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Retrograde Myotomy as an Alternative to Antegrade Myotomy in Peroral Endoscopic Myotomy (POEM) for Achalasia Cardia – Is It Better?

Background: Antegrade approach myotomy is usually performed in peroral endoscopic myotomy (POEM) for achalasia cardia. This study assessed the feasibility of retrograde approach as an alternative. Methods: This is a retrospective review of a prospectively maintained database of patients undergoing POEM, comparing the 2 techniques of antegrade myotomy (AM) and retrograde myotomy (RM). AM was performed by the conventional technique of proximal to distal myotomy while RM was from the distal end to proximal. The time required for myotomy, complications, and technical nuances were compared. Results: Of the 24 cases of POEM, 6 were done by RM and 18 by AM approach. The baseline characteristics, symptomatology, type of achalasia, and preprocedure Eckardt score were similar between the 2 technique arms. The median myotomy time for AM was 21 minute while for RM was 25 minute (P=0.07). Complication rates were similar. Technical issues during RM included: (1) difficulty in visualizing the depth of myotomy; (2) incomplete myotomy requiring back and forth scope adjustment; (3) need for antegrade movement for completion of myotomy; (4) difficulty visualizing the axis of myotomy; (5) added arm strain during posterior myotomy. Conclusion: Our study did not find any additional benefit of RM compared with AM approach for POEM.