Treatment of Achalasia with Peroral Endoscopic Myotomy (POEM): Analysis of 42 Consecutive Patients

Erica D Kane, MD, MPH1, Mersadies Martin, MD1, Amy Banks-Venegoni, MD2, David B Earle, MD1, David J Desilets, MD, PhD1, John R Romanelli, MD1. 1Baystate Medical Center, 2Spectrum Health Medical Group, Grand Rapids, MI

Introduction:  Per oral endoscopic myotomy (POEM) has become an acceptable incisionless treatment for achalasia based on encouraging short-term outcomes in multiple series worldwide. 

Methods and Procedures:  Data were collected prospectively on all patients undergoing POEM at a single institution from June 2011 through September 2015.  Preoperative diagnosis was confirmed by high-resolution manometry, barium swallow, and endoscopy. 

Results:  Forty-two POEM patients were included, 40 diagnosed with achalasia (types I-III), 1 with nutcracker esophagus, and 1 diagnosed intraoperatively with scleroderma. The mean age was 55.8 +/- 17.0 years. Mean BMI was 29.3 +/- 8.7.  Preoperative mean Eckardt score was 7.5 +/- 2.7 (range 1-12), with mean dysphagia component 2.6.  Thirty-six patients presented with dysphagia, 24 with regurgitation, 18 with chest pain, 14 with weight loss, and 1 with aerophagia. Of the 42, 6 (14.3%) patients had intramuscular botulinum toxin injection pre-operatively, and 19 (45.3%) had previous dilations.  Median OR time was 145 minutes (range 70-462) and median length of stay was 1 day (range 0.8-8). Average myotomy length was 12.9 +/- 2.5cm. Average number of clips for mucosal closure was 4.5 +/- 2.3. Of 20 full-thickness dissections noted through muscular layers, 12 patients developed intra-operative pneumoperitoneum, 8 were decompressed by Veress needle, and none suffered further sequelae. One early case was converted to a laparoscopic Heller myotomy (due to Botox injection ten days preoperatively) and two cases were aborted; one due to extensive submucosal fibrosis and the other to intra-operative capnopericardium. There were no deaths. Two intra-operative complications occurred: one major – cardiac arrest due to capnopericardium; the other minor – a mucosal injury at the gastroesophageal junction successfully repaired with clips. The patient whom experienced capnopericardium was the only patient with post-operative complications – intubation for respiratory distress and development of atrial fibrillation.  Mean post-operative Eckardt score was 1 +/- 1.7 (range 0-8) at 2-6 weeks (p<0.0001, compared with pre-operative score), with mean dysphagia component 0.3 (p<0.0001, compared to pre-operative score).  Two recurrences were identified, both at 6 months.

Conclusions:  POEM is a safe and durable treatment for achalasia, although longer-term data will be helpful.  We demonstrated a marked improvement of symptoms in all completed cases evidenced by significant improvement in Eckardt score.  There was an acceptable serious adverse event rate of 2.4% in this series and recurrences occurring in only 4.7% of cases in the short term. 

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