Since the first published case series, per-oral endoscopic myotomy (POEM) has emerged as one
of the standard treatment options for achalasia. The procedure offers a scarless endoscopic
alternative to conventional surgical myotomy. In a recent randomized controlled trial, POEM
was found to achieve similar treatment success rate when compared with surgical myotomy. POEM
was also found to have reduced serious adverse events. When compared with endoscopic
pneumatic dilatation, POEM was demonstrated to have a significantly higher clinical success
rate.
One of the major limitations of POEM was the higher incidence of post-procedural acid reflux.
During surgical myotomy, a partial fundoplication would routinely be performed to reinforce
the gastro-esophageal junction, and such procedure has been proven to reduce post-operative
reflux. Multiple studies have confirmed the higher incidence of endoscopic reflux esophagitis
and proton pump requirements after POEM than surgical myotomy, including the aforementioned
randomized trial.
Modification and standardization of the POEM techniques were proposed to reduce the incidence
of reflux esophagitis. Limitation of gastric myotomy length to below 2cm was found to be a
useful maneuver. Identification of the two penetrating vessels at cardia may help to
correctly measure the length of gastric myotomy, together with the use of double scope
technique.
In an attempt to reduce the risk of post-POEM reflux, researchers have also pioneered
procedures to mimic surgical fundoplication. The POEM + fundoplication (POEM+F) procedure,
was first reported in 2019. It involved anterior myotomy, followed by an anterior partial
fundoplication using endoscopic clips and detachable loop. The same group subsequently
modified the technique by using a novel endoscopic needle holder device. A recent
single-center study reporting results of 25 POEM+F procedures in India also confirmed its
reproducibility and safety, as well as a reasonably low incidence of reflux.
A recently developed endoscopic tacking device, X-TackTM (Apollo EndoSurgery, Inc, United
States), allows approximation of tissue with the use of a helix tacking system connected to a
suture. It could be applied for closure of defect after endoscopic resection. The novel
device may also potentially be used for the endoscopic fundoplication by approximating the
anterior fundus to the edge of esophageal myotomy during POEM+F. The simple design of the
device could make the fundoplication easier and less time consuming. The investigators
designed this pilot study to confirm the feasibility of using X-TackTM for POEM+F in patients
with achalasia.