558 OUTCOMES OF PER ORAL ENDOSCOPIC MYOTOMY IN ACHALASIA IN PATIENTS WITH END-STAGE ESOPHAGUS. (17th September 2021)

• Record Type: Journal Article
• Authors: Raja, Siva; Adhikari, Saurav; Sudarshan, Monisha; Sanaka, Madhusudhan; Murthy, Sudish; Thota, Prashanti; Gabbard, Scott; Ahmad, Usman
• Is Part Of: Diseases of the esophagus. Volume 34(2021)Supplement 1
• Publication Date: 2021-09-17
• Subjects: Esophagus -- Diseases -- Periodicals; 616.32
• DOI: 10.1093/dote/doab052.558
• Languages: English
• ISSNs: 1120-8694

Abstract

Abstract: : Per oral endoscopic myotomy (POEM) has emerged as a favorable alterative to Heller myotomy for achalasia. However data is limited on the effectiveness in palliation of symptoms in patients who have an esophagus with a sigmoid/tortuous configuration, or a mega-esophagus with width more than 5 cm, due to long-standing achalasia. Our objective is to investigate the outcomes after POEM procedure in patients diagnosed with achalasia and considered end-stage. Methods: A retrospective cohort study was conducted in a large hospital between April 2014 and July 2019. A total of 504 patients were identified with 218 undergoing POEM during the study time period of which 57 patients had a sigmoid or tortuous esophagus, and/or had a barium column width of more than 5 cm on timed barium esophagograms (TBE). Primary outcome was symptom relief during follow-up, defined as a post-operative Eckardt score ≤ 3. We also explored integrated resting pressure (IRP) on manometry, barium column height and width on TBE, complications and procedure related parameters. Statistical analyses were performed using R. Results: Significant decrease in median Eckardt scores were observed, 7.5 [6, 8.8] pre-operatively to 0 [0, 1] at 2 months (p < 0.001). At 2 years, 12 of 14 patients (85%), reported scores of ≤3. Improvements at 2 months were noted in median IRP (25.4 mmHg [15.5, 35.9] vs. 4.0 mmHg [2.2, 9.0]), 1 min TBE height (11.5 cm [7.5, 15.0] vs. 6.8 cm [4.7, 9.0]) and width (5.0 cm [4.1, 6.1] vs. 2.8 cm [1.9, 3.1]), p < 0.001. At 2 years, they were 9.5 cm [5, 12.8] and 3.0 cm [2.4, 4.5], respectively. Post-operative pH studies in 35(61%) patients demonstrated a DeMeester score ≥ 14.72 in 17(49%) patients. Almost all patients reported return to activities of daily living within 7 days. Conclusion: POEM is an effective and safe modality in achalasia patients with end-stage esophagus. Patients in this cohort historically have had poor outcome to interventions and our data shows excellent short-to-medium term outcome with low morbidity after POEM. Given its efficacy, minimal invasiveness and short return to function, POEM is a reasonable first and gold standard palliative therapy in this difficult cohort and should be attempted before considering esophagectomy.