Tu1499 Optical Coherence Tomography (OCT) Prior to PerOral Endoscopic Myotomy (POEM): a New Standard?

Abstract

Tu1499 Optical Coherence Tomography (OCT) Prior to PerOral Endoscopic Myotomy (POEM): a New Standard? Amit P. Desai*, Amy Tyberg, Prashant Kedia, Nikhil A. Kumta, Sanjay Salgado, Monica Gaidhane, Arnon Lambroza, Reem Z. Sharaiha, Amrita Sethi, Michel Kahaleh Interventional Endoscopy, Methodist Dallas Medical Center, Dallas, TX; Division of Gastroenterology & Hepatology, Weill Cornell Medical College, New York, NY; Digestive and Liver Diseases Columbia University Medical Center, Columbia University Medical Center, New York, NY Background & Aims: POEM has emerged as an endoscopic option for the treatment of achalasia. There are currently no pre-procedural imaging modalities to predict the safest and most efficacious approach. Our aim is to evaluate the use of OCT in providing a pre-procedural, in-vivo assessment of the esophagus to determine the optimal approach. Methods: All patients undergoing POEM from July 2013 to November 2014 were prospectively captured in a dedicated POEM registry. Demographics, esophageal motility studies, prior treatment, Eckardt scores, compliance and OCT were included. Patients who underwent OCT pre-POEM (“OCT arm”) were compared to patients without pre-POEM OCT (“control arm”). OCT images were assessed for the degree of vascularity and the thickness of the circular muscular layer (Figure 1). An approach was determined based on these findings in the OCT group. Procedural times, adverse events and clinical follow up data were compared. Technical success was defined as completion of adequate pre-POEM OCT. Clinical success was defined as lack of further re-intervention post-POEM. Results: 27 patients were captured in the registry. 15 patients underwent pre-POEM OCT. The average age in the OCT arm was higher than the control group (63.6 vs. 47.4 years, pZ0.03). The Charlson Co-Morbidity Index (CCI) was higher in the OCT arm than the control group (3.2 vs 1.3, pZ0.0316). The average baseline Eckardt scores in the OCT arm was similar to the control group (6.53 vs 6.54, p Z 0.77). More patients in the OCT arm were previously treated with Botox compared to the control group (7 vs. 2, pZ0.10) (Table 1). OCT demonstrated thick anterior or posterior muscle in 66% (nZ10) of patients and large palisading vessels in 60% (nZ9) of patients. Using OCT as a guide, 60% (nZ9) of patients underwent anterior POEM while 40% (nZ6) underwent posterior POEM. There was 100% technical success in completing adequate OCT prior to POEM. Clinical success was achieved in all patients except 1 (4%) in the control group who underwent repeat POEM due to refractory symptoms. In follow up, there was significant improvement in Eckardt scores in both OCT (6.53 vs 1.6, pZ0.0004) and control (6.54 vs. 1.5, pZ0.005) groups. The procedural time was similar among OCT and control groups (103 vs. 109 mins). Significantly less bleeding occurred in the OCT arm when compared to the control group (7% vs. 58%, pZ0.025) with similar rates of adverse non-bleeding events (6% vs. 8%, pZ0.41). Conclusion: OCT provides an in-vivo anatomic assessment of the esophagus prior to POEM. Although the OCT group was older, had higher CCI scores and underwent more Botox injections, the risk of peri-procedure bleeding was significantly lower due to avoidance of vessels seen on OCT. Therefore, OCT should be performed in the evaluation of all patients prior to POEM.