Sa1262 A LARGE SINGLE-CENTER STUDY ON THE CLINICAL OUTCOMES OF PER-ORAL ENDOSCOPIC MYOTOMY FOR SIGMOID TYPE 2 ACHALASIA

Abstract

Per-oral endoscopic myotomy (POEM) has been recognized as a safe and effective minimally-invasive endoscopic treatment for achalasia. Good clinical outcomes have been reported on the application of POEM in straight type achalasia. On the other hand, results of POEM in sigmoid type achalasia, especially sigmoid type 2, are limited. This study aims to report the clinical outcomes of POEM for sigmoid type 2 achalasia. A single-center retrospective study was conducted. A prospectively collected database of 2000 patients who underwent POEM in Showa University between September 2008 to June 2019 has been reviewed. Patients who were diagnosed as sigmoid type 2 achalasia and underwent POEM were included in this study. Sigmoid type 2 achalasia was defined as an enormously dilated and tortuous esophagus in barium esophagram and double esophageal lumen in some CT slices. The primary outcome was the success rate, defined as an Eckardt Symptom Score(ESS) of less than 3 without additional treatments such as balloon dilation or redo POEM. The secondary outcomes were integrated relaxation pressure(IRP), mean lower esophageal sphincter(LES) pressure, and GERD after POEM. Patient’s characteristics: A total of 108 patients (age: 58.4±14.7 y/o, 51 females(47%), BMI: 21.7±4.6kg/m2) were included. Based on Chicago Classification, the type of achalasia seen were as follows: Type I/II/III= 28/8/1, and there were 71 unidentified cases due to the difficulty of inserting catheters. Diameter of esophagus was 48.1±17.5mm. Duration of symptoms was 17.4(7.7-29)years. ESS was 5(3-7). As pre-treatment, 49 patients had balloon dilation, Hellor-Dor in 8 patients, and Heller myotomy in 2 patients. Procedure-related parameters: Operation time was 95.9±32.1min. Myotomy length was 7(5-9)cm at the esophageal side, and 3(2-3)cm at the gastric side. Post-operative hospital stay was 4(4-5) days. The following complications were noted: mucosal perforation in 3 patients, submucosal hematoma or bleeding in 3 patients. Treatment outcomes: Success rate after 2 months was 89.1%(82/92). Pre- and 2-months post-POEM ESS were 5.0±2.5 and 1.1±1.0 (p<0.0001), respectively. Pre- and 2-months post-POEM IRP were 15.7±9.9 and 8.6±5.5 mmHg (p=0.0012), respectively. Pre- and 2-months post-POEM mean LES pressure were 19.9±13.9 and 14.6±7.7 mmHg (p=0.066), respectively. GERD 2-months post-POEM were as follows: Grade(N/A/B/C/D=37/29/13/7/1). Patients with GERD symptoms were 11.3%(10/88). PPI usage rate was 16.1%(13/81). Success rate after 1 year was 87.8%(43/49). Since good results of the short- and mid-term success rate and significant improvement of ESS and IRP value were achieved, POEM shows to be an effective procedure for sigmoid type 2 achalasia. Long-term results are expected in future studies.CT slice showing double esophageal lumenView Large Image Figure ViewerDownload Hi-res image Download (PPT)