Intentional selective myotomy of the lower esophageal sphincter and gastric during peroral endoscopic myotomy. PREPOEMSELECT study, preliminary results

Aims The technical feasibility of performing selective myotomy at the lower esophageal sphincter level, including gastric myotomy (LES+Gm), during peoral endoscopy myotomy (POEM) has not been evaluated in Western countries. The aim was to evaluate the rate of intentional selective LES+Gm during POEM in our region.

Methods Preliminary results of a prospective multicenter registry of consecutive cases of POEM performed between May-October 2024. Demographic, clinical, manometric and endoscopic variables were included, as well as videos and images of myotomies. In all cases, selective myotomy of the LES+Gm was attempted. As standard practice, selective esophageal myotomy was also performed. The rate of selective myotomy of LES+Gm was evaluated overall and by operator. In this preliminary phase, confirmation of intentional selective myotomy was only performed by the operating team. If an unintentional full thickness myotomy (without achieving prior selective myotomy) was performed, it was considered a failure of selective LES+Gm. If intentional selective LES+Gm was achieved, it was at the discretion of each operator to perform a full thickness myotomy before completing the procedure.

Results Eight operators participated, performing 46 POEM (52% men, median age 56 years; IQR 43-72). The main indication was type II achalasia (62%) and 28% had received previous treatment (Heller=3, Dilation=1, Botox=1, Heller+POEM=1). 22% had sigmoid esophagus [1].

Selective LES+Gm was successfully achieved in 80% of cases. Of these, 46% were subsequently converted to full thickness myotomy. Selective esophageal myotomy was performed in 94% of the cases. The median duration of myotomy was 22 minutes (IQR 16-36) and the total duration of the procedure was 71 minutes (IQR 57-95). The median rate of intentional selective LES+Gm per operator was 80% (IQR 75-100). There was only one POEM-related adverse event, a small mucosal defect closed with clips, and three anesthesia-related adverse events (two bronchoaspirations and one bronchospasm).

Conclusions Intentional selective LES+Gm is technically feasible in the majority of POEM.

Conflicts of Interest

Hugo Uchima collaborates as proctor with Erbe Spain and Olympus Iberia. Has received congress registration from Casen Recordati

• References

• 1 Shiwaku H, Inoue H, Sato H. et al. Peroral endoscopic myotomy for achalasia: a prospective multicenter study in Japan. Gastrointest Endosc 2020; 91 (05): 1037-1044.e2 Epub 2019 Nov 21. PMID: 31759035

Publication History

Article published online:
27 March 2025