Endoscopic management of spontaneous esophageal and postoperative motility disorders

Considerable progress has been made in therapeutic endoscopy over recent years and new techniques now offer access to a new space, the submucosal space, thus paving the way for new therapeutic perspectives, in particular, for functional endoscopy. The first of these applications, POEM (Per-oral endoscopic myotomy), has become, since the beginning of the 2010's, an endoscopic alternative to Heller myotomy for the treatment of achalasia. The results of this technique have been fully documented, and the technique has replaced pneumatic dilatation and become the standard treatment for this indication with equivalent effectiveness compared to traditional surgery, but with less morbidity. Indeed, the overall efficacy is around 90%, results are stable over time, and severe morbidity is less than 1%. Later, other motility disorders, such as spastic disorders, have been treated, certainly with less impressive outcomes than for achalasia, but still, of interest. This approach has also been applied to post-fundoplication motility disorders, whose de novo prevalence can be as high as 20%, and for which management is complex; this represents another new non-surgical perspective. The POEM procedure for this indication, in addition to myotomy, allows performance of a partial incision of the wrap with substantial symptomatic relief. In conclusion, the technique seems to have a bright future as it is progressively applied to more and more motility disorders.