POEM is safe, effective in achalasia

Peroral endoscopic myotomy is a safe and effective therapy for achalasia, with 82% of patients in symptom remission at 12 months post treatment.

"With [peroral endoscopic myotomy] it seems possible to emulate the surgical principles of laparoscopic Heller myotomy without the need for skin incisions and to reduce the procedural trauma," reported Dr. Daniel Von Renteln and colleagues. The findings are in the August issue of Gastroenterology.

According to Dr. Von Renteln of the University Hospital Hamburg-Eppendorf in Hamburg, Germany, peroral endoscopic myotomy (POEM) is a novel alternative achalasia treatment.

As described previously (Endoscopy 2010;42:265-71), under general anesthesia and following endoscopy to visualize the gastroesophageal junction, a mucosal incision is made to create entry to the submucosal space. A submucosal tunnel is then created, extending downward, allowing myotomy of the esophageal sphincter. The mucosal entry site is then closed with hemostatic clips.

In the present study, the researchers looked at 70 patients who underwent the procedure at five centers in Europe and North America.

The mean procedure time for POEM was 105 minutes and the mean length of myotomy was 13 cm. Patients experienced a small but significant drop in hemoglobin post procedure (from 13 to 12 g/dL, P less than .001) as well as small but significant increases in leukocyte count and C-reactive protein levels.

At 3 months post procedure, treatment success was achieved in 97% of cases, with mean Eckhardt scores decreasing from 7 pre procedure to 1 post procedure (P less than .001).

Of the 61 patients who underwent manometry at 3 months, the researchers found that the mean pretreatment and posttreatment lower esophageal sphincter pressures were 28 mm Hg versus 9 mm Hg, respectively (P less than .001).

Results at 6 months and 12 months were comparable, with treatment success of 88.5% and 82.4%, respectively, and mean Eckhardt scores of 1.3 and 1.7, respectively (P less than .001 for both).

Patients who failed treatment subsequently underwent laparoscopic Heller myotomy (n = 3) or balloon dilatation (n = 5), with safe and effective outcomes, reported the authors.

"Because the target area for the myotomy during POEM is lateral (on the lesser curvature side) and the myotomy during LHM is anterior, subsequent LHM seems to be a feasible second-line treatment if POEM fails."

Moreover, roughly half of the patients in the current study had previously undergone endoscopic balloon dilatation or botulinum toxin injection before POEM, the researchers wrote. "This shows that POEM is safe and efficient after previous treatments."

Nevertheless, the procedure is not without risk. "Visible complete transmural openings into the mediastinum and into the peritoneal cavity occurred in the majority of patients," they pointed out. "Therefore, POEM potentially carries the risk of mediastinitis/peritonitis and/or damage to surrounding organs."

Clip dislocation at mucosal closure (n = 3), mucosal injury through electrocautery or laceration (n = 3), and bleeding requiring intervention also occurred (n = 1).

Finally, looking at postprocedure reflux rates, at 12 months, roughly 37% of patients complained of gastroesophageal reflux, with just under 8% of these patients reporting reflux symptoms daily.

Overall, 29% were prescribed a proton pump inhibitor; 19.6% of these used a PPI daily.

The authors disclosed no conflicts of interest. The study was supported by EURO-NOTES Foundation – a partnership between the European Association for Endoscopic Surgery and the European Society of Gastrointestinal Endoscopy – and Olympus, maker of endotherapeutic supplies.

Peroral endoscopic myotomy is a safe and effective therapy for achalasia, with 82% of patients in symptom remission at 12 months post treatment.

"With [peroral endoscopic myotomy] it seems possible to emulate the surgical principles of laparoscopic Heller myotomy without the need for skin incisions and to reduce the procedural trauma," reported Dr. Daniel Von Renteln and colleagues. The findings are in the August issue of Gastroenterology.

According to Dr. Von Renteln of the University Hospital Hamburg-Eppendorf in Hamburg, Germany, peroral endoscopic myotomy (POEM) is a novel alternative achalasia treatment.

As described previously (Endoscopy 2010;42:265-71), under general anesthesia and following endoscopy to visualize the gastroesophageal junction, a mucosal incision is made to create entry to the submucosal space. A submucosal tunnel is then created, extending downward, allowing myotomy of the esophageal sphincter. The mucosal entry site is then closed with hemostatic clips.

In the present study, the researchers looked at 70 patients who underwent the procedure at five centers in Europe and North America.

The mean procedure time for POEM was 105 minutes and the mean length of myotomy was 13 cm. Patients experienced a small but significant drop in hemoglobin post procedure (from 13 to 12 g/dL, P less than .001) as well as small but significant increases in leukocyte count and C-reactive protein levels.

At 3 months post procedure, treatment success was achieved in 97% of cases, with mean Eckhardt scores decreasing from 7 pre procedure to 1 post procedure (P less than .001).

Of the 61 patients who underwent manometry at 3 months, the researchers found that the mean pretreatment and posttreatment lower esophageal sphincter pressures were 28 mm Hg versus 9 mm Hg, respectively (P less than .001).

Results at 6 months and 12 months were comparable, with treatment success of 88.5% and 82.4%, respectively, and mean Eckhardt scores of 1.3 and 1.7, respectively (P less than .001 for both).

Patients who failed treatment subsequently underwent laparoscopic Heller myotomy (n = 3) or balloon dilatation (n = 5), with safe and effective outcomes, reported the authors.

"Because the target area for the myotomy during POEM is lateral (on the lesser curvature side) and the myotomy during LHM is anterior, subsequent LHM seems to be a feasible second-line treatment if POEM fails."

Moreover, roughly half of the patients in the current study had previously undergone endoscopic balloon dilatation or botulinum toxin injection before POEM, the researchers wrote. "This shows that POEM is safe and efficient after previous treatments."

Nevertheless, the procedure is not without risk. "Visible complete transmural openings into the mediastinum and into the peritoneal cavity occurred in the majority of patients," they pointed out. "Therefore, POEM potentially carries the risk of mediastinitis/peritonitis and/or damage to surrounding organs."

Clip dislocation at mucosal closure (n = 3), mucosal injury through electrocautery or laceration (n = 3), and bleeding requiring intervention also occurred (n = 1).

Finally, looking at postprocedure reflux rates, at 12 months, roughly 37% of patients complained of gastroesophageal reflux, with just under 8% of these patients reporting reflux symptoms daily.

Overall, 29% were prescribed a proton pump inhibitor; 19.6% of these used a PPI daily.

The authors disclosed no conflicts of interest. The study was supported by EURO-NOTES Foundation – a partnership between the European Association for Endoscopic Surgery and the European Society of Gastrointestinal Endoscopy – and Olympus, maker of endotherapeutic supplies.

Peroral endoscopic myotomy is a safe and effective therapy for achalasia, with 82% of patients in symptom remission at 12 months post treatment.

"With [peroral endoscopic myotomy] it seems possible to emulate the surgical principles of laparoscopic Heller myotomy without the need for skin incisions and to reduce the procedural trauma," reported Dr. Daniel Von Renteln and colleagues. The findings are in the August issue of Gastroenterology.

According to Dr. Von Renteln of the University Hospital Hamburg-Eppendorf in Hamburg, Germany, peroral endoscopic myotomy (POEM) is a novel alternative achalasia treatment.

As described previously (Endoscopy 2010;42:265-71), under general anesthesia and following endoscopy to visualize the gastroesophageal junction, a mucosal incision is made to create entry to the submucosal space. A submucosal tunnel is then created, extending downward, allowing myotomy of the esophageal sphincter. The mucosal entry site is then closed with hemostatic clips.

In the present study, the researchers looked at 70 patients who underwent the procedure at five centers in Europe and North America.

The mean procedure time for POEM was 105 minutes and the mean length of myotomy was 13 cm. Patients experienced a small but significant drop in hemoglobin post procedure (from 13 to 12 g/dL, P less than .001) as well as small but significant increases in leukocyte count and C-reactive protein levels.

At 3 months post procedure, treatment success was achieved in 97% of cases, with mean Eckhardt scores decreasing from 7 pre procedure to 1 post procedure (P less than .001).

Of the 61 patients who underwent manometry at 3 months, the researchers found that the mean pretreatment and posttreatment lower esophageal sphincter pressures were 28 mm Hg versus 9 mm Hg, respectively (P less than .001).

Results at 6 months and 12 months were comparable, with treatment success of 88.5% and 82.4%, respectively, and mean Eckhardt scores of 1.3 and 1.7, respectively (P less than .001 for both).

Patients who failed treatment subsequently underwent laparoscopic Heller myotomy (n = 3) or balloon dilatation (n = 5), with safe and effective outcomes, reported the authors.

"Because the target area for the myotomy during POEM is lateral (on the lesser curvature side) and the myotomy during LHM is anterior, subsequent LHM seems to be a feasible second-line treatment if POEM fails."

Moreover, roughly half of the patients in the current study had previously undergone endoscopic balloon dilatation or botulinum toxin injection before POEM, the researchers wrote. "This shows that POEM is safe and efficient after previous treatments."

Nevertheless, the procedure is not without risk. "Visible complete transmural openings into the mediastinum and into the peritoneal cavity occurred in the majority of patients," they pointed out. "Therefore, POEM potentially carries the risk of mediastinitis/peritonitis and/or damage to surrounding organs."

Clip dislocation at mucosal closure (n = 3), mucosal injury through electrocautery or laceration (n = 3), and bleeding requiring intervention also occurred (n = 1).

Finally, looking at postprocedure reflux rates, at 12 months, roughly 37% of patients complained of gastroesophageal reflux, with just under 8% of these patients reporting reflux symptoms daily.

Overall, 29% were prescribed a proton pump inhibitor; 19.6% of these used a PPI daily.

The authors disclosed no conflicts of interest. The study was supported by EURO-NOTES Foundation – a partnership between the European Association for Endoscopic Surgery and the European Society of Gastrointestinal Endoscopy – and Olympus, maker of endotherapeutic supplies.