Peroral endoscopic myotomy outcomes: Efficacy and gastroesophageal reflux disease

Achalasia is a well-defined neuromuscular disorder of esophageal swallowing function characterized by a nonrelaxing lower esophageal sphincter (LES) and aperistalsis of the esophageal body. Peroral endoscopic myotomy (POEM) is a flexible endoscopic approach to perform a selective circular myotomy of the distal esophagus and proximal stomach. More than a thousand cases have been performed worldwide. Most early reports on POEM focus on its feasibility and safety. Emerging long-term series have reported excellent subjective and objective outcomes of dysphagia relief for achalasia. With increasing experience, centers are expanding indications to end-stage achalasia and nonachalasia neuromuscular disorders such as diffuse esophageal spasm and nonrelaxing LES with hypertensive esophageal body contractions. The postoperative gastroesophageal reflux post-POEM is an issue that requires close objective follow-up, as the correlation of subjective reflux symptoms and objective testing in this setting is poor. Few series have indeed reported on equivalent excellent outcomes post-POEM as compared with a laparoscopic myotomy. This early experience with POEM has demonstrated the validity of this new technique in the management of benign disorders of esophageal swallowing. Refinements in technique and decreases in gastroesophageal reflux disease may make this procedure even more desirable, and potentially the first-line therapy in the management of spastic disorders of the esophagus.