Per oral endoscopic myotomy: Outcomes and lessons learned from starting a new POEM program at an academic institution

Albert Huang, MD, Vid Fikfak, MD, Carter Smith, MD, Nabil Tariq, Vadim Sherman, Lee Morris, Patrick Reardon, Brian Dunkin, MD. Houston Methodist

Background: POEM is a relatively new treatment for achalasia first reported by Inoue in 2010. POEM was first performed in the state of Texas at the Houston Methodist Hospital in 2013. This study presents the results of that work including the process of introducing a novel endoscopic procedure into the operating room and the outcomes of POEM procedures performed at our institution.

Methods: In preparation for starting a new POEM program, the principle investigator observed cases performed by Professor Inoue in Yokohama, Japan. Professor Inoue then visited the PI’s home institution as guest faculty and proctored POEM cases done by the PI in an animate lab. Following this experience, the PI rehearsed the procedure on porcine explants until able to reliably complete it without inadvertent mucosotomy. In conjunction with this technical rehearsal, a POEM operating room team was assembled, specialized equipment carts created, institution review board approval gained to monitor and report on patient outcomes, and a hospital credentialing pathway defined. Patients were then sequentially enrolled and an expert proctor was present for the first two clinical cases.

Results: Between September 2013 and October 2015, 42 POEM procedures were completed.  Mean operative times (minutes) were 148 ± 35 total, mucosotomy 6 ± 7, tunnel 69 ±31, and myotomy 34 ±21 with no decrease in time over the series.  Blood loss was ≤ 3ml on all cases and there were no mucosal perforations. Pneumoperitoneum occurred in 17 (4%) cases requiring Veress needle decompression in 15 (36%).  Postoperatively, the median length of stay was one day, most patients required no narcotics, and there were no leaks or delayed bleeding episodes. One patient underwent a negative CT scan for acute chest pain on post-operative day one. There were three treatment failures:  One in a patient with an uncategorized esophageal motility disorder where POEM was used as a final therapy before esophagectomy, and two with incomplete myotomy, rescued with pneumatic dilation. The mean dysphagia health index (DHI) decreased significantly (60.3 preop vs 22.5 postop; p<0.01) while heartburn quality of life scores did not change significantly (4.4 preop vs 6.5 post op).

Conclusion: This study presents a method for introducing POEM safely into the operating room while shortening the clinical learning curve. Quality of life survey results show efficacy with no serious complications.  We hope this initial experience will serve as a guide for other programs introducing this procedure into their institution.