Surgical Endoscopy

, Volume 30, Issue 9, pp 3774–3782 | Cite as

Factors predicting the technical difficulty of peroral endoscopic myotomy for achalasia

  • Xiaowei Tang
  • Yutang Ren
  • Zhengjie Wei
  • Jieqiong Zhou
  • Zhiliang Deng
  • Zhenyu Chen
  • Bo Jiang
  • Wei GongEmail author



Peroral endoscopic myotomy (POEM) has been described as a novel treatment for esophageal achalasia. Owing to its technical difficulty, POEM is not widely performed. This study was aimed to prospectively assess the factor predicting technical difficulty of POEM in a single center with large volume cases.


A total of 105 cases of achalasia treated by POEM from April 2011 to September 2014 were analyzed. Difficult cases of POEM were defined as procedure time ≥90 min and occurrence of adverse events, including mucosal perforation, pneumothorax, and major bleeding. Univariate and multivariate logistic regression analyses were performed to assess the predictive factors of difficult POEM.


POEM was successfully completed in all the patients, and no one was converted to laparoscopy. The number of cases with procedure time ≥90 min was 17. Mucosal perforations occurred in six (5.7 %) patients during submucosal tunnel creation, major bleeding occurred in seven (6.7 %) patients, and pneumothorax occurred in six (5.7 %) patients immediately after procedure. All the complications were managed conservatively. No other intraoperative and immediate postoperative complications, including infections and pneumoperitoneum, occurred. Multivariate analysis showed that early period (odds ratio [OR] 4.173, 95 % confidence interval [95 % CI] 1.36–6.829, P = 0.023) and triangular tip knife ([OR] 6.712, [95 % CI] 1.479–30.460, P = 0.014) were independent factors associated with technical difficulty regarding longer procedure time (procedure time ≥90 min).


POEM is safe for the treatment of esophageal achalasia. Triangular tip knife and early period were independent risk factors for longer procedural time.


Esophageal achalasia Peroral endoscopic myotomy Technical difficulty Complication Predictor 



This study was supported by the grant from the National Natural Science Foundation of China (No. 81101610), Scientific Research Projects of Guangdong Province (No. 2013B021800311), and Medical Research Foundation of Guangdong Province (No. WSTJJ2011110142092192119760913465X).

Compliance with ethical standards


Drs. Xiaowei Tang, Yutang Ren, Zhengjie Wei, Zhiliang Deng, Jieqiong Zhou, Zhenyu Chen, Bo Jiang, and Wei Gong have no conflicts of interest or financial ties to disclose.


  1. 1.
    Richter JE (2010) Achalasia—an update. J Neurogastroenterol Motil 16(3):232–242CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Boeckxstaens GE, Zaninotto G, Richter JE (2014) Achalasia. Lancet 383(9911):83–93CrossRefPubMedGoogle Scholar
  3. 3.
    Triadafilopoulos G, Boeckxstaens GE, Gullo R, Patti MG, Pandolfino JE, Kahrilas PJ, Duranceau A, Jamieson G, Zaninotto G (2012) The Kagoshima consensus on esophageal achalasia. Dis Esophagus 25(4):337–348CrossRefPubMedGoogle Scholar
  4. 4.
    Boeckxstaens GE, Annese V, des Varannes SB, Chaussade S, Costantini M, Cuttitta A, Elizalde JI, Fumagalli U, Gaudric M, Rohof WO, Smout AJ, Tack J, Zwinderman AH, Zaninotto G, Busch OR, European Achalasia Trial I (2011) Pneumatic dilation versus laparoscopic Heller’s myotomy for idiopathic achalasia. N Engl J Med 364(19):1807–1816CrossRefPubMedGoogle Scholar
  5. 5.
    Richter JE, Boeckxstaens GE (2011) Management of achalasia: surgery or pneumatic dilation. Gut 60(6):869–876CrossRefPubMedGoogle Scholar
  6. 6.
    Karamanolis G, Sgouros S, Karatzias G, Papadopoulou E, Vasiliadis K, Stefanidis G, Mantides A (2005) Long-term outcome of pneumatic dilation in the treatment of achalasia. Am J Gastroenterol 100(2):270–274CrossRefPubMedGoogle Scholar
  7. 7.
    Kilic A, Schuchert MJ, Pennathur A, Gilbert S, Landreneau RJ, Luketich JD (2009) Long-term outcomes of laparoscopic Heller myotomy for achalasia. Surgery 146(4):826–831 discussion 831–823 CrossRefPubMedGoogle Scholar
  8. 8.
    Bechara R, Ikeda H, Inoue H (2015) Peroral endoscopic myotomy: an evolving treatment for achalasia. Nat Rev Gastroenterol Hepatol 12(7):410–426CrossRefPubMedGoogle Scholar
  9. 9.
    Committee NPWP, 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. Gastrointest Endosc 80(1):1–15CrossRefGoogle Scholar
  10. 10.
    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 8:329–342CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Bang BW, Choi YC, Kim HG, Kwon KS, Shin YW, Lee DH, Kim JM (2013) Peroral endoscopic myotomy for treating achalasia in an animal model: a feasibility study. Clin Endosc 46(1):54–58CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Chiu PW, Wu JC, Teoh AY, Chan Y, Wong SK, Liu SY, Yung MY, Lam CC, Sung JJ, Chan FK, Lau JY, Ng EK (2013) Peroral endoscopic myotomy for treatment of achalasia: from bench to bedside (with video). Gastrointest Endosc 77(1):29–38CrossRefPubMedGoogle Scholar
  13. 13.
    Teitelbaum EN, Soper NJ, Arafat FO, Santos BF, Kahrilas PJ, Pandolfino JE, Hungness ES (2014) Analysis of a learning curve and predictors of intraoperative difficulty for peroral esophageal myotomy (POEM). J Gastrointest Surg 18(1):92–98 (discussion 98–99) CrossRefPubMedGoogle Scholar
  14. 14.
    Gockel I, Junginger T (2007) The value of scoring achalasia: a comparison of current systems and the impact on treatment–the surgeon’s viewpoint. Am Surg 73(4):327–331PubMedGoogle Scholar
  15. 15.
    Kochman ML, McClave SA, Boyce HW (2005) The refractory and the recurrent esophageal stricture: a definition. Gastrointest Endosc 62(3):474–475CrossRefPubMedGoogle Scholar
  16. 16.
    Bredenoord AJ, Fox M, Kahrilas PJ, Pandolfino JE, Schwizer W, Smout AJ, International High Resolution Manometry Working G (2012) Chicago classification criteria of esophageal motility disorders defined in high resolution esophageal pressure topography. Neurogastroenterol Motil 24(Suppl 1):57–65CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    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(9):761–764CrossRefPubMedGoogle Scholar
  18. 18.
    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(4):265–271CrossRefPubMedGoogle Scholar
  19. 19.
    Li H, Linghu E, Wang X (2012) Fibrin sealant for closure of mucosal penetration at the cardia during peroral endoscopic myotomy (POEM). Endoscopy 44(Suppl 2 UCTN):E215–E216PubMedGoogle Scholar
  20. 20.
    Saxena P, Chavez YH, Kord Valeshabad A, Kalloo AN, Khashab MA (2013) An alternative method for mucosal flap closure during peroral endoscopic myotomy using an over-the-scope clipping device. Endoscopy 45(7):579–581CrossRefPubMedGoogle Scholar
  21. 21.
    Ling T, Pei Q, Pan J, Zhang X, Lv Y, Li W, Zou X (2013) Successful use of a covered, retrievable stent to seal a ruptured mucosal flap safety valve during peroral endoscopic myotomy in a child with achalasia. Endoscopy 45(Suppl 2 UCTN):E63–E64PubMedGoogle Scholar
  22. 22.
    Phalanusitthepha C, Inoue H, Ikeda H, Sato H, Sato C, Hokierti C (2014) Peroral endoscopic myotomy for esophageal achalasia. Ann Transl Med 2(3):31PubMedPubMedCentralGoogle Scholar
  23. 23.
    Ren Z, Zhong Y, Zhou P, Xu M, Cai M, Li L, Shi Q, Yao L (2012) Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases). Surg Endosc 26(11):3267–3272CrossRefPubMedGoogle Scholar
  24. 24.
    Yang D, Wagh MS (2013) Peroral endoscopic myotomy for the treatment of achalasia: an analysis. Diagn Ther Endosc 2013:389596CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Yasumasa K, Nakajima K, Endo S, Ito T, Matsuda H, Nishida T (2006) Carbon dioxide insufflation attenuates parietal blood flow obstruction in distended colon: potential advantages of carbon dioxide insufflated colonoscopy. Surg Endosc 20(4):587–594CrossRefPubMedGoogle Scholar
  26. 26.
    Eckardt AJ, Eckardt VF (2011) Treatment and surveillance strategies in achalasia: an update. Nat Rev Gastroenterol Hepatol 8(6):311–319CrossRefPubMedGoogle Scholar
  27. 27.
    Beckingham IJ, Callanan M, Louw JA, Bornman PC (1999) Laparoscopic cardiomyotomy for achalasia after failed balloon dilatation. Surg Endosc 13(5):493–496CrossRefPubMedGoogle Scholar
  28. 28.
    Smith CD, Stival A, Howell DL, Swafford V (2006) Endoscopic therapy for achalasia before Heller myotomy results in worse outcomes than Heller myotomy alone. Ann Surg 243(5):579–584 (discussion 584–576) CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    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(7):1188–1192CrossRefPubMedGoogle Scholar
  30. 30.
    Ling T, Guo H, Zou X (2014) Effect of peroral endoscopic myotomy in achalasia patients with failure of prior pneumatic dilation: a prospective case-control study. J Gastroenterol Hepatol 29(8):1609–1613CrossRefPubMedGoogle Scholar
  31. 31.
    Ramsay CR, Grant AM, Wallace SA, Garthwaite PH, Monk AF, Russell IT (2000) Assessment of the learning curve in health technologies. A systematic review. Int J Technol Assess Health Care 16(4):1095–1108CrossRefPubMedGoogle Scholar
  32. 32.
    Kurian AA, Dunst CM, Sharata A, Bhayani NH, Reavis KM, Swanstrom LL (2013) Peroral endoscopic esophageal myotomy: defining the learning curve. Gastrointest Endosc 77(5):719–725CrossRefPubMedGoogle Scholar
  33. 33.
    Patel KS, Calixte R, Modayil RJ, Friedel D, Brathwaite CE, Stavropoulos SN (2015) The light at the end of the tunnel: a single-operator learning curve analysis for per oral endoscopic myotomy. Gastrointest Endosc 81(5):1181–1187CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Xiaowei Tang
    • 1
    • 2
  • Yutang Ren
    • 2
  • Zhengjie Wei
    • 2
  • Jieqiong Zhou
    • 1
    • 2
  • Zhiliang Deng
    • 1
  • Zhenyu Chen
    • 1
  • Bo Jiang
    • 1
    • 2
  • Wei Gong
    • 1
    Email author
  1. 1.Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
  2. 2.Department of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical CenterTsinghua UniversityBeijingChina

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