Improvement in Esophageal Emptying on Timed Barium Esophagram After Peroral Endoscopic Myotomy (POEM) for Achalasia

Abstract

Introduction: Timed barium esophagram (TBE) is used for objective assessment of esophageal emptying function in achalasia. Improvement in emptying after pneumatic dilation and Heller myotomy for achalasia have been shown to predict long term symptom relief. Peroral endoscopic myotomy (POEM) is an emerging treatment for achalasia combining the efficacy of surgical myotomy with an incisionless endoscopic procedure. Data on objective assessment of esophageal emptying by TBE after POEM is limited. Purpose of this study was to assess the improvement in esophageal emptying by TBE after POEM in patients with achalasia. Methods: Data on consecutive patients who had POEM for achalasia from April 2014 to April 2015 was collected from our Institutional Review Board approved prospective registry. Our patients routinely get TBE and high resolution esophageal manometry (HREM) before and 2 months after POEM. For TBE, patients were instructed to drink up to 230 ml of low density barium sulfate suspension (60% weight/volume) in upright position (volume of barium sulfate suspension ingested is based on patient tolerance). Then radiographs of the esophagus were taken at 1, 2 and 5 minutes with measurement of height and width of the barium column. Patient demographics, pre-and post-POEM symptoms by Eckardt scores and results of HREM and TBE at 2 month follow-up were analyzed. Data are presented as mean + standard deviation, median (P25, P75) or N (%). Differences between pre- and post-POEM were assessed with onesample t-test, non-parametric Wilcoxan signed rank test and test of symmetry. P < 0.05 was considered significant. Results: POEM was performed in 32 patients. Mean age of patients was 56 + 17 years and 56% were males. There was a significant decrease in all parameters of TBE except barium column height at minute 1. There was also significant improvement in Eckardt scores and LES pressures. Table 1 shows paired analysis assessing the changes in TBE, HREM and Eckardt symptom scores in patients who had tests done pre and post POEM at 2 month follow-up.Table 1: Pre vs. Post POEM characteristics in patients with 2-month follow-upConclusion: Esophageal emptying on TBE improves significantly after POEM in patients with achalasia. Similarly Eckardt symptom scores and LES pressures improve after POEM. Based on our TBE findings after POEM, we predict that POEM will provide durable long term symptom relief in patients with achalasia. However, further studies with long term follow-up are needed to confirm this.