Peroral endoscopic myotomy for achalasia cardia: Treatment analysis and follow up of over 200 consecutive patients at a single center Mohan Ramchandani, 1 D. Nageshwar Reddy, 1 Santosh Darisetty, 2 Rama Kotla, 2 Radhika Chavan, 1 Rakesh Kalpala, 1 Domenico Galasso, 4 Sundeep Lakhtakia 1 and G. V. Rao 3 Departments of 1 Gastroenterology, 2 Anesthesiology, 3 Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India, and 4 Digestive Endoscopy Unit, ‘A. Gemelli’ Hospital, Università Cattolica del Sacro Cuore, Rome, Italy Background and Aim: Peroral endoscopic myotomy (POEM) is a recently introduced technique for the treatment of achalasia car- dia (AC). Data regarding safety and efficacy are still emerging. We report our experience of POEM emphasizing its safety, efficacy and follow-up data. Methods: Patients with AC (220; mean age 39 years, range 9–74 years) underwent POEM from January 2013 to August 2014 for AC. Retrospective analysis of prospectively collected data was done. POEM was carried out by the standard technique of mucosal incision, submucosal tunneling, and myotomy of the esophageal and gastric muscle bundles followed by closure of the mucosal incision by hemoclips. Eckardt score, high-resolution manometry (HRM) and timed bar- ium esophagogram (TBE) were used to evaluate the results. Post-procedure patients were followed up. Results: Technical success rate of POEM was 96%. At 1 year, clin- ical success rate was 92%. Mean Eckardt score was 7.2 ± 1.55 prior to POEM and 1.18 ± 0.74 after POEM (P = 0.001). There was signif- icant improvement of esophageal emptying on TBE (38.4 ± 14.0 % vs 71.5 ± 16.1 % (P = 0.001). Pre-procedure and post-procedure mean lower esophageal sphincter pressure was 37.5 ± 14.5 mmHg and 15.2 ± 6.3 mmHg, respectively. (P = 0.001) Erosive esophagitis was seen in 16% of patients who underwent POEM. There were no major adverse events. Conclusions: Study demonstrates excellent safety profile of POEM with significant relief of symptoms, reduced pressure at HRM and improved emptying at TBE. Further prospective studies are required to compare with other treatment modalities. Key words: Achalasia cardia, Minimally invasive surgery, natural orifice transluminal endoscopic surgery, POEM, Per oral endoscopic myotomy INTRODUCTION A CHALASIA CARDIA (AC) is an idiopathic disorder of esophageal motility characterized by failure of lower esophageal sphincter (LES) relaxation and aperistalsis of the esophageal body. 1–3 Pathophysiologically, AC is caused by loss of inhibitory ganglion in the myenteric plexus of the esophagus and results in dysphagia, regurgita- tion, and esophageal dilation. Choices of treatment vary from medication to surgery. Medical and endoscopic treatment classically includes the use of various drugs, endoscopic pneumatic dilatation and botulinum toxin injec- tion. Surgically, AC can be treated by carrying out myotomy by laparoscopic or open access. 1–4 After the introduction of scarless natural orifice translumi- nal endoscopic surgery (NOTES) 5–8 in the last decade, many developments have occurred, especially in the technique of transluminal access through the submucosal tunnel approach. This technique was first introduced by Sumiyama et al. 9 in 2007 using submucosal endoscopy which offsets the mucostomy and myotomy sites. By means of the mucosal flap safety-valve technique, rapid secure closure of mucosal inci- sion by clips can be achieved. Pasricha et al. 10 further studied this technique in animal models and successfully carried out endoscopic LES myotomy. In 2010, this novel per oral endo- scopic myotomy (POEM) method was initially carried out in humans by Inoue et al. 11 and, since then, many large case series have been reported on POEM worldwide. Continued accumulation of safety and efficacy data of this relatively new procedure is warranted. We report our single-center experience carrying out POEM in 220 symptomatic patients (103 women, 117 men) present- ing with AC. Corresponding: D. Nageshwar Reddy, Department of Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India. Email: aigindia@yahoo.co.in Received 15 January 2015; accepted 22 May 2015. © 2015 The Authors Digestive Endoscopy © 2015 Japan Gastroenterological Endoscopy Society 19 Digestive Endoscopy 2016; 28: 19–26 doi: 10.1111/den.12495 Original Article