Peroral endoscopic myotomy: An emerging minimally invasive procedure for achalasia

Table 1 Complications after peroral endoscopic myotomy

Complication	Treatment
Mucosal injury	After completion of myotomy, mucosal defects should be closed to minimize risk of leak with clips or suturing device
Full thickness injury	Although certain centers have demonstrated safety with full thickness myotomy, if occurs at site of mucosectomy the operator must consider closure of this myotomy site to prevent potential leakage
Gas escape related complications
Subcutaneous emphysema	Observation
Pneumomediastinum	Observation, unless physiologic symptoms
Pneumothorax	Small volume closely observed with oxygen only. Volume > 30% may require decompression
Pneumoperitoneum	Large volume or physiologic symptoms requires decompression of the abdomen with Veress needle insertion
Pleural effusion	Small volume can be observed and will absorb. Larger volumes with symptoms require drainage
Bleeding	Most common at the GEJ or distal on stomach side due to increased vascularity. Supportive care and transfusions, endoscopic re-exploration if warranted for hemostasis
Leak/mediastinitis	Depending on time of presentation and extent of perforation will determine the interventions required, which may be as simple as endoscopic treatment or as severe as invasive surgical treatment

GEJ: Gastroesophageal junction.

Table 2 Reported outcomes for Large Volume Single Centers after peroral endoscopic myotomy

Ref.	Study size	Myotomy thicknes/length	Morbidity	Follow up(mo)	Clinical outcome - before/after	Manometry before/after	Postop PPI
Inoue et al[14] 2013	300	Partial	Pneumothorax 0.3%	12	Eckardt - 6.13/1.33	27.3/13.4	4.9%
		14.1 cm	Mucosal Injury - 2.0%		98.2% success
Ren et al[10] 2012	119	Partial	Pneumothorax - 25.2%	3	98.3% success	NA	NA
		9.2 cm	Pneumoperitoneum - 39.5% Bleeding 0.8%
Friedel et al[15] 2013	45	Full	Mucosal Injury - 20%	3	Eckardt - 7.8/0.4	NA	NA
		9 cm	Pneumoperitoneum - 13%		95% success
Bhayani et al[9] 2014	37	Partial	Perforation - 10.8% Bleeding - 2.7%	6.8	Eckardt - 5.4/1.2	41/16	NA
					Dysphagia - 0%
Vigneswaran et al[17] 2014	37	Partial	Perforation - 5.4%	11.3	Eckardt - 6.8/0.6	29.1/NA	22%
		12.8 cm	Mucosal Injury - 2.7%		100% success
Hungness et al[12] 2013	18	Partial	Perforation - 5.6%	6	Eckardt - 7/1	19/9	NA
		9 cm			89% success
von Renteln et al[7] 2012	16	Partial and full	Perforation - 0%	3	Eckardt - 8.8/1.4	27.2/11.8	6.3%
		12 cm	Pneumoperitoneum - 50%		94% success

NA: Not available; PPI: Proton pump inhibitor.