Abstract
Background
Since its introduction in 2010, per oral endoscopic myotomy (POEM) has offered an alternative to laparoscopic Heller myotomy for the treatment of achalasia. A gastric myotomy length of 3 cm has been recommended; however, it can be difficult to ensure that adequate submucosal dissection has been performed during the procedure. Commonly accepted endoscopic markers of the gastric side can be inaccurate, particularly in patients with prior endoscopic treatments, such as balloon dilation or Botox injection of the lower esophageal sphincter. We hypothesized that the use of a second endoscope would result in a more complete gastric myotomy.
Methods
One hundred consecutive achalasia patients were randomized into single- and double-scope POEM groups. In the treatment group, a second endoscope was used to obtain a retroflexed view of the gastric cardia, while the dissecting scope transilluminated from the end of the submucosal tunnel. Prospectively collected data were analyzed, including myotomy lengths, procedure times, adverse events, and clinical outcomes.
Results
POEM was completed with high rates of technical (98–100 %) and clinical success (93–97 %) in both groups, with a low rate of serious adverse events (2 %). The second endoscope resulted in a 17 min increase in procedure time (94 vs. 77 min), myotomy extension in 34 % of cases, and an increase in the average gastric myotomy length from 2.6 to 3.2 cm (p = 0.01).
Conclusion
A second endoscope is useful for ensuring a complete gastric myotomy during POEM. With minimal increase in procedure time and no increase in morbidity, it may be particularly useful in cases of sigmoid esophagus or otherwise altered anatomy that makes identification of the gastroesophageal junction difficult.
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References
Inoue H, Minami H, Kobayashi Y, Sato Y, Kaga M, Suzuki M, Satodate H, Odaka N, Itoh H, Kudo S (2010) Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 42:265–271
Bhayani NH, Kurian AA, Dunst CM, Sharata AM, Rieder E, Swanstrom LL (2014) A comparative study on comprehensive, objective outcomes of laparoscopic Heller myotomy with per-oral endoscopic myotomy (POEM) for achalasia. Ann Surg 259:1098–1103
Familiari P, Gigante G, Marchese M, Boskoski I, Tringali A, Perri V, Costamagna G (2015) Peroral endoscopic myotomy for esophageal achalasia: outcomes of the first 100 patients with short-term follow-up. Ann Surg. doi:10.1097/SLA.0000000000000992
Chen X, Li QP, Ji GZ, Ge XX, Zhang XH, Zhao XY, Miao L (2015) Two-year follow-up for 45 patients with achalasia who underwent peroral endoscopic myotomy. Eur J Cardio Thorac Surg 47:890–896
Sharata AM, Dunst CM, Pescarus R, Shlomovitz E, Wille AJ, Reavis KM, Swanstrom LL (2015) Peroral endoscopic myotomy (POEM) for esophageal primary motility disorders: analysis of 100 consecutive patients. J Gastrointest Surg 19:161–170
Teitelbaum EN, Soper NJ, Santos BF, Arafat FO, Pandolfino JE, Kahrilas PJ, Hirano I, Hungness ES (2014) Symptomatic and physiologic outcomes 1 year after peroral esophageal myotomy (POEM) for treatment of achalasia. Surg Endosc 28:3359–3365
Von Renteln D, Fuchs KH, Fockens P, Bauerfeind P, Vassiliou MC, Werner YB, Fried G, Breithaupt W, Heinrich H, Bredenoord AJ, Kersten JF, Verlaan T, Trevisonno M, Rosch T (2013) Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study. Gastroenterology 145:309–311
Costamagna G, Marchese M, Familiari P, Tringali A, Inoue H, Perri V (2012) Peroral endoscopic myotomy (POEM) for oesophageal achalasia: preliminary results in humans. Dig Liver Dis 44:827–832
Minami H, Isomoto H, Yamaguchi N, Matsushima K, Akazawa Y, Ohnita K, Takeshima F, Inoue H, Nakao K (2014) Peroral endoscopic myotomy for esophageal achalasia: clinical impact of 28 cases. Dig Endosc 26:43–51
Orenstein SB, Raigani S, Wu YV, Pauli EM, Phillips MS, Ponsky JL, Marks JM (2015) Per oral endoscopic myotomy (POEM) leads to similar results in patients with and without prior endoscopic or surgical therapy. Surg Endosc 29:1064–1070
Sharata A, Kurian AA, Dunst CM, Bhayani NH, Reavis KM, Swanstrom LL (2013) Peroral endoscopic myotomy (POEM) is safe and effective in the setting of prior endoscopic intervention. J Gastrointest Surg 17:1188–1192
Stavropoulos SN, Desilets DJ, Fuchs KH, Gostout CJ, Haber G, Inoue H, Kochman ML, Modayil R, Savides T, Scott DJ, Swanstrom LL, Vassiliou MC (2014) Per oral endoscopic myotomy white paper summary. Surg Endosc 28:2005–2019
Eleftheriadis N, Inoue H, Ikeda H, Onimaru M, Yoshida A, Hosoya T, Maselli R, Kudo SE (2012) Training in peroral endoscopic myotomy (POEM) for esophageal achalasia. Ther Clin Risk Manag 8:329–342
Oelschlager BK, Chang L, Pellegrini CA (2003) Improved outcome after extended gastric myotomy for achalasia. Arch Surg 138:490–495 (discussion 495–497)
Stavropoulos SN, Modayil RJ, Friedel D, Savides T (2013) The international per oral endoscopic myotomy survey (IPOEMS): a snapshot of the global POEM experience. Surg Endosc 27:3322–3338
Rieder E, Swanstrom LL, Perretta S, Lenglinger J, Riegler M, Dunst CM (2013) Intraoperative assessment of esophagogastric junction distensibility during per oral endoscopic myotomy (POEM) for esophageal motility disorders. Surg Endosc 27:400–405
Kumbhari V, Saxena P, Messallam AA, Aguila G, Tieu AH, El-Zein M, Kalloo AN, Khashab MA (2014) Fluoroscopy to document the extent of cardiomyotomy during peroral endoscopic myotomy. Endoscopy 46(Suppl 1):E369–370
Parra V, Kedia P, Minami H, Sharaiha RZ, Kahaleh M (2015) Endoscopic optical coherence tomography as a tool to evaluate successful myotomy after a peroral endoscopic myotomy. Gastrointest Endosc 81:1251
Baldaque-Silva F, Marques M, Vilas-Boas F, Maia JD, Sa F, Macedo G (2014) New transillumination auxiliary technique for peroral endoscopic myotomy. Gastrointest Endosc 79:544–545
Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213
Donahue PE, Teresi M, Patel S, Schlesinger PK (1999) Laparoscopic myotomy in achalasia: intraoperative evidence for myotomy of the gastric cardia. Dis Esophagus 12:30–36
Rohof WO, Hirsch DP, Kessing BF, Boeckxstaens GE (2012) Efficacy of treatment for patients with achalasia depends on the distensibility of the esophagogastric junction. Gastroenterology 143:328–335
Pandolfino JE, de Ruigh A, Nicodeme F, Xiao Y, Boris L, Kahrilas PJ (2013) Distensibility of the esophagogastric junction assessed with the functional lumen imaging probe (FLIP) in achalasia patients. Neurogastroenterol Motil 25:496–501
Teitelbaum EN, Soper NJ, Pandolfino JE, Kahrilas PJ, Boris L, Nicodeme F, Lin Z, Hungness ES (2014) An extended proximal esophageal myotomy is necessary to normalize EGJ distensibility during Heller myotomy for achalasia, but not POEM. Surg Endosc 28:2840–2847
Familiari P, Gigante G, Marchese M, Boskoski I, Bove V, Tringali A, Perri V, Onder G, Costamagna G (2014) EndoFLIP system for the intraoperative evaluation of peroral endoscopic myotomy. United Eur Gastroenterol J 2:77–83
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This study was conducted in accordance with the ethical standards of the Helsinki Declaration of 1964, as revised in 2013.
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Dr. Inoue is a member of the advisory board for Olympus. Kevin L. Grimes, Manabu Onimaru, Haruo Ikeda, Amarit Tansawet, Robert Bechara, and Shinwa Tanaka have no conflicts of interest or financial ties to disclose.
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Grimes, K.L., Inoue, H., Onimaru, M. et al. Double-scope per oral endoscopic myotomy (POEM): a prospective randomized controlled trial. Surg Endosc 30, 1344–1351 (2016). https://doi.org/10.1007/s00464-015-4396-2
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DOI: https://doi.org/10.1007/s00464-015-4396-2