OBJECTIVE: Early identification of patients needing hospital-specific interventional care (HIC) following endoscopic treatment is valuable for optimizing postoperative hospital stays. We aimed to develop and validate a risk-scoring system for predicting HIC in patients who underwent peroral endoscopic myotomy (POEM).
METHODS: This study included patients with esophageal motility disorders who underwent POEM at our hospital between April 2015 and March 2023. HIC was defined as any of the following situations: fasting for gastrointestinal rest to manage adverse events (AEs); intravenous administration of medications such as antibiotics and blood transfusion; endoscopic, radiologic, and surgical interventions; intensive care unit management; or other life-threatening events. A risk-scoring system for predicting HIC after postoperative day (POD) 1 was developed using multivariable logistic regression and was internally validated using bootstrapping and decision curve analysis.
RESULTS: Of the 589 patients, 50 (8.5%) experienced HIC after POD1. Risk scores were assigned for four factors as follows: age (0 points for <70 years, 1 point for 70-79 years, 2 points for ≥80 years), preoperative prognostic nutritional index (0 points for >45, 1 point for 40-45, 4 points for <40), postoperative surgical site AEs on second-look endoscopy (7 points), and postoperative pneumonia on chest radiography (6 points). The discriminative ability (concordance statistics, 0.85; 95% confidence interval, 0.78-0.91) and calibration (slope 1.00; 0.74-1.28) were satisfactory. The decision curve analysis demonstrated its clinical usefulness.
CONCLUSIONS: This risk-scoring system can predict the HIC after POD1 and provide useful information for determining discharge.

Peroral endoscopic myotomy (POEM) is an established treatment for achalasia, yet there is still a lack of technical standardization. No clear definition of \'long\', \'standard\', or \'short\' POEM exists to date. We conducted a systematic review with meta-analysis to analyze current POEM length standards. We included studies reporting technical details of POEM, in which no definite or comparative myotomy length was intentionally adopted (standard myotomy). The primary outcome was the pooled mean total myotomy length. Sub-group analyses were performed to explore heterogeneity across studies. From the initial 7172 records, 31 studies with 3023 patients were included. Pooled mean of total myotomy length was 10.39 cm (95% CI 10.06-10.71; I2 99.3%). Pooled mean of esophageal and gastric myotomy length, provided by 17 studies, was 7.11 cm (95% CI 6.51-7.71; I2 99.8%) and 2.81 cm (95% CI 2.41-3-22; I2 99.8%), respectively. On subgroup analysis for achalasia subtypes, pooled mean length in non-spastic achalasia (type I and II) was 10.17 cm (95% CI 9.91-10.43; I2 94.2%), while in type III it was 14.02 cm (95% CI 10.59-17.44; I2 98.9%). Pooled mean myotomy length for studies conducted between 2014-2020 was 10.53 cm (95% CI, 10.22-10.84; I2 99.1%) and 9.74 cm (95% CI, 7.95-11.54; I2 99.7%) in 2021-2022. Myotomy length during a \'standard\' POEM is 10.4 cm, remaining over 10 cm in non-spastic achalasia. The high heterogeneity across studies confirms that the POEM technique needs further standardization. We found no significant time trend towards adopting short POEM, despite recent evidence supporting its use.

Cricopharyngeal achalasia (CPA), also known as cricopharyngeal bar, is a rare motor disorder affecting the upper oesophageal sphincter. This comprehensive literature review focuses on clinical aspects that can assist physicians in daily decision-making. The diagnosis of CPA is primarily based on symptoms of upper dysphagia and radiological identification of a posterior bar. However, the diagnostic process is not standardized and necessitates a multimodal approach, including radiological, endoscopic, and manometric studies performed by various specialists. Treatment options for CPA include botulinum toxin injection, endoscopic balloon dilatation, open or endoscopic surgery, and cricopharyngeal peroral endoscopic myotomy (CP-POEM). CP-POEM is the latest indication for POEM and has shown promising results with minimal adverse events, though high-quality evidence is still lacking.

Achalasia, characterized by impaired lower esophageal sphincter (LES) relaxation and failed peristalsis, stands out as the most widely recognized primary esophageal motility disorder. It manifests with dysphagia to solid and liquid foods, chest pain, regurgitation, and weight loss, leading to significant morbidity and healthcare burden. Traditionally, surgical Heller myotomy and pneumatic dilation were the primary therapeutic approaches for achalasia. However, in 2009, Inoue and colleagues introduced a groundbreaking endoscopic technique called peroral endoscopic myotomy (POEM), revolutionizing the management of this condition. This review aims to comprehensively examine the recent advancements in the POEM technique for patients diagnosed with achalasia, delving into critical aspects, such as the tailoring of the myotomy, the prevention of intraprocedural adverse events (AEs), the evaluation of long-term outcomes, and the feasibility of retreatment in cases of therapeutic failure.

Zenker\'s diverticulum (ZD), also known as a cricopharyngeal pouch, is a pulsion pseudodiverticulum located dorsally at the pharyngoesophageal junction. The pathophysiology of ZD involves cricopharyngeal spasm, incoordination, impaired upper esophageal sphincter opening, and structural changes in the cricopharyngeal muscle, leading to symptoms such as dysphagia, regurgitation of undigested food, foreign body sensation, halitosis, unintentional weight loss, and respiratory issues. Treatment for symptomatic ZD typically involves myotomy of the cricopharyngeal muscle. Endoscopic techniques, particularly flexible endoscopy septotomy (FES) and Zenker peroral endoscopic myotomy (Z-POEM), have become preferred options due to their minimally invasive nature. This review discusses the techniques and clinical outcomes of FES and Z-POEM, focusing on specific clinical scenarios to guide the choice between these methods. Additionally, the variability in FES techniques, the effectiveness of Z-POEM, and the impact of different diverticulum sizes on treatment outcomes are analyzed, providing a comprehensive overview of current therapeutic approaches for ZD.

Non-achalasia oesophageal motility disorders (NAOMD) represent a heterogeneous group of rare diseases, including oesophagogastric junction outflow obstruction, distal oesophageal spasm, and hypercontractile oesophagus. Despite the differing aetiological, manometric and pathophysiological characteristics, these disorders are unified by similar clinical presentation, including dysphagia and chest pain. The management of these disorders remain a challenge for the clinician. Pharmacotherapy, botulinum toxin injection, endoscopic dilation, and laparoscopic Heller myotomy have been employed, with limited efficacy in the majority of patients. Currently, there are no controlled studies in literature that suggest which is the best management of these diseases. Since its introduction in clinical practice, PerOral Endoscopic Myotomy (POEM) has emerged as a very promising, minimally invasive and effective treatment for oesophageal achalasia. No longer after the first uses, POEM has been successfully used also for the management of selected patients with NAOMD, However, currently available data are limited by small study sample sizes and short-term follow-up.

Third space endoscopy (TSE) encompasses a breadth of procedures for the treatment of a variety of GI disorders. The widespread use of per-oral endoscopic myotomy (POEM) and its diversification to include extended indications and at locations other than the oesophagus has provided an insight into the potential complications encountered. The most common adverse events associated with POEM, the epitome of TSE procedures, include insufflation related injuries, bleeding, failure of mucosal barrier, infections, pain, blown out myotomy and gastroesophageal reflux disease. The purpose of this review is to highlight the pitfalls and to identify the risk factors that may lead to adverse events, and to recommend appropriate salvage interventions in the scope of the current evidence.

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OBJECTIVE: Per-oral endoscopic myotomy (POEM) is a recognised treatment for achalasia, with the accepted approach involving admission for imaging and dietary progression. However, recent publications suggest same-day discharge (SDD) may be possible, which could be time and cost-saving. We sought to investigate the safety of SDD following POEM.
METHODS: Fifty consecutive POEMs at two referral centres in New Zealand were performed between 2020-2023. All patients were planned for early dietary introduction and were eligible for SDD if symptoms were managed. Analgesia was available in recovery and supplied at discharge. Imaging and endoscopy were performed only if there were clinical concerns. Rates of discharge clearance, discharge, complications and re-admission were analysed.
RESULTS: All 50 POEMs were technically successful. A total of 41/50 (82%) received clearance for SDD. Additionally, 35/50 (70%) achieved discharge and 6/50 (12%) were observed overnight for social reasons, including lack of transport to the referring domicile. Of the patients not cleared for SDD, 7/9 (78%) were discharged within 24 hours, and the others after 48 and 72 hours. Procedural complications were recorded in three patients (6%), with one requiring endoscopic assessment and clipping. There were two re-admissions (4%), both lt;24-hour hospital stays, and managed medically.
CONCLUSIONS: The majority of patients achieved same-day discharge clearance (82%) and 96% required less than 24 hours hospital stay. Complication and re-admission rates were low overall. We have demonstrated that POEM can be an SDD procedure facilitated by early dietary introduction and liberal analgesia, without the need for routine imaging or endoscopy.