Sean B Orenstein, MD, Siavash Raigani, BA, Yuhsin V Wu, MD, Eric M Pauli, MD, Melissa S Phillips, MD, Jeffrey L Ponsky, MD, Jeffrey M Marks, MD. Department of Surgery, University Hospitals Case Medical Center, Cleveland OH; Department of Surgery, Penn State Hershey Medical Center, Hershey PA; Department of Surgery, University of Tennessee, Knoxville, TN.
INTRODUCTION: Traditional treatment for the esophageal motility disorder, achalasia, ranges from endoscopic botulinum toxin (Botox) injections or balloon dilatation, to laparoscopic or open surgical myotomy. Recent advances in endoscopic therapy have led to peroral endoscopic myotomy (POEM) as a viable alternative to traditional techniques for myotomy. Uncertainty exists as to whether the procedure is feasible for patients that have already received prior endoscopic or surgical procedures for therapy, as these groups experience higher failure rates as well as intraoperative mucosal perforations and technical difficulty during Heller myotomy. We describe our first 40 patients that have undergone POEM and compare outcomes between patients that have or have not received previous treatment for achalasia.
METHODS AND PROCEDURES: We retrospectively evaluated our prospectively-collected database of POEM procedures performed by two surgeons (JLP and JMM) at a single institution. Perioperative data was collected for operative and hospital outcomes. Patients completed pre- and post-operative GERD-Health Related Quality of Life Questionnaires (GERD-HRQL) and SF-12 surveys for symptom scoring.
RESULTS: Forty patients received a POEM procedure between 2011-2013. Of these, 40% (n=16) had had at least one prior endoscopic or surgical procedure. Nine had prior Botox injections, 7 had balloon dilations, 3 had both Botox and dilations, and 3 received prior laparoscopic Heller myotomy (two with Dor fundoplication). Mean operative time was 102 minutes for patients with prior procedures (Group1) and 118 minutes for patients without any prior procedure (Group2) (p=0.07). Intraoperative complication rates for Group1 were 12.5% (one pneumoperitoneum requiring catheter evacuation and one full-thickness mucosal tear requiring endoscopic stenting and extended hospitalization), versus 16.7% for Group2 (two arrhythmias, one pneumoperitoneum requiring catheter evacuation, and one superficial mucosal tear not requiring any intervention). One patient in Group1 was readmitted for postoperative Mallory-Weiss tear requiring blood transfusion and upper endoscopy. Mean follow-up was 10 months. There were no statistical differences between the two groups for pre- or post-operative reflux and dysphagia scores. Both groups independently demonstrated clinical improvement, with statistical differences for pre- versus post-operative total GERD-HRQL and dysphagia scores (p<0.05).
CONCLUSIONS: We found favorable outcomes following POEM in patients that have had prior endoscopic or surgical treatments for achalasia, as well as for patients without prior intervention. There were no differences between these two groups with regards to operative times and patient symptom scoring. One complication requiring intervention occurred in a patient that had received prior Botox injections and balloon dilatations. POEM appears to be a viable alternative for treatment of achalasia compared to traditional techniques, however, long-term data are needed to establish the durability of this technique and to determine whether symptoms will recur necessitating re-intervention.
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