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Background: Peroral endoscopic myotomy (POEM) is a novel, minimally invasive treatment for esophageal achalasia. We retrospectively examined and evaluated the results following POEM to verify the technique’s efficacy and safety. Methods: We retrospectively analyzed data for patients who underwent POEM at eight Japanese facilities between September 2008 and October 2015. Pre- and postoperative assessments 3 months and 1 year after POEM included patient interviews, endoscopy, and manometry. Results: A total of 1346 patients underwent POEM during the study period. Achalasia was the straight type in 1105 patients (82%) and the sigmoid type in 241 patients (18%). The average patient age was 47.2 years (range 3–95 years); 617 patients (46%) were men and 729 (54%) were women. Previous treatment included balloon dilatation in 381 patients (28%) and Heller–Dor operation in 43 patients (3%). The average operation time was 99.6 min. The mean length of the myotomy in the esophageal body was 10.8 cm, and the myotomy extended into the stomach a mean of 2.8 cm. The response rate (Eckardt score ≤ 3) was 95.1% 3 months postoperatively and 94.7% 1 year postoperatively. We noted 50 adverse events (3.7%) of Clavien–Dindo classification grade ≤ IIIa, and all resolved with conservative treatment. There were no Clavien–Dindo classification grade ≥ IIIb adverse events. After POEM, erosive esophagitis according to the Los Angeles classification was absent in 37% of the patients, grade A in 33%, B in 24%, C in 6%, and D in 0.2%. Symptomatic gastroesophageal reflux disease after POEM was confirmed in 14.8% of the patients; both erosive esophagitis and symptomatic gastroesophageal reflux disease responded to treatment with a proton-pump inhibitor. Conclusion: Our results confirmed the safety and efficacy of POEM in a large patient series and support POEM as the first-line and standard treatment for esophageal achalasia.

Objectives:The safety of peroral endoscopic myotomy (POEM) is still debated since comprehensive analysis of adverse events (AEs) associated with the procedure in large multicenter cohort studies has not been performed. To study (1) the prevalence of AEs and (2) factors associated with occurrence of AEs in patients undergoing POEM.Methods:Patients who underwent POEM at 12 tertiary-care centers between 2009 and 2015 were included in this case–control study. Cases were defined by the occurrence of any AE related to the POEM procedure. Control patients were selected for each AE case by matching for age, gender, and disease classification (achalasia type I and II vs. type III/spastic esophageal disorders).Results:A total of 1,826 patients underwent POEM. Overall, 156 AEs occurred in 137 patients (7.5%). A total of 51 (2.8%) inadvertent mucosotomies occurred. Mild, moderate, and severe AEs had a frequency of 116 (6.4%), 31 (1.7%), and 9 (0.5%), respectively. Multivariate analysis demonstrated that sigmoid-type esophagus (odds ratio (OR) 2.28, P=0.05), endoscopist experience <20 cases (OR 1.98, P=0.04), use of a triangular tip knife (OR 3.22, P=0.05), and use of an electrosurgical current different than spray coagulation (OR 3.09, P=0.02) were significantly associated with the occurrence of AEs.Conclusions:This large study comprehensively assessed the safety of POEM and highly suggests POEM as a relatively safe procedure when performed by experts at tertiary centers with an overall 7.5% prevalence of AEs. Severe AEs are rare. Sigmoid-type esophagus, endoscopist experience, type of knife, and current used can be considered as predictive factors of AE occurrence.

Since its introduction in 2010, per oral endoscopic myotomy (POEM) has offered an alternative to laparoscopic Heller myotomy for the treatment of achalasia. A gastric myotomy length of 3 cm has been recommended; however, it can be difficult to ensure that adequate submucosal dissection has been performed during the procedure. Commonly accepted endoscopic markers of the gastric side can be inaccurate, particularly in patients with prior endoscopic treatments, such as balloon dilation or Botox injection of the lower esophageal sphincter. We hypothesized that the use of a second endoscope would result in a more complete gastric myotomy. One hundred consecutive achalasia patients were randomized into single- and double-scope POEM groups. In the treatment group, a second endoscope was used to obtain a retroflexed view of the gastric cardia, while the dissecting scope transilluminated from the end of the submucosal tunnel. Prospectively collected data were analyzed, including myotomy lengths, procedure times, adverse events, and clinical outcomes. POEM was completed with high rates of technical (98–100 %) and clinical success (93–97 %) in both groups, with a low rate of serious adverse events (2 %). The second endoscope resulted in a 17 min increase in procedure time (94 vs. 77 min), myotomy extension in 34 % of cases, and an increase in the average gastric myotomy length from 2.6 to 3.2 cm (p= 0.01). A second endoscope is useful for ensuring a complete gastric myotomy during POEM. With minimal increase in procedure time and no increase in morbidity, it may be particularly useful in cases of sigmoid esophagus or otherwise altered anatomy that makes identification of the gastroesophageal junction difficult.

Although laparoscopic surgery is frequently performed for the treatment of gastric cancer, laparoscopic total gastrectomy is not widely performed because of its technical difficulty. Since December 2007 we have performed esophagojejunostomy after totally laparoscopic total gastrectomy (TLTG) in more than 110 cases in our institution by using a circular stapler with a trans-orally inserted anvil. We performed a single-center comparative study to evaluate the safety and efficacy of esophagojejunostomy using a trans-orally inserted anvil in patients who underwent TLTG for the treatment of gastric cancer. In the present study, we examined 329 patients with gastric cancer who underwent esophagojejunostomy using a circular stapler after total gastrectomy. Data on the clinicopathological features, operative time, amount of intraoperative blood loss, and incidence of anastomosis-related complications among the surgical groups were obtained by reviewing the medical records, which were then analyzed. Approximately 67 % of the patients were men, and the average patient age was 64.0 years (range 26–93 years). In addition, 166 (50.5 %) and 163 (49.5 %) patients underwent open and laparoscopic surgery, respectively. Leakage following esophagojejunostomy was noted in 7 (4.2 %) of 166 patients who underwent total gastrectomy with open laparotomy, and 0 of 46 patients who underwent laparoscopic-assisted total gastrectomy (LATG). However, only 2 (1.7 %) of 117 patients who underwent TLTG using a trans-orally inserted anvil exhibited leakage following esophagojejunostomy. Anastomotic stenosis of the esophagojejunostomy was observed in 5 (3.0 %) of 166 patients who underwent total gastrectomy with open laparotomy, 2 (4.3 %) of 46 patients who underwent LATG, and 2 (1.7 %) of 117 patients who underwent TLTG using a trans-orally inserted anvil. We believe that esophagojejunostomy using a trans-orally inserted anvil after TLTG for gastric cancer is a safe and useful surgical procedure.