Abstract
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Despite these developments, we remain far from achieving consensus to make POEM the preferred method for the treatment of achalasia. Training remains highly restricted to postgraduate courses, and different resources are required to successfully execute these procedures. In addition, at the moment, very few centers have large volume experience with POEM. 2 In contrast, we are still working on the basic questions: What are the ideal characteristics (length, depth) of the endoscopic myotomy that will ensure durability of procedure? How much postprocedure gastroesophageal reflux disease (GERD) is acceptable? What is the adequate complication rate? And finally, what is the rescue procedure for failed POEM? In the current state, we have more questions than answers.
In this updated series, the authors compared the safety and efficacy of a full thickness myotomy (FTM) with circular myotomy (CM) in patients with severe achalasia. 3 The authors have a large experience with POEM and have transitioned from CM to FTM because of poor outcomes observed in some patients. Specifically, they favored FTM in patients with severe achalasia because of the completeness of the myotomy postulating that it may offer better long-term outcomes. Even though I commend the authors for their vast experience and their follow-up data (97%), this article failed to offer revealing information compared with their 2016 publication elsewhere. 4 Success rates for both groups were comparable for complications, symptoms resolution (98%), decreased esophageal diameter, and decreased lower esophageal sphincter pressure. They also observed shorter procedure times for FTM without increasing complications. This phenomenon has two potential explanations: perhaps they started FTM after completing their learning curve with CM, and second, while performing CM, much time is consumed trying to preserve the longitudinal fibers, which could explain the extended times.
As the authors carefully acknowledged in this and their previous article, 4 the postmyotomy incidence of objective GERD was higher in patients after FTM than after CM. This finding is not surprising, yet exceedingly concerning because POEM has already shown a higher rate of pathological reflux than laparoscopic Heller myotomy. 5
Based on these findings, better understanding of the anticipated benefits of the FTM has to be realized. Even though a significant reduction in procedure time was observed, the results postprocedure were equivalent. It, therefore, seems justifiable to ask why to perform a procedure that increases the prevalence of GERD without obvious clinical benefits.