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Per-oral endoscopic myotomy white paper summary

2014; Elsevier BV; Volume: 80; Issue: 1 Linguagem: Inglês

10.1016/j.gie.2014.04.014

ISSN

1097-6779

Autores

Stavros N. Stavropoulos, David J. Desilets, Karl‐Hermann Fuchs, Christopher J. Gostout, Gregory Haber, Haruhiro Inoue, Michael L. Kochman, Rani J. Modayil, Thomas J. Savides, Daniel J. Scott, Lee L. Swanström, Melina C. Vassiliou,

Tópico(s)

Dysphagia Assessment and Management

Resumo

Achalasia is an uncommon esophageal motility disorder in which there is selective loss of inhibitory neurons resulting in loss of peristalsis and failure of adequate relaxation of the lower esophageal sphincter (LES) in response to food bolus. There is no current curative treatment that reverses the pathophysiology of achalasia. The treatment options are aimed at improving the passage of solids and liquids through the gastroesophageal junction (GEJ). The traditional treatment options include surgical myotomy and endoscopic methods that disrupt or weaken the LES, such as endoscopic balloon dilation and botulinum toxin injection (BI). Per-oral endoscopic myotomy (POEM) represents a natural orifice transluminal endoscopic surgery (NOTES) approach to Heller myotomy. Preliminary data suggest that this minimally invasive endoscopic procedure may achieve clinical results similar to those of surgical myotomy. As part of the annual Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) meeting held in Chicago in July 2012, a conference was organized to collaboratively review POEM and develop a consensus document on the current status of POEM. An International POEM Survey (IPOEMS) was designed and conducted by the session moderators as part of this NOSCAR initiative to attempt to supplement the scant published literature with current data from POEM early adopters. The survey, which has now been published in detail,1Stavropoulos S.N. Modayil R. Friedel D. et al.The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience.Surg Endosc. 2013; 27: 3322-3338Crossref PubMed Scopus (205) Google Scholar included 5 Asian, 7 North American, and 4 European expert centers with a combined experience of 841 POEM procedures, including all high-volume centers (>30 cases per center) at the time of the survey in July 2012. These data span every aspect of POEM and were made available to the NOSCAR POEM panel presenters to assist them with preparation of their panel presentations that served as the basis of this white paper. This white paper is intended to discuss the development of POEM and outline the current state of POEM with regard to technique, indications and/or contraindications, peri-procedural evaluation and care, efficacy, safety, training, approach to starting a POEM program, and future perspectives. The sources of evidence used included: (1) published data up to December 2013 [given the scarcity of series published in full form, we included selected abstracts with significant numbers of POEMs and adequate discussion of outcomes], (2) data from the IPOEMS, and (3) the minutes of the round-table discussion that followed the presentations by panel members of the POEM section at the annual NOSCAR meeting in Chicago in July 2012. This discussion included additional POEM operators from the United States and abroad beyond the panelists. This document represents the shorter print version of a more detailed online white paper document. Initial work by the Mayo Clinic Developmental Endoscopy Unit and the Apollo Group on widespread endoscopic mucosal resection, identified that with this endoscopic technique, the mucosa readily separates from the deeper layers of the gut wall, often referred to as delamination.2Rajan E. Gostout C.J. Feitoza A.B. et al.Widespread EMR: a new technique for removal of large areas of mucosa.Gastrointest Endosc. 2004; 60: 623-627Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar The 2004 Submucosal Inside Out Project began to transform the submucosa into an endoscopic working space.3Gostout C.J. Knipschield M.A. Submucosal endoscopy with mucosal resection: a hybrid endoscopic submucosal dissection in the porcine rectum and distal colon.Gastrointest Endosc. 2012; 76: 829-834Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 4ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery: white paper October 2005.Gastrointest Endosc. 2006; 63: 199-203Abstract Full Text Full Text PDF PubMed Scopus (361) Google Scholar, 5Sumiyama K. Gostout C.J. Rajan E. et al.Submucosal endoscopy with mucosal flap safety valve.Gastrointest Endosc. 2007; 65: 688-694Abstract Full Text Full Text PDF PubMed Scopus (174) Google Scholar, 6Sumiyama K. Gostout C.J. Rajan E. et al.Transesophageal mediastinoscopy by submucosal endoscopy with mucosal flap safety valve technique.Gastrointest Endosc. 2007; 65: 679-683Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar Strategies were developed to work beneath the mucosa toward the lumen to enable en bloc excision of mucosal disease. Strategies also were developed to exit the gut wall by using a tunneled offset entry point for safe entry into body cavities, by means of a myotomy, with the overlying mucosa serving as a protective sealant flap (submucosal endoscopy with mucosal flap). Animal studies confirmed the feasibility and safety of exiting the esophagus into the mediastinum through a 2-cm myotomy.5Sumiyama K. Gostout C.J. Rajan E. et al.Submucosal endoscopy with mucosal flap safety valve.Gastrointest Endosc. 2007; 65: 688-694Abstract Full Text Full Text PDF PubMed Scopus (174) Google Scholar, 6Sumiyama K. Gostout C.J. Rajan E. et al.Transesophageal mediastinoscopy by submucosal endoscopy with mucosal flap safety valve technique.Gastrointest Endosc. 2007; 65: 679-683Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar It was suggested that the myotomy could be applied as an alternative therapy for achalasia. A subsequent animal study confirmed that submucosal endoscopy with mucosal flap combined with incision of the inner circular muscle layer could reduce the LES pressure in pigs.7Pasricha P.J. Hawari R. Ahmed I. et al.Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia.Endoscopy. 2007; 39: 761-764Crossref PubMed Scopus (372) Google Scholar Shortly thereafter, POEM was performed by using the submucosal endoscopy with mucosal flap principle with a technique adapted from endoscopic submucosal dissection (ESD) to create the submucosal space.8Inoue H. Ikeda H. Hosoya T. et al.Per-oral endoscopic myotomy (POEM) for esophageal achalasia.Nihon Shokakibyo Gakkai Zasshi. 2012; 109 ([Japanese]): 728-731PubMed Google Scholar The initial work and subsequent work by other investigators involved blunt balloon dissection to create the submucosal tunnel to protect the overlying mucosa from injury and to expedite esophageal dissection.9Stavropoulos S.N. Harris M.D. Hida S. et al.Endoscopic submucosal myotomy for the treatment of achalasia.Gastrointest Endosc. 2010; 72: 1309-1311Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar Animal studies demonstrated that submucosal endoscopy with mucosal flap dissection deep within the gastric cardia (at least 2 cm) and cardiomyotomy are the potential defining components of a successful myotomy to treat achalasia.10Perretta S. Dallemagne B. Donatelli G. et al.Transoral endoscopic esophageal myotomy based on esophageal function testing in a survival porcine model.Gastrointest Endosc. 2011; 73: 111-116Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar Further, NOSCAR-supported animal studies compared circular muscle layer versus full-thickness myotomy. These studies demonstrated that the effect on LES pressure was similar with either method and that full-thickness myotomy was easier and more expeditious.11Bonin E.A. Moran E. Bingener J. et al.A comparative study of endoscopic full-thickness and partial-thickness myotomy using submucosal endoscopy with mucosal safety flap (SEMF) technique.Surg Endosc. 2012; 26: 1751-1758Crossref PubMed Scopus (19) Google Scholar POEM appears to be a safe and effective alternative for the treatment of classic achalasia.12Inoue H. Minami H. Kobayashi Y. et al.Peroral endoscopic myotomy (POEM) for esophageal achalasia.Endoscopy. 2010; 42: 265-271Crossref PubMed Scopus (1234) Google Scholar, 13Inoue H. Tianle K.M. Ikeda H. et al.Peroral endoscopic myotomy for esophageal achalasia: technique, indication, and outcomes.Thorac Surg Clin. 2011; 21: 519-525Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar, 14von Renteln D. Inoue H. Minami H. et al.Peroral endoscopic myotomy for the treatment of achalasia: a prospective single center study.Am J Gastroenterol. 2012; 107: 411-417Crossref PubMed Scopus (295) Google Scholar, 15Costamagna G. Marchese M. Familiari P. et al.Peroral endoscopic myotomy (POEM) for oesophageal achalasia: preliminary results in humans.Dig Liver Dis. 2012; 44: 827-832Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar, 16Swanstrom L. Rieder E. Dunst C.M. A stepwise approach and early clinical experience in peroral endoscopic myotomy for the treatment of achalasia and esophageal motility disorders.J Am Coll Surg. 2011; 213: 751-758Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar, 17Swanstrom L.L. Kurian A. Dunst C.M. et al.Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure.Ann Surg. 2012; 256: 659-667Crossref PubMed Scopus (247) Google Scholar, 18Ren Z. Zhong Y. Zhou P. et al.Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases).Surg Endosc. 2012; 26: 3267-3272Crossref PubMed Scopus (172) Google Scholar, 19Hungness E.S. Teitelbaum E.N. Santos B.F. et al.Comparison of perioperative outcomes between per oral esophageal myotomy (POEM) and laparoscopic Heller myotomy.J Gastrointest Surg. 2013; 17: 228-235Crossref PubMed Scopus (209) Google Scholar, 20Inoue H. Ikeda H. Onimaru M. et al.Clinical results in 300 cases of POEM for esophageal achalasia a single institute registered prospective study.Gastrointest Endosc. 2013; 77 ([abstract]): AB121-AB122Google Scholar, 21Chiu P.W. Wu J.C. Teoh A.Y. et al.Peroral endoscopic myotomy for treatment of achalasia: from bench to bedside (with video).Gastrointest Endosc. 2013; 77: 29-38Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar, 22Stavropoulos S.N. Modayil R. Friedel D. Achalasia.Gastrointest Endosc Clin N Am. 2013; 23: 53-75Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 23Stavropoulos S.N. Friedel D. Modayil R. et al.Endoscopic approaches to treatment of achalasia.Therapeut Adv Gastroenterol. 2013; 6: 115-135Crossref PubMed Scopus (20) Google Scholar, 24Lee B.H. Shim K.Y. Hong S.J. et al.Peroral endoscopic myotomy for treatment of achalasia: initial results of a Korean study.Clin Endosc. 2013; 46: 161-167Crossref PubMed Scopus (60) Google Scholar, 25Minami H, Isomoto H, Yamaguchi N, et al. Peroral endoscopic myotomy for esophageal achalasia: clinical impact of 28 cases. Dig Endosc. Epub 2013 Apr 14.Google Scholar, 26Verlaan T. Rohof W.O. Bredenoord A.J. et al.Effect of peroral endoscopic myotomy on esophagogastric junction physiology in patients with achalasia.Gastrointest Endosc. 2013; 78: 39-44Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar, 27Stavropoulos S.N. Modayil R.J. Brathwaite C.E. et al.POEM (per oral endoscopic myotomy) for achalasia: excellent long-term safety and efficacy and durability in a large single center 4 year series.Am J Gastroenterol. 2013; 108: S619PubMed Google Scholar, 28Zhou P. Yao L. Zhang Y.Q. et al.Peroral endoscopic myotomy (POEM) for esophageal achalasia: 205 cases report.Gastrointest Endosc. 2012; 75 ([abstract]): AB132-AB133Abstract Full Text Full Text PDF Google Scholar, 29Von Renteln D. Fuchs K.H. Fockens P. et al.Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study.Gastroenterology. 2013; 145 (e1-3): 309-311Abstract Full Text Full Text PDF PubMed Scopus (276) Google Scholar, 30Charton J.P. Schumacher B. Toermer T. et al.Per oral endoscopic myotomy (POEM) for achalasia: pilot case series of a Western referral center.Gastrointest Endosc. 2013; 77: AB351Google Scholar However, its role and efficacy in patients with other hypertensive motor disorders, prior conventional achalasia treatments, end-stage achalasia, age extremes, and significant comorbid diseases is not clear. Preliminary data in the literature suggest POEM efficacy in motor disorders other than classic achalasia. Successful application of POEM in a small number of patients with diffuse esophageal spasm,1Stavropoulos S.N. Modayil R. Friedel D. et al.The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience.Surg Endosc. 2013; 27: 3322-3338Crossref PubMed Scopus (205) Google Scholar, 16Swanstrom L. Rieder E. Dunst C.M. A stepwise approach and early clinical experience in peroral endoscopic myotomy for the treatment of achalasia and esophageal motility disorders.J Am Coll Surg. 2011; 213: 751-758Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar, 31Shiwaku H. Inoue H. Beppu R. et al.Successful treatment of diffuse esophageal spasm by peroral endoscopic myotomy.Gastrointest Endosc. 2013; 77: 149-150Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 32Louis H. Covas A. Coppens E. et al.Distal esophageal spasm treated by peroral endoscopic myotomy.Am J Gastroenterol. 2012; 107: 1926-1927Crossref PubMed Scopus (42) Google Scholar, 33Kurian A. Dunst C. Sharata A. et al.Peroral endoscopic esophageal myotomy: defining the learning curve.Gastrointest Endosc. 2013; 77: 19-25Abstract Full Text Full Text PDF Scopus (164) Google Scholar hypertensive LES,1Stavropoulos S.N. Modayil R. Friedel D. et al.The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience.Surg Endosc. 2013; 27: 3322-3338Crossref PubMed Scopus (205) Google Scholar, 33Kurian A. Dunst C. Sharata A. et al.Peroral endoscopic esophageal myotomy: defining the learning curve.Gastrointest Endosc. 2013; 77: 19-25Abstract Full Text Full Text PDF Scopus (164) Google Scholar, 34Chiu P. Inoue H. Teoh A. et al.Per oral endoscopic myotomy for treatment of hypertensive lower esophageal sphincter.Gastrointest Endosc. 2011; 73 ([abstract]): AB107Google Scholar type III spastic achalasia,1Stavropoulos S.N. Modayil R. Friedel D. et al.The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience.Surg Endosc. 2013; 27: 3322-3338Crossref PubMed Scopus (205) Google Scholar, 14von Renteln D. Inoue H. Minami H. et al.Peroral endoscopic myotomy for the treatment of achalasia: a prospective single center study.Am J Gastroenterol. 2012; 107: 411-417Crossref PubMed Scopus (295) Google Scholar, 17Swanstrom L.L. Kurian A. Dunst C.M. et al.Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure.Ann Surg. 2012; 256: 659-667Crossref PubMed Scopus (247) Google Scholar, 21Chiu P.W. Wu J.C. Teoh A.Y. et al.Peroral endoscopic myotomy for treatment of achalasia: from bench to bedside (with video).Gastrointest Endosc. 2013; 77: 29-38Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar nutcracker esophagus,17Swanstrom L.L. Kurian A. Dunst C.M. et al.Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure.Ann Surg. 2012; 256: 659-667Crossref PubMed Scopus (247) Google Scholar, 33Kurian A. Dunst C. Sharata A. et al.Peroral endoscopic esophageal myotomy: defining the learning curve.Gastrointest Endosc. 2013; 77: 19-25Abstract Full Text Full Text PDF Scopus (164) Google Scholar and jackhammer esophagus35Khashab M.A. Saxena P. Kumbhari V. et al.Peroral endoscopic myotomy as a platform for the treatment of spastic esophageal disorders refractory to medical therapy (with video).Gastrointest Endosc. 2014; 79: 136-139Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar has been reported. It has been suggested that pain, a prominent symptom in many of these disorders, responds less well to POEM than does dysphagia, the predominant symptom in patients with typical achalasia.17Swanstrom L.L. Kurian A. Dunst C.M. et al.Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure.Ann Surg. 2012; 256: 659-667Crossref PubMed Scopus (247) Google Scholar In the international POEM survey, 11 of the 16 participating centers reported performing POEM for these extended manometric indications (accounting for 28% of the 841 POEMs reported in the survey).1Stavropoulos S.N. Modayil R. Friedel D. et al.The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience.Surg Endosc. 2013; 27: 3322-3338Crossref PubMed Scopus (205) Google Scholar Possibly somewhat diminished POEM efficacy was reported in patients with diffuse esophageal spasm and type III achalasia but excellent efficacy in hypertensive LES and nutcracker esophagus.1Stavropoulos S.N. Modayil R. Friedel D. et al.The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience.Surg Endosc. 2013; 27: 3322-3338Crossref PubMed Scopus (205) Google Scholar Based on the case reports in the literature and IPOEMS responses, longer esophageal myotomy is being performed for spastic disorders such as diffuse esophageal spasm that are characterized by long spastic segments of the distal esophagus.1Stavropoulos S.N. Modayil R. Friedel D. et al.The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience.Surg Endosc. 2013; 27: 3322-3338Crossref PubMed Scopus (205) Google Scholar POEM may be superior to laparoscopic Heller myotomy (LHM) in these patients because the myotomy can be extended proximally in the body of the esophagus. Prior BI causes submucosal fibrosis which, to varying degrees, obliterates the surgical planes that adversely affect surgical myotomy and possibly POEM.36Stefanidis D. Richardson W. Farrell T. et al.SAGES guidelines for the surgical treatment of esophageal achalasia.Surg Endosc. 2012; 26: 296-311Crossref PubMed Scopus (156) Google Scholar In IPOEMS, 43% of the 841 reported POEMs were performed in patients with prior failed treatments.1Stavropoulos S.N. Modayil R. Friedel D. et al.The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience.Surg Endosc. 2013; 27: 3322-3338Crossref PubMed Scopus (205) Google Scholar The general consensus among POEM operators is that the submucosal fibrosis caused by prior BI does result in a slower and more challenging dissection, but the effect is moderate and may be overcome by operator experience.1Stavropoulos S.N. Modayil R. Friedel D. et al.The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience.Surg Endosc. 2013; 27: 3322-3338Crossref PubMed Scopus (205) Google Scholar Although most POEM series have included a substantial proportion of patients, ranging from 18% to 69%,14von Renteln D. Inoue H. Minami H. et al.Peroral endoscopic myotomy for the treatment of achalasia: a prospective single center study.Am J Gastroenterol. 2012; 107: 411-417Crossref PubMed Scopus (295) Google Scholar, 15Costamagna G. Marchese M. Familiari P. et al.Peroral endoscopic myotomy (POEM) for oesophageal achalasia: preliminary results in humans.Dig Liver Dis. 2012; 44: 827-832Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar, 17Swanstrom L.L. Kurian A. Dunst C.M. et al.Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure.Ann Surg. 2012; 256: 659-667Crossref PubMed Scopus (247) Google Scholar, 18Ren Z. Zhong Y. Zhou P. et al.Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases).Surg Endosc. 2012; 26: 3267-3272Crossref PubMed Scopus (172) Google Scholar with prior standard achalasia treatments, outcomes specific to these patients have not been presented until recently, when two groups attempted to examine the effect of before-POEM endoscopic treatment on POEM outcomes. During subgroup analysis of patients with or without histories of endoscopic intervention, one group found no difference in procedure duration, intraoperative adverse events, or efficacy,37Sharata A. Kurian A.A. Dunst C.M. et al.Peroral endoscopic myotomy (POEM) is safe and effective in the setting of prior endoscopic intervention.J Gastrointest Surg. 2013; 17: 1188-1192Crossref PubMed Scopus (105) Google Scholar whereas the other group found prior endoscopic treatment to be a predictor of increased procedure time.38Teitelbaum EN, Soper NJ, Arafat FO, et al. Analysis of a learning curve and predictors of intraoperative difficulty for peroral esophageal myotomy (POEM). J Gastrointest Surg. Epub 2013 Sep 4.Google Scholar The discordant findings may be related to methodologic issues such as the very small numbers of previously treated patients included in these studies (4 and 12, respectively). POEM after failed surgical Heller myotomy is reported to be more challenging, but recent reports demonstrate excellent efficacy when POEM is performed by experienced operators.1Stavropoulos S.N. Modayil R. Friedel D. et al.The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience.Surg Endosc. 2013; 27: 3322-3338Crossref PubMed Scopus (205) Google Scholar, 13Inoue H. Tianle K.M. Ikeda H. et al.Peroral endoscopic myotomy for esophageal achalasia: technique, indication, and outcomes.Thorac Surg Clin. 2011; 21: 519-525Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar, 18Ren Z. Zhong Y. Zhou P. et al.Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases).Surg Endosc. 2012; 26: 3267-3272Crossref PubMed Scopus (172) Google Scholar, 22Stavropoulos S.N. Modayil R. Friedel D. Achalasia.Gastrointest Endosc Clin N Am. 2013; 23: 53-75Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 27Stavropoulos S.N. Modayil R.J. Brathwaite C.E. et al.POEM (per oral endoscopic myotomy) for achalasia: excellent long-term safety and efficacy and durability in a large single center 4 year series.Am J Gastroenterol. 2013; 108: S619PubMed Google Scholar, 39Zhou P.H. Li Q.L. Yao L.Q. et al.Peroral endoscopic remyotomy for the treatment of recurrent achalasia after Heller myotomy: a prospective single center study.Endoscopy. 2013; 45: 161-166Crossref PubMed Scopus (140) Google Scholar, 40Onimaru M. Inoue H. Ikeda H. et al.Peroral endoscopic myotomy is a viable option for failed surgical esophagocardiomyotomy instead of redo surgical Heller myotomy: a single center prospective study.J Am Coll Surg. 2013; 217: 598-605Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar POEM in severe sigmoid achalasia and megaesophagus was reported in only 3% and 4%, respectively, of all POEMs in IPOEMS.1Stavropoulos S.N. Modayil R. Friedel D. et al.The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience.Surg Endosc. 2013; 27: 3322-3338Crossref PubMed Scopus (205) Google Scholar Patients with severe sigmoidization and megaesophagus (end-stage achalasia) respond poorly to LHM, based on the LHM literature, and may ultimately come to esophagectomy.36Stefanidis D. Richardson W. Farrell T. et al.SAGES guidelines for the surgical treatment of esophageal achalasia.Surg Endosc. 2012; 26: 296-311Crossref PubMed Scopus (156) Google Scholar Unlike LHM, POEM appears to cause minimal adhesions,19Hungness E.S. Teitelbaum E.N. Santos B.F. et al.Comparison of perioperative outcomes between per oral esophageal myotomy (POEM) and laparoscopic Heller myotomy.J Gastrointest Surg. 2013; 17: 228-235Crossref PubMed Scopus (209) Google Scholar and, therefore, it should not significantly affect subsequent esophagectomy. Therefore, it could be considered as an initial treatment in these patients, with esophagectomy reserved for those with inadequate clinical response. Most published series have excluded patients with severe sigmoidization and/or megaesophagus (stage IV achalasia). One center has performed POEM in 20 stage IV patients.27Stavropoulos S.N. Modayil R.J. Brathwaite C.E. et al.POEM (per oral endoscopic myotomy) for achalasia: excellent long-term safety and efficacy and durability in a large single center 4 year series.Am J Gastroenterol. 2013; 108: S619PubMed Google Scholar POEM in such patients is more challenging than in stage I to III patients, with significantly longer procedure times (mean procedure time in 20 stage IV patients = 129 minutes compared with 100 minutes in 80 patients at other stages (P < .02, unpublished data). No significant difference in efficacy or adverse events was noted. Another concern regarding POEM revolves around age extremes. There are reports of successful POEM in patients as young as 3 years and as old as 97 years, which suggests that POEM may be a feasible treatment option for appropriately selected patients, even at extremes of age.1Stavropoulos S.N. Modayil R. Friedel D. et al.The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience.Surg Endosc. 2013; 27: 3322-3338Crossref PubMed Scopus (205) Google Scholar, 20Inoue H. Ikeda H. Onimaru M. et al.Clinical results in 300 cases of POEM for esophageal achalasia a single institute registered prospective study.Gastrointest Endosc. 2013; 77 ([abstract]): AB121-AB122Google Scholar, 27Stavropoulos S.N. Modayil R.J. Brathwaite C.E. et al.POEM (per oral endoscopic myotomy) for achalasia: excellent long-term safety and efficacy and durability in a large single center 4 year series.Am J Gastroenterol. 2013; 108: S619PubMed Google Scholar, 41Maselli R. Inoue H. Misawa M. et al.Peroral endoscopic myotomy (POEM) in a 3-year-old girl with severe growth retardation, achalasia, and Down syndrome.Endoscopy. 2012; 44: E285-E287Crossref PubMed Scopus (51) Google Scholar, 42Chen W.F. Zhou P.H. Li Q.L. et al.Clinical impact of peroral endoscopic myotomy for achalasia of pediatric patients: a prospective single center study.Endoscopy. 2012; 44: A11Crossref Google Scholar, 43Familiari P. Marchese M. Gigante G. et al.Peroral endoscopic myotomy for the treatment of achalasia in children.J Pediatr Gastroenterol Nutr. 2013; 57: 794-797Crossref PubMed Scopus (53) Google Scholar The majority of IPOEMS respondents considered POEM contraindicated in patients with a history of severe pulmonary disease, cirrhosis with portal hypertension, severe coagulopathy, and prior interventions resulting in significant submucosal fibrosis such as esophageal irradiation, ablation therapy, and extensive EMR (Table 1).1Stavropoulos S.N. Modayil R. Friedel D. et al.The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience.Surg Endosc. 2013; 27: 3322-3338Crossref PubMed Scopus (205) Google ScholarTable 1POEM in patients with comorbiditiesComorbidities not deemed contraindications for POEM by most IPOEMS respondentsComorbidities deemed contraindications for POEM by most IPOEMS respondentsImmunosuppression (examples) Patient with IBD on maintenance anti-TNF Patient with rheumatoid arthritis on methotrexate Patient with HIV on HAART with CD4 count of 200-500/mm3Moderate pulmonary disease (examples) COPD Pulmonary fibrosis ASA class IIMedically managed cardiovascular disease (examples) Ejection fraction 50,000 and <100,000/mm3Obesity, body mass index ≥35Prior mediastinoscopyPrior surgery in posterior mediastinum in POEM fieldPatient with end-stage renal disease on hemodialysisCompensated cirrhosis without portal hypertensionPrior irradiation to mediastinum or esophagusSevere pulmonary disease (example) Extensive bullous disease Prior lung resection Home oxygen dependent ASA class III Forced expiratory volume/1 sec Forced vital capacity <70% pCO2 ≥45 pO2<75CoagulopathyBaseline platelet count <30,000-50,000/mm3 (examples) Immune thrombocytopenic purpura Myelodysplastic syndrome HypersplenismPrior esophageal EMR or other mucosal ablative treatment (examples) Photodynamic therapy Radio frequency ablationCompensated cirrhosis with portal hypertension even if no or trace esophageal varices on EGDPOEM, Per-oral endoscopic myotomy; IPOEMS, International POEM Survey; IBD, inflammatory bowel disease; TNF, tumor necrosis factor; HAART, highly active anti-retroviral therapy; COPD, chronic obstructive pulmonary disease; ASA, American Society of Anesthesiologists Physical Status Classification System. Open table in a new tab POEM, Per-oral endoscopic myotomy; IPOEMS, International POEM Survey; IBD, inflammatory bowel disease; TNF, tumor necrosis factor; HAART, highly active anti-retroviral therapy; COPD, chronic obstructive pulmonary disease; ASA, American Society of Anesthesiologists Physical Status Classification System. Pre-procedural evaluation and preparation do not differ significantly from those of LHM. IPOEMS collected detailed data on evaluation and preparation and revealed mostly minor variations among respondents.1Stavropoulos S.N. Modayil R. Friedel D. et al.The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience.Surg Endosc. 2013; 27: 3322-3338Crossref PubMed Scopus (205) Google Scholar A more detailed discussion is presented on the online full-length version of this white paper. Many, but not all, centers perform an EGD 1 to 3 days before the POEM procedure in order to remove any solid or li

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