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Health Related Quality of Life and Physiologic Outcomes of Per-Oral Endoscopic Myotomy for Achalasia
Adam A. Golas1, Jacob Benedict1, Joel Richter2, Vic Velanovich*1
1Surgery, University of South Florida, Tampa, FL; 2Medicine, University of South Florida, Tampa, FL
Background: Per-Oral Endoscopic Myotomy (POEM) is a relatively new endoscopic procedure for the treatment of achalasia. In patients with achalasia this incisionless endoscopic procedure has been shown to have significant improvement of symptoms and objective motility parameters on high resolution manometry (HRM) and timed barium esophagogram (TBE) similar to that of the surgical gold standard, laparoscopic Heller myotomy. The aim of this study was to assess symptomatic, quality of life and physiologic outcomes of POEM using standardized methods.
Methods: 24 patients (10 female, 14 males) who underwent the POEM procedure 9/2013 to 8/2015 were evaluated pre and post-operatively with timed barium esophagogram, high resolution manometry (HRM), Urbach’s “Measure of Achalasia Disease Severity” (ADS) health-related quality of life scale (best score 10, worst score 31), and general quality of life (QOL) scale using the SF-36 (best score 100, worst score 0). 9 patients completed postoperative upper endoscopy, HRM, TBS, and 48 hours esophageal pH monitoring. A p-value of <0.05 was considered statistically significant.
Results: There was statistically significant improvement in the ADS scores (p<0.05) and in the social functioning domain of the SF-36 (p<0.05). Although there was improved score in 6 of the 7 other domains, this was not statistically significant (Table). HRM integrated relaxation pressures (IRP) showed significant improvement from a preoperative average of 31.4±10.8 and a post-operative average of 12.3±6.7 (p<0.05) and lower esophageal sphincter pressure (LESP) also showed significant improvement with an average preoperative value of 49.1±16.9 mmHg and a post-operative value of 23.1±9.4 mmHg (p<0.05). TBE improved in 8 of 9 patients. Upper endoscopy demonstrated esophagitis in 5 of 9 patients (57%), with 2 LA grade A and 3 LA grade B findings. Of the 24 patients 7 received postoperative 48 hour pH monitoring. 5 patients (71%) demonstrated pathologic reflux with an average Demeester score of 23.1 ± 19.1. There was a statistically significant negative linear correlation between LES pressure change and Demeester scores (r=-0.7, p=.03)(Figure).
Conclusion: The POEM procedure significantly improves achalasia related symptoms and social functioning. Physiologically, there is improvement in both IRP and LESP. Pathologic postoperative acid reflux is common and correlates with the degree of LESP reduction. Patients may require long-term acid reducing medication.
Table: Health Related Quality of Life Outcomes
| | Preoperative | Postoperative | | Achalasia Disease Severity | 24.8 +/- 2.8 | 13.2 +/- 3.7 | | SF-36, Physical Functioning | 75.7 +/- 19.9 | 86.1 +/- 25.6 | | SF-36, Role-Physical | 73.3 +/- 35.9 | 72.2 +/- 44.1 | | SF-36, Role-Emotional | 75.5 +/- 38.8 | 81.4 +/- 37.7 | | SF-36, Bodily Pain | 65.3 +/- 26.9 | 71.7 +/- 27.9 | | SF-36, Vitality | 53.3 +/- 15.9 | 61.1 +/- 26.7 | | SF-36, Mental Health | 77.6 +/- 14.8 | 81.3 +/- 16.7 | | SF-36, Social Functioning | 59.8 +/- 24.6 | 81.3 +/- 21.8 | | SF-36, General Health | 64.1 +/- 22.6 | 77.1 +/- 19.7 |
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