Esophageal peroral endoscopic myotomy (POEM) for treatment of esophagogastric junction outflow obstruction: results from the first prospective trial

Abstract

Background and study aims Esophagogastric junction outflow obstruction (EGJOO) is a rare esophageal dysmotility disease that is characterized by elevated integrated relaxation pressuse (IRP) with evidence of preserved peristalsis. The role of peroral endoscopic myotomy (POEM) in management of EGJOO is currently unknown. Patients and methods This is a prospective trial conducted in a single US tertiary care center from June 2015 to June 2019. Symptomatic patients, diagnosed with EGJOO on both HRM and endoluminal functional lumen imaging probe (EndoFLIP), who were eligible for POEM were recruited. Primary outcome was clinical success, defined as Eckardt score (ES) ≤ 3, at 6 months post-POEM. Other outcomes included dysphagia score, quality of life as measured by 36-item Short Form health survey scales (SF-36), post-POEM HRM, EndoFLIP, and pH measurements, and adverse events. Results A total of 15 patients (51.8 yr. 9 F) with EGJOO underwent POEM. Pre-POEM mean IRP on HRM and Distensibility index (DI) on EndoFLIP were 24.3 ± 2.2 mmHg and 1.1 ± 0.6 mm2/mmHg, respectively. Clinical success was achieved in 93 % at 6 months post-POEM. There was significant decrease in IRP (-17.6 mmHg) post-POEM. There was significant improvement at 6 months in two of the SF-36 subscales. Ten patients underwent post-POEM pH testing, seven of whom had abnormal DeMeester score. Seven patients underwent EGD evaluation revealing esophagitis in five (2 Los Angeles grade A and 3 grade B). Conclusions POEM offers a high clinical success rate for patients with EGJOO confirmed by impedance planimetry.

Functional luminal imaging probe in the evaluation of esophago-gastric junction outflow obstruction

“…Another study found that 75% of patients diagnosed with EGJOO by HRM had an abnormal DI (<2.0 mm 2 /mmHg) [28 ▪▪ ]. Based on the several recent studies, it appears that FLIP can confirm a manometric diagnosis of EGJOO diagnosis in 53–75% of cases [9,28 ▪▪ ,29 ▪ ] (Table 1).…”

“…A prospective study of 28 patients by Ichkhanian et al showed that those who had a CCv3.0 diagnosis of EGJOO with no apparent mechanical cause and who had the diagnosis confirmed by FLIP (mean EGJ-DI 2.0 mm 2 /mmHg at 40 ml balloon fill volume) had 93% clinical success with (POEM) at 6 months follow-up [29 ▪ ]. The EGJOO cohort who underwent POEM was carefully selected, and 13 or the 28 patients were excluded based on FLIP panometry results.…”

Devices for esophageal function testing

“…27 Similarly, a recent study showed POEM to be a highly successful treatment for EGJOO confirmed by FLIP. 28 Assessment of treatment. A growing body of literature supports the role of FLIP in the real-time assessment of EGJ function during endoscopic or operative therapy for achalasia.…”

“… 27 Similarly, a recent study showed POEM to be a highly successful treatment for EGJOO confirmed by FLIP. 28 …”

Changes in the Treatment of Primary Esophageal Motility Disorders Imposed by the New Classification for Esophageal Motility Disorders on High Resolution Manometry (Chicago Classification 4.0)

“…This necessary update from version 3.0 including supportive testing and clinical correlation was fundamental to preventing overdiagnosis and unnecessary treatment since most individuals with a manometric picture of EJGOO are asymptomatic or have few symptoms which may often resolve spontaneously [25]. A surge in the indication of POEM for EJGOO was indeed seen after Chicago 3.0 [26][27][28]. These series apparently diagnosed EJGOO based mostly on manometric findings since supportive tests are not clearly mentioned and chest pain and/or dysphagia is not present in some patients.…”