PERORAL ENDOSCOPIC MYOTOMY IN SPASTIC ESOPHAGEAL DISORDERS: CLINICAL OUTCOMES AND OPTIMAL APPROACHES

Abstract

Objectives: The efficacy and safety of peroral endoscopic myotomy (POEM) for spastic esophageal disorders (SED), including type Ⅲ achalasia, distal esophageal spasm (DES), and jackhammer esophagus (JE), remain uncertain due to its rarity. This study aimed to evaluate the clinical outcomes and optimal strategies for managing SED.

Methods: A retrospective analysis was conducted on patients who underwent POEM for SED between March 2014 and December 2023. Myotomy was tailored to target spastic segments in all cases. For type Ⅲ achalasia, the myotomy extended into the gastric cardia, while for DES and JE, the procedure either preserved the lower esophageal sphincter (LES) or included a gastric myotomy. Outcomes assessed included procedural details, technical and clinical success, adverse events, and the incidence of gastroesophageal reflux disease (GERD) post-POEM. Clinical success was defined as an Eckardt score of ≤3.

Results: Among 2938 POEM procedures, 106 (3.6%) were for SED. The cohort included 58 patients (54.8%) with type Ⅲ achalasia, 24 (22.6%) with DES, and 24 (22.6%) with JE. The technical success rate was 100%, with clinical success rates of 98.1% at 2-3 months and 92.6% at 1 year. Erosive esophagitis occurred in 27.7% at 2-3 months and 16.1% at 1 year. LES-preserving POEM for DES and JE showed comparable efficacy to POEM with gastric myotomy, with a trend toward reduced GERD incidence.

Conclusion: Peroral endoscopic myotomy is an effective treatment for all types of SED. LES-preserving POEM is a viable strategy for treating DES and JE, offering comparable efficacy, while potentially minimizing GERD risk.