Preliminary Observations on Peroral Endoscopic Myotomy Using a Super Pulsed Thulium Fiber Laser

Aims 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, has also been reported for POEM [1]. This study aims to evaluate the feasibility and effectiveness of a novel 1920 nm super pulsed thulium fiber laser (POEM-L) in Peroral Endoscopic Myotomy (POEM), comparing it with historical data of POEM performed using diathermy (POEM-D) at our center [2].

Methods We retrospectively analyzed data from the first ten achalasia patients undergoing POEM-L at Haukeland University Hospital between February 2022 and March 2023. The study focused on acute and delayed complications, treatment efficiency using the Eckardt score (ES), and procedural details. This was compared to historical POEM-D data from 84 patients treated between January 2014 and 2019. POEM-L procedures were performed under general anesthesia using a 365 or 550 micron 1920 nm super pulsed thulium fiber laser and a 4.5-7 Fr triple-lumen cannula for fiber stability, with energy settings of 10-30W.

Results Ten patients, 4 males and 6 females, with symptomatic achalasia and Eckardt score≥6 were included. The mean age was 38.5. Based on HRM, two 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 lower esophageal sphincter (LES) was 24.4 mmHg (Range (14.1-45.0 mmHg) before POEM. All ten 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 6-12 months (p<0.001). None of the patients reported post-operative symptoms of daily reflux, while one patient had used PPI regularly before POEM. Patients who underwent POEM-L were hospitalized for mean 1.0 days compared to a mean of 3.2 days after POEM-D (p<0.001). In nine cases, we used the same instrument to complete all steps of the POEM procedure, including mucosal injection and incision, submucosal tunneling, vessel dissection, and myotomy.

Conclusions POEM utilizing a thulium fiber laser appears feasible and potentially non-inferior to POEM-D. Notable advantages include shorter procedure times and hospital stays. While promising, POEM-L requires a learning curve and dedicated instruments. Further studies are necessary to validate these preliminary findings.

Publikationsverlauf

Artikel online veröffentlicht:
15. April 2024

• References

• 1 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
• 2 Liu J.. et al. Preliminary study of 1940 nm thulium laser usage in peroral endoscopic myotomy for achalasia. Dis. Esophagus 2018; 31: 1-6