Impact of Prior Interventions on Outcomes During Per Oral Endoscopic Myotomy

Andreas M Schneider, MD, Brian E Louie, MD, Drew B Schembre, MD, Ralph W Aye, MD. Swedish Medical Center Cancer Institute

Introduction: Per Oral Endoscopic Myotomy (POEM) for achalasia is performed by accessing the submucosal space of the esophagus.  This space may be impacted by prior interventions such as injections of Botulinum toxin, balloon dilations or previous myotomy. There is uncertainty if these interventions make myotomy more difficult to perform and thus may deter surgeons from POEM during their early experience.  We sought to determine the impact of prior interventions on our early POEM experience.

Methods: Prospective study of consecutive patients undergoing POEM from July 2014 to September 2015.  Patients were grouped apriori according to their anticipated complexity: Group I – No prior interventions; Group II – Prior interventions such as Botulinum injections and/or dilations, Group III – Sigmoidal esophagus, prior esophageal surgery or myotomy.  We compared procedure length, subjective outcomes, inadvertent mucosotomy rates and other complications between groups.

Results: A total of 29 patients underwent POEM for Achalasia Type I (n=7), Type II (n=14), Type III (n=5) and other dysmotility disorders (n=3). In Group II, 6 patients had balloon dilations and submucosal injections performed, 4 patients had dilation alone. Group III had 2 prior myotomies and one prior esophageal atresia repair.

Group I and II were comparable in operative time and mucosotomy rates (I=4, II=1 and III=1), but Group III had longer operative times (I=141.1mins, II=141.2mins, III=256.7mins, p<0.0001). One patient in Group 1 required a stent for 24 hrs to cover a mucosotomy and one patient in Group III underwent laparoscopic re-myotomy without symptom relief.

At short term follow up, all groups (Table 1) had significant improvement of their Eckhardt scores and improved QOLRAD scores.  

Conclusion: Prior interventions with Botulinum or dilations did not seem to impact operative times or mucosotomy rates during our early POEM experience. Patients with sigmoid esophagi or prior myotomy required nearly double the operative time. Patients in all groups had significant improvement of their symptoms and improved quality of life.

Table 1.Group I(n=12)Group II(n=10)Group III(n=7)
Eckhardt Pre-Post6.4(+/-2)6.1(+/-2.4)7.4(+/-2.8)
P-Value                        <0.001                0.002                   0.004
QOLRAD Pre-Post4.35(+/-1.1)4.22(+/-1.9)3.94(+/-1.5)
P-Value                          0.002                   0.36                    0.001              

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