Background and study aims  The efficacy of per oral endoscopic myotomy (POEM) in non-achalasia esophageal motility disorders such as esophagogastric junction outflow obstruction (EGJOO), diffuse esophageal spasm (DES), and jackhammer esophagus (JE) has not been well demonstrated. The aim of this international multicenter study was to assess clinical outcomes of POEM in patients with non-achalasia disorders, namely DES, JE, and EGJOO, in a large cohort of patients. Patients and methods  This was a retrospective study at 11 centers. Consecutive patients who underwent POEM for EGJOO, DES, or JE between 1/2014 and 9/2016 were included. Rates of technical success (completion of myotomy), clinical response (symptom improvement/Eckardt score ≤ 3), and adverse events (AEs, severity per ASGE lexicon) were ascertained . Results  Fifty patients (56 % female; mean age 61.7 years) underwent POEM for EGJOO (n = 15), DES (n = 17), and JE (n = 18). The majority of patients (68 %) were treatment-naïve. Technical success was achieved in all patients with a mean procedural time of 88.4 ± 44.7 min. Mean total myotomy length was 15.1 ± 4.7 cm. Chest pain improved in 88.9 % of EGJOO and 87.0 % of DES/JE ( P  = 0.88). Clinical success was achieved in 93.3 % of EGJOO and in 84.9 % of DES/JE ( P  = 0.41) with a median follow-up of 195 and 272 days, respectively. Mean Eckardt score decreased from 6.2 to 1.0 in EGJOO ( P  < 0.001) and from 6.9 to 1.9 in DES/JE ( P  < 0.001). A total of 9 (18 %) AEs occurred and were rated as mild in 55.6 % and moderate in 44.4 %. Conclusion  POEM is effective and safe in management of non-achalasia esophageal motility disorders, which include DES, JE, and EGJOO.

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Background Automated impedance manometry pressure‐flow analysis (AIM analysis) determines pressure measurements relative to bolus flow and has to date shown subtle variations in esophageal motility in relation to dysphagia. In this study, we assessed intra‐ and inter‐rater reproducibility of AIM metrics derived using purpose designed software. Methods Fifty patients referred for evaluation of gastro‐esophageal reflux symptoms (33 men, age 52 ± 1.9 years) underwent combined high‐resolution impedance manometry and completed a dysphagia questionnaire. From 10 liquid and 10 viscous swallows, a subset of four swallows (two saline and two viscous) was systematically selected from each patient for manual and AIMplot analysis, which was performed twice by five observers (two experts, three non‐experts). Intra‐ and inter‐rater agreement were determined using intraclass correlation coefficients. Key Results AIMplot‐based analysis showed high intra‐rater and inter‐rater reproducibility for all metrics (mean ICCs of 0.95 and 0.94, respectively). Reproducibility of metrics derived for liquid and viscous did not differ (ICCs of 0.96 and 0.91 for liquid and viscous, respectively). In addition, metrics derived by experts had an equivalent level of reproducibility compared to non‐experts (ICCs of 0.96 and 0.94, respectively). Variables that could be derived with commercial software (ManoView™) correlated highly with variables from AIMplot‐based analysis, such as 4‐s integrated relaxation pressure (r = 0.85) and the 20‐mmHg isobaric contour defect (r = 0.92). Conclusions & Inferences Esophageal AIM analysis is highly reproducible, independent of an observer's level of experience in esophageal motility. Therefore, AIM analysis produces data that are reliable for clinical and research purposes.

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Background and Aims: Although Peroral Endoscopic Myotomy (POEM) is highly effective for the management of achalasia, clinical failures may occur. The optimal management of patients who fail POEM is not well known. This study aims to compare the outcomes of different management strategies in patients who had failed POEM. Patients and Methods: This is an international, multicenter, retrospective study at 16 tertiary centers between 1/2012 and 11/2019. All patients who underwent POEM and experienced persistent or recurrent symptoms (Eckardt score (ES) > 3) were included. The primary outcome was to compare the rate of clinical success (ES ≤ 3) between different management strategies. Results: A total of 99 patients (50 (50.5%) males, mean age 51.4 (16.2) yrs.) experienced clinical failure during the study period with a mean ES of 5.5 (0.2). A total of 29 (32.2%) patients were managed conservatively and 70 (71%) underwent re-treatment [repeat POEM 33 (33%), pneumatic dilation (PD) 30 (30%), and laparoscopic Heller myotomy (LHM) 7 (7.1%)]. During a median follow-up of 10 (IQR: 3-20) months, clinical success was highest in patients who underwent repeat POEM (25/33 (76%), mean ES 2.1 (2.1)), followed by PD (18/30 (60%), mean ES 2.8 (2.3)), and LHM (2/7 (29%), 4 (1.8)) (p=0.12). A total of 11 (37.9%, mean ES 4 (1.8)) patients in the conservative achieved clinical success. Conclusion: This study comprehensively assessed an international cohort of patients who underwent management of failed POEM. Repeat POEM and PD achieved acceptable clinical success with excellent safety profile.