Peroral Endoscopic Myotomy for Complex Achalasia and the POEM Difficulty Score

Abstract

Background

Peroral endoscopic myotomy (POEM) for achalasia is technically more challenging to perform in patients with type III, multiple prior treatments, prior myotomy, and sigmoid‐type. Here we present a series of consecutive patients with complex achalasia and introduce the POEM Difficulty Score (PDS).

Aim

To demonstrate the application and discuss the utility of the PDS, and present the feasibility, safety, and efficacy of POEM in complex achalasia patients.

Methods

40 consecutive POEMs were performed with 28 meeting the criteria for complex achalasia. The primary outcome was clinical success (Eckardt score <3) at a minimum of 3 months' follow‐up. Secondary outcomes included: adverse events, procedural velocity and PDS.

Results

28 complex and 12 non‐complex POEM procedures were performed with 100% and 92% clinical success, respectively without any major adverse events with a median follow‐up of 15 months (complex) and 8 months (non‐complex) months. The mean velocities for non‐complex, type III, prior myotomy, >4 procedures and sigmoid‐type were: 4.4±1.6minutes/cm, 4.8±1.5 mins/cm, 5.9±2.2mins/cm, 6.9±2.2minutes/cm and 8.2±3.2minutes/cm, respectively. The median PDS for non‐complex, type III, prior myotomy, >4 treatments and sigmoid‐type were 1 (0‐3), 2 (0‐4), 2.5 (1‐6), 3 (2‐6) and 3.5 (1‐6), respectively. The PDS was shown to correlate well with the procedural velocity with a correlation coefficient of 0.772 (Spearman's p < 0.001).

Conclusions

The PDS identifies the factors that contribute to challenging POEM procedures and correlates well with procedural velocity. The order of increasing difficulty of POEM in complex achalasia appears to be type III, prior myotomy, >4 treatments and sigmoid‐type.

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