A novel anatomically guided strategy for evaluation of sufficient myotomy during peroral endoscopic myotomy in patients with achalasia

Background and Aims

Peroral endoscopic myotomy (POEM) necessitates proper orientation of the anatomical landmarks throughout the whole procedure to assess the myotomy, which is the main target of POEM. Insufficient myotomy renders the procedure ineffective and may lead to nonresponse or recurrence, although longer myotomy may increase the risk of reflux. The current conventional methods for esophagogastric junction (EGJ) detection are often operator-dependent, time-consuming, and have questionable accuracy. We aimed to provide a novel anatomically based approach for more precise tailoring of myotomy.

Methods

It depends on the clear demarcation of the meeting of 3 landmarks at the EGJ (the EGJ triad): esophageal adventitia, diaphragmatic crura and perigastric peritoneum. Once this triad is seen, after commencing the full-thickness myotomy procedure, then an optimum length of myotomy should be achieved, and no further myotomy is needed.

Results

The technique is considered a feasible, effective, and reproducible method that might be attractive for experienced endoscopists practicing POEM. This method is time-preserving and reproducible and enhances the endoscopist’s capabilities in dealing with problematic cases through increasing his or her familiarity with the surgical anatomy at the EGJ and at the same time avoids procedure failure or recurrence of symptoms and decreases the risk of reflux.

Conclusions

This approach provides a potential supportive method for achieving an optimum myotomy during POEM procedures, ensuring effective treatment and avoiding POEM-induced reflux.