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: 8.33). 10/2012; 256(4):659-67. DOI: 10.1097/SLA.0b013e31826b5212
Source: PubMed


: 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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    • "However, the LES hypertonicity returns over time and repeated interventions are needed. Gastroesophageal reflux disease (GERD) may occur due to disrupted LES after PD as well as after surgery and POEM.11–14 Then, the occurrence of GERD after treatment might be a prognostic factor for a favorable long-term outcome in patients with achalasia. "
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    ABSTRACT: Background/Aims The occurrence of gastroesophageal reflux disease (GERD) is known to be associated with lower post-treatment lower esophageal sphincter pressure in patients with achalasia. This study aimed to elucidate whether GERD after pneumatic balloon dilatation (PD) has a prognostic role and to investigate how the clinical course of GERD is. Methods A total of 79 consecutive patients who were first diagnosed with primary achalasia and underwent PD as an initial treatment were included in this retrospective study. Single PD was performed using a 3.0 cm balloon. The patients were divided into two groups: 1) who developed GERD after PD (GERD group) and 2) who did not develop GERD after PD (non-GERD group). GERD was defined as pathological acid exposure, reflux esophagitis or typical reflux symptoms. Results Twenty one patients (26.6%) developed GERD after PD during follow-up. There were no significant differences between the two groups in demographic or clinical factors including pre- and post-treatment manometric results. All patients in GERD group were well responsive to maintenance proton pump inhibitor therapy including on demand therapy or did not require maintenance. During a median follow-up of 17.8 months (interquartile range, 7.1–42.7 months), achalasia recurred in 15 patients (19.0%). However, the incidence of recurrence did not differ according to the occurrence of GERD after PD. Conclusions GERD often occurs after even a single PD for achalasia. However, GERD after PD is well responsive to PPI therapy. Our data suggest that GERD after PD during follow-up does not appear to have a prognostic role.
    Full-text · Article · Apr 2014 · Journal of neurogastroenterology and motility
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    • "Up to 10% of patients who undergo POEM have pneumoperitoneum after the procedure [28]. One of the main concerns of this procedure is that an antireflux procedure cannot be performed, and objectively confirmed GERD rates after POEM are 46% [29]. "
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    ABSTRACT: Achalasia is an esophagealmotility disorder that leads to dysphagia, chest pain, and weight loss. Its diagnosis is clinically suspected and is confirmed with esophageal manometry. Although pneumatic dilation has a role in the treatment of patients with achalasia, laparoscopic Hellermyotomy is considered bymany experts as the best treatment modality formost patients with newly diagnosed achalasia. This review will focus on the surgical treatment of achalasia, with special emphasis on laparoscopic Heller myotomy.We will also present a brief discussion of the evaluation of patients with persistent or recurrent symptoms after surgical treatment for achalasia and emerging technologies such as LESS, robot-assisted myotomy, and POEM.
    Full-text · Article · Oct 2013 · Gastroenterology Research and Practice
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    • "In our series of 18 patients with achalasia treated with POEM, 12 patients complained of preoperative chest pain. Two patients (17%) continued to complain of intermittent chest pain at 6 months though intensity and frequency were markedly reduced [19] "
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    ABSTRACT: Achalasia is a well-defined neuromuscular disorder of esophageal swallowing function characterized by a nonrelaxing lower esophageal sphincter (LES) and aperistalsis of the esophageal body. Peroral endoscopic myotomy (POEM) is a flexible endoscopic approach to perform a selective circular myotomy of the distal esophagus and proximal stomach. More than a thousand cases have been performed worldwide. Most early reports on POEM focus on its feasibility and safety. Emerging long-term series have reported excellent subjective and objective outcomes of dysphagia relief for achalasia. With increasing experience, centers are expanding indications to end-stage achalasia and nonachalasia neuromuscular disorders such as diffuse esophageal spasm and nonrelaxing LES with hypertensive esophageal body contractions. The postoperative gastroesophageal reflux post-POEM is an issue that requires close objective follow-up, as the correlation of subjective reflux symptoms and objective testing in this setting is poor. Few series have indeed reported on equivalent excellent outcomes post-POEM as compared with a laparoscopic myotomy. This early experience with POEM has demonstrated the validity of this new technique in the management of benign disorders of esophageal swallowing. Refinements in technique and decreases in gastroesophageal reflux disease may make this procedure even more desirable, and potentially the first-line therapy in the management of spastic disorders of the esophagus.
    Full-text · Article · Jul 2013 · Techniques in Gastrointestinal Endoscopy
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