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PER ORAL ENDOSCOPIC MYOTOMY PRODUCES DURABLE IMPROVEMENT IN DYSPHAGIA SYMPTOMS AND PATIENT QUALITY OF LIFE
Anahita D. Jalilvand*, Jennifer Schwartz, Edward L. Jones, Michael Meara, Jeffrey W. Hazey, Kyle A. Perry
General Surgery, Ohio State Medical Center, Hilliard, OH
BACKGROUND: Laparoscopic Heller myotomy is the gold standard therapy for achalasia due to effective and durable dysphagia relief. While endoscopic pneumatic dilation provides similar short-term outcomes, it often requires repeated treatments which increase the risk of esophageal perforation. Per Oral Endoscopic Myotomy (POEM) combines the advantages of surgical myotomy and pneumatic dilation, but concerns about post-operative reflux and long-term outcomes remain. The objective of this study was to assess the long-term impact of POEM on patient symptoms and quality of life.
METHODS: We performed a retrospective review of patients undergoing POEM in 2012 and 2013. Demographic, preoperative, operative and outcome data were collected prospectively and maintained in an IRB approved database. The primary outcome measure was dysphagia relief as measured on a 5 point Likert scale. Secondary outcomes included disease-specific (GERD-HRQL), and global (SF-36) quality of life scores, gastroesophageal reflux symptom score (GERSS) and PPI use. Outcomes were assessed at baseline and post-operatively in the clinic setting and by telephone after 1 and 3 years. Data are presented as incidence (%), mean ± SD, or median (range) as appropriate. A p-value <0.05 was considered statistically significant.
RESULTS: Twenty-five patients with a primary symptom of dysphagia underwent POEM during the study period. Twenty-four (96%) had achalasia. Patents had an average age of 53.5 ± 18.0 years, BMI of 28.4 ± 5.2, and 52% (n=13) were male. All cases were completed successfully with an OR time of 99 (57-176) minutes. There were no complications and median hospital stay was 1 (1-2) day. Three-year follow-up data was available for 21 (84%) patients. Dysphagia scores improved from 4 (0-5) at baseline to 1 (0-4, p<0.01) after 1 year and 1 (0-5, p<0.01) after 3 years. Four patients (16%) underwent endoscopic dilation during the follow-up period and 2 (8%) required a redo myotomy. GERSS improved from 30 (4-64) at baseline to 7 (0-38, p<0.01) after 1 year and 14 (0-60, p<0.01 ) after 3 years. GERSS (p=0.39) and PPI use (18% vs. 38%, p=0.10) were not significantly different between 1 and 3 years. GERD-HRQL improved from 23 (3-43) to 3 (0-29, p<0.01) after 1 year and 6 (1-41, p<0.01) after 3 years. One patient underwent a laparoscopic fundoplication for significant reflux symptoms 2.5 years after POEM. Three years after POEM, patients demonstrated significant improvements in physical function (p=0.02), emotional well-being (p=0.04) and social functioning (p=0.01) compared to baseline.
CONCLUSION: POEM provides an effective treatment strategy for achalasia that yields excellent dysphagia relief and improved disease-specific and global quality of life after 3 years. Although associated with post-procedure reflux symptoms in some cases, these are typically well controlled with medical therapy.
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