• achalasia
• botulinum toxin
• laparoscopic Heller myotomy
• peroral endoscopic myotomy
• pneumatic dilation

• Achalasia
• Dysphagia
• Laparoscopic Heller myotomy
• Per-oral endoscopic myotomy
• Symptomatic treatment

Currently, there are few studies on the efficacy of peroral endoscopic myotomy (POEM) in the anterior or posterior approach; however, limited studies have shown contradictory findings. Thus, the goal was to obtain more quantitative and objective outcomes and further compare the clinical efficacy of these two approaches in this meta-analysis.

A comprehensive search of PubMed, Embase, Cochrane Library, and Web of Science was conducted to find studies relevant to POEM. The retrieval time was from database inception to September 2021. Studies reporting the effects of POEM according to the anterior or posterior approach were included. STATA 16.0 was used to perform statistical analysis, mainly comparing the quantitative objective indicators (lower esophageal sphincter (LES) pressure and Eckardt scores, etc.) in anterior and posterior approaches by meta-analysis.

A total of 19 studies with 1261 patients were finally included. Except for shorter procedure time in the posterior approach, other factors (pooled difference of LES pressure, Eckardt scores, clinical success, length of total myotomy, hospital stays, gastroesophageal reflux (GERD), and adverse event) were compared, and all above confirmed that there is no difference between anterior and posterior approaches, and the safety of POEM is ensured. In addition, both anterior and posterior myotomy can improve LES pressure and Eckardt scores, and the difference in anterior and posterior myotomy was unconspicuous.

The terms of the pooled difference in LES pressure, Eckardt scores, and other factors (clinical success, length of total myotomy, hospital stays, GERD, adverse events, and procedure time) seemed to be similar for the anterior and posterior approaches. However, the further prognosis after POEM via anterior and posterior approaches needs to be answered in the future.

Several studies have reported partial recovery of peristalsis in patients with achalasia after myotomy. The aim of our study is to analyze esophageal motility patterns after peroral endoscopic myotomy (POEM) and to assess the potential predictors and clinical impact of peristaltic recovery.

We performed a retrospective analysis of prospectively collected data of consecutive patients with achalasia undergoing POEM at a tertiary center. High-resolution manometry (HRM) studies prior to and after POEM were reviewed and the Chicago classification was applied.

A total of 237 patients were analyzed. The initial HRM diagnoses were achalasia type I, 42 (17.7%); type II, 173 (73.0%); and type III, 22 (9.3%). Before POEM, peristaltic fragments were present in 23 (9.7%) patients. After POEM the Chicago classification diagnoses were 112 absent contractility, 42 type I achalasia, 15 type II, 11 type III, 26 ineffective esophageal motility, 18 esophagogastric junction outflow obstruction, 10 fragmented peristalsis, and 3 distal esophageal spasm. Altogether 68 patients (28.7%) had signs of contractile activity, but the contractions newly appeared in 47 patients (47/214, 22.0%). Type II achalasia showed a trend for appearance of contractions (P = 0.097). Logistic regression analysis did not identify any predictors of peristaltic recovery. The post-POEM Eckardt score did not differ between patients with and without contractions nor did the parameters of timed barium esophagogram.

More than 20% of achalasia patients have signs of partial recovery of esophageal peristalsis after POEM. It occurs predominantly in type II achalasia but the clinical relevance seems to be negligible.

• Esophageal achalasia
• Manometry
• Myotomy
• Peristalsis

• Esophageal achalasia
• Myotomy
• Peroral endoscopic myotomy
• Sigmoid-type achalasia

• 24-hour pH testing
• Heller’s myotomy
• achalasia
• gastroesophageal reflux disease (GERD)
• pH study
• peroral endoscopic myotomy (POEM)

• achalasia
• esophageal motility disorder
• quality of life
• sarcopenia

• Achalasia
• Gastroesophageal reflux
• Long-term effects
• Peroral endoscopic myotomy

• Adolescent
• Adult
• Aged
• Aged, 80 and over
• Blood Loss, Surgical
• Cardia
• Endoscopy, Digestive System/adverse effects
• Endoscopy, Digestive System/methods
• Esophageal Achalasia/surgery
• Esophageal Motility Disorders/surgery
• Esophageal Sphincter, Lower/surgery
• Female
• Hemothorax/epidemiology
• Hemothorax/etiology
• Humans
• Intraoperative Complications/epidemiology
• Intraoperative Complications/etiology
• Ischemia/epidemiology
• Ischemia/etiology
• Length of Stay
• Male
• Middle Aged
• Natural Orifice Endoscopic Surgery/adverse effects
• Natural Orifice Endoscopic Surgery/methods
• Pneumothorax/epidemiology
• Pneumothorax/etiology
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Stomach Diseases/epidemiology
• Stomach Diseases/etiology
• Treatment Outcome
• Young Adult

AIM: To assess and compare the esophageal function after peroral endoscopic myotomy (POEM) vs other conventional treatments in achalasia.

METHODS: Chart review of all achalasia patients who underwent POEM, laparoscopic Heller myotomy (LHM) or pneumatic dilation (PD) at our institution between January 2012 and March 2015 was performed. Patient demographics, type of achalasia, prior treatments, pre- and post-treatment timed barium swallow (TBE) and high-resolution esophageal manometry (HREM) findings were compared between the three treatment groups. Patients who had both pre- and 2 mo post-treatment TBE or HREM were included in the final analysis. TBE parameters compared were barium column height, width and volume of barium remaining at 1 and 5 min. HREM parameters compared were basal lower esophageal sphincter (LES) pressures and LES-integrated relaxation pressures (IRP). Data are presented as mean ± SD, median [25^th, 75^th percentiles] or frequency (percent). Analysis of variance, Kruskal-Wallis test, Pearsons χ² test and Fishers Exact tests were used for analysis.

RESULTS: A total of 200 achalasia patients were included of which 36 underwent POEM, 22 underwent PD and 142 underwent LHM. POEM patients were older (55.4 ± 16.8 years vs 46.5 ± 15.7 years, P = 0.013) and had higher BMI than LHM (29.1 ± 5.9 kg/m²vs 26 ± 5.1 kg/m², P = 0.012). More number of patients in POEM and PD groups had undergone prior treatments compared to LHM group (72.2% vs 68.2% vs 44.3% respectively, P = 0.003). At 2 mo post-treatment, all TBE parameters including barium column height, width and volume remaining at 1 and 5 min improved significantly in all three treatment groups (P = 0.01 to P < 0.001) except the column height at 1 min in PD group (P = 0.11) . At 2 mo post-treatment, there was significant improvement in basal LES pressure and LES-IRP in both LHM (40.5 mmHg vs 14.5 mmHg and 24 mmHg vs 7.1 mmHg respectively, P < 0.001) and POEM groups (38.7 mmHg vs 11.4 mmHg and 23.6 mmHg vs 6.6 mmHg respectively, P < 0.001). However, when the efficacy of three treatments were compared to each other in terms of improvement in TBE or HREM parameters at 2 mo, there was no significant difference (P > 0.05).

CONCLUSION: POEM, PD and LHM were all effective in improving esophageal function in achalasia at short-term. There was no difference in efficacy between the three treatments.

• Achalasia
• Dysphagia
• Heller myotomy
• Peroral endoscopic myotomy
• Manometry
• Pneumatic dilation

• Adult
• Aged
• Barium Sulfate/administration & dosage
• Chi-Square Distribution
• Contrast Media/administration & dosage
• Deglutition
• Dilatation
• Esophageal Achalasia/diagnosis
• Esophageal Achalasia/physiopathology
• Esophageal Achalasia/surgery
• Esophageal Sphincter, Lower/physiopathology
• Esophageal Sphincter, Lower/surgery
• Female
• Humans
• Laparoscopy/adverse effects
• Male
• Manometry
• Middle Aged
• Multivariate Analysis
• Natural Orifice Endoscopic Surgery/adverse effects
• Ohio
• Pressure
• Recovery of Function
• Retrospective Studies
• Time Factors
• Treatment Outcome

• Achalasia
• Diffuse esophageal spasm
• Hypercontractile esophagus
• Jackhammer esophagus
• Natural orifice transluminal endoscopic surgery (NOTES)
• Peroral endoscopic myotomy (POEM)

AIM: To investigate the esophageal motility characteristics by high resolution manometry (HRM) in patients with different subtypes of achalasia categorized by 2014 Chicago classification criteria.

METHODS: Thirty untreated achalasia patients referred to our clinic between March 2014 and December 2014 were enrolled for HRM examination and typing by the Chicago classification criteria. The esophageal motility characteristics of different subtypes of achalasia were analyzed.

RESULTS: Of the 30 achalasia patients, 7 (23.3%) were classified as having subtype Ⅰ, 19 (63.3%) as having subtype Ⅱ and 4 (13.3%) as having subtype Ⅲ. No significant difference was found among the three subtypes in lower esophageal sphincter (LES) resting pressure, average LES length, average intraabdominal LES length and integrated relaxation pressure (IRP) (P > 0.05). The percentage of patients with panesophageal pressurization in subtype Ⅱ patients was 91.76% ± 3.12%, significantly higher than that of subtype Ⅲ patients (53.33% ± 11.81%, P < 0.05). Compared to subtype Ⅰ patients, upper esophageal sphincter (UES) resting pressure was significantly higher in subtype Ⅱ patients (65.74 mmHg ± 5.21 mmHg vs 38.73 mmHg ± 3.37 mmHg, P < 0.05), but no significant difference was noted between subtypes Ⅰ and Ⅲ or between subtypes Ⅱ and Ⅲ. Although no significant difference was found among the three subtypes in UES residual pressure, in subtype Ⅱ, UES residual pressure was 13.41 mmHg ± 1.55 mmHg, higher than normal value (12 mmHg), which means abnormal relaxation of UES.

CONCLUSION: In patients with achalasia, subtype Ⅱ is more common. Subtype Ⅱ patients often exhibit LES relaxation disorder, panesophageal pressurization, UES resting pressure increase and UES abnormal relaxation. HRM contributes to early diagnosis and accurate classification and thus helps to make proper treatment choices.

• 2014 Chicago classification criteria
• Achalasia
• High resolution manometry
• Esophagus motility