Outcomes of anterior myotomy versus posterior myotomy during POEM: a randomized pilot study

Abstract

Background and study aims Peroral endoscopic myotomy (POEM) can be performed via an anterior or posterior approach, depending on the operator’s preference. Data are lacking on comparative outcomes of both approaches. Patients and methods This is a pilot randomized study comparing endoscopic anterior and posterior myotomy during POEM in patients with Achalasia cardia (AC). Patients were randomized into 2 groups (n = 30 in each group); anterior myotomy group (AG) and posterior myotomy group (PG) and were followed at 1, 3 and 6 months after POEM. Results Technical success was achieved in 100 % of cases in both groups and total operative time was comparable (AG – 65 ± 17.65 minutes versus PG – 61.2 ± 16.67; P = 0.38); Mucosotomies were more frequent in AG (20 % vs 3.3 %; P = 0.02). Difference in other perioperative adverse events (AE) including insufflation-related AE and bleeding in both groups were statistically insignificant. At 1-month follow-up Eckardt score AG 0.57 ± 0.56 vs PG 0.53 ± 0.71; ( P = 0.81), mean LES pressure AG 11.93 ± 6.36 vs PG 11.77 ± 6.61; ( P = 0.59) and esophageal emptying on timed barium swallow at 5 minutes AG 1.32 ± 1.08 cm vs PG 1.29 ± 0.79 cm; ( P = 0.09) were comparable in both groups. At 3 months, Eckardt score (0.52 ± 0.59 vs 0.63 ± 0.62; P = 0.51) was similar in both groups. Incidence of esophagitis on EGD was comparable in both groups (24 % vs 33.3 %; P = 0.45), however, pH metry at 3 months showed significantly more esophageal acid exposure in posterior group (2.98 % ± 4.24 vs 13.99 % ± 14.48; P < 0.01). At 6 months clinical efficacy and LES pressures were comparable in both groups. Conclusion Anterior and posterior approaches to POEM seem to have equal efficacy. However, the occurrence of mucosotomies was higher in the anterior myotomy group and acid exposure was higher with the posterior myotomy approach during POEM.

Peroral Endoscopic Myotomy in a Patient with Achalasia Cardia with Prior Heller’s Myotomy

“…On the stomach, the myotomy size should be more than 1 cm but less than 2 cm to deal with reflux. The POEM procedure consists of making a submucosal tunnel of 10 cm proximal to the gastroesophageal junction of the esophagus and myotomy of circular muscle layers approximately 2 cm into the cardia [9]. The longer myotomy size is often necessary in diffuse esophageal spasm jackhammer esophagus and type III achalasia [10].…”

“…It was reported that the anterior approach of POEM has equal efficacy as the posterior approach, but the anterior approach has a higher rate of mucosal injury (20 vs. 3.3 %). On the other hand, the posterior approach has a higher acid exposure than the anterior one (2.98 vs. 13.99 %) [9]. POEM after failed surgical myotomy also has a short-term clinical success rate of 92-100% by preventing previous myotomy scars including submucosal fibrosis [10].…”

“…Several adverse events of POEM were reported, such as mucosal perforation, pneumothorax, pleural effusion, insufflation-related problem, and bleeding (massive intraprocedural hemorrhage and delayed submucosal hematoma) [9,10]. Injury on the branch of the left gastric artery on the gastric side can cause bleeding in the proximal or distal cardia during the tunneling or myotomy [9]. Attention should be paid to perforation due to the connection between submucosal tunnel gas, the mediastinum, and peritoneum.…”

“…This perforation can be detected intraprocedurally and closed with clips. The POEM procedure, especially posterior myotomy, involves cutting the clasps and sling fiber at the gastroesophageal junction resulting in an increase in reflux that should be minimized [9]. Even though reflux esophagitis and symptomatic gastroesophageal reflux disease were well controlled by proton pump inhibitors for 3 months [15], the double-scope method can be used to reduce the reflux.…”

Aktuelle Therapie der Achalasie 2019

“…Allerdings sollte aus Sicherheitsgründen in der oberen Speiseröhre, oberhalb der Trachealbifurkation, kein anteriores POEM durchgeführt werden, wegen der Kolokalisation der Pars membranacea der Trachea. Zwei kleine randomisierte Studien haben die Ergebnisse nach anteriorem und posteriorem POEM untersucht [29,30]. In einer Arbeit wurde eine etwas erhöhte Rate der Mukosaläsionen nach anteriorem POEM und eine etwas erhöhte Refluxrate nach posteriorem POEM berichtet [30].…”