Introduction Per-oral endoscopic myotomy (POEM) is a novel technique which involves performing a myotomy endoscopically after creating a submucosal tunnel. Despite being widely adopted in the USA, Europe and Asia, its introduction into the UK has been limited. We describe one of the first series of POEM procedures in the UK, assessing its feasibility, safety and efficacy.
Method POEM was performed as inpatient under general anaesthesia with endotracheal intubation using the Olympus video endoscopy system. Two experienced endoscopists performed the procedures after undergoing hands on training in live animal models. The procedure involved mucosal entry, submucosal tunnelling, myotomy and clip closure of mucosal defect. The Endolumenal Functional Lumen Imaging Probe (EndoFLIP) was used to assess the gastroesophageal junction (GOJ) distensibility at balloon volumes of 30 and 40 ml at the start and end of procedures. Contrast swallow was performed 24–48 hours prior to discharge. Eckardt scores were prospectively recorded at the time initial clinic visit and at follow up visits, 4–8 weeks post procedure.
Results Twenty six patients underwent POEM at our institution. Median age was 51 years (interquartile range (IQR) 42–60) and 69% were males. 17 patients (65%) had type II achalasia; 5 (19%) were type I; 2 (8%) type III; and 2 (8%) unclassified. Procedure failed in 2 patients who were excluded from the analysis. Median length of hospital stay was 3 days (IQR 2–3) days. Median (IQR) GOJ pressures reduced from 18.2 (15.3–27.9) and 33.0 (28.2–40.5) to 14.2 (12.4–18) and 23.1 (18–26.3) mmHg at 30 ml (p=0.10) and 40 ml (p=0.002) volumes, respectively. Median (IQR) Eckardt score was 8 (6-9) pre-procedure and 1 (1-2) post procedure (p<0.001). Perioperative complications included pneumoperitoneum (n=1) and mucosal laceration (n=3) all treated successfully. No post-operative complications occurred during a median (IQR) follow up of 6 months (1-10).
Conclusion Evidence from this early series of POEM procedures in the UK confirms its feasibility, safety and efficacy in the treatment of achalasia by experienced endoscopists with adequate training. The use of EndoFLIP assists in assessing response to myotomy immediately post procedure.
Disclosure of Interest None Declared
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