BACKGROUND: Long-term outcome data are limited for non-achalasia esophageal motility disorders treated by peroral endoscopy myotomy (POEM) as a separate group. We investigated a subset of symptomatic patients with hypercontractile esophagus (Jackhammer esophagus).
METHODS: Forty two patients (mean age 60.9 years; 57% female, mean Eckardt score 6.2 ± 2.1) treated by primary peroral myotomy for symptomatic Jackhammer esophagus 2012-2018 in seven European centers were retrospectively analyzed; myotomy included the lower esophageal sphincter but did not extend more than 1 cm into the cardia in contrast to POEM for achalasia. Manometry data were re-reviewed by an independent expert. The main outcome was the failure rate defined by retreatment or an Eckardt score >3 after at least two years following POEM.
RESULTS: Despite 100% technical success (mean intervention time 107 ± 48.9 min, mean myotomy length 16.2 ± 3.7 cm), the 2-year success rate was 64.3% in the entire group. In a subgroup analysis, POEM failure rates were significantly different between Jackhammer-patients without (n = 22), and with esophagogastric junction outflow obstruction (EGJOO, n = 20) (13.6% % vs. 60%, p = 0.003) at a follow-up of 46.5 ± 19.0 months. Adverse events occurred in nine cases (21.4%). 14 (33.3%) patients were retreated, two with surgical fundoplication due to reflux. Including retreatments, an improvement in symptom severity was found in 33 (78.6%) at the end of follow-up (Eckardt score ≤3, mean Eckardt change 4.34, p < 0.001). EGJOO (p = 0.01) and frequency of hypercontractile swallows (p = 0.02) were predictors of POEM failure. The development of a pseudodiverticulum was observed in four cases within the subgroup of EGJOO.
CONCLUSIONS: Patients with symptomatic Jackhammer without EGJOO benefit from POEM in long-term follow-up. Treatment of Jackhammer with EGJOO, however, remains challenging and probably requires full sphincter myotomy and future studies which should address the pathogenesis of this variant and alternative strategies.

OBJECTIVE: Gastric balloons and endoscopic sleeve gastroplasty appear to work by delaying gastric emptying. We hypothesized that pylorus-sparing antral myotomy would inhibit the antral pump, inducing gastric retention and similarly resulting in weight loss.
METHODS: In this single-center pilot study, we assessed bariatric endoscopic antral myotomy (BEAM) using submucosal tunneling. The primary outcomes were feasibility, safety, and efficacy at 6 and 12 months, whereas the secondary outcomes were changes in the gastric-emptying rate and gastroparesis cardinal symptom index (GCSI) score.
RESULTS: Six subjects underwent successful BEAM. One required needle decompression, and another developed pulmonary embolism, treated without sequela. At 6 and 12 months, patients achieved 9.1% ± 8.9% and 12.2% ± 7.1% total weight loss (P < .0005). The gastric-emptying rate was delayed by 36.6% in those with ≥10% total weight loss. The GCSI score increased significantly at 12 months, particularly regarding early satiety.
CONCLUSIONS: This pilot study suggests BEAM is feasible and appears to induce delayed gastric emptying that is associated with significant weight loss, without symptoms of gastroparesis.

Distal esophageal spasm is characterized by premature contractions of the distal esophageal smooth muscle leading to non-obstructive dysphagia and non-cardiac chest pain. Diagnosis requires the presence of symptoms along with evidence of at least 20% premature contractions in the setting of a normal lower esophageal sphincter relaxation on high-resolution manometry. New updates to the Chicago Classification have improved the diagnostic accuracy of this method. Functional lumen imaging probe is a growing diagnostic modality that gives a more complete picture of esophageal motility. Pharmacologic treatment remains inadequate. Endoscopic myotomy might be of benefit for non-achalasia esophageal motility disorders. More research is required to better understand the pathophysiology and develop safe and long-lasting management for this disease.

OBJECTIVE: Achalasia often presents with chronic food stasis and fermentation in the esophageal lumen, which may lead to alterations of the esophageal microbiome, with associated mucosal inflammation and dysplastic changes. The study aims to evaluate the characteristics of the esophageal microbiome in achalasia and changes of the esophageal microbiome before and after peroral endoscopic myotomy (POEM).
METHODS: This is a prospective case-control study. This study enrolled patients with achalasia and asymptomatic subjects as control group. Endoscopic brushing for esophageal microbiome collection was performed in all subjects, with additional follow-up endoscopy and brushing 3 months after POEM in achalasia patients. The composition of the esophageal microbiome was determined and compared between (1) achalasia patients and asymptomatic controls and (2) achalasia patients before and after POEM.
RESULTS: Thirty-one achalasia patients (mean age 53.5 ± 16.2 years; male 45.2%) and 15 controls were analyzed. We observed a distinct esophageal microbial community structure in achalasia patients, with increased Firmicutes and decreased Proteobacteria when compared with the control group at the phylum level. The discriminating enriched genera in achalasia patients were Lactobacillus, followed by Megasphaera and Bacteroides, and the amount of Lactobacillus was associated with the severity of achalasia. Twenty patients were re-examined after POEM, and a high prevalence of erosive esophagitis (55%) was noted, alongside an increase in genus Neisseria and decrease in Lactobacillus and Bacteroides.
CONCLUSIONS: The altered esophageal microenvironment in achalasia leads to dysbiosis with a high abundance of genus Lactobacillus. Increased Neisseria and decreased Lactobacillus were observed after POEM. The long-term effect of microbial changes warrants further study.

Although pediatric neurogastroenterology and motility (PNGM) disorders are prevalent, often debilitating, and remain challenging to diagnose and treat, this field has made remarkable progress in the last decade. Diagnostic and therapeutic gastrointestinal endoscopy emerged as a valuable tool in the management of PNGM disorders. Novel modalities such as functional lumen imaging probe, per-oral endoscopic myotomy, gastric-POEM, and electrocautery incisional therapy have changed the diagnostic and therapeutic landscape of PNGM. In this review, the authors highlight the emerging role of therapeutic and diagnostic endoscopy in esophageal, gastric, small bowel, colonic, and anorectal disorders and disorders of gut and brain axis interaction.

Peroral endoscopic myotomy (POEM) is rapidly becoming the procedure of choice for treating esophageal achalasia. In most centers, contrast-enhanced swallow studies (CESS) are routinely performed postoperatively to confirm mucosal integrity. The aim of this study was to determine the necessity of performing these studies routinely after POEM.
A retrospective review of a prospectively maintained database of patients who underwent POEM between December 2012 and November 2020 was performed. All patients underwent a CESS on the first postoperative day. Medical records including vital signs, complete blood count, and POD-1 CESS were evaluated.
One hundred thirty-four consecutive patients were included in the study. Sixty-nine (51.49%) CESS showed abnormal findings; while most findings did not change the postoperative course, five (7.2%) demonstrated tunnel leaks, which did alter the overall management. Screening patients for fever, tachycardia, or leukocytosis on POD-1 had a 100% sensitivity and a 62% specificity for finding a clinically significant complication on CESS.
The study findings suggest that performing routine contrast-enhanced swallow studies on all patients is not necessary following POEM, as leaks can be screened for by clinical or laboratory abnormalities. Herein, we propose an algorithm based on objective measurable findings for the selection of patients who should undergo CESS.

Submucosal endoscopy (third-space endoscopy) can be defined as an endoscopic procedure performed in the submucosal space. This procedure is novel and has been utilized for delivery to the submucosal space in a variety of gastrointestinal diseases, such as a tumor, achalasia, gastroparesis, and subepithelial tumors. The main submucosal endoscopy includes peroral endoscopic myotomy, gastric peroral endoscopic myotomy, Zenker peroral endoscopic myotomy, submucosal tunneling for endoscopic resection, and endoscopic submucosal tunnel dissection. Submucosal endoscopy has been used as a viable alternative to surgical techniques because it is minimally invasive in the treatment and diagnosis of gastrointestinal diseases and disorders. However, there is limited evidence to prove this. This article reviews the current applications and evidence regarding submucosal endoscopy while exploring the possible future clinical applications in this field. As our understanding of these procedures improves, the future of submucosal endoscopy could be promising in the fields of diagnostic and therapeutic endoscopy.

UNASSIGNED: Peroral endoscopic myotomy (POEM) has been rapidly accepted as a safe and effective therapy for achalasia and other esophageal motility disorders, and has inspired novel submucosal tunneling techniques. This study analyzed the trends in POEM research and compared contributions from different countries, regions, institutions, journals, and authors using bibliometric analysis to predict the trends and potential hotspots in POEM research.
UNASSIGNED: Publications concerning POEM from January 1, 2010 to February 25, 2022, were extracted from the Web of Science database. Book chapters, retrieved manuscripts, news, erratum, non-English language publications, and irrelevant publications were excluded. Data, including keywords for each article, were collected, and network analysis was conducted. Microsoft Excel and VOSviewer were used to collect publication data, analyze publication trends, and visualize relevant results.
UNASSIGNED: A total of 1,853 publications were identified. Gastrointestinal Endoscopy has been the most popular journal in this field (n=383, 20.67%). Research from the United States was the largest contributor to POEM research worldwide and has provided a pivotal influence (n=743), followed by research from China (n=346) and Japan (n=223). Showa University (Japan) was the most active institution in the field of POEM research. In terms of authors, Dr. Inoue published the most papers in the field with the highest average citation number. Keywords were categorized into 5 clusters: management and outcomes, POEM-derived new techniques, diagnosis and classification, comparison with other treatment approaches, and fundoplication and POEM in children. Average appearing years of keywords was calculated. The topics of adverse events, gastroparesis, and gastric POEM (G-POEM) appeared most recently.
UNASSIGNED: Researchers from the United States, China, and Japan have published the most articles in the field of POEM research, but there was a disparity between the quantity and quality of publications. Research of management and POEM-derived novel techniques were considered potential areas of focus for future research.

Peroral endoscopic myotomy (POEM) and Heller myotomy with fundoplication (HMF) effectively treat achalasia, an esophageal motor disease. Although a significant number of meta-analyses have compared POEM and HMF, these studies showed discrepant postoperative gastroesophageal reflux disease (GERD) conclusions. This review aimed to objectively compare GERD over time, as well as the efficiency, safety, and adverse events in POEM versus HMF for treating achalasia. We performed a systematic review and meta-analysis by searching Medline, Embase, Cochrane Library, Scopus, and Clinicaltrials.gov. The evaluated outcomes included early (within 12 months) and late (beyond 12 months) endoscopic assessment of GERD using the Lyon Consensus, clinical success, operative duration (OD), length of stay (LOS), and major adverse events (MAE). A total of 29 observational studies and two randomized clinical trials (RCTs) with 13,914 patients were included. GERD was 28% higher among RCTs discussing POEM at early assessment (95%CI 0.02, 0.54) and was not different at late evaluation (95% confidence interval (CI) = 0.00, 0.22). No difference in reflux was observed among observational studies in both periods. The clinical success was 9% higher (95% CI = 0.05, 0.12), and the OD was 37.74 minutes shorter (95% CI = -55.44, -20.04) in POEM among observational studies, whereas it was not different among RCTs. The LOS and MAE were similar in the groups. Comparisons among studies yielded divergent results. RCTs revealed that POEM had a higher incidence of GERD in the early assessment, whereas observational studies showed higher clinical success and a shorter OD in POEM. Ultimately, the between-group difference waned over time in GERD in all comparisons, resulting in no difference among RCTs in the late evaluation. Our meta-analysis demonstrated a non-preferential treatment of achalasia between endoscopic or surgical cardiomyotomy, prioritizing an individualized approach in the long term.

BACKGROUND: Esophageal achalasia causes dysphagia following impaired relaxation of the lower esophageal sphincter due to the degeneration of Auerbach\'s plexus in the esophageal smooth muscle. Recently, peroral endoscopic myotomy (POEM) has become one of the preferred treatment options for esophageal achalasia. However, pathomorphological changes after POEM have not been well examined.
METHODS: A 65-year-old man with a history of POEM for esophageal achalasia was diagnosed with clinical stage II (cT2-N0-M0) thoracic esophageal squamous cell carcinoma and was consequently treated with neoadjuvant chemotherapy followed by thoracoscopic esophagectomy. Intraoperatively, the esophagus appeared dilated, reflecting esophageal achalasia; however, fairly slight fibrous adhesions were observed between the esophagus and the pericardial surface despite previously performed POEM via an anterior incision. Histopathological examination revealed esophageal wall thickening, edema, and fibrosis extending from the lamina propria to the submucosa. Besides, the majority of the inner layer and some proportion of the outer layer of the muscularis propria were found to be missing or atrophic at the esophagogastric junction (EGJ). No ganglion cells could be detected at the Auerbach\'s plexus.
CONCLUSIONS: The previous history of POEM did not affect circumferential mediastinal periesophageal dissection during thoracoscopic esophagectomy. Nevertheless, a large proportion of the inner layer of the muscularis propria at the EGJ level seemed to have become lost or atrophic because of the POEM procedure.