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Tu1527 Long Term Outcome of PerOral Endoscopic Myotomy (POEM) in Achalasia Patients
Abstracts SF-36 outcomes.SF-36 domain scores preoperative and at each follow-up Physical functioning Role limitations due to physical problems Role limitations due to emotional problems Energy/fatigue Emotional well-being Social functioning Pain General health
Preoperative
1 month
88 (76-90) 88 (55-100)
90 (86-94) 100 (81-100)
p
6 months
p
100 (17-100)
100 (100-100) 0.103 100 (100-100) 0.059
80 (57-84) 80 (72-88) 100 (58-100) 62 (45-100) 46 (35-73)
85 (80-85) 84 (81-88) 100 (83-100) 92 (72-100) 75 (57-77)
0.017 90 (90-95) 0.007 0.024 100 (100-100) 0.026
0.004 80 (81-85) 0.126 84 (80-88) 0.043 100 (100-100) 0.018 95 (84-100) 0.005 85 (72-97)
0.007 0.189 0.042 0.011 0.003
Tu1525 Management and Treatment for Complication (Accident) After PerOral Endoscopic Myotomy (POEM) in Achalasia Weon-Jin Ko*2, Suk Pyo Shin2, Ga Won Song2, Jun Hwan Yoo2, Duk Hwan Kim2, Kim Wonhee2, Kwang Hyun Ko2, Joo Young Cho2, Ki Baik Hahm2, Sung-Pyo Hong2, Pil Won Park2, Jun-Hyung Cho1 1 Digestive Disease Center, Soonchunhyang University Hospital, Seoul, Korea (the Republic of); 2Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam-si, Korea (the Republic of) Background: The aim of this study was to inform the safety of peroral endoscopic myotomy(POEM). So we investigated the management for complications after POEM in patients suffering from esophageal achalasia. Methods: A total of 54 cases for achalasia patients who underwent POEM from November 2011 to August 2014 were enrolled. The complications that arose after operation, and during follow-up were analyzed. Results: Postoperative complications included pneumoperitoneum(42.6%, 23/54), pleural effusion (37.0%, 20/54), subcutaneous emphysema(31.5%, 17/54), atelectasis of the lungs(20.4%, 11/54), pneumomediastinum(18.5%, 10/54), pneumonia(14.8%, 8/54), pneumoretroperitoneum(13.0%, 7/54), pulmonary congestion(3.7%, 2/54), gastric emphysema(1.9%, 1/ 54), and alveolar hemorrhage(1.9%, 1/54). No deaths occurred. All complications were resolved through conservative treatment. Conclusion: Complications arising after POEM can be treated and resolved by using conservative treatment. POEM was the safe endoscopic operation and can be expected to become the preferred treatment for achalasia.
Tu1526 PerOral Endoscopic Myotomy Is Safe and Effective for Achalasia With Failed Endoscopic Balloon Dilation Junfeng Zhou, Yuyong Tan, Tianying Duan, Deliang Liu* Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China Objective: Peroral endoscopic myotomy (POEM) is a promising technique for the treatment of achalasia (AC), however little is known about the safety and efficacy of POEM for AC patients with failure of prior endoscopic dilations. Our aim was to explore the safety and efficacy of POEM for AC with failed endoscopic balloon dilation (EBD). Methods: A retrospective study on AC patients who underwent POEM after failed EBD was performed. During August 2011 to May 2014, a total of 25 consecutive patients were included, clinical data about Eckardt score, lower esophageal sphincter pressure (LESP), esophageal diameter and POEM-related complications were collected and analyzed. Results: All the patients underwent POEM successfully with an average operation time of 64 minutes. The incidence of complications was 8% (2/25). After the procedure, the Eckardt score decreased significantly (6.08 VS 0.36, P!0.01), the LESP declined notably (32.01mmHg VS 13.64mmHg, P!0.01),the esophageal diameter reduced distinctly(54.44mm VS 32.68mm，P!0.01).Treatment success was achieved in 96% (24/25) of the cases with a follow-up of 6～36 months (median 24 months), no recurrence were noted. Conclusion: POEM is a safe and effective method for treatment of AC with failed EBD. Its long-term efficacy and complications need to be further assessed.
AB496 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
Tu1527 Long Term Outcome of PerOral Endoscopic Myotomy (POEM) in Achalasia Patients Weon-Jin Ko*2, Suk Pyo Shin2, Ga Won Song2, Jun Hwan Yoo2, Duk Hwan Kim2, Kim Wonhee2, Kwang Hyun Ko2, Joo Young Cho2, Ki Baik Hahm2, Sung-Pyo Hong2, Pil Won Park2, Jun-Hyung Cho1 1 Digestive Disease Center, Soonchunhyang University Hospital, Seoul, Korea (the Republic of); 2Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam-si, Korea (the Republic of) Background/Aims: Peroral endoscopic myotomy (POEM) was introduced as an alternative treatment for achalasia patients. The aim of this study was to evaluate the long term outcomes of POEM in achalasia patients. Methods: This is a retrospective analysis at two tertiary referral centers. A total of 12 achalasia patients underwent POEM between November 2011 and September 2012. Then the patients received periodic follow-up over 2 years. The main outcomes were Eckardt score, basal lower esophageal sphincter (LES) pressure, integrated relaxation pressure (IRP) score and procedure-related complications before and after POEM. Results: The length of myotomy was 8.65.4 cm. All patients showed a significant improvement in Eckardt score before and after POEM during median follow-up of 27.8 months (6.43.6 vs. 0.41.6; p!0.001). Also, significant decrease in LES pressure and IRP was found (30.8726.23 vs. 16.406.80;
www.giejournal.org
Abstracts
pZ0.003 and 26.2021.10 vs. 10.509.00; pZ0.007). Over 2 years, no symptom recurs occurred. Conclusion: Long term outcome of POEM for achalasia are excellent. In the future, large scale studies are needed to confirm this result.
Tu1528 Endoscopic Management of an Intramural Sinus Tract After Per Oral Endoscopic Myotomy (POEM) Amit Bhatt*1, Bradley Confer1, Jordan Holmes1, Matthew Kroh2, Scott L. Gabbard1, Arthi Kumaravel1, John H. Rodriguez2, Tyler Stevens1, Mansour A. Parsi1, John J. Vargo1, Jeffrey Ponsky2 1 Gastroenterology, Cleveland Clinic, Cleveland, OH; 2General Surgery, Cleveland Clinic, Cleveland, OH Introduction: As the volume of POEM procedures grows there will invariably be adverse events. It is important that effective treatments for these adverse events are discussed. We describe here the successful endoscopic management of a patient with a long intramural sinus tract originating from an open mucostomy site and incomplete myotomy after a POEM procedure. Case Presentation: A 43yo male with morbid obesity underwent a POEM procedure for type 3 achalasia. The procedure was performed without incident. 1. A mucosal incision was performed at 26cm from the incisors 2. A submucosal tunnel was formed with its extent beyond the gastroesophageal junction confirmed by retroflexion examination of the cardia. 3. A 14 cm circular muscle myotomy was performed. 4. Mucostomy site was closed with hemoclips. 14 days after the procedure the patient presented to hospital with chest pain. An upper GI series revealed a tight gastroesophageal junction with a long intramural sinus tract originating from the mucosotomy site. (Figure 1) Our working hypothesis was that the incomplete myotomy had resulted in increased esophageal pressures and disruption of the mucostomy closure site. So our attention was focused on addressing both the open mucosotomy site and the pressure at the GEJ. We accomplished this by placing tandem fully covered esophageal stents (23mm x 15cm and 23mm x 10cm) covering both the gastroesophageal junction and mucosotomy site. (Figure 2) The patient was started on total parental nutrition (TPN) and kept nil per mouth. The esophageal stents were removed 1 week later, and a subsequent upper GI series showed complete resolution of the intramural sinus. The incomplete myotomy may have been due to inaccurate endoscopic identification of submucosal tunnel extent that may occur as fluid and dye migrate into the cardia from the esophagus. The patient responded well to Botox injection into the lower esophageal sphincter. Conclusion: Post-POEM mucosotomy site leaks may be successfully treated with covered esophageal stent placement. In treating mucostomy site leaks an underlying etiology should be sought and addressed as well.
Figure 2.
Tu1529 Superior Patient Preference and High Diagnostic Accuracy for the Detection of Barrett’s Esophagus Using a Novel, Portable, ProbeBased TransNasal Endoscope Sarmed S. Sami*1, Massimiliano Di Pietro2, Jacobo Ortiz-Fernández-Sordo1, Jonathan R. White1, Indra Neil Guha1, Rebecca C. Fitzgerald2, Krish Ragunath1 1 Nottingham Digestive Diseases Centre and NIHR Biomedical Research Unit, University of Nottingham, Nottingham, United Kingdom; 2 Hutchison/MRC Research Centre, MRC Cancer Unit, Cambridge, United Kingdom
Figure 1.
www.giejournal.org
Introduction and Aims: Barrett’s Esophagus (BE) is the only recognized precursor to esophageal adenocarcinoma. The second generation EG ScanÔ system is portable with a disposable, ultrathin, probe-based imaging capsule; therefore it may be used in the community setting closer to the patient’s home. We aimed to compare the performance of unsedated transnasal endoscopy (TNE) using the EG ScanÔ with conventional esophagogastroduodenoscopy (C-EGD) for the detection of BE. Methods: This was a prospective, two-center, diagnostic study with tandem design. Consecutive adult patients with histologically confirmed BE and those referred for assessment of reflux or dyspepsia, were invited to participate. We excluded patients with recurrent epistaxis; nasal obstruction; and disease of the nasal cavity. All subjects underwent TNE (index test) followed by C-EGD (reference standard) on the same day, by two different operators blinded to the findings of each other. The primary outcome measure was the diagnostic accuracy for BE. In addition, procedure preference; tolerability (10-point visual analogue scale (VAS), 0 Z worst and 10 Z best); anxiety (6-item state-trait anxiety inventory); and adverse events questionnaires were administered on day 0 and day 14 after the procedures. Results: 100 patients agreed to participate out of 439 subjects who were invited (22.8%). The mean age was 59.5 years (+/-13.7) and 63% were males. Prevalence of BE was 50%.89 patients (89%) completed both procedures (11% failed TNE due to the inability to intubate the nasopharynx). Sensitivity, specificity and area under the receiver operating characteristic of TNE for the diagnosis of BE were 0.96 (95% confidence interval (CI) 0.85-0.99), 0.91 (95%CI 0.78-0.97), and 0.93 (95%CI 0.880.99), respectively.Patients reported higher preference for TNE compared to C-EGD on both day 0 (73.0% vs. 18.0%%, p!0.001) and day 14 (64.2% vs. 16.0%, p!0.001). Preference for TNE remained significantly higher in patients who had C-EGD under sedation (57.1% vs. 31.4%, p!0.001). Subjects also reported significantly better experience (mean VAS) with TNE compared to C-EGD on day 0 (7.5 vs. 5.6, p!
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB497
Preoperative
1 month
88 (76-90) 88 (55-100)
90 (86-94) 100 (81-100)
p
6 months
p
100 (17-100)
100 (100-100) 0.103 100 (100-100) 0.059
80 (57-84) 80 (72-88) 100 (58-100) 62 (45-100) 46 (35-73)
85 (80-85) 84 (81-88) 100 (83-100) 92 (72-100) 75 (57-77)
0.017 90 (90-95) 0.007 0.024 100 (100-100) 0.026
0.004 80 (81-85) 0.126 84 (80-88) 0.043 100 (100-100) 0.018 95 (84-100) 0.005 85 (72-97)
0.007 0.189 0.042 0.011 0.003
Tu1525 Management and Treatment for Complication (Accident) After PerOral Endoscopic Myotomy (POEM) in Achalasia Weon-Jin Ko*2, Suk Pyo Shin2, Ga Won Song2, Jun Hwan Yoo2, Duk Hwan Kim2, Kim Wonhee2, Kwang Hyun Ko2, Joo Young Cho2, Ki Baik Hahm2, Sung-Pyo Hong2, Pil Won Park2, Jun-Hyung Cho1 1 Digestive Disease Center, Soonchunhyang University Hospital, Seoul, Korea (the Republic of); 2Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam-si, Korea (the Republic of) Background: The aim of this study was to inform the safety of peroral endoscopic myotomy(POEM). So we investigated the management for complications after POEM in patients suffering from esophageal achalasia. Methods: A total of 54 cases for achalasia patients who underwent POEM from November 2011 to August 2014 were enrolled. The complications that arose after operation, and during follow-up were analyzed. Results: Postoperative complications included pneumoperitoneum(42.6%, 23/54), pleural effusion (37.0%, 20/54), subcutaneous emphysema(31.5%, 17/54), atelectasis of the lungs(20.4%, 11/54), pneumomediastinum(18.5%, 10/54), pneumonia(14.8%, 8/54), pneumoretroperitoneum(13.0%, 7/54), pulmonary congestion(3.7%, 2/54), gastric emphysema(1.9%, 1/ 54), and alveolar hemorrhage(1.9%, 1/54). No deaths occurred. All complications were resolved through conservative treatment. Conclusion: Complications arising after POEM can be treated and resolved by using conservative treatment. POEM was the safe endoscopic operation and can be expected to become the preferred treatment for achalasia.
Tu1526 PerOral Endoscopic Myotomy Is Safe and Effective for Achalasia With Failed Endoscopic Balloon Dilation Junfeng Zhou, Yuyong Tan, Tianying Duan, Deliang Liu* Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China Objective: Peroral endoscopic myotomy (POEM) is a promising technique for the treatment of achalasia (AC), however little is known about the safety and efficacy of POEM for AC patients with failure of prior endoscopic dilations. Our aim was to explore the safety and efficacy of POEM for AC with failed endoscopic balloon dilation (EBD). Methods: A retrospective study on AC patients who underwent POEM after failed EBD was performed. During August 2011 to May 2014, a total of 25 consecutive patients were included, clinical data about Eckardt score, lower esophageal sphincter pressure (LESP), esophageal diameter and POEM-related complications were collected and analyzed. Results: All the patients underwent POEM successfully with an average operation time of 64 minutes. The incidence of complications was 8% (2/25). After the procedure, the Eckardt score decreased significantly (6.08 VS 0.36, P!0.01), the LESP declined notably (32.01mmHg VS 13.64mmHg, P!0.01),the esophageal diameter reduced distinctly(54.44mm VS 32.68mm，P!0.01).Treatment success was achieved in 96% (24/25) of the cases with a follow-up of 6～36 months (median 24 months), no recurrence were noted. Conclusion: POEM is a safe and effective method for treatment of AC with failed EBD. Its long-term efficacy and complications need to be further assessed.
AB496 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
Tu1527 Long Term Outcome of PerOral Endoscopic Myotomy (POEM) in Achalasia Patients Weon-Jin Ko*2, Suk Pyo Shin2, Ga Won Song2, Jun Hwan Yoo2, Duk Hwan Kim2, Kim Wonhee2, Kwang Hyun Ko2, Joo Young Cho2, Ki Baik Hahm2, Sung-Pyo Hong2, Pil Won Park2, Jun-Hyung Cho1 1 Digestive Disease Center, Soonchunhyang University Hospital, Seoul, Korea (the Republic of); 2Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam-si, Korea (the Republic of) Background/Aims: Peroral endoscopic myotomy (POEM) was introduced as an alternative treatment for achalasia patients. The aim of this study was to evaluate the long term outcomes of POEM in achalasia patients. Methods: This is a retrospective analysis at two tertiary referral centers. A total of 12 achalasia patients underwent POEM between November 2011 and September 2012. Then the patients received periodic follow-up over 2 years. The main outcomes were Eckardt score, basal lower esophageal sphincter (LES) pressure, integrated relaxation pressure (IRP) score and procedure-related complications before and after POEM. Results: The length of myotomy was 8.65.4 cm. All patients showed a significant improvement in Eckardt score before and after POEM during median follow-up of 27.8 months (6.43.6 vs. 0.41.6; p!0.001). Also, significant decrease in LES pressure and IRP was found (30.8726.23 vs. 16.406.80;
www.giejournal.org
Abstracts
pZ0.003 and 26.2021.10 vs. 10.509.00; pZ0.007). Over 2 years, no symptom recurs occurred. Conclusion: Long term outcome of POEM for achalasia are excellent. In the future, large scale studies are needed to confirm this result.
Tu1528 Endoscopic Management of an Intramural Sinus Tract After Per Oral Endoscopic Myotomy (POEM) Amit Bhatt*1, Bradley Confer1, Jordan Holmes1, Matthew Kroh2, Scott L. Gabbard1, Arthi Kumaravel1, John H. Rodriguez2, Tyler Stevens1, Mansour A. Parsi1, John J. Vargo1, Jeffrey Ponsky2 1 Gastroenterology, Cleveland Clinic, Cleveland, OH; 2General Surgery, Cleveland Clinic, Cleveland, OH Introduction: As the volume of POEM procedures grows there will invariably be adverse events. It is important that effective treatments for these adverse events are discussed. We describe here the successful endoscopic management of a patient with a long intramural sinus tract originating from an open mucostomy site and incomplete myotomy after a POEM procedure. Case Presentation: A 43yo male with morbid obesity underwent a POEM procedure for type 3 achalasia. The procedure was performed without incident. 1. A mucosal incision was performed at 26cm from the incisors 2. A submucosal tunnel was formed with its extent beyond the gastroesophageal junction confirmed by retroflexion examination of the cardia. 3. A 14 cm circular muscle myotomy was performed. 4. Mucostomy site was closed with hemoclips. 14 days after the procedure the patient presented to hospital with chest pain. An upper GI series revealed a tight gastroesophageal junction with a long intramural sinus tract originating from the mucosotomy site. (Figure 1) Our working hypothesis was that the incomplete myotomy had resulted in increased esophageal pressures and disruption of the mucostomy closure site. So our attention was focused on addressing both the open mucosotomy site and the pressure at the GEJ. We accomplished this by placing tandem fully covered esophageal stents (23mm x 15cm and 23mm x 10cm) covering both the gastroesophageal junction and mucosotomy site. (Figure 2) The patient was started on total parental nutrition (TPN) and kept nil per mouth. The esophageal stents were removed 1 week later, and a subsequent upper GI series showed complete resolution of the intramural sinus. The incomplete myotomy may have been due to inaccurate endoscopic identification of submucosal tunnel extent that may occur as fluid and dye migrate into the cardia from the esophagus. The patient responded well to Botox injection into the lower esophageal sphincter. Conclusion: Post-POEM mucosotomy site leaks may be successfully treated with covered esophageal stent placement. In treating mucostomy site leaks an underlying etiology should be sought and addressed as well.
Figure 2.
Tu1529 Superior Patient Preference and High Diagnostic Accuracy for the Detection of Barrett’s Esophagus Using a Novel, Portable, ProbeBased TransNasal Endoscope Sarmed S. Sami*1, Massimiliano Di Pietro2, Jacobo Ortiz-Fernández-Sordo1, Jonathan R. White1, Indra Neil Guha1, Rebecca C. Fitzgerald2, Krish Ragunath1 1 Nottingham Digestive Diseases Centre and NIHR Biomedical Research Unit, University of Nottingham, Nottingham, United Kingdom; 2 Hutchison/MRC Research Centre, MRC Cancer Unit, Cambridge, United Kingdom
Figure 1.
www.giejournal.org
Introduction and Aims: Barrett’s Esophagus (BE) is the only recognized precursor to esophageal adenocarcinoma. The second generation EG ScanÔ system is portable with a disposable, ultrathin, probe-based imaging capsule; therefore it may be used in the community setting closer to the patient’s home. We aimed to compare the performance of unsedated transnasal endoscopy (TNE) using the EG ScanÔ with conventional esophagogastroduodenoscopy (C-EGD) for the detection of BE. Methods: This was a prospective, two-center, diagnostic study with tandem design. Consecutive adult patients with histologically confirmed BE and those referred for assessment of reflux or dyspepsia, were invited to participate. We excluded patients with recurrent epistaxis; nasal obstruction; and disease of the nasal cavity. All subjects underwent TNE (index test) followed by C-EGD (reference standard) on the same day, by two different operators blinded to the findings of each other. The primary outcome measure was the diagnostic accuracy for BE. In addition, procedure preference; tolerability (10-point visual analogue scale (VAS), 0 Z worst and 10 Z best); anxiety (6-item state-trait anxiety inventory); and adverse events questionnaires were administered on day 0 and day 14 after the procedures. Results: 100 patients agreed to participate out of 439 subjects who were invited (22.8%). The mean age was 59.5 years (+/-13.7) and 63% were males. Prevalence of BE was 50%.89 patients (89%) completed both procedures (11% failed TNE due to the inability to intubate the nasopharynx). Sensitivity, specificity and area under the receiver operating characteristic of TNE for the diagnosis of BE were 0.96 (95% confidence interval (CI) 0.85-0.99), 0.91 (95%CI 0.78-0.97), and 0.93 (95%CI 0.880.99), respectively.Patients reported higher preference for TNE compared to C-EGD on both day 0 (73.0% vs. 18.0%%, p!0.001) and day 14 (64.2% vs. 16.0%, p!0.001). Preference for TNE remained significantly higher in patients who had C-EGD under sedation (57.1% vs. 31.4%, p!0.001). Subjects also reported significantly better experience (mean VAS) with TNE compared to C-EGD on day 0 (7.5 vs. 5.6, p!
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB497