Peroral endoscopic myotomy (POEM) for achalasia in the Middle East: The type of myotomy matters.

Sir, Achalasia is a rare disease, that negatively affects human life with progressive dysphagia.[1] The Chicago Classification and the introduction of the peroral endoscopic myotomy (POEM) procedure (PP) into clinical practice revolutionized the treatment of achalasia.[2] The main goal of current therapeutic modalities is to reduce lower esophageal sphincter (LES) pressure.[3] Recently, Al Lehibi et al. examined 67 patients with achalasia where 95.5% achieved Eckardt scores of ≤3 at ≥3 months after the procedure.[3] It is important to determine myotomy according to the achalasia type, but as the authors stated, 10 cm in types I–II and 12 cm in type III may not be sufficient. It should be noted that in another study, good results were obtained when performing a myotomy with an average of 14.4 cm.[4] Similarly, long myotomy in the PP in patients with type III achalasia (16 vs 8 cm) is associated with better clinical outcomes.[5] The length of myotomy distal to the gastroesophageal junction (GEJ) is important in achalasia. Adequate gastric myotomy has been shown to prevent recurrent dysphagia in achalasia cases. Traditionally, the length of gastric myotomy varies from 2 to 3 cm.[6] İn the study by Al Lehibi et al, we believe that the myotomy was short, which is performed up to 2 cm distal to the GEJ. The authors did not specify what type of myotomy they performed in their study, but several randomized trials and systematic reviews have confirmed that the orientation of myotomy (anterior or posterior), has no substantial impact on the outcomes of POEM.[6] However, Al Lehibi et al. did not state whether selective circular myotomy or full‐thickness myotomy was performed in their study. In addition, the rate of pneumoperitoneum was relatively high (32.8%) during PP, which may be related to the general anesthesia‐related positive pressure ventilation utilized to prevent adverse events of CO2. Sometimes, it is necessary to pause the POEM for a while to prevent CO2 from leaking into the various tissue planes.[7] Generally, air leaks resolve spontaneously and a chest tube should be inserted when severe pneumothorax develops. In essence, POEM is a safe procedure for the treatment of achalasia. Myotomy length should be determined according to achalasia type and distal segment involvement. It may require redo POEM in the case of recurrent disease or esophagectomy in the case of the sigmoid esophagus.