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.

Keywords: gastroesophageal reflux disease; lower esophageal sphincter preservation; peroral endoscopic myotomy; spastic esophageal disorder.

Figure 1

Treatment algorithm for spastic esophageal disorders. For type III achalasia, extended myotomy of both the esophageal body and lower esophageal sphincter (LES) is necessary. In cases of distal esophageal spasm (DES) and jackhammer esophagus (JE), if hypercontractile or premature contractions can be differentiated from the LES on high‐resolution myotomy (HRM), peroral endoscopic myotomy (POEM) with LES preservation is recommended. If symptoms persist after LES‐preserving POEM, a redo POEM may be considered. When differentiation is not possible, a short myotomy extending 1–2 cm into the gastric side is considered sufficient.

Figure 2

Peroral endoscopic myotomy (POEM) with lower esophageal sphincter (LES) preservation. (a) For distal esophageal spasm (DES) and jackhammer esophagus (JE) myotomy, we terminate the incision when the inner circular muscle becomes thin (blue arrow). (b, c) Double‐scope method around the lower esophageal sphincter (LES). Transillumination was confirmed at the level where the palisade vessels are visible, ensuring that the incision did not extend to the LES. (d) The scope‐holding sign in the retroflex view was used for additional verification.