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Per-Oral Esophageal Myotomy (POEM) After the Learning Curve: Durable Results and A Low Complication Rate
Eric S. Hungness*, Joel M. Sternbach*, Ezra N. Teitelbaum*, Rym El Khoury*, Peter J. Kahrilas*, John E. Pandolfino*, Nathaniel J. Soper
Northwestern University, Feinberg School of Medicine, Chicago, IL

OBJECTIVE(S):
POEM has become an established, natural-orifice approach for treating esophageal motility disorders (EMDs). To date, published outcomes and comparative-effectiveness studies have included patients from the early POEM experience. We aimed to report long-term outcomes after the learning curve.
METHODS:
Patients undergoing POEM after the initial 15 cases and a minimum of one-year post-op were included. Treatment success was defined as an Eckardt score ≤3 and freedom from reintervention. Positive pH-testing or reflux esophagitis > LA grade A constituted objective evidence of gastro-esophageal reflux (GER).
RESULTS:
Between January 2012 and November 2014, 95 patients underwent POEM at a single, high-volume center. Operative time was significantly shorter after the learning curve (102 vs 123 minutes, p=0.02). Length of stay was one day for 89/95 patients. One patient underwent repeat endoscopy to rule out submucosal hematoma. Three patients were readmitted for spastic or reflux-associated chest pain and one for non-POEM related sigmoid volvulus. At an average of 2.5 years post-POEM (range 12-47 months), the overall success rate was 92%. Objective evidence of GER was present in 37% of patients, with pre-operative hiatal hernia the only significant predictor.
CONCLUSIONS:
After the learning curve, POEM provided durable symptomatic relief in 95% of patients with non-spastic and 84% of patients with spastic/contractile EMDs, with a low rate of complications. Slightly more than one-third of patients had objective evidence of GER.
POEM Outcomes After the Learning Curve
*p<0.001 vs pre-POEMType I (n=23)Type II (n=47)Spastic/Contractile (n=25)Total (n=95)
Mean Age (years), Male (#)49.1, 14 (61%)50.5, 32 (68%)60.2, 10 (40%)52.7, 56 (59%)
Symptom Duration (years), Prior Treatment (#)5.3, 9 (39%)2.8, 9 (19%)3.2, 11 (44%)3.5, 29 (31%)
Mean Eckardt Score (Pre/Post-POEM)7.5 / 1.2*6.9 / 0.8*5.7 / 1.4*6.8 / 1.1*
Symptomatic Relief95% (21/22)96% (44/46)84% (21/25)92% (86/93)
Pre-POEM Integrated Relaxation Pressure (mmHg)27.434.028.530.9
Post-POEM Integrated Relaxation Pressure (mmHg)11.8* (n=12)12.1* (n=26)13.5* (n=14)12.4*
Pre-POEM 5min TBE height (cm)10.614.011.512.6
Post-POEM 5min TBE height (cm)6.3 (n=11)3.3* (n=25)3.2* (n=14)3.9*
Objective Evidence of Reflux36% (5/14)36% (9/25)40% (6/15)37% (20/54)


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