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Introduction: Peroral endoscopic myotomy (POEM) is a novel intervention for the treatment of achalasia, which combines the advantages of endoscopic access and myotomy. The purpose of this study was to perform a systematic review of the literature to evaluate the efficacy and safety of POEM., Methods: The systematic review was conducted following the PRISMA guidelines. Evidence-Based Medicine Reviews, Cochrane Central Register of Controlled Trials, Ovid MEDLINE (R) including in-process and non-indexed citations were searched for POEM studies using the keywords: esophageal achalasia, POEM, endoscopy, natural orifice surgery, laparoscopic Heller myotomy (LHM), and related terms. Eckardt score, lower esophageal sphincter (LES) pressure, and reported complications were the main outcomes. Two authors reviewed the search result independently. A third reviewer resolved all disagreements. Data abstraction was pilot-tested and approved by all authors. Data were examined for clinical, methodological, and statistical heterogeneity with the aim of determining whether evidence synthesis using meta- analysis was possible., Results: The search strategy retrieved 2894 citations. After removing duplicates and applying the exclusion criteria, 54 studies were selected for full-text review of which a total of 19 studies were considered eligible for further analysis. There were 10 retrospective and 9 prospective studies, including 1299 POEM procedures. No randomized control trial (RCT) was identified. Overall, the pre- and post-POEM Eckardt scores and LES pressure were significantly different. The most frequently reported complications were mucosal perforation, subcutaneous emphysema, pneumoperitoneum, pneumothorax, pneumomediastinum, pleural effusion, and pneumonia. The median follow-up was 13 months (range 3-24)., Conclusion: POEM is a safe and effective alternative for the treatment of achalasia. However, only short-term follow-up data compared with LHM are available. RCTs and long-term follow-up studies are needed to establish the efficacy and safety of POEM in the management of patients with achalasia.

Background: Esophageal obstruction is a known complication of laparoscopic adjustable gastric band (LAGB) and usually occurs in the context of band slippage. Current reports of pseudoachalasia post-LAGB describe that in some patients esophageal function improves after band removal. For those without improvement, current treatments include division of the fibrotic band post-LAGB or revisional surgery. Our hypothesis, illustrated in the submitted video, is that an endoscopic division of LAGB-induced stricture will improve esophageal function., Methods: This video presents the case of a patient presenting with dysphagia post-LAGB removal. The preoperative high-resolution manometry was compatible with a type I achalasia. Using a high-definition endoscope and the equipment used for per-oral endoscopic myotomy (POEM) procedure, the intramural fibrotic tissue caused by the LAGB is divided, thus releasing the stricture and restoring baseline esophageal function. This is demonstrated with intraoperative endoscopic functional lumen imaging probe (EndoFLIP; Crospon Ltd, Galway, Ireland)., Results: Similar to the POEM technique, a 12-cm tunnel and 8-cm myotomy were performed. No intra-procedural or post-procedural complications were noted. Using impedance planimetry, the division of the LAGB-induced stricture induced an increase in the minimal diameter from 5.3 to 8.6 mm. The cross-sectional area increased from 22 to 58 mm(2). The patient denies any residual dysphagia, regurgitation, or heartburn at 6-month follow-up. On the postoperative high-resolution manometry, significant improvement in LES pressure parameters was seen post-myotomy with return of 30 % peristalsis., Discussion: In LAGB patients with pseudoachalasia in which removal of fluid from the band does not result in clinical or manometric improvement, laparoscopic removal of the band with division of the peri-esophageal scar tissue has been advocated. This video illustrates that an endoscopic division of the LAGB-induced esophageal fibrosis is another potential treatment for adjustable gastric band-induced achalasia.

Introduction: Obtaining an adequate mucosal closure is one of the crucial steps in per-oral endoscopic myotomy (POEM). Thus far, there have been no objective data comparing the various available closure techniques. This case-controlled study attempts to compare the application of endoscopic clips versus endoscopic suturing for mucosotomy closure during POEM cases., Methods: A retrospective review of our prospective POEM database was performed. All cases in which endoscopic suturing was used to close the mucosotomy were matched to cases in which standard endoclips were used. Overall complication rate, closure time and mucosal closure costs between the two groups were compared., Results: Both techniques offer good clinical results with good mucosal closure and the absence of postoperative leak. Closure time was significantly shorter (p = 0.044) with endoscopic clips (16 ± 12 min) when compared to endoscopic suturing (33 ± 11 min). Overall, the total closure cost analysis showed a trend toward lower cost with clips (1502 ± 849 USD) versus endoscopic suturing (2521 ± 575 USD) without reaching statistical significance (p = 0.073)., Conclusion: The use of endoscopic suturing seems to be a safe method for mucosal closure in POEM cases. Closure time is longer with suturing than conventional closure with clips, and there is a trend toward higher overall cost. Endoscopic suturing is likely most cost-effective for difficult cases where conventional closure methods fail.

Per-oral endoscopic myotomy (POEM) is a new minimally invasive endoscopic treatment for achalasia. Since the first modern human cases were published in 2008, around 2,000 cases have been performed worldwide. This technique requires advanced endoscopic skills and a learning curve of at least 20 cases. POEM is highly successful with over 90 % improvement in dysphagia while offering patients the advantage of a low impact endoscopic access. The main long-term complication is gastroesophageal reflux (GER) with an estimated incidence of 35 %, similar to the incidence of GER post-laparoscopic Heller with fundoplication. Although POEM represents a paradigm shift in the treatment of achalasia, more long-term data are clearly needed to further define its role in the treatment algorithm of this rare disease.