Mauricio Ramirez, MD, Cecilia Zubieta, MD, Franco Ciotola, MD, Adolfo Badaloni, MD, Fabio Nachman, MD, Alejandro Nieponice, MD. Hospítal Universitario Fundación Favaloro
Objective: to report our experience in POEM vs. LHM, with particular focus on myotomy extension.
Background: POEM has been adopted worldwide as a treatment for achalasia. While resolution of dysphagia is above 90%, postoperative reflux ranges from 10-57%. Myotomy length during LHM has always been a controversial topic. With POEM a shorter myotomy on the gastric side may provide equal relief of dysphagia with less postoperative reflux.
Methods: Thirty-five cases of POEM were prospectively analyzed and compared retrospectively to the last 35 patients that underwent LHM, from December 2010 to August 2016. Mean follow-up was 10months (6/32) for POEM and 20months (6/68) for LHM. All patients with LHM had a myotomy extension >=3cm on the gastric side. In POEM cases, extension was defined by direct vision (Hill type II) and never exceeded 2cm. Endpoints included Eckardt score (ES), presence of symptomatic reflux by GERD-HRQL, need for PPI, and esophagitis ruled out by endoscopy.
Results: LHM and POEM were completed and followed-up in 100% of patients. Efficacy (ES<=3) was 33/35 (94.2%) for POEM and 32/35 (91.4%) for LHM in a short term follow up. And 31/35 (88.6%), 27/35 (77.1%) respectably, in a long term follow up, with average ES drop from 9 to 1.2 (p=0.0001) in POEM vs. 9.2 to 1.3 (p=0.0001) in LHM. Post operative complications occurred in 1 patient (leak) for LHM requiring reoperation and 1 patient (massive capnothorax) in POEM. Hospital stay was shorter for POEM than for LHM (1.3 vs. 2.1 respectively) (p=0.0001). Symptomatic reflux cases included 7/35 POEM (20 %) vs. 6/35 LHM (17.1%) (p=0.4620). Esophagitis signs in endoscopy appeared in 1/21 POEM (4.7%) vs. 1/22 LHM (%4.5) (p=1.000). Patients requiring PPI included 8/35 POEM (22.8%) vs.7/35 LHM (20%) (p=0.6642). Further treatment (endoscopic dilation) was performed in 10/35 POEM (28.5%) vs.8/35 LHM (22.8%).
Conclusions: Our results confirm the efficacy of POEM with similar perioperative outcomes than LHM. The shorter myotomy on the gastric side in POEM may contribute to an acceptable reflux rate with comparable relief of dysphagia. Although our follow up for POEM is shorter than for LHM, the trends are promising and warrant future prospective studies to address this topic.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 78646
Program Number: S074
Presentation Session: Flexible / Therapeutic Endoscopy and NOTES
Presentation Type: Podium