Abstract
Background
POEM (Per Oral Endoscopic Myotomy) is rapidly becoming a valid option for surgical myotomy in achalasia patients. Several techniques to perform POEM are described, but all concentrate on the division of the circular muscle fibers in a proximal-to-distal fashion. Our aim is to present the distal-to-proximal, or the bottom-up technique using the Flush/Dual knife, which overcomes the disadvantages of the standard technique.
Methods
A retrospective study on a prospectively maintained database was performed on all patients treated by POEM in our institution. Clinical presentation, operating time, adverse events, and outcomes were studied.
Results
POEM was performed on 105 achalasia patients. The first 15 cases were performed using the standard technique and were compared to the next 90 cases performed using the bottom-up technique. The average preop Eckardt scores in the standard and bottom-up groups were 9.5 and 8.8, respectively, declining to 1.4 and 0.5, 3 months post myotomy (p < 0.001). The average procedure time was 111.2 min for the standard technique and 74.3 for the bottom-up technique. (p = 0.002). Perioperative adverse events included 14 instances of pneumoperitoneum, 3 tunnel leaks, and 4 patients with fever on postoperative day one. Pneumoperitoneum needing decompression and postoperative fever were more prevalent in the standard technique group.
Conclusions
As POEM is becoming more common for the treatment of achalasia, refinements of the technique and instruments used are valuable. We compared our experience of the standard technique to our bottom-up technique and found the latter to be equally effective as well as safer, faster, and easier. We, therefore, suggest considering performing POEM in this technique.
Similar content being viewed by others
References
Zaninotto GBC, The CMK et al (2018) ISDE Achalasia Guidelines. Dis Esophagus 2018:31
Kahrilas PJPJ (2017) Treatments for achalasia in 2017: how to choose among them. Curr Opin Gastroenterol 33:270–276
Schaheen LWSM, Luketich JD (2018) Peroral Endoscopic myotomy for achalasia. Thorac Surg Clin 28:499–506
Kawahara YSK, Tajiri H (2015) Chemically assisted peroral endoscopic myotmy with submucosal mesna injection in a porcine model. Minim Invasive Therapy & Allied Technologies 24:334–339
Sumiyama KTH, Gostout CJ (2008) Submucosal endoscopy with mucosal flap safety valve (SEMF) technique: a safe access method into the peritoneal cavity and mediastinum. Minim Invasive Therapy & Allied Technologies 17:365–369
Inoue HSH, Iwakiri K et al (2018) Clinical practice guidelines for peroral enodscopic myotomy. Dig Endosc 30:563–579
Inoue HUA (2019) Shimamura Y et al Peroral endoscopic myotomy and fundoplication: a novel NOTES procedure. Endoscopy 51:161–164
Ramchandani MNZ, Reddy DN et al (2018) Outcomes of anterior myotomy versus posterior myotomy during POEM; a randomized pilot study. Endosc Int Open 6:E190–E198
Tan YLL, Wang X et al (2018) Efficacy of anterior versus posterior per-oral endoscopic myotomy for treating achalasia: a randomized, prospective study. Gastrointest Endosc 88:46–54
Kahrilas PJKD, Richter JE (2017) Clinical Practice Update: The Use of Per-Oral Endoscopic Myotomy in Achalasia: Expert Review and Best Practice Advice from the AGA Institute. Gastoenterology 153:1205–1211
Stavropoulos SNFD, Modayil R et al (2013) Endoscopic approaches to treatment of achalasia. Therap Adv Gastroenterol 6:115–135
Gockel IJT (2007) THe value of scoring achalasia: a comparison of current systems and the impact on treatment- the surgeon’s viewpoint. Am Surg 73:327–331
Li HPW, Huang S et al (2019) The 2 Years’ long-term efficacy and safety of peroral endoscopic myotomy for the treatment of achalasia a systematic review. J CadriothoracSurg. https://doi.org/10.1186/s13019-018-0811-9
Cho YKKS (2018) Current Status of Peroral Endoscopic Myotomy. Clin Endosc 51:13–18
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Disclosures
Drs. Gad Marom, Harold Jacob, Ariel Benson, Tiberiu Hershcovici, Rachel Gefen, Jonathan B Yuval, Ronit Brodie, Avraham I Rivkind, and Yoav Mintz have no conflicts of interest or financial ties to disclose.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Marom, G., Jacob, H., Benson, A. et al. The POEM bottom-up technique for achalasia. Surg Endosc 35, 6117–6122 (2021). https://doi.org/10.1007/s00464-020-08106-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-020-08106-1