Symptomatic and physiologic outcomes one year after peroral esophageal myotomy (POEM) for treatment of achalasia

Abstract

Background: Peroral esophageal myotomy (POEM) is a new endoscopic operation for the treatment of achalasia. Here, we report 1-year physiologic and symptomatic outcomes following the procedure.

Methods: POEM patients from a single-institution series who were more than 1 year removed from surgery were studied. Eckardt and GerdQ scores were obtained to assess symptoms. High-resolution manometry (HRM), timed barium esophagram (TBE), and upper endoscopy were preformed preoperatively and at 1-year follow-up. 24-h pH monitoring was also performed at 1 year follow-up.

Results: The study population was comprised of 41 patients who were more than 1 year post-POEM. One (2%) major complication, a contained leak at the EGJ requiring re-operation, and 7 (17%) minor complications occurred. Mean length of stay was 1.4 days. At mean 15-month follow-up, Eckardt scores improved from pre-POEM 7 ± 2 to post-POEM 1 ± 2, (scale 0-12, p < .001), and 92% of patients achieved treatment success (Eckardt score <4). Two of the three treatment failures in the series occurred in the initial three patients. 15% of patients had post-POEM symptoms suggestive of gastroesophageal reflux (GerdQ >7). On follow-up HRM, esophagogastric junction integrated relaxation pressure was decreased significantly (pre-POEM 28 ± 12 mmHg vs. post-POEM 11 ± 4 mmHg, p < .001), and 47% of patients studied had partial recovery of peristalsis. On follow-up TBE, barium column heights were decreased compared with preoperatively. Postoperative upper endoscopy revealed esophagitis in 59% of patients (11 LA Grade A, 2 LA Grade D). However, of the 13 24-h pH monitoring studies performed, only four (31%) demonstrated pathologic esophageal acid exposure.

Conclusions: In this series, POEM resulted in greater than 90% symptomatic treatment success at mean 15-month follow-up. Rates of iatrogenic gastroesophageal reflux, as measured both by symptoms and 24-h pH monitoring, appeared to be on par with recent studies of patients undergoing laparoscopic Heller myotomy and pneumatic dilation.