Difficult peroral endoscopic myotomy: definition and management strategies

ABSTRACT

Introduction: Peroral endoscopic myotomy (POEM) has been established as an alternative endoscopic method for the treatment of achalasia, and several studies have confirmed its relatively long-term efficacy. Although most of the POEM procedures can be smoothly completed, technical difficulties do arise during the treatment of some patients, which may lead to prolonged procedure duration, increased procedure-related complications, or even aborted POEM.

Area covered: In the present review, we provide a comprehensive review of difficult POEM, focusing on its definition, risk factors, and intraoperative management strategies. The present review is expected to provide tips for not so experienced operators who perform POEM.

Expert commentary: Submucosal fibrosis and sigmoid-type esophagus are associated with difficult POEM. Sometimes, the following may also be associated with difficult POEM: previous endoscopic or surgical treatments, spastic esophageal disorders (type III achalasia, distal esophageal spasm, and hypercontractile esophagus), achalasia with diverticulum or situs inversus. For operators who begin to perform POEM, I suggest an exclusion of patients with severe submucosal fibrosis or sigmoid-type esophagus, and begin to perform POEM for these patients when they have completed at least 50 cases of ‘easy POEM’ and the proposed management strategies may be helpful.

KEYWORDS:

• Achalasia
• endoscopic surgery
• esophageal motility disorders
• Peroral endoscopic myotomy
• technique difficulty

Article highlights

• Most of the POEM procedure could be smoothly completed, however, difficult POEM does occur in several cases.

• We present a definition of difficult POEM as: difficult POEM is characterized by a prolonged procedure time, occurrence of major intraoperative adverse events or aborted POEM procedures owing to the morphological or pathophysiologic changes of esophagus.

• Submucosal fibrosis and sigmoid-type esophagus are associated with difficult POEM.

• Patients with the following situations sometimes may also encounter difficult POEM: previous endoscopic or surgical treatments, spastic esophagus (type III achalasia, distal esophageal spasm, and hypercontractile esophagus), achalasia with diverticulum or situs inversus.

• Most of the technical difficulties experienced during POEM could be managed by modifications of the POEM procedure.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This study was funded by Development and Reform Commission of Hunan Province (no. XFGTZ2014713).