A Comparison On Early Outcomes of Per-Oral Endoscopic Myotomy (POEM) and Laparoscopic Heller Myotomy

Thanasan Pratumrat, MD, Max S Jitraphongsathorn, MD, Virachai Mahatharadol, MD, Jerasak Wannaprasert, MD, Thawee Ratanachu-ek, MD, Poochong Timratana, MD. Rajavithi Hospital

INTRODUCTION – Achalasia is a rare esophageal motility disorder. The gold standard of treatment is Laparoscopic Heller Myotomy (LHM). Per-oral endoscopic myotomy (POEM) is a novel endoscopic treatment. There had only been a few studies comparing POEM with LHM. The aim of this study was to report the early outcomes of per-oral endoscopic myotomy (POEM) compared with Laparoscopic Heller Myotomy (LHM) in Rajavithi Hospital.

METHODS AND PROCEDURES – A retrospective review of 33 patients who underwent POEM and LHM in our institution from April 2007 to February 2014. The patient’s data was collected by a chart review and a questionnaire by phone call. Eckardt score was collected preoperatively, 3 months and 6 months postoperatively. Variables were analyzed by standard descriptive statistics, student T-test, fisher’s exact test or Mann-Whitney test. The primary outcome was symptom improvement compared in both groups. The secondary outcome was rate of complications.

RESULTS – There were 33 patients with a diagnosis of achalasia, 10 patients underwent POEM, 23 patients underwent LHM and Dor fundoplication was performed in only 13 patients (56.5%). The median age, operative time and symptom duration were compared between the POEM group and the LHM group with the result of 38.5 yr (19-59) vs 48 yr (27-72) P=0.08, 155 min (40-295) vs 135 min (80-250) P=0.63, 42 mo (7-72) vs 24 mo (6-180) P=0.58, respectively. The median follow up time was longer in the LHM group (42 mo vs 13.5 mo, P=0.0025). The median length of stay (LOS) was longer in the POEM group (8 vs 6 days, P=0.0036). All patients had an ASA score of 1 and 2. Comparison of the mean Eckardt score between the POEM group and the LHM group at preoperatively, 3 mo and 6 mo postoperatively were 7.4±2.1 vs 7.1±1.4 P=0.639, 1.0±1.0 vs 1.9±1.2 P=0.025, 1.2±1.1 vs 1.6±1.3 P=0.208, respectively. Comparison of the mean dysphagia score between the POEM group and the LHM group at preoperatively, 3 mo and 6 mo postoperatively were 2.9±0.3 vs 2.8±0.3 P=0.593, 0.5±0.8 vs 1.0±0.5 P=0.009, 0.8±0.9 vs 0.8±0.6 P= 0.463, respectively. Treatment success (Eckart score ≤3) in the POEM group and the LHM group were 100% and 91.3% at 3 mo and 6 mo follow-up. Heart burn symptoms presented postoperatively in the POEM group in 1 patient (10%) while LHM with fundoplication in 2/13 (15.4%) and LHM without fundoplication in 4/10 (40%). Minor complications in the POEM group were found in 3 patients (30%), an esophageal mucosal tear in one, a tear at the hypopharynx in one and esophageal wall necrosis in one that improved with conservative treatment. Capnoperitoneum was found in 2 patients (20%) in the POEM group. One patient (4%) in LHM group had an esophageal mucosal tear and was repaired intraoperatively. There was no postoperative mortality.

CONCLUSIONS – POEM and LHM have similar relief in patient symptoms in the early period. Minor complications can be resolved by using endoscopic and conservative treatment. POEM is comparable with LHM in safety and efficacy in the treatment of achalasia.

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