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873 Improvement in Esophageal Function After PerOral Endoscopic Myotomy Compared to Other Treatment Modalities for Achalasia
Abstracts
POEM was performed according to the Inoue’s technique. In case of type I and type II achalasia a 8-12 cm myotomy was performed. In case of type III achalasia myotomy was usually longer (>12cm). ANOVA and Pearson Chi-square test were used to find associations between achalasia types with baseline characteristic (age, gender, Eckardt score, symptoms duration, previous treatments, esophageal shape, diameter and LES pressure), procedure time and POEM outcomes (ECK<4). If there was a statistically significant difference a post hoc analysis was performed using LSD method. Results: A total of 182 patients were enrolled (mean age 46.4 years, mean follow-up 12.8 months, range 6-48 months). Fifty-two patients (29%) had Type I achalasia, 112 (61%) Type II and 18 (10%) type III. At univariate analysis significant differences were found among patients with type I, type II and type III achalasia with regards to basal LES pressure (33.3 mmHg, 47.9 mmHg and 57.3mmHg, respectively. p<0.005), 4sIRP (26.7mmHg, 32.6mmHg and 33.2 mmHg, respectively. p<0.005) and esophageal diameter (5.2cm, 4.7cm and 3.6 cm, respectively. p<0.005). No differences were found regarding age, gender, preoperative symptoms, symptoms duration, previous treatments and esophageal shape. At post-hoc analysis myotomy was significantly longer in patients with type III achalasia (14.32.8cm) compared to type I (10.92.3cm) or type II (11.42.2cm) (p<0.0001) Success rate was similar in all patients, 96.2% for type I, 96.4 % for type II and 94.4% for type III achalasia (p ns). Conclusions: When myotomy is customized on HRM findings, POEM outcomes do not significant differ in patients with type I, II and III achalasia.
873 Improvement in Esophageal Function After PerOral Endoscopic Myotomy Compared to Other Treatment Modalities for Achalasia Madhusudhan R. Sanaka*1, Umar Hayat1, Ramprasad Jegadeesan1, Prashanthi N. Thota1, Monica Ray1, Scott L. Gabbard1, Neha Wadhwa1, Rocio Lopez1, Sudish Murthy2, Siva Raja2 1 Gastroenterology, Cleveland Clinic, Cleveland, OH; 2Thoracic Surgery, Cleveland Clinic, Cleveland, OH Background/Aims: Standard treatments of achalasia include laparoscopic Heller myotomy with partial fundoplication (HM), Pneumatic dilation (PD) and recently emerging peroral endoscopic myotomy (POEM). Our aims were to compare the response to these treatments by objective assessment of improvement in esophageal function by findings on timed barium esophagram (TBE) and high resolution esophageal manometry (HREM). Methods: Chart review of all achalasia patients who underwent one of the three treatment modlaities at our institution between January 2012 and March 2015. Patient demographics, type of achalasia, prior treatments, pre and post treatment TBE and HREM findings were compared between the three treatment groups. Patients had TBE and HREM performed before and at two months post-treatment as part of our standard clinical practice. Data are presented as mean standard deviation, median [25th, 75thpercentiles] or frequency (percent). Analysis of variance, Kruskal-Wallis test, Pearsons chi-square test and Fishers Exact tests were used for analysis. SAS version 9.4 (Cary, NC) was used and p<0.05 was considered significant. Results: A total of 200 patients were included of which 22 underwent PD, 142 underwent HM and 36 underwent POEM. Patient characteristics are summarized in table 1. POEM patients were older and had higher BMI than others. POEM and PD patients had more prior treatments compared to HM patients. Table 2 presents a summary of TBE and HREM findings along with multivariate analysis.Most of the PD patients didnot have HREM performed, hence this was not included in multivariate analysis. There was significant improvement in both TBE and HREM parameters (pre and post treatment) in all the three treatments groups. There was no statistically significant difference in efficacy between the groups in terms of changes in TBE or HREM findings. Conclusions: All three treatment modalitiess, PD, HM and POEM are effective in improving objective esophageal function assessed by TBE and HREM in achalasia. However, there was no significant difference in efficacy between the three treatment modalities at short term follow-up.Prospective studies with homogeneous patient populations and longer follow-up are required to compare the efficacy of various treatment modalities in achalasia. Table 1. Patient Characterstics Factor
Age at diagnosis of Achalasia ( years) Age at Intervention ( years) Body Mass Index Achalasia Type Type I Type II Type III Unclassified Patients who underwent prior treatments
Pneumatic Dilation (n[22)
Heller Myotomy (n[142)
POEM(n [36)
PValue
47.5 17
45.815.6
52.617.2
0.078
50.317.9 27.16.9
46.515.7 265.1
55.416.8 29.15.9
0.013 0.012 0.023
5 (35.7) 6 (42.9) 2 (14.3) 9 (40.9) 15 (68.2)
30 (25) 82 (68.3) 1 (0.83) 29 (20.4) 62 (44.3)
13 18 3 2 26
(38.2) (52.9) (8.8) (5.5) (72.2)
Table 2. Esophageal Manometry and Timed Barium Esophagram
Findings
Factor Pre-intervention Manometry Basal LES pressure (mm HG) Mean LES IRP (mm HG) Preintervention TBE Height at 1 minute (cm) Width at 1 minute( cm) Residual Volume at 1 minute(cc) Height at 5 minutes (cm) Width at 5 minutes (cm) Residual Volume at 5 minutes ( cc) Post Intervention Manometry Findings Mean LES pressure (mm HG) Mean LES-IRP (mm HG) Post intervention TBE at 2 months Height at 1 minute ( cm) Width at 1 minute( cm) Residual Volume at 1 minute(cc) Height at 5 minutes (cm) Width at 5 minutes ( cm) Residual Volume at 5 minutes (cc) Change in Esophageal Function Parameters: Multivariate Analysis Change in Mean Basal LES pressure (mm HG) Change in mean LES-IRP (mm HG) Change in Barium Height at 1 minute (cm) Change in Barium width at 1 minute (cm) Change in residual barium volume at 1minute (cc) Change in Barium Height at 5 minutes (cm) Change in Barium width at 5 minutes (cm) Change in residual barium volume at 5 minutes (cc)
Pneumatic Dilation (n[22)
31.9[10.6,53.2] 29.1[12, 34.5]
10.2[7, 13.6] 3.4[2.5,4] 67.3[44, 126.2]
Heller myotomy (n[142)
POEM (n[36)
40.5[27.2, 38.7[27, 48.7] 51.7] 24[17.5, 34.4] 23.6 [20.2, 33.4]
Pvalue
0.89 0.92
9.5 [7.2, 15] 3[2.5, 4] 71.6 [41.1, 131.9] 8[5,12.5] 2.5[2, 3.7] 49.1 [15.7, 91.6]
9.8[4,14.5] 3.4[2,4.4] 52.8[37.7, 119.2] 5.3[2.5, 10] 2.5[1.5, 4] 25.4 [11.3, 62.8]
14.5[7.6, 22.7] 7.1[3.9, 10.7]
11.4[8.2, 20.2]
0.32
6.6[3.3, 11.1]
0.18
6.7 [4.5, 10.2] 6.3[2.1, 9.5] 2 [1.2, 2.5] 1.6[0.5, 2.5] 20.4[6, 49.8] 12.8[0.79, 47.7] 2.5[0, 6.2] 2.3[0,6.9] 1 [0, 2.1] 0.5[0,2] 2.7[0, 21.2] 0.54 [0, 18.8]
0.39 0.28 0.31
-27.5[-30.3, -24.5] -20.1[-22.2, -17.9] -4.6[-5.5, -3.7]
-33.1[-38, -27.6] -20.9[-24.7, -16.5] -5.4[-7.1, -3.5]
0.084
-1.7[-2.2, -1.2]
0.28
-81.8[-112.4, -44.3]
-1.3[-1.5, -1.03] -79.3[-92.7, -64.8]
-95.6[-119.4, -67.6]
0.58
-5.8[-7.7, -3.7]
-6 [-6.8, -5.2]
-5.8[-7.3, -4.1]
0.95
-1.6[-2.4, -0.74]
-1.5 [-1.8, -1.1] -51.2 [-60.9, -41]
-1.9[-2.5, -1.3]
0.47
-64.6[-82, -45.3]
0.28
6.5[4,10.5] 2.7 [2,3.6] 40.8[15.5, 73.1]
22 [18.8, 25.1] 10.8[10.5, 19.4]
8[5.8, 11] 2 [1.5, 2.5] 25.4[14.1, 41.7] 2.2[0, 6.5] 1.05[0, 2.6] 4.1 [0, 30.2]
-2.7[-5.1,-0.05]
-1.4[-1.9,-0.77]
-68.2[-89.9, -43.5]
0.43 0.93 0.44 0.063 0.83 0.12
0.94 0.97 0.98
0.76 0.21
LES, lower esophageal sphincter; IRP, integrated relaxation pressure;
0.003
Values presented as Mean SD, frequency (percent)
AB174 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 5S : 2016
www.giejournal.org
POEM was performed according to the Inoue’s technique. In case of type I and type II achalasia a 8-12 cm myotomy was performed. In case of type III achalasia myotomy was usually longer (>12cm). ANOVA and Pearson Chi-square test were used to find associations between achalasia types with baseline characteristic (age, gender, Eckardt score, symptoms duration, previous treatments, esophageal shape, diameter and LES pressure), procedure time and POEM outcomes (ECK<4). If there was a statistically significant difference a post hoc analysis was performed using LSD method. Results: A total of 182 patients were enrolled (mean age 46.4 years, mean follow-up 12.8 months, range 6-48 months). Fifty-two patients (29%) had Type I achalasia, 112 (61%) Type II and 18 (10%) type III. At univariate analysis significant differences were found among patients with type I, type II and type III achalasia with regards to basal LES pressure (33.3 mmHg, 47.9 mmHg and 57.3mmHg, respectively. p<0.005), 4sIRP (26.7mmHg, 32.6mmHg and 33.2 mmHg, respectively. p<0.005) and esophageal diameter (5.2cm, 4.7cm and 3.6 cm, respectively. p<0.005). No differences were found regarding age, gender, preoperative symptoms, symptoms duration, previous treatments and esophageal shape. At post-hoc analysis myotomy was significantly longer in patients with type III achalasia (14.32.8cm) compared to type I (10.92.3cm) or type II (11.42.2cm) (p<0.0001) Success rate was similar in all patients, 96.2% for type I, 96.4 % for type II and 94.4% for type III achalasia (p ns). Conclusions: When myotomy is customized on HRM findings, POEM outcomes do not significant differ in patients with type I, II and III achalasia.
873 Improvement in Esophageal Function After PerOral Endoscopic Myotomy Compared to Other Treatment Modalities for Achalasia Madhusudhan R. Sanaka*1, Umar Hayat1, Ramprasad Jegadeesan1, Prashanthi N. Thota1, Monica Ray1, Scott L. Gabbard1, Neha Wadhwa1, Rocio Lopez1, Sudish Murthy2, Siva Raja2 1 Gastroenterology, Cleveland Clinic, Cleveland, OH; 2Thoracic Surgery, Cleveland Clinic, Cleveland, OH Background/Aims: Standard treatments of achalasia include laparoscopic Heller myotomy with partial fundoplication (HM), Pneumatic dilation (PD) and recently emerging peroral endoscopic myotomy (POEM). Our aims were to compare the response to these treatments by objective assessment of improvement in esophageal function by findings on timed barium esophagram (TBE) and high resolution esophageal manometry (HREM). Methods: Chart review of all achalasia patients who underwent one of the three treatment modlaities at our institution between January 2012 and March 2015. Patient demographics, type of achalasia, prior treatments, pre and post treatment TBE and HREM findings were compared between the three treatment groups. Patients had TBE and HREM performed before and at two months post-treatment as part of our standard clinical practice. Data are presented as mean standard deviation, median [25th, 75thpercentiles] or frequency (percent). Analysis of variance, Kruskal-Wallis test, Pearsons chi-square test and Fishers Exact tests were used for analysis. SAS version 9.4 (Cary, NC) was used and p<0.05 was considered significant. Results: A total of 200 patients were included of which 22 underwent PD, 142 underwent HM and 36 underwent POEM. Patient characteristics are summarized in table 1. POEM patients were older and had higher BMI than others. POEM and PD patients had more prior treatments compared to HM patients. Table 2 presents a summary of TBE and HREM findings along with multivariate analysis.Most of the PD patients didnot have HREM performed, hence this was not included in multivariate analysis. There was significant improvement in both TBE and HREM parameters (pre and post treatment) in all the three treatments groups. There was no statistically significant difference in efficacy between the groups in terms of changes in TBE or HREM findings. Conclusions: All three treatment modalitiess, PD, HM and POEM are effective in improving objective esophageal function assessed by TBE and HREM in achalasia. However, there was no significant difference in efficacy between the three treatment modalities at short term follow-up.Prospective studies with homogeneous patient populations and longer follow-up are required to compare the efficacy of various treatment modalities in achalasia. Table 1. Patient Characterstics Factor
Age at diagnosis of Achalasia ( years) Age at Intervention ( years) Body Mass Index Achalasia Type Type I Type II Type III Unclassified Patients who underwent prior treatments
Pneumatic Dilation (n[22)
Heller Myotomy (n[142)
POEM(n [36)
PValue
47.5 17
45.815.6
52.617.2
0.078
50.317.9 27.16.9
46.515.7 265.1
55.416.8 29.15.9
0.013 0.012 0.023
5 (35.7) 6 (42.9) 2 (14.3) 9 (40.9) 15 (68.2)
30 (25) 82 (68.3) 1 (0.83) 29 (20.4) 62 (44.3)
13 18 3 2 26
(38.2) (52.9) (8.8) (5.5) (72.2)
Table 2. Esophageal Manometry and Timed Barium Esophagram
Findings
Factor Pre-intervention Manometry Basal LES pressure (mm HG) Mean LES IRP (mm HG) Preintervention TBE Height at 1 minute (cm) Width at 1 minute( cm) Residual Volume at 1 minute(cc) Height at 5 minutes (cm) Width at 5 minutes (cm) Residual Volume at 5 minutes ( cc) Post Intervention Manometry Findings Mean LES pressure (mm HG) Mean LES-IRP (mm HG) Post intervention TBE at 2 months Height at 1 minute ( cm) Width at 1 minute( cm) Residual Volume at 1 minute(cc) Height at 5 minutes (cm) Width at 5 minutes ( cm) Residual Volume at 5 minutes (cc) Change in Esophageal Function Parameters: Multivariate Analysis Change in Mean Basal LES pressure (mm HG) Change in mean LES-IRP (mm HG) Change in Barium Height at 1 minute (cm) Change in Barium width at 1 minute (cm) Change in residual barium volume at 1minute (cc) Change in Barium Height at 5 minutes (cm) Change in Barium width at 5 minutes (cm) Change in residual barium volume at 5 minutes (cc)
Pneumatic Dilation (n[22)
31.9[10.6,53.2] 29.1[12, 34.5]
10.2[7, 13.6] 3.4[2.5,4] 67.3[44, 126.2]
Heller myotomy (n[142)
POEM (n[36)
40.5[27.2, 38.7[27, 48.7] 51.7] 24[17.5, 34.4] 23.6 [20.2, 33.4]
Pvalue
0.89 0.92
9.5 [7.2, 15] 3[2.5, 4] 71.6 [41.1, 131.9] 8[5,12.5] 2.5[2, 3.7] 49.1 [15.7, 91.6]
9.8[4,14.5] 3.4[2,4.4] 52.8[37.7, 119.2] 5.3[2.5, 10] 2.5[1.5, 4] 25.4 [11.3, 62.8]
14.5[7.6, 22.7] 7.1[3.9, 10.7]
11.4[8.2, 20.2]
0.32
6.6[3.3, 11.1]
0.18
6.7 [4.5, 10.2] 6.3[2.1, 9.5] 2 [1.2, 2.5] 1.6[0.5, 2.5] 20.4[6, 49.8] 12.8[0.79, 47.7] 2.5[0, 6.2] 2.3[0,6.9] 1 [0, 2.1] 0.5[0,2] 2.7[0, 21.2] 0.54 [0, 18.8]
0.39 0.28 0.31
-27.5[-30.3, -24.5] -20.1[-22.2, -17.9] -4.6[-5.5, -3.7]
-33.1[-38, -27.6] -20.9[-24.7, -16.5] -5.4[-7.1, -3.5]
0.084
-1.7[-2.2, -1.2]
0.28
-81.8[-112.4, -44.3]
-1.3[-1.5, -1.03] -79.3[-92.7, -64.8]
-95.6[-119.4, -67.6]
0.58
-5.8[-7.7, -3.7]
-6 [-6.8, -5.2]
-5.8[-7.3, -4.1]
0.95
-1.6[-2.4, -0.74]
-1.5 [-1.8, -1.1] -51.2 [-60.9, -41]
-1.9[-2.5, -1.3]
0.47
-64.6[-82, -45.3]
0.28
6.5[4,10.5] 2.7 [2,3.6] 40.8[15.5, 73.1]
22 [18.8, 25.1] 10.8[10.5, 19.4]
8[5.8, 11] 2 [1.5, 2.5] 25.4[14.1, 41.7] 2.2[0, 6.5] 1.05[0, 2.6] 4.1 [0, 30.2]
-2.7[-5.1,-0.05]
-1.4[-1.9,-0.77]
-68.2[-89.9, -43.5]
0.43 0.93 0.44 0.063 0.83 0.12
0.94 0.97 0.98
0.76 0.21
LES, lower esophageal sphincter; IRP, integrated relaxation pressure;
0.003
Values presented as Mean SD, frequency (percent)
AB174 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 5S : 2016
www.giejournal.org