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Peroral Endoscopic Myotomy (POEM) for Esophageal Primary Motility Disorders: Analysis of 100 Consecutive Patients

  • 2014 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Introduction

Peroral endoscopic myotomy (POEM) is a flexible endoscopic approach to the lower esophageal sphincter (LES) providing access for a  myotomy to relieve dysphagia. The technique has been adopted worldwide due to reports of excellent short-term clinical outcomes. We report on a consecutive patient cohort with clinical and objective outcomes representing the establishment of a POEM program within a busy esophageal surgical practice.

Methods

Comprehensive data was collected prospectively on all patients undergoing POEM from October 2010 to November 2013 at a single institution. Patients were classified based on high-resolution manometry (HRM). Operative data and immediate outcomes were reviewed. Symptom scores, HRM, and timed barium swallow (TBS) were performed prior to the procedure. Patients were asked to undergo routine postoperative testing 6–12 months after surgery with the addition of standard 24-h pH to the preoperative protocol. Morbidity was defined as requiring additional procedures or prolonged hospital stay >2 days.

Results

One hundred POEM patients were included in the final analysis. The mean age was 58 years (18–83 years). Primary presenting symptoms included dysphagia 81, chest pain 10, and regurgitation 9. The mean follow-up was 16 months. HRM diagnoses were 75 achalasia (30 type I, 43 type II, 2 type III), 12 nutcracker esophagus, 5 diffuse esophageal spasm (DES), and 8 isolated hypertensive non-relaxing LES.

The mean operative time was 128 min. The median hospital length of stay (LOS) was 1 day. The overall morbidity was 6 %; all were treated endoscopically or with conservative management without further sequelae (three had intra-tunnel leak diagnosed on routine esophagram and one developed a postoperative intra-tunnel hemorrhage, one developed Ogilvie’s, and one required prolonged intubation for CO2 retention).

The average LES resting/residual pressure significantly decreased (44.3/22.2 to 19.6/11.7 in millimeters of mercury). Esophageal emptying improved from 40 to 90 % on TBS with 93 % patients demonstrating >90 % emptying at 1 min. Of the achalasia patients, 36 % (17/47) showed some return of normal peristalsis (≥70 % peristalsis) on post-op HRM.

Abnormal acid exposure was present on postoperative testing in 38 % (26/68). Of these, 14 were asymptomatic. No reflux patient required additional antireflux procedure.

Eckardt scores decreased from 6 to 1. Dysphagia was improved or eradicated in 97 % with a complete resolution accomplished in 89 %. Complete dysphagia relief was better for achalasia patients (46/47 patients; 97.8 %) vs. non-achalasia patients (17/24; 70.8 %). Of those with preoperative chest pain, 91.5 % reported complete relief.

Four patients have refractory dysphagia. Two non-achalasia patients underwent subsequent laparoscopic Heller myotomy and two are improved following serial endoscopic dilatations.

Conclusion

This study represents the largest POEM series to date that includes objective data. Despite reflux in one/three of patients, POEM provides excellent relief of dysphagia (97 %) and chest pain (91.5 %) for patients with esophageal spastic disorders with acceptable procedural morbidity.

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Conflict of Interest

No support or funding was obtained for this study.

Author information

Authors and Affiliations

  1. Foundation for Surgical Innovation and Education, 4805 NE Glisan St., Suite 6N60, Portland, OR, 97213, USA

    Ahmed M. Sharata, Christy M. Dunst, Aaron J. T. Wille, Kevin M. Reavis & Lee L. Swanström

  2. Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 3805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA

    Christy M. Dunst, Kevin M. Reavis & Lee L. Swanström

  3. Department of Surgery, Providence Portland Medical Center, 3805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA

    Christy M. Dunst, Radu Pescarus, Eran Shlomovitz & Lee L. Swanström

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  1. Ahmed M. Sharata
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Correspondence to Lee L. Swanström.

Additional information

Discussant

Dr. Eric S Hungness (Chicago, IL):

I would like to first offer congratulations on a fine presentation, although the title is a little misleading since type 1 and type 2 achalasia really are not “spastic” esophageal disorders. The Oregon Clinic group is to be commended for taking the US lead for POEM and continuing to offer the surgical community updates on their experience with this promising procedure. This presentation outlines 2-year data demonstrating outstanding clinical improvement and low morbidity on par with that of Heller myotomy.

I have 3 questions:

The first is regarding recognized full-thickness and mucosal perforations (23 % of your cases), which seem quite high, and your training program. In your previously published learning curve manuscript, there was a 40 % mucosal injury rate during your first 25 cases which then appropriately dropped to 6 % for the last part of that study up to patient 40. If my calculations are correct, the mucosal or full-thickness injury rate has increased to 22 % for the last 60 cases where fellows have been the primary surgeon. What do you think has contributed to the higher rate recently, and if so, what is being done to address it? Does it even really matter?

Second, were you able to evaluate your POEM achalasia outcomes, such as reflux rates, in regard to the Chicago classification subtype?

Lastly, are there any contraindications to POEM or any subset of patients that would benefit more from a laparoscopic myotomy instead of POEM, such as those with hiatal hernia or obesity?

Closing Discussant

Dr. Sharata:

Thank you Dr. Hungness for your comments.

The answer for the first question regarding inadvertant  mucosotomy is it is truly a learning curve marker. Our previously published learning curve paper represented our early experience showed this clearly; since then, we have trained an additional six fellows. The fellows were the primary surgeons for most of the POEM procedures, and as expected, their learning curve contributed to the increased mucosotomy injury rate.

In general, we recommend training for POEM on porcine explants and live porcine models to shorten the learning curve. We have shown that the mucosotomy injuries do not affect the clinical outcomes of the POEM patients. Therefore, mucosotomy injury is not included as one of the morbid complications according to the Portland esophagotomy classification of POEM and remains just  a learning curve marker.

Unfortunately, I am unable to tell you the clinical outcomes of our POEM achalasia patients according to the Chicago classification since we have only 3 patients with type III achalasia compared to the larger number of patients for achalasia types I and II.

Since POEM is a refluxogenic procedure for at least one/three of patients, we feel hiatal hernia is a contraindication except under very specific circumstances. Generally, we prefer a laparoscopic myotomy to allow concomitant hernia repair and partial fundoplication.

Currently, the only absolute contraindication to POEM is a lack of ability to undergo general anesthesia. In contrast, we believe that obese patients and non-achalasia patients can obtain great benefits from having the POEM procedure as compared with a laparoscopic myotomy.

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Sharata, A.M., Dunst, C.M., Pescarus, R. et al. Peroral Endoscopic Myotomy (POEM) for Esophageal Primary Motility Disorders: Analysis of 100 Consecutive Patients. J Gastrointest Surg 19, 161–170 (2015). https://doi.org/10.1007/s11605-014-2610-5

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