Outcomes in Patients With Over One-Year Follow-up After Peroral Endoscopic Myotomy (POEM)

Marc A Ward, MD1, Matt E Gitelis, BA2, Lava Y Patel2, Yalini Vigneswaran1, Joann Carbray2, Michael B Ujiki, MD2. 1University of Chicago Hospitals Department of Surgery, 2NorthShore University HealthSystem Department of Surgery

Introduction: Peroral endoscopic myotomy is a promising therapy in the treatment of achalasia.  The study was designed to report outcomes, including quality of life, in patients with at least one-year follow-up. 

Methods: Patients from an institutional review board-approved protocol underwent POEM and were followed prospectively.  Health-related quality of life (HRQOL) was measured preoperatively and 1 year postoperatively using Short Form 36 Health Survey Version 2 (SF-36v2).  Comparisons were made with patients from a prospective database who underwent laparoscopic Heller myotomy over the same period.  Paired t tests were used to determine statistical significance.  

Results: We analyzed 41 consecutive POEM patients with at least one-year follow-up.  Mean age was 63 +/- 17.9 years and 61% were male.  Chicago Classification included 12 Type I, 16 Type II, and 9 Type III.  Twenty-eight previous esophageal interventions were performed in these patients including 13 botox injections, 16 pneumatic dilations, and 7 LHM.  Significant improvements in quality of life between baseline and 1 year were found in role limitations due to physical health (81.8 +/- 25.8 vs 65.9 +/- 31.6, p=0.002) and social functioning (83 +/- 19.1 vs 64.6 +/- 31.3, p=0.002).  In addition, the reflux severity index (RSI) was significantly decreased at one-year (8.0+/-7.8 vs 23.5+/-11.1, p<0.002) with most improvement found in decreased symptoms related to GERD and dysphagia.  When compared to 24 patients who underwent LHM, there was no difference in average Eckardt scores (0.9+/-1.6 vs 1.0+/-1.3, p >0.05) or incidence of PPI use (65% vs 61%, p=0.75).  However, when looking at just type III patients, POEM patients had a higher remission rate (100% vs 62.5%) and significantly lower post-operative Eckardt scores at 1 year (1.1 vs 3.1, p < 0.05).  The average myotomy length of type III achalasia patients undergoing POEM was 18.6 cm (+/-6.9) compared to 10.3 cm (+/- 1.0) in LHM patients (p < 0.01), which may have contributed to this difference.  

Conclusion: POEM provides a significant quality of life benefit at one year while having similar relief of dysphagia and post-operative PPI use compared to LHM.  Type III achalasia patients may have better outcomes with POEM compared to LHM.

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