stability. Physiological saline was used for irrigation, and the energy used was 10-30W for all the phases of POEM-L.

Results

Ten patients, 4 males and 6 females with symptomatic achalasia and Eckardt score ≥6 were included. The mean age was 38.5 years old. Based on HRM, 2 patients had achalasia type I, 6 type II, and two with type III. Four patients (40 %) were treatment naïve, 3 (30%) had undergone pneumatic balloon dilatation, 1 (10%) had previous Heller´s myotomy combined with Dor fundoplication, and 3 (30%) had undergone previous POEM. The patients who had redo-POEM had POEM-D as the first treatment. The median resting pressure over the lower esophageal sphincter (LES) was 24.4 mmHg (Range (14.1-45.0 mmHg) prior to POEM. All 10 patients (100 %) patients had posterior myotomy. The median myotomy length was 7 cm (range 5-14 cm). The procedure time was mean 107 min for POEM-L, compared to 130 min for POEM-D, p=0.01. Dysphagia improved in all patients on follow-up, but clinical success (ES≤3) in nine patients. The ES was significantly reduced from median 7 (range 5-10) before POEM to 0.5 (range 0-8) at 1-12 months (p <0.001). None of the patients reported post-operative symptoms of daily reflux, while one had used PPI regularly before POEM. Patients who underwent POEM-L were hospitalized for mean 2.0 days compared to a mean of 3.2 days after POEM-D (p<0.001)
In 9 cases, we were able to use the same instrument to complete all steps of the POEM procedure including mucosal injection and incision, submucosal tunneling, vessel dissection and coagulation, and myotomy.

Conclusion

POEM with a novel 1920 nm super pulsed thulium fiber laser is feasible. Treatment results seem non-inferior to POEM-D. Compared to POEM-D, patients who underwent POEM-L have significantly shorter hospital stay. The mean procedure time was shorter. POEM-L is promising, but a learning curve and dedicated accessories are needed. Further studies are needed to confirm the findings.

References

1. Liu, J. et al. Preliminary study of 1940 nm thulium laser usage in peroral endoscopic myotomy for achalasia. Dis. Esophagus 31, 1–6 (2018).
2. Pham, K. D. C. et al. The outcome of primary per oral endoscopic myotomy (POEM) for treatment of achalasia: Norwegian single-center experience with long-term follow-up. Scand. J. Surg. (2022) doi:10.1177/14574969221139706.

Disclosure

Pham KDC is a consultant for Ambu, Olympus, Taewoong Medical, and Ziehm Imaging and has received a speaker fee from Boston Scientific, Nanovi and Ovesco

Introduction

Per-oral endoscopic myotomy (POEM) is highly effective in the short-term management of achalasia, with recent studies showing durable success.^1,2 The aim of this study was to evaluate long term clinical outcomes of POEM for oesophageal motility disorders, in a tertiary portuguese center.

Aims & Methods

This was a retrospective single center cohort study, from prospective collecting data, of consecutive patients who underwent POEM between January 2017 and February 2021, with a minimum of 24 months follow-up. Clinical response was defined by an Eckardt score ≤ 3. Gastroesophageal reflux was assessed through clinical interview and endoscopy.

Results

A total of 72 patients underwent POEM with technical success, during the specified study period. Nine (12.5%) were lost to follow-up before at least 24 months. Of the remaining 63 patients, 57% were female, median age was 54 years (range 17-79) and 41.3% had prior treatments. Indication for intervention was achalasia in 62 patients (type 1, n=18; type 2, n=36; type 3, n=7; one non-specified) and esophagogastric junction outflow obstruction in one, with preoperative median Eckardt score of 6 (range 2-11). Median follow-up duration was 42 months (range 24-63). Clinical response at one month was achieved in 61 patients (96.8%). Of the patients with initial response, clinical response at last follow-up was 90.2%. In the long term, six patients required additional treatment, with median symptom relapse at 35.5 months (range 12-48). Two patients underwent re-poem with clinical response. Gastroesophageal reflux symptoms were reported in 27.9%, with 68.9% maintaining daily proton pump inhibitor therapy at last follow-up. Endoscopic evaluation was performed in 46 patients, showing reflux esophagitis in 22.

Conclusion

POEM is an effective therapy for achalasia, with durable success rate and possible reintervention in case of relapse. Gastroesophageal reflux is a common late adverse event. Studies with longer follow-up are needed to determine long term effectiveness and reflux exposure risk.

References

1 – Brewer Gutierrez OI, et al. Long-term outcomes of per-oral endoscopic myotomy in achalasia patients with a minimum follow-up of 4 years: a multicenter study. Endoscopy International Open. 2020 April; 08(05):E650—E655. https://doi.org/10.1055/a-1120-8125
2 - Modayil RJ, et al. Peroral endoscopic myotomy: 10-year outcomes from a large, single-center U.S. series with high follow-up completion and comprehensive analysis of long-term efficacy, safety, objective GERD, and endoscopic functional luminal assessment. Gastrointestinal Endoscopy, vol. 94, 5. 2021 May. https://doi.org/10.1016/j.gie.2021.05.014

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

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

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.

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

Gastroparesis is a heterogeneous condition lacking in actionable biomarkers with which to guide treatments. Gastric per oral endoscopic myotomy (G-POEM) has emerged as a promising treatment for refractory gastroparesis, however as many as half of patients can fail to benefit.

Aims & Methods

We assessed the ability of body surface gastric mapping (BSGM) using Gastric Alimetry®, a non-invasive test of gastric function to enhance patient selection for G-POEM. Patients with suspected gastroparesis at Kings College Hospital were recruited (Nov 2022 - Sep 2024). BSGM included 30 m fasting, standard nutrient drink + oatmeal bar (482 kcal), and 4 h postprandial recording. BSGM phenotyping followed an established classification scheme. G-POEM success was defined as <1 point reduction in gastroparesis cardinal symptom index (GCSI) with sensitivity analysis using >50% GCSI improvement. Mixed models accounted for repeated measures.

Results

22 patients completed initial follow-up (median 3.3 months; 77% female; median age 35.5; IQR 21-76). Gastroparesis aetiologies included 9 (41%) diabetic, 12 (55%) idiopathic, and 1 post-surgical. BSGM spectral analysis showed 4 (18.2%) with high frequencies, 3 (13.6%) with neuromuscular dysfunction (low rhythm stability and/or low amplitude), and the remainder had normal spectral metrics (n=15; 68.2%). Symptom profiles had a continuous pattern in 8 (36.4%), meal responsive pattern in 14 (59.1%; of whom 6 had sensorimotor correlation), and a 1 (4%) with a post-gastric pattern. GCSI scores significantly improved after G-POEM (median -0.92; IQR -1.8 to -0.34, p=0.0001) with 11 (50%) experiencing at least a 1 point GCSI reduction, and 7 (31.8%) experiencing >50% GCSI score reduction. Neuromuscular phenotype was associated with treatment success (27.3% vs 0%; and 28.6% vs 6.7% in sensitivity analysis), in keeping with responders having a lower BMI-adjusted amplitude (median 30.3 [IQR 23.1-41.0] vs median 45 [36.5-53.4]; p=0.03). Conversely, the high frequency phenotype was associated with treatment failure (9.1% vs 27.3%; and 0% vs 26.7% in sensitivity analysis). Elevated gastric frequency with comorbid diabetes was associated with higher post-G-POEM GCSI (β = 1.61, 95% CI 0.08 - 3.13, p=0.04) and a lower GCSI change (median -0.3 vs overall GCSI improvement -0.9, p=0.005).

Conclusion

At initial analysis of this ongoing clinical study, Gastric Alimetry demonstrates provisional utility in predicting GPOEM success based on underlying disease mechanisms in patients with refractory gastroparesis. First data suggests biomarkers for diabetic vagal dysregulation (high frequencies) were associated with reduced response to G-POEM, while patients with gastric neuromuscular dysfunction showed clearest benefit. Additional recruitment is ongoing to validate these findings.

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.

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