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) - 12/01/18

Doi : 10.1016/j.gie.2017.10.039

Xiaocen Zhang, MD ^1,^3,^⁎, Rani J. Modayil, MD ², David Friedel, MD ², Krishna C. Gurram, MD ², Collin E. Brathwaite, MD ², Sharon I. Taylor, MD ², Maria M. Kollarus, RN ², Sony Modayil, MD ², Bhawna Halwan, MD ², James H. Grendell, MD ², Stavros N. Stavropoulos, MD ²
¹ Endoscopic Center and Endoscopic Research Institute, Zhongshan Hospital affiliated to Fudan University, Shanghai, China
² Division of Gastroenterology, Hepatology & Nutrition, New York University, Winthrop Hospital, Mineola, New York, USA
³ Department of Medicine, Mount Sinai St. Luke’s-West Hospital Center, New York, USA

^∗Reprint requests: Stavros N. Stavropoulos, MD, FASGE, Director, GI Endoscopy, Director, Program in Advanced GI Endoscopy, NYU Winthrop Hospital, Division of Gastroenterology, Hepatology & Nutrition, Adjunct Clinical Professor of Medicine, Temple University, 222 Station Plaza N., Suite 429, Mineola, NY 11501.Director, GI Endoscopy, Director, Program in Advanced GI EndoscopyNYU Winthrop HospitalDivision of GastroenterologyHepatology & Nutrition, Adjunct Clinical Professor of MedicineTemple University222 Station Plaza N., Suite 429MineolaNY11501

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Abstract

Background and Aims

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.

Methods

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.

Results

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.

Conclusion

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.

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Abbreviations : AE, HM, LES, POEM, TBE

Plan

Methods

Patients and study design

Equipment, procedures, and perioperative management

HM versus non-HM patients

Discussion

	DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.
	If you would like to chat with an author of this article, you may contact Dr Stavropoulos at sstavropoulos@winthrop.org;sns10@columbia.edu.