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Background and Aims: There are few data favoring the need for septotomy at the time of peroral endoscopic myotomy (POEM) or if POEM alone is sufficient. Our aim was to compare POEM outcomes with and without septotomy (POEM+S or POEM-S) in patients with symptomatic epiphrenic diverticula (ED) and an underlying motility disorder., Methods: This was an international, multicenter retrospective study involving 21 centers between January 2014 and January 2023. Patients with ED and an underlying motility disorder who underwent POEM were included. The primary outcome was clinical success (Eckardt score [ES] ≤3 or a 1-point drop in ES for patients with baseline ES <3) without the need for repeat surgical/endoscopic interventions during follow-up., Results: A total of 85 patients (mean age, 64.29 ± 17.1 years; 32 [37.6%] female) with ED and underlying motility disorder underwent POEM+S (n = 47) or POEM-S (n = 38). Patients in the POEM+S group had a significantly higher mean pre-POEM ES (7.3 ± 2.1 vs 5.8 ± 2; P = .002). The most common indication for POEM was achalasia (51% in the POEM+S cohort and 51.8% in the POEM-S cohort; P = .7). A posterior approach was favored in the POEM+S group (76.6% vs 52.6%; P = .02). A similar rate of technical success was seen in both groups (97.9% vs 100%; P = .1). The rate of adverse events was similar between the 2 cohorts (4.2% vs 8.1%; P = .6). The median length of hospital stay after POEM-S was significantly longer compared with POEM+S (2 days [interquartile range (IQR), 1-4 days] vs 1 day [IQR, 1-2 days]; P = .005). Clinical success was equivalent between the 2 groups (83% vs 86.8%; P = .6) at a median follow-up duration of 8 months (IQR, 3-19 months)., Conclusions: In patients with ED and an underlying motility disorder, both POEM+S and POEM-S are equally safe and effective, with similar procedure duration and a low recurrence rate at short-term follow-up. Future comparative prospective studies with long-term follow-up are required to validate these findings., Competing Interests: Disclosure The following authors disclosed financial relationships: A. Schlachterman: receives monetary support from Lumendi, ConMed, Olympus, and Fujifilm. V. Velanovich: Consultant for Enterra Medical, Inc. R. Pawa: Consultant for Boston Scientific and Cook Medical. S. Pawa: Consultant for Boston Scientific. R. Bechara: receives monetary support from Olympus (consultant), Pentax (consultant) and Medtronic (advisory committee or review panels). M. A. Al-Haddad: Consultant for Boston Scientific and Interpace Diagnostics; grant/research support from Amplified Sciences, Cook Endoscopy, and Creatics LLC. M. Ujiki: receives grant funding from Medtronic; board member for Boston Scientific; consultant for Olympus and Cook; and receives payment for lectures from Gore, Medtronic, and ERBE. M. Barret: consultant for Medtronic and Norgine. K. Chang: receives monetary support from Apollo, Aqua Medical, Boston Scientific, Cook Medical, Creo Medical, Endogastric Solutions, ERBE, Medtronic, Mauna Kea, Olympus, Ovesco, and Pentax. H. Inoue: advisor for Olympus and Top Corporation; and receives educational grants from Olympus and Takeda Pharmaceuticals. M. A. Khashab: consultant for Boston Scientific, Olympus, Medtronic, Laborie, Pentax, and Apollo Endosurgery; and receives research/grant support from Boston Scientific and royalties from UpToDate and Elsevier. All other authors disclosed no financial relationships., (Copyright © 2024. Published by Elsevier Inc.)

Background and Aims: Peroral endoscopic myotomy (POEM) is a safe and effective endoscopic treatment for achalasia and other esophageal motility disorders, and a versatile knife (TriangleTipKnife J [TTJ]; Olympus, Tokyo, Japan) is currently widely used in POEM. Recently, we reported a novel modification of TTJ, which was adjusted to a knife length of 2 mm by attaching a disposable clip (QuickClip Pro; Olympus) sheath to the tip as a hood attachment. This study compares the safety and effectiveness of TTJ and TTJ with a hood attachment (TTJ-H) in POEM., Methods: This 1:1 propensity score-matched retrospective cohort study compared the procedure time, myotomy efficiency, number of coagulation forceps usage, adverse events, length of hospital stay after POEM, procedural success, and clinical success between the TTJ and TTJ-H groups., Results: A total of 682 consecutive patients who underwent POEM between January 2021 and June 2023 were examined. We excluded 134 patients who had already undergone POEM or laparoscopic Heller myotomy as prior myotomy. Finally, 98 propensity score-matched pairs (n = 196) were identified. The mean procedure time was shortened from 93.5 minutes to 80.2 minutes (14% reduction, P = .012) when comparing the TTJ-H group versus the TTJ group. The mean myotomy efficiency was improved from 2.76 min/cm to 2.32 min/cm (16% improvement, P ≤ .001), and usage of coagulation forceps for hemostasis was decreased from 3.87 to .55 (86% reduction, P ≤ .001)., Conclusions: This study showed that use of TTJ-H could reduce total procedure time, improve myotomy efficiency, and reduce costs compared with TTJ., Competing Interests: Disclosure The following author disclosed financial relationships: H. Inoue: Advisor of Olympus Corporation and Top Corporation; and education grants from Olympus Corporation. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and Aims: The risk of bleeding and thromboembolic events in patients undergoing peroral endoscopic myotomy (POEM) who are receiving antithrombotic therapy is unknown. Our primary aim was to assess the safety of POEM in this patient subset. Secondary outcomes were rates of clinical success, GERD, and procedure-related outcomes., Methods: This was an international, 1:1, case-control study performed at 10 centers using prospectively maintained databases. All consecutive patients who underwent POEM before November 2019 were considered for inclusion. Cases were patients on antiplatelet and/or anticoagulant therapy. Controls not receiving antithrombotics were matched for age and esophageal motility disorder. Primary outcomes were major bleeding and thromboembolic events on postprocedural day 30., Results: Of 2895 patients who underwent POEM, 126 cases (103 on antiplatelets, 35 anticoagulants, 12 both) and 126 controls were enrolled. The rate of major bleeding was higher for the antithrombotics users (5.6% vs 0.8%, P = .03). Anticoagulants and clopidogrel were temporarily interrupted in all cases. Aspirin was continued in 40.5% of users without increasing the bleeding risk. One thromboembolic event occurred in each group (0.79%; P = 1.00). No POEM-related deaths were noted. Rates of clinical success (91.7% vs 96% in controls, P = .20), postprocedural GERD, and technical-related outcomes were similar in both groups. Antithrombotic management was heterogeneous, and guidelines were not adhered to in 23.8% of cases., Conclusions: POEM is safe and effective in patients receiving antithrombotic therapy although it is associated with a greater risk of major bleeding., (Copyright © 2021 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Peroral endoscopic myotomy (POEM) is an available treatment modalities for achalasia. The reported efficacy of POEM in the only prospective multicenter study was 82%; however, a retrospective multicenter study in Japan reported a higher efficacy rate of 95%. The aim of this study was to prospectively verify treatment outcomes after POEM at multiple facilities in Japan., Methods: This was a prospective single-arm trial of POEM for achalasia at 8 facilities in Japan between April 2016 and March 2018 to evaluate its safety and efficacy. Patients were re-evaluated at 3 months and up to 1 year after POEM., Results: Among the 233 patients with achalasia who underwent POEM, procedure-related adverse events occurred in 24 patients (10.3%), none of whom required surgical intervention. In the 207 patients satisfying the inclusion criteria, the efficacy rate of POEM, defined by an Eckardt score ≤3 at 1 year, was 97.4% (95% CI, 95.3%-99.7%). The Eckardt score decreased significantly from 6.6 ± 2.0 preoperatively to 1.1 ± 1.1, 1 year after POEM. Postoperative reflux esophagitis, severe reflux esophagitis, and symptomatic GERD were reported in 54.2%, 5.6%, and 14.7%, respectively, and proton pump inhibitors were administered in 21.1%., Conclusions: Our prospective multicenter study in Japan showed greater efficacy of POEM for achalasia compared with the results of a previous prospective multicenter study. POEM is safe and highly effective for at least 1 year. (Clinical trial registration number: UMIN 000021550.)., (Copyright © 2020 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Per-oral endoscopic myotomy (POEM) for achalasia is particularly appealing in the elderly because it is minimally invasive. However, data in patients aged ≥80 years are scarce. The aim of this study was to assess the clinical outcome of POEM in octogenarians., Methods: This was a multicenter retrospective study at 8 centers. Consecutive octogenarians with achalasia who underwent POEM between 2010 and 2016 were included. Rates of technical success (completion of myotomy), clinical response (Eckardt score ≤3), and adverse events (severity graded as per American Society for Gastrointestinal Endoscopy lexicon) were assessed., Results: A total of 76 patients (47.4% female, mean age 84 years) underwent POEM for treatment of achalasia: type I, 17.1%; type II, 35.5%; type III, 17.1%; and unspecified, 30.3%. Overall, 41.1% were treatment naïve, whereas others had previous botulinum toxin injection and/or pneumatic dilation. The mean (± standard deviation [SD]) age-adjusted Charlson comorbidity index score was 6.2 ± 2.4, with the majority of patients having American Society of Anesthesiologists Physical Status Classification System (ASA) scores of II/III. Technical success was 93.4%, with a median follow-up of 256 days. Fourteen adverse events occurred in 11 patients (14.5%). There were 3 inadvertent mucosotomies, 6 cases of symptomatic capnoperitoneum and/or capnomediastinum, 2 esophageal leaks, 1 cardiac arrhythmia, and 2 other). The severities of these adverse events were mild (78.6%), moderate (14.3%), and severe (7.1%). Clinical success was achieved in 90.8% of patients, with a mean (± SD) Eckardt score reduction from 7.0 ± 2.3 to 0.8 ± 0.1 (P < .001), a median follow-up of 256 days, and interquartile range of 66 to 547., Conclusion: Although the rate of technical success may be somewhat lower and the rate of adverse events slightly higher than previously reported, our data suggest that POEM in octogenarians is safe and effective, supporting its role as a primary modality for achalasia in this patient population., (Copyright © 2018 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted due to overlapping/duplicate material. Data from some patients from this study have previously been published in other journals without cross-referencing. Twenty patients overlap with a paper by Kumbhari et al. 1 Thirty-five patients overlap with the study by Ngamruengphong et al. 2 ., (Copyright © 2018.)

Background and Aims: Per-oral endoscopic myotomy (POEM) has shown promising safety and efficacy in short-term studies. However, long-term follow-up data are very limited. The aims of this study were to assess (1) clinical outcome of patients with a minimum post-POEM follow-up of 2 years and (2) factors associated with long-term clinical failure after POEM., Methods: A retrospective chart review was performed that included all consecutive patients with achalasia who underwent POEM with a minimum follow-up of 2 years at 10 tertiary-care centers. Clinical response was defined by a decrease in Eckardt score to 3 or lower., Results: A total of 205 patients (45.8% men; mean age, 49 years) were followed for a median of 31 months (interquartile range, 26-38 months). Of these, 81 patients (39.5%) had received previous treatment for achalasia before POEM. Clinical success was achieved in 98% (185/189), 98% (142/144), and 91% (187/205) of patients with follow-up within 6 months, at 12 months, and ≥24 months, respectively. Of 185 patients with clinical response at 6 months, 11 (6%) experienced recurrent symptoms at 2 years. History of previous pneumatic dilation was associated with long-term treatment failure (odds ratio, 3.41; 95% confidence interval, 1.25-9.23). Procedure-related adverse events occurred in 8.2% of patients and only 1 patient required surgical intervention. Abnormal esophageal acid exposure and reflux esophagitis were documented in 37.5% and 18% of patients, respectively. However, these rates are simply a reference number among a very selective group of patients., Conclusions: POEM is safe and provides high initial clinical success and excellent long-term outcomes. Among patients with confirmed clinical response within 6 months, 6% had recurrent symptoms by 2 years., (Copyright © 2017 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Eight years have passed since the introduction of the per-oral endoscopy myotomy (POEM) procedure. POEM was initially received as an investigational procedure, but since the revelation of promising safety and efficacy data, it is becoming the preferred treatment for achalasia. With the recent completion of our 1000th POEM procedure, we share our experience and knowledge through the discussion of clinical pearls, pitfalls, and practical considerations., Methods: The various aspects of the procedure and conditions that warrant special attention are discussed from our perspective, with a focus on areas in which there is currently limited evidence., Results: The key points on patient position, submucosal tunneling, myotomy, closure, intraprocedural bleeding, and advanced sigmoid achalasia are presented., Conclusions: The dissemination of this information serves as a foundation for new POEM operators and as a catalyst for more-experienced operators to further refine and advance their POEM skills and stimulate international discourse and collaboration., (Copyright © 2016 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: Limited data exist on the use of peroral endoscopic myotomy (POEM) for therapy of spastic esophageal disorders (SEDs)., Objective: To study the efficacy and safety of POEM for the treatment of patients with diffuse esophageal spasm, jackhammer esophagus, or type III (spastic) achalasia., Design: Retrospective study., Setting: International, multicenter, academic institutions., Patients: All patients who underwent POEM for treatment of SEDs refractory to medical therapy at 11 centers were included., Interventions: POEM., Main Outcome Measurements: Eckardt score and adverse events., Results: A total of 73 patients underwent POEM for treatment of SEDs (diffuse esophageal spasm 9, jackhammer esophagus 10, spastic achalasia 54). POEM was successfully completed in all patients, with a mean procedural time of 118 minutes. The mean length of the submucosal tunnel was 19 cm, and the mean myotomy length was 16 cm. A total of 8 adverse events (11%) occurred, with 5 rated as mild, 3 moderate, and 0 severe. The mean length of hospital stay was 3.4 days. There was a significant decrease in Eckardt scores after POEM (6.71 vs 1.13; P = .0001). Overall, clinical response was observed in 93% of patients during a mean follow-up of 234 days. Chest pain significantly improved in 87% of patients who reported chest pain before POEM. Repeat manometry after POEM was available in 44 patients and showed resolution of initial manometric abnormalities in all cases., Limitations: Retrospective design and selection bias., Conclusion: POEM offers a logical therapeutic modality for patients with SEDs refractory to medical therapy. Results from this international study suggest POEM as an effective and safe platform for these patients., (Copyright © 2015 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: Per-oral endoscopic myotomy (POEM) for achalasia with esophagocardiomyotomy in the lesser curvature (LC myotomy) is now established and accepted widely. However, in some cases LC myotomy is precluded by previous procedures, such as Heller myotomy, or by other anatomic considerations that obscure the normal dissection planes. It may also be difficult to identify the esophagogastric junction (EGJ), which can result in an incomplete gastric myotomy and poor rates of symptom relief. On the other hand, the angle of His is always located in the greater curvature of the stomach and serves as a consistent, definite landmark of the gastric side., Objective: To evaluate esophagocardiomyotomy in the greater curvature (GC myotomy) as an alternative POEM technique in cases where a prior LC myotomy or supervening anatomic constraints make identification of the EGJ technically challenging., Design: Prospective., Setting: Single-center study., Patients: Twenty-one achalasia patients who received POEM with GC myotomy., Interventions: POEM., Main Outcome Measurements: Efficacy and safety of GC myotomy measured in terms of reduction in lower esophageal sphincter (LES) pressures, improvement in Eckardt scores, and development of intraoperative or postoperative adverse events., Results: Identification of the EGJ was achieved in all cases, resulting in a mean gastric myotomy length of 2.6±1.1 cm. Mean LES pressure and Eckardt symptom scores decreased significantly (21.2±7.3 vs 10.5±2.7 mm Hg, 5 [2-8] vs 1 [0-5], respectively) (P<.01). Endoscopic evidence of gastroesophageal reflux was identified in 52% of patients (11/21) postmyotomy; however, only 9.5% (2/11) were symptomatic, and these patients were successfully controlled with proton pump inhibitors. No severe adverse events were encountered., Limitations: Single center., Conclusions: GC myotomy is a promising, safe modification of the POEM technique and may be especially useful in cases of redo POEM, POEM post-Heller myotomy, or when the EGJ is difficult to recognize because of supervening anatomic constraints., (Copyright © 2015 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: Recent technological advances have allowed superficially spreading intramucosal carcinomas of the esophagus to be successfully resected by circumferential endoscopic submucosal dissection (cESD). After this procedure, esophageal strictures develop in most patients and are mainly treated by endoscopic balloon dilation (EBD)., Objective: To compare oral steroids plus EBD with EBD alone for the management of benign esophageal strictures after cESD., Design: Retrospective cohort study., Setting: Tertiary-care referral center., Patients: We studied 23 consecutive patients who underwent complete cESD for superficial esophageal carcinoma (22 squamous cell carcinomas and 1 adenocarcinoma associated with Barrett's esophagus)., Intervention: After cESD, patients were managed with EBD alone (EBD, n = 13) or with EBD and oral prednisolone (steroid + EBD, n = 10), 30 mg daily, started 2 days after cESD and gradually tapered and discontinued after 8 weeks., Main Outcome Measurements: Total number of EBD sessions and total EBD period (months)., Results: Steroid + EBD patients required fewer sessions (13.8 ± 6.9 vs 33.5 ± 22.9; P < .001) and a shorter management period (4.8 ± 2.3 vs 14.2 ± 17.5 months, P = .005) compared with the EBD group. An additional 3 patients received oral steroids a mean interval of 158 days after cESD. These patients required more EBD sessions (46.3 ± 30.0; P = .002), and the EBD period was significantly longer (17.5 ± 13.0 months; P = .005) than in the early steroid + EBD group., Limitations: Nonrandomized study; retrospective analysis., Conclusion: After cESD, oral steroid therapy dramatically reduced the need for EBD. We conclude that oral steroid therapy after EBD is an effective strategy for the management of esophageal strictures after complete cESD., (Copyright © 2013 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)