Submucosal tunnel endoscopy: Peroral endoscopic myotomy and peroral endoscopic tumor resection

Table 1 Indications and contraindications of peroral endoscopic myotomy

Indications

Absolute indications

Primary idiopathic achalasia of all types [classical (I), vigorous (II), spastic (III)] (Chicago

Classification)

Relative indications

Other hypertensive motor disorders (diffuse esophageal spasm, nutcracker or jackhammer esophagus). HRTM necessary

Failed surgical myotomy (POEM at the opposite site manly posterior POEM)

Failed pneumatic balloon dilatation

Failed previous POEM. Redo POEM at the opposite site mainly posterior POEM necessary

Advanced sigmoid type achalasia with mega esophagus (bilateral POEM may be necessary)

Children with achalasia (relative indication in experienced hands and specialized centers only)

Elderly with achalasia and comorbidities and non-surgical candidates (relative indication in experienced hands and specialized centers only)

Contraindications

Absolute contraindications

Severe cardiopulmonary disease or other serious disease

Pseudoachalasia

Failure in creating the submucosal tunnel because of severe fibrosis and adhesion

Relative contraindications

Severe esophagitis and/or very large ulcer in the lower esophagus

Recent endoscopic treatment such as EMR, ESD

POEM: Peroral endoscopic myotomy; HRTM: High resolution topographic manometry; EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection.