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PerOral Endoscopic Myotomy (POEM) Is Well-Suited to Control Dysphagia and Chest Pain in Achalasia Patients
Burkhard H. a. Von Rahden*1, Christoph-Thomas Germer1, Stanislaus Reimer2, Joerg Filser1
1Department of Surgery, University Hospital Wuerzburg, Wuerzburg, Germany; 2Department of Gastroenterology, University Hospital Wuerzburg, Wuerzburg, Germany
Background. Peroral endoscopic myotomy (POEM) is a promising new technique for performing a Heller myotomy through the endoscopic route. This approach challenges the previous standard treatment, laparoscopic Heller myotomy (LHM).
Patients & Methods. Between March and November 2013 we performed POEM procedures in altogether 17 patients for different types of achalasia (n=5 type I , n=3 type II, n= 6 type III, n=2 EGJ outflow obstruction, n=1 distal esophageal spasm, DES). Four patients had undergone specific pre-treatment for achalasia (n=PD, n=1 BTx, n=1 LHM). Three patients had undergone previous surgery (subtotal gastrectomy, Lap. Nissen, Lap. Toupet for upside-down-stomach).
Results. The POEM procedure was successfully completed in all cases, irrespective of types of achalasia, endoscopic pre-treatmentand previous upper GI surgery. POEM was also successful in patients after previous upper GI surgery. One myotomy (re-do after failed LHM) was performed as posterior approach. One myotomy (for DES) was performed as long (20cm) esophageal myotomy. The mortality was nil. There was one major complication with severe bleeding from an EGJ vein during myotomy (managed conservatively). POEM lead to good control of dysphagia in the short-term (3 months follow-up). There was significant improvement of the Eckardt-scores from median 8 to 1 in all patients (p=0.001). All patients suffering from chest pain prior to the operation (n=9) reported about improvement or complete remission of this symptom. The IRP of the LES was significantly decreased from mean 30.8 to 12.5 mmHg (p=0.001). However, in three patients, the Eckardt score deteriorated during further follow up. Two patients receive dilation with 20mm Ballon. Only one of the patients (the one having received POEM after failed LHM, 5.9%) had mild reflux symptoms (well controlled with PPI). None of the patients had esophagitis on re-endoscopy (0%). Two patients had acid exposure in the esophagus on pH-metry (11.8%).
Conclusion. Short-term (3 months) results of POEM are promising with good control of dysphagia. Clinical reflux symptoms are rare, but some patients have acid exposure on pH-metry. POEM may be superior to LHM with respect to control of concomitant chest pain.
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