Safety Of Peroral Endoscopic Myotomy Research Articles

A CASE OF BILATERAL PNEUMOTHORACES, PNEUMOMEDIASTINUM, PNEUMOPERITONEUM, SUBCUTANEOUS EMPHYSEMA AFTER PERORAL ENDOSCOPIC MYOTOMY PROCEDURE

SESSION TITLE: Fellows Procedures Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Peroral endoscopic myotomy (POEM) is a form of natural orifice transluminal endoscopic surgery. It is a relatively safe procedure, with 8% of reported adverse events. These include pneumoperitoneum, subcutaneous emphysema, pneumothorax, and gastroesophageal reflux. However, the occurrence of bilateral pneumothoraces, pneumomediastinum pneumoperitoneum,pneumoretroperitoneum with subcutaneous emphysema in the same patient is a rare occurence. CASE PRESENTATION: Our case depicts a 60-year-old female with a history of dyslipidemia, mild intermittent asthma, gastroesophageal reflux disease who presented with complaints of worsening epigastric pain for one year. She also reported occasional episodes of chest tightness along with odynophagia and dysphagia to both solids and liquids. Patient underwent fluoroscopic imaging of esophagus that revealed a large-sized hiatal hernia, patulous mid to upper esophagus with non-propulsive tertiary contractions involving the distal third portion of the esophagus. Esophagogastroduodenoscopy showed Barrett's esophagus with low-grade dysplasia, a large hiatal hernia, and gastroparesis in the fundus. A working diagnosis of distal esophageal spasm was confirmed with manometry. She thus underwent a POEM procedure for diffuse esophageal spasm. Patient reported dyspnea with pleuritic chest pain in the immediate post operative period. A chest X-ray, later a Computerized tomography scan was obtained showing large bilateral pneumothoraces, pneumomediastinum, subcutaneous emphysema along with intraperitoneal and retroperitoneal air. Her vital signs were stable; there was reduced intensity of breath sounds bilaterally on chest auscultation, with remaining normal systemic physical examination. Patient underwent bilateral tube thoracostomies. A contrast evaluation was performed for the integrity of the gastroesophageal junction which was negative for extravasation. Over the course of the hospitalization, there was complete resolution of the pneumothoraces, pneumomediastinum and pneumoperitoneum and pneumoretroperitoneum. Thereupon, bilateral chest tubes were removed. DISCUSSION: Gas related complications are seen after POEM procedure because of gas insufflation into esophageal wall during the procedure and the close proximity to pleura and mediastinal structures, leading to gas leak. To minimize the risk of complications, the use of insufflation and CO2 flow should be minimized especially when the endoscope is within submucosal tunnel. Particular attention to the changes in airway pressures and hemodynamic changes allow early detection and prompt intervention during the procedure. Tension pneumothorax and tension pneumopericardium are life-threatening complications CONCLUSIONS: Our case highlights the realm of complications after POEM procedure. Endoscopists, anesthesiologists, and perioperative clinicians must be aware of the complications. Reference #1: Khashab MA, El Zein M, Kumbhari V, et al. Comprehensive analysis of efficacy and safety of peroral endoscopic myotomy performed by a gastroenterologist in the endoscopy unit: a single-center experience. Gastrointest Endosc. 2016;83(1):117–125. Reference #2: Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases). DISCLOSURES: No relevant relationships by Nafiisah Rajabalee, source=Web Response No relevant relationships by Roberto Solis, source=Web Response No relevant relationships by Rishitha Yelisetti, source=Web Response

How does per-oral endoscopic myotomy compare to Heller myotomy? The Latin American perspective.

Background and study aims Both Heller myotomy (HM) and per-oral endoscopic myotomy (POEM) are efficacious therapies for achalasia. The efficacy and safety of POEM vs HM in Latin America and specifically in patients with Chagas disease is unknown. Patients and methods Consecutive patients undergoing either HM or POEM for achalasia were included from nine Latin American centers in a prospective registry over 5 years. Technical success was defined as undergoing a successful myotomy. Clinical success was defined as achieving an Eckardt score < 3. Data on demographics, procedure info, Eckardt score, and adverse events (AEs) were collected. Student’s t test, Chi squared, and logistic regression analyses were conducted. Results One hundred thirty-three patients were included (59 male; 44 %; mean age 47). POEM was performed in 69 patients, HM in 64 patients. A total of 35 patients had Chagas disease, 17 of 69 in the POEM group, 18 of 64 in the HM group. Both groups had significant reduction in Eckardt scores ( P < 0.00001), but successful initial therapy was significantly higher in the POEM group compared to the HM group ( P = 0.01304). AEs were similar in both group (17 % vs 14 %) and consisted of pneumothorax (n = 3 vs 2), bleeding requiring transfusion (n = 3 vs 2), and mediastinitis (n = 3 vs 1). Hospital stay was longer in the HM group than in the POEM group ( P < 0.00001). In the Chagas subgroup, post-procedure Eckardt score in the POEM group was significantly reduced by 5.71 points ( P < 0.00001) versus 1.56 points in the HM group ( P = 0.042793). Conclusion Both HM and POEM are efficacious for achalasia, but POEM was associated with higher initial therapy success and shorter hospital stay in Latin America. In Chagas patients with achalasia, POEM was significantly more effective than HM.

Efficacy and Safety of Peroral Endoscopic Myotomy in Achalasia Patients with Failed Previous Intervention: A Systematic Review and Meta-Analysis.

Peroral endoscopic myotomy (POEM) has emerged as a rescue treatment for recurrent or persistent achalasia after failed initial management. Therefore, we aimed to investigate the efficacy and safety of POEM in achalasia patients with failed previous intervention. We searched the MEDLINE, Embase, Cochrane, and PubMed databases using the queries “achalasia,” “peroral endoscopic myotomy,” and related terms in March 2019. Data on technical and clinical success, adverse events, Eckardt score and lower esophageal sphincter (LES) pressure were collected. The pooled event rates, mean differences (MDs) and risk ratios (RR) were calculated. A total of 15 studies with 2,276 achalasia patients were included. Overall, the pooled technical success, clinical success and adverse events rate of rescue POEM were 98.0% (95% confidence interval [CI], 96.6% to 98.8%), 90.8% (95% CI, 88.8% to 92.4%) and 10.3% (95% CI, 6.6% to 15.8%), respectively. Seven studies compared the clinical outcomes of POEM between previous failed treatment and the treatment naïve patients. The RR for technical success, clinical success, and adverse events were 1.00 (95% CI, 0.98 to 1.01), 0.98 (95% CI, 0.92 to 1.04), and 1.17 (95% CI, 0.78 to 1.76), respectively. Overall, there was significant reduction in the pre- and post-Eckardt score (MD, 5.77; p<0.001) and LES pressure (MD, 18.3 mm Hg; p<0.001) for achalasia patients with failed previous intervention after POEM. POEM appears to be a safe, effective and feasible treatment for individuals who have undergone previous failed intervention. It has similar outcomes in previously treated and treatment-naïve achalasia patients.

Peroral endoscopic myotomy for management of gastrointestinal motility disorder.

Achalasia is a type of esophageal motility disorder, consisting of relaxation dysfunction of the lower esophagus and disturbed esophageal peristalsis. Related clinical symptoms include dysphagia, regurgitation, chest pain, and weight loss. Traditional treatment options include endoscopic botulinum toxin injection, endoscopic pneumatic dilation, and laparoscopic Heller's myotomy. These therapies mainly relieve symptoms by reducing the pressure on the lower esophageal sphincter and reducing blood flow resistance at the esophagogastric junction. Based on endoscopic submucosal dissection and natural orifice transluminal endoscopic surgery, peroral endoscopic myotomy (POEM) is a purely endoscopic method of myotomy with minimal invasiveness and a low rate of adverse events when performed by experienced operators. Since then, numerous studies have shown the significant clinical efficacy and safety of POEM. The purpose of this article is to introduce different modified POEMs, special indications for different POEMs, and their advantages as well as disadvantages.

Sa1312 CLINICAL OUTCOME OF PERORAL ENDOSCOPIC MYOTOMY IN ADVANCED ACHALASIA TREATMENT STRATIFIED BY MORPHOLOGICAL SUBTYPES

Peroral endoscopic myotomy (POEM) has been first-line treatment of achalasia. However, the efficacy and safety of POEM on advanced achalasia remains to be clarified. Our purpose was to evaluate the feasibility and clinical outcome of POEM for advanced AC with various esophageal morphological changes. From June 2015 to March 2019, a total of 50 patients were enrolled with advance achalasia (megaesophagus type in 23 patients, sigmoid type in 19 patients and both type in 8 patients). Primary endpoint was symptomatic relief during follow-up, defined as an Eckardt score ≤3. Secondary endpoints were intra-procedural details such as operation time, length of myotomy, post-treatment adverse events, hospital stay, as well as delayed AE, named gastroesophageal reflux disease (GERD). All patients successfully received endoscopic myotomy, with a mean procedure time of 38.5±26.3 (range, 10.7-162.6) min. In 10 patients (20%) adverse events were encountered, including mild (n=8) and moderate (n=6) without conversion to surgery and ICU admission. During a mean follow-up of 23.8 months, despite 41 (89.1%) patients achieved treatment success with a decrease in mean Eckardt score from 7.2 to 1.7 (P=6.7×10-9), only 4 (57.1%) patients in subgroup 3 (dilation and sigmoid esophagus) obtained clinical success. Symptomatic reflux occurred in 13 patients (13/46, 28.3%), and all reflux symptoms were easily controlled by intermittent oral medication with PPIs. In advanced achalasia patients with various esophageal morphological changes, POEM was a technically feasible, safe and effective option. POEM appears to be less effective in patients with significant dilated and distorted esophagus, which should be paid more attention in future managements.

Sa1282 PERORAL ENDOSCOPIC MYOTOMY FOR ACHALASIA PATIENTS WITH PRIOR HELLER MYOTOMY: A SYSTEMATIC REIVEW AND META-ANALYSIS

Heller myotomy (HM) is considered the standard surgical treatment for achalasia patients. However, approximately 10-20% of achalasia patients after HM have persistent or recurrent symptoms requiring further therapy. Several studies have reported the outcomes of peroral endoscopic myotomy (POEM) in these patients. Objective: A systematic review and meta-analysis were performed to evaluate the efficacy and safety of POEM in achalasia patients with prior HM. The databases of PubMed, EMBASE, The Cochrane library were systematically searched. Studies evaluating the outcomes of POEM in achalasia patients with prior HM were eligible for inclusion. Two reviewers independently reviewed the studies, extracted data and assessed study quality. Heterogeneity among studies was assessed using the I2 statistic. Pooled estimates were calculated using random or fixed-effects models, according to the level of heterogeneity. A total of 9 studies with 272 achalasia patients were recruited in this review. POEM was successfully performed in 270 (99.3%) patients after prior HM. There was a significant reduction in Eckardt score by 5.14 (weighted mean differences (WMD) 5.14, 95%CI, 4.19-6.09, P< 0.001, I2=86.4%). Clinical success (post-POEM Eckardt score≤3) was achieved in 90% (95%CI, 83%-98%, I2=58.5%) of patients after POEM. Lower esophageal sphincter (LES) pressure was significantly lowered by 12.01 mmHg (WMD 12.01, 95%CI, 6.74–17.27, P< 0.001, I2 = 85.1%). The pooled rates of postoperative symptomatic gastroesophageal reflux, esophagitis based on after-POEM endoscopy, and abnormal acid exposure at pH monitoring were 37% (95% CI, 21%-53%), 33% (95% CI, 10%-56%), 48% (95%CI, 33%-62%), respectively. Most of the adverse effects related to POEM procedure were self-limiting and could be managed conservatively. No publication bias was found using Egger's test. POEM is a safe and effective treatment for achalasia patients with prior HM. Further data from large randomized controlled trials are needed to confirm these findings.

Peroral endoscopic myotomy (POEM): a comparative study between Chagasic and idiopathic achalasia.

Background and study aims Achalasia can be classified as either primary (idiopathic) achalasia or secondary achalasia, which is a consequence of another systemic disease. Peroral endoscopic myotomy (POEM) is an effective and safe treatment for achalasia. We evaluated the efficacy and safety of POEM in patients with Chagasic achalasia compared to idiopathic achalasia. Patients and methods We evaluated POEM procedures performed at a single institution from November 2016 to January 2018. Demographic data, Eckardt score, lower esophageal sphincter (LES) pressure, body mass index, post-operative erosive esophagitis, adverse events, length of hospital stay, and procedure-related parameters were analyzed. Results Fifty-one patients underwent POEM as a treatment for achalasia in this period (20 patients with Chagasic and 31 with Idiopathic etiology). The overall clinical success rate was 92.1 %, with no statistical difference between groups (90 % in the Chagasic group vs. 93.5 % in the Idiopathic group, P = 0.640). Both groups had significant reduction in Eckardt score and in LES pressure, and increase in bodey mass index (BMI) at 1-year follow-up. There was no statistical difference between groups regarding Eckardt score ( P = 0.439), LES pressure (p = 0.507), BMI ( P = 0.254), post erosive esophagitis (35 % vs. 38.7 %, P = 0.789), adverse events (30 % vs. 12 %, P = 0.163,) length of hospital stay (3.75 days vs. 3.58 days, P = 0.622), and operative time (101.3 min vs. 99.1 min, P = 0.840). Conclusion POEM is an effective and safe treatment for patients with achalasia. There is no difference in POEM outcomes for those patients with Chagasic or Idiopathic achalasia.

Per oral endoscopic myotomy as salvage therapy in patients with achalasia refractory to endoscopic or surgical therapy is technically feasible and safe: Systematic review and meta-analysis.

Per oral endoscopic myotomy (POEM) has been reported as an effective and safe salvage therapy for achalasia but there is limited composite data. We performed a systematic review and meta-analysis of studies that reported the rates of clinical success and adverse events among patients who underwent POEM after failed conventional endoscopic or surgical therapy. Electronic literature search was conducted from inception through December 2018 for articles reporting the efficacy and safety of POEM in patients with achalasia who failed endoscopic or surgical therapy. Primary outcome was the pooled estimated rates of clinical success, defined as Eckardt score≤3 after POEM. Secondary outcomes were procedural time, the rates of POEM-related gastroesophageal reflux disease (GERD) and procedure-related adverse events. Seven studies reporting outcomes on 487 patients met our criteria. Pooled estimated rate of clinical success of POEM was 88% (95% confidence interval (CI) 79-94%). Mean procedural time was 64minutes (95% CI 44-85minutes). POEM-related GERD was found in 20% (95% CI 16-24%) of patients. Estimated incidence of overall adverse events was 10% (95% CI 5-18%) with individual risk of bleeding, mucosotomy, pneumothorax, pneumoperitoneum hydrothorax/mediastinitis, and subcutaneous emphysema ranging from 1 to 4%. Per oral endoscopic myotomy after failed endoscopic or surgical therapy in patients with achalasia is an effective and safe treatment. Further long-term follow-up studies in a larger number of patients are warranted to validate the sustainable efficacy of POEM for achalasia.

Peroral endoscopic myotomy alone is effective for esophageal motility disorders and esophageal epiphrenic diverticulum: a retrospective single-center study.

Esophageal epiphrenic diverticulum (ED) is associated with esophageal motility disorder (EMD). If a diverticulum associated with EMD is enlarging with worsening symptoms, surgical intervention, including laparoscopic epiphrenic diverticulectomy with myotomy and fundoplication, is indicated. However, some studies suggest that myotomy alone, with less adverse events, is sufficient to improve symptoms. Additionally, peroral endoscopic myotomy (POEM) is considered effective and safe for EMD. Since theoretically, POEM is endoscopic Heller myotomy, POEM without diverticulectomy is considered a less invasive, promising treatment option for EMD and ED. We aimed to determine the efficacy and safety of POEM alone for ED with EMD. This single-center study was retrospective. A total of 298 patients underwent POEM in Kobe University Hospital from April 2015 to October 2018. Of them, 14 patients had ED. Procedure-related outcomes and treatment outcomes 3months post POEM were evaluated in these patients. The median maximum ED diameter was 29 (range 9-90) mm; and the median POEM procedure time, 77.5 (range 41-123) min. Pneumoperitoneum, which required needle decompression, occurred in one patient, but no fatal adverse events occurred. The median Eckardt score significantly decreased from 5 [range 2-11] pre POEM to 0 [range 0-2] post POEM (P < 0.0001). The median integrated relaxation pressure significantly decreased from 22.5 [13.9-34.3] mmHg pre POEM to 10.2 [0.7-23.9] mmHg post POEM (P < 0.0001). Of 14 patients, only one patient complained of gastroesophageal reflux disease symptoms, which could be controlled with a potassium-competitive acid blocker. POEM alone seemed effective and safe for patients with EMD and ED.

Efficacy and safety of peroral endoscopic myotomy in the management of recurrent achalasia after failed Heller myotomy: a systematic review and meta-analysis.

BackgroundHeller myotomy (HM) is an established treatment for achalasia but can fail in up to 10-20% of patients. Peroral endoscopic myotomy (POEM) may be an appropriate treatment for patients with failed HM.MethodsWe searched several databases to identify non-comparative studies evaluating the efficacy and/or safety of POEM after failed HM and comparative studies comparing the efficacy and/or safety of POEM in patients with and without prior HM. Outcomes assessed included clinical success, technical success, adverse events, post-treatment gastroesophageal reflux disease (GERD), and presence of esophagitis on endoscopy. We calculated weighted pooled rates with 95% confidence intervals (CI) for all outcomes in patients undergoing POEM with prior HM. We calculated pooled odds ratios with 95%CI to compare the outcomes between patients with and without previous HM who underwent POEM.ResultsWe included 11 observational studies with 1205 patients. Weighted pooled rates (95%CI) for overall clinical success and technical success in patients with failed HM were 87% (81-91%) and 97% (94-99%), respectively. Weighted pooled rates (95%CI) for major adverse events, new-onset GERD and presence of esophagitis on endoscopy were 5% (2-10%), 33% (26-41%), and 38% (22-58%), respectively. There were no differences in clinical success, adverse events, post-treatment GERD and esophagitis between patients with and without previous HM.ConclusionsPOEM is safe and effective in patients with failed HM and should be considered in patients with recurrent achalasia after HM. Outcomes of POEM are comparable in patients with and without prior HM.

Multicenter Evaluation of Clinical Efficacy and Safety of Per-oral Endoscopic Myotomy in Children.

Per-oral endoscopic myotomy (POEM) is a recommended treatment modality for achalasia, but there is little published data for its use in children. The objective of the present study was to evaluate whether POEM is clinically effective and safe for children. International multicenter retrospective study conducted in 14 tertiary centers that included consecutive children who underwent POEM between January 2012 and August 2018. Outcomes, such as clinical response were assessed whenever available. Adverse events and factors associated with clinical failure were also investigated. A total of 117 patients (mean ± SD age: 14.2 ± 3.7 years) underwent POEM for achalasia (type I, n = 36; type II n=66; type III, n=8). Among these, 30 (26%) were pretreated (botulinum injection and/or pneumatic dilatation). Mean ± SD baseline Eckardt score was 7.5 ± 2.0. Clinical success was achieved in 90.6% of cases (95%CI [83.8%;95.2%]) in the intention-to-treat analysis. The mean ± SD Eckardt score post-POEM was 0.9 ± 1.2 (P < 0.001). The mean duration of follow-up time 545 days (range: 100-1612). A total of 7 adverse events occurred (4 mucosotomies, 2 subcutaneous emphysema, 1 esopleural fistula). Gastroesophageal reflux symptoms were seen in 17 patients (15%); missing data for 10 patients (9%). There was a trend towards more frequent clinical failure in achalasia associated with genetic disorders (40% vs 8%, P = 0.069). POEM in pediatric patients appears to be effective and safe, although there was a trend towards more frequent clinical failure achalasia associated with genetic disorders. Further studies are needed to assess the long-term outcomes, especially the consequences of GERD.

926 POEM Is a Safe and Effective Treatment for Achalasia: A Large Single Center Experience

INTRODUCTION: Achalasia is a primary motility disorder characterized by aperistalsis and failure of lower esophageal sphincter relaxation. Traditionally, treatment modalities have consisted of drug therapy, botulinum toxin injections, laparoscopic Heller myotomy, and balloon pneumatic dilatation. However, in the past several years, the novel technique peroral endoscopic myotomy (POEM) has gained popularity, as prior studies have suggested that it offers excellent short-term outcomes. In this study, we analyze the efficacy of POEM with a focus on both short-term and long-term outcomes. METHODS: This retrospective study utilized collected data at our tertiary referral center. A total of 71 patients underwent POEM. 18 patients were lost to follow-up post-procedure. 47 patients were included in the short-term assessment, defined as less than 6 months removed from the procedure, while 15 patients were included in the long-term assessment, defined as greater than or equal to 6 months removed from the procedure. Eckhardt score was assessed before POEM and afterwards for short-term follow-up and long-term follow-up. RESULTS: Mean age was 56.5 years old. 54% of patients were female. Mean short term follow-up time was 2.96 months. Mean long-term follow-up time was 13.0 (8-27) months. The mean pre-POEM Eckhardt score was 7.6. The mean short-term post-POEM Eckhardt score was 1.2 (P &lt; 0.001) while the mean long-term post-POEM Eckhardt score was 1.8 (P &lt; 0.001). There was no significant difference between short-term and long-term Eckhardt scores. Additionally, there were no adverse outcomes or effects in any of the 65 POEM cases. CONCLUSION: This study was one of the largest single-center studies that examining the efficacy and safety of POEM . Eckhardt scores decreased significantly after POEM, remained significantly decreased at longer-term follow-up, and there were no adverse outcomes. In short, this study supports that POEM is a safe, effective, and durable option for the treatment of achalasia.

Tu1154 PERORAL ENDOSCOPIC MYOTOMY FOR THE TREATMENT OF ESOPHAGEAL MOTILITY DISORDERS: BASELINE CHARACTERISTICS AND PROCEDURAL OUTCOMES IN YOUNG AND ELDERLY PATIENTS

Peroral endoscopic myotomy (POEM) has been proven to be effective for the treatment of achalasia. There are limited data on efficacy and safety of POEM in elderly patients. We therefore aimed to assess the role of POEM in patients aged ≥65 years. We retrospectively analyzed POEM outcomes in young (≥18≤40 years) and elderly (≥65 years) patients, who were treated between May 2011 and April 2017. Demographic data, clinical data and treatment outcomes were compared between the two groups. During the study period, 204 patients (116 Young Group [YG], 56% male, mean age 31 ± 6.4, and 88 Elderly Group [EG] 44.3% male, mean age 72.2 ± 4.7) were enrolled. Pediatric patients (n=26) and patients aged between 41 and 64 years (n=232) were excluded. There were no differences with regard to gender or ethnicity between the two groups. High resolution manometry (HRM) was performed in 101 patients in the YG and 81 in the EG, without significant differences about the prevalence of type I and type II achalasia in the two groups. A higher prevalence of spastic motility disorders (type III achalasia, Jackhammer esophagus and Distal Esophageal Spasm –DES) was observed in the EG (25.9% vs 8.9 in EG and YG, respectively. p=0.0041). Duration of symptoms before the procedure was similar. Patients in the YG had more severe symptoms compared to EG (mean Eckardt score 8 ± 2.0 vs 7.4 ± 2.0 p=0.0350), with special regard to dysphagia (3 ± 0.2 vs 2.8 ± 0.5 p=0.0001) and chest pain (1.3 ± 1 vs 0.9 ± 0.8 p=0.0024). Mean duration of the procedure was similar in the two groups, although myotomy was longer in EG (12±3 cm vs 13±3 cm p=0.0211). This data could be explained by the higher prevalence of spastic disorders in EG. No significant differences in the rate of adverse events were found. At 6-month and at mean follow-up (24 months for both groups), clinical success (Eckardt score ≤3) was achieved in 96.4% and 96.4% of patients in YG and 96.5% and 95.4% in EG, respectively (p=n.s.). No significant differences in the two groups were observed with regard to post-POEM 4sIRP, Gastro-Esophageal Reflux and Esophagitis-rate. As well as in younger patients, POEM is a very safe and effective procedure for the treatment of major esophageal motility disorders, also in elderly patients. POEM might be recommended as the first line therapy to elderly achalasia patients.

POEM in the Treatment of Esophageal Disorders.

PURPOSE OF THE REVIEW: Peroral endoscopic myotomy (POEM) is a novel minimally invasive technique that has emerged as the preferred option for the treatment of achalasia and spastic esophageal disorders (SED) at many centers around the world. In this article, we review and summarize the recent literature on POEM in patients with achalasia and SED. The current article is largely focused on the new developments and findings, extended applications, and long-term outcomes of POEM in patients with achalasia and SED. POEM is a safe and effective therapy for patients with achalasia and SED. POEM is comparable to Heller myotomy (HM) in terms of safety, efficacy, and complications, including gastroesophageal reflux disease (GERD). Outcomes of POEM are excellent even in patients who had prior failed therapies for achalasia, including failed HM and prior POEM. Recent data also suggest the efficacy and safety of POEM in both pediatric and geriatric patients. GERD after POEM is common, and the majority of patients are asymptomatic. The management, goals of therapy, and long-term outcomes of GERD after POEM are unclear. Objective testing for all patients is recommended. POEM is a validated treatment for all patients with achalasia and SED. Candidates should be carefully selected and appropriately counseled on expected outcomes and the need for long-term surveillance.

Per-oral endoscopic myotomy in patients with or without prior Heller’s myotomy: comparing long-term outcomes in a large U.S. single-center cohort (with videos)

Heller's myotomy (HM) is one of the most effective treatments for esophageal achalasia. However, failures do exist, and the success rate tends to decrease with time. The efficacy of rescue treatments for patients with failed HM is limited. A few small-scale studies have reported outcomes of per-oral endoscopic myotomy (POEM) in these patients. We conducted this study to systematically assess feasibility, safety, and efficacy of POEM on patients who have had HM. Patients at least 3 months out from POEM were selected from our prospective database: 318 consecutive POEMs performed from October 2009 to October 2016. The efficacy and safety of POEM were compared between the 46 patients with prior HM and the remaining 272 patients. Patients with prior HM had longer disease history, more advanced disease, more type I and less type II achalasia, lower before-POEM Eckardt scores, and lower before-POEM lower esophageal sphincter (LES) pressure (all P< .01). Procedure parameters and follow-up results (clinical success rate, Eckardt score, LES pressure, GERD score, esophagitis, and pH testing) showed no significant difference between the 2 groups. For the 46 HM-POEM patients, no clinically significant perioperative adverse events occurred. Their overall clinical success rate (Eckardt score≤3 and no other treatment needed) was 95.7% at a median follow-up of 28 months. POEM as a rescue treatment for patients with achalasia who failed HM is feasible, safe, and highly effective. It should be the treatment of choice in managing these challenging cases at centers with a high level of experience with POEM.

Feasibility and Safety of Peroral Endoscopic Myotomy After Bariatric Surgery: 2017 Presidential Poster Award

Background: Per-oral endoscopic myotomy (POEM) has emerged as a safe and effective treatment modality for achalasia. POEM can be performed after prior endoscopic interventions (botox injection, pneumatic dilation and after POEM) as well as after Laparoscopic Heller myotomy (LHM). However, limited data exists on POEM in patients with prior bariatric surgery. We present two cases of POEM performed in patients with achalasia after bariatric surgery. Case Presentation: Case 1: A 54-year-old male with sleeve gastrectomy for obesity 4 years prior, presented with dysphagia for 9 months. Esophagram showed gastroesophageal junction (GEJ) obstruction to passage of a 13 mm barium pill. High-resolution manometry (HRM) showed type 1 achalasia. He underwent LHM and repair of a 5 cm para-esophageal hernia. Dysphagia recurred in 4 weeks, along with regurgitation, chest pain and weight loss (Eckardt score = 9). After a multi-disciplinary evaluation he decided to undergo POEM. A 12 cm posterior submucosal tunnel and a 9 cm myotomy was performed. Significant angulation, tortuosity and scarring was observed near the GEJ. Surgical sutures in the submucosa and muscle were carefully avoided. Follow up esophagram showed no leak and contrast readily emptied into the stomach. Eckardt score significantly improved to 2 at 3 months. Case 2: A 43-year-old female with RY gastric bypass 7 years prior, presented with dysphagia for 6 months, regurgitation with every meal, chest fullness, and 25 lbs weight loss (Eckardt score 10). HRM showed type 2 achalasia. POEM was considered due to surgically altered anatomy making LHM technically more challenging. A 14 cm submucosal tunnel and 10 cm myotomy was performed posteriorly. Patient had significant clinical improvement at 1 month with Eckardt score 2 and esophagram showed unimpeded passage of contrast into the stomach. Discussion: Achalasia in patients with obesity requiring bariatric surgery is rare but with increasing number of bariatric procedures being performed, endoscopists will likely face challenging situations like those reported here. As POEM gains widespread acceptance for management of achalasia, these cases highlight the fact that POEM can be performed in patients with bariatric surgery, though technically challenging due to angulation, tortuosity and scarring, as well as reduced gastric lumen from prior surgery.Figure: Surgical sutures seen during endoscopic myotomy.

Issue Highlights

Issue Highlights

Comprehensive Analysis of Adverse Events Associated With Per Oral Endoscopic Myotomy in 1826 Patients: An International Multicenter Study.

The safety of peroral endoscopic myotomy (POEM) is still debated since comprehensive analysis of adverse events (AEs) associated with the procedure in large multicenter cohort studies has not been performed. To study (1) the prevalence of AEs and (2) factors associated with occurrence of AEs in patients undergoing POEM. Patients who underwent POEM at 12 tertiary-care centers between 2009 and 2015 were included in this case-control study. Cases were defined by the occurrence of any AE related to the POEM procedure. Control patients were selected for each AE case by matching for age, gender, and disease classification (achalasia type I and II vs. type III/spastic esophageal disorders). A total of 1,826 patients underwent POEM. Overall, 156 AEs occurred in 137 patients (7.5%). A total of 51 (2.8%) inadvertent mucosotomies occurred. Mild, moderate, and severe AEs had a frequency of 116 (6.4%), 31 (1.7%), and 9 (0.5%), respectively. Multivariate analysis demonstrated that sigmoid-type esophagus (odds ratio (OR) 2.28, P=0.05), endoscopist experience <20 cases (OR 1.98, P=0.04), use of a triangular tip knife (OR 3.22, P=0.05), and use of an electrosurgical current different than spray coagulation (OR 3.09, P=0.02) were significantly associated with the occurrence of AEs. This large study comprehensively assessed the safety of POEM and highly suggests POEM as a relatively safe procedure when performed by experts at tertiary centers with an overall 7.5% prevalence of AEs. Severe AEs are rare. Sigmoid-type esophagus, endoscopist experience, type of knife, and current used can be considered as predictive factors of AE occurrence.

Tu1255 Evaluation of Safety of Per-Oral Endoscopic Myotomy (POEM) for Achalasia Cardia Performed in an Endoscopy Unit: an Anaesthetist's Perspective

Tu1255 Evaluation of Safety of Per-Oral Endoscopic Myotomy (POEM) for Achalasia Cardia Performed in an Endoscopy Unit: an Anaesthetist's Perspective

Tu1236 Efficacy and Safety of Peroral Endoscopic Myotomy for Esophageal Achalasia After a Year of Training at the High-Volume Center

Tu1236 Efficacy and Safety of Peroral Endoscopic Myotomy for Esophageal Achalasia After a Year of Training at the High-Volume Center