POEM in Latin America: The Rise of a New Standard.

BACKGROUND: Per-oral endoscopic myotomy (POEM) has become the preferred alternative treatment to standard Heller myotomy for patients with esophageal achalasia, in Latin American countries. The aim of our study was to evaluate the efficacy and safety of a POEM in the management of achalasia with and without Chagas disease in patients receiving POEM. METHODS: Patients who underwent POEM from tertiary centers in Latin America were included in a dedicated registry. Countries included Brazil, Colombia, Ecuador, Mexico, Nicaragua, and Venezuela. Patients enrolled needed to have a preoperative manometry and swallow contrast study confirming achalasia. Clinical success was defined as significant improvement in Eckardt score after therapy. RESULTS: POEM was technically successful in 81/89 (91%) patients (mean age, 44 y). There was a significant decrease in preprocedure and postprocedure Eckardt score from 8.7 (range, 3 to 12) to 2.15 (0 to 10) (P<0.001), preprocedure and postprocedure barium swallow evaluation (98% vs. 89%; P=0.017), and preprocedure and postprocedure lower esophageal sphincter pressure measurement (from 35 to 13.8 mm Hg; P<0.001). Clinical success was achieved in 93% of patients. Patients with Chagas disease (n=58) were 9.5 times more likely to respond to POEM (P=0.0020; odds ratio, 9.5). CONCLUSIONS: POEM is an efficacious and safe therapeutic modality for treatment of achalasia in Latin America. Chagas disease-related achalasia seems to particularly respond better to POEM when it is performed by experienced endoscopists.

The Learning Curve for Peroral Endoscopic Myotomy in Latin America: A Slide to the Right?

BACKGROUND/AIMS: Peroral endoscopic myotomy (POEM) has been increasingly used for achalasia in Latin America, where Chagas disease is prevalent, and this makes POEM more challenging. The aim of this study was to determine the learning curve for POEM in Latin America. METHODS: Patients undergoing POEM in Latin America with a single operator were included from a prospective registry over 4 years. Non-linear regression and cumulative sum control chart (CUSUM) analyses were conducted for the learning curve. RESULTS: A total of 125 patients were included (52% male; mean age, 59 years), of which 80 had type II achalasia (64%), and 38 had Chagas disease (30%). The average pre-procedure and post-procedure Eckardt scores were 6.79 and 1.87, respectively. Technical success was achieved in 93.5% of patients, and clinical success was achieved in 88.8%. Adverse events occurred in 27 patients (22%) and included bleeding (4 patients), pneumothorax (4 patients), mucosal perforation (13 patients), mediastinitis (2 patients), and leakage (4 patients).
The CUSUM chart showed a median procedure time of 97 min (range, 45-196 min), which was achieved at the 61st procedure. Procedure duration progressively decreased, with the last 10 procedures under 50 min approaching a plateau (p-value <0.01). CONCLUSION: Mastering POEM in Latin America requires approximately 61 procedures for both POEM efficiency and to accomplish the procedure within 97 minutes.

How does per-oral endoscopic myotomy compare to Heller myotomy? The Latin American perspective.

Background and study aims Both Heller myotomy (HM) and per-oral endoscopic myotomy (POEM) are efficacious therapies for achalasia. The efficacy and safety of POEM vs HM in Latin America and specifically in patients with Chagas disease is unknown. Patients and methods Consecutive patients undergoing either HM or POEM for achalasia were included from nine Latin American centers in a prospective registry over 5 years. Technical success was defined as undergoing a successful myotomy. Clinical success was defined as achieving an Eckardt score < 3. Data on demographics, procedure info, Eckardt score, and adverse events (AEs) were collected. Student's t test, Chi squared, and logistic regression analyses were conducted. Results One hundred thirty-three patients were included (59 male; 44 %; mean age 47). POEM was performed in 69 patients, HM in 64 patients. A total of 35 patients had Chagas disease, 17 of 69 in the POEM group, 18 of 64 in the HM group. Both groups had significant reduction in Eckardt scores ( P  < 0.00001), but successful initial therapy was significantly higher in the POEM group compared to the HM group ( P  = 0.01304). AEs were similar in both group (17 % vs 14 %) and consisted of pneumothorax (n = 3 vs 2), bleeding requiring transfusion (n = 3 vs 2), and mediastinitis (n = 3 vs 1). Hospital stay was longer in the HM group than in the POEM group ( P  < 0.00001). In the Chagas subgroup, post-procedure Eckardt score in the POEM group was significantly reduced by 5.71 points ( P  < 0.00001) versus 1.56 points in the HM group ( P  = 0.042793). Conclusion Both HM and POEM are efficacious for achalasia, but POEM was associated with higher initial therapy success and shorter hospital stay in Latin America. In Chagas patients with achalasia, POEM was significantly more effective than HM.