Figure - available from: Gastroenterology Research and Practice
This content is subject to copyright. Terms and conditions apply.
(a-1) The myotomy was begun at about 2 cm distal to the mucosal entry. In partial full-thickness myotomy, not only the circular muscle layer but also the longitudinal muscle layer was cut at 2 cm above the EGJ. (a-2) Distal of full-thickness myotomy was extended to the fundus of the stomach. Incision was closed by endoscopic metallic clips. (b-1) The myotomy was begun at about 2 cm distal to the mucosal entry in partial full-thickness myotomy. In circular muscle myotomy, only circular muscle layer was resected and the longitudinal muscle layer was carefully protected. (b-2) Distal of circular muscle myotomy was extended to the fundus of the stomach. Incision was closed by endoscopic metallic clips.
Source publication
Background. Here we aimed to evaluate and compare the efficacy and safety between partial full-thickness myotomy and circular muscle myotomy during POEM procedure in achalasia patients. Methods. Clinical data of achalasia of cardia (AC) patients who underwent POEM in our center during January 2014 to January 2015 was collected (34 cases). 19 patien...
Similar publications
Citations
... cm, including 3 cm on the gastric wall [5,6]. Recently, several improvements have been proposed about myotomy length, depth, and location in POEM [6][7][8]. A few studies have suggested that a shorter myotomy (approximately 5.4-8 cm in total length) can achieve the same outcomes in type I or II achalasia, shorten the operation time, and possibly reduce the postoperative reflux rate [6,[9][10][11][12]. ...
Background
Although myotomy is crucial in peroral endoscopic myotomy (POEM) surgeries, its optimum length remains controversial. Herein, we propose a modified POEM with new method of tailoring myotomy length aim to evaluate the safety, efficacy, and clinical outcomes of this modified POEM compared with standard POEM in type I or II achalasia.
Methods
Seventy-five patients with type I or II achalasia who underwent POEM at the First Hospital of Jilin University between January 2018 and December 2022 were retrospectively analyzed. According to the myotomy approach, these patients were divided into the retrograde on-demand myotomy (RDM, n = 34), with myotomy beginning on gastric side and length tailored by determining the degree of lower esophageal sphincter (LES) distention, and standard myotomy (SM, n = 41) groups. The baseline data, myotomy length, operation time, clinical success rate, adverse event rate, and reflux-related adverse events were compared and analyzed.
Results
The median myotomy length in the RDM group was significantly shorter than that in the SM group (6 vs. 8 cm, respectively; p < 0.001). Moreover, the median myotomy time in the RDM group was significantly shorter than that in the SM group (10 vs. 16 min, respectively; p < 0.001). POEM was successfully performed in all the patients. At the 2-year follow-up, high clinical success rates were observed in both the RDM and SM groups (92.0% vs. 93.3%, respectively; p = 1.000). The incidence of intraoperative adverse events and postoperative reflux-related adverse events was low and comparable in both groups.
Conclusions
RDM POEM is a safe and effective method for patients with type I or II achalasia. Furthermore, it has a shorter myotomy length and operation time than standard POEM technique.
... Theoretically, any orientation could be performed (50), in fact, a second tunnel with a different orientation is an alternative in patients with submucosal fibrosis found in the initial tunnel (51). Full-thickness myotomy reduces the procedure duration without impairing clinical success nor increasing reflux (52). Also, the length of esophageal myotomy is not standardized, and shorter myotomies for type I and II achalasia have been successfully reported (53). ...
The "third space endoscopy" or also called "submucosal endoscopy" is a reality we can transfer to our patients since 2010. Various modifications of the submucosal tunneling technique allow access to the submucosa or deeper layers of the gastrointestinal tract. In addition to peroral endoscopic myotomy for the treatment of achalasia, also called esophageal POEM, other variants have emerged that make it possible to treat different esophageal motility disorders, esophageal diverticula, subepithelial tumors of various locations, gastroparesis, reconnection of complete esophageal strictures or even thanks to exceptional endoscopists, pediatric disorders such as Hirschsprung's disease. Although some technical aspects are yet to be standardized, these procedures are becoming widespread worldwide and will likely become the standard treatment of these pathologies soon.
... Notably, the circular and longitudinal muscle fibers are particularly difficult to discern near the gastroesophageal junction and thereby selective myotomy can be technically challenging, with the risk for potential incomplete myotomy. Data suggest that partial and full-thickness myotomy have similar safety and efficacy but the latter appears faster [24][25][26]. In our practice, we still elect towards a selective circular myotomy until 1-2 cm above the lower esophageal sphincter, at which point we convert to a full-thickness myotomy, primarily due to the difficulty in discerning the circular and longitudinal muscles at this level. ...
Over the years, our growing experience with endoscopic submucosal dissection along with technological advances has solidified our comfort and knowledge on working in the submucosa, also referred to as the “third space.” Per-oral endoscopic myotomy (POEM) was the first prototype third-space endoscopy (TSE) procedure, demonstrating the feasibility and clinical utility of endoscopic esophagogastric myotomy via submucosal tunneling. The launch of POEM accelerated the evolution of TSE from a vanguard concept to an expanding field with a wide range of clinical applications. In this review, we discuss the status and future directions of multiple TSE interventions.
... [32,33]. The current literature does not conclude about the superiority of complete over partial myotomy (internal circular layer) neither in terms of efficacy nor safety [34,35]. We did not take serous perforations into account in the complication rate, since it could happen during myotomy, without clinical relevance, even when pneumoperitoneum or pneumomediastinum occurs [14]. ...
Background
Peroral endoscopic myotomy (POEM) is a very effective treatment for achalasia. However, training remains non-standardized. We evaluated a training curriculum, including ex vivo cases, followed by patients’ cases under expert supervision. The objective was to establish a learning curve of POEM.Materials and Methods
Four operators having completed advanced endoscopy fellowship were involved. They had already observed > 30 cases performed by experts. They performed 30 POEMs standardized (tunnel and myotomy lengths) procedures on ex vivo porcine model. Procedural times, number/volume of injections, mucosal and serous perforations, and myotomy length were collected. The learning curve was assessed using dissection speed (DS) and a dedicated performance score (PS), including learning rate (LR) and learning plateau (LP).ResultsThe operators completed all cases within 4 months (median of 3.5 cases/week). The mean procedural time was 43.3 min ± 14.4. Mean myotomy length was 70.0 mm ± 15.6 mm. Dissection speed averaged 1.78 mm/min ± 0.78. Using DS and PS as parameter, the LR was reached after 12.2 cases (DS = 2.0 mm/min) and 10.4 cases, respectively. When comparing the LP and the plateau phase, the DS was slower (1.3 ± 0.5 mm/min versus 2.1 ± 0.54 mm/min, p < 0.005) and perforations were decreased: 0.35 ± 0.82 in LP vs. 0.16 ± 0.44 in PP. Following this training, all operators performed 10 supervised cases and are competent in POEM.Conclusion
The association of observed cases and supervised ex vivo model training is effective for starting POEM on patients. The learning curve is 12 cases to reach a plateau.
... Subsequent studies described a progressive fullthickness myotomy (selective circular in upper portion and full thickness in distal) and complete full-thickness myotomy during the POEM procedure. Limited data comparing the outcomes between full-thickness and selective circular myotomy suggest that besides reduced procedure duration with full-thickness myotomy, there is no clinically relevant difference between the two techniques, especially with regard to clinical success (17)(18)(19). The incidence of GERD was higher after full-thickness myotomy in one study and similar in another study (17,19). ...
... Clinically relevant GERD was significantly higher in the full-thickness myotomy group (37.5% vs. 12.5%; p < 0.05). In another study (34 patients), the incidence of symptomatic GERD and reflux esophagitis was similar in the partial full-thickness myotomy and the full-thickness myotomy groups (18). Contrasting results from these studies suggest that randomized controlled trials comparing circular myotomy to full-thickness myotomy are required before concluding the benefits of selective circular or partial-thickness myotomy for the prevention of GERD. ...
Peroral endoscopic myotomy (POEM) is an established frontline treatment modality for achalasia cardia. Since its initial description, several modifications have been proposed to the technique of POEM. Broadly speaking, these modifications follow the basic principles of submucosal endoscopy, but incorporate variations in the POEM technique, including the difference in the orientation of myotomy (anterior or posterior), length of myotomy (short or long), and thickness of myotomy (selective circular or full thickness). Some of these modifications have been shown to reduce procedural duration without compromising the efficacy of the POEM procedure. More recently, several alterations have been reported that intend to reduce gastroesophageal reflux after POEM. These include preservation of sling fibers during posterior POEM and addition of NOTES fundoplication to the POEM procedure. Although some of the modified techniques have been compared with the conventional techniques in quality trials, randomized studies are awaited for others. The incorporation of some of these modifications will likely make POEM a technically easy and safer modality in near future. This review aims to discuss the current evidence with regard to the impact of modified techniques on the outcome of POEM.
... In our study, the clinical success rates were 100%, 100%, 100%, and 88.9% within six months, 1 year, 2 years, and beyond 2 years after the procedure, respectively. Based on data from recently published literature, the clinical success rates of POEM procedures ranged from 87.9% to 100% at 1 year after POEM [21][22][23][24][25]. The treatment efficacy within 1 year post-POEM in the current study was comparable to that of these studies. ...
... Full-thickness myotomy may increase the incidence of acid reflux-related adverse events after POEM. Interestingly, the incidence of acid reflux-related adverse events was not different between full-thickness myotomy and circular muscle myotomy in some reports [20,23,33]. Our results suggest that shorter and full-thickness myotomy did not increase the postoperative incidence of acid reflux-related adverse events. ...
Aim:
This retrospective study is aimed at evaluating the outcomes of a modified peroral endoscopic myotomy (POEM) technique in patients with type II achalasia.
Methods:
We performed a modified POEM procedure, which involved a shorter (total myotomy length = 4 cm), full-thickness myotomy, on 31 patients with type II achalasia. Clinical success rates, technical success rates, pre- and postoperative esophageal manometry results, complications, and reflux-related adverse events were evaluated.
Results:
The clinical success (Eckardt score ≤ 3) rates were 100% and 88.9% within 2 years and beyond 2 years postoperatively, respectively. The median lower esophageal sphincter pressures (LESP) decreased from 31.6 (26.7-49.7) mmHg preoperatively to 13.4 (10.5-21.6) and 11.8 (7.4-16.7) mmHg (P < 0.001) at 6 and 12 months postoperatively, respectively. The median integrated relaxation pressure (IRP) decreased from 27.8 (20.6-37.5) mmHg preoperatively to 12.9 (11.3-23.4) and 11.6 (9.6-16.8) mmHg (P < 0.001) at 6 and 12 months after POEM, respectively. Only one case (3.2%) of mucosal injury, four (12.9%) cases of reflux esophagitis, and two (6.5%) cases of gastroesophageal reflux symptoms were reported.
Conclusions:
The modified POEM technique showed excellent outcomes in patients with type II achalasia.
... However, the concept of selective myotomy of the circular muscle layer was challenged as being more difficult, time consuming, and not always possible. One retrospective analysis by Li et al 16 demonstrated similar symptom relief and postprocedure manometry results without significant differences in adverse events when comparing circular myotomy to full-thickness myotomy. Further, mean procedure time was significantly reduced in the full-thickness group compared with the circular myotomy group (56.7 vs 88.2 minutes, P < .01). ...
Achalasia is an esophageal motility disorder characterized by impaired lower esophageal sphincter (LES) relaxation and failed peristalsis. Common clinical manifestations include dysphagia to solid and liquid foods, chest pain, regurgitation, and weight loss, resulting in significant morbidity and healthcare burden. Historically surgical Heller myotomy and pneumatic dilation represented first-line therapeutic options for achalasia. This convention was shaken in 2009 when Inoue and colleagues introduced an endoscopic approach to dissect the muscle fibers of the LES, known as per-oral endoscopic myotomy (POEM). Since incorporation of POEM into standard practice, the overall myotomy technique has remained unchanged, however, adaptations in the thickness and length of myotomy have evolved. Full thickness myotomy is recognized to have similar clinical success and faster procedure times compared to selective circular muscle myotomy. While myotomy length for Type 1 and Type 2 achalasia has classically been >6 cm, recent studies demonstrate similar outcomes with reduction of myotomy length to <3cm. Length of myotomy for type 3 achalasia has been tailored to treat the entire length of spastic muscle segment, and the modality to gauge the optimal thickness and length of myotomy in this group has yet to be established. In addition to changes in POEM technique, the post-operative management of POEM has also changed, favoring reduced post-procedure imaging, antibiotic use, and hospitalizations.
... 60 This fact has not been substantiated in other studies. 61,62 The functional lumen imaging probe (FLIP) has recently been evaluated as a tool to predict post-POEM GER. Teitelbaum et al reported that a distensibility index (DI) < 6 mm 2 / mm Hg was predictive of lower risk for GER. ...
Peroral endoscopic myotomy (POEM) is an accepted treatment for achalasia cardia (AC), and results are comparable to those of laparoscopic Heller myotomy (LHM). In recent years, several reports have confirmed higher incidence of gastroesophageal reflux (GER) following POEM. This review evaluates the current evidence regarding post-POEM GER, critically examines the potential contributing factors responsible for GER, limitations of the current available functional testing, and precautions and preventive measures, and provides future directions for research. Factors conclusively contributing to increased post-POEM GER include injury to the sling fibers of the lower esophageal sphincter, length of gastric myotomy > 2 cm, and others. Historically, these same factors have been implicated for development of GER after surgical (laparoscopic) myotomy. Although less invasive, optimal technique of POEM may be important to control post-POEM GER. Most post-POEM GER occurs during the immediate post-POEM period, is mild, and is easily treatable using proton-pump inhibitors. GER incidence plateaus at 2 years and is comparable to that after LHM. Patients should therefore be prescribed proton-pump inhibitors for at least 2 years. Antireflux procedures (ARPs) are infrequently required in these patients as the incidence of refractory GER is low. Novel ARPs have been recently described and are currently under evaluation. Conclusive diagnosis of GER is a clinical challenge. Most patients are asymptomatic, and GER is diagnosed only on abnormal esophageal acid exposure (EAE). Studies have demonstrated that current measures to diagnose GER are inadequate, inaccurate, and cannot differentiate between true GER and abnormal EAE due to food fermentation in the distal esophagus. The Lyon Consensus criteria should be implemented for confirmation of diagnosis of GER. Finally, the review recommends an evidence-based clinical algorithm for evaluation and management of post-POEM GER and provides guidelines for future research in this field.
... As we know, the procedure of G-POEM was based on POEM. Simple circular myotomy didn't always lead to satisfactory outcome in studies of POEM for achalasia, but full-thickness myotomy could cover the shortage of circular myotomy [40][41][42][43]. Additionally, completeness of myotomy was also considered the prerequisite for excellent long-term results of conventional surgical myotomy [42,44,45]. ...
... According to the muscle anatomy, the longitudinal muscle closes to the circular muscle and has weak connection with the serous membrane. Full-thickness myotomy could decrease the procedure time because the time consumed by carefully distinguishing and protecting the longitudinal muscle was saved [43]. Till now, no data showed full-thickness myotomy could increase the procedure-related adverse events. ...
Background
Postsurgical gastroparesis is recognized as a gastrointestinal dysfunction syndrome following foregut surgery. Gastric peroral endoscopic myotomy (G-POEM) is suggested as a minimally invasive therapy for gastroparesis. But the long-term efficacy and safety of G-POEM in treating postsurgical gastroparesis are rarely explored.
Methods
The primary outcomes included the symptomatic improvement based on gastroparesis cardinal symptoms index (GCSI) and the improvement of gastric emptying. The secondary outcomes included the improvement of gastroesophageal reflux symptoms and complications of G-POEM.
Results
The severity of postsurgical gastroparesis was not associated with the onset time and the course of the disease. G-POEM significantly reduced GCSI throughout the follow-up period (p < 0.0001). For different anastomotic site, a significant improvement of GCSI was found at 6 month post-G-POEM (F4,165 = 74.18, p < 0.0001). Subscale analysis of GCSI showed that nausea/vomiting, post-prandial fullness/early satiety, and bloating were improved significantly at 6-month post-G-POEM (p < 0.0001, respectively). Half-emptying and whole-emptying time were significantly shortened in patients with different anastomotic site post-G-POEM (half-emptying time: F3,174 = 65.44, p < 0.0001; whole-emptying time: F3,174 = 54.85, p < 0.0001). The emptying of ioversol was obviously accelerated after G-POEM. GCSI wasn't related to pyloric length, pyloric diameter, and thickness of pyloric wall. GERDQ was also used to evaluate the clinical efficacy of G-POEM. For each time points, GERDQ didn't differ significantly in patients with different anastomotic site (F4,104 = 0.8075, p = 0.5231). For patients with different anastomotic site, GERDQ was improved significantly at different time points (F4,104 = 59.11, p < 0.0001). The higher the esophageal anastomotic site was, the faster G-POEM improved the symptoms of gastroesophageal reflux. No one required re-hospitalization for any complication.
Conclusion
G-POEM is a minimally invasive therapy with long-term effectiveness and safety in treating postsurgical gastroparesis.
... They reported no significant differences in clinical reflux, treatment scores or LES pressures between the 2 groups, though patients with a full thickness myotomy had a shorter procedural time [31]. This study finding was subsequently echoed by other groups as well, which also noted no increase in periprocedural complications [32]. Based on an international survey of POEM operators conducted in 2013, it appeared that most POEM operators still prefer a selective circular myotomy [33]. ...
Achalasia is the most common primary esophageal motility disorder. Since its introduction in 2009, Per-Oral Endoscopic Myotomy (POEM) for achalasia has been gaining widespread popularity throughout the world, with its minimally invasive nature and excellent results. This review article summarises the literature on the techniques and outcomes of POEM, as well as the latest and future clinical applications of this technique, for the management of achalasia, and other motility disorders of the gastrointestinal tract.
