Per-oral endoscopic myotomy (POEM): mid-term efficacy and safety
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Background and aims
Per-oral endoscopic myotomy (POEM) is becoming a standard treatment for achalasia. Long-term efficacy and the rate of post-POEM reflux should be further investigated. The main aim of this study was to analyze safety and mid-term (12 and 24 months) clinical outcomes of POEM.
Data on single tertiary center procedures were collected prospectively. The primary outcome was treatment success defined as an Eckardt score < 3 at 12 and 24 months. A total of 155 consecutive patients with achalasia underwent POEM; 133 patients were included into the analysis (22 patients will be analyzed separately as part of a multicenter randomized clinical trial).
POEM was successfully completed in 132 (99.2%) patients, and the mean length of the procedure was 69.8 min (range 31–136). One patient underwent a drainage for pleural effusion; no other serious adverse events occurred. Treatment success at 3, 12, and 24 months was observed in 95.5% (CI 89.6–98.1), 93.4% (86.5–96.8), and 84.0% (71.4–91.4) of patients, respectively. A total of 11 patients (8.3%) reported initial treatment failure (n = 5) or later recurrence (n = 6). The majority of relapses occurred in patients with achalasia type I (16.7 vs. 1.1% achalasia type II vs. 0% achalasia type III; p<0.05). At 12 months, post-POEM reflux symptoms were present in 29.7% of patients. At 3 months, mild reflux esophagitis was diagnosed in 37.6% of patients, and pathological gastroesophageal reflux was detected in 41.5% of patients. A total of 37.8% of patients had been treated with a proton pump inhibitor.
POEM resulted in greater than 90% treatment success at 12 months which tends to decrease to 84% after 2 years. More than one-third of the patients had mild reflux symptoms and/or mild esophagitis.
KeywordsPer-oral endoscopic myotomy Achalasia Gastroesophageal reflux
Integrated relaxation pressure
Lower esophageal sphincter
Laparoscopic Heller myotomy
Per-oral endoscopic myotomy
Timed barium esophagogram
Quality of life
The authors would like to express their thanks to Mrs. Jana Rauvolfova, Mrs. Gabriela Petranova, Mr. Tomas Hobza and Mr. Petr Haffner for their help and support of our POEM program.
There was no financial support from other parties.
J. Martinek: study concept, design, analysis of data, performing POEM, drafting the manuscript. H. Svecova, Z. Vackova, J. Krajciova, P. Loudova, L. Zdrhova: data acquisition and analysis, critical revision of the manuscript. R. Dolezel, T. Harustiak, A. Pazdro: study design, data acquisition and analysis, critical revision of the manuscript. P. Stirand: POEM performance, critical revision of the manuscript. O. Ngo: statistical analysis. E. Kieslichova, R. Janousek: analysis of complications and X-ray findings. J. Spicak: study concept and critical revision of the manuscript.
Compliance with Ethical Standards
Jan Martinek, Hana Svecova, Zuzana Vackova, Radek Dolezel, Ondrej Ngo, Jana Krajciova, Eva Kieslichova, Radim Janousek, Alexander Pazdro, Tomas Harustiak, Lucie Zdrhova, Pavla Loudova, Petr Stirand, Julius Spicak have no conflicts of interest or financial ties to disclose.
- 1.NOSCAR POEM White Paper Committee, Stavropoulos SN, Desilets DJ, Fuchs KH et al (2014) Per-oral endoscopic myotomy white paper summary. Gastrointest Endosc 80(1):1–15. doi: 10.1016/j.gie.2014.04.014
- 3.Familiari P, Gigante G, Marchese M, Boskoski I, Tringali A, Perri V, Costamagna G (2014) Peroral endoscopic myotomy for esophageal achalasia: outcomes of the first 100 patients with short-term follow-up. Ann Surg 30(11):4817–4826Google Scholar
- 4.Von Renteln D, Fuchs KH, Fockens P, Bauerfeind P, Vassiliou MC, Werner YB, Fried G, Breithaupt W, Heinrich H, Bredenoord AJ, Kersten JF, Verlaan T, Trevisonno M, Rösch T (2013) Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study. Gastroenterology 145(2):309-11.e1–309-11.e3. doi: 10.1053/j.gastro.2013.04.057 Google Scholar
- 5.Von Renteln D, Inoue H, Minami H, Werner YB, Pace A, Kersten JF, Much CC, Schachschal G, Mann O, Keller J, Fuchs KH, Rösch T (2012) Peroral endoscopic myotomy for the treatment of achalasia: a prospective single center study. Am J Gastroenterol 107(3):411–417. doi: 10.1038/ajg.2011.388 CrossRefGoogle Scholar
- 6.Teitelbaum EN, Soper NJ, Santos BF, Arafat FO, Pandolfino JE, Kahrilas PJ, Hirano I, Hungness ES (2014) Symptomatic and physiologic outcomes one year after peroral esophageal myotomy (POEM) for treatment of achalasia. Surg Endosc 28(12):3359–3365. doi: 10.1007/s00464-014-3628-1 CrossRefPubMedGoogle Scholar
- 11.Werner YB, Costamagna G, Swanström LL, von Renteln D, Familiari P, Sharata AM, Noder T, Schachschal G, Kersten JF, Rösch T (2015) Clinical response to peroral endoscopic myotomy in patients with idiopathic achalasia at a minimum follow-up of 2 years. Gut 65(6):899–906. doi: 10.1136/gutjnl-2014-308649 CrossRefPubMedGoogle Scholar
- 12.Bhayani NH, Kurian AA, Dunst CM, Sharata AM, Rieder E, Swanstrom LL (2014) A comparative study on comprehensive, objective outcomes of laparoscopic Heller myotomy with per-oral endoscopic myotomy (POEM) for achalasia. Ann Surg 259(6):1098–1103. doi: 10.1097/SLA.0000000000000268 CrossRefPubMedGoogle Scholar
- 15.Ramchandani M, Nageshwar Reddy D, Darisetty S, Kotla R, Chavan R, Kalpala R, Galasso D, Lakhtakia S, Rao GV (2016) Peroral endoscopic myotomy for achalasia cardia: treatment analysis and follow up of over 200 consecutive patients at a single center. Dig Endosc 28(1):19–26. doi: 10.1111/den.12495 CrossRefPubMedGoogle Scholar
- 17.Ngamruengphong S, Inoue H, Chiu P, Yip HC, Bapaye A, Ujiki M, Patel L, Desai PN, Hayee B, Haji A, Wong V, Perretta S, Dorwat S, Pioche M, Roman S, Rivory J, Mion F, Ponchon T, Garros A, Nakamura J, Hata Y, Balassone V, Onimaru M, Hajiyeva G, Ismail A, Chen YI, Bukhari M, Haito-Chavez Y, Kumbhari V, Maselli R, Repici A, Khashab MA (2016) Long-term outcomes of per-oral endoscopic myotomy in achalasia patients with a minimum follow-up of 2 years: an international multicenter study. Gastrointest Endosc 85(5):927–933. doi: 10.1016/j.gie.2016.09.017 CrossRefPubMedGoogle Scholar
- 19.Boeckxstaens GE, Annese V, des Varannes SB, Chaussade S, Costantini M, Cuttitta A, Elizalde JI, Fumagalli U, Gaudric M, Rohof WO, Smout AJ, Tack J, Zwinderman AH, Zaninotto G, Busch OR, European Achalasia Trial Investigators (2011) Pneumatic dilation versus laparoscopic Heller’s myotomy for idiopathic achalasia. N Engl J Med. 364(19):1807–1816. doi: 10.1056/NEJMoa1010502
- 20.Moonen A, Annese V, Belmans A, Bredenoord AJ, Bruley des Varannes S, Costantini M, Dousset B, Elizalde JI, Fumagalli U, Gaudric M, Merla A, Smout AJ, Tack J, Zaninotto G, Busch OR, Boeckxstaens GE (2016) Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut 65(5):732–739. doi: 10.1136/gutjnl-2015-310602
- 21.Yaghoobi M, Mayrand S, Martel M, Roshan-Afshar I, Bijarchi R, Barkun A (2013) Laparoscopic Heller’s myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized, controlled trials. Gastrointest Endosc 78(3):468–475. doi: 10.1016/j.gie.2013.03.1335 CrossRefPubMedGoogle Scholar
- 23.Rawlings A, Soper NJ, Oelschlager B, Swanstrom L, Matthews BD, Pellegrini C, Pierce RA, Pryor A, Martin V, Frisella MM, Cassera M, Brunt LM (2012) Laparoscopic Dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomized-controlled trial. Surg Endosc 26(1):18–26. doi: 10.1007/s00464-011-1822-y CrossRefPubMedGoogle Scholar
- 24.Falkenback D, Johansson J, Oberg S, Kjellin A, Wenner J, Zilling T, Johnsson F, Von Holstein CS, Walther B (2003) Heller’s esophagomyotomy with or without a 360 degrees floppy Nissen fundoplication for achalasia. Long-term results from a prospective randomized study. Dis Esophagus 16(4):284–290CrossRefPubMedGoogle Scholar
- 25.Richards WO, Torquati A, Holzman MD, Khaitan L, Byrne D, Lutfi R, Sharp KW (2004) Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg 240(3):405–412; discussion 412–415Google Scholar
- 27.Teitelbaum EN, Soper NJ, Arafat FO, Santos BF, Kahrilas PJ, Pandolfino JE, Hungness ES (2014) Analysis of a learning curve and predictors of intraoperative difficulty for peroral esophageal myotomy (POEM). J Gastrointest Surg 18(1):92–98; discussion 98–99. doi: 10.1007/s11605-013-2332-0