Peroral endoscopic myotomy for advanced achalasia with sigmoid-shaped esophagus: long-term outcomes from a prospective, single-center study

Abstract

The 2-year outcomes of POEM for advanced achalasia with sigmoid-shaped esophagus were excellent, resulting in long-term symptom relief in over 96% cases and without serious complications. The morphological changes of esophagus may make subsequent endoscopic tunneling more challenging and time-consuming, but do not prevent successful POEM.

Peroral Endoscopic Myotomy for Treating Achalasia and Esophageal Motility Disorders

“…19,36,[38][39][40][41][42] Most of these series demonstrated a sustained clinical success of POEM in > 90% of patients, with the follow-up duration ranging from 12 months to > 36 months. 19,36,[38][39][40][41][42] However, one international prospective multicenter study showed some decline in clinical success over time. 39 Von Renteln et al 39 demonstrated a 97% treatment success at 3 months, 88.5% at 6 months, and 82.4% at 12 months, which significantly declined from the initial treatment success.…”

“…17 In our experience, the deepest possible submucosal tunneling could help maintain the correct aboral direction of the submucosal tunnel by ensuring the direction to be perpendicular to the circular muscle fibers. Although some experts reported good feasibility and efficacy of POEM even in these advanced patients, 8,40 these cases seem to be particularly challenging and should be performed only by highly experienced operators.…”

Peroral endoscopic myotomy (POEM) for treating esophageal motility disorders

“…The mucosal injury rate was fairly high at 37.5%. Some technical advices suggested by the author included: (I) to design a straight path for submucosal tunnelling, e.g., posterior wall of esophagus along the spine; (II) to navigate in the tunnel perpendicular to circular muscle layer; (III) to expect a higher mucosal perforation rate because of fibrosis and limited space within the tunnel; (IV) POEM for sigmoidal esophagus should be performed in expert centers (18).…”

“…This path may have different flow-dynamics to reduce the amount of reflux during gastric contraction; the line of myotomy goes along the spine and provides a straighter submucosal tunnel in sigmoidal esophagus. In patients with previous anterior myotomy, it can provide a virgin plane (8,9,18,19). There is not enough evidence to recommend one over the other, currently it depends on endoscopists' preference, except in re-do patients to avoid previous site of myotomy.…”

“…Attempting to preserve the thin longitudinal muscle fibre may cause incomplete circular myotomy. The procedure is also considered to be simpler and faster (18). A retrospective study comparing the outcomes of full-thickness and circular muscle myotomy showed the mean operative time was significantly shorter in the full-thickness group and there was no increase in procedural related adverse event (28).…”