Peroral endoscopic myotomy (POEM) is effective in treatment of noncardiac chest pain caused by hypercontractile esophageal motility disorders: results of the POEM-HYPE-Study

Abstract

Background Noncardiac chest pain (NCCP) is recurrent angina pectoris-like pain without evidence of coronary heart disease in conventional diagnostic evaluation. In gastroenterology, managing of patients with NCCP is ambiguous to detect gastroesophageal reflux and hypercontractile esophageal motility disorders. Recently, peroral endoscopic myotomy (POEM) was established as treatment option in achalasia. However, limited data exist on the effectivity of POEM in NCCP with hypercontractile esophageal motility disorders. Material and methods In this prospective study (POEM-HYPE), we evaluated 14 patients with NCCP and hypercontractile esophageal motility disorders (type III achalasia, n = 7; hypercontractile esophagus, n = 6; distal esophageal spasm, n = 1). All patients underwent standardized diagnostic work-up including esophagogastroduodenoscopy with esophageal biopsies, high-resolution esophageal manometry, and combined intraluminal impedance and pH testing before and 3 weeks after POEM. A standardized symptom questionnaire was disposed before POEM, 3 weeks after, and every 6 months after the POEM. Results After POEM, 12 patients showed significant symptom relief (pre-Eckardt score: 7.78 ± 1.47, 3 weeks post: 1.64 ± 1.44, 6 months: 2.0 ± 1.84 and 1.86 ± 1.89 after 15.0 ± 10.0 months post-intervention). High-resolution manometry showed significant reduction in integrated relaxation pressure (pre-POEM: 24.74 ± 18.9 mm Hg, post-POEM: 13.8 ± 16.5 mm Hg) and distal contractile integral (pre-POEM: 2880 ± 3700 mmHg*s*cm, post-POEM: 1109 ± 1042 mmHg*s*cm). One lesion of the submucosal tunnel occurred as a moderate adverse event and was handled endoscopically. The long-term clinical success rate was 85.7 %. No severe gastroesophageal reflux occurred after interventions. Two patients required secondary therapy with injection of botulinum toxin in the tubular esophagus and balloon dilation. Conclusion The results suggest that POEM is an effective and safe therapeutic option for patients with NCCP and hypercontractile esophageal motility disorders.

Jackhammer esophagus: A meta‐analysis of patient demographics, disease presentation, high‐resolution manometry data, and treatment outcomes

“…Interestingly, POEM seemed to be beneficial in JE patients with and without concomitant EGJOO. [49][50][51]53 While POEM seemed superior to medical treatment, emerging studies on JE, certain clinical or manometric data, such as IRP, may become relevant as predictors of disease outcomes and may therefore serve as indicators as to whether and how aggressively patients should be treated.…”

“…The pooled clinical success rate of POEM specifically was 82.3% [95% CI: 75.0%-89.7%; Cochran's Q = 0.9, I 2 = 0%]. 25,[49][50][51]53 This was also significantly superior to medical treatment (P = .004).…”

Achalasie und Ösophagusmotilitätsstörungen

“…In einer kleinen Fallserie aus Deutschland wurden 14 Patienten mit nicht kardialen Brustschmerzen, denen eine hyperkontraktile Ösophagusstörung zugrunde lag, mit POEM behandelt. 12 der 14 Patienten (87,5 %) waren im Verlauf anhaltend beschwerdegebessert [36]. Prospektive Langzeitstudien fehlen derzeit, weshalb diese Patientengruppen nur im Rahmen von klinischen Studien mit POEM behandelt werden sollten.…”

Minimally invasive surgery for non-achalasia primary esophageal motility disorders is currently underused

“…There are no studies on Heller's myotomy for distal esophageal spasm (previously diffuse spasm) based on the new classification. Some case reports of POEM for distal spasm have been reported [7][8][9] with multicenter studies encompassing a larger number of patients but always inferior to 20 in total [10] . Experience with the method is too short to draw conclusions.…”