CC BY-NC-ND 4.0 · Endosc Int Open 2017; 05(05): E331-E339
DOI: 10.1055/s-0043-105517
Original article
Eigentümer und Copyright ©Georg Thieme Verlag KG 2017

Per-oral endoscopic myotomy for achalasia cardia: outcomes in over 400 consecutive patients

Zaheer Nabi
1   Asian Institute of Gastroenterology – Gastroenterology, Hyderabad, India
,
Mohan Ramchandani
1   Asian Institute of Gastroenterology – Gastroenterology, Hyderabad, India
,
Radhika Chavan
1   Asian Institute of Gastroenterology – Gastroenterology, Hyderabad, India
,
Rakesh Kalapala
1   Asian Institute of Gastroenterology – Gastroenterology, Hyderabad, India
,
Santosh Darisetty
2   Asian Institute of Gastroenterology – Anaestheisa, Hyderabad, India
,
Guduru Venkat Rao
3   Asian Institute of Gastroenterology – Surgical Gastroenterology, Hyderabad, India
,
Nageshwar Reddy
1   Asian Institute of Gastroenterology – Gastroenterology, Hyderabad, India
› Author Affiliations
Further Information

Publication History

submitted 25 September 2016

accepted after revision 17 January 2017

Publication Date:
05 May 2017 (online)

Abstract

Background and study aims Per-oral endoscopic myotomy (POEM) has emerged as an efficacious treatment modality for the management of achalasia cardia (AC) and non-achalasia spastic esophageal motility disorders. Initial results are encouraging. We analyzed the safety and efficacy of POEM in a large cohort of patients with AC.

Patients and methods The data from patients who underwent POEM (from January 2013 to June 2016) was prospectively collected and analyzed. Clinical success was defined as Eckardt score ≤ 3 after POEM procedure. Objective parameters including high-resolution manometry (HRM) and timed barium swallow (TBS) were analyzed and compared before and after the procedure. Gastroesophageal reflux was analyzed using 24-hour pH impedance study and esophagogastro-duodenoscopy.

Results A total of 408 patients (mean age 40 years, range 4 – 77 years) underwent POEM during the specified period. POEM could be successfully completed in 396 (97 %) patients. Clinical success rates at 1, 2 and 3 years were 94 %, 91 % and 90 %, respectively. Mean Eckardt score was 7.07 ± 1.6 prior to POEM and 1.27 ± 1.06 after POEM (P = 0.001) at 1 year. Significant improvement in esophageal emptying on TBE (> 50 %) was documented in 93.8 % patients who completed 1-year follow up. Pre-procedure and post-procedure mean lower esophageal sphincter pressure was 45 ± 16.5 mmHg and 15.6 ± 6.1 mmHg, respectively (P = 0.001). Technical and clinical success were comparable in naïve vs prior treated cases (97.3 % vs 96.8 %, P = 0.795) (95.7 % vs 92.6 %, P = 0.275). GERD was documented in 28.3 % patients with 24-hour pH-impedance study and erosive esophagitis was seen in 18.5 % of patients who underwent POEM.

Conclusions POEM is safe, effective and has a durable response in patients with achalasia cardia. Prior treatment does not influence the outcomes of POEM.

 
  • References

  • 1 Gockel I, Becker J, Wouters MM. et al. Common variants in the HLA-DQ region confer susceptibility to idiopathic achalasia. Nat Genet 2014; 46: 901-904
  • 2 Vela MF, Richter JE, Khandwala F. et al. The long-term efficacy of pneumatic dilatation and Heller myotomy for the treatment of achalasia. Clin Gastroenterol Hepatol 2006; 4: 580-587
  • 3 Pratap N, Kalapala R, Darisetty S. et al. Achalasia cardia subtyping by high-resolution manometry predicts the therapeutic outcome of pneumatic balloon dilatation. J Neurogastroenterol Motil 2011; 17: 48-53
  • 4 Yaghoobi M, Mayrand S, Martel M. et al. Laparoscopic Heller's myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized, controlled trials. Gastrointest Endosc 2013; 78: 468-475
  • 5 Moonen A, Annese V, Belmans A. et al. Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut 2016; 65: 732-739
  • 6 Swanstrom LL, Kurian A, Dunst CM. et al. Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure. Ann Surg 2012; 256: 659-667
  • 7 von Renteln D, Inoue H, Minami H. et al. Peroral endoscopic myotomy for the treatment of achalasia: a prospective single center study. The American journal of gastroenterology 2012; 107: 411-417
  • 8 Swanstrom LL. Poetry is in the air: first multi-institutional results of the per-oral endoscopic myotomy procedure for achalasia. Gastroenterology 2013; 145: 272-273
  • 9 Ramchandani M, Nageshwar Reddy D, Darisetty S. et al. Peroral endoscopic myotomy for achalasia cardia: Treatment analysis and follow up of over 200 consecutive patients at a single center. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society 2016; 28: 19-26
  • 10 Barbieri LA, Hassan C, Rosati R. et al. Systematic review and meta-analysis: Efficacy and safety of POEM for achalasia. United European gastroenterology journal 2015; 3: 325-334
  • 11 Inoue H, Sato H, Ikeda H. et al. Per-Oral Endoscopic Myotomy: A Series of 500 Patients. J Am Coll Surg 2015; 221: 256-264
  • 12 Werner YB, Costamagna G, Swanstrom LL. et al. Clinical response to peroral endoscopic myotomy in patients with idiopathic achalasia at a minimum follow-up of 2 years. Gut 2016; 65: 899-906
  • 13 Hu Y, Li M, Lu B. et al. Esophageal motility after peroral endoscopic myotomy for achalasia. Journal of gastroenterology 2016; 51: 458-464
  • 14 Yao S, Linghu E. Peroral endoscopic myotomy can improve esophageal motility in patients with achalasia from a large sample self-control research (66 patients). PloS one 2015; 10: e0125942
  • 15 Teitelbaum EN, Sternbach JM, El Khoury R. et al. The effect of incremental distal gastric myotomy lengths on EGJ distensibility during POEM for achalasia. Surgl Endosc 2016; 30: 745-750
  • 16 Hungness ES, Sternbach JM, Teitelbaum EN. et al. Per-oral Endoscopic Myotomy (POEM) After the Learning Curve: Durable Long-term Results With a Low Complication Rate. Ann Surg 2016; 264: 508-517
  • 17 Kumbhari V, Saxena P, Messallam AA. et al. Fluoroscopy to document the extent of cardiomyotomy during peroral endoscopic myotomy. Endoscopy 2014; 46 (Suppl. 01) UCTN: E369-370
  • 18 Grimes KL, Inoue H, Onimaru M. et al. Double-scope per oral endoscopic myotomy (POEM): a prospective randomized controlled trial. Surg Endosc 2016; 30: 1344-1351
  • 19 Khashab MA, Kumbhari V, Azola A. et al. Intraoperative determination of the adequacy of myotomy length during peroral endoscopic myotomy (POEM): the double-endoscope transillumination for extent confirmation technique (DETECT). Endoscopy 2015; 47: 925-928
  • 20 Sharata A, Kurian AA, Dunst CM. et al. Peroral endoscopic myotomy (POEM) is safe and effective in the setting of prior endoscopic intervention. J Gastrointest Surg 2013; 17: 1188-1192
  • 21 Jones EL, Meara MP, Pittman MR. et al. Prior treatment does not influence the performance or early outcome of per-oral endoscopic myotomy for achalasia. Surg Endosc 2016; 30: 1282-1286
  • 22 Fumagalli U, Rosati R, De Pascale S. et al. Repeated Surgical or Endoscopic Myotomy for Recurrent Dysphagia in Patients After Previous Myotomy for Achalasia. J Gastrointest Surg 2016; 20: 494-499
  • 23 Zhou PH, Li QL, Yao LQ. et al. Peroral endoscopic remyotomy for failed Heller myotomy: a prospective single-center study. Endoscopy 2013; 45: 161-166
  • 24 Li Y, LingHu E, Ding H. et al. Peroral endoscopic myotomy with simultaneous submucosal and muscle dissection for achalasia with severe interlayer adhesions. Gastrointest Endosc 2016; 83: 651-652
  • 25 Li QL, Yao LQ, Xu XY. et al. Repeat peroral endoscopic myotomy: a salvage option for persistent/recurrent symptoms. Endoscopy 2016; 48: 134-140
  • 26 Yang S, Zeng MS, Zhang ZY. et al. Pneumomediastinum and pneumoperitoneum on computed tomography after peroral endoscopic myotomy (POEM): postoperative changes or complications?. Acta Radiologica 2015; 56: 1216-1221
  • 27 Cai MY, Zhou PH, Yao LQ. et al. Thoracic CT after peroral endoscopic myotomy for the treatment of achalasia. Gastrointest Endosc 2014; 80: 1046-1055
  • 28 Banks-Venegoni AL, Desilets DJ, Romanelli JR. et al. Tension capnopericardium and cardiac arrest as an unexpected adverse event of peroral endoscopic myotomy (with video). Gastrointest Endosc 2015; 82: 1137-1139
  • 29 Binmoeller KF, Bhat YM. Underwater peroral endoscopic myotomy. Gastrointest Endosc 2016; 83: 454
  • 30 Bechara R, Ikeda H, Inoue H. Peroral endoscopic myotomy: an evolving treatment for achalasia. Nature Rev Gastroenterol Hepatol 2015; 12: 410-426
  • 31 Pescarus R, Shlomovitz E, Sharata AM. et al. Endoscopic suturing versus endoscopic clip closure of the mucosotomy during a per-oral endoscopic myotomy (POEM): a case-control study. Surg Endosc 2016; 30: 2132-2135
  • 32 Modayil R, Friedel D, Stavropoulos SN. Endoscopic suture repair of a large mucosal perforation during peroral endoscopic myotomy for treatment of achalasia. Gastrointest Endosc 2014; 80: 1169-1170
  • 33 Familiari P, Gigante G, Marchese M. et al. Peroral Endoscopic Myotomy for Esophageal Achalasia: Outcomes of the First 100 Patients With Short-term Follow-up. Ann Surg 2016; 263: 82-87
  • 34 Familiari P, Greco S, Gigante G. et al. Gastroesophageal reflux disease after peroral endoscopic myotomy: Analysis of clinical, procedural and functional factors, associated with gastroesophageal reflux disease and esophagitis. Digest Endosc 2016; 28: 33-41
  • 35 Jones EL, Meara MP, Schwartz JS. et al. Gastroesophageal reflux symptoms do not correlate with objective pH testing after peroral endoscopic myotomy. Surg Endosc 2016; 30: 947-952
  • 36 Shiwaku H, Inoue H, Sasaki T. et al. A prospective analysis of GERD after POEM on anterior myotomy. Surg Endosc 2016; 30: 2496-2504