Yuki B. Werner

Peroral Endoscopic Myotomy for the Treatment of Achalasia: A Prospective Single Center Study

OBJECTIVES:Endoscopic balloon dilatation and laparoscopic myotomy are established treatments for achalasia. Recently, a new endoscopic technique for complete myotomy was described. Herein, we report the results of the first prospective trial of peroral endoscopic myotomy (POEM) in Europe.METHODS:POEM was performed under general anesthesia in 16 patients (male:female (12:4), mean age 45 years, range 26–76). The primary outcome was symptom relief at 3 months, defined as an Eckhard score ≤3. Secondary outcomes were procedure-related adverse events, lower esophageal sphincter (LES) pressure on manometry, reflux symptoms, and medication use before and after POEM.RESULTS:A 3-month follow-up was completed for all patients. Treatment success (Eckhard score ≤3) was achieved in 94% of cases (mean score pre- vs. post-treatment (8.8 vs. 1.4); P<0.001). Mean LES pressure was 27.2 mm Hg pre-treatment and 11.8 mm Hg post-treatment (P<0.001). No patient developed symptoms of gastro-esophageal reflux after treatment, but one patient was found to have an erosive lesion (LA grade A) on follow-up esophagogastroduodenoscopy. No patient required medication with proton pump inhibitors or antacids after POEM.CONCLUSIONS:POEM is a promising new treatment for achalasia resulting in short-term symptom relief in >90% of cases. Studies evaluating long-term efficacy and comparing POEM with established treatments have been initiated.

Peroral Endoscopic Myotomy for the Treatment of Achalasia: An International Prospective Multicenter Study

Pilot studies have indicated that peroral endoscopic myotomy (POEM) might be a safe and effective treatment for achalasia. We performed a prospective, international, multicenter study to determine the outcomes of 70 patients who underwent POEM at 5 centers in Europe and North America. Three months after POEM, 97% of patients were in symptom remission (95% confidence interval, 89%-99%); symptom scores were reduced from 7 to 1 (P < .001) and lower esophageal sphincter pressures were reduced from 28 to 9 mm Hg (P < .001). The percentage of patients in symptom remission at 6 and 12 months was 89% and 82%, respectively. POEM was found to be an effective treatment for achalasia after a mean follow-up period of 10 months.

POEM and Submucosal Tunneling

Opinion statementSubmucosal endoscopy has introduced new and important aspects into gastrointestinal endoscopic therapeutics by opening the way to interventions even outside of the GI tract. At present, innovative techniques for submucosal endoscopy in different esophageal diseases include peroral endoscopic myotomy (POEM) for idiopathic achalasia and related motility disorders, submucosal tunneling endoscopic resection (STER) for submucosal tumors arising from the muscularis propria, and endoscopic submucosal tunneling dissection (ESTD) for superficial esophageal neoplastic lesions. POEM for achalasia—still a rare disease—is currently evaluated in comparison to endoscopic and surgical standard therapies, while this procedure enabling a long thoracic myotomy might constitute an advantage over the laparoscopic approach in treatments of spastic esophageal diseases. Removal of smaller submucosal esophageal tumors may appear tempting, but the clinical indications are limited by the facts that the vast majority of such smaller tumors are asymptomatic and benign.For all these innovative and technically demanding techniques, learning curves have to be taken into account, not only with regard to technical competence but also to clinical assessment, ranging from proper indication and patient selection to the management of (potential) complications and logistics/back-up. Although preliminary results from high-skilled endoscopic centers have been very encouraging, long-term data as well as prospective randomized controlled trials are needed to validate the efficacy and safety of the modalities.