Peroral endoscopic myotomy (POEM) for complex achalasia and the POEM difficulty score

Abstract

Background Peroral endoscopic myotomy (POEM) for achalasia is technically challenging to carry out in patients with type III, multiple prior treatments, prior myotomy, and sigmoid type. Herein, we present a series of consecutive patients with complex achalasia and introduce the POEM difficulty score (PDS). Aim To demonstrate the application and discuss the utility of PDS and present the feasibility, safety, and efficacy of POEM in complex achalasia patients. Methods Forty consecutive POEM were carried out with 28 meeting the criteria for complex achalasia. Primary outcome was clinical success (Eckardt score ≤3) at a minimum of 3 months follow‐up. Secondary outcomes included adverse events, procedural velocity and PDS. Results Twenty‐eight complex and 12 non‐complex POEM procedures were carried out with 100% and 92% clinical success, respectively, without any major adverse events with a median follow up of 15 months (complex) and 8 months (non‐complex). Mean velocities for non‐complex, type III, prior myotomy, ≥4 procedures and sigmoid type were as follows: 4.4 ± 1.6, 4.8 ± 1.5, 5.9 ± 2.2, 6.9 ± 2.2 and 8.2 ± 3.2 min/cm, respectively. Median PDS for non‐complex, type III, prior myotomy, ≥4 treatments and sigmoid type were 1 (0–3), 2 (0–4), 2.5 (1–6), 3 (2–6) and 3.5 (1–6), respectively. PDS was shown to correlate well with procedural velocity with a correlation coefficient of 0.772 (Spearman's P < 0.001). Conclusions PDS identifies the factors that contribute to challenging POEM procedures and correlates well with procedural velocity. The order of increasing difficulty of POEM in complex achalasia appears to be type III, prior myotomy, ≥4 treatments and sigmoid type.

Novel triangle tip‐jet knife increases efficiency in peroral endoscopic myotomy for achalasia

“…The total score is calculated additively, with a maximum score of 10. Higher difficulty scores have been shown to correlate with lower efficiency 9 …”

“…The procedural difficulty was described using the POEM difficulty score (PDS), which has been used previously to quantify the difficulty of complex procedures. 9 The PDS takes into account five factors involved in procedural difficulty, summarized by the acronym “FOODS”: f ibrosis, o ozing (hemorrhage), o rientation, d istention of the submucosal tunnel, and s pastic contractions. Each factor is assigned a value between 0 and 2, with 2 representing the most difficulty.…”

Pilot prospective study on formal training in per-oral endoscopic myotomy (POEM) during advanced endoscopy fellowship

“…Procedural degree of difficulty and other technical parameters, including procedure time, were also documented. Procedural difficulty was assessed using a POEM difficulty score as previously proposed by Bechara et al [27]. This scoring system consists of five variables: fibrosis, oozing, orientation, distention of tunnel and spastic contractions.…”

Morphologic Changes in Esophageal Body Movement During Bolus Transport After Peroral Endoscopic Myotomy in Type III Achalasia

“…7,8 Additionally, POEM has been reported to be especially effective for type III achalasia and cases of failure or recurrence after PD or Heller myotomy. 9,10 Based on previous studies, we can hypothesize that in addition to decreasing LES pressure, POEM can also modify esophageal body movement in achalasia, and the effect may be distinguishable in type III achalasia compared to type I and II achalasia. The answer to this hypothesis will provide useful information for deciding the treatment strategy for achalasia, such as the length of myotomy, as well as for providing essential evidence for applying POEM in spastic esophageal motility disorders other than type III achalasia, such as jackhammer esophagus and distal esophageal spasm, in which LES relaxation during primary peristalsis is intact and the main pathophysiology is confined to the esophageal body.…”