Erica D Kane, MD, MPH, Erin M Thompson, MD, Vikram Budhraja, MD, David J Desilets, MD, PhD, John R Romanelli, MD. University of Massachusetts Medical School-Baystate Medical Center
INTRODUCTION: High-resolution esophageal manometry (HREM) is essential in characterizing achalasia subtype and the extent of affected segment in order to plan the starting point of the myotomy during per-oral endoscopic myotomy (POEM). Type 3 achalasia presents manometrically with a measurable spastic segment. However, evidence demonstrating the efficacy of tailoring the myotomy to the length suggested by HREM data is lacking. We sought to investigate whether utilizing HREM data to inform the starting point and length of myotomy in POEM patients impacts post-operative outcomes.
METHODS: Comparative analysis of HREM-tailored to non-tailored patients extracted from a prospectively-collected database of all patients who underwent POEM at our institution between January 2011 through July 2017. A tailored myotomy is defined as one the extends beyond the length of the diseased segment, as initially measured on HREM. Outcomes included procedure success (Eckardt <3) and pre- to post-operative change in Eckardt score.
RESULTS: Forty patients were included (11 tailored versus 29 non-tailored). There were no differences in patient age (52.5±10.3 v. 54.7±14.8; p=0.6491) or BMI (36.8±7.3 v. 30.4±10.0; p=0.0677). Myotomy lengths were significantly longer for tailored compared to non-tailored (16.6±2.2 v. 13.5±1.8; p<0.0001), which remained true when looking only at type 3 achalasia (15.9±2.4 v. 12.7±1.2; p=0.0453). This appeared to be due to more proximal starting position in tailored cases (26.0±2.2 v. 30.0±2.7; p<0.0001).
Procedure success (Eckardt <3) was equivalent across groups overall (p=0.5558), as was post-operative Eckardt score (0.2±0.4 v. 0.8±2.3; p=0.4004). However, post-operative Eckardt score was significantly decreased in the tailored group versus non-tailored when looking only at type 3 (0.2±0.4 v. 1.3±1.5; p=0.0435). While no correlation was noted between myotomy length and improvement in Eckardt score for the tailored group (p=0.8114), a correlation was seen between increased length and greater improvement in Eckardt score in the non-tailored group (p=0.0170).
CONCLUSIONS: Utilization of HREM data to inform surgeons of the proximal location of the diseased segment appears to result in longer myotomies, starting higher in the esophagus, and thus, spanning the entire affected segment. For this reason, differences in the absolute lengths of the myotomies in the HREM-tailored group did not affect outcomes. Conversely, when surgeons did not tailor the myotomies to HREM results, they were significantly shorter and resulted in less symptomatic improvement post-operatively.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87135
Program Number: S072
Presentation Session: Flexible Endoscopy Session
Presentation Type: Podium