A staged approach to submucosal tunnel entry during per-oral endoscopic myotomy.
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ABSTRACT:
SUBMITTER: Suarez AL
PROVIDER: S-EPMC5990344 | biostudies-literature | 2016 Dec
REPOSITORIES: biostudies-literature
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A staged approach to submucosal tunnel entry during per-oral endoscopic myotomy.
Suarez Alejandro L AL Shetty Akshay A Bosshardt Charles C Elmunzer B Joseph BJ
VideoGIE : an official video journal of the American Society for Gastrointestinal Endoscopy 20161008 4
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Project description:IntroductionPeroral endoscopic myotomy (POEM) is the standard treatment for achalasia. Functional luminal imaging probe (FLIP) technology enables objective measurement of lower esophageal sphincter (LES) geometry, with literature linking specific values to improved post-POEM outcomes. Our study assesses FLIP's intraoperative use in evaluating myotomy extent in real-time.MethodsRetrospective data from all patients undergoing POEM with intraoperative FLIP measurements were extracted from June 2020 to January 2023. The primary endpoint was intraoperative FLIP measurements, management changes, and symptom improvement (Eckardt score).ResultsFourteen patients (age 56 ± 14 years, BMI 28 ± 7 kg/m2) were identified. Most patients were female (64%). Predominantly, patients presented with type II achalasia (50%). FLIP measurements were taken before and after myotomy, demonstrating increases in mean distensibility index (DI) 1.6 ± 1. 4 to 5.4 ± 2.1 mm2/mmHg (p < 0.05) and mean diameter (Dmin) 6 ± 1.8 to 10.9 ± 2.3 mm (p < 0.05) at 50 ml balloon fill. Additional myotomy was performed in one patient when an inadequate increase in FLIP values were noted. Mean operative time was 98 ± 28 min, and there were no intraoperative complications. At the 30-day follow-up, median Eckardt score decreased from mean a preoperative score of 7 ± 2 to a post-operative mean of 2 ± 3, with 10 patients (78%) having a score ≤ 2. In total, four patients experienced symptom recurrence, with repeat FLIP values revealing a significant decrease in DI from 7 ± 2.2 post-POEM to 2.5 ± 1.5 at recurrence. FLIP technology identified LES pathology in 3 out of 4 (75%) patients, facilitating referral to LES-directed therapy.ConclusionOur study adds to the literature supporting the use of FLIP technology during the POEM procedure, with most patients achieving ideal values after a standard-length myotomy. This suggests the potential benefits of shorter myotomies guided by FLIP to achieve comparable outcomes and reduce postoperative GERD risk. Collaborative standardization of study designs and outcome measures is crucial for facilitating prospective trials and cross-setting outcome comparisons.
| S-EPMC11362179 | biostudies-literature
Project description: Not available
| S-EPMC6492919 | biostudies-literature
Project description:Background and aimsCurrent devices used for per-oral endoscopic myotomy (POEM) function predominantly to either cut tissue or coagulate vessels. When bleeding vessels are encountered within the submucosa or muscle, dedicated coagulation grasping devices are often necessary. An endoscopic "hot" scissor-type knife is available that combines coagulation and cutting functions. Scissor-type knives may therefore be helpful during the POEM procedure.MethodsWe report 4 cases of achalasia that were treated by the POEM procedure using the Stag Beetle scissor-type knife for myotomy. Patients were identified from a prospectively maintained database of patients undergoing POEM at our center between September and October 2017. A single operator (K.J.C.) performed all of the procedures using both a hybrid knife and an SB knife. Demographic and clinical data were collected for all patients.ResultsAll 4 POEM procedures were performed successfully without any adverse events. Only 3 spontaneous bleeding episodes occurred among the 4 procedures, and no perforation occurred. The patients were all doing very well at clinic follow-up at 4 weeks.ConclusionsThe technique of using the SB knife during myotomy during the POEM procedure is feasible and appears safe. Muscle tissue and blood vessels can be coagulated and cut simultaneously, reducing bleeding and improving control. Further comparative studies are warranted to evaluate the efficacy, safety, and cost effectiveness against existing techniques.
| S-EPMC6470349 | biostudies-literature
Project description:Background and study aims Both Heller myotomy (HM) and per-oral endoscopic myotomy (POEM) are efficacious therapies for achalasia. The efficacy and safety of POEM vs HM in Latin America and specifically in patients with Chagas disease is unknown. Patients and methods Consecutive patients undergoing either HM or POEM for achalasia were included from nine Latin American centers in a prospective registry over 5 years. Technical success was defined as undergoing a successful myotomy. Clinical success was defined as achieving an Eckardt score < 3. Data on demographics, procedure info, Eckardt score, and adverse events (AEs) were collected. Student's t test, Chi squared, and logistic regression analyses were conducted. Results One hundred thirty-three patients were included (59 male; 44 %; mean age 47). POEM was performed in 69 patients, HM in 64 patients. A total of 35 patients had Chagas disease, 17 of 69 in the POEM group, 18 of 64 in the HM group. Both groups had significant reduction in Eckardt scores ( P < 0.00001), but successful initial therapy was significantly higher in the POEM group compared to the HM group ( P = 0.01304). AEs were similar in both group (17 % vs 14 %) and consisted of pneumothorax (n = 3 vs 2), bleeding requiring transfusion (n = 3 vs 2), and mediastinitis (n = 3 vs 1). Hospital stay was longer in the HM group than in the POEM group ( P < 0.00001). In the Chagas subgroup, post-procedure Eckardt score in the POEM group was significantly reduced by 5.71 points ( P < 0.00001) versus 1.56 points in the HM group ( P = 0.042793). Conclusion Both HM and POEM are efficacious for achalasia, but POEM was associated with higher initial therapy success and shorter hospital stay in Latin America. In Chagas patients with achalasia, POEM was significantly more effective than HM.
| S-EPMC7508649 | biostudies-literature
Project description:Video 1Video available at: https://www.jtcvs.org/article/S2666-2507(21)00513-7/fulltext.Video 2Video available at: https://www.jtcvs.org/article/S2666-2507(21)00513-7/fulltext.Video 3Video available at: https://www.jtcvs.org/article/S2666-2507(21)00513-7/fulltext.Video 4Video available at: https://www.jtcvs.org/article/S2666-2507(21)00513-7/fulltext.Video 5Video available at: https://www.jtcvs.org/article/S2666-2507(21)00513-7/fulltext.Video 6Video available at: https://www.jtcvs.org/article/S2666-2507(21)00513-7/fulltext.Video 7Video available at: https://www.jtcvs.org/article/S2666-2507(21)00513-7/fulltext.
| S-EPMC8690962 | biostudies-literature
Project description:Background and study aims Gastroenterology societies have recently proposed core curricula for training in per-oral endoscopic myotomy (POEM) based on expert opinion with limited data on its applicability for advanced endoscopy fellowship (AEF) trainees. We prospectively evaluated the feasibility of a structured POEM training curriculum during a dedicated AEF and the trainee's performance during independent practice. Methods This was a single-center prospective study evaluating a trainee's performance of POEM using a structured assessment tool (POEMAT) to assess core cognitive and technical skills. The trainee's performance was then prospectively assessed during the first 12 months of independent practice. Results The trainee, who had not prior background in submucosal endoscopy, first observed 22 POEM cases followed by 35 hands-on procedures during his advanced endoscopy fellowship. Based on the POEMAT, submucosal entry and mucosal incision closure were the most challenging technical aspects, while cognitive skills were uniformly attained early in training. Overall, the trainee was able to cross the threshold for competence in his POEMAT performance score in 15 of his last 18 cases (83.3 %). The trainee performed 16 POEMs (baseline mean Eckardt 7.2) in his first 12 months of independent practice. Mean procedural time was 79.8 minutes (interquartile range: 67-94 minutes minutes) with no adverse events. Clinical success (Eckardt score < 3) was achieved in 100 % of the cases at a median follow-up of 20 weeks. Conclusions Results from this pilot study support the adoptability of the recently proposed core curricula for POEM training within the context of a dedicated AEF and provide a potential blueprint for future studies of performance in POEM among trainees.
| S-EPMC8671003 | biostudies-literature
Project description:The field of endoscopic esophageal surgery is based on the concept of natural orifice transluminal endoscopic surgery (NOTES). Submucosal space surgery or third space surgery with the use of flexible endoscopy allows for decreased morbidity and hospital length of stay with equivalent outcomes for patients. In the case of achalasia, per oral endoscopic myotomy (POEM) allows for management of refractory cases in setting of previous Heller Myotomy or in patients whom laparoscopic or thoracoscopic surgery is contraindicated. Lastly, POEM more directly divides circular muscular layer of esophagus without destroying surrounding structures that exist to prevent reflux. The innovations in endoscopic surgery began in the animal lab with experiments in the porcine model to develop a way to access the peritoneal cavity through an entry point in the gastric mucosa. Over the last 10 years, the biggest treatment innovations in endoscopy have focused on management of achalasia with the use of POEM. POEM became possible as technology was developed that revolutionized the use of flexible technology and the methods of mucosal closure. In addition to benign esophageal disease, endoscopic methods improved in management of esophageal malignancy with endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). The innovations of endoscopic surgery have been developed through the utilization of the submucosal space as a method to ensure adequate closure of the mucosal entry point into the peritoneal cavity. The goal of this review paper is to explore POEM and other techniques in endoscopic esophageal surgery for the management of esophageal diverticulum, submucosal tumors, gastroparesis, and gastrointestinal esophageal reflux disease.
| S-EPMC8184417 | biostudies-literature
Project description: Not available
| S-EPMC6251941 | biostudies-literature
Project description:ImportanceSeveral professional practice guidelines recommend per-oral endoscopic myotomy (POEM) as a potential first-line therapy for the management of achalasia, yet payers remain hesitant to reimburse for the procedure owing to unanswered questions regarding safety.ObjectiveTo evaluate the use, safety, health care utilization, and costs associated with the use of POEM for treatment of achalasia relative to laparoscopic Heller myotomy (LHM) and pneumatic dilation (PD).Design, setting, and participantsThis was a retrospective national cohort study of commercially insured patients, aged 18 to 63 years, who underwent index intervention for achalasia with either LHM, PD, or POEM in the US between July 1, 2010, and December 31, 2017. Patient data were obtained from a national commercial claims database. Included in the study were patients with at least 12 months of enrollment after index treatment and a minimum of 6 months of continuous enrollment before their index procedure. Patients 64 years or older were excluded to avoid underestimation of health care claims from enrollment in Medicare supplemental insurance. Data were analyzed from July 1, 2019, to July 1, 2021.Main outcomes and measuresChanges in the proportion of annual procedures performed for achalasia were evaluated over time. The frequency of severe procedure-related adverse events, including perforation, pneumothorax, bleeding, and death, were compared. Negative binomial regression was used to compare the incidence rates of subsequent diagnostic testing, reintervention, and unplanned hospitalization. Generalized linear models were used to compare differences in 1-year health-related expenditures across procedures.ResultsThis cohort study included a total of 1921 patients (median [IQR] age: LHM group, 48 [37-56] years; 737 men [51%]; PD group, 51 [41-58] years; 168 men [52%]; POEM group, 50 [40-57] years; 80 men [56%]). The use of POEM increased 19-fold over the study period, from 1.1% (95% CI, 0.2%-3.2%) of procedures in 2010 to 18.9% in 2017 (95% CI, 13.6%-25.3%; P = .01). Adverse events were rare and did not differ between procedures. Compared with LHM, POEM was associated with more subsequent diagnostic testing (incidence rate ratio [IRR], 2.2; 95% CI, 1.9-2.6) and reinterventions (IRR, 1.9; 95% CI, 1.1-3.3). When compared with PD, POEM was associated with more subsequent diagnostic testing (IRR, 1.5; 95% CI, 1.3-1.8) but fewer reinterventions (IRR, 0.4; 95% CI, 0.2-0.6). The total 1-year health care costs were similar between POEM and LHM, but significantly lower for PD (mean cost difference, $7674; 95% CI, $657-$14 692).Conclusions and relevanceResults of this cohort study suggest that POEM was associated with higher health care utilization compared with LHM and lower subsequent health care utilization but higher costs compared with PD. The use of POEM is increasing rapidly; payers should recognize the totality of evidence and current treatment guidelines as they consider reimbursement for POEM. Patients should be informed of the trade-offs between approaches when considering treatment.
| S-EPMC9021980 | biostudies-literature
Project description: Not available
| S-EPMC6362324 | biostudies-literature