Peroral endoscopic myotomy (POEM) for esophageal achalasia[*]

Background: Peroral endoscopic myotomy (POEM) was developed by our group to provide a less invasive permanent treatment for esophageal achalasia.

Patients and methods: POEM was performed in 17 consecutive patients with achalasia (10 men, 7 women; mean age 41.4 years). A long submucosal tunnel was created (mean length 12.4 cm), followed by endoscopic myotomy of circular muscle bundles of a mean total length of 8.1 cm (6.1 cm in distal esophagus and 2.0 cm in cardia). Smooth passage of an endoscope through the gastroesophageal junction was confirmed at the end of the procedure.

Results: In all cases POEM significantly reduced the dysphagia symptom score (from mean 10 to 1.3; P = 0.0003) and the resting lower esophageal sphincter (LES) pressure (from mean 52.4 mmHg to 19.9 mmHg; P = 0.0001). No serious complications related to POEM were encountered. During follow-up (mean 5 months), additional treatment or medication was necessary in only one patient (case 17) who developed reflux esophagitis (Los Angeles classification B); this was well controlled with regular intake of protein pump inhibitors (PPIs).

Conclusions: The short-term outcome of POEM for achalasia was excellent; further studies on long-term efficacy and on comparison of POEM with other interventional therapies are awaited.

References

• 1 Kalloo A N, Singh V K, Jagannath S B. et al . Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions.  Gastrointest Endosc. 2004;  60 114-117
• 2 Spiess A E, Kahrilas P J. Treating achalasia: from whalebone to laparoscope.  JAMA. 1998;  280 638
• 3 Pehlivanov N, Pasricha P J. Achalasia: botox, dilatation or laparoscopic surgery in 2006.  Neurogastroenterol Motil. 2006;  18 799-804
• 4 Woltman T A, Pellegrini C A, Oelschlager B K. Achalasia.  Surg Clin N Am. 2005;  85 483-493
• 5 Inoue H, Minami H, Satodate H. et al . First clinical experience of submucosal endoscopic myotomy for esophageal achalasia with no skin incision.  Gastrointest Endosc. 2009;  69 AB122
• 6 Pasricha P J, Hawari R, Ahmed I. et al . Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia.  Endoscopy. 2007;  39 761-764
• 7 Ortega J A, Madureri V, Perez I. Endoscopic myotomy in the treatment of achalasia.  Gastrointest Endosc. 1980;  26 8-10
• 8 Inoue H, Minami H, Kaga M. et al . Endoscopic mucosal resection and endoscopic submucosal dissection for esophageal dysplasia and carcinoma.  Gastrointest Endosc Clin N Am. 2010;  20 25-34
• 9 Csendes A, Braghetto I, Burdies P. et al . Very late results of esophagomyotomy for patients with achalasia: clinical, endoscopic, histologic, manometric, and acid reflux studies in 67 patients for a mean follow up of 190 months.  Ann Surg. 2006;  243 196-203
• 10 Tamiya Y, Nakahara K, Kominato K. et al . Pneumomediastinum is a frequent but minor complication during esophageal endoscopic submucosal dissection.  Endoscopy. 2010;  42 8-14
• 11 Vantrappen G, Jannsens J. To dilate or operate? That is the question.  Gut. 1983;  24 1013-1019
• 12 Mercer C D, Hill L D. Reoperation after failed esophagomyotomy for achalasia.  Can J Surg. 1986;  29 177-180
• 13 Gorecki P J, Hinder R A, Libbey J S. et al . Redo laparoscopic surgery for achalasia: is it feasible?.  Surg Endosc. 2002;  16 772-776

1 These results were reported at DDW 2009 in Chicago (2 June 2009) and at UEGW 2009 in London (25 November 2009).