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Comparison of Perioperative Outcomes After Per-Oral Esophageal Myotomy (POEM) and Laparoscopic Heller Myotomy
Eric S. Hungness*1, Ezra N. Teitelbaum1, Byron F. Santos1, Fahd O. Arafat1, John E. Pandolfino2, Nathaniel J. Soper1
1Surgery, Northwestern University, Chicago, IL; 2Gastroenterology, Northwestern University, Chicago, IL
Introduction: Per-oral esophageal myotomy (POEM) is a novel procedure for the treatment of achalasia creating a myotomy across the esophagogastric junction (EGJ) without skin incisions. To date, no study has compared POEM perioperative outcomes with the surgical standard-of-care, laparoscopic Heller myotomy (LHM).
Methods: A review was conducted of a single-institution database to compare outcomes after POEM and LHM. 11 patients underwent POEM from 8/2010-11/2011 under the following IRB-approved inclusion criteria: age 18-85, no prior treatment for achalasia, and non-sigmoid esophagus. 50 patients were identified who had undergone LHM from 3/2004-7/2011 and fit these same criteria. T-tests and Fisher exact tests were used to compare results.
Results: There were 7 (64%) and 26 (52%) male patients in the POEM and LHM groups respectively (p=ns). POEM patients were younger (36 ±11 vs. 50 ±16 years; p<0.01). BMI and ASA classifications were similar. There was no difference in duration of symptoms prior to surgery (2 ±5 vs. 2 ±3 years). POEM and LHM had similar procedure times (121 ±42 vs. 126 ±29 min; p=ns). POEM had less EBL (≤10ml in all cases vs. 91 ±55ml; p<.001) but LHM had longer myotomy lengths (8.0 ±1.1 vs. 8.5 ±0.7cm; p=.04). Pain scores were similar on the day of surgery (3.3 ±3.1 vs. 2.1 ±2.3; p=ns) and on POD#1 (2.5 ±2.8 vs. 2.1 ±2.3; p=ns). Patients used similar amounts of narcotics on the day of surgery (4.8 ±5.2 vs. 2.8 ±4.3 mg morphine equivalents; p=ns) and POD#1 (6.9 ±7.7 vs. 4.6 ±5; p=ns) despite the fact that fewer POEM patients received ketorolac (18% vs. 78%; p<.001) due to concern for potential post-op bleeding in the sub-mucosal tunnel. Length of stay was similar (2.3 ±3.6 vs. 1.6 ±2.9 days; p=ns) and all POEM patients except for one were discharged by POD#2. No mortalities and 1 major complication occurred in each group: a POEM patient had a contained leak at the EGJ requiring laparoscopic drain placement and a LHM patient had a delayed esophageal leak requiring thoracotomy for drainage and repair. 3 (27%) minor complications occurred in POEM patients, compared with 7 (14%) in LHM patients (p=ns). Per-protocol post-op high-resolution manometry (HRM) and timed barium esophagram (TBE) at six weeks showed that POEM patients had decreased basal expiratory EGJ pressures (12 ±7 vs. 25 ±10 mmHg, p=.04) and relaxation pressures (15 ±3 vs. 29 ±17 mmHg, p<.05) and decreased contrast column heights at 1, 2 and 5-minutes (4, 2 and 2 vs. 17, 16 and 11cm), although only significantly at 1 and 2-minutes (p=.02 and .004). LHM patients did not routinely undergo repeat HRM or TBE.
Conclusions: POEM is a feasible procedure for creating an endoscopic myotomy for the treatment of achalasia. POEM and LHM appear to have similar perioperative outcomes. Further data are needed to define and compare long-term functional outcomes after POEM.
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