RESUMEN
BACKGROUND: Treatment for achalasia has traditionally been Heller myotomy (HM). Despite its excellent efficacy rate, a number of patients remain symptomatic post-procedure. Limited data exist as to the best management for recurrence of symptoms post-HM. We present an international, multicenter experience evaluating the efficacy and safety of post-HM peroral endoscopic myotomy (POEM). METHODS: Patients who underwent POEM post-HM from 13 centers from January 2012 to January 2017 were included as part of a prospective registry. Technical success was defined as successful completion of the myotomy. Clinical success was defined as an Eckardt score of ≤3 on 12-month follow up. Adverse events (AE) including anesthesia-related, operative, and postoperative complications were recorded. RESULTS: Fifty-one patients were included in the study (mean age 54.2, 47% male). Technical success was achieved in 100% of patients. Clinical success on long-term follow up was achieved in 48 patients (94%), with a mean change in Eckardt score of 6.25. Seven patients (13%) had AE: six experienced periprocedural mucosal defect treated endoscopically and two patients developed mediastinitis treated conservatively. CONCLUSION: For patients with persistent symptoms after HM, POEM is a safe salvation technique with good short-term efficacy. As a result of the challenge associated with repeat HM, POEM might become the preferred technique in this patient population. Further studies with longer follow up are needed.
Asunto(s)
Acalasia del Esófago/cirugía , Esfínter Esofágico Inferior/cirugía , Esofagoscopía/métodos , Miotomía/métodos , Cirugía Endoscópica por Orificios Naturales/métodos , Terapia Recuperativa/métodos , Acalasia del Esófago/diagnóstico , Esfínter Esofágico Inferior/fisiopatología , Humanos , Manometría , Persona de Mediana Edad , Presión , Estudios Prospectivos , Resultado del TratamientoRESUMEN
Background and study aims Per-oral endoscopic myotomy (POEM) is associated with a short-term clinical response of 82â% to 100â% in treatment of patients with achalasia. Data are limited on the long-term durability of the clinical response in these patients. The aim of this study was to determine the long-term outcomes of patients undergoing POEM for management of achalasia. Methods This was a retrospective multicenter cohort study of consecutive patients who underwent POEM for management of achalasia. Patients had a minimum of 4â years follow-up.âClinical response was defined by an Eckardt score ≤â3. Results A total of 146 patients were included from 11 academic medical centers. Mean (±âSD) age was 49.8 (±â16) years and 79 (54â%) were female. The most common type of achalasia was type II, seen in 70 (47.9â%) patients, followed by type I seen in 41 (28.1â%) patients. Prior treatments included: pneumatic dilation in 29 (19.9â%), botulinum toxin injection in 13 (8.9â%) and Heller myotomy in seven patients (4.8â%). Eight adverse events occurred (6 mucosotomies, 2 pneumothorax) in eight patients (5.5â%). Median follow-up duration was 55 months (IQR 49.9-60.6). Clinical response was observed in 139 (95.2â%) patients at follow-up of ≥â48 months. Symptomatic reflux after POEM was seen in 45 (32.1â%) patients, while 35.3â% of patients were using daily PPI at 48 months post POEM. Reflux esophagitis was noted in 16.8â% of patients who underwent endoscopy. Conclusion POEM is a durable and safe procedure with an acceptably low adverse event rate and an excellent long-term clinical response.