- Email: [email protected]
OC.04.2: Oesophageal Motor Function in Chronic Intestinal Idiopathic Pseudo-Obstruction: A Study with High Resolution Manometry
Abstracts of the 23rd National Congress of Digestive Diseases / Digestive and Liver Disease 49S2 (2017) e73–e223
7 days. Colons were subjected to histological processing and immunohistochemistry was performed to evaluate myenteric neuron’s expression of Erβ, VIP, neuronal nitric oxide synthases (nNOS) and choline acetyltransferase (ChAT). The data were compared between the groups using non parametric t-test. Results: Erβ is expressed in the neurons of the myenteric plexus. The thickness of muscle layer in LY3201-treated group was greater than in vehicle (mean 144.48±20.92 vs. 88.53±18.13). The density (cell number/colon length) of colonic myenteric neurons (Neunpositive) in treated group was increased compared to the vehicle (respectively mean 29.85±9.82; 6.93±3.42; p<0.004). In LY3201treated group, the density of Sox2-positive cells (a subset of neural progenitor cells) was higher (mean 34.76±9.53 treated; 8.94±1.53 vehicle; p<0.0017). Moreover the drug increased Chat (mean 14.8±2.6 treated; 1.9±0.9 vehicle; p<0.003) and nNOS (mean 11.6±2.1 treated; 2.3±0.8 vehicle; p<0.0065) expression while didn’t affect VIP significantly. Conclusions: LY3201 increased thickness of the smooth muscle layer and the number of neurons and Sox2-positive cells in the myenteric plexus. Probably it can promote Sox2+ progenitor cells differentiating into neurons. Moreover LY3201 restored neuron’s ability to produce neurotransmitters (nNOS/Chat) damaged by HFD. Thus LY3201, a selective ERβ agonist, can ameliorate HFD induced colonic neuropathy and myopathy.
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performed endoscopic treatment in selected cases and 19.4% in all cases, while 25.7% practiced surveillance. For high-grade dysplasia BE or intramucosal adenocarcinoma, 84.8% performed endoscopic treatment in all patients (80.3%) or in selected cases (4.5%), 13.1% referred to surgery and 2% practiced surveillance. More than half of responders (68.1%) were able to perform a technique of endoscopic therapy; the endoscopy treatment most frequently used was endoscopic mucosal resection (51.3%), followed by radiofrequency ablation (30.3%). Conclusions: This data would suggest that the majority of endoscopists in Italy use the recommended C & M Prague classification, Seattle biopsy protocol and advanced imaging techniques, and performs endoscopic treatment for low-grade and high-grade dysplasia BE. However, a substantial proportion does not use the proximal extent of gastric folds to define EGJ, does not practice endoscopic surveillance for non-dysplastic BE every 3–5 years and, in addition, performs endoscopic treatment for non-dysplastic BE in selected cases.
OC.04.2 OESOPHAGEAL MOTOR FUNCTION IN CHRONIC INTESTINAL IDIOPATHIC PSEUDO-OBSTRUCTION: A STUDY WITH HIGH RESOLUTION MANOMETRY A. Mauro ∗ , G. Basilisco, M. Franchina, A. Elvevi, D. Pugliese, D. Conte, R. Penagini
OC.04 Esophagus – Stomach – Endoscopy
OC.04.1 CURRENT PRACTICE OF ITALIAN ENDOSCOPISTS IN THE MANAGEMENT OF BARRETT’S ESOPHAGUS: A SURVEY OF ITALIAN SOCIETY OF DIGESTIVE ENDOSCOPY (SIED) R.M. Zagari 1 , S. Rabitti ∗,1 , M. Bianchi 2 , L.H. Eusebi 1 , V. Boarino 3 , E. Cavargini 4 , L. Pasquale 5 , P.A. Testoni 6 , M. Neri 7 di Bologna, Bologna, Italy; 2 Presidio Ospedaliero San Filippo Neri, Roma, Italy; 3 Policlinico di Modena, Modena, Italy; 4 Ospedale di Forlì, Forlì, Italy; 5 Ospedale di Avellino, Avellino, Italy; 6 IRCCS Ospedale San Raffaele, Milano, Italy; 7 Ospedale SS. Annunziata, Chieti, Italy 1 Università
Background and aim: An appropriate management of Barrett’s esophagus (BE) is essential for an early diagnosis of esophageal cancer and for reducing disease-related public health costs. Although several guidelines have been released in the field of BE, the adherence of the Italian endoscopists to guidelines has never been investigated. Thus, we aimed to assess practice patterns of Italian endoscopists in the management of patients with BE. Material and methods: We performed a questionnaire-based survey on the current practice of Italian endoscopists. The questionnaire contained a total of 17 questions regarding physician’s demographics and their practice in the diagnosis and management of BE. Results: A total of 216 Italian endoscopists (72.2% males) participated to the survey. Of these, 50.5% practiced in the North and 49.5% in the Centre/South of Italy; 66.8% worked in a community setting and 64.3% had >10 years of experience. The majority of responders used the C & M Prague classification (87.2%), Seattle biopsy protocol (84.5%) and advanced endoscopic imaging techniques (81.5%). However, only 65.2% used the proximal extent of gastric folds to define the esophagogastric junction (EGJ). In the management of nondysplastic BE, 56.9% practiced surveillance and 43.1% endoscopic treatment in selected cases. Only 65.5% of respondents practiced surveillance every 3–5 years. For low-grade dysplasia BE, 54.8%
Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation; Università degli Studi di Milano, Milano, Italy Background and aim: Chronic intestinal idiopatic pseudobstruction (CIIPO) is a rare disease in which no specific diagnostic tests exist. Oesophageal motility has been shown to be impaired in a minority of patient with CIIPO at traditional manometry whereas no studies have evaluated HRM in CIIPO patients. Aim was to evaluate the presence of major and minor motor disorder with oesophageal HRM in a consecutive series of patients with CIIPO. Material and methods: 14 CIIPO patients (chronic symptoms of obstruction, radiological evidence of distended gut with air-fluid levels, exclusion of any organic obstruction of the gut lumen and exclusion of secondary causes of chronic intestinal pseudoobstruction or scleroderma) were enrolled (5 M; median 42 years; range 29–50). 50 consecutive patients (18 M; 53 years; 39–68) with oesophageal symptoms and a diagnosis of ineffective esophageal motility (IEM) served as a control group. All diagnosis were based according to Chicago 3 Classification. All patients underwent 10 single 5 ml water swallows (SS) and 2 multiple 10 ml rapid swallows (MRS) during HRM protocol. During MRS the absence of peristaltic reserve (absence of after contraction or MRS/SS DCI ratio ≤1) was evaluated. Anorectal manometry was also performed and rectoanal inhibitory (RAI) reflex measured. Mann-Whitney, Chi-squared or Fisher test were used when appropriate. Results: All CIIPO patients had pathological HRM: one had type II achalasia, one aperistalsis and 12 minor disorder of peristalsis (11 IEM and 1 fragmented peristalsis). 3/12 CIIPO patients with minor disorder of peristalsis had no peristaltic reserve. In the group of CIIPO patients with minor disorders of peristalsis RAI reflex was absent in 2/3 without and in none of 9 with peristaltic reserve (Fisher exact test: P=0.04). Comparing the 12 CIIPO patients with minor disorder of peristalsis to the control group, no differences were seen on HRM parameters except for a higher percentage of ineffective waves in CIIPO patients (see Table 1). Conclusions: The observation that all CIIPO patients have oesophageal dysmotility suggests that normal oesophageal HRM might exclude the diagnosis of CIIPO. Presence of major oesophageal dis-
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Abstracts of the 23rd National Congress of Digestive Diseases / Digestive and Liver Disease 49S2 (2017) e73–e223
total, acid, weakly acidic, weakly alkaline and proximal refluxes (37 vs. 59.3, 26 vs. 39.3, 10.6 vs. 19.5, 0.1 vs. 3.5, 19.1 vs. 26.4, 46.7 vs. 45.4), although reduced, and the mean lower esophageal sphincter basal pressure (9.0 vs. 15.0 mmHg), although improved, did not reach a significant difference (p>0.05). Conclusions: In our experience with TAF using MUSE™ in GERD pts, one case of severe complication occurred (4.8%). The 6-month data showed efficacy of this treatment, allowing significant improvement of symptom scores of GERD-HRQL and RSI questionnaires, and withdrawal or reduction ≥50% of PPI use in 50% and 29% of pts, respectively. Functional results were in favor of TAF, too, although the few cases analyzed did not permit to achieve statistically significant results.
OC.04.4
motility or absent peristaltic reserve might suggest a more severe and widespread motor disorder. The significant association between the absence of oesophageal peristaltic reserve and the absence of RAI reflex suggests a widespread visceral neuropathy in some of the patients.
OC.04.3 TRANSORAL ANTERIOR FUNDOPLICATION (TAF) WITH MEDIGUS ULTRASOUND SURGICAL ENDOSTAPLER (MUSE™) FOR THE TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE (GERD): 6-MONTH RESULTS FROM A SINGLE-CENTER PROSPECTIVE STUDY P.A Testoni ∗ , S.G.G. Testoni, G. Mazzoleni, L. Fanti, S. Passaretti Division of Gastroenterology & G.I. Endoscopy, Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milano, Italy Background and aim: TAF with MUSE™ (Medigus, Omer, Israel) is a new treatment for GERD, alternative to long-term proton pump inhibitors (PPIs) and surgical fundoplication. Aim of the study was to assess the safety of TAF with MUSE™ and its 6-month effects on GERD symptoms, PPI use and functional results in patients (pts) with GERD and PPI-daily dependence. Material and methods: TAF was performed in a series of consecutive pts with symptomatic GERD responsive to PPI, in a single-center study. All pts underwent GERD-related quality of life (GERD-HRQL) and reflux symptom index (RSI) questionnaires, upper gastrointestinal endoscopy (GIE), high-resolution esophageal manometry, and 24h pH-impedance recording before and 6 months after TAF. We evaluated the TAF’s safety and clinical efficacy based on ≥50% improvement in GERD questionnaires score, suspension or reduction ≥50% of PPI use, and reduction of total acid exposure on functional tests. The 6-month efficacy data were compared to baseline by using Fisher’s exact test for frequencies and two-tailed Wilcoxon signed-rank test for nonparametric data (p value ≤0.05 statistically significant). Results: Twenty-one pts underwent TAF over a 12-month period (M/F=12/9): 6 (28.6%) had esophagitis, 2 (9.5%) Barrett’s esophagus, and 13 (62%) pathological functional findings. Hiatal hernia ≤2 cm was present in 17 pts (81%). TAF was successful in 20 pts. Esophageal perforation occurred in 1 case (overall complication rate: 4.8%). Fourteen pts completed 6-month follow-up. Compared to baseline, mean ± SD GERD-HRQL (18±16 vs. 43±14) and RSI (10±9 vs. 21±7) scores were significantly improved (p=0.003 and p=0.009). Eleven pts (79%) stopped or halved PPI use, 3 pts (21%) did not reduce PPI dose. Compared to baseline, the median N. of
PER-ORAL ENDOSCOPIC MYOTOMY AS RESCUE THERAPY IN PATIENTS WITH SYMPTOMS RECURRENCE AFTER SURGICAL MYOTOMY. A SINGLE CENTRE EXPERIENCE WITH MID-TERM FOLLOW-UP R. Landi ∗ , P. Familiari, A. Calì, F. Borrelli De Andreis, P. Massinha, V. Bove, I. Boškoski, A. Tringali, G. Costamagna Università Cattolica del Sacro Cuore, Fondazione Policlinico A. Gemelli, Roma, Italy Background and aim: Heller myotomy (HM) is considered the most reliable treatment for achalasia. However, recurrence occur in 10–20% of patients at long term follow-up. The treatment of recurrences is still controversial, and Per-Oral Endoscopic Myotomy (POEM) has been proposed as rescue therapy. We report on a consecutive series of patients with symptoms recurrence after HM treated with POEM. Material and methods: A total of 393 patients underwent POEM in a tertiary referral endoscopy center between April 2011 and November 2016. Patients who underwent POEM because of recurrent symptoms after a failed HM were identified from a prospectively collected database. Clinical history, procedural, and follow-up data were recorded. POEM was usually indicated by a 4sIRP >15 mmHg at HRM and/or barium retention for more than 5 minutes. POEM clinical success was defined by Eckardt score ≤3. Technical and clinical success, procedure duration, mean hospitalization, preand post-operative Eckardt score, and complication rate were compared in myotomy-naive patients (controls) and in those who had undergone HM (HM-group). Results: Fourteen patients (8 male, mean age 53.5 years) underwent POEM after a failed HM. The mean time interval between HM and POEM was 9 (0.25 – 53) years. Three patients (22%) had type 1 achalasia, 8 (57%) type 2, 2 (14%) type III, and 1 (7%) did not undergo HRM. Six patients had received pneumatic dilation before POEM. Mean preoperative Eckardt score was 6.4±1.8 and 7.9±2.2, in HM-group and controls respectively (p<0.05). Technical success was 100% in HM-group and 97.6% in controls (p ns). Mean myotomy length in HM-group was 12±2.7cm. The mean duration of the procedure was 69±29 min and 64±24 min in HM-group and controls, respectively (p ns). Mean hospitalization was similar (3 days) in both groups. Clinical success was 78.6% in HM-group and 93.7% in controls (p ns), after a mean follow-up of 14.6±13.9months and 18.7±14.3 months, respectively (p ns). Mean postoperative Eckardt score was 1.9±1.6 and 0.9±1.3 in HM-group and controls, respectively (p<0.01). No complications were recorded in HM-group; 4 controls (1%) had complications (p ns). 50% of patients in the HM- and 26% in the control-group (p=0.09) experienced clinically relevant GERD during follow-up.
7 days. Colons were subjected to histological processing and immunohistochemistry was performed to evaluate myenteric neuron’s expression of Erβ, VIP, neuronal nitric oxide synthases (nNOS) and choline acetyltransferase (ChAT). The data were compared between the groups using non parametric t-test. Results: Erβ is expressed in the neurons of the myenteric plexus. The thickness of muscle layer in LY3201-treated group was greater than in vehicle (mean 144.48±20.92 vs. 88.53±18.13). The density (cell number/colon length) of colonic myenteric neurons (Neunpositive) in treated group was increased compared to the vehicle (respectively mean 29.85±9.82; 6.93±3.42; p<0.004). In LY3201treated group, the density of Sox2-positive cells (a subset of neural progenitor cells) was higher (mean 34.76±9.53 treated; 8.94±1.53 vehicle; p<0.0017). Moreover the drug increased Chat (mean 14.8±2.6 treated; 1.9±0.9 vehicle; p<0.003) and nNOS (mean 11.6±2.1 treated; 2.3±0.8 vehicle; p<0.0065) expression while didn’t affect VIP significantly. Conclusions: LY3201 increased thickness of the smooth muscle layer and the number of neurons and Sox2-positive cells in the myenteric plexus. Probably it can promote Sox2+ progenitor cells differentiating into neurons. Moreover LY3201 restored neuron’s ability to produce neurotransmitters (nNOS/Chat) damaged by HFD. Thus LY3201, a selective ERβ agonist, can ameliorate HFD induced colonic neuropathy and myopathy.
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performed endoscopic treatment in selected cases and 19.4% in all cases, while 25.7% practiced surveillance. For high-grade dysplasia BE or intramucosal adenocarcinoma, 84.8% performed endoscopic treatment in all patients (80.3%) or in selected cases (4.5%), 13.1% referred to surgery and 2% practiced surveillance. More than half of responders (68.1%) were able to perform a technique of endoscopic therapy; the endoscopy treatment most frequently used was endoscopic mucosal resection (51.3%), followed by radiofrequency ablation (30.3%). Conclusions: This data would suggest that the majority of endoscopists in Italy use the recommended C & M Prague classification, Seattle biopsy protocol and advanced imaging techniques, and performs endoscopic treatment for low-grade and high-grade dysplasia BE. However, a substantial proportion does not use the proximal extent of gastric folds to define EGJ, does not practice endoscopic surveillance for non-dysplastic BE every 3–5 years and, in addition, performs endoscopic treatment for non-dysplastic BE in selected cases.
OC.04.2 OESOPHAGEAL MOTOR FUNCTION IN CHRONIC INTESTINAL IDIOPATHIC PSEUDO-OBSTRUCTION: A STUDY WITH HIGH RESOLUTION MANOMETRY A. Mauro ∗ , G. Basilisco, M. Franchina, A. Elvevi, D. Pugliese, D. Conte, R. Penagini
OC.04 Esophagus – Stomach – Endoscopy
OC.04.1 CURRENT PRACTICE OF ITALIAN ENDOSCOPISTS IN THE MANAGEMENT OF BARRETT’S ESOPHAGUS: A SURVEY OF ITALIAN SOCIETY OF DIGESTIVE ENDOSCOPY (SIED) R.M. Zagari 1 , S. Rabitti ∗,1 , M. Bianchi 2 , L.H. Eusebi 1 , V. Boarino 3 , E. Cavargini 4 , L. Pasquale 5 , P.A. Testoni 6 , M. Neri 7 di Bologna, Bologna, Italy; 2 Presidio Ospedaliero San Filippo Neri, Roma, Italy; 3 Policlinico di Modena, Modena, Italy; 4 Ospedale di Forlì, Forlì, Italy; 5 Ospedale di Avellino, Avellino, Italy; 6 IRCCS Ospedale San Raffaele, Milano, Italy; 7 Ospedale SS. Annunziata, Chieti, Italy 1 Università
Background and aim: An appropriate management of Barrett’s esophagus (BE) is essential for an early diagnosis of esophageal cancer and for reducing disease-related public health costs. Although several guidelines have been released in the field of BE, the adherence of the Italian endoscopists to guidelines has never been investigated. Thus, we aimed to assess practice patterns of Italian endoscopists in the management of patients with BE. Material and methods: We performed a questionnaire-based survey on the current practice of Italian endoscopists. The questionnaire contained a total of 17 questions regarding physician’s demographics and their practice in the diagnosis and management of BE. Results: A total of 216 Italian endoscopists (72.2% males) participated to the survey. Of these, 50.5% practiced in the North and 49.5% in the Centre/South of Italy; 66.8% worked in a community setting and 64.3% had >10 years of experience. The majority of responders used the C & M Prague classification (87.2%), Seattle biopsy protocol (84.5%) and advanced endoscopic imaging techniques (81.5%). However, only 65.2% used the proximal extent of gastric folds to define the esophagogastric junction (EGJ). In the management of nondysplastic BE, 56.9% practiced surveillance and 43.1% endoscopic treatment in selected cases. Only 65.5% of respondents practiced surveillance every 3–5 years. For low-grade dysplasia BE, 54.8%
Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation; Università degli Studi di Milano, Milano, Italy Background and aim: Chronic intestinal idiopatic pseudobstruction (CIIPO) is a rare disease in which no specific diagnostic tests exist. Oesophageal motility has been shown to be impaired in a minority of patient with CIIPO at traditional manometry whereas no studies have evaluated HRM in CIIPO patients. Aim was to evaluate the presence of major and minor motor disorder with oesophageal HRM in a consecutive series of patients with CIIPO. Material and methods: 14 CIIPO patients (chronic symptoms of obstruction, radiological evidence of distended gut with air-fluid levels, exclusion of any organic obstruction of the gut lumen and exclusion of secondary causes of chronic intestinal pseudoobstruction or scleroderma) were enrolled (5 M; median 42 years; range 29–50). 50 consecutive patients (18 M; 53 years; 39–68) with oesophageal symptoms and a diagnosis of ineffective esophageal motility (IEM) served as a control group. All diagnosis were based according to Chicago 3 Classification. All patients underwent 10 single 5 ml water swallows (SS) and 2 multiple 10 ml rapid swallows (MRS) during HRM protocol. During MRS the absence of peristaltic reserve (absence of after contraction or MRS/SS DCI ratio ≤1) was evaluated. Anorectal manometry was also performed and rectoanal inhibitory (RAI) reflex measured. Mann-Whitney, Chi-squared or Fisher test were used when appropriate. Results: All CIIPO patients had pathological HRM: one had type II achalasia, one aperistalsis and 12 minor disorder of peristalsis (11 IEM and 1 fragmented peristalsis). 3/12 CIIPO patients with minor disorder of peristalsis had no peristaltic reserve. In the group of CIIPO patients with minor disorders of peristalsis RAI reflex was absent in 2/3 without and in none of 9 with peristaltic reserve (Fisher exact test: P=0.04). Comparing the 12 CIIPO patients with minor disorder of peristalsis to the control group, no differences were seen on HRM parameters except for a higher percentage of ineffective waves in CIIPO patients (see Table 1). Conclusions: The observation that all CIIPO patients have oesophageal dysmotility suggests that normal oesophageal HRM might exclude the diagnosis of CIIPO. Presence of major oesophageal dis-
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Abstracts of the 23rd National Congress of Digestive Diseases / Digestive and Liver Disease 49S2 (2017) e73–e223
total, acid, weakly acidic, weakly alkaline and proximal refluxes (37 vs. 59.3, 26 vs. 39.3, 10.6 vs. 19.5, 0.1 vs. 3.5, 19.1 vs. 26.4, 46.7 vs. 45.4), although reduced, and the mean lower esophageal sphincter basal pressure (9.0 vs. 15.0 mmHg), although improved, did not reach a significant difference (p>0.05). Conclusions: In our experience with TAF using MUSE™ in GERD pts, one case of severe complication occurred (4.8%). The 6-month data showed efficacy of this treatment, allowing significant improvement of symptom scores of GERD-HRQL and RSI questionnaires, and withdrawal or reduction ≥50% of PPI use in 50% and 29% of pts, respectively. Functional results were in favor of TAF, too, although the few cases analyzed did not permit to achieve statistically significant results.
OC.04.4
motility or absent peristaltic reserve might suggest a more severe and widespread motor disorder. The significant association between the absence of oesophageal peristaltic reserve and the absence of RAI reflex suggests a widespread visceral neuropathy in some of the patients.
OC.04.3 TRANSORAL ANTERIOR FUNDOPLICATION (TAF) WITH MEDIGUS ULTRASOUND SURGICAL ENDOSTAPLER (MUSE™) FOR THE TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE (GERD): 6-MONTH RESULTS FROM A SINGLE-CENTER PROSPECTIVE STUDY P.A Testoni ∗ , S.G.G. Testoni, G. Mazzoleni, L. Fanti, S. Passaretti Division of Gastroenterology & G.I. Endoscopy, Vita-Salute San Raffaele University, San Raffaele Scientific Institute, Milano, Italy Background and aim: TAF with MUSE™ (Medigus, Omer, Israel) is a new treatment for GERD, alternative to long-term proton pump inhibitors (PPIs) and surgical fundoplication. Aim of the study was to assess the safety of TAF with MUSE™ and its 6-month effects on GERD symptoms, PPI use and functional results in patients (pts) with GERD and PPI-daily dependence. Material and methods: TAF was performed in a series of consecutive pts with symptomatic GERD responsive to PPI, in a single-center study. All pts underwent GERD-related quality of life (GERD-HRQL) and reflux symptom index (RSI) questionnaires, upper gastrointestinal endoscopy (GIE), high-resolution esophageal manometry, and 24h pH-impedance recording before and 6 months after TAF. We evaluated the TAF’s safety and clinical efficacy based on ≥50% improvement in GERD questionnaires score, suspension or reduction ≥50% of PPI use, and reduction of total acid exposure on functional tests. The 6-month efficacy data were compared to baseline by using Fisher’s exact test for frequencies and two-tailed Wilcoxon signed-rank test for nonparametric data (p value ≤0.05 statistically significant). Results: Twenty-one pts underwent TAF over a 12-month period (M/F=12/9): 6 (28.6%) had esophagitis, 2 (9.5%) Barrett’s esophagus, and 13 (62%) pathological functional findings. Hiatal hernia ≤2 cm was present in 17 pts (81%). TAF was successful in 20 pts. Esophageal perforation occurred in 1 case (overall complication rate: 4.8%). Fourteen pts completed 6-month follow-up. Compared to baseline, mean ± SD GERD-HRQL (18±16 vs. 43±14) and RSI (10±9 vs. 21±7) scores were significantly improved (p=0.003 and p=0.009). Eleven pts (79%) stopped or halved PPI use, 3 pts (21%) did not reduce PPI dose. Compared to baseline, the median N. of
PER-ORAL ENDOSCOPIC MYOTOMY AS RESCUE THERAPY IN PATIENTS WITH SYMPTOMS RECURRENCE AFTER SURGICAL MYOTOMY. A SINGLE CENTRE EXPERIENCE WITH MID-TERM FOLLOW-UP R. Landi ∗ , P. Familiari, A. Calì, F. Borrelli De Andreis, P. Massinha, V. Bove, I. Boškoski, A. Tringali, G. Costamagna Università Cattolica del Sacro Cuore, Fondazione Policlinico A. Gemelli, Roma, Italy Background and aim: Heller myotomy (HM) is considered the most reliable treatment for achalasia. However, recurrence occur in 10–20% of patients at long term follow-up. The treatment of recurrences is still controversial, and Per-Oral Endoscopic Myotomy (POEM) has been proposed as rescue therapy. We report on a consecutive series of patients with symptoms recurrence after HM treated with POEM. Material and methods: A total of 393 patients underwent POEM in a tertiary referral endoscopy center between April 2011 and November 2016. Patients who underwent POEM because of recurrent symptoms after a failed HM were identified from a prospectively collected database. Clinical history, procedural, and follow-up data were recorded. POEM was usually indicated by a 4sIRP >15 mmHg at HRM and/or barium retention for more than 5 minutes. POEM clinical success was defined by Eckardt score ≤3. Technical and clinical success, procedure duration, mean hospitalization, preand post-operative Eckardt score, and complication rate were compared in myotomy-naive patients (controls) and in those who had undergone HM (HM-group). Results: Fourteen patients (8 male, mean age 53.5 years) underwent POEM after a failed HM. The mean time interval between HM and POEM was 9 (0.25 – 53) years. Three patients (22%) had type 1 achalasia, 8 (57%) type 2, 2 (14%) type III, and 1 (7%) did not undergo HRM. Six patients had received pneumatic dilation before POEM. Mean preoperative Eckardt score was 6.4±1.8 and 7.9±2.2, in HM-group and controls respectively (p<0.05). Technical success was 100% in HM-group and 97.6% in controls (p ns). Mean myotomy length in HM-group was 12±2.7cm. The mean duration of the procedure was 69±29 min and 64±24 min in HM-group and controls, respectively (p ns). Mean hospitalization was similar (3 days) in both groups. Clinical success was 78.6% in HM-group and 93.7% in controls (p ns), after a mean follow-up of 14.6±13.9months and 18.7±14.3 months, respectively (p ns). Mean postoperative Eckardt score was 1.9±1.6 and 0.9±1.3 in HM-group and controls, respectively (p<0.01). No complications were recorded in HM-group; 4 controls (1%) had complications (p ns). 50% of patients in the HM- and 26% in the control-group (p=0.09) experienced clinically relevant GERD during follow-up.