Findings Support Per-Oral Endoscopic Myotomy as Safe, Effective for Esophagogastric Junction Outflow Obstruction

Endoscopy of the esophagus showing grade 2 esophagitis
Results of a multicenter, retrospective study of per-oral endoscopic myotomy (POEM) for EGJOO suggest that POEM is an effective and safe therapy.

Preliminary data support per-oral endoscopic myotomy (POEM) as an effective and safe therapy for a variety of non-achalasia motility disorders, including esophagogastric junction outflow obstruction (EGJOO), according to the results of  a study published in Clinical Gastroenterology and Hepatology.1

EGJOO is a rare but increasingly recognized diagnosis that is characterized by elevated integrated relaxation pressure of the lower esophageal sphincter  with some preserved esophageal peristalsis.2-4 There is little consensus on the preferred therapeutic approach for this disorder. Researchers conducted a multicenter, retrospective study to investigate the safety and efficacy of POEM for the treatment of symptomatic EGJOO in 55 patients between 2014 and 2020.1 The mean duration of symptoms prior to POEM was 70.1 months; nearly half of patients (45.5%) had failed prior treatment.

The researchers found that technical success was achieved in all patients (100%) with a mean procedure time of 73.2±35.6 minutes, and clinical success was attained in 47/55 patients (94%) at a median follow-up of 117 days. Two minor (mucosal perforation), 2 mild (pneumoperitoneum requiring decompression), and 1 severe adverse event (mucosal perforation treated with esophageal stent with full recovery) were reported.

A mean post-POEM, integrated relaxation pressure (n=17) of 8.88±7.03 mmHg was recorded — a mean difference of 10.64 (95% CI, 5.82-15.46; P =.0003) from pre-POEM high-resolution manometry. Post-POEM pH monitoring (n=18) was abnormal in 66% of patients, and esophagitis was observed in 10 out of the 25 patients who had post-POEM endoscopy.  

Study limitations include limited data on the utility of POEM in EGJOO, a lack of standardized pre- and postprocedure management, and potential selection bias.

“Our findings support the possible role of POEM as safe and effective in everyday practice but also the need for further larger prospective studies,” concluded the authors.1

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1. Jacobs CC, Perbtani Y, Yang D, et al. Per-oral endoscopic myotomy (POEM) for esophagogastric junction outflow obstruction (EGJOO): a multicenter pilot study [published online August 21, 2020]. Clin Gastroenterol Hepatol. doi: 10.1016/j.cgh.2020.08.048

2. Kahrilas PJ, Bredenoord AJ, Fox M, et al; for the International High Resolution Manometry Working Group. The Chicago Classification of esophageal motility disorders, v3.0. Neurogastroenterol Motility. 2015;27(2):160-174.

3. Pérez-Fernández M-T, Santander C, Marinero A, Burgos-Santamaría D, Chavarría-Herbozo C. Characterization and follow-up of esophagogastric junction outflow obstruction detected by high resolution manometry. Neurogastroenterol Motility. 2016;28(1):116-126.

4. Ihara E, Muta K, Fukaura K, Nakamura K. Diagnosis and treatment strategy of achalasia subtypes and esophagogastric outflow obstruction based on high-resolution manometry. Digestion. 2017;95(1):29-35.