177 Variables Associated With Clinical Failure After PerOral Endoscopic Myotomy (POEM): a Case Control Study

Abstract

177 Variables Associated With Clinical Failure After PerOral Endoscopic Myotomy (POEM): a Case Control Study Vivek Kumbhari*, Pietro Familiari, Niels C. Bjerregaard, Saowanee Ngamruengphong, Mathieu Pioche, Bu Hayee, Nicholas Eleftheriadis, Weon-Jin Ko, Francois Mion, Sabine Roman, Alan H. Tieu, Mohamad H. El Zein, Joo Young Cho, Amyn Haji, Thierry Ponchon, Rastislav Kunda, Guido Costamagna, Mouen Khashab Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD; Gastroenterologie, Gemelli University Hospital, Rome, Italy; Gastroenterology, Aarhus university hospital, Aarhus, Denmark; gastroenterology, Pavillon H Hopital Edouard Herriot, Lyon, France; gastroenterology, kings hospital, London, United Kingdom; Showa University Northern Yokohama Hospital, Yokohama, Japan; Gastroenterology, Soonchunhyang University Hospital, Bucheon, Korea (the Democratic People’s Republic of); Gastroenterology, Lyon university, Lyon, France; Gastroenterology, Digestive Endoscpy Unit Universita Cattolica del Sacro Cuore, Rome, Italy Background: Peroral endoscopic myotomy (POEM) aims to palliate symptoms of achalasia by reducing pressure at the lower esophageal sphincter (LES). However, the currently accepted determinant of outcomes for POEM is the symptom based Eckardt score. Current data demonstrates short-term clinical response in 82% to 100% of patients. Despite more than 7000 procedures performed worldwide, it is unclear what patient and procedural factors are associated with clinical failures after POEM. Determining such factors may facilitate better patient selection and optimize procedural techniques to improve procedural outcomes. Aims: To evaluate 1) pre and intra-procedural variables associated with and 2) physiologic characteristics of the LES, in patients with clinical failure post POEM. Method: Consecutive patients undergoing POEM at 7 tertiary centers (1 US, 5 European. 1 Asian) were included. Patients were excluded if their clinical follow up was less than 3 months. Relevant data was abstracted from a retrospective review of a multicenter prospectively acquired database. Patients were divided into 2 groups:1) those with a post POEM Eckardt score O3(Cases) and 2) those with a post POEM Eckardt score!3(Controls). Multivariate to identify factors associated with clinical failure was performed. Results: A total of 243 patients (mean age 49yr, female 52%) were included. The median pre-procedure Eckardt score was 8. A total of 18 (7.4%) patients had a post procedure Eckardt score of O3 (Cases) with the remaining 225 (92.6%) with serving as Controls. There were 44% of clinical failures with normalization of LES pressures (4s-IRP!15mmHg). On univariate analysis, there was no significant difference between the groups with regards to pre procedural characteristics including: age, sex, race, BMI, achalasia subtype and HREM. A sigmoid esophagus (OR 5.7, 95% CI 1.324.4, pZ0.03), prior Heller myotomy (OR 5.0, 95% CI 1.5-17.8, pZ0.01) and a higher mean baseline Eckardt score (OR 1.4, 95% CI 1.1-1.9, pZ0.01) were found to be significant risk factors for clinical failure. There was no significant difference in the groups with regards to intraprocedural characteristics including: length gastric myotomy, length of esophageal myotomy, orientation of myotomy (anterior vs. posterior) and thickness (full vs. inner circular) of myotomy. Multivariate analysis demonstrated a higher mean baseline Eckardt score was associated with risk of failure. Conclusions: In this large international multicenter study, clinical failures occurred in 7.4%. Sigmoid esophagus, prior Heller myotomy and higher mean baseline Eckardt score were associated with clinical failure. No intraprocedural factors were associated with clinical failure post POEM. Nearly half of clinical failures are unlikely to benefit from further therapy targeted at the LES and management of such patients is a clinical challenge. 178 Safety and Effectiveness of Per-Oral Endoscopic Myotomy (POEM) for Elderly Patients With Achalasia: a Comparison of Results for Older and Younger Patients Kanefumi Yamashita, Hironari Shiwaku*, Toshihiro Ohmiya, Richiko Beppu, Shinsuke Takeno, Takamitsu Sasaki, Satoshi Nimura, Haruhiro Inoue, Yuichi Yamashita Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan; Pathology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan; Digestive Disease Center, Showa University KotoToyosu Hospital, Tokyo, Japan Objective: The proportion of elderly persons in Japan is 25%, a rate that has been increasing every year. Therefore, it is of considerable clinical importance to review treatment plans for elderly patients with achalasia. The objective of this study is to evaluate the safety and effectiveness of POEM for elderly patients by comparing results from older and younger patients. Methods: A retrospective review was performed for 80 consecutive patients with achalasia who underwent POEM in our institution between September 2011 and May 2014. The patients were classified into two group: (A) those older and (B) those younger than 65 years. Age, previous treatment for achalasia, preoperative comorbidities, duration of symptoms, preand post-POEM Eckardt score, manometry findings, and treatment outcomes, including www.giejournal.org Vol duration of hospitalization and occurrence of complications, were compared between groups using chi-square and Student t-tests. Result: There were 19 patients in group A and 61 in group B. The median age was 76.1 7.1 years (range, 65-91 years) for group A and 39.9 12.4 years (range, 9-62 years) for group B. Group A had significantly more preoperative comorbidities than group B (47.4% vs. 13.1%; p Z 0.003). The mean duration of symptoms was significantly longer for group A than for group B (139.7 months [range, 1-396 months] vs. 89.3 months [range, 7-552 months]; p Z 0.001. The length of myotomy was statistically different between groups (10.3 cm [range, 5-26] in group A and 13.6 cm [range, 6-25] in group B; p Z 0.043). There were no statistical group differences for previous treatment for achalasia, median operation time, mean hospitalization, or occurrence of complications. Significant Eckardt score and integrated relaxation pressure reductions were achieved in both groups. No perioperative mortality or major postoperative complications occurred. Conclusions: POEM is a safe and effective operation for both older and younger patients. Although the elderly patients in our study had preoperative comorbidities, they achieved similar results to the younger patients, with similar rates of perioperative complications. Long-term follow-up studies are desirable to determine whether POEM may become an appropriate therapy for elderly patients with achalasia in the near future. 179 PerOral Endoscopic Short Versus Long Myotomy for the Treatment of Achalasia: a Case-Control Study Xiaowei Tang, Zhiliang Deng, Wei Gong*, Bo Jiang Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China Background: Peroral esophageal myotomy (POEM) is a novel endoscopic treatment for esophageal achalasia. It has gained popularity worldwide among surgeons and endoscopists, but no studies have compared peroral endoscopic short with long myotomy for achalasia. Aim: To compare clinical efficacy and safety between peroral endoscopic short and long myotomy. Methods: Between December 2011 and August 2013, 21 patients underwent peroral endoscopic short myotomy (myotomy length %7cm) in our department. These patients were 1:1 by age, gender, symptoms duration, Eckardt score, Chicago classification of achalasia, and LES pressure with 56 patients who underwent long myotomy (myotomy length O7cm). Procedure-related parameters, symptom relief and adverse events, manometry outcomes were compared between two groups. Results: A total of 77 patients, with a mean age of 54 19 years, underwent POEM. There was no significant differences in the age, sex and other baseline characteristics between the two groups. Mean myotomy length was 6.0 0.6 cm in short myotomy group, and 11.63 3.4 cm in long myotomy group (pZ0.01). The mean operation time was significantly shorter in shorter myotomy group than long myotomy group (49.2 19.2 min vs, 64.9 24.4 min , pZ0.01). During 6 months follow-up, treatment success (Eckardt score % 3) was achieved in 96.0% (20 of 21) of patients in short myotomy group and 95.0% (53 of 56) of patients in long myotomy group (pZ0.75). There was no significant differences in preand post-treatment D-value of symptom scores and lower esophageal sphincter pressures between groups (both pO0.05). There was also no statistical difference in the incidence of intraoperative complications (9.5% vs 8.9%, pZ0.18) and gastroesophageal reflux rate (10.7% vs 9.4%, pZ0.38) between the two groups. Conclusion: Peroral endoscopic short myotomy is comparable with long myotomy for treating achalasia with regard to short-term clinical efficacy and safety, and have the advantage of shorter procedure time. Table 1. Clinical outcomes of POEM procedure ume 81, No. 5S : 2015 Long myotomy