Creating efficiency in Per Oral Endoscopic Myotomy

Homero Rivas, MD, MBA, Shushmita Ahmed, MD, Michael Russo, MD. Stanford University School of Medicine.

Introduction: Per oral endoscopic myotomy (POEM) is a novel endoscopic procedure for treatment of esophageal achalasia. We have implemented POEM at our institution since early 2012, and now it represents the treatment of choice of most patients with esophageal achalasia. We report our experience with twenty five POEM procedures performed at our institution.

Methods and Procedures: Twenty five POEM procedures were performed since 2012. Twenty three of them were done for esophageal achalasia. Two of them were done for diffuse esophageal spasm (DES). Achalasia patients had a 10 cm myotomy extending from 7-8 cm proximal to the GE junction to 2-3 cm into the cardia of the stomach. Patients with DES had a myotomy extending 15-18cm. Average preop Eckardt score was 9-11. Our patients age range from 21-90 years old (66.5), operative time 80-190 minutes (122.5) and the hospital stay was 1-8 days (1.8). Endoscopic examination at the conclusion of each procedure was performed to evaluate for injury or perforation, as well as for adequacy of the myotomy in improving passage of the endoscope into the stomach. All patients were admitted to the hospital following the procedure. A gastrograffin swallow study was performed for each patient on difficulty and post-operative day #1. Only in one patient there was a confined tear of pyriform sinus likely as a result of use of an overtube. No major complications. All but one patient had relief from achalasia symptoms (Eckardt score <2). Such failure patient underwent a laparoscopic Heller myotomy one month after POEM with no technical with optimal results.

Conclusions: Per oral endoscopic myotomy is safe and effective for treatment of esophageal achalasia. With increased experience of the entire surgical team, case efficiency improved. POEM is an excellent first surgical treatment for esophageal achalasia. Even when incomplete myotomy may be present, further therapy is not compromised.

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