SAGES guidelines for the use of peroral endoscopic myotomy (POEM) for the treatment of achalasia

Abstract

Background

Peroral endoscopic myotomy (POEM) is increasingly used as primary treatment for esophageal achalasia, in place of the options such as Heller myotomy (HM) and pneumatic dilatation (PD)

Objective

These evidence-based guidelines from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) intend to support clinicians, patients and others in decisions about the use of POEM for treatment of achalasia.

Results

The panel agreed on 4 recommendations for adults and children with achalasia.

Conclusions

Strong recommendation for the use of POEM over PD was issued unless the concern of continued postoperative PPI use remains a key decision-making concern to the patient. Conditional recommendations included the option of using either POEM or HM with fundoplication to treat achalasia, and favored POEM over HM for achalasia subtype III.

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Abbreviations

POEM:

Peroral endoscopic myotomy

HM:

Heller myotomy

LHM:

Laparoscopic Heller myotomy

PD:

Pneumatic dilation

GERD:

Gastroesophageal reflux disease

RCT:

Randomized controlled trial

RR:

Risk ratio

CI:

Confidence interval

EtD:

Evidence to decision

PPI:

Proton pump inhibitor

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Acknowledgements

The authors thank Sarah Colon (SAGES) for administrative support

Author information

Affiliations

Authors

Contributions

GPK was the panel Chair, wrote the first draft of the manuscript and revised the manuscript based on author’s suggestions; RCD was the panel co-Chair, contributed to drafting and critical revisions of the manuscript and contributed to further drafts, and moderated the panel sessions, and checked the manuscript accuracy; MA provided methodological support; Guideline panel members (GPK, JC, CD, LL, JM, DM, CR, PS, LS, RW, AP, DS) participated in the creation of the EtD tables, critically reviewed the manuscript and provided suggestions for improvement; All authors approved the content.

Corresponding author

Correspondence to Geoffrey P. Kohn.

Additional information

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Appendices

Appendix 1: List of contributors

Panelists—Surgeons: Geoffrey P. Kohn: Monash University, VIC, Australia, Rebecca C. Dirks: Indiana University, IN, USA, Christy M. Dunst: The Oregon Clinic, OR, USA, Lars Lundell: Karolinska University Hospital, Sweden, Jeffrey Marks: University Hospitals Cleveland Medical Center, OH, USA, Daniele Molena: Memorial Sloan Kettering Cancer Center, NY, USA, Lee Swanstrom: Institut de Chirugie, Strasbourg, France, Aurora D. Pryor: Stony Brook University, NY, USA, Dimitrios Stefanidis: Indiana University, IN, USA. Gastroenterologists: Payal Saxena: University of Sydney, NSW, Australia. Reuben K. Wong: National University of Singapore, Singapore. Methodologist: Mohammed T Ansari: University of Ottawa, ON, Canada. Patient advocates: Jason Clay: International Foundation for Functional Gastrointestinal Disorders, USA. Ceciel Rooker: International Foundation for Functional Gastrointestinal Disorders, USA.

Appendix 2: Full declarations of conflict of interest

All conflicts of interest disclosures were assessed as not having influenced the construction of these Guidelines. Mohammed T Ansari: No conflict of interest to declare. Contracted by SAGES as a methodology consultant. Jason Clay: Nothing to disclose. Rebecca C Dirks: Equity in Johnson & Johnson. Christine Dunst: Nothing to disclose. Geoffrey P Kohn: Nothing to disclose. Lars Lundell: Nothing to disclose. Jeffrey Marks: Consultant fees from Olympus, Boston Scientific. Daniele Molena: Consultant fees from Johnson and Johnson, Urogen, Boston Scientific. Grant from Intuitive. Aurora D Pryor: Speaker for Ethicon, Gore, Merck, Stryker. On scientific advisory board for Obalon. Ceciel Rooker: Nothing to disclose. Payal Saxena: Nothing to disclose. Dimitrios Stefanidis: Nothing to disclose. Lee Swanstrom: Personal fees from Human Xtensions, Titan. Reuben Wong: Nothing to disclose.

Appendix 3: Evidence to decision tables

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Kohn, G.P., Dirks, R.C., Ansari, M.T. et al. SAGES guidelines for the use of peroral endoscopic myotomy (POEM) for the treatment of achalasia. Surg Endosc (2021). https://doi.org/10.1007/s00464-020-08282-0

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Keywords

  • Esophageal achalasia
  • POEM procedure
  • Heller myotomy
  • Pneumatic dilatation
  • Clinical practice guidelines