Esophageal Third Space Endoscopy: Recent Advances
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.
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.
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.
KeywordsThird 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)
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
- 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
- 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
- 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
- 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.• 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.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.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.• 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).
- 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
- 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.
- 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.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
- 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.
- 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.
- 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.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.
- 55.Nabi Z, Nageshwar Reddy D, Ramchandani M. Recent advances in third-space endoscopy. Gastroenterol Hepatol (NY). 2018;14(4):224–32.Google Scholar
- 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
- 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