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

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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

Authors and Affiliations

  1. Department of Surgery, Eastern Health Clinical School, Monash University, Clayton, VIC, Australia

    Geoffrey P. Kohn

  2. Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA

    Rebecca C. Dirks & Dimitrios Stefanidis

  3. School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada

    Mohammed T. Ansari

  4. International Foundation for Gastrointestinal Disorders, Mount Pleasant, USA

    Jason Clay & Ceciel Rooker

  5. The Oregon Clinic, Portland, OR, USA

    Christy M. Dunst

  6. Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden

    Lars Lundell

  7. Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA

    Jeffrey M. Marks

  8. Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA

    Daniela Molena

  9. AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Newtown, Sydney, NSW, Australia

    Payal Saxena

  10. Institut de Chirugie, IHU Strasbourg, Strasbourg, France

    Lee Swanstrom

  11. Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

    Reuben K. Wong

  12. Department of Surgery, Stony Brook University, Stony Brook, NY, USA

    Aurora D. Pryor

  13. Melbourne Upper GI Surgical Group, Melbourne, VIC, Australia

    Geoffrey P. Kohn

  14. Department of Surgery, Odense University Hospital, Odense, Denmark

    Lars Lundell

  15. Sydney Medical School, The University of Sydney, Sydney, NSW, Australia

    Payal Saxena

Authors
  1. Geoffrey P. Kohn
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  2. Rebecca C. Dirks
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  3. Mohammed T. Ansari
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  4. Jason Clay
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  5. Christy M. Dunst
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  6. Lars Lundell
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  7. Jeffrey M. Marks
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  8. Daniela Molena
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  9. Ceciel Rooker
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  10. Payal Saxena
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  11. Lee Swanstrom
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  12. Reuben K. Wong
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  13. Aurora D. Pryor
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  14. Dimitrios Stefanidis
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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.

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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 35, 1931–1948 (2021). https://doi.org/10.1007/s00464-020-08282-0

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  • DOI: https://doi.org/10.1007/s00464-020-08282-0

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