{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,6]],"date-time":"2026-10-06T11:24:14Z","timestamp":1791285854131,"version":"4.1.0"},"reference-count":51,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2022,8,18]],"date-time":"2022-08-18T00:00:00Z","timestamp":1660780800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med."],"abstract":"<jats:p>Peroral endoscopic myotomy (POEM) is an established frontline treatment modality for achalasia cardia. Since its initial description, several modifications have been proposed to the technique of POEM. Broadly speaking, these modifications follow the basic principles of submucosal endoscopy, but incorporate variations in the POEM technique, including the difference in the orientation of myotomy (anterior or posterior), length of myotomy (short or long), and thickness of myotomy (selective circular or full thickness). Some of these modifications have been shown to reduce procedural duration without compromising the efficacy of the POEM procedure. More recently, several alterations have been reported that intend to reduce gastroesophageal reflux after POEM. These include preservation of sling fibers during posterior POEM and addition of NOTES fundoplication to the POEM procedure. Although some of the modified techniques have been compared with the conventional techniques in quality trials, randomized studies are awaited for others. The incorporation of some of these modifications will likely make POEM a technically easy and safer modality in near future. This review aims to discuss the current evidence with regard to the impact of modified techniques on the outcome of POEM.<\/jats:p>","DOI":"10.3389\/fmed.2022.948299","type":"journal-article","created":{"date-parts":[[2022,8,18]],"date-time":"2022-08-18T06:03:06Z","timestamp":1660802586000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":17,"title":["Impact of modified techniques on outcomes of peroral endoscopic myotomy: A narrative review"],"prefix":"10.3389","volume":"9","author":[{"given":"Zaheer","family":"Nabi","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"D.","family":"Nageshwar Reddy","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2022,8,18]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"462","DOI":"10.1097\/MOG.0000000000000757","article-title":"Third space endoscopy: the future of treating gastrointestinal dysmotility.","volume":"37","author":"Nabi","year":"2021","journal-title":"Curr Opin Gastroenterol."},{"key":"B2","doi-asserted-by":"crossref","first-page":"265","DOI":"10.1055\/s-0029-1244080","article-title":"Peroral endoscopic myotomy (POEM) for esophageal achalasia.","volume":"42","author":"Inoue","year":"2010","journal-title":"Endoscopy."},{"key":"B3","doi-asserted-by":"publisher","first-page":"213","DOI":"10.1016\/j.gie.2019.04.231","article-title":"ASGE guideline on the management of achalasia.","volume":"91","author":"Khashab","year":"2020","journal-title":"Gastrointest Endosc."},{"key":"B4","doi-asserted-by":"publisher","first-page":"180","DOI":"10.5056\/jnm20014","article-title":"2019 Seoul consensus on esophageal achalasia guidelines.","volume":"26","author":"Jung","year":"2020","journal-title":"J Neurogastroenterol Motil."},{"key":"B5","doi-asserted-by":"crossref","first-page":"1393","DOI":"10.14309\/ajg.0000000000000731","article-title":"ACG clinical guidelines: diagnosis and management of achalasia.","volume":"115","author":"Vaezi","year":"2020","journal-title":"Am J Gastroenterol."},{"key":"B6","doi-asserted-by":"crossref","first-page":"498","DOI":"10.1055\/a-1160-5549","article-title":"Endoscopic management of gastrointestinal motility disorders - part 1: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.","volume":"52","author":"Weusten","year":"2020","journal-title":"Endoscopy."},{"key":"B7","doi-asserted-by":"publisher","first-page":"256","DOI":"10.1016\/j.jamcollsurg.2015.03.057","article-title":"Per-Oral endoscopic myotomy: a series of 500 patients.","volume":"221","author":"Inoue","year":"2015","journal-title":"J Am Coll Surg."},{"key":"B8","doi-asserted-by":"publisher","first-page":"E190","DOI":"10.1055\/s-0043-121877","article-title":"Outcomes of anterior myotomy versus posterior myotomy during POEM: a randomized pilot study.","volume":"6","author":"Ramchandani","year":"2018","journal-title":"Endosc Int Open."},{"key":"B9","doi-asserted-by":"publisher","first-page":"46","DOI":"10.1016\/j.gie.2018.03.009","article-title":"Efficacy of anterior versus posterior per-oral endoscopic myotomy for treating achalasia: a randomized, prospective study.","volume":"88","author":"Tan","year":"2018","journal-title":"Gastrointest Endosc."},{"key":"B10","doi-asserted-by":"publisher","first-page":"288","DOI":"10.1016\/j.gie.2019.07.034","article-title":"Peroral endoscopic myotomy: anterior versus posterior approach: a randomized single-blinded clinical trial.","volume":"91","author":"Khashab","year":"2020","journal-title":"Gastrointest Endosc."},{"key":"B11","doi-asserted-by":"publisher","first-page":"462","DOI":"10.1055\/a-1204-4242","article-title":"Outcomes of anterior versus posterior peroral endoscopic myotomy 2 years post-procedure: prospective follow-up results from a randomized clinical trial.","volume":"53","author":"Ichkhanian","year":"2021","journal-title":"Endoscopy."},{"key":"B12","doi-asserted-by":"publisher","first-page":"330","DOI":"10.1016\/j.gie.2016.03.1469","article-title":"Per-oral endoscopic myotomy, 1000 cases later: pearls, pitfalls, and practical considerations.","volume":"84","author":"Bechara","year":"2016","journal-title":"Gastrointest Endosc."},{"key":"B13","doi-asserted-by":"publisher","first-page":"251","DOI":"10.1055\/a-1090-0788","article-title":"Anterior versus posterior approach in peroral endoscopic myotomy (POEM): a systematic review and meta-analysis.","volume":"52","author":"Mohan","year":"2020","journal-title":"Endoscopy."},{"key":"B14","doi-asserted-by":"crossref","first-page":"383","DOI":"10.1007\/s00464-020-07412-y","article-title":"Risk factors for gastroesophageal reflux after POEM for achalasia: a systematic review and meta-analysis.","volume":"35","author":"Mota","year":"2021","journal-title":"Surg Endosc."},{"key":"B15","doi-asserted-by":"publisher","first-page":"1370","DOI":"10.1016\/j.gie.2014.11.014","article-title":"Greater curvature myotomy is a safe and effective modified technique in per-oral endoscopic myotomy (with videos).","volume":"81","author":"Onimaru","year":"2015","journal-title":"Gastrointest Endosc."},{"key":"B16","doi-asserted-by":"publisher","first-page":"G431","DOI":"10.1152\/ajpgi.00182.2016","article-title":"Regulation and dysregulation of esophageal peristalsis by the integrated function of circular and longitudinal muscle layers in health and disease.","volume":"311","author":"Mittal","year":"2016","journal-title":"Am J Physiol Gastrointest Liver Physiol."},{"key":"B17","doi-asserted-by":"publisher","first-page":"9419","DOI":"10.3748\/wjg.v22.i42.9419","article-title":"Full-thickness myotomy is associated with higher rate of postoperative gastroesophageal reflux disease.","volume":"22","author":"Wang","year":"2016","journal-title":"World J Gastroenterol."},{"key":"B18","doi-asserted-by":"publisher","first-page":"2676513","DOI":"10.1155\/2017\/2676513","article-title":"Clinical outcomes and safety of partial full-thickness myotomy versus circular muscle myotomy in peroral endoscopic myotomy for achalasia patients.","volume":"2017","author":"Li","year":"2017","journal-title":"Gastroenterol Res Pract."},{"key":"B19","doi-asserted-by":"publisher","first-page":"442","DOI":"10.1016\/j.jamcollsurg.2013.04.033","article-title":"Peroral endoscopic myotomy for the treatment of achalasia: a clinical comparative study of endoscopic full-thickness and circular muscle myotomy.","volume":"217","author":"Li","year":"2013","journal-title":"J Am Coll Surg."},{"key":"B20","doi-asserted-by":"crossref","first-page":"490","DOI":"10.1001\/archsurg.138.5.490","article-title":"Improved outcome after extended gastric myotomy for achalasia.","volume":"138","author":"Oelschlager","year":"2003","journal-title":"Arch Surg."},{"key":"B21","doi-asserted-by":"publisher","first-page":"720","DOI":"10.1111\/dote.12280","article-title":"Safety and efficacy of the modified peroral endoscopic myotomy with shorter myotomy for achalasia patients: a prospective study.","volume":"28","author":"Wang","year":"2015","journal-title":"Dis Esophagus."},{"key":"B22","doi-asserted-by":"crossref","first-page":"477","DOI":"10.1007\/s10388-020-00739-4","article-title":"Peroral endoscopic shorter versus longer myotomy for the treatment of achalasia: a comparative retrospective study.","volume":"17","author":"Huang","year":"2020","journal-title":"Esophagus."},{"key":"B23","doi-asserted-by":"publisher","first-page":"1304","DOI":"10.1016\/j.gie.2020.10.006","article-title":"Safety and efficacy of peroral endoscopic myotomy with standard myotomy versus short myotomy for treatment-naive patients with type II achalasia: a prospective randomized trial.","volume":"93","author":"Gu","year":"2021","journal-title":"Gastrointest Endosc."},{"key":"B24","doi-asserted-by":"publisher","first-page":"63","DOI":"10.5056\/jnm20022","article-title":"Comparison of short versus long esophageal myotomy in cases with idiopathic achalasia: a randomized controlled trial.","volume":"27","author":"Nabi","year":"2021","journal-title":"J Neurogastroenterol Motil."},{"key":"B25","doi-asserted-by":"publisher","first-page":"261","DOI":"10.4103\/sjg.sjg_438_21","article-title":"Short versus long esophageal myotomy during peroral endoscopic myotomy: a systematic review and meta-analysis of comparative trials.","volume":"28","author":"Nabi","year":"2021","journal-title":"Saudi J Gastroenterol."},{"key":"B26","doi-asserted-by":"publisher","first-page":"643","DOI":"10.1055\/a-1133-4354","article-title":"Gastroesophageal reflux disease after peroral endoscopic myotomy is unpredictable, but responsive to proton pump inhibitor therapy: a large, single-center study.","volume":"52","author":"Nabi","year":"2020","journal-title":"Endoscopy."},{"key":"B27","doi-asserted-by":"crossref","first-page":"1037","DOI":"10.1016\/j.gie.2019.11.020","article-title":"Peroral endoscopic myotomy for achalasia: a prospective multicenter study in Japan.","volume":"91","author":"Shiwaku","year":"2020","journal-title":"Gastrointest Endosc."},{"key":"B28","doi-asserted-by":"publisher","first-page":"134","DOI":"10.1001\/jama.2019.8859","article-title":"Effect of peroral endoscopic myotomy vs pneumatic dilation on symptom severity and treatment outcomes among treatment-naive patients with achalasia: a randomized clinical trial.","volume":"322","author":"Ponds","year":"2019","journal-title":"JAMA."},{"key":"B29","doi-asserted-by":"crossref","first-page":"2219","DOI":"10.1056\/NEJMoa1905380","article-title":"Endoscopic or surgical myotomy in patients with idiopathic achalasia.","volume":"381","author":"Werner","year":"2019","journal-title":"N Engl J Med."},{"key":"B30","doi-asserted-by":"publisher","first-page":"2158","DOI":"10.1111\/jgh.14814","article-title":"Novel per-oral endoscopic myotomy method preserving oblique muscle using two penetrating vessels as anatomic landmarks reduces postoperative gastroesophageal reflux.","volume":"34","author":"Tanaka","year":"2019","journal-title":"J Gastroenterol Hepatol."},{"key":"B31","doi-asserted-by":"publisher","first-page":"206","DOI":"10.1111\/den.12957","article-title":"Two penetrating vessels as a novel indicator of the appropriate distal end of peroral endoscopic myotomy.","volume":"30","author":"Tanaka","year":"2018","journal-title":"Dig Endosc."},{"key":"B32","doi-asserted-by":"publisher","first-page":"E37","DOI":"10.1055\/a-0986-3112","article-title":"A simple modification in technique preserves oblique muscle fibers during peroral endoscopic myotomy.","volume":"52","author":"Nabi","year":"2020","journal-title":"Endoscopy."},{"key":"B33","doi-asserted-by":"publisher","first-page":"2963","DOI":"10.1007\/s00464-019-07079-0","article-title":"Gastric myotomy length affects severity but not rate of post-procedure reflux: 3-year follow-up of a prospective randomized controlled trial of double-scope per-oral endoscopic myotomy (POEM) for esophageal achalasia.","volume":"34","author":"Grimes","year":"2020","journal-title":"Surg Endosc."},{"key":"B34","doi-asserted-by":"crossref","first-page":"161","DOI":"10.1055\/a-0820-2731","article-title":"Peroral endoscopic myotomy and fundoplication: a novel NOTES procedure.","volume":"51","author":"Inoue","year":"2019","journal-title":"Endoscopy."},{"key":"B35","doi-asserted-by":"publisher","first-page":"1114","DOI":"10.1055\/a-1332-5911","article-title":"Single-session endoscopic fundoplication after peroral endoscopic myotomy (POEM+F) for prevention of post gastroesophageal reflux - 1-year follow-up study.","volume":"53","author":"Bapaye","year":"2021","journal-title":"Endoscopy."},{"key":"B36","doi-asserted-by":"publisher","first-page":"196","DOI":"10.1097\/01.sla.0000197469.12632.e0","article-title":"Very late results of esophagomyotomy for patients with achalasia: clinical, endoscopic, histologic, manometric, and acid reflux studies in 67 patients for a mean follow-up of 190 months.","volume":"243","author":"Csendes","year":"2006","journal-title":"Ann Surg."},{"key":"B37","doi-asserted-by":"publisher","first-page":"244","DOI":"10.1016\/j.vgie.2020.02.018","article-title":"Peroral endoscopic fundoplication: a brand-new intervention for GERD.","volume":"5","author":"Toshimori","year":"2020","journal-title":"VideoGIE."},{"key":"B38","doi-asserted-by":"publisher","DOI":"10.1007\/s00455-021-10339-8","article-title":"Per-oral endoscopic myotomy with division of septum (D-POEM) in epiphrenic esophageal diverticula: outcomes at a median follow-up of two years.","author":"Nabi","year":"2021","journal-title":"Dysphagia."},{"key":"B39","doi-asserted-by":"publisher","first-page":"14","DOI":"10.1016\/j.vgie.2018.09.009","article-title":"Per-oral endoscopic myotomy with endoscopic septum division in a case of achalasia with large epiphrenic diverticulum.","volume":"4","author":"Nabi","year":"2019","journal-title":"VideoGIE."},{"key":"B40","doi-asserted-by":"publisher","first-page":"509","DOI":"10.1080\/00365521.2020.1745881","article-title":"S-POEM in treatment of achalasia and esophageal epiphrenic diverticula - single center experience.","volume":"55","author":"Demeter","year":"2020","journal-title":"Scand J Gastroenterol."},{"key":"B41","doi-asserted-by":"publisher","first-page":"5447","DOI":"10.1007\/s00464-019-07340-6","article-title":"Peroral endoscopic myotomy alone is effective for esophageal motility disorders and esophageal epiphrenic diverticulum: a retrospective single-center study.","volume":"34","author":"Kinoshita","year":"2020","journal-title":"Surg Endosc."},{"key":"B42","doi-asserted-by":"crossref","first-page":"943","DOI":"10.2169\/internalmedicine.8196-21","article-title":"Esophageal diverticulum - indications and efficacy of therapeutic endoscopy.","volume":"61","author":"Sato","year":"2022","journal-title":"Intern Med."},{"key":"B43","doi-asserted-by":"crossref","DOI":"10.23736\/S2724-5985.21.02984-3","article-title":"Peroral endoscopic myotomy (POEM) for esophageal diverticula.","author":"Samanta","year":"2021","journal-title":"Minerva Gastroenterol."},{"key":"B44","first-page":"1399","article-title":"[Comparison of peroral endoscopic myotomy with transverse entry incision versus longitudinal entry incision for achalasia].","volume":"33","author":"Zhai","year":"2013","journal-title":"Nan Fang Yi Ke Da Xue Xue Bao."},{"key":"B45","first-page":"892","article-title":"[Factors affecting the safety and efficacy of peroral endoscopic myotomy for achalasia].","volume":"36","author":"Ma","year":"2016","journal-title":"Nan Fang Yi Ke Da Xue Xue Bao."},{"key":"B46","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1093\/dote\/doz052","article-title":"Open peroral endoscopic myotomy for the treatment of achalasia: a case series of 82 cases.","volume":"32","author":"Liu","year":"2019","journal-title":"Dis Esophagus."},{"key":"B47","doi-asserted-by":"publisher","first-page":"e101","DOI":"10.1016\/j.jtcvs.2016.01.047","article-title":"Creation of a second submucosal tunnel enabled successful per-oral endoscopic myotomy (POEM).","volume":"151","author":"Sanaka","year":"2016","journal-title":"J Thorac Cardiovasc Surg."},{"key":"B48","doi-asserted-by":"publisher","first-page":"E1335","DOI":"10.1055\/a-1499-6817","article-title":"Double tunnel technique reduces technical failure during POEM in cases with severe submucosal fibrosis.","volume":"9","author":"Nabi","year":"2021","journal-title":"Endosc Int Open."},{"key":"B49","doi-asserted-by":"publisher","first-page":"953","DOI":"10.1055\/s-0042-112575","article-title":"Peroral endoscopic myotomy for sigmoid-type achalasia: the myotomy length and ways to facilitate the procedure.","volume":"48","author":"Tan","year":"2016","journal-title":"Endoscopy."},{"key":"B50","doi-asserted-by":"publisher","first-page":"267","DOI":"10.1111\/den.13000","article-title":"Double-scope method for creating a straight submucosal tunnel during peroral endoscopic myotomy.","volume":"30","author":"Shiwaku","year":"2018","journal-title":"Dig Endosc."},{"key":"B51","doi-asserted-by":"publisher","first-page":"933","DOI":"10.1080\/17474124.2019.1674648","article-title":"Difficult peroral endoscopic myotomy: definition and management strategies.","volume":"13","author":"Tan","year":"2019","journal-title":"Expert Rev Gastroenterol Hepatol."}],"container-title":["Frontiers in Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2022.948299\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,8,18]],"date-time":"2022-08-18T06:03:22Z","timestamp":1660802602000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2022.948299\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,8,18]]},"references-count":51,"alternative-id":["10.3389\/fmed.2022.948299"],"URL":"https:\/\/doi.org\/10.3389\/fmed.2022.948299","relation":{},"ISSN":["2296-858X"],"issn-type":[{"value":"2296-858X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,8,18]]},"article-number":"948299"}}