Introduction Per-oral endoscopic myotomy (POEM) has been adopted as a minimally invasive treatment option for achalasia. The first case of POEM was performed at King’s College Hospital in late 2013. Here we present our initial case series with video demonstration of technique.
Methods Prospective data was collected for consecutive patients undergoing POEM including demographics, procedure technique, the use of Endoluminal Functional Lumen Imaging Probe (EndoFLIP) and adverse events. Follow up data at 3 months and 12–24 months post-POEM including Eckardt scores and lower oesophageal sphincter integrated resting pressure (IRP-4s) were compared with pre-POEM findings. Post-POEM Gastro-oesophageal Reflux Health-Related Quality of Life scale (GORD-HQL) was recorded. Statistical analysis was achieved using Wilcoxon matched-pairs signed rank test.
Results POEM was performed in 33 patients (12 F, age 49.5±13.25 years). Pre-operative high-resoloution manometry confirmed type II achalasia in all patients. 19 patients had previous treatment (Botulinum n = 8, Pneumatic dilatation n = 10, Heller myotomy n = 5, POEM n = 1, >1 treatment n = 2). Median pre-POEM Eckardt Score 8, range 3–12.
Median gastric and oesophageal myotomy was 3 cm (range 2–4) and 12 cm (range 5–16) respectively with a selective circular myotomy in all cases and a posterior approach in n = 5.
There was significant reduction in post-operative Eckardt score at 3 months Median 0, range 0–6 (p < 0.0001) and IRP-4s (p = 0.0078, figs. 1 and 2). Sustained improvement in Eckardt score was observed at 12–24 months post-POEM (p = 0.0005). One patient required revision of POEM at 6 months.
Intra-operative EndoFLIP measurements before and after myotomy have been implemented to aid confirmation of adequate myotomy (Figure 3).
One patient underwent single clip displacement and was replaced at gastroscopy day 1 post POEM. There were no cases of perforation, infection or major bleeding.
Post-POEM GORD-HQL score was collected in 26 patients with a median score of 2.5, range 0–31. Two cases of reflux (positive 24 hr pH at 3 months) were identified and successfully managed with maintenance proton pump inhibitor.
Conclusion POEM was performed successfully in 33 patients in whom 57.5% had prior endoscopic or surgical treatment representing a potentially more challenging patient population. This study is in line with international consortia and ASGE findings1 that POEM is a safe and efficacious procedure for the treatment of achalasia for both short term and sustained symptomatic benefit.
Reference 1 Stavropoulos S, Desilets D, Fuchs KH et al; Per-oral endoscopic myotomy white paper summary; Gastrointestinal Endoscopy. 2014;1:1–15.
Disclosure of Interest None Declared