Article

Long-Term Outcomes of an Endoscopic Myotomy for Achalasia: The POEM Procedure.

*Division of GI and MIS, The Oregon Clinic, Portland, OR †Oregon Health and Science University, Portland, OR ‡Providence Portland Cancer Center, Providence Health System, Portland, OR.
Annals of surgery (Impact Factor: 7.19). 10/2012; 256(4):659-67. DOI: 10.1097/SLA.0b013e31826b5212
Source: PubMed

ABSTRACT : Esophageal achalasia is most commonly treated with laparoscopic myotomy or endoscopic dilation. Per-oral endoscopic myotomy (POEM), an incisionless selective myotomy, has been described as a less invasive surgical treatment. This study presents 6-month physiological and symptomatic outcomes after POEM for achalasia.
: Data on single-institution POEMs were collected prospectively. Pre- and postoperative symptoms were quantified with Eckardt scores. Objective testing (manometry, endoscopy, timed-barium swallow) was performed preoperatively and 6 months postoperatively. At 6 months, gastroesophageal reflux was evaluated by 24-hour pH testing. Pre-/postmyotomy data were compared using paired nonparametric statistics.
: Eighteen achalasia patients underwent POEMs between October 2010 and October 2011. The mean age was 59 ± 20 years and mean body mass index was 26 ± 5 kg/m. Six patients had prior dilations or Botox injections. Myotomy length was 9 cm (7-12 cm), and the median operating time was 135 minutes (90-260). There were 3 intraoperative complications: 2 gastric mucosotomies and 1 full-thickness esophagotomy, all repaired endoscopically with no sequelae. The median hospital stay was 1 day and median return to normal activity was 3 days (3-9 days). All patients had relief of dysphagia [dysphagia score ≤ 1 ("rare")]. Only 2 patients had Eckardt scores greater than 1, due to persistent noncardiac chest pain. At a mean follow-up of 11.4 months, dysphagia relief persisted for all patients. Postoperative manometry and timed barium swallows showed significant improvements in lower esophageal relaxation characteristics and esophageal emptying, respectively. Objective evidence of gastroesophageal reflux was seen in 46% patients postoperatively.
: POEM is safe and effective. All patients had dysphagia relief, 83% having relief of noncardiac chest pain. There is significant though mild gastroesophageal reflux postoperatively in 46% of patients in 6-month pH studies. The lower esophageal sphincter shows normalized pressures and relaxation.

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    ABSTRACT: Abstract Objective. Per-oral endoscopic myotomy (POEM) has recently been introduced as a minimal invasive alternative to conventional treatment for achalasia. This study aimed to clarify the feasibility and the short-term clinical efficacy of POEM as compared to laparoscopic Heller myotomy (LHM). Methods. Treatment outcomes were prospectively recorded and compared between the procedures in a nonrandomized fashion. Reduction rate (RR) in timed barium esophagogram (TBE) was calculated at 1, 2 and 5 min after barium ingestion as: RR = 1- postoperative barium height/preoperative barium height. Risk factors for treatment failure defined as the proportion of patients with RR <0.5 (1 min) and gastroesophageal reflux (GER) after POEM were analyzed. Results. Forty-two consecutive patients who underwent POEM were compared to 41 patients who had a LHM during the immediate time period prior to the introduction of POEM. Ninety percent of the cases reported complete symptom relief after POEM. The percentage of esophageal emptying and RR in TBE improved dramatically by both procedures without significant difference. A longer operation time (odds ratio [OR] 32.80, 95%CI 2.99-359.82, p = 0.004) and younger age (OR 26.81, 95%CI 2.09-344.03, p = 0.012) were the independent predictors of treatment failure after POEM. GER was observed in seven patients where previous dilatation (OR 8.59, 95%CI 1.16-63.45, p = 0.035) and higher body mass index (OR 8.69, 95%CI 1.13-66.63, p = 0.037) were the independent predictors for symptomatic GER after POEM. Conclusion. POEM seems to be a safe and effective treatment option for achalasia in the short-term perspective; an effect well comparable to LHM.

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