CLINICAL OUTCOMES 4 YEARS AFTER POEM FOR TREATMENT OF ACHALASIA
Ryan J. Campagna*1, Arturo Cirera1, Joseph Triggs2, Ezra N. Teitelbaum1, Dustin Carlson2, John E. Pandolfino2, Eric S. Hungness1
1Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; 2Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
Introduction
Achalasia is a rare esophageal motility disorder for which surgical myotomy and pneumatic dilation are first-line treatments. Per-oral esophageal myotomy (POEM) is well established endoscopic surgical therapy that has demonstrated excellent short-term efficacy, but long-term outcomes data are limited. Herein, we present the long-term follow up data from our institution's POEM experience after the learning curve.
Methods
Patients greater than 3.5 years removed from POEM for treatment of achalasia or esophagogastric outflow obstruction (EGJOO) were studied. Patients were evaluated pre-operatively and 3-4 years post-operatively. The distensibility index (DI), calculated using functional luminal imaging probe (FLIP) impedance planimetry, was measured intraoperatively. Symptomatic outcomes were measured using Eckardt Symptom (ES) and GerdQ scores. Clinical success was defined as an ES ≤ 3 and freedom from reintervention for achalasia. Patients underwent pre- and post-operative high-resolution manometry, esophagogastroduodenoscopy (EGD), timed barium esophagram (TBE), and 24h pH studies. Objective GERD was defined as a positive pH study or LA Grade B or worse esophagitis on EGD.
Results
120 consecutive patients underwent POEM between January 2012 and April 2015. Six of our 120 patients died or had catastrophic events unrelated to achalasia or POEM. Eighty-nine of the remaining patients (78%, 89/114) had long-term data available. A pre-operative diagnosis of Type II achalasia was most common, per Chicago Classification v3.0 (22 Type I, 45 Type II, 17 Type III/spastic, 5 EGJOO). Mean intraoperative DI was reduced significantly at the conclusion of the operation as compared to baseline values (n=52, 8.0 mm2/mmHg vs 1.2 mm2/mmHg, p<0.001). Mean clinical follow up was 51.5 months post-operatively. Mean ES was significantly improved from preop (n=89, 1±2 vs 7±2, p<0.001). Overall clinical success was 85%. 8 patients had a current ES > 3 and 5 patients required reintervention (2 laparoscopic Heller myotomy, 3 pneumatic dilation). Reinterventions were successful in 80% of patients (4/5), with current ES ≤ 3. GerdQ scores were abnormal (>7) in 22% of patients (20/89). The rate of objective GERD was 33% (10/30, 8+ EGD and 2+ pH study). 52% of patients (45/89) were on PPI therapy at the time of follow up assessment. Esophageal physiology was improved with a decrease in median IRP (n=28, 13±5 mmHg vs 31±15 mmHg, p<0.001), and TBE column height (n=22, 4±3 cm vs 14±8 cm, p<0.001).
Conclusions
POEM provides durable symptom relief and improvement in physiologic EGJ relaxation parameters over 4 years postoperatively. Reinterventions are rare and effective. This study represents the largest series of patients with greater than 4-year follow-up and supports the ongoing use of POEM as first-line therapy for achalasia.
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