The number of hospitalizations for gastroparesis has risen over 300% in recent decades with increased physical, psychological, and healthcare burdens. Gastric per-oral endoscopic myotomy (G-POEM) is a promising therapy for patients with refractory gastroparesis. This article reviews important considerations for G-POEM.

Predictive factors for clinical success after G-POEM include diabetic and idiopathic gastroparesis, shorter gastroparesis duration, symptoms predominant of nausea and emesis, and gastric emptying study showing gastric retention of > 20% at 4 h. Mucosal closure is a critical step for G-POEM; both sutures and clips have high success rates, with clips having a trend to lower success rates but with significantly shorter procedure time and cheaper cost. G-POEMs have an overall 61% pooled success rate at one year with a yearly 13% symptom recurrence rate. A careful patient selection can yield higher clinical success rates. Further studies are needed on variant G-POEM techniques for more durable outcomes.

This article provides an overview of the techniques for closure of the mucosal entry point following advanced procedures in the third space. The outbreak of natural orifice transluminal endoscopic surgery (NOTES) has significantly impacted the treatment of various benign and malignant conditions. Reliable and secure closure of the mucosal entrance is essential for avoiding serious adverse events. Although small defects are typically closed using through-the-scope clips (TTSCs) or over-the-scope clips (OTSCs), challenges may occur with larger or transmural defects. Alternative methods, such as specialised stitches and full-thickness suturing systems, have been developed to address these challenges with promising results. Each method has its own pros and cons, and the choice of closure technique depends on various factors such as anatomical location, endoscopist expertise, costs, and clinical context. By understanding the technical specifications of each closure device, endoscopists can make decisions that enhance patient outcomes and minimise the risk of complications associated with the approximation of defect edges. Continued research is essential to optimise the evolution of newer closure devices and techniques for advancing NOTES.

Gastroparesis (GP) can be a severe and debilitating disease. Its pathophysiology is complex and not completely understood. Two principal mechanisms are responsible for the development of symptoms - gastric hypomotility and pylorospasm. Pylorus targeted therapies aim to decrease presumably elevated pyloric tone - pylorospasm. There is a growing body of evidence about their role in the treatment algorithm of GP. G-POEM (endoscopic pyloromyotomy) is an extensively studied pylorus targeted therapy. Its efficacy ranges between 56 and 80% and the number of recurrences among those with treatment effect seems low. G-POEM is a safe procedure with very low frequency of severe adverse events. At present, G-POEM should not be considered as an experimental approach and may be offered to all patients with refractory and severe GP. Nevertheless, G-POEM is not a first line treatment. Conservative measures such as diet modification and pharmacotherapy should always be tried before G-POEM is considered. Further research must focus on better patient selection as at present there are no standardized criteria. Functional imaging such as impedance planimetry (EndoFlip) may hold promise in this regard.

Gastric peroral endoscopic myotomy (G-POME) is an emerging minimally invasive endoscopic technique involving the establishment of a submucosal tunnel around the pyloric sphincter. In 2013, Khashab et al used G-POME for the first time in the treatment of gastroparesis with enhanced therapeutic efficacy, providing a new direction for the treatment of gastroparesis. With the recent and rapid development of G-POME therapy technology, progress has been made in the treatment of gastroparesis and other upper digestive tract diseases, such as congenital hypertrophic pyloric stenosis and gastric sleeve stricture, with G-POME. This article reviews the research progress and future prospects of G-POME for the treatment of upper digestive tract gastrointestinal diseases.

Our review delves into the realm of peroral endoscopic myotomies (POEMs) in the upper gastrointestinal tract (UGT). In recent years, POEMs have brought about a revolution in the treatment of UGT motility disorders. Esophageal POEM, the first to be introduced, has now been validated as the primary treatment for achalasia. Subsequently developed, G-POEM displays promising results in addressing refractory gastroparesis. Over time, multiple endoscopic myotomy techniques have emerged for the treatment of Zenker's diverticulum, including Z-POEM, POES, and hybrid approaches. Despite the well-established efficacy outcomes, new challenges arise in the realm of POEMs in the UGT. For esophageal POEM, the future scenario lies in customizing the myotomy extent to the minimum necessary, while for G-POEM, it involves identifying patients who can optimally benefit from the treatment. For ZD, it is crucial to validate an algorithm that considers various myotomy options according to the diverticulum's size and in relation to individual patients. These challenges align with the concept of precision endoscopy, personalizing the technique for each subject. Within our text, we comprehensively examine each myotomy technique, analyzing indications, outcomes, and adverse events. Additionally, we explore the emerging challenges posed by myotomies within the context of the evolving field of precision endoscopy.

Background and study aims  Mucosal closure after gastric per-oral endoscopic myotomy (G-POEM) can be difficult due to the thick gastric mucosa. We evaluated the use of a novel through-the-scope (TTS) suture system for G-POEM mucosotomy closure. Patients and methods  This was a single-center prospective study on consecutive patients who underwent G-POEM with TTS suture closure between February 2022 and August 2022. Technical success was defined as complete mucosotomy closure with TTS suture alone. On subgroup analysis, we compared performance on TTS suturing between the advanced endoscopist and the advanced endoscopy fellow (AEF) under supervision. Results  Thirty-six consecutive patients (median age 60 years, interquartile range [IQR] 48.5-67], 72 % women) underwent G-POEM with TTS suture of the mucosotomy. Median mucosal incision length was 2 cm (IQR: 2-2.5). Mean mucosal closure and total procedure time were 17.5 ± 10.8 and 48.4 ± 16.8 minutes, respectively. Technical success was achieved in 24 patients (66.7 %) and 100 % of the cases were adequately closed with a combination of TTS suture and clips. When compared to the advanced endoscopist, the AEF required > 1 TTS suture system for complete closure significantly more frequently (66.7 % vs. 8.3 %, P  = 0.009) and more time for mucosal closure (20.4 ± 12.1 vs. 11.9 ± 4.9 minutes, P  = 0.03). Conclusions  TTS suturing is effective and safe for G-POEM mucosal incision closure. With experience, technical success is high, and most closures may be achieved using a single TTS suture system alone, which has important cost and time implications. Additional comparative trials with other closure devices are need1ed.

Over the years, our growing experience with endoscopic submucosal dissection along with technological advances has solidified our comfort and knowledge on working in the submucosa, also referred to as the "third space." Per-oral endoscopic myotomy (POEM) was the first prototype third-space endoscopy (TSE) procedure, demonstrating the feasibility and clinical utility of endoscopic esophagogastric myotomy via submucosal tunneling. The launch of POEM accelerated the evolution of TSE from a vanguard concept to an expanding field with a wide range of clinical applications. In this review, we discuss the status and future directions of multiple TSE interventions.

The peroral endoscopic myotomy (POEM) procedure, as described over 10 years ago, is a submucosal endoscopy procedure that allows access to the muscle layers throughout the gastrointestinal (GI) tract. With this access, and ability to cut the muscle fibers, POEM can be performed not only for motility disorders but for structural pathology as well, such as Zenker diverticulum. Regardless of the location, there are 4 steps to the procedure: mucosotomy, submucosal tunneling, myotomy, and mucostomy closure. This review outlines these key components as well as variations in techniques for POEM throughout the GI tract.