Advertisement

Esophageal Third Space Endoscopy: Recent Advances

  • Malav P. Parikh
  • Niyati M. Gupta
  • Madhusudhan R. SanakaEmail author
Esophagus (PG Iyer, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Esophagus

Abstract

Purpose of the review

The novel concept of third space endoscopy was first applied to humans in 2008 for the management of achalasia through peroral endoscopic myotomy (POEM) procedure. Over the ensuing 10 years, this revolutionary procedure, which started in Japan, has been adopted and mastered by surgeons and gastroenterologists across the globe. In this article, we review the recent innovations and applications of third space endoscopy in the management of esophageal disorders.

Recent findings

With experience and innovation, the application of third-space endoscopy has extended beyond achalasia, and currently, it is used in the management of other esophageal disorders including, spastic esophageal disorders, subepithelial tumors, complete esophageal obstruction, and esophageal diverticula.

Summary

The recent advances in third space endoscopic procedures have not only permitted endoscopic access to places, previously thought impossible, but also enabled the precision of surgery along with reduced peri-operative morbidity due to its minimally invasive nature. While short- and mid-term outcome studies have shown excellent results, we eagerly await the long-term outcome studies before these procedures could be established as the procedures of choice.

Keywords

Third space endoscopy Peroral endoscopic myotomy (POEM) Submucosal tunneling endoscopic resection (STER) Peroral endoscopic tunneling for restoration of the esophagus (POETRE) Submucosal tunneling endoscopic septum division (STESD) 

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare that there is no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, et al. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions. Gastrointest Endosc. 2004;60:114–7.CrossRefPubMedGoogle Scholar
  2. 2.
    Sumiyama K, Gostout CJ, Rajan E, Bakken TA, Knipschield MA, Marler RJ. Submucosal endoscopy with mucosal flap safety valve. Gastrointest Endosc. 2007;65:688–94.CrossRefPubMedGoogle Scholar
  3. 3.
    Pasricha PJ, Hawari R, Ahmed I, Chen J, Cotton P, Hawes R, et al. Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy. 2007;39:761–4.CrossRefPubMedGoogle Scholar
  4. 4.
    Inoue H, Minami H, Kobayashi Y, Sato Y, Kaga M, Suzuki M, et al. Peroral endocopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010;42:265–71.CrossRefPubMedGoogle Scholar
  5. 5.
    Khashab MA, Benias PC, Swanstrom LL. Endoscopic myotomy for foregut motility disorders. Gastroenterology. 2018;154(7):1901–10.CrossRefPubMedGoogle Scholar
  6. 6.
    Sanaka MR, Hayat U, Thota PN, Jegadeesan R, Ray M, Gabbard SL, et al. Efficacy of peroral endoscopic myotomy vs other achalasia treatments in improving esophageal function. World J Gastroenterol. 2016;22(20):4918–25.CrossRefPubMedGoogle Scholar
  7. 7.
    • Ramchandani M, Nabi Z, Reddy DN, Talele R, Darisetty S, Kotla R, et al. Outcomes of anterior myotomy versus posterior myotomy during POEM: a randomized pilot study. Endosc Int Open. 2018;6(2):E190–8. Randomized pilot study comparing outcomes of anterior vs. posterior myotomy in POEM.Google Scholar
  8. 8.
    Grimes KL, Inoue H, Onimaru M, Ikeda H, Tansawet A, Bechara R, et al. Double-scope per oral endoscopic myotomy (POEM): a prospective randomized controlled trial. Surg Endosc. 2016;30(4):1344–51.CrossRefPubMedGoogle Scholar
  9. 9.
    Inoue H, Sato H, Ikeda H, Onimaru M, Sato C, Minami H, et al. Per-Oral endoscopic myotomy: a series of 500 patients. J Am Coll Surg. 2015;221(2):256–64.CrossRefPubMedGoogle Scholar
  10. 10.
    Nabi Z, Ramchandani M, Chavan R, Kalapala R, Darisetty S, Rao GV, et al. Per-oral endoscopic myotomy for achalasia cardia: outcomes in over 400 consecutive patients. Endosc Int Open. 2017;5(5):E331–9.CrossRefPubMedGoogle Scholar
  11. 11.
    Akintoye E, Kumar N, Obaitan I, Alayo QA, Thompson CC. Peroral endoscopic myotomy: a meta-analysis. Endoscopy. 2016;48(12):1059–68 Epub 2016 Sep 12. Review.Google Scholar
  12. 12.
    Perbtani YB, Mramba LK, Yang D, et al. Life after per-oral endoscopic myotomy: long-term outcomes of quality of life and their association with Eckardt scores. Gastrointest Endosc. 2018;87(6):1415–1420.e1.CrossRefPubMedGoogle Scholar
  13. 13.
    Chen WF, Li QL, Zhou PH, Yao LQ, Xu MD, Zhang YQ, et al. Long-term outcomes of peroral endoscopic myotomy for achalasia in pediatric patients: a prospective, single-center study. Gastrointest Endosc. 2015;81(1):91–100.CrossRefPubMedGoogle Scholar
  14. 14.
    Miao S, Wu J, Lu J, Wang Y, Tang Z, Zhou Y, et al. Peroral endoscopic myotomy in children with achalasia: a relatively long-term single-center study. J Pediatr Gastroenterol Nutr. 2018;66(2):257–62.CrossRefPubMedGoogle Scholar
  15. 15.
    • Chen YI, Inoue H, Ujiki M, et al. An international multicenter study evaluating the clinical efficacy and safety of per-oral endoscopic myotomy in octogenarians. Gastrointest Endosc. 2018;87(4):956–61 International multicenter study assessing POEM outcomes in patient > 80 years of age.CrossRefPubMedGoogle Scholar
  16. 16.
    Kim WH, Cho JY, Ko WJ, Hong SP, Hahm KB, Cho JH, et al. Comparison of the outcomes of peroral endoscopic myotomy for achalasia according to manometric subtype. Gut and Liver. 2017;11(5):642–7.CrossRefPubMedGoogle Scholar
  17. 17.
    Sanaka MR, Parikh MP, Subramaniam S, et al. Peroral endoscopic myotomy (poem) is an effective treatment modality for all subtypes of achalasia. In: Program No. P2040. ACG 2018 Annual Scientific Meeting Abstracts. Philadelphia, Pennsylvania: American College of Gastroenterology; 2018.Google Scholar
  18. 18.
    • Sanaka MR, Parikh MP, Thota PN, Sarvepalli S, Gupta NM, Muthukuru S, et al. Tu1196. Obesity does not impact clinical outcomes or gastroesophageal reflux after peroral endoscopic myotomy (POEM) in patients with achalasia. Gastrointest Endosc. 87(6):AB565–6.   https://doi.org/10.1016/j.gie.2018.04.2226.First study comparing outcomes of POEM in obese and non-obese patients.
  19. 19.
    Sanaka MR, Parikh MP, Thota PN, et al. Severity of obesity does not impact the outcomes of peroral endoscopic myotomy (POEM) in achalasia. In: Program No. P2039. ACG 2018 Annual Scientific Meeting Abstracts. Philadelphia, Pennsylvania: American College of Gastroenterology; 2018.Google Scholar
  20. 20.
    Sato H, Takahashi K, Mizuno KI, Hashimoto S, Yokoyama J, Terai S. A clinical study of peroral endoscopic myotomy reveals that impaired lower esophageal sphincter relaxation in achalasia is not only defined by high-resolution manometry. PLoS One. 2018 Apr 2;13(4):e0195423.Google Scholar
  21. 21.
    • Sanaka MR, Parikh MP, Thota PN, Gupta NM, Gabbard S, Lopez R, et al. Peroral Endoscopic Myotomy Is Effective for Patients With Achalasia and Normal Lower-Esophageal Sphincter Relaxation Pressures. Clin Gastroenterol Hepatol. 2018.  https://doi.org/10.1016/j.cgh.2018.08.059.First study from USA showing efficacy of POEM in patients with normal lower esophageal sphincter-integrated relaxation pressure (LES-IRP).
  22. 22.
    Hungness ES, Sternbach JM, Teitelbaum EN, Kahrilas PJ, Pandolfino JE, Soper NJ. Per-oral endoscopic myotomy (POEM) after the learning curve: durable long-term results with a low complication rate. Ann Surg. 2016;264(3):508–17.CrossRefPubMedGoogle Scholar
  23. 23.
    Werner YB, Costamagna G, Swanström LL, von Renteln D, Familiari P, Sharata AM, et al. Clinical response to peroral endoscopic myotomy in patients with idiopathic achalasia at a minimum follow-up of 2 years. Gut. 2016;65(6):899–906.CrossRefPubMedGoogle Scholar
  24. 24.
    Khashab MA, Messallam AA, Onimaru M, Teitelbaum EN, Ujiki MB, Gitelis ME, et al. International multicenter experience with peroral endoscopic myotomy for the treatment of spastic esophageal disorders refractory to medical therapy (with video). Gastrointest Endosc. 2015;81(5):1170–7.CrossRefPubMedGoogle Scholar
  25. 25.
    Kahrilas PJ, Katzka D, Richter JE. Clinical practice update: the use of per-oral endoscopic myotomy in achalasia: expert review and best practice advice from the AGA Institute. Gastroenterology. 2017;153(5):1205–11.CrossRefPubMedGoogle Scholar
  26. 26.
    Khan MA, Kumbhari V, Ngamruengphong S, Ismail A, Chen YI, Chavez YH, et al. Is POEM the answer for management of spastic esophageal disorders? A systematic review and meta-analysis. Dig Dis Sci. 2017;62:35–44.CrossRefPubMedGoogle Scholar
  27. 27.
    Hu JW, Li QL, Zhou PH, Yao LQ, Xu MD, Zhang YQ, et al. Peroral endoscopic myotomy for advanced achalasia with sigmoid-shaped esophagus: long-term outcomes from a prospective, single-center study. Surg Endosc. 2015;29(9):2841–50.CrossRefPubMedGoogle Scholar
  28. 28.
    Bhayani NH, Kurian AA, Dunst CM, Sharata AM, Rieder E, Swanstrom LL. A comparative study on comprehensive, objective outcomes of laparoscopic Heller myotomy with per-oral endoscopic myotomy (POEM) for achalasia. Ann Surg. 2014;259(6):1098–103.CrossRefPubMedGoogle Scholar
  29. 29.
    • Schlottmann F, Luckett DJ, Fine J, et al. Laparoscopic Heller myotomy versus peroral endoscopic myotomy (POEM) for achalasia: a systematic review and meta-analysis. Ann Surg. 2018;267(3):451–60 A meta-analysis comparing outcomes between 5834 LHM and 1958 POEM patients.CrossRefPubMedGoogle Scholar
  30. 30.
    Awaiz A, Yunus RM, Khan S, Memon B, Memon MA. Systematic review and meta-analysis of perioperative outcomes of peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM) for achalasia. Surg Laparosc Endosc Percutan Tech. 2017;27(3):123–31.CrossRefPubMedGoogle Scholar
  31. 31.
    Sanaka MR, Parikh MP, Thota PN, Sarvepalli S, Gupta NM, Muthukuru S, et al. Tu1157. Comparison of outcomes of peroral endoscopic myotomy (POEM) in achalasia patients with or without prior laparoscopic Heller’s myotomy. Gastrointest Endosc. 87(6):AB546.  https://doi.org/10.1016/j.gie.2018.04.2187.
  32. 32.
    Onimaru M, Inoue H, Ikeda H, Yoshida A, Santi EG, Sato H, et al. 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. 2013;217(4):598–605.CrossRefPubMedGoogle Scholar
  33. 33.
    • Greenleaf EK, Winder JS, Hollenbeak CS, et al. Cost-effectiveness of per oral endoscopic myotomy relative to laparoscopic Heller myotomy for the treatment of achalasia. Surg Endosc. 2018;32(1):39–45 A study comparing cost-effectiveness of POEM and LHM.CrossRefPubMedGoogle Scholar
  34. 34.
    Meng F, Li P, Wang Y, Ji M, Wu Y, Yu L, et al. Peroral endoscopic myotomy compared with pneumatic dilation for newly diagnosed achalasia. Surg Endosc. 2017;31:4665–72.CrossRefPubMedGoogle Scholar
  35. 35.
    Ponds FA, Fockens P, Neuhaus H, Beyna T, Frieling T, Chiu P, et al. Peroral endoscopic myotomy (POEM) versus pneumatic dilatation in therapy-naive patients with achalasia: results of a randomized controlled trial. Gastroenterology. 2017;152(5 suppl 1):S139.CrossRefGoogle Scholar
  36. 36.
    Sanaka MR, Parikh MP, Thota PN, et al. Peroral endoscopic myotomy (poem) is a safe and effective treatment modality for achalasia patients after failed pneumatic dilatation (PD). Program No. 32. ACG 2018 Annual Scientific Meeting Abstracts. Philadelphia, Pennsylvania: American College of Gastroenterology; 2018.Google Scholar
  37. 37.
    van Hoeij FB, Ponds FA, Werner Y, Sternbach JM, Fockens P, Bastiaansen BA, et al. Management of recurrent symptoms after per-oral endoscopic myotomy in achalasia. Gastrointest Endosc. 2018;87(1):95–101.Google Scholar
  38. 38.
    Repici A, Fuccio L, Maselli R, et al. GERD after per-oral endoscopic myotomy as compared with Helle’s myotomy with fundoplication: a systematic review with meta-analysis. Gastrointest Endosc. 2018;87(4):934–943.e18.CrossRefPubMedGoogle Scholar
  39. 39.
    Sanaka MR, Thota PN, Parikh MP, Hayat U, Gupta NM, Gabbard S, et al. Peroral endoscopic myotomy leads to higher rates of abnormal esophageal acid exposure than laparoscopic Heller myotomy in achalasia. Surg Endosc. 2018.  https://doi.org/10.1007/s00464-018-6522-4.
  40. 40.
    Zhang XC, Li QL, Xu MD, et al. Major perioperative adverse events of peroral endoscopic myotomy: a systematic 5-year analysis. Endoscopy. 2016;48(11):967–78.CrossRefPubMedGoogle Scholar
  41. 41.
    Ell C, May A, Gossner L, Pech O, Günter E, Mayer G, et al. Endoscopic mucosal resection of early cancer and high-grade dysplasia in Barrett’s esophagus. Gastroenterology. 2000;118(4):670–7.CrossRefPubMedGoogle Scholar
  42. 42.
    Sanaka MR, Parikh MP, Muthukuru S, Raja S, Murthy S, Ahmad U, et al. Outcomes of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) in early esophageal adenocarcinoma associated with Barrett’s esophagus. Gastrointest Endosc. 87(6):AB551.  https://doi.org/10.1016/j.gie.2018.04.2196.
  43. 43.
    Oyama T, Tomori A, Hotta K, Morita S, Kominato K, Tanaka M, et al. Endoscopic submucosal dissection of early esophageal cancer. Clin Gastroenterol Hepatol. 2005;3(7 Suppl 1):S67–70.CrossRefPubMedGoogle Scholar
  44. 44.
    Parikh MP, Thota PN, Raja S, et al. Outcomes of endoscopic submucosal dissection in esophageal adenocarcinoma staged T1bN0 by endoscopic ultrasound in non-surgical patients. J Gastrointest Oncol. 2018.  https://doi.org/10.21037/jgo.2018.07.12.
  45. 45.
    Sanaka MR, Parikh MP, Raja S, CJ Tsai CJ, El-Hayek KM, Gorgun E, et al. Starting an endoscopic sub-mucosal dissection (ESD) program in the United States: initial experience of twenty cases. Gastrointest Endosc. 85(5):AB655.  https://doi.org/10.1016/j.gie.2017.03.1511.
  46. 46.
    Rajan E, Wong Kee Song LM. Endoscopic full thickness resection. Gastroenterology. 2018;154(7):1925–1937.e2.CrossRefPubMedGoogle Scholar
  47. 47.
    Xu MD, Cai MY, Zhou PH, Qin XY, Zhong YS, Chen WF, et al. Submucosal tunneling endoscopic resection: a new technique for treating upper GI submucosal tumors originating from the muscularis propria layer (with videos). Gastrointest Endosc. 2012;75(1):195–9.CrossRefPubMedGoogle Scholar
  48. 48.
    Chen T, Zhang C, Yao LQ, et al. Management of the complications of submucosal tunneling endoscopic resection for upper gastrointestinal submucosal tumors. Endoscopy. 2016;48(2):149–55.PubMedGoogle Scholar
  49. 49.
    Li QY, Meng Y, Xu YY, Zhang Q, Cai JQ, Zheng HX, et al. Comparison of endoscopic submucosal tunneling dissection and thoracoscopic enucleation for the treatment of esophageal submucosal tumors. Gastrointest Endosc. 2017;86(3):485–91.CrossRefPubMedGoogle Scholar
  50. 50.
    Sanaka MR, Parikh MP, Thota PN, Gupta NM, Raja S. Use of a novel submucosal tunneling and endoscopic resection (STER) technique for the removal of an esophageal leiomyoma. Am J Gastroenterol. 2017;111(12):986.CrossRefPubMedGoogle Scholar
  51. 51.
    Sanaka MR, Parikh MP, Thota PN, Gupta NM, Raja S. Erratum: use of a novel submucosal tunneling and endoscopic resection (STER) technique for the removal of an esophageal leiomyoma. Am J Gastroenterol. 2018;113(1):154.CrossRefPubMedGoogle Scholar
  52. 52.
    Ye LP, Zhang Y, Mao XL, Zhu LH, Zhou X, Chen JY. Submucosal tunneling endoscopic resection for small upper gastrointestinal subepithelial tumors originating from the muscularis propria layer. Surg Endosc. 2014;28(2):524–30.CrossRefPubMedGoogle Scholar
  53. 53.
    Wang H, Tan Y, Zhou Y, Wang Y, Li C, Zhou J, et al. Submucosal tunneling endoscopic resection for upper gastrointestinal submucosal tumors originating from the muscularis propria layer. Eur J Gastroenterol Hepatol. 2015;27(7):776–80.CrossRefPubMedGoogle Scholar
  54. 54.
    Yang D, Draganov PV. Expanding role of third space endoscopy in the management of esophageal diseases. Curr Treat Options Gastroenterol. 2018;16(1):41–57.CrossRefPubMedGoogle Scholar
  55. 55.
    Nabi Z, Nageshwar Reddy D, Ramchandani M. Recent advances in third-space endoscopy. Gastroenterol Hepatol (NY). 2018;14(4):224–32.Google Scholar
  56. 56.
    Lv XH, Wang CH, Xie Y. Efficacy and safety of submucosal tunneling endoscopic resection for upper gastrointestinal submucosal tumors: a systematic review and meta-analysis. Surg Endosc. 2017;31:49–63.CrossRefPubMedGoogle Scholar
  57. 57.
    Tan Y, Lv L, Duan T, Zhou J, Peng D, Tang Y, et al. Comparison between submucosal tunneling endoscopic resection and video assisted thoracoscopic surgery for large esophageal leiomyoma originating from the muscularis propria layer. Surg Endosc. 2016;30:3121–7.CrossRefPubMedGoogle Scholar
  58. 58.
    Chen T, Lin ZW, Zhang YQ, Chen WF, Zhong YS, Wang Q, et al. Submucosal tunneling endoscopic resection vs thoracoscopic enucleation for large submucosal tumors in the esophagus and the esophagogastric junction. J Am Coll Surg. 2017;225(6):806–16.CrossRefPubMedGoogle Scholar
  59. 59.
    Demetri GD, Von Mehren M, Antonescu CR, et al. NCCN Task Force report: update on the management of patients with gastrointestinal stromal tumors. J Natl Compr Canc Netw. 2010;8(suppl 2):S1–S41 quiz S42–44.Google Scholar
  60. 60.
    Lawson JD, Otto K, Grist W, Johnstone PAS. Frequency of esophageal stenosis after simultaneous modulated accelerated radiation therapy and chemotherapy for head and neck cancer. Am J Otolaryngol. 2008;29:13–9.CrossRefPubMedGoogle Scholar
  61. 61.
    Boyce HW, Estores DS, Gaziano J, Padhya T, Runk J. Endoscopic lumen restoration for obstructive aphagia: outcomes of a 25-year experience. Gastrointest Endosc. 2012;76:25–31.CrossRefPubMedGoogle Scholar
  62. 62.
    Gornals JB, Consiglieri C, Castellvi JM, et al. Treatment of complete esophageal stenosis using endoscopic ultrasound-guided puncture: a novel technique for access to the distal lumen. Endoscopy. 2014;46(Suppl 1 UCTN):E2–3.PubMedGoogle Scholar
  63. 63.
    Wagh MS, Draganov PV. Per-oral endoscopic tunneling for restoration of the esophagus: a novel endoscopic submucosal dissection technique for therapy of complete esophageal obstruction. Gastrointest Endosc. 2017;85(4):722–7.CrossRefPubMedGoogle Scholar
  64. 64.
    Smith CD. Esophageal strictures and diverticula. Surg Clin North Am. 2015;95(3):669–81.CrossRefPubMedGoogle Scholar
  65. 65.
    Quan-Lin L, Wei-Feng C, Xiao-Cen Z, et al. Submucosal tunneling endoscopic septum division: a novel technique for treating Zenker’s diverticulum. Gastroenterology. 2016;151:1071–4.CrossRefGoogle Scholar
  66. 66.
    Mou Y, Zeng H, Wang Q, Yi H, Liu W, Wen D, et al. Giant mid-esophageal diverticula successfully treated by per-oral endoscopic myotomy. Surg Endosc. 2016;30(1):335–8.CrossRefPubMedGoogle Scholar
  67. 67.
    Cai M, Xu M, Li Q, et al. Preliminary results of submucosal tunneling endoscopic septum division in the treatment of esophageal diverticulum. Zhonghua Wei Chang Wai Ke Za Zhi. 2017;25;20(5):530–4 Chinese.Google Scholar
  68. 68.
    Watemberg S, Landau O, Avrahami R. Zenker’s diverticulum: reappraisal. Am J Gastroenterol. 1996;91:1494–8.PubMedGoogle Scholar
  69. 69.
    Ishaq S, Hassan C, Antonello A, et al. Flexible endoscopic treatment for Zenker’s diverticulum: a systematic review and meta-analysis. Gastrointest Endosc. 2016;83:1076–1089.e5.CrossRefPubMedGoogle Scholar
  70. 70.
    Hernández Mondragón OV, Solórzano Pineda MO, Blancas Valencia JM. Zenker’s diverticulum: submucosal tunneling endoscopic septum division (Z-POEM). Dig Endosc. 2018;30(1):124.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Malav P. Parikh
    • 1
  • Niyati M. Gupta
    • 1
  • Madhusudhan R. Sanaka
    • 1
    Email author
  1. 1.Department of Gastroenterology and HepatologyCleveland Clinic FoundationClevelandUSA

Personalised recommendations