Abstract
Background
Per oral endoscopic myotomy (POEM) has evolved as a novel therapeutic option for the treatment of esophageal motility disorders such as achalasia. The originally described dissection technique involves cutting the inner circular esophageal muscle fibers in an antegrade fashion. We have modified this technique by commencing the muscular division at the most distal aspect of the submucosal tunnel and continuing the dissection in a retrograde fashion. We present our initial series of patients performed using this modified technique.
Methods
We retrospectively reviewed our prospectively collected database. Peri- and postoperative data were collected and analyzed. POEM procedures were performed in a near-identical manner as previously published.
Results
Retrograde myotomy was performed on five patients with a diagnosis of achalasia. Four had a history of prior treatment including balloon dilation, with one of these having a prior surgical myotomy. Retrograde POEM procedures were performed with trace blood loss and without any complications. Mean operative time was 85 min. All patients had normal esophagram studies, and diets were advanced as per protocol.
Conclusion
POEM was developed as a minimally invasive method for the treatment of achalasia. Our retrograde dissection modification allows the most critical portion of the case, namely division of the lower esophageal and upper gastric circular muscle fibers, to be performed earlier in the case. This ensures adequate dissection of the primary site of esophageal dysfunction should problems arise during the procedure. The modification is straightforward, without the need for additional training or equipment, and appears to provide a more rapid myotomy with less charring in this small cohort of patients.
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References
Pasricha PJ, Hawari R, Ahmed I, Chen J, Cotton PB, Hawes RH, Kalloo AN, Kantsevoy SV, Gostout CJ (2007) Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy 39:761–764
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
Ponsky JL, Marks JM, Pauli EM (2012) How i do it: per-oral endoscopic myotomy (POEM). J Gastrointest Surg 16:1251–1255
Campos GM, Vittinghoff E, Rabl C, Takata M, Gadenstatter M, Lin F, Ciovica R (2009) Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis. Ann Surg 249:45–57
Blatnik JA, Ponsky JL (2014) Advances in the Treatment of Achalasia. Curr Treat Options Gastroenterol 12:49–58
Chuah SK, Chiu CH, Tai WC, Lee JH, Lu HI, Changchien CS, Tseng PH, Wu KL (2013) Current status in the treatment options for esophageal achalasia. World J Gastroenterol 19:5421–5429
Pescarus R, Shlomovitz E, Swanstrom LL (2014) Per-Oral Endoscopic Myotomy (POEM) for esophageal achalasia. Curr Gastroenterol Rep 16:369
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
Onimaru M, Inoue H, Ikeda H, Yoshida A, Santi EG, Sato H, Ito H, Maselli R, Kudo SE (2013) Peroral endoscopic myotomy is a viable option for failed surgical esophagocardiomyotomy instead of redo surgical Heller myotomy: a single center prospective study. J Am Coll Surg 217:598–605
Yang D, Wagh MS (2013) Peroral endoscopic myotomy for the treatment of achalasia: an analysis. Diagn Ther Endosc 2013:389596
Bredenoord AJ, Rosch T, Fockens P (2014) Peroral endoscopic myotomy for achalasia. Neurogastroenterol Motil 26:3–12
Acknowledgments
This study was funded by institutional support from University Hospitals Case Medical Center.
Disclosures
JLP has received consulting and/or speaking fees from US Endoscopy. JMM has received consulting fees from Olympus Corp, Merck, and Apollo Endosurgery. SBO has no financial disclosures or conflicts of interest.
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This study was funded by institutional support from University Hospitals Case Medical Center.
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Ponsky, J.L., Marks, J.M. & Orenstein, S.B. Retrograde myotomy: a variation in per oral endoscopic myotomy (POEM) technique. Surg Endosc 28, 3257–3259 (2014). https://doi.org/10.1007/s00464-014-3568-9
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DOI: https://doi.org/10.1007/s00464-014-3568-9