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

Swanstrom, Lee L. MD*,†; Kurian, Ashwin MD*,‡; Dunst, Christy M. MD*,†; Sharata, Ahmed MD*; Bhayani, Neil MD*,‡; Rieder, Erwin MD*

doi: 10.1097/SLA.0b013e31826b5212
Papers of the 132nd ASA Annual Meeting

Background: 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.

Methods: 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.

Results: 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/m2. 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.

Conclusions: 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.

Per-oral endoscopic myotomy (POEM) is a highly selective distal esophageal myotomy performed by trans-oral flexible endoscopy. This study is the first comprehensive follow-up of the POEM procedure reporting both subjective and comprehensive objective outcomes. This novel treatment is a highly effective and well-tolerated treatment of achalasia.

*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.

Reprints: Lee L. Swanstrom, MD, Division of GI and MIS, The Oregon Clinic, 4805 NE Glisan, 6N50 Portland, OR 97213. E-mail: lswanstrom@orclinic.com.

Disclosure: No outside funding was received for the performance of this study. L.L.S. receives research support not related to this study and is on the advisory committees of Olympus Medical and Boston Scientific.

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© 2012 Lippincott Williams & Wilkins, Inc.