Peroral endoscopic myotomy for achalasia: the journey continues

We read with great interest the case series from the United States of 6 patients undergoing peroral endoscopic myotomy with fundoplication (POEM-F).1Shrigiriwar A. Zhang L.Y. Ghandour B. et al.Technical Details and Outcomes of Peroral Endoscopic Myotomy with Fundoplication: The First U.S. Experience (with video).Gastrointest Endosc. 2023; 97: 585-593Abstract Full Text Full Text PDF Scopus (2) Google Scholar The investigators report that POEM-F was both feasible and safe, and adds to the growing body of evidence regarding the optimal approach to treating achalasia. Their results are consistent with experiences of investigators from.2Bapaye A. Dashatwar P. Dharamsi S. et al.Single-session endoscopic fundoplication after peroral endoscopic myotomy (POEM+ F) for prevention of post gastroesophageal reflux–1-year follow-up study.Endoscopy. 2021; 53: 1114-1121Crossref PubMed Scopus (14) Google Scholar, 3Nabi Z. Ramchandani M. Darisetty S. et al.Peroral endoscopic myotomy with endoscopic fundoplication in a patient with idiopathic achalasia.Endoscopy. 2020; 52: 74-75Crossref PubMed Scopus (12) Google Scholar, 4Patil G. Dalal A. Maydeo A. Early outcomes of peroral endoscopic myotomy with fundoplication for achalasia cardia: is it here to stay?.Dig Endosc. 2021; 33: 561-568Crossref PubMed Scopus (5) Google Scholar Although they report the procedural characteristics and clinical outcomes in detail, the lack of a control arm remains a shortcoming and highlights the current state of POEM-F. The authors’ main focus was on a reduction in the rate of post-POEM GERD, which was complicated by the fact that the patients were prescribed proton pump inhibitors (PPIs) despite a reduction in symptoms after discharge, and the duration of follow-up care was only 1 month. The incidence rate of Barrett's esophagus followed by conventional stand-alone POEM with regulatory PPI use is only 2% over 5 years of follow-up visits.5Kuipers T. Ponds F.A. Fockens P. et al.Peroral endoscopic myotomy versus pneumatic dilation in treatment-naive patients with achalasia: 5-year follow-up of a randomised controlled trial.Lancet Gastroenterol Hepatol. 2022; 7: 1103-1111Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Longer-term follow-up care is needed, preferably as part of a comparison between POEM-F, POEM, and pneumatic dilation. The frequency and severity of adverse events specific to POEM-F, such as injury to important structures of the peritoneal cavity, the length of mucosal incision required, the need for endoscopic suturing, and the requirement of more through-the-scope clips are noteworthy and would require further study. Although their results are very encouraging, it is critical that POEM-F be further evaluated to identify the most suitable patients. The incidence of GERD controlled by the consumption of PPIs after the operation also requires further study. The successful use of single-session endoscopic fundoplication after POEM, which has been reported in several Asian countries, suggests that POEM-F will prove to be both feasible and reproducible. Therapeutic success should evaluate both clinical and surgical success, such as an Eckardt score ≤3 without severe adverse events or need for retreatment, rather than technical success (ie, completion of the POEM-F procedure). Third space endoscopy, an offshoot of NOTES, has achieved global acceptance by the GI medical and surgical community.6Nabi Z. Reddy D.N. Third space endoscopy: the future of treating gastrointestinal dysmotility.Curr Opin Gastroenterol. 2021; 37: 462-469Crossref Scopus (3) Google Scholar,7Inoue H. Maydeo A. Peroral endoscopic myotomy (POEM) opens the door of third-space endoscopy.Endoscopy. 2019; 51: 1010-1012Crossref PubMed Scopus (6) Google Scholar New techniques promise that the shortcomings of the present-day approach to POEM can be circumvented, provided we continue to focus on short-term and long-term safety while optimizing efficacy. Achalasia treatment must be individualized, and careful consideration should be made of the risks and benefits of each treatment modality. The authors thank David Y. Graham, MD, Professor of Medicine, Molecular Virology, and Microbiology, Baylor College of Medicine, for his encouragement and assistance in revising the manuscript. All authors disclosed no financial relationships.