Andrew Tang, Usman Ahmad, MD, Sudish C Murthy, MD, PhD, Thomas Rice, MD, Prasanthi N Thota, Scott Gabbard, Madhusudhan R Sanaka, Siva Raja, MD, PhD. Cleveland Clinic
Background: Achalasia symptoms can recur after Heller myotomy. These patients can be rescued with dilation, redo-Heller myotomy or more recently per-oral endoscopic myotomy (POEM). The aim of this study was to determine the feasibility, safety and long-term efficacy of POEM for patients with recurrent symptoms after Heller myotomy.
Methods: Thirty-three achalasia patients with recurrent symptoms after Heller myotomy underwent POEM between April 2014 and April 2018. Patient demographics, procedural, and post-procedural details were collected. Endpoints were decrease in lower esophageal sphincter (LES) pressures on high-resolution esophageal manometry (HRM), emptying on timed barium esophagogram (TBE), and adverse events at two months and longitudinal clinical relief of symptoms (Eckardt score < 3). Mixed longitudinal effect modeling was used to determine the trend of Eckardt scores.
Results: POEM was successfully completed in all 33 patients (100%). Median age was 53 years and 16 (49%) were males. Median duration of symptoms prior to POEM was 6 years [IQR: 4- 8]. Six patients had prior submucosal injection of botulinum toxin to LES, 9 patients had pneumatic dilation, and 3 underwent savory dilation. Median duration between Heller myotomy and POEM was 4.8 years [IQR: 2.9 – 11.3]. Three (10%) patients had sigmoid esophagus. Median length of stay after POEM was 1 day and return to activities of daily living was less than 7 days. There were no complications requiring endoscopic or surgical reintervention. Median Eckardt scores were significantly lower at two-months (6 versus 0, p < 0.001) and at one or more years following POEM (6 versus 2.5, p<0.001). Residual LES pressures (20.5 versus 4.2 mm Hg p<0.001) also decreased significantly. TBE height and width at 1 minute did not change, but decreased significantly at 5 minutes (Height: 7.1 versus 4.5, p=0.01, Width: 3.5 versus 2, p=0.002).
Conclusions: There is mixed objective short-term improvement in esophageal drainage following achalasia after Heller myotomy, which is likely due to the heterogenous population. POEM after Heller myotomy is a safe and effective treatment for palliating patient symptoms in the short and possibly long term.
This abstract was accepted for Podium presentation at the 2020 SAGES Virtual Meeting in the Foregut topic. Its program number was: S095 and its Abstract ID was: 102502