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455 Laparoscopic Heller Myotomy Can Be Used As Primary Therapy for Esophageal Achalasia Regardless of Age
452 Analysis of a Single-Series Learning Curve for PerOral Esophageal Myotomy (POEM) Ezra N. Teitelbaum, Byron F. Santos, Fahd O. Arafat, Nathaniel J. Soper, Eric S. Hungness
453 PerOral Endoscopic Myotomy (POEM) Feasible As Reoperation Following Heller Myotomy Amy K. Yetasook, Jin-cheng Zhao, Woody Denham, John G. Linn, Michael B. Ujiki Peroral Endoscopic Myotomy (POEM) is a promising new treatment for achalasia. We present three cases of recurrent achalasia after failed therapy with reoperation by POEM. Additionally, we also demonstrate our technique with a patient who underwent POEM after failed endoscopic intervention and laparoscopic Heller myotomy (LHM) with reoperation by POEM. This case series illustrates feasbility of completing a peroral minimally invasive approach in the management of recurrent achalasia. 454 Idiopathic Pulmonary Fibrosis and Gastroesophageal Reflux. Implications for Treatment Marco E. Allaix, P. Marco Fisichella, Fernando A. Herbella, Marco G. Patti Background: While the pathogenesis of idiopathic pulmonary fibrosis (IPF) is multifactorial, it has been shown that the prevalence of abnormal reflux (GERD) is very high, and that antireflux surgery may affect the progression of this disease. Aims: The aims of this study were to compare in a group of patients with GERD and a group of patients with GERD and IPF: a) the clinical presentation; b) the esophageal function as defined by high resolution manometry; and c) the reflux profile by dual sensor pH monitoring. Patients and methods: We compared the clinical presentation, the esophageal function and the reflux profile in 80 patients with GERD and in 22 patients with GERD and IPF. Results: Data are expressed as mean ± SD. Conclusions: The results of this study show that in patients with GERD and IPF: a) heartburn is present in less than 60% of patients; b) with the exception of a weaker UES, the esophageal function is preserved; and c) proximal reflux is more common, and in the supine position it is coupled with a slower acid clearance. Because these factors expose IPF patients to the risk of aspiration, antireflux surgery should be considered early in the course of the disease.
S-1051
455 Laparoscopic Heller Myotomy Can Be Used As Primary Therapy for Esophageal Achalasia Regardless of Age Renato Salvador, Mario Costantini, Francesco Cavallin, Elena Finotti, Cristina Longo, Michela Di Giunta, Nicola Passuello, Loredana Nicoletti, Giovanni Capovilla, Stefano Merigliano, Ermanno Ancona, Giovanni Zaninotto Background: Laparoscopic Heller-Dor (LHD) surgery is the current treatment of choice for patients with esophageal achalasia, but elderly patients are generally referred for less invasive treatments (pneumatic-dilations or botulinum-toxin injections). The aim was to assess the effect of age on the surgical outcome of patients receiving laparoscopic Heller-Dor as primary treatment. Methods: We evaluated the patients who underwent surgery from 1992 to January 2012 . Patients who had already been treated for esophageal achalasia and patients with sigmoid-shaped mega-esophagus (stage 4) were excluded. Symptoms were scored using a detailed questionnaire for dysphagia, regurgitation, and chest pain; barium swallow, endoscopy, and esophageal-manometry were performed, before and 6 months after the treatment. Patients were classified in three age brackets: group A ( ≤45 years), group B (45-70) and group C (≥70). Treatment was defined as a failure if the postoperative symptom-score was .10th percentile of the preoperative score (i.e. .8) Results: We consecutively performed the LHD as primary treatment in 514 achalasia patients, 272 (53%) in group A, 208 (40.4%) in group B and 34 (6.6%) in group C. The mortality was nil; the conversion and morbidity rates were both 1.2% with no-difference in the 3 groups. Group C patients had higher preoperative symptom scores (p=0.02), while the symptom duration was similar in all groups. At a median follow-up of 40 months (IQR 15-80), the median of symptom scores was significantly lower after surgery (18 [IQR 14-20] vs 0 [IQR 0-3]; p ,0.0001). The median of resting LES pressure decreased from 27mmHg (IQR 19-36) to 11mmHg (IQR 8-14) (p,0.001) and the residual LES pressure from 10mmHg (IQR 5-17) to 3mmHg (QR: 1-5) (p,0.001). No statistically significant differences emerged between the 3 groups in any of these aspects. Mucosal tears occurred in 16 patients (3%): 5 (1.8%) in group A; 8 (3.9%) in group B; and 3 (8.9%) in group C (p=0.06). The postoperative hospital stay was slightly longer for group C (p=0.06). The treatment failure rate was quite similar: 31 failures in group A (11.4%), 19 in group B (9.1%) and 2 in group C (5.9%) (p=0.55)(table). The failures were seen more in manometric-pattern III (22.2%, p=0.002). All the patients whose surgical treatment failed were treated with pneumatic dilations. The overall success rate of this combined treatment was therefore 98.4% (507/515). Postoperative 24-hour pH-monitoring was abnormal in 16 patients (6.6%): 7 patients were in group A, 6 in group B and 3 in group C (p: n.s.) Discussion: LHD is often performed in old patients as a "last resource", after other treatments have failed. Given our high success and low complication rate, this study supports the use of LHD as the first treatment of achalasia in elderly patients with an acceptable surgical risk. Table. Postoperative findings in the three groups. Data are shown as median and IQR (in brackets).
SSAT Abstracts
SSAT Abstracts
Background: Peroral esophageal myotomy (POEM) is a novel endoscopic operation for the treatment of achalasia. The operator learning curve for POEM and patient factors associated with operative difficulty are not known. Methods: A single-institution prospective POEM outcomes database was analyzed. All POEM procedures were performed conjointly by the same two surgeons. Associations between preoperative patient variables (series case number, gender, age, BMI, ASA class, prior treatment with dilation or Botox, symptom duration, manometric pressures, achalasia subtype) and operative outcomes (procedure time, tunnel length, myotomy length, number of clips used for closure, EBL, mucosal perforation, need to decompress pneumoperitoneum) were tested using bivariate linear correlation. To assess for changes in efficiency over the course of the series, the total procedure time and the time required for each individual procedural step (submucosal access, tunnel creation, myotomy, and mucosal closure) were tested for best fit to linear, logarithmic, and exponential regression curves using case number as the dependent variable. A subgroup analysis of treatment-naïve patients was secondarily performed. Results: 30 patients underwent POEM, of which 26 were treatment-naïve. Preoperative symptom duration was positively associated with increased operative time (r^2=.55, p,.01). Prior achalasia treatment and EGJ resting pressure were both positively associated with operative time at a trend level (p=.08 for both). Case number correlated negatively with the number of clips required for closure (r^2=-.51, p ,.01), whereas duration of symptoms was positively correlated with clip number (r^2=.40, p ,.05). Case number correlated negatively, whereas duration of symptoms correlated positively, with occurrence of a mucosal perforation, both at a trend level (p=.06 and .07). Myotomy length proximal to the EGJ increased over the course of the series (r^2=.44, p=.02), whereas there was no change in myotomy length distal to the EGJ. Total procedure time and time to perform tunnel creation, myotomy and mucosal closure did not change over the course of the series. Submucosal access time decreased over the course of the series (r^2=.22, p,.01) with best fit to a logarithmic curve. In treatment-naïve patients only, mucosal closure time decreased over the series (r^2=.17, p=.03) with best fit to an exponential curve. Conclusions: In this POEM series, the time needed to access the submucosa and the number of clips required to close the mucosotomy both decreased with experience. Myotomy length proximal to the EGJ increased with experience. Total procedure time did not change over the course of the series, and may not be an important marker of procedural skill for POEM. Longer symptom duration and prior endoscopic treatment may result in increased operative difficulty.
453 PerOral Endoscopic Myotomy (POEM) Feasible As Reoperation Following Heller Myotomy Amy K. Yetasook, Jin-cheng Zhao, Woody Denham, John G. Linn, Michael B. Ujiki Peroral Endoscopic Myotomy (POEM) is a promising new treatment for achalasia. We present three cases of recurrent achalasia after failed therapy with reoperation by POEM. Additionally, we also demonstrate our technique with a patient who underwent POEM after failed endoscopic intervention and laparoscopic Heller myotomy (LHM) with reoperation by POEM. This case series illustrates feasbility of completing a peroral minimally invasive approach in the management of recurrent achalasia. 454 Idiopathic Pulmonary Fibrosis and Gastroesophageal Reflux. Implications for Treatment Marco E. Allaix, P. Marco Fisichella, Fernando A. Herbella, Marco G. Patti Background: While the pathogenesis of idiopathic pulmonary fibrosis (IPF) is multifactorial, it has been shown that the prevalence of abnormal reflux (GERD) is very high, and that antireflux surgery may affect the progression of this disease. Aims: The aims of this study were to compare in a group of patients with GERD and a group of patients with GERD and IPF: a) the clinical presentation; b) the esophageal function as defined by high resolution manometry; and c) the reflux profile by dual sensor pH monitoring. Patients and methods: We compared the clinical presentation, the esophageal function and the reflux profile in 80 patients with GERD and in 22 patients with GERD and IPF. Results: Data are expressed as mean ± SD. Conclusions: The results of this study show that in patients with GERD and IPF: a) heartburn is present in less than 60% of patients; b) with the exception of a weaker UES, the esophageal function is preserved; and c) proximal reflux is more common, and in the supine position it is coupled with a slower acid clearance. Because these factors expose IPF patients to the risk of aspiration, antireflux surgery should be considered early in the course of the disease.
S-1051
455 Laparoscopic Heller Myotomy Can Be Used As Primary Therapy for Esophageal Achalasia Regardless of Age Renato Salvador, Mario Costantini, Francesco Cavallin, Elena Finotti, Cristina Longo, Michela Di Giunta, Nicola Passuello, Loredana Nicoletti, Giovanni Capovilla, Stefano Merigliano, Ermanno Ancona, Giovanni Zaninotto Background: Laparoscopic Heller-Dor (LHD) surgery is the current treatment of choice for patients with esophageal achalasia, but elderly patients are generally referred for less invasive treatments (pneumatic-dilations or botulinum-toxin injections). The aim was to assess the effect of age on the surgical outcome of patients receiving laparoscopic Heller-Dor as primary treatment. Methods: We evaluated the patients who underwent surgery from 1992 to January 2012 . Patients who had already been treated for esophageal achalasia and patients with sigmoid-shaped mega-esophagus (stage 4) were excluded. Symptoms were scored using a detailed questionnaire for dysphagia, regurgitation, and chest pain; barium swallow, endoscopy, and esophageal-manometry were performed, before and 6 months after the treatment. Patients were classified in three age brackets: group A ( ≤45 years), group B (45-70) and group C (≥70). Treatment was defined as a failure if the postoperative symptom-score was .10th percentile of the preoperative score (i.e. .8) Results: We consecutively performed the LHD as primary treatment in 514 achalasia patients, 272 (53%) in group A, 208 (40.4%) in group B and 34 (6.6%) in group C. The mortality was nil; the conversion and morbidity rates were both 1.2% with no-difference in the 3 groups. Group C patients had higher preoperative symptom scores (p=0.02), while the symptom duration was similar in all groups. At a median follow-up of 40 months (IQR 15-80), the median of symptom scores was significantly lower after surgery (18 [IQR 14-20] vs 0 [IQR 0-3]; p ,0.0001). The median of resting LES pressure decreased from 27mmHg (IQR 19-36) to 11mmHg (IQR 8-14) (p,0.001) and the residual LES pressure from 10mmHg (IQR 5-17) to 3mmHg (QR: 1-5) (p,0.001). No statistically significant differences emerged between the 3 groups in any of these aspects. Mucosal tears occurred in 16 patients (3%): 5 (1.8%) in group A; 8 (3.9%) in group B; and 3 (8.9%) in group C (p=0.06). The postoperative hospital stay was slightly longer for group C (p=0.06). The treatment failure rate was quite similar: 31 failures in group A (11.4%), 19 in group B (9.1%) and 2 in group C (5.9%) (p=0.55)(table). The failures were seen more in manometric-pattern III (22.2%, p=0.002). All the patients whose surgical treatment failed were treated with pneumatic dilations. The overall success rate of this combined treatment was therefore 98.4% (507/515). Postoperative 24-hour pH-monitoring was abnormal in 16 patients (6.6%): 7 patients were in group A, 6 in group B and 3 in group C (p: n.s.) Discussion: LHD is often performed in old patients as a "last resource", after other treatments have failed. Given our high success and low complication rate, this study supports the use of LHD as the first treatment of achalasia in elderly patients with an acceptable surgical risk. Table. Postoperative findings in the three groups. Data are shown as median and IQR (in brackets).
SSAT Abstracts
SSAT Abstracts
Background: Peroral esophageal myotomy (POEM) is a novel endoscopic operation for the treatment of achalasia. The operator learning curve for POEM and patient factors associated with operative difficulty are not known. Methods: A single-institution prospective POEM outcomes database was analyzed. All POEM procedures were performed conjointly by the same two surgeons. Associations between preoperative patient variables (series case number, gender, age, BMI, ASA class, prior treatment with dilation or Botox, symptom duration, manometric pressures, achalasia subtype) and operative outcomes (procedure time, tunnel length, myotomy length, number of clips used for closure, EBL, mucosal perforation, need to decompress pneumoperitoneum) were tested using bivariate linear correlation. To assess for changes in efficiency over the course of the series, the total procedure time and the time required for each individual procedural step (submucosal access, tunnel creation, myotomy, and mucosal closure) were tested for best fit to linear, logarithmic, and exponential regression curves using case number as the dependent variable. A subgroup analysis of treatment-naïve patients was secondarily performed. Results: 30 patients underwent POEM, of which 26 were treatment-naïve. Preoperative symptom duration was positively associated with increased operative time (r^2=.55, p,.01). Prior achalasia treatment and EGJ resting pressure were both positively associated with operative time at a trend level (p=.08 for both). Case number correlated negatively with the number of clips required for closure (r^2=-.51, p ,.01), whereas duration of symptoms was positively correlated with clip number (r^2=.40, p ,.05). Case number correlated negatively, whereas duration of symptoms correlated positively, with occurrence of a mucosal perforation, both at a trend level (p=.06 and .07). Myotomy length proximal to the EGJ increased over the course of the series (r^2=.44, p=.02), whereas there was no change in myotomy length distal to the EGJ. Total procedure time and time to perform tunnel creation, myotomy and mucosal closure did not change over the course of the series. Submucosal access time decreased over the course of the series (r^2=.22, p,.01) with best fit to a logarithmic curve. In treatment-naïve patients only, mucosal closure time decreased over the series (r^2=.17, p=.03) with best fit to an exponential curve. Conclusions: In this POEM series, the time needed to access the submucosa and the number of clips required to close the mucosotomy both decreased with experience. Myotomy length proximal to the EGJ increased with experience. Total procedure time did not change over the course of the series, and may not be an important marker of procedural skill for POEM. Longer symptom duration and prior endoscopic treatment may result in increased operative difficulty.