{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,14]],"date-time":"2026-08-14T03:01:27Z","timestamp":1786676487888,"version":"build-2736575974"},"reference-count":31,"publisher":"Wiley","issue":"2","license":[{"start":{"date-parts":[[2019,2,3]],"date-time":"2019-02-03T00:00:00Z","timestamp":1549152000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Digestive Endoscopy"],"published-print":{"date-parts":[[2019,3]]},"abstract":"<jats:sec><jats:title>Background<\/jats:title><jats:p>Peroral endoscopic myotomy (<jats:styled-content style=\"fixed-case\">POEM<\/jats:styled-content>) for achalasia is technically challenging to carry out in patients with type <jats:styled-content style=\"fixed-case\">III<\/jats:styled-content>, multiple prior treatments, prior myotomy, and sigmoid type. Herein, we present a series of consecutive patients with complex achalasia and introduce the <jats:styled-content style=\"fixed-case\">POEM<\/jats:styled-content> difficulty score (<jats:styled-content style=\"fixed-case\">PDS<\/jats:styled-content>).<\/jats:p><\/jats:sec><jats:sec><jats:title>Aim<\/jats:title><jats:p>To demonstrate the application and discuss the utility of <jats:styled-content style=\"fixed-case\">PDS<\/jats:styled-content> and present the feasibility, safety, and efficacy of <jats:styled-content style=\"fixed-case\">POEM<\/jats:styled-content> in complex achalasia patients.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Forty consecutive <jats:styled-content style=\"fixed-case\">POEM<\/jats:styled-content> were carried out with 28 meeting the criteria for complex achalasia. Primary outcome was clinical success (Eckardt score \u22643) at a minimum of 3 months follow\u2010up. Secondary outcomes included adverse events, procedural velocity and <jats:styled-content style=\"fixed-case\">PDS<\/jats:styled-content>.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Twenty\u2010eight complex and 12 non\u2010complex <jats:styled-content style=\"fixed-case\">POEM<\/jats:styled-content> procedures were carried out with 100% and 92% clinical success, respectively, without any major adverse events with a median follow up of 15\u00a0months (complex) and 8\u00a0months (non\u2010complex). Mean velocities for non\u2010complex, type <jats:styled-content style=\"fixed-case\">III<\/jats:styled-content>, prior myotomy, \u22654 procedures and sigmoid type were as follows: 4.4\u00a0\u00b1\u00a01.6, 4.8\u00a0\u00b1\u00a01.5, 5.9\u00a0\u00b1\u00a02.2, 6.9\u00a0\u00b1\u00a02.2 and 8.2\u00a0\u00b1\u00a03.2\u00a0min\/cm, respectively. Median <jats:styled-content style=\"fixed-case\">PDS<\/jats:styled-content> for non\u2010complex, type <jats:styled-content style=\"fixed-case\">III<\/jats:styled-content>, prior myotomy, \u22654 treatments and sigmoid type were 1 (0\u20133), 2 (0\u20134), 2.5 (1\u20136), 3 (2\u20136) and 3.5 (1\u20136), respectively. <jats:styled-content style=\"fixed-case\">PDS<\/jats:styled-content> was shown to correlate well with procedural velocity with a correlation coefficient of 0.772 (Spearman's <jats:italic>P<\/jats:italic>\u00a0&lt;\u00a00.001).<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p><jats:styled-content style=\"fixed-case\">PDS<\/jats:styled-content> identifies the factors that contribute to challenging <jats:styled-content style=\"fixed-case\">POEM<\/jats:styled-content> procedures and correlates well with procedural velocity. The order of increasing difficulty of <jats:styled-content style=\"fixed-case\">POEM<\/jats:styled-content> in complex achalasia appears to be type <jats:styled-content style=\"fixed-case\">III<\/jats:styled-content>, prior myotomy, \u22654 treatments and sigmoid type.<\/jats:p><\/jats:sec>","DOI":"10.1111\/den.13294","type":"journal-article","created":{"date-parts":[[2018,11,12]],"date-time":"2018-11-12T10:46:45Z","timestamp":1542019605000},"page":"148-155","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":30,"title":["Peroral endoscopic myotomy (POEM) for complex achalasia and the POEM difficulty score"],"prefix":"10.1111","volume":"31","author":[{"given":"Robert","family":"Bechara","sequence":"first","affiliation":[{"name":"Division of Gastroenterology Kingston Health Sciences Center Queens University Kingston General Hospital Ontario Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew","family":"Woo","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology Kingston Health Sciences Center Queens University Kingston General Hospital Ontario Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lawrence","family":"Hookey","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology Kingston Health Sciences Center Queens University Kingston General Hospital Ontario Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wiley","family":"Chung","sequence":"additional","affiliation":[{"name":"Division of Thoracic Surgery Kingston Health Sciences Center Queens University Kingston General Hospital Ontario Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kevin","family":"Grimes","sequence":"additional","affiliation":[{"name":"Department of Surgery MetroHealth Medical Center Case Western Reserve University School of Medicine Cleveland USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Haruo","family":"Ikeda","sequence":"additional","affiliation":[{"name":"Digestive Diseases Center Showa University Koto\u2010Toyosu Hospital Tokyo Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Manabu","family":"Onimaru","sequence":"additional","affiliation":[{"name":"Digestive Diseases Center Showa University Koto\u2010Toyosu Hospital Tokyo Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kazuya","family":"Sumi","sequence":"additional","affiliation":[{"name":"Digestive Diseases Center Showa University Koto\u2010Toyosu Hospital Tokyo Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jun","family":"Nakamura","sequence":"additional","affiliation":[{"name":"Department of Endoscopy Fukushima Medical University Hospital Fukushima Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yoshitaka","family":"Hata","sequence":"additional","affiliation":[{"name":"Department of Medicine and Bioregulatory Science Kyushu University Fukuoka Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shota","family":"Maruyama","sequence":"additional","affiliation":[{"name":"Department of Surgery Tohoku University Graduate School of Medicine Miyagi Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kuniyo","family":"Gomi","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology Showa University Fujigaoka Hospital Kanagawa Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4107-9264","authenticated-orcid":false,"given":"Yuto","family":"Shimamura","sequence":"additional","affiliation":[{"name":"Digestive Diseases Center Showa University Koto\u2010Toyosu Hospital Tokyo Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Haruhiro","family":"Inoue","sequence":"additional","affiliation":[{"name":"Digestive Diseases Center Showa University Koto\u2010Toyosu Hospital Tokyo Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2019,2,3]]},"reference":[{"key":"e_1_2_7_2_1","doi-asserted-by":"publisher","DOI":"10.1053\/j.gastro.2010.06.024"},{"issue":"249","key":"e_1_2_7_3_1","first-page":"vi","article-title":"Etiology and pathogenesis of achalasia","volume":"11","author":"Paterson WG","year":"2001","journal-title":"Gastrointest. 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