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

Abstract

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.

Outcomes of Per-Oral Endoscopic Myotomy in the Treatment of Esophageal Achalasia: Over One Hundred Cases in a Single Tertiary Center

“…Adverse events occurred in a total of 26 cases (24.1%), half of which resulted from use of the anterior approach, 13/26 cases (50.0%) and the majority of these (10) occurred in the first 16 cases. A randomized pilot study and a narrative review supported the correlation between anterior myotomy and increased risk of mucosal injuries due to its need for greater scope tip angulation 23,24 , but the majority of findings of randomized clinical trials and systematic reviews have reported comparable outcomes for the two approaches. [25][26][27] In our study, the significant complications from anterior approach might be from early period of learning curve.…”

POEM from A to Z: current perspectives

“…Some procedures such as POEM in achalasia and other EMD are in the first line of treatment for these pathologies and will probably appear as the treatment of choice in the updates to the main clinical guidelines. In achalasia, most of the technical and management aspects are clearly defined, although there are still areas for improvement (51). However, in other pathologies, the possibility of treatment by submucosal endoscopy needs to be defined both at a technical level and positioned in the therapeutic algorithms.…”

“…Later, most groups have shifted to the posterior orientation due to shorter and easier procedures with less inadvertent mucosotomy rate and same clinical success and reflux rate (47-49). Theoretically, any orientation could be performed (50), in fact, a second tunnel with a different orientation is an alternative in patients with submucosal fibrosis found in the initial tunnel (51). Full-thickness myotomy reduces the procedure duration without impairing clinical success nor increasing reflux (52).…”

Precision Endoscopy in Peroral Myotomies for Motility Disorders of the Upper Gastrointestinal Tract: Current Insights and Prospective Avenues—A Comprehensive Review

“…Regarding the depth of myotomy, although full-thickness myotomy was initially believed to have a major positive impact on clinical success, both limited to the inner circular layer and full-thickness have shown similar efficacy and safety [11][12][13]. The latter is preferred at our institution due to its speed.…”