Lung cancer metastasis-induced distal esophageal segmental spasm confirmed by individualized peroral endoscopic myotomy:A case report

BACKGROUND Peroral endoscopic myotomy(POEM)has been widely performed as a standard treatment for achalasia;however,its efficacy and safety for treating distal esophageal segmental spasms induced by cancer metastasis remain unknown.CASE SUMMARY A 72-year-old male was referred to our hospital and complained of progressive dysphagia for two years.Endoscopy revealed a 2 cm long segment esophageal stenosis with intact mucosa and normal cardia.Computed tomography showed a right upper lung mass,and pathology of the right pleural effusion confirmed the diagnosis of right upper lung adenocarcinoma with multiple rib and mediastinal lymph node metastases and right malignant pleural effusion.Individualized POEM was performed first to alleviate dysphagia,and the final diagnosis was changed to esophageal muscle metastasis arising from lung adenocarcinoma.After treatment,the patient could eat soft solid food and received multiple rounds of pembrolizumab-combination chemotherapy.The patient’s progression-free survival was approximately 16 months.Long stable disease was obtained during the 24-month follow-up.CONCLUSION The incidence of distal esophageal segmental spasms induced by muscular metastasis arising from lung adenocarcinoma is extremely low.Individualized POEM can effectively improve a patient’s nutritional status before subsequent chemotherapy can be combined with immune checkpoint inhibitors.

Applications of gastric peroral endoscopic myotomy in the treatment of upper gastrointestinal tract disease

Gastric peroral endoscopic myotomy(G-POME)is an emerging minimally invasive endoscopic technique involving the establishment of a submucosal tun-nel around the pyloric sphincter.In 2013,Khashab et al used G-POME for the first time in the treatment of gastroparesis with enhanced therapeutic efficacy,prov-iding a new direction for the treatment of gastroparesis.With the recent and rapid development of G-POME therapy technology,progress has been made in the treatment of gastroparesis and other upper digestive tract diseases,such as congenital hypertrophic pyloric stenosis and gastric sleeve stricture,with G-POME.This article reviews the research progress and future prospects of G-POME for the treatment of upper digestive tract gastrointestinal diseases.

Safety and efficacy of peroral endoscopic myotomy for treating achalasia in pediatric and geriatric patients:A meta-analysis

BACKGROUND As a less invasive technique,peroral endoscopic myotomy(POEM)has recently been widely accepted for treating achalasia with an excellent safety profile,durability,and efficacy in adults.In pediatric and geriatric patients,the treatment is more difficult.AIM To discuss the clinical outcomes of POEM in pediatric and geriatric patients with achalasia.METHODS We conducted a comprehensive search of PubMed,Embase and Cochrane Library databases from inception to July 2024.The primary outcomes were technical and clinical success.Secondary outcomes of interest included adverse events and gastroesophageal reflux disease(GERD).The pooled event rates were calculated by comprehensive meta-analysis software.RESULTS A total of 32 studies with 547 pediatric patients and 810 geriatric patients were included in this study.The pooled event rates of technical success,clinical success,GERD and adverse events of POEM for treating achalasia in pediatric patients were 97.1%[95%confidence interval(CI):95.0%-98.3%;I^(2)=0%;P<0.000],93.2%(95%CI:90.5%-95.2%;I^(2)=0%;P<0.000),22.3%(95%CI:18.4%-26.7%;I^(2)=43.874%;P<0.000)and 20.4%(95%CI:16.6%-24.8%;I^(2)=67.217%;P<0.000),respectively.Furthermore,in geriatric patients,the pooled event rates were 97.7%(95%CI:95.8%-98.7%;I^(2)=15.200%;P<0.000),93.2%(95%CI:90.3%-95.2%;I^(2)=0%;P<0.000),23.9%(95%CI:19.4%-29.1%;I^(2)=75.697%;P<0.000)and 10.8%(95%CI:8.3%-14.0%;I^(2)=62.938%;P<0.000],respectively.CONCLUSION Our findings demonstrated that POEM was an effective and safe technique for pediatric and geriatric patients with achalasia.

Effect and safety of mark-guided vs standard peroral endoscopic myotomy: A retrospective case control study

BACKGROUND Peroral endoscopic myotomy(POEM)is a promising therapeutic modality for esophageal achalasia worldwide.However,clinical failure and adverse events of POEM have still been concerned.AIM To compare the efficacy and safety of a novel mark-guided POEM with standard POEM.METHODS A total of 133 patients with esophageal achalasia who underwent POEM from May 2013 to May 2019 were enrolled in this retrospective study.Of the 133 patients,there were 64 patients in the mark-guided POEM group and 69 patients in the standard POEM group.The clinical success,procedural duration and adverse events were compared between the two groups at 3 mo,12 mo and 24 mo postoperatively.RESULTS Characteristic baseline was similar in the mark-guided POEM group and standard POEM group.The clinical success was comparable between the two groups,ranging from 92%to 98%,at 3 mo,12 mo and 24 mo postoperatively(all P>0.5).Eckart score,Gastroesophageal Reflux Disease Questionnaire score and SF-36 score were not different between the two groups after treatment(all P>0.05).No severe adverse events occurred in the two groups.However,markguided POEM required shorter procedural duration,and less use of proton pump inhibitors and lower incidence of reflux symptoms than the standard POEM(all P<0.001).CONCLUSION Mark-guided POEM and standard POEM were both effective and safe for the treatment of esophageal achalasia.However,the mark-guided POEM was characterized by shorter procedural duration,less use of proton pump inhibitors and lower incidence of reflux symptoms.

Fibrin sealant for closure of mucosal penetration at the cardia during peroral endoscopic myotomy: A retrospective study at a single center

AIM To assess the efficacy and safety of fibrin sealant for closure of mucosal penetration at the cardia during peroral endoscopic myotomy(POEM).METHODS Twenty-four patients who underwent POEM and experienced mucosal injury of the cardia during the procedure were retrospectively identified. Of the 24 patients, 21 had mucosal penetration and 3 had only slight mucosal damage without penetration. The 21 patients with mucosal penetration received fibrin sealant for closure at the site of penetration. Penetration-related characteristics, treatment, and recovery were reviewed for all 21 patients to assess the efficacy and safety of fibrin sealant for closure of mucosal penetration at the cardia. Clinical data, including general characteristics, procedure-related parameters, Eckardt scores, lower esophageal sphincter pressures (LESP), and esophagogastroduodenoscopy(EGD) results, were analyzed to determine their influence on treatment success after mucosal penetration during POEM.RESULTS All 21 patients had a solitary mucosal penetration in the cardia (12 in esophageal region of the cardia, 9 in the stomach region of the cardia, and 1 in both the esophageal and stomach regions). Twelve had ahole-like penetration and 9 had a linear penetration. For those with a hole-like penetration, the mean size was 0.14 cm2 (0.02-0.32 cm2). For those with a linear penetration, the median size was 0.37 cm (0.10-1.00 cm). Closure of the mucosal penetration using fibrin sealant was performed successfully in all 21 patients(two patients required 5 m L fibrin sealant, and the remaining 19 patients required 2.5 mL). Two patients had a nasogastric tube placed for five days after POEM; the remaining 19 patients were kept fasting for 3 d. All 21 patients were discharged after a median of 5 d(range: 5-7 d) postoperatively. During a median 42 mo (range: 9-62 mo) follow-up, all 21 patients with a mucosal penetration successfully healed without the occurrence of infection, ulcer, or esophagitis. Furthermore, the median LESP decreased from 31.9 mm Hg (range: 21.9-67.1 mm Hg) preoperatively to 20.3 mm Hg (range: 6.0-41.0 mm Hg) postoperatively(P < 0.05). The median preoperative and postoperative Eckardt scores were 5.0(range; 4-10) and 1.0(range: 0-4), respectively (P < 0.05). Of the 21 patients with mucosal penetration, symptom remission, which is defined as a postoperative Eckardt score ≤ 3, was achieved in 20 patients(95.2%) indicating that mucosal penetration did not influence the success of POEM treatment if closed successfully using fibrin sealant.CONCLUSION Fibrin sealant is safe and effective for closure of mucosal penetration during POEM. Mucosal penetrations do not appear to influence the treatment success of POEM if closed successfully using fibrin sealant. Additional studies regarding the feasibility, efficacy, and safety of fibrin sealant for closure of larger mucosal penetrations is warranted.

Combination of concurrent endoscopic submucosal dissection and modified peroral endoscopic myotomy for an achalasia patient with synchronous early esophageal neoplasms

with an increased risk for developing esophageal squamous cell carcinoma. In our paper, we introduced an achalasia patient combined with synchronous early esophageal neoplasms. We performed a combination of concurrent endoscopic submucosal dissection (ESD) and peroral endoscopic myotomy (POEM). No complications other than postoperative pain that needed morphine treatment for two days had occurred. Dysphagia was significantly improved. Neither reflux nor cough occurred. The short-term efficacy and safety of our case is favorable and suggests that concurrent ESD and POEM could be a treatment option to such patients.

Endoscopic ultrasound-measured muscular thickness of the lower esophageal sphincter and long-term prognosis after peroral endoscopic myotomy for achalasia

BACKGROUND People with achalasia typically have a thick lower esophageal muscularis propria(LEMP),and peroral endoscopic myotomy(POEM)has been effective in treating most patients.LEMP thickness may be associated with the outcomes and prognosis after POEM.However,more evidence is needed regarding the relationship between LEMP thickness and patient prognosis after POEM.AIM To assess the association between LEMP thickness,measured using endoscopic ultrasound(EUS),and long-term prognosis,especially relapse,after POEM for achalasia.METHODS All medical records,including EUS data,of patients who underwent POEM to treat achalasia at Shengjing Hospital of China Medical University from January 2012 to September 2018 were retrospectively reviewed.LEMP thickness was measured by EUS,and a thickness of≥3 mm was defined as thickened.The severity of patient symptoms was evaluated using the Eckardt score.Relapse was defined as a 3-point rise in the Eckardt score after a period of clinical remission.The relationship between patient characteristics,muscle thickness,and recurrence was analyzed.RESULTS Eighty-two patients(32 males and 50 females,aged 17-78 years)and 85 POEM procedures were included.In total,76.8%(63/82 patients)of patients had a thickened muscularis propria.Older age and longer disease course were associated with muscularis propria thickening(P<0.05).The mean postoperative follow-up time was 35.4±17.2 mo(range,8-87.5 mo)in 60 patients.Five patients with Eckardt scores>3 refused further management after their symptoms were relieved.The relapse rate was 12.73%(7/55 cases).Five patients,four of whom had muscularis propria thickening,had disease recurrence within 12 mo after the procedure.Achalasia relapsed in one patient who had a thickened muscularis propria after 24 mo and in another patient who did not have a thickened muscularis propria after 30 mo.Patients with recurrence were typically younger and had a shorter disease course(P<0.05).The relapse rate in patients with a non-thickened muscularis propria tended to be higher(18.2%,2/11 patients)than that in patients with a thickened muscularis propria(11.4%,5/44 patients),although no significant difference was found.Age(hazard ratio=0.92;95%confidence interval:0.865-0.979;P<0.05)and being male(hazard ratio=7.173;95%confidence interval:1.277-40.286;P<0.05)were identified as risk factors for symptomatic recurrence by multivariable analysis using the Cox model.CONCLUSION Patients with a thickened muscularis are typically older and have a longer disease course.Younger age and the male sex are associated with increased recurrence.Patients with a thin muscularis propria may be prone to relapse,although further validation is needed.

High Eckardt score and previous treatment were associated with poor postperoral endoscopic myotomy pain control:A retrospective study

BACKGROUND Peroral endoscopic myotomy(POEM)is a safe and effective endoscopic treatment for achalasia.However,postoperative pain management for these patients is often neglected by anesthesiologists because of the short operative time,short hospital stay and the minimally invasive nature of the procedure.AIM To assess the pain and sleep quality of achalasia patients receiving the POEM procedure and investigate factors that affect postoperative pain.METHODS This observational study included patients with achalasia who underwent POEM at Zhongshan Hospital from December 2017 to March 2018.General anesthesia was performed with endotracheal intubation.The postoperative visual analog scale(VAS),postoperative sleep quality,basic patient information,and surgical parameters were collected.Depending on whether the 12-h post-POEM VAS score was less than 4,patients were divided into two groups,a well-controlled pain group and a poorly controlled pain group.Univariate,multivariate,and stepwise logistic regression analyses were used to investigate risk factors for poor pain control.A prediction model of post-POEM pain risk was established in the form of a nomogram.The calibration curve and receiver operating characteristic curve were used to evaluate the clinical usage of the prediction model.Repeated measures analysis of variance and simple effect analysis were used to verify whether differences in the VAS and sleep scores of the high-and low-risk groups,divided by the model from the raw data,were statistically significant.RESULTS A total of 45 eligible patients were included.Multivariate logistic regression and further stepwise logistic regression analysis found that the preoperative Eckardt score[odds ratio(OR):1.82,95% confidence interval(CI):1.17-2.84,P<0.001],previous treatment(OR:7.59,95%CI:1.12-51.23,P=0.037)and the distance between the end of the muscle incision and the cardia(OR:1.52,95%CI:0.79-293.93,P=0.072)were risk factors for post-POEM pain.Repeated measures analysis of variance demonstrated that VAS(P=0.0097)and sleep scores(P=0.043)were higher in the highrisk group,and the interactions between the two main effects were obvious(VAS score:P=0.019,sleep score:P=0.035).Further simple effect analysis found that VAS scores were higher in the high-risk group at 2 h,6 h and 12 h(P=0.005,P=0.019,P<0.001),and sleep scores were higher in the high-risk group at day 1(P=0.006).CONCLUSION Achalasia patients who underwent POEM experienced serious postoperative pain,which may affect sleep quality.A higher Eckardt score,previous treatment,and a longer distance between the muscle incision ending and the cardia were risk factors for poor post-POEM pain control.

Peroral endoscopic myotomy for treatment of Guillain-Barre syndrome-associated achalasia: A rare case

Guillain-Barre syndrome (GBS)-associated achalasia is a very rare disease of uncertain cause. We report the case of a patient diagnosed with GBS-associated type I achalasia who was successfully treated with peroral endoscopic myotomy (POEM). A 30-year-old man who was diagnosed with GBS 3 mo before was referred to our department with dysphagia and meal-related regurgitation. The results of esophagography, endoscopy, and high-resolution manometry (HRM) revealed type I achalasia. POEM that utilized a submucosal tunneling technique was performed to treat the GBS-associated type I achalasia. After POEM, smooth passage of a contrast agent into the stomach was shown in follow-up esophagography, and follow-up HRM revealed a decrease in the mean integrated relaxation pressure 22.9 mmHg to 9.6 mmHg. The patient remained without dysphagia for 7 mo, even though the patient&#x02019;s neurological problems were not fully resolved. POEM may be a safe and effective treatment for GBS-associated type I achalasia.

Repeat peroral endoscopic myotomy with simultaneous submucosal and muscle dissection as a salvage option for recurrent achalasia

BACKGROUND For recurrent achalasia after initial peroral endoscopic myotomy(POEM)failure,repeat POEM(Re-POEM)has been reported as a treatment option.However,severe esophageal interlayer adhesions caused by previous procedures impede the successful establishment of a submucosal tunnel and lead to aborted Re-POEM procedures.Our team previously described POEM with simultaneous submucosal and muscle dissection(POEM-SSMD)as a feasible solution for achalasia with severe interlayer adhesions.AIM To investigate the effectiveness and safety of Re-POEM with simultaneous submucosal and muscle dissection(Re-POEM-SSMD).METHODS A total of 1049 patients with achalasia who underwent successful endoscopic myotomy at the Digestive Endoscopic Center of Chinese PLA General Hospital from December 2014 to May 2022 were reviewed.Patients with recurrent achalasia who experienced initial POEM clinical failure were retrospectively included in this study.The primary endpoint was retreatment clinical success,defined as an Eckardt score≤3 during the postretreatment follow-up and no need for additional treatment.Procedure-related adverse events,changes in manometric lower esophageal sphincter(LES)pressure and reflux complications,as well as procedure-related parameters,were recorded.RESULTS Sixteen patients underwent Re-POEM(9 patients)or Re-POEM-SSMD(7 patients)successfully at a median of 45.5 mo(range,4-95 mo)after initial POEM.During a median followup period of 31 mo(range,7-96 mo),clinical success(Eckardt score≤3)was achieved in 8(88.9%)and 6(85.7%)patients after Re-POEM and Re-POEM-SSMD,respectively(P=0.849).The median Eckardt score dropped from 4(range,3-8)at preretreatment to 1(range,0-5)at postretreatment in the Re-POEM group(P=0.025)and from 5(range,2-8)to 2(range,0-4)in the Re-POEM-SSMD group(P<0.001).The mean manometric LES pressure decreased from 23.78±9.04 mmHg to 11.45±5.37 mmHg after Re-POEM(P<0.001)and from 26.80±7.48 mmHg to 11.05±4.38 mmHg after Re-POEM-SSMD(P<0.001).No serious adverse events were recorded in both groups.CONCLUSION In conclusion,Re-POEM-SSMD appears to be a safe and effective salvage therapy for recurrent achalasia with severe interlayer adhesions.

Peroral endoscopic myotomy for management of gastrointestinal motility disorder

Achalasia is a type of esophageal motility disorder,consisting of relaxation dysfunction of the lower esophagus and disturbed esophageal peristalsis.Related clinical symptoms include dysphagia,regurgitation,chest pain,and weight loss.Traditional treatment options include endoscopic botulinum toxin injection,endoscopic pneumatic dilation,and laparoscopic Heller’s myotomy.These therapies mainly relieve symptoms by reducing the pressure on the lower esophageal sphincter and reducing blood flow resistance at the esophagogastric junction.Based on endoscopic submucosal dissection and natural orifice transluminal endoscopic surgery,peroral endoscopic myotomy(POEM)is a purely endoscopic method of myotomy with minimal invasiveness and a low rate of adverse events when performed by experienced operators.Since then,numerous studies have shown the significant clinical efficacy and safety of POEM.The purpose of this article is to introduce different modified POEMs,special indications for different POEMs,and their advantages as well as disadvantages.

Peroral endoscopic myotomy assisted with an elastic ring for achalasia with obvious submucosal fibrosis:A case report

BACKGROUND Peroral endoscopic myotomy(POEM)is an established treatment option for esophageal achalasia.However,technical challenges and failures exist.Submucosal fibrosis is a rare cause of aborted POEM procedures.CASE SUMMARY We performed POEM with an elastic ring for achalasia with obvious submucosal fibrosis.The short-term outcome was excellent,surgery time was significantly shorter,and success rate was higher with POEM for achalasia with obvious submucosal fibrosis.CONCLUSION POEM performed with an elastic ring is a feasible and effective endoscopic treatment modality for achalasia with obvious submucosal fibrosis.

Peroral endoscopic myotomy in a pregnant woman diagnosed with mitochondrial disease:A case report

BACKGROUND Achalasia is a primary esophageal motility disease characterized by impairment of normal esophageal peristalsis and absence of relaxation of the lower esophageal sphincter.Sometimes is can be a part of some genetic disorders.One of the causes of gastrointestinal motility disorders,including achalasia,is mitochondrial defects.CASE SUMMARY We report about a pregnant woman with a history of symptoms associated with inherited mitochondrial disease,which was confirmed by genetic tests,and who was treated via peroral endoscopic myotomy.CONCLUSION Peroral endoscopic myotomy is possible treatment option for a pregnant woman with achalasia caused by mitochondrial disease.

Efficacy and safety of peroral endoscopic myotomy after prior sleeve gastrectomy and gastric bypass surgery

BACKGROUND Per-oral endoscopic myotomy(POEM)is safe and effective for the treatment of achalasia.There is limited data on performance of POEM in patients with altered upper gastrointestinal anatomy,especially after bariatric surgery.Outcomes in patients with prior sleeve gastrectomy have not been reported.AIM To assess the efficacy and safety of POEM in patients with prior bariatric surgery.METHODS A prospective POEM database was reviewed from 3/2017-5/2020 to identify patients who underwent POEM after prior bariatric surgery.Efficacy was assessed by technical success(defined as the ability to successfully complete the procedure)and clinical success[decrease in Eckardt score(ES)to≤3 post procedure].Safety was evaluated by recording adverse events.RESULTS Six patients(50%male,mean age 48 years)with a history of prior bariatric surgery who underwent POEM were included.Three had prior sleeve gastrectomy(SG)and three prior Roux-en-Y gastric bypass(RYGB).Four patients had achalasia subtype II and 2 had type I.Most(4)patients had undergone previous achalasia therapy.Technical success was 100%.Clinical success was achieved in 4(67%)patients at mean follow-up of 21 mo.In one of the clinical failures,EndoFLIP evaluation demonstrated adequate treatment and candida esophagitis was noted as the likely cause of dysphagia.There were no major adverse events.CONCLUSION POEM is technically feasible after both RYGB and SG and offers an effective treatment for this rare group of patients where surgical options for achalasia are limited.

Early esophageal carcinomas in achalasia patient after endoscopic submucosal dissection combined with peroral endoscopic myotomy:A case report

BACKGROUND Achalasia is associated with high risk of esophageal carcinoma.However,the optimal endoscopic surgery for patients with early esophageal carcinoma concomitant with achalasia remains unclear.CASE SUMMARY A combination of concurrent endoscopic submucosal dissection(ESD)and modified peroral endoscopic myotomy(POEM)was performed on a 62-year-old male,who presented with multiple early esophageal carcinomas concomitant with achalasia.The patient exhibited an improvement in feeding obstruction,and presented no evidence of disease during the 3-year follow-up.CONCLUSION The combination of ESD and POEM is a feasible treatment modality for patients with early esophageal carcinoma concomitant with achalasia.

Direct cost variance analysis of peroral endoscopic myotomy vs heller myotomy for management of achalasia:A tertiary referral center experience

BACKGROUND Laparoscopic Heller myotomy(LHM)has been the traditional surgical treatment for achalasia.Recently,peroral endoscopic myotomy(POEM)has demonstrated similar clinical outcomes with shorter procedure times.Studies comparing the direct cost-effectiveness of POEM vs LHM are limited.AIM To compare costs of POEM vs LHM.METHODS Haider SA et al.Comparing costs:POEM vs Heller myotomy WJGE https://www.wjgnet.com 594 October 16,2023 Volume 15 Issue 10 This retrospective chart review aimed to compare the outcomes and cost of clinical care between patients who underwent POEM and LHM procedures for achalasia.The study was conducted at a tertiary academic center from January 2019 to December 2020.Clinical outcomes,including post-operative Eckardt scores and adverse events,were assessed and compared between the two groups.Direct cost variance analysis was utilized to evaluate the cost of clinical care incurred by patients undergoing POEM in the year preceding the procedure,during the index admission,and one year post-procedure,in comparison to patients undergoing LHM.RESULTS Of 30 patients were included(15 POEM and 15 LHM)in the study.Patients in the POEM group had a mean Eckardt score of 0.5±0.5 post-procedure,which was no different from patients in the LHM group(0.7±0.6,P=0.17)indicating comparative efficacy.However,the total costs of the admission for the procedure in the LHM group were on average$1827 more expensive than in the POEM group(P<0.01).Total healthcare costs one year prior to index procedure were$7777 higher in the LHM group,but not statistically different(P=0.34).The patients in the LHM group one year after the index procedure had accrued$19730.24 larger total cost,although this was not statistically different from POEM group(P=0.68).CONCLUSION Despite similar clinical outcomes,the cost of the index procedure admission for POEM was significantly lower than for LHM.The difference was primarily related to shorter time increments utilized in the operating room during the index procedure,and shorter length of hospital stay following POEM.

Advances and challenges in peroral endoscopic myotomy:Safety,precision,and post-procedure management

Peroral endoscopic myotomy(POEM)has revolutionized the treatment of upper gastrointestinal tract motility disorders,particularly achalasia.This editorial explores the efficacy,safety,and challenges of POEM,emphasizing its role as a primary treatment with excellent long-term outcomes and minimal adverse events.The evolution of POEM underscores the need for precision in myotomy techniques and the importance of interdisciplinary collaboration,especially regar-ding anesthetic considerations.Despite significant advances,challenges remain in standardizing safety protocols and managing complications.As POEM appli-cations expand,precision endoscopy continues to enhance therapeutic outcomes,promising a transformative impact on gastrointestinal motility disorder manage-ment.

Ling classification describes endoscopic progressive process of achalasia and successful peroral endoscopy myotomy prevents endoscopic progression of achalasia

AIM To verify the hypothesis that the Ling classification describes the endoscopic progressive process of achalasia and determine the ability of successful peroral endoscopic myotomy (POEM) to prevent endoscopic progression of achalasia. METHODS We retrospectively reviewed the endoscopic findings, symptom duration, and manometric data in patients with achalasia. A total of 359 patients (197 women, 162 men) with a mean age of 42.1 years (range, 12-75 years) were evaluated. Symptom duration ranged from 2 to 360 mo, with a median of 36 mo. Patients were classified with Ling type I (n = 119), II a (n = 106),II b (n = 60),II c (n = 60), or III (n = 14), according to the Ling classification. Of the 359 patients, 349 underwent POEM, among whom 21 had an endoscopic follow-up for more than 2 years. Pre-treatment and post-treatment Ling classifications of these 21 patients were compared. RESULTS Symptom duration increased significantly with increasing Ling classification (from I to III) (p < 0.05), whereas lower esophageal sphincter pressure decreased with increasing Ling type (from I to III) (p < 0.05). There was no difference in sex ratio or onset age among the Ling types, although the age at time of diagnosis was higher in Ling types I c and III than in Ling types I, IIa, and I b. Of the 21 patients, 19 underwent high-resolution manometry both before and after treatment. The mean preoperative and postoperative lower esophageal sphincter pressure were 34.6 mmHg (range, 15.3-59.4 mmHg) and 15.0 mmHg (range, 2.1-21.6 mmHg), respectively, indicating a statistically significant decrease after POEM. All of the 21 patients were treated successfully by POEM (postoperative Eckardt score <= 3) and still had the same Ling type during a mean follow-up period of 37.8 mo (range, 24-51 mo). CONCLUSION The Ling classification represents the endoscopic progressive process of achalasia and may be able to serve as an endoscopic assessment criterion for achalasia. Successful POEM (Eckardt score <= 3) seems to have the ability to prevent endoscopic evolvement of achalasia. However, studies with larger populations are warranted to confirm our findings.

Gastroesophageal reflux following per-oral endoscopic myotomy:Can we improve outcomes?

This editorial is an analysis the review article by Nabi et al recently published in this journal.Achalasia Cardia is a disease whose pathophysiology is still unclear.It is known that there is inflammation of unknown aetiology leading to loss of ganglion cells in the muscularis propria.The end result is lower oesophageal sphincter spasm,loss of receptive relaxation,decreased oesophageal peristalsis,all leading on to varying degrees of dysphagia.The treatment of this condition is palliative in nature,performed by myotomy of the lower oesophagus either surgically or endoscopically.Gastroesophageal reflux disease(GERD)has been associated with the myotomy performed,particularly with the Peroral Endoscopic Myotomy(POEM)procedure.Nabi et al have provided an excellent overview of the latest developments in predicting,preventing,evaluating,and managing GERD subsequent to POEM.Based on this theme,this review article explores the concept of using histology of the oesophageal muscle layer,to grade the disease and thereby help tailoring the length/type of myotomy performed during the POEM procedure.In the future,will a histology based algorithm available preoperatively,help modify the POEM procedure,thereby decreasing the incidence of GERD associated with POEM?

Peroral endoscopic longer vs shorter esophageal myotomy for achalasia treatment:A systematic review and meta-analysis

BACKGROUND Peroral endoscopic myotomy(POEM)has been demonstrated to be safe and effective in the treatment of achalasia.Longer myotomy is the standard POEM procedure for achalasia but when compared with shorter myotomy,its effectiveness is not as well known.AIM To compare the clinical effectiveness of longer and shorter myotomy.METHODS PubMed,EmBase,Cochrane Library,web of science and clinicaltrials.gov were queried for studies comparing shorter and longer POEM for achalasia treatment.The primary outcome was clinical success rate.Secondary outcomes comprised of operative time,adverse events(AEs)rate,gastroesophageal reflux disease(GERD)and procedure-related parameters.The Mantel-Haenszel fixed-effects model was primarily used for the analysis.Publication bias was assessed.RESULTS Six studies were included in this analysis with a total of 514 participants.During the follow-up period of 1-28.7 mo,longer and shorter myotomy in treating achalasia showed similar excellent effectiveness[overall clinical success(OR=1,95%CI:0.46-2.17,P=1,I2:0%;subgroup of abstract(OR=1.19,95%CI:0.38 to 3.73;P=0.76;I2:0%);subgroup of full text(OR=0.8695%CI:0.30 to 2.49;P=0.78;I2:0%)].Shorter myotomy had significantly reduced mean operative time compared with the longer procedure.There were no statistically significant differences in AEs rates,including GERD(overall OR=1.21,95%CI:0.76-1.91;P=0.42;I2:9%;subgroup of abstract OR=0.77,95%CI:0.40-1.47;P=0.43;I2:0%;subgroup of full text OR=1.91,95%CI:0.98-3.75;P=0.06;I2:0%),hospital stay(overall MD=-0.07,95%CI:-0.30 to 0.16;P=0.55;I2:24%;subgroup of abstract MD=0.20,95%CI:-0.25 to 0.65;P=0.39;I2:0;subgroup of full text MD=-0.16,95%CI:-0.42 to 0.10;P=0.23;I2:42%),and major bleeding(overall OR=1.25,95%CI:0.58-2.71;P=0.56;I2:0%)between the two procedures.These differences remained statistically non-significant in all sensitivity analyses.CONCLUSION POEM was effective in treating achalasia.Shorter and longer myotomy procedures provided similar therapeutic effects in terms of long-term effectiveness.In addition,shorter myotomy reduced the operative time.