Per-oral endoscopic myotomy for palliation of achalasia: A video atlas.
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ABSTRACT:
SUBMITTER: Raja S
PROVIDER: S-EPMC8690962 | biostudies-literature |
REPOSITORIES: biostudies-literature
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| S-EPMC6492919 | 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: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:Peroral endoscopic myotomy (POEM) has been recently considered as the first treatment option for achalasia. The standard POEM procedures are often successful in most patients, but sometimes technical challenges are encountered. We report a new technique that is divided between two tunneling sites in the esophagus for sigmoid-type achalasia. A 40-year-old male patient with dysphagia for 10 years was diagnosed with a sigmoid-shaped esophagus at our hospital. We devised a two-stage myotomy technique to treat sigmoidtype achalasia. The myotomy was first performed in the upper part of the greater flexion area and then in the lower part of the flexion. We termed this method "two-stage POEM", which was successfully performed without any complications. This new POEM method can also be used to improve symptoms in patients with achalasia who have a structural deformity that may result in a high change of treatment failure.
| S-EPMC7137558 | biostudies-literature
Project description:Background and study aims The aim of this study was to evaluate whether timed barium esophagram within 24 hours post-per-oral endoscopic myotomy (POEM) (TBE-PP) could predict clinical outcomes. Patients and methods This was a single-center retrospective study of prospectively collected data on consecutive patients with ≥ 6-month follow-up who underwent POEM followed by TBE-PP. Esophageal contrast retention 2 minutes after TBE-PP was assessed as Grade 1 (< 10 %), 2 (10 %-49 %), 3 (50 %-89 %) or 4 (> 90 %). Eckardt score, esophagogastroduodenoscopy (EGD), high-resolution manometry (HRM) and function lumen imaging probe (FLIP) of the esophagogastric junction (EGJ) were obtained at baseline. These tests along with pH testing of antisecretory therapy were repeated 6 and 24 months after POEM. Clinical response by Eckardt score ≤ 3, EGJ-distensibility index (EGJ-DI) > 2.8 mm 2 /mm Hg, and integrated relaxation pressure (IRP) < 15 mm Hg and incidence of gastroesophageal reflux disease (GERD) were compared by transit time. Results Of 181 patients (58 % male, mean 53 ± 17 yr), TBE-PP was classified as Grade 1 in 122 (67.4 %), Grade 2 in 41 (22.7 %), Grade 3 in 14 (7.7 %) and Grade 4 in 4 (2.2 %). At 6 months, overall clinical response by ES (91.7 %), IRP (86.6 %), EGJ-DI (95.7 %) and the diagnosis of GERD (68.6 %) was similar between Grade 1 and Grade 2-4 TBE-PP. At 24 months, Grade 1 had a higher frequency of a normal IRP compared to Grades 2-4 (95.7 % vs. 60 %, P = 0.021) but overall response by ES (91.2 %), EGJ-DI (92.3 %) and the diagnosis of GERD (74.3 %) were similar. Conclusions Contrast emptying rate by esophagram after POEM has limited utility to predict clinical response or risk of post-procedure GERD.
| S-EPMC8589564 | biostudies-literature
Project description:This paper presented a case of esophageal achalasia treated by peroral endoscopic myotomy with HybridKnife and discuss the feasibility and the possible advantages of using it.
| S-EPMC3415097 | biostudies-literature
Project description:Background/aimsSeveral studies have reported partial recovery of peristalsis in patients with achalasia after myotomy. The aim of our study is to analyze esophageal motility patterns after peroral endoscopic myotomy (POEM) and to assess the potential predictors and clinical impact of peristaltic recovery.MethodsWe performed a retrospective analysis of prospectively collected data of consecutive patients with achalasia undergoing POEM at a tertiary center. High-resolution manometry (HRM) studies prior to and after POEM were reviewed and the Chicago classification was applied.ResultsA total of 237 patients were analyzed. The initial HRM diagnoses were achalasia type I, 42 (17.7%); type II, 173 (73.0%); and type III, 22 (9.3%). Before POEM, peristaltic fragments were present in 23 (9.7%) patients. After POEM the Chicago classification diagnoses were: 112 absent contractility, 42 type I achalasia, 15 type II, 11 type III, 26 ineffective esophageal motility, 18 esophagogastric junction outflow obstruction, 10 fragmented peristalsis, and 3 distal esophageal spasm. Altogether 68 patients (28.7%) had signs of contractile activity, but the contractions newly appeared in 47 patients (47/214, 22.0%). Type II achalasia showed a trend for appearance of contractions (P = 0.097). Logistic regression analysis did not identify any predictors of peristaltic recovery. The post-POEM Eckardt score did not differ between patients with and without contractions nor did the parameters of timed barium esophagogram.ConclusionsMore than 20% of achalasia patients have signs of partial recovery of esophageal peristalsis after POEM. It occurs predominantly in type II achalasia but the clinical relevance seems to be negligible.
| S-EPMC8026367 | biostudies-literature
Project description:Background and study aims Symptomatic gastroesophageal reflux is a recognized potential adverse event following peroral endoscopic myotomy (POEM). Proton pump inhibitors (PPIs) are an effective first-line therapy; although their efficacy can be affected by genotype cytochrome P450 2C19 (CYP2C19) variability leading to enhanced clearance of PPIs. The aim of our study was to evaluate the incidence of CYP2C19 genotype variability in POEM patients with refractory gastroesophageal reflux symptoms. Patients and methods This was a single-center, prospective, cohort study of consecutive POEM cases during a 7-year study period (2013-2020). Reflux symptoms were assessed with the validated gastroesophageal reflux disease questionnaire (GerdQ) and objective pH testing after POEM. CYP2C19 genotype testing was obtained in all patients with refractory gastroesophageal reflux disease (GERD) symptoms, defined as an abnormal pH study and GerdQ score ≥ 8 while on PPIs twice daily. Results POEM was performed in 325 consecutive patients (48.3 % female; mean age 57 years) during the study period. Twenty patients (6.8 %) had PPI-refractory, post-POEM gastroesophageal reflux based on their GerdQ score (median 9, range 8-11) and abnormal pH studies. CYP2C19 genotype testing identified 55 % (11/20) of these patients as being rapid metabolizers. Out of these, 9 (82 %) had improvement in clinical GERD symptoms after changing to a PPI less affected by CYP2C19 pharmacogenetics. Conclusions Post-POEM, PPI-refractory GERD is rare. As shown in this study, rapid metabolizers commonly respond by changing to a PPI less affected by CYP2C19 pharmacogenetics, thereby reducing the risk of long-term consequences from GERD and unnecessary anti-reflux surgery.
| S-EPMC8159581 | 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:Per oral endoscopic myotomy (POEM) is a complex technique used in achalasia. Preclinical training is essential but little is known about the number of procedures needed. The aim of this study was to determine the number of procedures required to master POEM in an animal model.This prospective comparative study was conducted in two swine models at a single institution in Mexico City between November 2012 and October 2014: Group 1 (G1) = 30 ex vivo and Group 2 (G2) = 20 live swine models. POEM was mastered after finishing the five steps without complications. Time, characteristics, and complications were recorded. Velocity of tunnelization and myotomy (VTM) was determined. Ex vivo analysis was done in G1 immediately after finishing POEM and at day 30 in G2.A total of 50 POEM were done in both groups (G1 = 30, G2 = 20). The mean times were 90.17 min (G1) and 89.50 min (G2) (P = 0.92). Myotomy was faster in G2 (21.10 vs 27.97 min; P = 0.009) with a slightly slower tunnelization (40.35 vs 41.13 min; P = 0.86). Myotomy was longer in G2 (9.25 vs 8.83 cm; P = 0.26). VTM between the groups was similar (G1 = 0.159 vs G2 = 0.157 cm/min; P = 0.925). Complications were: mucosotomy (G1 = 18 %, G2 = 8 %; P = 0.430), mediastinal perforation (G1 = 12 %, G2 = 8 %; P = 1.0), and perforation at the gastroesophageal junction (GEJ) level (G1 = 16 %, G2 = 4 %; P = 0.149). Seven models in G2 presented minor bleeding and there was one death not attributed to the procedure. Mastery was obtained after 26 cases.We suggest that centers interested in learning POEM consider 26 procedures in animal models to master it before performing it in patients with achalasia.
| S-EPMC4683141 | biostudies-other