Double tunnel technique reduces technical failure during POEM in cases with severe submucosal fibrosis

Abstract

Background and study aims Submucosal fibrosis (SMF) is one of the major reasons for technical failure during per-oral endoscopic myotomy (POEM). In this study, we aimed to evaluate the impact of double tunnel technique (DT-POEM) on the technical success of POEM in cases with severe SMF.

Patients and methods Data from patients with achalasia in whom SMF was encountered during POEM from Jan 2013 to Jan 2020 at our center were retrospectively evaluated. The technical success and adverse events (AEs) were analyzed and compared between cases with SMF who underwent POEM via single tunnel versus DT-POEM technique.

Results A total of 1,150 patients underwent POEM during the study period. There were 14 technical failures (1.2 %). SMF and severe SMF was found in 104 (9 %) and 21 (1.8 %) patients, respectively. The majority of patients (17, 80.9 %) with severe SMF had type I achalasia. Overall, technical failures occurred in 14 cases (1.2 %) and severe SMF resulted in the majority of the technical failures (10, 71.4 %). DT-POEM was utilized in 11 cases (52.4 %) with severe SMF. The median procedure time with DT-POEM was 150 minutes (85–210). There were no major AEs and DT-POEM was technically successful in all the patients. The technical success of POEM in cases with SMF improved after the adoption of the double tunnel technique (98.4 % vs 68.3 %, P = 0.0001).

Conclusions Severe SMF is the most common reason for technical failure during POEM. DT-POEM improves the technical success rates of POEM in patients with severe SMF.

Publication History

Received: 20 December 2020

Accepted: 02 March 2021

Article published online:
16 August 2021

• References

• 1 Inoue H, Sato H, Ikeda H. et al. Per-oral endoscopic myotomy: a series of 500 patients. J Am Coll Surg 2015; 221: 256-264
• 2 Shiwaku H, Inoue H, Onimaru M. et al. Multicenter collaborative retrospective evaluation of peroral endoscopic myotomy for esophageal achalasia: analysis of data from more than 1300 patients at eight facilities in Japan. Surg Endosc 2020; 34: 464-468
• 3 Shiwaku H, Inoue H, Sato H. et al. Peroral endoscopic myotomy for achalasia: a prospective multicenter study in Japan. Gastrointest Endosc 2020; 91: 1037-1044 e1032
• 4 Nabi Z, Ramchandani M, Chavan R. et al. Peroral endoscopic myotomy in treatment-naive achalasia patients versus prior treatment failure cases. Endoscopy 2018; 50: 358-370
• 5 Wu QN, Xu XY, Zhang XC. et al. Submucosal fibrosis in achalasia patients is a rare cause of aborted peroral endoscopic myotomy procedures. Endoscopy 2017; 49: 736-744
• 6 Wang Y, Liu ZQ, Xu MD. et al. Clinical and endoscopic predictors for intraprocedural mucosal injury during per-oral endoscopic myotomy. Gastrointest Endosc 2019; 89: 769-778
• 7 Xu S, Chai N, Tang X. et al. Outcomes of peroral endoscopic myotomy in challenging achalasia patients: a long-term follow-up study. Surg Endosc 2020;
• 8 Feng X, Linghu E, Chai N. et al. New endoscopic classification of esophageal mucosa in achalasia: A predictor for submucosal fibrosis. Saudi J Gastroenterol 2018; 24: 122-128
• 9 Ramchandani M, Nageshwar RD, Darisetty S. et al. Peroral endoscopic myotomy for achalasia cardia: Treatment analysis and follow up of over 200 consecutive patients at a single center. Dig Endosc 2016; 28: 19-26
• 10 Nabi Z, Ramchandani M, Sayyed M. et al. Comparison of short versus long esophageal myotomy in cases with idiopathic achalasia: a randomized controlled trial. J Neurogastroenterol Motil 2020;
• 11 Nabi Z, Reddy DN, Ramchandani M. Adverse events during and after per-oral endoscopic myotomy: prevention, diagnosis, and management. Gastrointest Endosc 2018; 87: 4-17
• 12 Ngamruengphong S, Inoue H, Ujiki MB. et al. Efficacy and Safety of peroral endoscopic myotomy for treatment of achalasia after failed Heller myotomy. Clin Gastroenterol Hepatol 2017; 15: 1531-1537 e1533
• 13 Werner YB, von Renteln D, Noder T. et al. Early adverse events of per-oral endoscopic myotomy. Gastrointest Endosc 2017; 85: 708-718 e702
• 14 Sanaka MR, Thota PN, Murthy SC. et al. Creation of a second submucosal tunnel enabled successful per-oral endoscopic myotomy (POEM). J Thorac Cardiovasc Surg 2016; 151: e101-e102
• 15 Li Y, LingHu E, Ding H. et al. Peroral endoscopic myotomy with simultaneous submucosal and muscle dissection for achalasia with severe interlayer adhesions. Gastrointest Endosc 2016; 83: 651-652
• 16 Liu W, Zeng XH, Yuan XL. et al. Open peroral endoscopic myotomy for the treatment of achalasia: a case series of 82 cases. Dis Esophagus 2019; 32: 1-7
• 17 Nabi Z, Reddy DN, Ramchandani M. Severe submucosal fibrosis – the “Achillesʼ heel” of peroral endoscopic myotomy. Endoscopy 2017; 49: 1116
• 18 Gu L, Ouyang Z, Lv L. et al. Safety and efficacy of peroral endoscopic myotomy with standard myotomy versus short myotomy for treatment-naive patients with type II achalasia: a prospective randomized trial. Gastrointest Endosc 2021; 93: 1304-1312
• 19 Wang J, Tan N, Xiao Y. et al. Safety and efficacy of the modified peroral endoscopic myotomy with shorter myotomy for achalasia patients: a prospective study. Dis Esophagus 2015; 28: 720-727
• 20 Li L, Chai N, Linghu E. et al. Safety and efficacy of using a short tunnel versus a standard tunnel for peroral endoscopic myotomy for Ling type IIc and III achalasia: a retrospective study. Surg Endosc 2019; 33: 1394-1402
• 21 Huang S, Ren Y, Peng W. et al. Peroral endoscopic shorter versus longer myotomy for the treatment of achalasia: a comparative retrospective study. Esophagus 2020; 17: 477-483