Novel per‐oral endoscopic myotomy method preserving oblique muscle using two penetrating vessels as anatomic landmarks reduces postoperative gastroesophageal reflux

Abstract

Background and AimOne of the main concerns related to peroral endoscopic myotomy (POEM) is postoperative gastroesophageal reflux (GER). The two penetrating vessels (TPVs) that are found at the boundary between the circular and oblique muscles in the posterior cardia wall have been suggested to be a good indicator of the optimal distal extent of POEM. However, the effect of performing myotomy using the TPVs as an anatomical reference on the frequency of post‐POEM GER has not been studied.MethodsThis study involved consecutive patients who underwent POEM for the treatment of achalasia between April 2015 and June 2017. All enrolled patients underwent POEM in the 5 o'clock position and were divided into two groups: the conventional line group (CL group, n = 31), in which the TPVs were not exposed during submucosal tunnel dissection in the cardia, and the TPVs line group (TPVs group, n = 83), in which the TPVs were exposed and gastric myotomy was performed along the right side of the TPVs to preserve the oblique muscle. Examinations for post‐POEM GER were conducted 3 months after the POEM.ResultsThe frequency of grade B or higher reflex esophagitis was 26/83 (31.3%) in the TPVs group and 18/31 (58.1%) in the CL group (P = 0.017). Nine of 83 patients (10.8%) had GER symptoms in the TPVs group, and six of 31 (19.4%) had GER symptoms in the CL group (P = 0.23).ConclusionsThe novel myotomy method preserving oblique muscle using TPVs as anatomical landmarks significantly reduced the frequency of post‐POEM GER.

Gastroesophageal reflux disease after peroral endoscopic myotomy is unpredictable, but responsive to proton pump inhibitor therapy: a large, single-center study

“…Similarly, a high BMI was not associated with an increased incidence of post-POEM GERD in a recent study [25]. More recently, Tanaka and colleagues evaluated a novel technique for POEM to preserve the oblique muscle fibers and prevent GERD [26]. Reflux esophagitis of grade B and higher severity was significantly less frequent in the group treated with the new technique (31.3 % vs. 58.1 %; P = 0.02).…”

Intraoperative high-resolution esophageal manometry during peroral endoscopic myotomy

“…Although intraoperative HRM could theoretically help in guiding the length of the myotomy in patients with type III achalasia, the absence of esophageal contractions under general anesthesia precludes this use of intraoperative HRM. Furthermore, the higher frequency of GERD symptoms in patients with an extended myotomy calls into question the part of the stomach where the gastric myotomy should be best extended 15 .…”

Peroral endoscopic myotomy with simultaneous submucosal and muscle dissection in spastic esophageal disorder

“…3). Submucosal tunneling was continued until two penetrating vessels were seen, indicating the distal end of the POEM [4,5], and the endoscopic myotomy was completed once the pene-trating vessels were reached. A standard endoscope was then passed smoothly through into the stomach.…”