SSAT - PerOral Endoscopic Myotomy (POEM) Offers Consistent Success Rates for All Achalasia Types

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PerOral Endoscopic Myotomy (POEM) Offers Consistent Success Rates for All Achalasia Types
Matthew E. Gitelis^*, Gene Chiao, Matthew Zapf, Amy K. Yetasook, Joann Carbray, Michael B. Ujiki
Surgery, NorthShore University HealthSystem, Evanston, IL

Background and Objective: Type III achalasia, characterized by presence of esophageal spasms, is a difficult subtype to treat endoscopically or surgically. Previous studies have shown Laparoscopic Heller Myotomy (LHM), often considered the gold standard treatment for achalasia, to have a 30% failure rate for Type III patients. Current treatment options target the lower esophageal sphincter (LES), but not the full-length spastic muscle contractions of the esophagus. POEM offers the ability to perform a long myotomy, which may provide relief for patients suffering esophageal spasms. This study aims to evaluate whether POEM will have equally successful outcomes for all three subtypes of achalasia.
Methods: Institutional review board-approved prospective analysis of 35 consecutive patients who underwent POEM. Patients diagnosed with achalasia via high resolution manometry were divided into the three Chicago types. Outcomes at 3 weeks, 3 and 6 months, 1 and 2 years were analyzed. Remission was defined as an Eckardt score of 3 or less. Study includes all clinically available data and quality of life (QoL) responses from August 2011.
Results: Mean pre- and post-operative Eckardt Scores were 6.9 +/- 2.5; 1.0 +/- 1.4 (Type I; p < .001), 6.9 +/- 2.4; 0.7 +/- 0.8 (Type II; p < .001), and 6.3 +/- 3.1; 0.6 +/- 1.0 (Type III; p < .001). Per most recent Eckardt score, 8/8 Type I, 13/13 Type II, and 9/9 Type III are in remission. Preoperative LES resting and relaxed pressures were 28.3 +/- 20.2; 17.8 +/- 16.1 mmHg (Type I), 38.0 +/- 17.6; 18.9 +/- 13.6 mmHg (Type II), and 23.9 +/- 14.3; 9.4 +/- 10.5 mmHg (Type III), respectively. The average length of myotomy was 10.0 cm for Type I and II, and 18.1 +/- 5.1 cm for Type III. Pre- and post-operative Endoflip measurements were 7.8 +/- 3.4; 10.4 +/- 4.4 mm (Type I), 5.7 +/- 3.0; 9.9 +/- 5.3 mm (Type II), and 6.0 +/- 3.4; 11.3 +/- 6.1 mm (Type III). The average procedure time was 148 +/- 45 minutes (Type I), 107 +/- 40 minutes (Type II), and 168 +/- 72 minutes (Type III). Average follow-up months were 8.1 +/- 4.7 (Type I), 6.8 +/- 6.7 (Type II), and 4.6 +/- 4.3 (Type III). QoL trended towards significant improvement in multiple variables in all three subtypes. There were equal numbers of previous interventions among all groups. Patient demographics including age, sex, BMI and ASA class were comparable.
Conclusion: POEM has demonstrated equally successful outcomes for all three subtypes of achalasia. POEM may offer an attractive alternative to LHM for patients with Type III achalasia.

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