LONG MYOTOMY MAY NOT BE NECESSARY FOR TREATMENT OF SPASTIC ESOPHAGEAL MOTILITY DISORDERS
Simon Che*1, Stephanie Joseph1,3, Julia R. Amundson1,2, Vanessa N. VanDruff1,2, Kristine Kuchta1, Shun Ishii1, Christopher J. Zimmermann1, H M. Hedberg1, Michael Ujiki1
1Surgery, NorthShore University HealthSystem, Evanston, IL; 2University of Chicago Pritzker School of Medicine, Chicago, IL; 3Wayne State University School of Medicine, Detroit, MI
Introduction:
Peroral Endoscopic Myotomy (POEM) has revolutionized the treatment of achalasia. A myotomy performed endoscopically can extend more proximally than conventional laparoscopic approaches. As a result, the POEM technique is a useful method to treat spastic esophageal motility disorders. However, the ideal myotomy length is still unknown. The purpose of this study is to describe the clinical outcomes of patients with spastic esophageal motility disorders undergoing a standard (≤10 cm) or long (>10 cm) endoscopic myotomy.
Methods and Procedures:
We performed a single institution retrospective review of a prospective quality database. All patients with type III Achalasia, Distal Esophageal Spasm (DES) and Jackhammer Esophagus (JE) undergoing POEM were included. Manometry confirmed the diagnosis of hypercontractile esophageal dysmotility. Patients underwent either a standard myotomy (≤10 cm) or long myotomy (>10 cm) at the discretion of the operating surgeon. The primary outcome was Eckardt score at follow up, with clinical success defined as Eckardt score less than three. Secondary outcomes included operative time, procedural complications, resolution of symptoms, post-operative pH assessment, reflux severity index (RSI) and GERD health-related quality of life (GERD-HRQL) questionnaire scores. Comparisons were made using chi-square and Wilcoxon rank-sum tests.
Results:
From 2012 to 2022, 53 patients with hypercontractile esophageal motility disorders (n=37 type III achalasia, n=14 DES, n=2 JE) underwent POEM, 15 (28.3%) of which were standard myotomies. The procedure was performed by two foregut surgeons at a single institution. The average length of standard and long myotomies were 8.9 ± 1.9 cm and 19.3 ± 4.7 cm (p<0.001), respectively. There were no differences in operative time (102 ± 58 minutes and 104 ± 44 minutes, p=0.323), intraoperative complication rate (6.7% and 2.6%, p=0.489) or 30-day complication rate (6.7% and 10.5%, p=0.825). Clinical success was comparable between groups at first follow up visit (78.6% and 77.3%, p=0.686) and persisted for both groups up to the fourth follow-up at a median of 17 months post-op (Table 1). At one year, differences in RSI (11.5 ± 12.3 and 14.1 ± 13.9, p=0.872), GERD-HRQL (5.6 ± 5.3 and 9.5 ± 10.9, p=0.560) and dysphagia scores (1.0 ± 0.0 and 1.4 ± 0.9, p=0.198) were unremarkable. When comparing myotomy lengths in type III achalasia patients alone, again there was no change.
Conclusion:
In the endoscopic treatment of spastic esopahgeal motility disorders, standard myotomy is non-inferior to long myotomy.
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