Tu1507 Creation of a Second Sub-Mucosal Tunnel Enabled Successful Per-Oral Endoscopic Myotomy (POEM) in a Patient With Previous Thoracocotomy and Heller's Myotomy

Tu1507 Creation of a Second Sub-Mucosal Tunnel Enabled Successful Per-Oral Endoscopic Myotomy (POEM) in a Patient With Previous Thoracocotomy and Heller's Myotomy

Abstracts Tu1505 Endoluminal Functional Lumen Imaging Probe (EndoFLIP) During PerOral Endoscopic Myotomy (POEM) for Achalasia Predict Postoperative C...

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Abstracts

Tu1505 Endoluminal Functional Lumen Imaging Probe (EndoFLIP) During PerOral Endoscopic Myotomy (POEM) for Achalasia Predict Postoperative Clinical Success: a Single Center Study Study Sepideh Besharati, Saowanee Ngamruengphong, Vivek Kumbhari, Mohamad H. El Zein, Ahmed Abdelgelil*, Alan H. Tieu, Patrick I. Okolo, John O. Clarke, Mouen Khashab Johns Hopkins Medical Institute, Baltimore, MD Background: Peroral endoscopic myotomy (POEM) is a novel treatment modality for esophageal motility disorders such as achalasia. The endoluminal functional lumen imaging probe (EndoFLIP) system is used for the measurement of the diameter/area and physiologic aspects (e.g. pressure, distensibility) of the esophagogastric junction (EGJ). Aim: To evaluate association between intraoperative biomechanical parameters measured by EndoFLIP and clinical response after POEM. Method: We conducted a retrospective review of consecutive patients who underwent POEM and intraoperative EndoFLIP between 5/2013 and 11/2014 at an academic tertiary-care center. Patients were divided into 2 groups based on clinical response measured by Eckardt Score (ES): 1) ES ! 3 (response group) and 2) ES R 3 (non-response group). FLIP measurements included EGJ diameter, cross-sectional areas (CSA) and distensibility index (DI). DI was defined as the minimum CSA divided by intra-bag pressure using a bag distension volume of 30 ml and 40ml. Analysis were performed using t-test to determine the association between endoFLIP parameters and clinical response and development of post-POEM reflux (defined as DeMeester score O14.72). Results: A total of 38 patients (21 females (55%); mean age 4916.76 yr) underwent POEM and intraoperative EndoFLIP. Of these, 34 (89%) patients had ES ! 3 (response group) and 4 patients (11%) had ES R 3 (non-response group) after POEM. There was no significant difference in age, gender, BMI, preoperative LES relaxation pressure, baseline ES, achalasia subtype and baseline FLIP measurements between the two groups. Overall, preoperative ES of patients decreased from 7.94  1.57 to a post-POEM score of 0.84  1.15 (p ! 0.001). Mean LES relaxation pressure decreased from 31.85 11.72 mmHg to 11.56  7.40 mmHg (p!0.001). The mean diameter and EGJ CSA significantly increased from 6.52  1.58 mm to 10.832.06 mm (p!0.001) and 36.47 19.24 mm2 to 93.1123.71 mm2 (p!0.001), respectively. The EGJ distensibility was significantly improved from 1.41 1.15 mm2/mmHg before myotomy to 4.79 2.16 mm2 /mmHg after myotomy (p!0.001) (table 1). Post-myotomy endoFLIP parameters (GEJ diameter, CSA and distensability) and LES relaxation pressure were not significantly different between the response group vs non-response group (table 2). EGJ CSA (using 30ml bag volume) was significantly higher in patients with postPOEM reflux ( 92.8415.66 vs. 53 59.39 .pZ0.03) compared with those with normal pH study. Conclusion: POEM improved esophageal biomechanical parameters measured with endoFlip. High post-myotomy EGJ CSA is associated with postPOEM reflux. Further large studies are needed to assess the usefulness of this technology in predicting clinical outcomes and risk of reflux following POEM in achalasia patients. Table 1. Biomechanical parameter before and after POEM 30 ml Volume EGJ diameter CSA Bag pressure DI LES residual pressure

Pre-POEM

Post-POEM

P value

6.521.58 36.4719.24 32.8811.96 1.411.15 31.8511.72

10.832.06 93.1123.71 22.749.03 4.792.16 11.567.40

!0.001 !0.001 !0.001 !0.001 !0.001

Table 2. EndoFLIP measurement in response group and non-response group using a 30 ml bag distension volume 30 ml Volume EGJ diameter CSA Bag pressure DI Delta EGJ diameter Delta CSA Delta Bag pressure Delta DI

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Good responders (ES!3)

Poor responders (R3)

P value

10.782.14 91.3319.62 24.33 24.00 6.64 4.43 0.70 0.46 1.991.24 -0.240.21 3.262.62

11.31.35 93.27 24.30 22.63 6.03 4.53 1.66 0.89 0.48 2.652.36 -0.360.39 4.810.90

0.63 0.89 0.76 0.10 0.44 0.41 0.41 0.32

Tu1506 Balloon Tunneling Technique in Per-Oral Endoscopic Myotomy (POEM) for the Treatment of Achalasia Seth E. Homer*, Daniel J. Waintraub, Sam Serouya, Petros C. Benias, David L. Carr-Locke Mount Sinai Beth Israel Medical Center, New York, NY Background: The traditional approach to the treatment of achalasia has included multiple techniques with varying degrees of success including endoscopic balloon dilatation, botulinum toxin injection and Heller myotomy. Per-oral endoscopic myotomy (POEM), a novel natural orifice transluminal endoscopic surgical (NOTES) approach, is a safe and effective alternative for the treatment of classic achalasia[1]. This technique involves the creation of a submucosal tunnel in the esophagus by means of electrosurgical dissection[2] or balloon tunneling[3],[4] allowing endoscopic access to the lower esophageal sphincter. Experience has demonstrated significant reductions in Eckardt score and lower esophageal sphincter (LES) pressure in greater than 80% of patients[5]. Aims: We present here our first eight POEM procedures where a biliary dilation balloon was utilized to create a submucosal tunnel prior to myotomy, and we discuss the technique and benefits of this approach. Technique: At 15 cm above the LES, a submucosal injection of methylene blue and saline was made to lift the mucosa. An IT2 knife (Olympus) was used to make the initial incision into the submucosal space and a 6mm diameter Hurricane biliary dilation balloon (Boston Scientific) was used to expand the submucosal tunnel followed by passage of an Olympus GIF190HJ endoscope. An IT2 knife was used to perform a full-thickness myotomy at the LES and the mucosal entry was closed with clips. Results: Mean total time of procedure was 46 minutes from endoscope insertion to withdrawal. There was one case of self-resolving capnoperitoneum and two of self-resolving capnomediastinum. There were no instances of mucosal disruption. Conclusion: Use of a dilation balloon for blunt dissection of the submucosal tunnel in POEM is faster than electrosurgical dissection and has potential to decrease the risk of perforation.[1] Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010;42:265-71[2] Stavropoulos SN, Modayil R, Friedel D. Achalasia. Gastrointest Endosc Clin N Am 2013;23:53-75[3] Stavropoulos SN, Harris MD, Hida S, et al. Endoscopic submucosal my-otomy for the treatment of achalasia. Gastrointest Endosc 2010;72: 1309-11.[4] Stavropoulos SN, Friedel D, Modayil R, et al. Endoscopic approaches to treatment of achalasia. Therapeut Adv Gastroenterol 2013;6:115-35[5] Stavropoulos, Stavros N. et al. “Per-oral endoscopic myotomy white paper summary.” Surgical Endoscopy and Other Interventional Techniques 28.7 (2014): 2005-2019. Print.

Tu1507 Creation of a Second Sub-Mucosal Tunnel Enabled Successful PerOral Endoscopic Myotomy (POEM) in a Patient With Previous Thoracocotomy and Heller’s Myotomy Siva Raja2, Prashanthi N. Thota1, Murthy C. Sudish2, Madhusudhan R. Sanaka*1 1 Gastroenterology, Cleveland Clinic, Cleveland, OH; 2Thoracic surgery, Cleveland Clinic, Cleveland, OH Introduction: Per-Oral Endoscopic Myotomy (POEM) is an evolving treatment modality for Achalasia. Standard steps of POEM include a 2 cm mucosotomy in mid esophagus, creation of submucosal tunnel extending 2-4 cm onto gastric side, then dividing the inner circular muscle in distal 5-6 cm of esophagus and extending 2-4 cm on gastric side, and closure of mucosotomy with endoscopic clips. Prior treatments such as Botox injections, Pneumatic dilation or Heller’s myotomy pose a technical challenge due to submucosal fibrosis adding complexity. We present one such case with severe submucosal fibrosis absolutely precluding submucosal tunneling in whom successful POEM was possible by creation of a second submucosal tunnel. Case: A 62 year old man with prior Heller’s myotomy via thoracotomy 25 years ago for Achalasia presented with recurrent symptoms of dysphagia, regurgitation and weight loss with an Eckardt score of 5. Timed barium swallow study showed sigmoid esophagus with narrowing at gastroesophageal junction (GEJ) and delayed esophageal emptying. Esophageal manometry catheter did not pass through the lower esophageal sphincter but revealed esophageal aperistalsis consistent with Type I Achalasia. Upper endoscopy revealed dilated esophagus with tight GEJ without a mass. We elected POEM for palliation, performed under general anesthesia, with creation of mucostomy on the postero-medial wall of the mid esophagus due to prior Heller’s myotomy on the anterior wall. During submucosal tunneling, we encountered severe scarring, fibrosis and obliteration of submucosal space in the lower esophagus, precluding further tunneling. We elected to create a second tunnel at an angle of 90 degrees opposite the first tunnel. We were able to successfully continue the second tunnel onto the gastric side and complete the myotomy. At the end, both mucostomies were closed with endoscopic clips. He was started on liquid diet next day after a negative swallow study and was discharged home. Patient had significant improvement of symptoms at 2 months follow-up with an Eckardt’s score of 0. Discussion: Submucosal scarring and fibrosis from previous treatments such as Botox injections, Pneumatic dilation or Heller’s myotomy are known to make submucosal tunneling difficult and prolonged. However, in some cases submucosal tunneling is impossible due to near complete obliteration of submucosal space as encountered in our patient. Our patient might have had a longer myotomy compared to those undergoing transabdominal laparoscopic Heller’s myotomy, resulting in pronounced scarring and fibrosis. To our knowledge, this is the first reported case of POEM in which creation of a second submucosal tunnel on the opposite wall was created to complete the myotomy.

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Abstracts

Hence POEM operators should consider this option, when it is impossible to extend a submucosal tunnel during POEM procedure.

Tu1508 Comparison of Conventional Versus Hybrid Knife PerOral Endoscopic Myotomy Methods for Esophageal Achalasia: a CaseControl Study Xiaowei Tang, Zhiliang Deng, Wei Gong*, Bo Jiang Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China Background and Aim: POEM has been developed to treat esophageal achalasia as novel less invasive modality. But there is a rarity of data comparing the clinical outcomes between different endoscopic devices. The aim of this study was to compare the efficacy and safety of conventional versus Hybrid knife methods during POEM procedure. Methods: Between July 2011 and may 2014, 34 patients underwent POEM using Hybrid knife in our department (HK group). These patients were 1:1 by age, gender, symptoms duration, Eckardt score, Chicago classification of achalasia, and LES pressure with 40 patients underwent POEM using conventional method (injection needle and triangular tip knife) (TT group). Procedure-related parameters, symptom relief and adverse events, manometry outcomes were compared between two groups. Results: There was no significant differences in the age, sex and other baseline characteristics between the two groups. The mean procedural times were significantly shorter in HK group than TT group (52.5616.65min vs, 66.7727.90min , pZ0.012). The mean frequency of devices exchange was 2 in HK group and 8 in TT group (p!0.01), and the mean frequency of coagulation forceps use was 1.5 in HK group and 7 in TT group (p!0.01). No serious adverse events happened postoperatively in both groups. At 1-year’ follow up, a total of 93% treatment success was achieved in all patients (92% in HK group and 91% in TT group, pO0.05). Conclusion: Hybrid knife in POEM can shorten the procedural time, and achieved similar treatment success rate compared to TT. Table 1. Clinical outcomes of POEM procedure

Operative time (min), meanSD Submucosal tunnel length, (cm), meanSD Myotomy length of POEM (cm), meanSD Esophageal Stomach Total Eckardt score, median (range) Before POEM After POEM Before/after POEM D-value LES pressure (mm Hg), meanSD Before POEM After POEM Before/after POEM D-value Adverse events (n) Subcutaneous emphysema Pneumothorax Major bleeding Hospital stay (days)

HK group (n[34)

TT group (n[40)

P Value

52.5616.65 13.353.36

66.7727.90 14.234.02

0.012 0.160

6.032.55 2.291.00 8.322.72

6.613.18 2.721.31 9.334.09

0.632 0.231 0.258

8(3-12) 0(0-6) 5.742.16

7(5-12) 1(0-4) 6.232.16

0.953 0.578 0.350

38.6111.71 14.637.70 28.1118.16

40.0814.01 13.864.26 24.5214.50

0.651 0.666 0.465

2 0 2 9.853.47

8 0 1 9.385.26

0.079 1 0.465 0.652

Tu1509 Feasibility and Safety of PerOral Endoscopy Myotomy for Achalasia After Failed Endoscopic or Surgical Interventions: a Prospective Study Xiaowei Tang, Zhiliang Deng, Wei Gong*, Bo Jiang Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China Background: With the advancement in natural orifice translumenal endoscopic surgery, peroral endoscopy myotomy have been a novel treatment for esophageal achalasia. Aim: To investigate the feasibility and safety of peroral endoscopic myotomy in achalasia patients wth failed endoscopic or surgical interventions. Methods: Data on all patients undergoing POEM treatment of achalasia are collected prospectively. Between July 2012 toaugust 2013, 77 patients underwent POEM for achalasia. Of these, 23 had undergone Botox injection, pneumatic balloon dilation or surgical myotomy preoperatively. Preoperative, operative, and short-term outcome data were analyzed. Results: Among the 77 patients, 23 received endoscopic or surgical therapy before being referred for surgery (20 dilation only, 2 both Botox and dilation, 2 laparoscopic Heller myotomy). The preoperative intervention and nonpreoperative intervention group were matched for preoperative demographics and

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Eckardt score. Procedure time in the preoperative intervention group wasn’t longer than the non-preoperative intervention group (60.7221.01min vs. 60.1330.38min, pZ0.923). Both groups demonstrated significant improvement in symptoms and Eckardt scores at 1-year follow-up. There was no significant differences in pre- and post-treatment D-value of symptom scores and lower esophageal sphincter pressures between groups (both pO0.05). There was also no statistical difference in the incidence of intraoperative complications (20.3% vs 17.4%, pZ0.2) and gastroesophageal reflux rate (8.2% vs 9.1%, pZ0.38) between the two groups. Conclusion: POEM is safe and effective even for treating achalasia in the sitting of failed endoscopic or surgical interventions. Table 1. Operative Results of POEM procedure

Operative time (min), meanSD Submucosal tunnel length, (cm), meanSD Myotomy length of POEM (cm), meanSD Esophageal Stomach Total Eckardt score, median (range) Before POEM After POEM Before/after POEM D-value LES pressure (mm Hg), meanSD Before POEM After POEM Before/after POEM D-value Adverse events (n) Subcutaneous emphysema Pneumothorax Major bleeding Hospital stay (days)

No Preoperative Intervention group (n[54)

Preoperative Intervention group (n[23)

P Value

60.7221.01 13.604.62

60.1330.38 13.433.12

0.923 0.873

7.303.57 2.961.43 10.264.23

6.612.59 3.041.07 9.652.93

0.404 0.807 0.531

7(3-12) 1(0-6) 6.152.01

7(2-12) 1.5(0-4) 5.602.41

0.937 0.090 0.339

39.4314.40 14.986.45 24.7114.89

42.2316.03 13.155.26 29.7318.24

0.490 0.335 0.326

8 0 2 8.963.00

2 0 2 10.746.64

0.468 1.00 0.369 0.109

Tu1510 Implementation of PerOral Endoscopic Myotomy (POEM) and Prolonged Dilatation As Treatment for Achalasia: Is It Worth the Cost? Erwin Rieder*1, Johannes Lenglinger1, Georg O. Spaun2, Sawsan Mari1, Reza Asari1, Lee L. Swanstrom3, Sebastian F. Schoppmann1 1 Department of Surgery, Medical University of Vienna, Vienna, Austria; 2 Department of General and Visceral Surgery, Sisters of Charity Hospita, Linz, Austria; 3Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, Portland, OR Background: Per oral endoscopic myotomy (POEM) or prolonged dilatation (PRD) have recently challenged laparoscopic Heller myotomy (LHM) and balloon dilatation (BD) as treatment for achalasia. However, increasing economic pressure might influence therapeutic decisions and implementation of new techniques. The aim of this analysis was to compare hospital costs and short-term outcome of currently used therapies for achalasia. To estimate the potential impact of new methods previous achalasia treatment was reviewed. Methods: Patients treated for achalasia from 05/2013 - 11/2014 were analyzed for hospital cost as well as short-term outcome. POEM, LHM and PRD, based on temporary placement of a large diameter (30 mm) stent, were performed in the OR. BD using the EsoFLIPÒ Dilation catheter with integrated planimetry was mainly performed as an outpatient procedure. Additionally, the achalasia database (1995-2012) at a single academic institution was retrospectively reviewed. Results: After a median follow-up of 6 months all patients (6/6) treated by POEM (including one re-myotomy after failed Heller, BD and PRD) had successful outcome with an Eckardt score % 3. One patient had developed subcutaneous emphysema and was observed at the ICU overnight, which doubled treatment costs. However, median hospital costs for POEM (* $ 9659) were not significantly different to LHM ($ 8860). LHM (nZ4) was not successful in one patient, where re-myotomy was performed after failed Heller and PRD. Interestingly, success rate of PRD (nZ10) was 80 % after a median follow-up of 10 months, but the need for additional days in hospital significantly increased costs of PRD ($ 11782). As BD (nZ7) was mainly performed as an outpatient procedure, costs were significantly lower (V 1708) compared to all other treatments (p!0,01). In the previous 18 years treatment concepts were based on initial serial dilatations followed by myotomy in case of insufficient symptom release. 213 patients had 311 dilatations overall. 93 patients (44%) had no additional treatment after one endoscopic dilatation but 66 patients (31%) had up to four dilatations. 54 (25%) patients were treated with LHM

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