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Per-Oral Endoscopic Myotomy (POEM) for Esophageal Spastic Disorders: Analysis of 100 Patients
Ahmed M. Sharata*1, Christy M. Dunst1, Radu Pescarus2, Eran Shlomovitz2, Kevin M. Reavis1, Lee L. Swanstrom1
1GMIS, Oregon Clinic, Portland, OR; 2GMIS, Providence Portland Medical Center, Portland, OR
INTRODUCTION:
POEM is a flexible endoscopic approach to lower esophageal sphincter (LES) myotomy to relieve dysphagia. The technique has been rapidly adopted world-wide with short term clinical outcomes. We report on a consecutive patient cohort with clinical and objective outcomes representing the establishment of a POEM program within a busy esophageal surgical practice.
METHODS:
Comprehensive data was collected prospectively on all patients undergoing POEM from October 2010 to November 2013 at a single institution. Patients were classified based on high resolution manometry (HRM). Operative data and immediate outcomes were reviewed. Symptom scores, HRM and timed-barium swallow (TBS) were performed prior to procedure. Patients were asked to undergo routine postoperative testing 6-12 months after surgery with the addition of standard 24-h pH. Morbidity was defined as requiring additional procedures or prolonged hospital stay > 2 days.
RESULTS:
One hundred POEM patients were included in the final analysis. The mean age was 58 years (18-83 years). Presenting symptoms included dysphagia 81, chest pain 10 and regurgitation 9. Mean follow-up was 16 months. HRM diagnosis was 75 achalasia (30 Type I, 43 Type II, 2 Type III), 12 nutcracker, 5 DES and 8 hypertensive non-relaxing LES.
Mean operative time was 128 mins. Median hospital LOS was 1 day. Overall morbidity was 8%; the majority of these were treated endoscopically without further sequelae (2 full-thickness esophageal perforations, 3 had intra-tunnel leak diagnosed on routine esophagram and 1 developed a postoperative intra-tunnel hemorrhage, 1 developed Ogilvie's and 1 required prolonged intubation for CO2 retention).
Average LES resting/residual pressure significantly decreased (44.3/22.2 to 19.6/11.7 in mmHg). Esophageal emptying improved from 30% to 95% on TBS with 84.2% patients demonstrating >90% emptying at one minute. Of the achalasia patients, 18% (7/39) showed normal peristalsis (>80% peristalsis) on post-op HRM.
Abnormal acid exposure was present in 35.5% (21/59). Of these, 14 were asymptomatic. No reflux patient required additional antireflux procedure.
Eckardt scores decreased from 6 to 1. Dysphagia was improved or eradicated in 97% with a complete resolution accomplished in 89%. Dysphagia relief was better for achalasia patients (46/47 patients; 97%) vs. non-achalasia patients (17/24; 70%). Of those with preoperative chest pain, 95% reported complete relief.
Four patients have refractory dysphagia. Two non-achalasia patients underwent laparoscopic Heller myotomy and 2 are improving with serial endoscopic dilatations.
CONCLUSION:
This study represents the largest POEM series to include objective data. Despite reflux in 1/3 of patients, POEM provides excellent relief of dysphagia (97%) and chest pain (95%) for patients with esophageal spastic disorders.
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