Submucosal fibrosis in achalasia patients is a rare cause of aborted peroral endoscopic myotomy procedures

Abstract

Peroral endoscopic myotomy (POEM) is now an established treatment for esophageal achalasia. The standard protocol ensures a smooth operation in most patients, but technical challenges and failures exist and little is known about the incidence, causes, and impact of aborted procedures. Here, using a large patient cohort, we attempted to answer these questions. All patients admitted for planned POEM between August 2010 and July 2015 underwent chart review. Aborted POEM was defined as the inability to finish the procedure after submucosal injection. The cause of the failure, clinical course, management, and follow-up data were analyzed.Thirteen of the 1693 POEMs (0.77 %) were aborted. Out of the 13 failures, 12 (92.3 %) were due to severe submucosal fibrosis, which precluded tunneling, and one (7.7 %) was due to atrial fibrillation related to the electric current of the endoscopic knife. Submucosal fibrosis, prior Heller myotomy, and age ( ≥ 60 years) were related to technical failure, while a disease duration of ≥ 6 years, sigmoid esophagus, mucosal edema, and prior interventions were risk factors for the presence of fibrotic changes. In turn, fibrosis was correlated with a prolonged operation, longer hospital stay, more mucosal injuries, and more major perioperative adverse events. Finally, the yearly frequency of aborted POEMs decreased after the second year as operators became more experienced. Aborted POEM is a rare event and is largely due to the presence of submucosal fibrosis, which not only causes increased procedural difficulties, but also gives rise to major adverse events.

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

“…The PDS was shown to correlate well with procedural velocity and is an accurate measure of procedural difficulty. It has previously been shown that operative time indirectly correlates with complications . This supports the theory that the PDS will also correlate with complication rate.…”

“…Variables such as fibrosis, orientation, and spastic contractions have been reported to impact the performance of POEM . The PDS was created based on expert consensus within our group of POEM operators in addition to the variables previously described in the literature.…”

“…Presence of submucosal fibrosis is associated with increased procedure time and risk of adverse events in both endoscopic submucosal dissection (ESD) and POEM . Here, we used the same classification of submucosal fibrosis described by Jeong et al .…”

“…Variables such as fibrosis, orientation, and spastic contractions have been reported to impact the performance of POEM. 14,25,26 The PDS was created based on expert consensus within our group of POEM operators in addition to the variables previously described in the literature. The score consists of five variables: Fibrosis, Oozing, Orientation, Distention of tunnel and Spastic contractions ("FOODS").…”

“…Presence of submucosal fibrosis is associated with increased procedure time and risk of adverse events in both endoscopic submucosal dissection (ESD) and POEM. 25,27,28 Here, we used the same classification of submucosal fibrosis described by Jeong et al 29 Rarely, in severe fibrosis, POEM cannot be carried out as a result of inability to create the tunnel. 25 Submucosal fibrosis score ranges from 0 to 2 increasing with increments of 1 and is graded as follows: 0, minimal to no fibrosis (submucosa appears as a blue transparent layer); 1, mild-moderate fibrosis (submucosa appears as a white web-like tissue); 2, severe fibrosis (submucosa appears as white muscle-like structure without a blue transparent layer; Figure 2).…”