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Peroral endoscopic myotomy in a patient with failed Heller's myotomy by use of a novel bipolar radiofrequency device.

ABSTRACT:

SUBMITTER: Nabi Z

PROVIDER: S-EPMC7125408 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Peroral endoscopic myectomy: a novel thought to reduce recurrence after previous failed myotomy.

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Peroral endoscopic myotomy for a residual Zenker's diverticulum following endoscopic myotomy.

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Peroral endoscopic myotomy for cricopharyngeal bar.

Project description:Background and aimsDefinitive treatment options for refractory dysphagia due to cricopharyngeal bar are limited. We aimed to demonstrate a novel adaptation of peroral endoscopic myotomy to treat this condition (cricopharyngeal peroral endoscopic myotomy [c-POEM]).MethodsThe approach to c-POEM is similar to that in the distal esophagus for the treatment of achalasia. A submucosal injection and overlying mucosal incision are performed, ideally 1.5 to 2 cm upstream of the upper esophageal sphincter, and then a submucosal tunnel is extended beyond the level of the cricopharyngeus. The target muscle is then transected before closure of the mucosotomy.ResultsIn 3 cases of refractory cricopharyngeal bar, c-POEM was successfully performed. Although no major adverse events occurred, significant postprocedural edema at the level of the upper esophageal sphincter prolonged hospitalization in 2 of the 3 patients. After recovery, all patients reported complete resolution of dysphagia and tolerated an unrestricted diet.ConclusionsC-POEM allows reliable and complete muscular division in patients with refractory cricopharyngeal bar who have limited treatment options.

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Learning curve for peroral endoscopic myotomy.

Project description:Although peroral endoscopic myotomy (POEM) is being performed more frequently, the learning curve for gastroenterologists performing the procedure has not been well studied. The aims of this study were to define the learning curve for POEM and determine which preoperative and intraoperative factors predict the time that will be taken to complete the procedure and its different steps.Consecutive patients who underwent POEM performed by a single expert gastroenterologist for the treatment of achalasia or spastic esophageal disorders were included. The POEM procedure was divided into four steps: mucosal entry, submucosal tunneling, myotomy, and closure. Nonlinear regression was used to determine the POEM learning plateau and calculate the learning rate.A total of 60 consecutive patients underwent POEM in an endoscopy suite. The median length of procedure (LOP) was 88 minutes (range 36 - 210), and the mean (± standard deviation [SD]) LOP per centimeter of myotomy was 9 ± 5 minutes. The total operative time decreased significantly as experience increased (P < 0.001), with a "learning plateau" at 102 minutes and a "learning rate" of 13 cases. The mucosal entry, tunneling, and closure times decreased significantly with experience (P < 0.001). The myotomy time showed no significant decrease with experience (P = 0.35). When the mean (± SD) total procedure times for the learning phase and the corresponding comparator groups were compared, a statistically significant difference was observed between procedures 11 - 15 and procedures 16 - 20 (15.5 ± 2.4 min/cm and 10.1 ± 2.7 min/cm, P = 0.01) but not thereafter. A higher case number was significantly associated with a decreased LOP (P < 0.001).In this single-center retrospective study, the minimum threshold number of cases required for an expert interventional endoscopist performing POEM to reach a plateau approached 13.

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Endoscopic techniques to detect gastroesophageal junction in peroral endoscopic myotomy.

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Red dichromatic imaging in peroral endoscopic myotomy: a novel image-enhancing technique.

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Efficacy and safety of peroral endoscopic myotomy in the management of recurrent achalasia after failed Heller myotomy: a systematic review and meta-analysis.

Project description:BackgroundHeller myotomy (HM) is an established treatment for achalasia but can fail in up to 10-20% of patients. Peroral endoscopic myotomy (POEM) may be an appropriate treatment for patients with failed HM.MethodsWe searched several databases to identify non-comparative studies evaluating the efficacy and/or safety of POEM after failed HM and comparative studies comparing the efficacy and/or safety of POEM in patients with and without prior HM. Outcomes assessed included clinical success, technical success, adverse events, post-treatment gastroesophageal reflux disease (GERD), and presence of esophagitis on endoscopy. We calculated weighted pooled rates with 95% confidence intervals (CI) for all outcomes in patients undergoing POEM with prior HM. We calculated pooled odds ratios with 95%CI to compare the outcomes between patients with and without previous HM who underwent POEM.ResultsWe included 11 observational studies with 1205 patients. Weighted pooled rates (95%CI) for overall clinical success and technical success in patients with failed HM were 87% (81-91%) and 97% (94-99%), respectively. Weighted pooled rates (95%CI) for major adverse events, new-onset GERD and presence of esophagitis on endoscopy were 5% (2-10%), 33% (26-41%), and 38% (22-58%), respectively. There were no differences in clinical success, adverse events, post-treatment GERD and esophagitis between patients with and without previous HM.ConclusionsPOEM is safe and effective in patients with failed HM and should be considered in patients with recurrent achalasia after HM. Outcomes of POEM are comparable in patients with and without prior HM.

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