Feasibility of the peroral endoscopic myotomy (POEM) procedure with a new small-caliber endoscope (thin-POEM) in patients with achalasia
submitted 12 May 2018
accepted after revision 10 October 2018
10 January 2019 (online)
Background Peroral endoscopic myotomy (POEM) is a recognized technique for patients with achalasia. We aimed to evaluate the feasibility of using a small-caliber endoscope (thin-POEM) to perform POEM in patients with achalasia.
Methods Naïve or previously treated patients were included between February 2016 and April 2018. A small-caliber (5.9 mm) nasoendoscope was used, with a modified closure method using cyanoacrylate. Strict follow-up was performed.
Results 45 patients were included, aged 45.5 years (interquartile range [IQR] 22 – 69); 53 % (24/45) had type II achalasia. Median total time for thin-POEM was 54 minutes (IQR 37 – 77) and median myotomy length was 13.5 cm (IQR 6 – 20). Results pre-procedure and 3 months post were Eckardt score 10 vs. 1 (P < 0.001), integrated relaxation pressure (IRP) 25.3 vs. 8.5 mmHg (P < 0.001), and timed barium esophagram (TBE) 100 % severely delayed vs. 86 % normal (P < 0.001), respectively. Type III patients had the longest thin-POEM times (median 58 minutes [IQR 52 – 77]). Reflux was confirmed at 3 months clinically in 17 % of patients, endoscopically in 20 %, and on pH monitoring in 53 %. At 6 months and 12 months, 40 % and 33 % of patients remained positive on pH monitoring and were medically managed.
Conclusions Thin-POEM seems to be a safe, effective, and efficient procedure for POEM in patients with achalasia, with good short-term follow-up results.
- 1 Kroch DA, Grimm IS. POEM for achalasia. Am Surg 2018; 84: 489-495
- 2 Grimes KL, Inoue H. Per oral endoscopic myotomy for achalasia. a detailed description of the technique and review of the literature. Thorac Surg Clin 2016; 26: 147-162
- 3 Li QL, Wu QN, Zhang XC. et al. Outcomes of per-oral endoscopic myotomy for treatment of esophageal achalasia with a median follow-up of 49 months. Gastrointest Endosc 2018; 87: 1405-1412
- 4 Chiu PWY, Inoue H, Rösch T. From POEM to POET : Applications and perspectives for submucosal tunnel endoscopy. Endoscopy 2016; 48: 1134-1142
- 5 Akintoye E, Kumar N, Obatian I. et al. Peroral endoscopic myotomy: a meta-analysis. Endoscopy 2016; 48: 1059-1068
- 6 Werner YB, Rösch T. POEM and submucosal tunneling. Curr Treat Options Gastroenterol 2016; 14: 163-167
- 7 Kahrilas PJ, Bredenoord AJ, Fox M. et al. The Chicago Classification of esophageal motility disorders, v3.0.. Neurogastroenterol Motil 2015; 27: 160-174
- 8 Rezende JM. Classificação radiológica do megaesôfago. Rev Goiana Med 1982; 28: 187-191
- 9 Eckardt VM, Aignherr C, Bernhard G. Predictors of outcome in patients with achalasia treated by pneumatic dilation. Gastroenterology 1992; 103: 1732-1738
- 10 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
- 11 Schlottmann F, Patti MG. Laparoscopic Heller myotomy versus per oral endoscopic myotomy: evidence-based approach to the treatment of esophageal achalasia. Am Surg 2018; 84: 496-500
- 12 Hernandez Mondragon OV, Solorzano Pineda O, Blanco Velasco G. et al. Use of cyanoacrylate to treat mucosal perforation during or after peroral endoscopic myotomy. Endoscopy 2016; 48: E330-E331
- 13 Hernandez Mondragon OV, Gonzalez Martinez MA, Blancas Valencia JM. et al. Long-term quality of life after peroral endoscopic myotomy remains compromised in patients with achalasia type III. Endoscopy 2017; 49: 1209-1218
- 14 Haito-Chavez Y, Inoue H, Beard KW. et al. Comprehensive analysis of adverse events associated with per oral endoscopic myotomy in 1826 patients: an international multicenter study. Am J Gastroenterol 2017; 112: 1267-1276
- 15 Repici A, Fuccio L, Maselli R. et al. GERD after per-oral endoscopic myotomy as compared with Heller´s myotomy with funduplication: a systematic review with meta-analysis. Gastrointest Endosc 2018; 87: 934-943