J. S. Schwartz1, M. P. Meara1, J. W. Hazey1, K. A. Perry1 1Ohio State University,Division Of General And Gastrointestinal Surgery,Columbus, OH, USA
Introduction: Laparoscopic Heller myotomy is the gold standard therapy for achalasia in the United States due to its ability to produce effective and durable dysphagia relief. There is evidence that endoscopic pneumatic dilation can provide similar outcomes without the need for invasive surgical therapy; however, this approach has failed to gain widespread acceptance due to the need for repeated treatments and the increasing risk of esophageal perforation. Per Oral Endoscopic Myotomy (POEM) is emerging as an approach that combines the advantages of the currently available laparoscopic and endoscopic therapies. The objective of this study was to assess the impact of POEM on patient symptoms and quality of life.
Methods: POEM was introduced in August of 2012 under an IRB approved protocol. The first 10 cases were performed in patients without a prior history of endoscopic or surgical treatment. All patients remained in the hospital overnight and underwent an esophagram on post-operative day one to evaluate for esophageal leak. The primary outcome measure was dysphagia relief as measured on a 5 point Likert scale. Secondary outcomes included operative data, complications, and length of stay. Dysphagia score, GERD symptom scores (GERSS), disease specific quality of life assessment (GERD-HRQL), and global quality of life assessment (SF-36) were assessed at baseline, 6 weeks, and 6 months post-operatively.
Results: Between August 2012 and October 2013, 26 patients underwent POEM, 25 for management of achalasia and 1 long myotomy for treatment of diffuse esophageal spasm. Patients averaged 54 ± 18 years of age with a mean BMI of 28.4 ± 5.1 kg/m2. Fourteen (54%) patents were male, and the median baseline dysphagia score was 4 (2-5). POEM was successfully completed in all cases. There were no intraoperative complications or post-operative esophageal leaks. The mean operative time was 105 ± 30 minutes, and blood loss was minimal in all cases. Median hospital stay was 1 (1-2) day. Dysphagia score (4 versus 0, p<0.01); GERD symptom score (32.5 versus 9.3, p<0.01); GERD-HRQL (19.7 versus 6.1, p<0.01); and SF-36 social functioning (56.5 v 82.6, p<0.01) and general health (56.2 versus 65.4, p<0.01) significantly improved at 6 weeks compared to baseline. At 6 month follow-up, median dysphagia score was 1 (0-4), and 40% of patients were taking a daily PPI for reflux control. GERD symptom scores (12.2, p<0.01) and GERD-HRQL (6.1, p<0.01) remained significantly improved compared to baseline.
Conclusion: POEM represents a safe and effective treatment strategy for achalasia which yields excellent dysphagia relief and improved disease specific and global quality of life. Although associated with post-procedure reflux symptoms in some cases, these are typically well controlled with medical therapy. Long-term studies are required to assess the durability of symptom relief in these patients.