Efficacy of anterior versus posterior per-oral endoscopic myotomy for treating achalasia: a randomized, prospective study

Tan, Yuyong; Lv, Liang; Wang, Xuehong; Zhu, Hongyi; Chu, Yi; Luo, Min; Li, Chenjie; Zhou, Hao; Huo, Jirong; Liu, Deliang

doi:10.1016/j.gie.2018.03.009

Cited by 70 publications

(41 citation statements)

References 32 publications

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“…Alternatively, the posterior approach (5 to 6 o'clock position) carries a lower risk of bleeding as it avoids the branches of the left gastric artery during submucosal tunneling and myotomy. Despite limited prior evidence supporting the above hypotheses [9,10], results from our initial RCT [7] did not provide support for these assumptions. The rate of GERD measured by abnormal acid exposure, GERDQ score, and PPI use, as well as the rate of adverse events (including bleeding) were not significantly different between the two groups.…”

Section: Discussionmentioning

confidence: 70%

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Outcomes of anterior versus posterior peroral endoscopic myotomy 2 years post-procedure: prospective follow-up results from a randomized clinical trial

et al. 2020

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Background Peroral endoscopic myotomy (POEM) is considered a primary treatment modality for achalasia. It can be performed using either the anterior or posterior approach. A previous randomized clinical trial (RCT) showed that the posterior approach was noninferior to the anterior approach at 1 year post-POEM in terms of clinical success, rate of adverse event, and risk of gastroesophageal reflux disease (GERD). The aim of this post-RCT study was to compare outcomes at ≥ 2 years post-POEM. Methods Patients who previously completed the 1-year follow-up were contacted and their Eckardt, dysphagia, and GERD questionnaire (GERDQ) scores and frequency of proton pump inhibitor use were recorded. Clinical success was defined as an Eckardt score < 3. Results 150 patients were initially randomized and 138 completed the 1-year follow-up. Of the 138, 111 (anterior group 54, posterior group 57) also completed ≥ 2 years of follow-up, with an overall clinical success decrease from 89 % to 82 %. At ≥ 2 years post-POEM, clinical success was achieved in 46/54 (85 %) and 45/57 (79 %) in the anterior and posterior groups, respectively (P = 0.43). A similar decrease in clinical success was noted in both groups at ≥ 2 years (anterior: 90 % to 85 %; posterior 89 % to 79 %; P = 0.47). GERDQ score was 6 (interquartile range 6 – 8; P = 0.08) in both treatment groups. Conclusions The anterior and posterior POEM techniques remained equally effective at 2 years and decreases in efficacy were similar between the two approaches over time. GERD outcomes were also similar in both groups during medium-term follow-up.

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Section: Discussionmentioning

confidence: 70%

“…Available comparative outcome data between the anterior and posterior techniques are limited to three randomized trials with a follow-up time of up to 1 year post-POEM [7,9,10]. Overall, clinical efficacy is believed to be equivalent during shortterm follow-up.…”

Section: Discussionmentioning

confidence: 99%

Outcomes of anterior versus posterior peroral endoscopic myotomy 2 years post-procedure: prospective follow-up results from a randomized clinical trial

et al. 2020

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“…Allerdings sollte aus Sicherheitsgründen in der oberen Speiseröhre, oberhalb der Trachealbifurkation, kein anteriores POEM durchgeführt werden, wegen der Kolokalisation der Pars membranacea der Trachea. Zwei kleine randomisierte Studien haben die Ergebnisse nach anteriorem und posteriorem POEM untersucht [29,30]. In einer Arbeit wurde eine etwas erhöhte Rate der Mukosaläsionen nach anteriorem POEM und eine etwas erhöhte Refluxrate nach posteriorem POEM berichtet [30].…”

Section: Technische Aspekte Poemunclassified

Aktuelle Therapie der Achalasie 2019

Rahden

2019

Zentralbl Chir

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ZusammenfassungDie Therapie der primär idiopathischen Achalasie, der häufigsten der seltenen Ösophagusmotilitätsstörungen, unterliegt derzeit einem Wandel. Zunehmend setzt sich das Prinzip der „Heller-Myotomie“ als Standard durch. Mit der von dem deutschen Chirurgen Ernst Heller im Jahr 1913 erstbeschriebenen Kardiomyotomie lässt sich meist eine sehr gute Symptomkontrolle erzielen. Metaanalysen randomisierter Studien (Level-1A-Evidenz) zeigen die Überlegenheit der laparoskopischen Heller-Myotomie (LHM) gegenüber der pneumatischen Dilatation (PD). Protagonisten der PD beziehen sich zumeist auf die Ergebnisse der europäischen Multicenterstudie, die mit häufig wiederholten PD vergleichbare Ergebnisse wie die LHM erzielt hat, mit allerdings einer (nicht Intention-to-treat inkludierten) initialen PD-Serie mit inakzeptabel hoher Perforationsrate (33%). Zur Prävention eines postoperativen gastroösophagealen Refluxes (GER) nach LHM ist die Hinzunahme einer Fundoplicatio obligat. Die Manschette der Wahl ist die anteriore 180°-Fundoplicatio nach Dor. Allerdings wird dieser Standard (LHM + Dor-Prozedur) nun bereits wieder herausgefordert. Die 2010 durch Haruhiro Inoue eingeführte und seither weltweit klinisch erprobte perorale endoskopische Myotomie (POEM) ermöglicht die Durchführung der „Heller-Myotomie“ auf rein endoskopischem Wege. Die Komplikationsraten von POEM sind gering, die Symptomkontrolle ist in systematischen Reviews der publizierten Serien zur LHM vergleichbar oder sogar diskret überlegen. Vorteile der POEM sind u. a. die Möglichkeit, eine lange Myotomie (erforderlichenfalls des gesamten Ösophagus) durchzuführen und die relativ freie Wählbarkeit der Lokalisation der Myotomie (anteriores/posteriores POEM). Nachteile von POEM sind die bewiesen höhere postoperative Refluxrate nach POEM im Vergleich zur LHM, bei allerdings meist guter Behandelbarkeit des Refluxes mit PPI, erforderlichenfalls (selten) nachträglicher laparoskopischer Dor-Fundoplicatio. (Vorläufige) Ergebnisse von 2 prospektiv randomisierten Studien zeigen die Überlegenheit der POEM gegenüber der PD und Gleichwertigkeit der POEM zu LHM + Dor-Prozedur, bei erhöhtem GER. Im eigenen Vorgehen werden POEM und LHM in einem „Tailored Approach“ (maßgeschneidert) verwendet: POEM wird bevorzugt bei Typ III und Typ II mit Brustschmerzen, LHM bei sigmoidaler Achalasie und morphologischen Begleitveränderungen (Hernie, Divertikel etc.), ansonsten liberalere Verfahrenswahl.

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“…24 Although initially it was thought that anterior approach of POEM would cause less GERD as compared to the posterior approach, a recent trial has shown similar rates of GERD with both approaches; the authors advocated preservation of sling fibers by going toward right of the perforators encountered on the gastric side. 25 Finally, the long-term effect of GERD in the form peptic stricture and Barrett's esophagus remains a concern as a few case reports have shown. [26][27][28]…”

Section: Long-term Adverse Events Specific To Per Oral Endoscopic Myomentioning

confidence: 99%

“An Odyssey of Third Space Endoscopy”—from Entry into the Tunnel to Entry into the Peritoneal Cavity

Mandavdhare

Mishra

Samanta

et al. 2019

Journal of Digestive Endoscopy

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The last decade has seen the growth of a completely new and exciting entity called the third space endoscopy (TSE) that has brought about a paradigm shift in the way we manage various disorders of the gastrointestinal tract. The journey started with per oral endoscopic myotomy (POEM) for achalasia cardia and within a decade the concept has been exploited to its best potential for disorders including submucosal tumor resection, pyloromyotomy for gastroparesis, complete division of septum without the risk of perforation in diverticular diseases of esophagus, restoration of esophageal lumen in long strictures, restoration of bowel movement in Hirschsprung's disease, and then taking the concept to the next level of pure NOTES (natural orifice transluminal endoscopic surgery) by entering the peritoneal cavity and performing fundoplication. This review will discuss the history of TSE with brief discussion about the various applications and what has been achieved till present. AbstractKeywords ► third space ► per oral endoscopic myotomyfundoplication ► robotic ► endoscopy

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Efficacy of anterior versus posterior per-oral endoscopic myotomy for treating achalasia: a randomized, prospective study

Cited by 70 publications

References 32 publications

Outcomes of anterior versus posterior peroral endoscopic myotomy 2 years post-procedure: prospective follow-up results from a randomized clinical trial

Outcomes of anterior versus posterior peroral endoscopic myotomy 2 years post-procedure: prospective follow-up results from a randomized clinical trial

Aktuelle Therapie der Achalasie 2019

“An Odyssey of Third Space Endoscopy”—from Entry into the Tunnel to Entry into the Peritoneal Cavity

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