Difficult peroral endoscopic myotomy: definition and management strategies

Tan, Yuyong; Li, Chen; Yan, Jin; Long, Ling; Huo, Jirong; Liu, Deliang

doi:10.1080/17474124.2019.1674648

Cited by 9 publications

(7 citation statements)

References 87 publications

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“…It is well known that prior treatment may induce submucosal fibrosis, increasing the technical difficulty of subsequent myotomy and thus increasing the time of surgery and the risk of severe AEs. For the patient with treatment history, we performed an opposite myotomy avoiding the previous myotomy site or cutting the fibrotic tissue; details have been elaborated in our earlier research ( 33 ). In the present study, two patients who received prior treatment had significant symptoms of remission and reduced LES pressure after performing POEM and were satisfied with their life quality at present.…”

Section: Discussionmentioning

confidence: 99%

Peroral Endoscopic Myotomy for Pediatric Achalasia: A Retrospective Analysis of 21 Cases With a Minimum Follow-Up of 5 Years

Peng

Tan

et al. 2022

Front. Pediatr.

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BackgroundPeroral endoscopic myotomy (POEM) has shown promising short-term safety and efficacy in pediatric patients, while long-term outcomes are largely unknown. This study aimed to assess the clinical effects of POEM for pediatric achalasia who had a follow-up of at least 5 years.MethodsPediatric patients from a single center who underwent a POEM between October 2011 and November 2016 were, respectively, collected and analyzed for long-term clinical outcomes. Patients were contacted to evaluate their current symptoms and encouraged repeat endoscopy and manometry. The clinical success, procedure-related parameters, adverse events, gastroesophageal reflux disease after POEM, and quality of life were evaluated.ResultsA total of twenty-four patients who underwent POEM in our center were studied, with a mean age of 14.42 ± 2.65. Two of the 24 patients (8.3%) had previous treatment. The mean of the procedure time was 58.67 ± 19.10 min, 8.3% (2/24) of patients experienced perioperative adverse events. The current symptom scores were obtained from 21 patients at a mean follow-up of 92.57 months, the remainder were lost to follow-up after a mean of 38 months. Eckardt scores were significantly improved from preoperative baseline (preoperative 7.67 ± 1.62 vs. current 0.86 ± 1.28, P < 0.001). Long-term overall success was achieved in 95.8% of patients and none required retreatment for symptoms. 12.5% of patients were suffered from clinical reflux. 76.2% of patients expressed satisfaction with POEM. No severe adverse events were observed during the operation and the 5-years follow-up.ConclusionPOEM resulted in successful symptomatic mitigation in a majority of pediatric patients after 5 years. A multi-center large-scale, prospective study is necessary for a confirmed conclusion.

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Section: Discussionmentioning

confidence: 99%

Peroral Endoscopic Myotomy for Pediatric Achalasia: A Retrospective Analysis of 21 Cases With a Minimum Follow-Up of 5 Years

Peng

Tan

et al. 2022

Front. Pediatr.

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“…In cases with advanced sigmoid achalasia, it may be difficult to maintain orientation during submucosal tunneling mainly attributable to the tortuosity of the esophagus. Several techniques have been reported to circumvent the issue of losing orientation during POEM and including fluoroscopy-guided POEM, use of guidewire, double-scope method, and open POEM technique (49)(50)(51). These techniques have been described in case reports and small case series and, therefore, utilized as a "last-ditch effort" in difficult POEM cases.…”

Section: Peroral Endoscopic Myotomy In Difficult Casesmentioning

confidence: 99%

Impact of modified techniques on outcomes of peroral endoscopic myotomy: A narrative review

Nabi

Reddy

2022

Front. Med.

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Peroral endoscopic myotomy (POEM) is an established frontline treatment modality for achalasia cardia. Since its initial description, several modifications have been proposed to the technique of POEM. Broadly speaking, these modifications follow the basic principles of submucosal endoscopy, but incorporate variations in the POEM technique, including the difference in the orientation of myotomy (anterior or posterior), length of myotomy (short or long), and thickness of myotomy (selective circular or full thickness). Some of these modifications have been shown to reduce procedural duration without compromising the efficacy of the POEM procedure. More recently, several alterations have been reported that intend to reduce gastroesophageal reflux after POEM. These include preservation of sling fibers during posterior POEM and addition of NOTES fundoplication to the POEM procedure. Although some of the modified techniques have been compared with the conventional techniques in quality trials, randomized studies are awaited for others. The incorporation of some of these modifications will likely make POEM a technically easy and safer modality in near future. This review aims to discuss the current evidence with regard to the impact of modified techniques on the outcome of POEM.

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“…Various authors have defined difficult POEM as that requiring prolonged procedure time ( > 90 min), the occurrence of major intraoperative adverse events, or even aborted POEM procedures owing to the morphological or pathophysiological changes of the esophagus. [54][55][56] Risk factors that can predict difficult POEM include operator's experience, institutional experience <1 year, air insufflation, submucosal fibrosis, sigmoid esophagus, previous treatment with either pneumatic balloon dilatation, LHM or POEM. [57][58][59][60] Recently, a POEM difficulty score was developed in which the presence of type III achalasia, history of previous myotomy, > 4 previous treatment, and sigmoid-type esophagus were associated with increasing difficulty of POEM.…”

Section: Poem In Complex Achalasia With Technical Difficultymentioning

confidence: 99%

“…It leads to difficulty in lifting the mucosa, entering the submucosal tunnel as well as increasing the risk of inadvertent mucosal injury. 56 Various modifications of POEM in presence of significant submucosal fibrosis include making tunnel away from the area of submucosal fibrosis and doing tunnel free or open POEM (concurrent tunneling and myotomy). [62][63][64][65] The sigmoid esophagus increases the technical difficulty, risk of intraprocedural adverse events, and risk of submucosal fibrosis.…”

Section: Poem In Complex Achalasia With Technical Difficultymentioning

confidence: 99%

Per-oral Endoscopic Myotomy and Other Applications of Third Space Endoscopy: Current Status and Future Perspectives

Mandavdhare

Mishra

Kumar

et al. 2021

Surgical Laparoscopy, Endoscopy &Amp; Percutaneous Techniques

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Introduction:The modification of NOTES (natural orifice transluminal endoscopic surgery) by mucosal safety flap has introduced us to the world of third space endoscopy (TSE). POEM (per-oral endoscopic myotomy) for achalasia cardia being its first vista, the realm expanded so that we can now remove en bloc a subepithelial/ intramural tumor by POET (per-oral endoscopic tumor resection), perform G-POEM (gastric per-oral endoscopic myotomy) for refractory gastroparesis, restore esophageal continuity in complete obstruction by performing POETRE (per-oral endoscopic tunneling for the restoration of the esophagus), divide the septum in Zenker diverticulum completely with negligible risk of perforation by Z-POEM (Zenker per-oral endoscopic myotomy) and relieve constipation in Hirschsprung disease by PREM (per-rectal endoscopic myotomy). However, the real potential of TSE became evident with the introduction of POEM with fundoplication. TSE has opened the gates of the peritoneal cavity. Improved expertise and equipment will make the role of endoscopist complimentary to the surgeon with the dawn of a new field in therapeutic endoscopy.Areas Covered: This review intends to comprehensively discuss the various aspects of POEM for achalasia studied so far followed by a brief discussion about other applications of TSE and the future perspectives in this exciting field.

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Difficult peroral endoscopic myotomy: definition and management strategies

Cited by 9 publications

References 87 publications

Peroral Endoscopic Myotomy for Pediatric Achalasia: A Retrospective Analysis of 21 Cases With a Minimum Follow-Up of 5 Years

Peroral Endoscopic Myotomy for Pediatric Achalasia: A Retrospective Analysis of 21 Cases With a Minimum Follow-Up of 5 Years

Impact of modified techniques on outcomes of peroral endoscopic myotomy: A narrative review

Per-oral Endoscopic Myotomy and Other Applications of Third Space Endoscopy: Current Status and Future Perspectives

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