Tu1172 LONG - TERM RESULTS OF PERORAL ENDOSCOPIC MYOTOMY (POEM) FOR ACHALASIA

Abstract

Per-oral endoscopic myotomy (POEM) has gained trust by proved safety and short-term efficacy and at present, it is considered as a standard and safe method for treatment of achalasia. The aim of this prospective single-center case series was to assess the long-term clinical outcome of POEM with emphasis on post-POEM reflux evaluated by pH monitoring, endoscopy findings, reflux symptoms and use of proton pump inhibitors (PPIs) and to summarize adverse events of this procedure. Since 2012 until October 2017, a total of 223 patients with achalasia underwent 233 POEM procedures. Follow-up visits at 3, 12, 24 and 36 months were completed in 194, 144, 80 and 44 patients. Upper GI endoscopy, high-resolution manometry (HRM) and 24-hour pH monitoring were performed 3 months after POEM; endoscopy was then repeated between 24-36 months. Main outcomes were treatment success defined as Eckardt score < 3, recurrence rate, post-POEM reflux and adverse events. At 3, 12, 24 and 36 months, treatment success was achieved in 97% (CI 95%; 95-100), 99% (97-100), 94% (88-100) and 93% (86-100) of patients. A total of 15 patients experienced treatment failure (n=5) or recurrence (n=10). The recurrences occurred most often in patients with achalasia type I (4 out of 35, 11.4%) followed by type II (5 out of 144; 3.5%) vs. none in type III (0 out of 21.0%); p=0.022. At 3 months, reflux esophagitis was diagnosed in 68/194 patients (35%; severe esophagitis LA C or D in 8 patients). Abnormal acid exposure was detected in 68/194 (39.7%) patients. At 24-36 months, endoscopy was performed in 51 patients and reflux esophagitis was present in 15 patients (29%). A proton pump inhibitor was administered to 37% and 38% of patients at 3 and 24M, respectively. The most common adverse event was capnoperitoneum with necessity of a puncture (57.6%), subcutaneous emphysema (36.6%). Periprocedural bleeding, mucosal injury and fever were observed in less than 7% of patients. A total of three severe adverse events occured: two patients required a prolonged hospitalization due to fluidothorax and pneumofluidothorax, both patients recovered uneventfully. A 67-years old female patient experienced electromechanical dissociation with fatal cardiac arrest during the procedure, the resuscitation was not successful. The autopsy revealed severe coronary artery disease and pulmonary hypertension (unrecognized prior to POEM), these conditions were considered likely to be the cause of the death. POEM is effective treatment modality for achalasia with treatment success of 94% at 2 and 3 years. Reflux esophagitis and abnormal esophageal acid exposure are diagnosed in almost 40% of patients; reflux is successfully manageable with proton pump inhibitors. Eventhough POEM is considered a safe procedure, severe (fatal) adverse events may occur.