Assessing lower esophageal sphincter integrity during peroral endoscopic myotomy: navigating the challenges of preservation versus division

We read with great interest the article by Perananthan et al., which presents an insightful evaluation of lower esophageal sphincter (LES)-sparing peroral endoscopic myotomy (POEM) in patients with non-achalasia esophageal motility disorders (NAEMDs) [1]. We commend the authors for their innovative approach in redefining endoscopic techniques for NAEMD.

Our commentary focuses on several key aspects of this study. Primarily, NAEMDs are characterized by the absence of LES involvement, differentiating them from achalasia. This distinction underpins the rationale for LES-sparing myotomy, aiming to alleviate symptoms without increasing the risk of gastroesophageal reflux disease (GERD). However, the practical challenges in accurately identifying the LES intraoperatively, especially in an NAEMD, where the LES is not pathologically implicated, are noteworthy. Despite the authors’ efforts to circumvent inadvertent inclusion of the LES in the myotomy, the infallibility of these methods remains questionable. Additionally, the anatomical complexity of the LES, extending over 3–4 cm, complicates the determination of its absolute involvement in the myotomy [2].

Another point of interest is the post-procedural assessment of GERD. The study reports a low incidence of esophagitis (12.5%) at follow-up; however, the role of proton pump inhibitors (PPIs) during this period is not clarified. Given that post-POEM reflux has shown responsiveness to PPI therapy, withholding PPIs could provide a more accurate evaluation of GERD post-procedure [3].

Lastly, we raise concerns regarding the variability and potential progression of NAEMDs [4]. This is exemplified by a case of distal esophageal spasm that progressed to type III achalasia in the study and is corroborated by other published case reports [5]. Incorporating the LES in the myotomy, while carefully avoiding extensive dissection into the stomach, could potentially offer a relapse-free alternative. This approach may minimize the risk of GERD, which is theoretically attributed to excessive myotomy on the gastric side.

In summary, while LES-sparing myotomy presents as an intuitive approach for NAEMDs, further research is needed for its standardization and comparative analysis with conventional techniques.

Publication History

Article published online:
29 August 2024

• References

• 1 Perananthan V, Gupta S, Whitfield A. et al. When less is more: lower esophageal sphincter-preserving peroral endoscopy myotomy is effective for non-achalasia esophageal motility disorders. Endoscopy 2024; DOI: 10.1055/a-2239-7371.
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