Sa1315 EFFECTIVENESS AND SAFETY OF PER ORAL ENDOSCOPIC MYOTOMY IN ACALASIA COMPARING ANTERIOR AND POSTERIOR APPROACH IN A REFERENCE CENTER

Abstract

Achalasia is an esophageal primary motor disorder, characterized manometrically by the incomplete relaxation of the lower esophageal sphincter and esophageal aperistalsis. Heller's myotomy is the gold standard therapie, but per oral endoscopic myotomy (POEM), with similar clinical and manometric success, is considered a safe alternative, the submucosal wall approach possible anterior or posterior esophagus depending on operator experience. As gastroesophageal reflux disease (GERD) is its main complication, there is few evidence about wich approach is safer and more effective. To describe in patients with achalasia who undergo POEM the manometric characteristics, pre and post procedure clinics with 6-month follow-up and compare the effectiveness and complications in anterior and posterior approach. We include patients with a diagnosis of achalasia virgins to treatment, candidates for POEM with anterior or posterior approach at the Hospital 1ero de Octubre ISSSTE in Mexico City from 2016 to 2018. We exclude patients with previous endoscopic and surgical treatment and other esophageal motor disorders. At the 6-month follow-up, we evaluated clinical response (Eckardt <3), manometric (integral relaxation pressure IRP <15 mmHg), endoscopy esophagitis (Los Angeles Classification), questionnaire of symptoms of gastroesophageal reflux (GERD Q> 8 points) and 24-hour pH-metry (Demeester> 14.7). Descriptive statistics were used; For difference of proportions between the 2 techniques in non-parametric variables X2and for parametric variables t of student; The statistical package SPSS V.22 was used and a p value of less than 0.05 was considered statistically significant. 51 patients were included, 21 with type II achalasia (41.2%); Average age of 59.3 years (25-88 years), 32 women (62.7%). Baseline Eckardt score of 9, baseline IRP of 35.7 mm Hg. Anterior approach in 29 cases (56.9%). The average procedure time was 62.3 minutes (range 34-118), the anterior technique with 60.3 minutes (p=0.348). In the follow-up clinical and manometric response of 90.2% in both groups, without significant differences between them. The most frequent adverse event was subcutaneous emphysema in 11 cases (21.6%), with a greater tendency in posterior approach 31.8% (p=0.114); In 4 patients perforations without difference between approaches (p=0.417) resolved with endoscopic management. Esophagitis was diagnosed in 15 cases (29.4%), positive pH-metry by Demeester in 33.3% of cases without significant differences. POEM is a safe procedure in both approaches (anterior or posterior), with no differences in procedure time and adverse events. We obtained a clinical and manometric success in the similar follow-up between groups, without finding significant differences in the presence of GERD by clinic, endoscopy and 24-hour pH-metry.