Treatment of Achalasia with Per-Oral Endoscopic Myotomy: Analysis of 50 Consecutive Patients.

BACKGROUND: Peroral endoscopic myotomy (POEM) has become an acceptable incisionless treatment for achalasia based on encouraging outcomes in multiple series worldwide. This report reflects our early experience. METHODS: Data were collected prospectively on all patients undergoing POEM between June 2011 and April 2016 under IRB approval. Diagnosis of achalasia was confirmed by standard preoperative work-up. Primary outcome was symptom relief, measured by Eckardt score. Secondary outcomes were operative time, length of stay (LOS), adverse events, failure, and recurrence. RESULTS: Fifty patients were included; 30 were female. Mean age was 55.7 ± 17.7 years. Mean BMI was 29.5 ± 9.2. Median OR time was 133.5 minutes (range 70-462); average myotomy was 13.1 ± 2.3 cm. One early case was converted to a laparoscopic Heller myotomy due to extensive submucosal fibrosis from a recent Botox injection. Two cases were aborted; one due to extensive submucosal fibrosis and the other to intraoperative capnopericardium. Median LOS was 1 day (range 0.8-8). Two major complications occurred: intraoperative cardiac arrest due to capnopericardium and postoperative submucosal hemorrhage. There were no deaths. Mean postoperative Eckardt score was 1.0 ± 1.9 (range 0-8) at 2-6 weeks (vs. preoperative score 7.7 ± 2.8; P < .0001); mean dysphagia component 0.35 ± 0.28 (vs. preoperative score 2.6 ± 0.7; P < .0001). Two recurrences were identified, both at 6 months. CONCLUSIONS: POEM is a safe and durable treatment for achalasia in the short term. We demonstrated marked improvement of symptoms in all completed cases. There was an acceptable serious adverse event rate of 4%, failure of 6% due to patient selection, and recurrences occurring in only 4% of cases.

Comparison of peritoneal closure versus non-closure in laparoscopic trans-abdominal preperitoneal inguinal hernia repair with coated mesh.

BACKGROUND: Peritoneal closure during laparoscopic trans-abdominal preperitoneal (TAPP) inguinal hernia repair has been the standard of care to prevent bowel obstruction due to adhesions generated by contact with mesh. However, with newer coated meshes, leaving the peritoneal layer open may be safe. While many studies compare methods of peritoneal flap closure, there is a deficit of literature reporting the outcomes of non-closure. METHODS: A retrospective comparison of peritoneal flap closure versus non-closure during primary laparoscopic TAPP inguinal hernia repair with coated mesh was performed for all patients at Baystate Medical Center meeting inclusion criteria between January 2005 and August 2016. Primary outcome was any procedure-related adverse outcome following repair. Secondary outcomes included operative time, resolution of pre-operative pain and/or gastrointestinal symptoms, and hernia recurrence. RESULTS: Of 231 patients, 55 (24%) underwent peritoneal flap closure and 176 (76%) underwent non-closure. Demographic, comorbidity, and hernia characteristics were comparable between groups with the exception of obesity (p = 0.01), current smoking status (p = 0.05) and hernia side [p = 0.04 (left), 0.0003 (right)]. Mean operative time was higher in the closure group than non-closure (98.1 ± 37.1 min vs. 76.8 ± 32.9, p < 0.0001). No cases were converted to open. Average follow-up was 21.6 ± 23.8 months. Ninety-three percent of closure patients had documented resolution of pre-operative pain versus 94.0% of non-closure (p = 0.81). The closure group experienced a higher percentage of post-operative complications, though this did not reach significance (5.5 vs. 2.3%; p = 0.36). Compared to the closure group, the non-closure groups experienced similar post-operative pain (3.6 vs. 1.2%; p = 0.24) and recurrence rate (1.8 vs. 4.0%; p = 0.68). There were no bowel obstructions, surgical site infections, unplanned readmissions, or unplanned re-operations. CONCLUSIONS: Equivalent patient outcomes were seen for both procedure types post-operatively and during follow-up. Operative times were significantly shorter for non-closure patients. Larger study population and longer follow-up is necessary to evaluate true long-term complication rates in flap non-closure.