CAN PERORAL ENDOSCOPIC MYOTOMY (POEM) BECOME THE TREATMENT OF CHOICE FOR ACHALASIA? RESULTS OF A SINGLE-CENTER INSTITUTE IN UK.
Gavriella Zoi Vrakopoulou*1, Lavinia Barbieri1, Andrei Ilczyszyn5, Karim Hamaoui6, Nikolaos Memos4, Edel Smyth1, Jafar Jafari2, Sebastian Zeki3, Terence Wong3, Jason M. Dunn3, Abraham Botha1
1Upper Gastrointestinal Surgical Unit, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; 2Upper GI Physiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; 3Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; 41st Propaedeutic Surgical Department, Hippokration General Hospital of Athens, National and Kapodistrian University of Athens, Athens, Greece; 5Bariatric Centre for Weight Management and Metabolic Surgery, University College Hospital London, London, United Kingdom; 6Department of Surgery&Cancer, Imperial College London, London, United Kingdom
Background: POEM was recently established as a treatment option in achalasia proving itself an effective and safe procedure. We aim to evaluate the clinical outcomes, resolution of dysphagia, incidence of postoperative gastro-oesophageal reflux disease (GORD), and quality of life (QoL) of patients after POEM.
Methods: A prospective review was performed for all patients in our institution who have undergone POEM from 2015 to 2018, and have completed a minimum follow up period of 6 months. All patients underwent a standardized diagnostic work-up including gastroscopy, barium study and high-resolution manometry (HRM). All patients underwent a clinical evaluation 6 weeks after treatment and a surveillance gastroscopy in the 1st postoperative year. Standardized questionnaires evaluating Eckardt, GERD and achalasia QoL (Urbach) scores were completed before and after POEM. HRM and pH studies were offered to all patients after 6 months.
Results: 72 patients had a POEM procedure during the study period of whom 39 had completed at least 6 months follow-up. The median hospital stay was 2 days (2-5). There was no mortality, but 3 patients (8%) had a complicated postoperative course treated conservatively (Clavien-Dindo II-IIIa). Thirty nine patients (36% female, 64% male) with a mean age of 41.8 (SD 18.2) years underwent POEM for Type II achalasia (n=21), Type I achalasia (n=11), Type III achalasia (n=2), EGJOO (n=2), variant achalasia (n=2) and not classified esophageal motility problems (n=1). 16 patients (41%) had prior treatment with 11 having Balloon dilatations (BD), 3 Botox therapy and two of them a combination of BD&Botox. The median follow up time was 18 months (6-39). The median myotomy length was 7 cm (5-15). The preoperative Eckardt, GERD and Urbach scores changed significantly after POEM: the median Eckardt score of 7 (4-11) decreased to a median of 1 (1-9, p<0.001), the GERD score showed a reduction from 26 (8-52) to 5 (0-40, p<0.001) and Urbach score from 25 (17-30) to 14 (10-28, p<0.001), respectively. Furthermore, preoperative dysphagia score was significantly reduced from a median of 3 (1-3) to a median of 0 (0-3). Long-term clinical success (Eckardt score ≤ 3) was achieved in 34 patients (87.2%). Postoperatively, 11 patients (29%) were taking PPIs for chest symptoms. Nine of these agreed to undergo pH studies of whom only 1 had a DeMeester score > 14.5. In the 22 patients who had routine endoscopic-surveillance at the time of the follow-up, 41% was diagnosed with oesophagitis grade A, yet only 5 of these patients were symptomatic.
Conclusion: POEM is an effective and safe treatment option for achalasia with good relief of dysphagia and improvement in patients' quality of life. About 30% of patients have chest symptoms postoperatively, but only 11% of these have confirmed GORD. POEM could become the primary treatment of choice for achalasia.
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