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180 PerOral Endoscopic Myotomy for Severe Achalasia: the Comparison of Full-Thickness Myotomy and Circular Myotomy
Abstracts
Before/after POEM D-value Adverse events (n) Subcutaneous emphysema Pneumothorax Major bleeding Hospital stay (days)
Long myotomy group (n[56)
Short myotomy group (n[21)
P Value
27.0114.95
25.8316.49
0.817
4 0 1 9.124.58
1 1 0 10.474.00
0.191 1.00 0.211 0.237
180 PerOral Endoscopic Myotomy for Severe Achalasia: the Comparison of Full-Thickness Myotomy and Circular Myotomy Tianying Duan, Junfeng Zhou, Yuyong Tan, Deliang Liu* Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China Objective: Selective circular myotomy involving the internal circular muscular fibers and preserving the longitudinal outer muscular fibers was proposed for the treatment of achalasia. However, completeness of myotomy is a prerequisite for the excellent long-term result of conventional surgical myotomy. Our study aims to compare the efficacy and safety of full-thickness peroral endoscopic myotomy (POEM) and circular myotomy for the patients with severe achalasia (Patients with Eckardt R6, esophgageal diameter R6 or sigmoid-type esophagus). Methods: The clinical data of 123 patients with severe achalasia that were admitted to the Second Xiangya Hospital of Central South University from August 2011 to May 2013 were retrospectively analyzed. 70 patients who received full-thickness myotomy were assigned to group A, while the other 53 patients who received circular myotomy were assigned to group B. The clinical efficacies and incidences of complications were compared between 2 groups. All of patients were followed up periodically at 1, 3, 6 and 12 months after POEM until October 2014. Results: All 123 patients underwent peroral endoscopic myotomy successfully, and the mean operation times were significantly shorter in group A of 578min compared with group B of 6312min (tZ3.421, p!0.05). The incidence of complication was 14.3% (10/70) in group A and 11.3% (6/53) in group B, with no significant differences between 2 groups (x2Z0.234, pO0.05). A total of 119 patients were followed up, with the median duration of 21 months (range 15 to 30 months). The persistence of treatment success was in 98.6% (69/70) cases of group A and 98.1% (52/53) cases of group B, and the diameters of esophagus at postoperative month 6 between the groups were similar (group A 3.20.3cm, group B 3.40.4cm, tZ1.927, pO0.05). While compared with pre-treatment, the diameters were significantly larger at postoperative month 6 and 12 (FZ780.923, 493.018, p!0.05). No recurrence was detected in both 2 groups during follow-up. Conclusion: Treatment efficacy in short-term between the two groups was comparable, and full-thickness myotomy significantly reduce the operative duration but not increase the incidence of complications.
Comparison of clinical data between 2 groups
Numbers Sex, M/F Age, meanSD, y Duration of symptoms, y Previous treatment, Yes/No, n Sigmoid esophagus,Yes/No, n Esophageal diameters preoperatively, meanSD, cm Eckardt scores preoperatively, meanSD Mean operation time, meanSD, min Length of tunnel, meanSD, cm Length of myotomy, meanSD, cm Esophageal diameters postoperatively, meanSD, cm Eckardt scores postoperatively, meanSD At postoperatively month 6 At postoperatively month 12 Complications Gas-related complications Mucosal perforation Reflux esophagitis
Group A
Group B
70 33/37 4314 5.0 (0.533.0) 10/60 6/64 5.920.96
53 30/23 4113 4.5 (0.520.0) 8/45 5/48 5.851.00
p Value 0.363 0.808 0.368 1.000 1.000 0.492
181 Outcomes of a 5-Year, Large Prospective Series of Per Oral Endoscopic Myotomy (POEM). Emphasis on Objective Assessment for GERD and Luminal Patency Stavros N. Stavropoulos*, Rani J. Modayil, Collin E. Brathwaite, Bhawna Halwan, Maria M. Kollarus, David Friedel, Sharon I. Taylor, James H. Grendell Medicine, Winthrop Univ. Hosp., Mineola, NY POEM represents a groundbreaking Natural Orifice Transluminal Endoscopic Surgery (NOTES) approach to lower esophageal sphincter (LES) myotomy that combines the long-term benefits of surgical myotomy with the advantages of a less invasive, endoscopic intervention. In 2009 we performed the first POEM outside of Japan and first worldwide by a gastroenterologist and currently have the largest single operator series by a gastroenterologist worldwide. The aim of this study is to report the outcomes of achalasia patients (pts) treated with POEM in a single tertiary referral center. Between 10/2009 and 11/2014, comprehensive data was collected prospectively on all patients undergoing POEM. Baseline characteristics on 174 achalasia pts undergoing POEM is reported in table 1 with mean follow up 17 months. We enrolled a large number of high risk, challenging and end-stage pts often excluded from POEM at most centers: 6.3% were R80 yo (four O90); 26% had severe comorbidities (ASA class III); 49% had treatments that make POEM challenging (36 Botox, 22 failed prior Heller), 26% had advanced or end-stage achalasia (46 esophageal diameter O6 cm with severe sigmoidization in 29/46). Initial 40 POEMs performed in OR and last 134 POEMs (77%) performed in endoscopy suite. Procedural characteristics include: mean myotomy length 12.9cm, mean procedure duration 91minutes, 50% anterior orientation, 63% closure with sutures. Intraoperative EndoFLIP with 30ml balloon after myotomy showed increase in diameter from 8mm to 12.3mm, cross-sectional area from 54mm2 to 122mm2,and distensibility Index (Cross Sectional Area/pressure) from 4.1 to 12.6 mm2/mmHg, p!0.0001. Clinical success (Eckardt score %3) seen in 98% (159/163), 97% (139/143), 96% (102/106) in pts with follow-up R3, R6, and R12 months, respectively. Mean Eckardt score and LES pressure improved, 7.8 to 0.2 (P!0.0001) and 42.8 to 17.9 mmHg (P!0.0001). Four pts (#1, 3, 7, 31) had relapse at intervals of 6-42 months all of whom responded to treatment with balloon (2) or standard length POEM (2 pts with 3-5 cm short initial POEM as reported by Inoue initially) . Timed BariumO50% emptying at 5 minutes in all 56 pts, 100% emptying in 36/56 (66%). No significant adverse events (AEs). No aborted POEMs, no POEM related readmissions. Minor technical AEs: mucosotomies 19%, capnoperitoneum requiring needle decompression 6%, 1 small capnothorax due to inadvertent air insufflation resolved without chest tube. Objective GERD assessment: 29/86 (34%) erosive esophagitis, 29/84 (35%) positive pH study. At mean follow-up of close to 2 years, POEM remains safe and effective on objective assessment even with inclusion of a large number of challenging pts.
Per Oral Endoscopic Myotomy (POEM): Patient Characteristics and Outcomes Baseline Characteristics Number: 174 patients
7.31.7 578 13.51.2 10.51.3 3.220.32
7.31.9 6312 13.71.2 10.51.2 3.370.36
0.769 0.045 0.453 0.756 0.758
0.360.62 0.340.65 10/70 6/70 2/70 2/70
0.470.75 0.550.82 6/53 5/53 1/53 0/53
0.431 0.144 0.788 0.868 1.000 0.506
AB118 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
Mean Age, years: 53 (10-93), 6.3% O80yrs
Gender: 63 female 111 male
Procedural Data
Outcomes (Subjective)
Mean procedure time, minutes 91 (25-240)
Pre/ Post Eckardt score 7.8/0.2, p!0.0001
Mean Myotomy length, cm 12.9 (3-26)
Clinical success with Eckardt score (less than 3) at 3 months 159/163 (98%) at 6months 139/143 (97%) at 12 months 102/106
Length of Stay, days 1.8 (1-6)
GERD No GERD 53% Minimal (few times/ month) 24% Moderate (few times/ week) 10% Severe (daily) 13%
Outcomes (Objective) Pre/Post LES pressure, mmHg 42.8/17.9, p!0.0001 Timed Barium Esophagram, emptying at 5 minutes O50% emptying 56/56 (100%) O80% emptying 51/56 (91%) 100% emptying 36/56 (64%) Passage of 13mm barium tablet 29/31 (94%) GERD: 48hr BRAVO 29/84 (35%) positive
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Before/after POEM D-value Adverse events (n) Subcutaneous emphysema Pneumothorax Major bleeding Hospital stay (days)
Long myotomy group (n[56)
Short myotomy group (n[21)
P Value
27.0114.95
25.8316.49
0.817
4 0 1 9.124.58
1 1 0 10.474.00
0.191 1.00 0.211 0.237
180 PerOral Endoscopic Myotomy for Severe Achalasia: the Comparison of Full-Thickness Myotomy and Circular Myotomy Tianying Duan, Junfeng Zhou, Yuyong Tan, Deliang Liu* Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China Objective: Selective circular myotomy involving the internal circular muscular fibers and preserving the longitudinal outer muscular fibers was proposed for the treatment of achalasia. However, completeness of myotomy is a prerequisite for the excellent long-term result of conventional surgical myotomy. Our study aims to compare the efficacy and safety of full-thickness peroral endoscopic myotomy (POEM) and circular myotomy for the patients with severe achalasia (Patients with Eckardt R6, esophgageal diameter R6 or sigmoid-type esophagus). Methods: The clinical data of 123 patients with severe achalasia that were admitted to the Second Xiangya Hospital of Central South University from August 2011 to May 2013 were retrospectively analyzed. 70 patients who received full-thickness myotomy were assigned to group A, while the other 53 patients who received circular myotomy were assigned to group B. The clinical efficacies and incidences of complications were compared between 2 groups. All of patients were followed up periodically at 1, 3, 6 and 12 months after POEM until October 2014. Results: All 123 patients underwent peroral endoscopic myotomy successfully, and the mean operation times were significantly shorter in group A of 578min compared with group B of 6312min (tZ3.421, p!0.05). The incidence of complication was 14.3% (10/70) in group A and 11.3% (6/53) in group B, with no significant differences between 2 groups (x2Z0.234, pO0.05). A total of 119 patients were followed up, with the median duration of 21 months (range 15 to 30 months). The persistence of treatment success was in 98.6% (69/70) cases of group A and 98.1% (52/53) cases of group B, and the diameters of esophagus at postoperative month 6 between the groups were similar (group A 3.20.3cm, group B 3.40.4cm, tZ1.927, pO0.05). While compared with pre-treatment, the diameters were significantly larger at postoperative month 6 and 12 (FZ780.923, 493.018, p!0.05). No recurrence was detected in both 2 groups during follow-up. Conclusion: Treatment efficacy in short-term between the two groups was comparable, and full-thickness myotomy significantly reduce the operative duration but not increase the incidence of complications.
Comparison of clinical data between 2 groups
Numbers Sex, M/F Age, meanSD, y Duration of symptoms, y Previous treatment, Yes/No, n Sigmoid esophagus,Yes/No, n Esophageal diameters preoperatively, meanSD, cm Eckardt scores preoperatively, meanSD Mean operation time, meanSD, min Length of tunnel, meanSD, cm Length of myotomy, meanSD, cm Esophageal diameters postoperatively, meanSD, cm Eckardt scores postoperatively, meanSD At postoperatively month 6 At postoperatively month 12 Complications Gas-related complications Mucosal perforation Reflux esophagitis
Group A
Group B
70 33/37 4314 5.0 (0.533.0) 10/60 6/64 5.920.96
53 30/23 4113 4.5 (0.520.0) 8/45 5/48 5.851.00
p Value 0.363 0.808 0.368 1.000 1.000 0.492
181 Outcomes of a 5-Year, Large Prospective Series of Per Oral Endoscopic Myotomy (POEM). Emphasis on Objective Assessment for GERD and Luminal Patency Stavros N. Stavropoulos*, Rani J. Modayil, Collin E. Brathwaite, Bhawna Halwan, Maria M. Kollarus, David Friedel, Sharon I. Taylor, James H. Grendell Medicine, Winthrop Univ. Hosp., Mineola, NY POEM represents a groundbreaking Natural Orifice Transluminal Endoscopic Surgery (NOTES) approach to lower esophageal sphincter (LES) myotomy that combines the long-term benefits of surgical myotomy with the advantages of a less invasive, endoscopic intervention. In 2009 we performed the first POEM outside of Japan and first worldwide by a gastroenterologist and currently have the largest single operator series by a gastroenterologist worldwide. The aim of this study is to report the outcomes of achalasia patients (pts) treated with POEM in a single tertiary referral center. Between 10/2009 and 11/2014, comprehensive data was collected prospectively on all patients undergoing POEM. Baseline characteristics on 174 achalasia pts undergoing POEM is reported in table 1 with mean follow up 17 months. We enrolled a large number of high risk, challenging and end-stage pts often excluded from POEM at most centers: 6.3% were R80 yo (four O90); 26% had severe comorbidities (ASA class III); 49% had treatments that make POEM challenging (36 Botox, 22 failed prior Heller), 26% had advanced or end-stage achalasia (46 esophageal diameter O6 cm with severe sigmoidization in 29/46). Initial 40 POEMs performed in OR and last 134 POEMs (77%) performed in endoscopy suite. Procedural characteristics include: mean myotomy length 12.9cm, mean procedure duration 91minutes, 50% anterior orientation, 63% closure with sutures. Intraoperative EndoFLIP with 30ml balloon after myotomy showed increase in diameter from 8mm to 12.3mm, cross-sectional area from 54mm2 to 122mm2,and distensibility Index (Cross Sectional Area/pressure) from 4.1 to 12.6 mm2/mmHg, p!0.0001. Clinical success (Eckardt score %3) seen in 98% (159/163), 97% (139/143), 96% (102/106) in pts with follow-up R3, R6, and R12 months, respectively. Mean Eckardt score and LES pressure improved, 7.8 to 0.2 (P!0.0001) and 42.8 to 17.9 mmHg (P!0.0001). Four pts (#1, 3, 7, 31) had relapse at intervals of 6-42 months all of whom responded to treatment with balloon (2) or standard length POEM (2 pts with 3-5 cm short initial POEM as reported by Inoue initially) . Timed BariumO50% emptying at 5 minutes in all 56 pts, 100% emptying in 36/56 (66%). No significant adverse events (AEs). No aborted POEMs, no POEM related readmissions. Minor technical AEs: mucosotomies 19%, capnoperitoneum requiring needle decompression 6%, 1 small capnothorax due to inadvertent air insufflation resolved without chest tube. Objective GERD assessment: 29/86 (34%) erosive esophagitis, 29/84 (35%) positive pH study. At mean follow-up of close to 2 years, POEM remains safe and effective on objective assessment even with inclusion of a large number of challenging pts.
Per Oral Endoscopic Myotomy (POEM): Patient Characteristics and Outcomes Baseline Characteristics Number: 174 patients
7.31.7 578 13.51.2 10.51.3 3.220.32
7.31.9 6312 13.71.2 10.51.2 3.370.36
0.769 0.045 0.453 0.756 0.758
0.360.62 0.340.65 10/70 6/70 2/70 2/70
0.470.75 0.550.82 6/53 5/53 1/53 0/53
0.431 0.144 0.788 0.868 1.000 0.506
AB118 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
Mean Age, years: 53 (10-93), 6.3% O80yrs
Gender: 63 female 111 male
Procedural Data
Outcomes (Subjective)
Mean procedure time, minutes 91 (25-240)
Pre/ Post Eckardt score 7.8/0.2, p!0.0001
Mean Myotomy length, cm 12.9 (3-26)
Clinical success with Eckardt score (less than 3) at 3 months 159/163 (98%) at 6months 139/143 (97%) at 12 months 102/106
Length of Stay, days 1.8 (1-6)
GERD No GERD 53% Minimal (few times/ month) 24% Moderate (few times/ week) 10% Severe (daily) 13%
Outcomes (Objective) Pre/Post LES pressure, mmHg 42.8/17.9, p!0.0001 Timed Barium Esophagram, emptying at 5 minutes O50% emptying 56/56 (100%) O80% emptying 51/56 (91%) 100% emptying 36/56 (64%) Passage of 13mm barium tablet 29/31 (94%) GERD: 48hr BRAVO 29/84 (35%) positive
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