Peroral endoscopic myotomy in children with achalasia: A review of the literature

Table 1 Achalasia diagnosis, classification and clinical implications

Aspect	Details
Diagnostic methods	1 Barium swallow study: Demonstrates dilated esophagus with tapering distal esophagus ("bird's beak sign")
	2 Esophageal manometry: Gold standard for diagnosis
Achalasia subtypes	Subtype I: Absent distal esophageal pressurization
	Subtype II: Panesophageal pressurization
	Subtype III (A, B, C, D): Spastic contractions (≥ 2) with or without periods of pressurization
	A: Spastic achalasia: Premature/spastic contractions with impaired LES relaxation
	B: Hypercontractile achalasia: High amplitude and long-duration contractions with incomplete LES relaxation
	C: Segmental achalasia: Abnormal contractions limited to specific segments (commonly distal third)
	D: Peristaltic achalasia: Proximal esophageal peristalsis retained with distal esophagus spastic activity
Clinical presentation	Subtype I: 100% failure of peristalsis
	Subtype II: Increased IRP, commonly associated with weight loss
	Subtype III: Chest pain common symptom
Clinical implications	Patients with subtype II are more likely to respond to operative interventions

LES: Lower esophageal sphincter; IRP: Integrated relaxation pressure.

Table 2 Characteristics of studies investigating peroral endoscopic myotomy

Ref.	Year	Country	n	Population	Mean pre-POEM Eckardt score	Mean post-POEM Eckardt score
Bapaye et al[41]	2023	India	1	Children	NR	NR
Bi et al[28]	2023	China	48	Children	8	1.1
Caldaro et al[7]	2015	Italy	9	Children	7	0
Chen et al[50]	2014	China	27	Children	8.3	0.7
Choné et al[38]	2019	France	117	Children	7.5	0.9
Familiari et al[29]	2013	Italy	3	Children	5.3	0
Filser et al[85]	2015	Germany	1	Children	8	1
Hsu et al[5]	2023	Taiwan	10	Children	5.7	1.1
Kethman et al[23]	2017	United States	10	Children	7	2.4
Korrapati et al[99]	2018	India	15	Children	7	1
Li et al[87]	2014	China	9	Children	7	0.8
Liu et al[34]	2019	China	130	Children	7.4	0.7
Luvsandagva et al[53]	2024	Mongolia	12	Children	7	1
Mangiola et al[88]	2018	Italy	26	Children	7.2	0.3
Miao et al[33]	2017	China	21	Children	7.18	0.75
Nabi et al[75]	2017	India	502	Children & adults	7.1	1.1
Nabi et al[42]	2018	India	10	Children	6.7	0.3
Nabi et al[68]	2019	India	44	Children	6.86	1.03
Nabi et al[16]	2022	India	69	Children	7	1
Nabi et al[76]	2019	India	17	Children	6.88	NR
Nishimoto et al[86]	2018	Japan	13	Children	7.0	1.1
Petrosyan et al[4]	2016	United States	33	Children	9.7	0.9
Petrosyan et al[32]	2022	United States	37	Children	6.73	0.6
Peng et al[43]	2022	China	24	Children	7.67	0.67
Pop et al[24]	2022	Romania	7	Children	6.5	NR
Ramchandani et al[47]	2016	India	220	Children & adults	7.2	1.18
Ren et al[69]	2012	China	119	Children & adults	NR	NR
Rizzo et al[14]	2020	Europe	1	Children	12	0
Saez et al[89]	2020	Chile	5	Children	10	0.5
Samarakkody et al[90]	2022	New Zealand	4	Children	5.5	0
Samejima et al[54]	2023	Japan	10	Children	6.4	0.5
Shiwaku et al[48]	2016	Japan	100	Children & adults	5.9	0.8
Shiwaku et al[49]	2019	Japan	1300	Children & adults	6.1	1.1
Smirnov et al[91]	2018	Russia	1	Children	7	1
Stavropoulos et al[92]	2017	United States	10	Children	7.9	0.4
Tan et al[93]	2016	China	12	Children	6.9	0.7
Tang et al[51]	2015	China	5	Children	7.5	0.7
van Lennep et al[18]	2019	Netherlands	68	Children	NR	NR
Wood et al[52]	2020	United States	21	Children	7	1
Yamashita et al[94]	2016	Japan	1	Children	7	0
Yamashita et al[95]	2018	Japan	218	Children & adults	NR	NR
Yeung et al[96]	2017	China	1	Children	9	0
Zhang et al[67]	2016	China	1679	Children & adults	NR	NR

NR: Not reported.

Table 3 Peroral endoscopic myotomy associated adverse events

Ref.	Year	n	Mucosal perforation	Recurrent dysphagia	Wound infection	Pneumothorax	Pneumoperitoneum	Pneumomediastinum	Pneumonia	Subcutaneous emphysema	Fever	GERD	Reflux esophagitis	Leak within the tunnel/Dehiscence at entry site	Mucosotomy
Bapaye et al[41]	2023	1	-	-	-	-	-	-	-	-	-	-	-	-	-
Bi et al[28]	2023	48	3	-	-	-	2	-	-	2	-	-	-	-	-
Caldaro et al[7]	2015	9	1	-	-	-	1	-	-	-	-	1	-	-	-
Chen et al[50]	2014	27	5	-	-	4	-	10	-	7	1	4	3	-	-
Choné et al[38]	2019	27	-	-	-	-	-	-	-	-	-	17	25	-	-
Familiari et al[29]	2013	3	-	-	-	-	-	-	-	-	-	-	-	-	-
Filser et al[85]	2015	1	-	-	-	-	-	-	-	-	-	-	-	-	-
Hsu et al[5]	2023	10	-	-	-	-	6	2	-	2	2	-	-	-	-
Hu et al[97]	2023	1	-	-	-	-	-	-	-	-	-	-	-	-	-
Inoue et al[31]	2010	10	-	-	-	-	-	-	-	-	-	-	1	-	-
Kethman et al[23]	2017	10	-	-	-	1	1	-	-	-	-	-	-	2	-
Li et al[87]	2014	9	-	-	-	-	-	-	-	1	-	-	1	-	-
Liu et al[34]	2019	130	-	-	-	1	-	-	-		-	30	17	-	-
Luvsandagva et al[53]	2024	12	-	2	-	-	-	-	-	2	-	3	3	-	-
Mangiola et al[88]	2018	26	-	-	-	-	4	-	1	4	-	-	-	-	-
Miao et al[33]	2017	21	-	-	-	-	1	1	-	1	1	6	2	-	-
Nabi et al[42]	2018	10	-	1	-	-	2	-	-	1	-	-	-	-	-
Nabi et al[76]	2019	17	-	-	-	-	1	-	-	-	-	-	9	-	-
Nabi et al[68]	2019	44	1	-	-	-	10	-	-	-	-	12	11	-	-
Nabi et al[16]	2022	69	-	-	-	-	-	-	-	-	-	29	14	-	-
Nabi et al[75]	2017	502	-	-	-	5	62	1	-	106	1	-	53	-	-
Nabi et al[98]	2017	1	-	-	-	-	-	-	-	-	-	-	-	-	-
Nishimoto et al[86]	2018	13	-	-	-	1	-	-	-	-	-	1	-	1	-
Petrosyan et al[4]	2016	33	2	5	1	1	-	-	-	-	-	-	-	-	-
Petrosyan et al[32]	2022	37	-	-	-	9	10	2	-	-	-	3	-	-	5
Pop et al[24]	2022	4	-	-	-	-	2	1	-	-	-	-	-	-	-
Ramchandani et al[47]	2016	220	14	-	-	3	40	-	-	32	-	-	14	-	-
Ren et al[69]	2012	119	-	1	-	30	47	35	-	66	-	-	-	-	-
Rizzo et al[14]	2020	1	-	-	-	-	-	-	-	-	-	-	-	-	-
Saez et al[89]	2020	5	-	-	-	-	-	-	-	-	-	-	-	-	-
Samarakkody et al[90]	2022	4	-	1	-	-	1	-	-	1	-	1	-	-	-
Samejima et al[54]	2023	10	-	-	-	-	-	-	-	-	-	-	1	-	-
Shiwaku et al[48]	2016	100	-	-	-	1	11	1	-	-	-	-	-	1	-
Shiwaku et al[49]	2019	1300	5	-	-	-	-	-	-	-	-	173	1176	-	-
Smirnov et al[91]	2018	1	-	-	-	-	-	-	-	-	-	-	-	1	-
Stavropoulos et al[92]	2017	10	3	-	-	-	-	-	-	-	-	-	2	-	-
Tan et al[93]	2016	12	-	-	-	-	-	-	-	1	-	-	2	-	-
Tang et al[51]	2015	5	-	-	-	-	-	-	-	-	-	-	-	-	-
van Lennep et al[18]	2019	68	-	-	-	-	-	-	-	-	-	-	-	-	-
Wood et al[52]	2020	21	-	-	-	-	1	-	-	-	1	-	-	-	-
Yamashita et al[94]	2016	1	-	-	-	-	-	-	-	-	-	-	-	-	-
Yeung et al[96]	2017	1	-	-	-	-	-	-	-	-	-	-	-	-	-
Zhang et al[67]	2016	1679	-	-	-	25	-	-	-	-	-	-	-	-	-

GERD: Gastroesophageal reflux disease.

Table 4 Comparison of peroral endoscopic myotomy with other treatments

Treatment	Peroral endoscopic myotomy	Laparoscopic heller myotomy	Pneumatic dilation
Complications (%)	> 20	7-30	0-10
Success rate (%)	96.2-100	35-100	0-100
Need for further surgery (%)	< 0.1	3-42	17-100