Mo1651 POEM (PerOral Endoscopic Myotomy): 3 Year Experience by a Gastroenterologist At a US Center. Still Safe and Effective Even in Patients With Advanced Age, Severe Achalasia and Severe Comorbidities

POEM (PerOral Endoscopic Myotomy): 3 Year Experience by a Gastroenterologist At a US Center. Still Safe and Effective Even in Patients With Advanced Age, Severe Achalasia and Severe Comorbidities Stavros N. Stavropoulos*, Rani J. Modayil, Collin E. Brathwaite, Bhawna Halwan, Vishal Ghevariya, Vineet Korrapati, Dolorita Dejesus, Shahzad Iqbal, David Friedel, James H. Grendell Medicine, Winthrop Univ. Hosp.-Columbia Univ., Roslyn, NY; Department of Gastroenterology, Hepatology and Nutrition, Winthrop University Hospital, Mineola, NY; Department of Surgery, Winthrop University Hospital, Mineola, NY Background: POEM represents a groundbreaking NOTES approach to LES myotomy that boasts excellent initial outcomes rivaling short-term outcomes of laparoscopic Heller myotomy (LHM). POEM represents a paradigm shift in treatment and is currently in an exponential growth phase. In 2009 we performed the first POEM outside of Japan and first worldwide by a gastroenterologist. Early adoption of POEM allowed maturation of our technique over the past 3 years which has now allowed us to increasingly perform POEM for “extended indications” including patients with significant comorbidities, advanced achalasia, prior failed treatments including failed LHM and advanced age. Many of these patients would not be considered candidates for LHM. Initial subjective data on post-POEM GERD suggested low incidence, however emerging objective data suggests it is similar to LHM with fundoplication. We report safety, efficacy, procedural and objective GERD data from our prospective series, one of the larger POEM series worldwide and possibly the largest single operator series by a gastroenterologist. Methods: 45 achalasia patients 18 y.o., able to consent, without contraindications to POEM were enrolled in a prospective IRB approved study. Preoperative evaluation included upper endoscopy, barium esophagram, chest CT, high resolution manometry. Our primary outcome was, as in other achalasia trials, decrease in the Eckardt score to 3. Secondary outcomes were post POEM adverse events, lower esophageal sphincter (LES) pressure, length of stay, reflux symptoms, esophageal pH study and timed barium. For the first 18 cases we used balloon dilation for tunnel dissection, a technique accessible to Western gastroenterologists with modest Endoscopic Submucosal Dissection (ESD) experience. For the last 27 cases we used ESD with a T-type hybrid knife that allows injection and dissection. Results: Table 1 depicts baseline characteristics and data on procedure, efficacy, GERD and adverse events (AE) for all patients from 10/2009 to 10/2012. Despite inclusion of “extended indication” patients during the latter half of the series, we demonstrate a learning curve effect in mean procedure time which decreased from 155 to 115 min after the first 20 cases (p 0.003). Two early patients (#3, #5) had treatment failure (Eckardt score 3) and underwent “salvage” balloon dilation with Eckardt score 1 at 23 months and 7 months post dilation. Conclusion: Our 3 year POEM series has the following notable features: 1.All cases performed by a gastroenterologist 2. Use of a technique accessible to operators with limited ESD experience 3. Inclusion of a number of “extended indication” patients without compromise in safety and efficacy, a sign of maturation of technique. Our objective data suggest GERD may be as common as after LHM with fundoplication.