Feasibility of the peroral endoscopic myotomy (POEM) procedure with a new small-caliber endoscope (thin-POEM) in patients with achalasia.

BACKGROUND:  Peroral endoscopic myotomy (POEM) is a recognized technique for patients with achalasia. We aimed to evaluate the feasibility of using a small-caliber endoscope (thin-POEM) to perform POEM in patients with achalasia.

METHODS:  Naïve or previously treated patients were included between February 2016 and April 2018. A small-caliber (5.9 mm) nasoendoscope was used, with a modified closure method using cyanoacrylate. Strict follow-up was performed.

RESULTS:  45 patients were included, aged 45.5 years (interquartile range [IQR] 22 - 69); 53 % (24/45) had type II achalasia. Median total time for thin-POEM was 54 minutes (IQR 37 - 77) and median myotomy length was 13.5 cm (IQR 6 - 20). Results pre-procedure and 3 months post were Eckardt score 10 vs. 1 ( P  < 0.001), integrated relaxation pressure (IRP) 25.3 vs. 8.5 mmHg ( P  < 0.001), and timed barium esophagram (TBE) 100 % severely delayed vs. 86 % normal ( P  < 0.001), respectively. Type III patients had the longest thin-POEM times (median 58 minutes [IQR 52 - 77]). Reflux was confirmed at 3 months clinically in 17 % of patients, endoscopically in 20 %, and on pH monitoring in 53 %. At 6 months and 12 months, 40 % and 33 % of patients remained positive on pH monitoring and were medically managed.

CONCLUSIONS:  Thin-POEM seems to be a safe, effective, and efficient procedure for POEM in patients with achalasia, with good short-term follow-up results.