PER-PROCEDURE TRIDIMENSIONAL HIGH RESOLUTION ESOPHAGEAL MANOMETRY DURING PERORAL ENDOSCOPIC MYOTOMY FOR ACHALASIA

Aims:

Peroral endoscopic myotomy (POEM) is a widely used technique for the treatment of achalasia. However, about 10% primary treatment failures are recorded. These failures could be explained by an insufficient length of the gastric myotomy. We assessed the feasibility a per-POEM manometric measurement to optimize the length of the gastric myotomy.

Methods:

In consecutive patients treated between November 2016 and June 2017, a tridimensional high resolution manometry (3D-HRM) assembly was introduced by a nasal route before the endoscope, and left in place during the POEM procedure. Baseline lower esophageal sphincter pressure, before incision, at the end of the tunnel, and after the myotomy were recorded. The myotomy was completed on the gastric side until the lower esophageal sphincter pressure dropped below 10 mmHg. Patient, disease, manometric and procedural characteristics were recorded at baseline and 3 months after POEM.

Results:

10 patients (mean age = 55 years old, 3 men) treated by POEM for a type I achalasia (3/10), a type II achalasia (3/10), a type III achalasia (3/10) or an esophagogastric junction outflow obstruction syndrome (1/10) were included. Posterior myotomy was performed in 7 patients, according to the localization of the maximal esophageal pressure on pre-POEM 3D-HRM. 3D-HRM recording was technically feasible in all patients. The mean integrated resting pressure of the lower esophageal sphincter was 23.7 mm Hg before myotomy, 15.6 mm Hg at the end of the tunnel step, and 7.2 mm Hg at the end of the myotomy. In 4 patients out of 10, the myotomy was extended based on per-POEM manometry measurements. No early complications were observed, and clinical success rateat 3 months was 100%.

Conclusions:

Tridimensional High Resolution Esophageal Manometry is feasible during the POEM procedure, and leads to a change in the gastric myotomy length in 4 out of 10 patients in our work.