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Per Oral Endoscopic Myotomy (POEM) for Achalasia : A Comprehensive Objective Follow-up
Ashwin A Kurian*, Neil Bhayani*, Ahmed Sharata*, Erwin Rieder*, Kevin Reavis*, Christy Dunst*, Lee Swanstrom
Oregon Clinic, Portland, OR


OBJECTIVE(S):
Per-Oral Endoscopic Myotomy (POEM) has recently been described as a surgical therapy for Achalasia. Selective distal esophageal myotomy is performed using trans-oral flexible endoscopic instruments, dividing only the circular muscle layer. We present comprehensive, physiologic and symptomatic outcomes evaluating this procedure at long-term follow-up.
METHODS
Patients with manometrically-defined achalasia, eligible for laparoscopic myotomy, were offered POEM. Preoperative data included symptom scores, manometry, endoscopy, and timed-barium swallow. These were repeated at 6 months along with 24 hour pH testing.
RESULTS
Eighteen patients underwent POEM. Ten patients had advanced achalasia (Eckardt symptom score >6). Eleven had prior endoscopic interventions, including one perforation. Mean operative time was 156 minutes. Mean myotomy length was 9 cm. Intra-operative complications included two gastric mucosotomies and one full-thickness esophagotomy. All were immediately recognized and managed endoscopically without clinical sequelae. Mean hospital stay was 1.1 days.
Table 1 details pre/post-operative outcomes. All patients had marked improvements in postoperative dysphagia symptoms with two (22%) complaining of heartburn. Timed Barium swallow, EGD, high resolution manometry confirmed adequate treatment. Three of nine patients had abnormal pH scores at 6 months; two had heartburn symptoms. 88% had normalization of LES relaxation.
CONCLUSIONS
This study is the most comprehensive follow up of the POEM procedure to date and proves its effectiveness in the treatment of achalasia. POEM may represent a significant evolution in surgical treatment of Achalasia.
POEM Outcomes
OutcomesPreoperative n=181 month Postoperative n=18p value6 months Post operative n=9p value
Dysphagia (median)300.000200.008
Chest pain (median)100.0100.02
Eckardt Score (median)610.000200.008
Timed Barium Swallow at 5 min (mean % emptying)39%--89%0.02
Resting LES Pressure(mean)48.9--190.02
Residual LES Pressure (mean)15.25--90.02
Endoscopic Hill Grade (median)1--20.01
DeMeester score >14.7(%)---33%-


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