title: Greater curvature myotomy is a safe and effective modified technique in per-oral endoscopic myotomy (with videos).
abstract: BACKGROUND
  Per-oral endoscopic myotomy (POEM) for achalasia with esophagocardiomyotomy in the lesser curvature (LC myotomy) is now established and accepted widely. However, in some cases LC myotomy is precluded by previous procedures, such as Heller myotomy, or by other anatomic considerations that obscure the normal dissection planes. It may also be difficult to identify the esophagogastric junction (EGJ), which can result in an incomplete gastric myotomy and poor rates of symptom relief. On the other hand, the angle of His is always located in the greater curvature of the stomach and serves as a consistent, definite landmark of the gastric side.
  
  
  OBJECTIVE
  To evaluate esophagocardiomyotomy in the greater curvature (GC myotomy) as an alternative POEM technique in cases where a prior LC myotomy or supervening anatomic constraints make identification of the EGJ technically challenging.
  
  
  METHODS
  Prospective.
  
  
  METHODS
  Single-center study.
  
  
  METHODS
  Twenty-one achalasia patients who received POEM with GC myotomy.
  
  
  METHODS
  POEM.
  
  
  METHODS
  Efficacy and safety of GC myotomy measured in terms of reduction in lower esophageal sphincter (LES) pressures, improvement in Eckardt scores, and development of intraoperative or postoperative adverse events.
  
  
  RESULTS
  Identification of the EGJ was achieved in all cases, resulting in a mean gastric myotomy length of 2.6±1.1 cm. Mean LES pressure and Eckardt symptom scores decreased significantly (21.2±7.3 vs 10.5±2.7 mm Hg, 5 [2-8] vs 1 [0-5], respectively) (P<.01). Endoscopic evidence of gastroesophageal reflux was identified in 52% of patients (11/21) postmyotomy; however, only 9.5% (2/11) were symptomatic, and these patients were successfully controlled with proton pump inhibitors. No severe adverse events were encountered.
  
  
  CONCLUSIONS
  Single center.
  
  
  CONCLUSIONS
  GC myotomy is a promising, safe modification of the POEM technique and may be especially useful in cases of redo POEM, POEM post-Heller myotomy, or when the EGJ is difficult to recognize because of supervening anatomic constraints.
authors: Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan.
authors: Manabu
authors: M
authors: Onimaru
authors: Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan.
authors: Haruhiro
authors: H
authors: Inoue
authors: Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan.
authors: Haruo
authors: H
authors: Ikeda
authors: Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan.
authors: Chiaki
authors: C
authors: Sato
authors: Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan.
authors: Hiroki
authors: H
authors: Sato
authors: Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan.
authors: Chainarong
authors: C
authors: Phalanusitthepha
authors: Section of Gastroenterology and Digestive Endoscopy, De La Salle University Medical Center, Cavite, Philippines.
authors: Esperanza Grace
authors: EG
authors: Santi
authors: Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan.
authors: Kevin L
authors: KL
authors: Grimes
authors: Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan.
authors: Hiroaki
authors: H
authors: Ito
authors: Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan.
authors: Shin-ei
authors: SE
authors: Kudo
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002299:Cardia / Q000601:surgery*; D015331:Cohort Studies; D016099:Endoscopy, Gastrointestinal / Q000379:methods*; D004931:Esophageal Achalasia / Q000601:surgery*; D049630:Esophageal Sphincter, Lower / Q000601:surgery*; D004947:Esophagus / Q000601:surgery; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009130:Muscle, Smooth / Q000601:surgery; D011446:Prospective Studies; D055815:Young Adult