Prior Treatment Does Not Influence the Performance Or Early Outcomes of Per Oral Endoscopic Myotomy for Achalasia

Edward L Jones, MD, Michael P Meara, MD, Matthew R Pittman, MD, Jeffrey W Hazey, MD, Kyle A Perry, MD. The Ohio State University

INTRODUCTION: Per-oral endoscopic myotomy (POEM) is an emerging treatment for esophageal achalasia. Pneumatic dilation, botulinum toxin injection, and previous Heller myotomy have been shown to increase the technical difficulty of laparoscopic Heller myotomy, but their impact on POEM remains unknown. The purpose of this study was to report our initial experience with this novel approach in patients who have undergone prior treatment for their achalasia compared to those undergoing POEM as primary therapy.

METHODS AND PROCEDURES: Data on all patients undergoing POEM was collected prospectively during the study period from 2012 to 2014. Baseline data collected included demographics, objective testing (manometry, endoscopy, barium swallow), Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) and GERD Symptom Scale (GERSS). Outcomes of interest included operative time, clips required for closure, blood loss, length of hospital stay, peri-operative complications, dysphagia, GERSS, and GERD-HRQL scores. Data are presented as incidence (%), mean ± SD, or median (range) as appropriate, and a p-value of <0.05 was considered statistically significant.

RESULTS: Forty-five patients underwent POEM during the study period, 15 (30%) had previous endoscopic or laparoscopic treatment (7 botox injection, 5 pneumatic dilation, and 3 Heller myotomy). Patients undergoing primary POEM had a mean age of 46 ± 17 years compared to 64 ± 12 years for those with prior treatment (p<0.001). The groups did not differ in terms of gender (60% female versus 67% female, p=0.66) or BMI (29.0 ± 9.2 kg/m2 versus 30.7 ± 6.6, p=0.50). All cases were completed successfully without conversion to Heller myotomy and there were no perioperative complications in either group. Operative time for primary POEM was 103 ± 27 minutes compared to 102 ± 29 minutes following prior treatment (p=0.84). Needle decompression of pneumoperitoneum was required in 40% of primary POEM cases and 27% following treatment (p=0.37). Mucosotomy closure required 7 (4-16) and 8 (5-16) clips respectively (p=0.08) and length of hospital stay was 1 day in each group. Dysphagia scores decreased from 4 (0-5) to 1 (0-4) following primary POEM and 4 (0-5) to 0 (0-4) following treatment (p=0.45). Median GERD-HRQL scores improved significantly in both groups (21 to 3, p<0.01; and 23 to 6, p<0.01) and the GERD-HRQL scores did not differ between groups (p=0.15). All patients in each group expressed satisfaction with their procedure and would elect to undergo the procedure again given the benefit of hindsight.

CONCLUSIONS: Per oral endoscopic myotomy is a safe and effective treatment for achalasia which improves dysphagia scores, disease-specific quality of life, and is associated with high levels of patient satisfaction. Previous endoscopic or laparoscopic treatment of achalasia does not appear to affect the performance or perioperative outcomes of POEM.