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      Systematic review and meta-analysis: Efficacy and safety of POEM for achalasia.

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          Abstract

          Peroral endoscopic esophageal myotomy (POEM) represents a less invasive alternative, as compared with conventional laparoscopic Heller myotomy for treating achalasia patients. In the last years, a number of prospective and retrospective experiences with POEM use for achalasia have been published.

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          Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia.

          P Pasricha, R Hawari, I. Ahmed … (2007)
          The most permanent method of treating achalasia is a surgical myotomy. Because of the requirement for a mucosal incision and the risk of perforation, this procedure has not generally been approached endoscopically. We hypothesized that we could perform a safe and robust myotomy by working in the submucosal space, accessed from the esophageal lumen. Four pigs were used for this experiment. Baseline lower esophageal sphincter (LES) pressures were recorded and the pigs underwent upper endoscopy using a standard endoscope. A submucosal saline lift was created approximately 5 cm above the LES and a small nick was made in the mucosa in order to facilitate the introduction of a dilating balloon. After dilation, the scope was introduced over the balloon into the submucosal space and advanced toward the now visible fibers of the LES. The circular layer of muscle was then cleanly incised using an electrocautery knife in a distal-to-proximal fashion, without complications. The scope was then withdrawn back into the lumen and the mucosal defect was closed with endoscopically applied clips. The entire procedure took less than 15 minutes. Manometry was repeated on day 5 after the procedure and the animals were euthanized on day 7. LES pressures fell significantly from an average of 16.4 mm Hg to an average of 6.7 mm Hg after the myotomy. The necropsy examinations revealed no evidence of mediastinitis or peritonitis. Endoscopic submucosal esophageal myotomy is feasible, safe, and effective in the short term. It has the potential for being useful in patients with achalasia. The submucosal space is a novel and potentially important field of operation for endoscopic procedures.
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            The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience.

            Thomas Savides, David M. Friedel, Stavros Stavropoulos … (2013)
            Per oral endoscopic myotomy (POEM) represents a Natural Orifice Transluminal Endoscopic Surgery (NOTES) approach to Heller myotomy. Even though we are now entering an exponential phase of growth with a large number of centers interested in POEM, published data to guide them are limited. As part of the July 2012 NOSCAR meeting, a conference was organized to review POEM and develop a consensus document. Authors SNS and TS who chaired the NOSCAR panel recognized the dearth of published data, which also may lag the rapid developments in POEM. Therefore, they undertook a survey of early POEM adopters around the world to rapidly obtain global, extensive, and current data on POEM. The raw survey data were made available to NOSCAR panel participants to assist with their presentations. We summarize the salient findings of the survey. A comprehensive POEM survey was created and tested. The final survey instrument consisted of 197 questions that covered all aspects of POEM, including operator discipline, prior training, patient selection, setting, technique preference, results, adverse events, regulatory requirements, and perspectives on the future. An automated online response collector was used. The International Per Oral Endoscopic Myotomy Survey (IPOEMS) involved 16 expert centers, 7 in North America, 5 in Asia, 4 in Europe, including all high-volume centers (≥30 POEMs per center), as of July 2012. These centers had performed 841 POEMs. There were modest variations among centers in technique and periprocedural management, but all centers uniformly reported excellent efficacy and safety outcomes. The international POEM survey provides a "global snapshot" of the experience of early adopters. The excellent outcomes over a large cumulative volume of procedures are in line with those of published small series and lend further support to the notion that POEM represents a paradigm shift in the treatment of achalasia.
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              Peroral endoscopic esophageal myotomy: defining the learning curve.

              L Swanstrom, Manju A. Kurian, M Dunst … (2013)
              Peroral endoscopic myotomy (POEM) is an endoscopic alternative to laparoscopic esophageal myotomy. It requires a demanding skill set that involves both advanced endoscopic skills and knowledge of surgical anatomy and complication management. Determine the learning curve for POEM. Prospective cohort study. Tertiary-care teaching hospital. The study involved the first 40 consecutive patients undergoing the POEM procedure under a prospective institutional review board protocol (research.gov #NCT01399476, 1056). Peroral endoscopic myotomy for esophageal motility disorders. Length of procedure (LOP) and technical errors (inadvertent mucosotomy). A total of 40 patients underwent POEM. The mean LOP was 126 ± 41 minutes. The mean myotomy length was 9 cm (range, 6-20 cm). The LOP per centimeter myotomy and variability decreased as our experience progressed. The means (± standard deviation) of the LOP per centimeter myotomy were as follows: first cohort, 16 ± 4 minutes; second, 17 ± 5 minutes; third, 13 ± 3 minutes; fourth, 15 ± 2 minutes; and fifth, 13 ± 4 minutes. The incidence of inadvertent mucosotomy also decreased with increasing experience, to 8, 6, 4, 0, and 1, respectively. These minor complications were repaired intraoperatively with clips. There were 7 patients with capnoperitonium and another with bilateral capnothoraces that were associated with hemodynamic instability but resolved by Veress needle decompression. Two patients required endoscopy in the early postoperative period: self-limited hematemesis in one and radiologic evidence of leakage at the mucosotomy site in another. Nonrandomized study. Mastery of operative technique in POEM is evidenced by a decrease in LOP, variability of minutes per centimeter of myotomy, and incidence of inadvertent mucosotomies and plateaus in about 20 cases for experienced endoscopists. The learning curve can be shortened with very close supervision and/or proctoring. Copyright © 2013 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.
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                Author and article information

                Journal
                Journal ID (iso-abbrev): United European Gastroenterol J
                Title: United European gastroenterology journal
                Publisher: SAGE Publications
                ISSN: 2050-6406
                ISSN (Print): 2050-6406
                Publication date (Electronic): Aug 2015
                Volume: 3
                Issue: 4
                Affiliations
                [1 ] Endoscopy Unit and Department of Surgery, Istituto Clinico Humanitas, Milan, Italy.
                Article
                Publisher Item ID: 10.1177_2050640615581732
                DOI: 10.1177/2050640615581732
                PMC ID: 4528214
                PubMed ID: 26279840
                SO-VID: 5d7cf4ee-792b-4048-86ea-41194263f898
                History

                Keywords: swallowing,safety,myotomy,Achalasia,complications,peristalsis,esophagus,adverse events,esophageal sphincter,endoscopic esphageal myotomy,review
                Data availability:
                Keywords: swallowing, safety, myotomy, Achalasia, complications, peristalsis, esophagus, adverse events, esophageal sphincter, endoscopic esphageal myotomy, review

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