Tu1195 LONG-TERM OUTCOMES OF PER-ORAL ENODOSCOPIC MYOTOMY IN ACHALASIA PATIENTS WITH A MINIMUM FOLLOW-UP OF 4 YEARS: A MULTICENTER STUDY

Abstract

Per-oral endoscopic myotomy (POEM) is associated with 82-100% short-term clinical response in patients with achalasia. However, durability of response is not well known as long-term data is limited. To study (1) clinical outcomes of patients with a minimum post-POEM follow-up of 4 years; and (2) factors associated with long−term clinical failure after POEM. We conducted a retrospective review of consecutive patients with achalasia who underwent POEM with a minimum follow-up of 4 years at 11 tertiary centers (2 US, 7 Europe, 2 Asia). Clinical response was defined by an Eckardt score of ≤3. A total of 146 patients (79 females (54%); mean age 49.8 yr.) with achalasia (41 type I, 70 type II, 9 type III and 26 with unspecified type) were included. Of these, 29 (19.9%) patients had prior pneumatic dilatation, 13 (8.9%) had botulinum toxin injection and 7 (4.8%) had a prior Heller myotomy. Anterior myotomy was performed in 77.8% and full-thickness LES myotomy was carried in 52.4% of patients. The mean length of esophageal myotomy was 8.5±2.5 cm and length of gastric myotomy was 3.2±1 cm. A total of 8 (5.5%) adverse events occured (6 mucosotomy, 2 pneumothorax). The median follow-up duration was 55 months (IQR 49.9-60.6). Clinical success was seen in 96.4% (136/141), 95.9% (118/123), 94.1% (127/135), 95.9% (118/123) and 95.2% (139/146) at 6 months, 12 months, 24 months, 36 months and ≥ 48 months, respectively. Of the 7 patients who experienced clinical failure at 4 years, 5 experienced initial response and then had a late (after 6 months) recurrence of symptoms. The mean Eckardt score decreased from 7.5±1.7 to 1.28±1.29 (p < 0.001) and 4sIRP pressure from 28.7 ± 11 to 10.1 ± 7.1 mmHg (P<0.001). On univariable analysis, male gender (OR 7.6, p 0.062), a sigmoid esophagus (OR 2.33, p 0.45), prior Heller myotomy (OR 3.7, p 0.26) and type III achalasia (OR 2.73, p 0.37) were associated with long-term treatment failure, although the association was not statistically significant. Four patients with clinical failure underwent re-treatment: 1 had a repeat POEM and 3 had a pneumatic balloon dilation. Clinical response was attained in 3 of the 4 patients. Symptomatic reflux was seen in 45/140 (32.1%) patients after POEM. Post-POEM pH monitoring testing was completed in 80 patients, of whom 38 (47.5%) had abnormal acid exposure. Reflux esophagitis was noted in 22 (16.8%) of the 131 patients who had an EGD after POEM. Regarding PPI use, 48 (35.3%) patients are currently using PPI on a daily basis and 15 (11%) occasionally, whereas 73 (53.7%) are not using the medication. POEM is a durable and safe procedure which provides high initial clinical success and excellent long-term outcomes. Less than 5% of patients who achieved clinical response at 6 months had recurrent symptoms at 4 years.Table 2. Univariable logistic regression analysis of factors associated with long-term clinical failure (≥ 4 years after POEM, n=7)View Large Image Figure ViewerDownload Hi-res image Download (PPT)