Ezra N Teitelbaum, MD, Nathaniel J Soper, MD, Byron F Santos, MD, Fahd O Arafat, MD, John E Pandolfino, MD, Peter J Kahrilas, MD, Ikuo Hirano, MD, Eric S Hungness, MD. Northwestern University Feinberg School of Medicine.
INTRODUCTION: Peroral endoscopic myotomy (POEM) is a novel surgical operation for the treatment of achalasia. Here we analyze symptomatic and physiologic outcomes at one-year follow-up from a single-institution POEM series.
METHODS: Patients underwent preoperative high-resolution manometry (HRM), upper endoscopy, and timed barium esophagram (TBE). IRB-approved eligibility criteria for POEM included a diagnosis of achalasia, age ≥18 years, and a non-sigmoid esophagus. Routine early follow-up HRM and TBE were performed at 2 months. At 12 months, patients were encouraged to undergo routine repeat HRM, TBE, as well as upper endoscopy and 24-hour pH monitoring off anti-secretory medication. Patients were contacted to obtain current Eckardt and GerdQ symptom scores. Only patients further than one year removed from surgery were included in this analysis.
RESULTS: Twenty-seven patients underwent POEM and were further than one year from their procedure. Seven (26%) patients were female, mean age was 42 ±14 years, and 3 (11%) had undergone prior endoscopic treatment. One major (Grade IIIb) complication occurred: a contained perforation at the EGJ that required a take-back laparoscopy for drainage. Four (15%) minor (Grade I) complications occurred. Median length of stay was 1 day (range 1-13). Current symptomatic follow-up was available for 24 patients at a mean of 16 months postoperatively. Mean Eckardt scores decreased from preoperatively (7.5 ±2.1 vs. 1.5 ±2.1, scale 0-12, p<.001), with a 92% treatment success rate (i.e. Eckardt <4). The two treatment failures (the first and third patients in the series) underwent reoperation with laparoscopic Heller myotomy and had subsequent symptom resolution. 6 (22%) patients had a GerdQ >7, indicating symptoms of gastroesophageal reflux. 19 patients underwent early follow-up HRM at 2 months and 12 had repeat HRM at a mean of 15 months postoperatively. EGJ relaxation pressures were decreased from preoperatively at both postoperative time points, and there was no difference between the early and late postoperative studies (pre-op: 28.3 ±12mmHg vs. early post-op: 10.4 ±2.9mmHg vs. late post-op: 10.9 ±3.5mmHg, p<.001 pre vs. both post-op, p=ns early vs. late post-op). 15 patients underwent TBE at 2 months and 11 had repeat TBE at a mean of 12 months. Contrast column height at 5 minutes post-swallow decreased from preoperatively at both postoperative time points, and there was no difference between the early and late studies (pre-op: 15.3 ±7.5cm vs. early: 3 ±3.8cm vs. late: 4.7 ±3.7cm, p<.01 pre vs. both post-op, p=ns early vs. late post-op). On follow-up upper endoscopy (n=14, mean 14 months post-op) esophagitis was present in 8 (57%) patients (all LA grade A) and 6 (43%) had retained clips from POEM. On follow-up 24-hour pH monitoring (n=7, mean 12 months post-op) esophageal acid exposure (pH<4) occurred a mean 1.5 ±2.3% of the study period, resulting in a mean DeMeester score of 5.4 ±6.7. One (14%) patient had abnormal esophageal acid exposure (i.e. time>4.2%).
CONCLUSIONS: In this series, POEM resulted in symptom resolution in over 90% of patients with a sustained improvement in EGJ physiology at one-year follow-up. Esophageal acid exposure after POEM may be less than previously reported.