Sa1457 Pneumatic Dilatation (PD) Versus Laparoscopic Heller Myotomy (Lhm) Versus PerOral Endoscopic Myotomy (POEM) for the Treatment of Achalasia: a Single Center Experience

Sa1456 Per-Oral Endoscopic Myotomy (POEM) for Non-Achlasia Neuromuscular Disorders of the Esophagus Ahmed M. Sharata*, Christy M. Dunst, Radu Pescarus, Eran Shlomovitz, Kevin M. Reavis, Lee L. Swanstrom GMIS, Oregon Clinic, Portland, OR; GMIS, Providence Portland Medical Center, Portland, OR Background: Per-Oral Endoscopic Myotomy (POEM) has recently been described as an alternative to conventional myotomy for neuromuscular disorders of the esophagus. While efficacy and outcomes in achalasia are good, there is a paucity of literature in Non-Achalasia Neuromuscular Disorders (NAND). Historically, laparoscopic myotomies are followed by unpredictable and generally poor outcomes for NAND. The aim of this study is to review our experience with POEM in NAND patients. Methods: Comprehensive data was collected prospectively on all patients undergoing POEM for NAND between 11/2010 and 11/2013. Patients were classified as having diffuse esophageal spasm (DES), hypertensive nonrelaxing lower esophageal sphincter (LES), nutcracker esophagus with/without-relaxing LES based on manometry. Pre/postoperative symptom scores and high resolution manometry data were collected. Operative data was compared to a separate cohort of achalasia POEM patients. Results: Twenty-five patients underwent POEM for NAND with a median age was 64 years (range, 36-83 years). Twelve had nutcracker esophagus with/without nonrelaxing LES, eight had hypertensive nonrelaxing LES and five patients had DES. There was no mortality. There were no conversions to laparoscopy or thoracoscopy, no mediastinitis. Mean operative time was 128 mins. The incidence of inadvertent mucosotomy was 8% (2/25 patients) and capnoperitoneum requiring Veress decompression was 12% (3/25 patients). These were not different from POEM for achalasia despite the increased length of myotomy ( 11 cm NAND, 8 cm achalasia). Patients with DES had longer myotomies (12-23). Median follow up was 20 months (range, 7-36months). Complete resolution of dysphagia was obtained in 70% (pre/post median score 3/0) and chest pain in 71.5% (pre/post median score 1/ 0). Two patients (one nutcracker esophagus and one DES) underwent unremarkable laparoscopic Heller myotomy for refractory symptoms. Five patients underwent endoscopic dilations (1-2 episodes) for occasional dysphagia or chest pain and two other patients underwent multiple dilatations. Average LES resting pressure decreased from 44.2 to 26.6mmHg (pZ0.01). Average DECA decreased from 126.7mmHg to 53.7mmHg (pZ0.0009). Heartburn and regurgitation scores were unchanged by POEM (pZ0.94; pZ0.12). Conclusion: The POEM approach provides an avenue for long esophageal myotomies which avoids the traditional mediastinal exposure required for the treatment of patients with Non-Achalasia Neuromuscular Disorders (NAND) such as diffuse esophageal spasm and nutcracker esophagus. This early experience suggests POEM is a safe and effective treatment option for a majority of NAND patients. Sa1457 Pneumatic Dilatation (PD) Versus Laparoscopic Heller Myotomy (Lhm) Versus PerOral Endoscopic Myotomy (POEM) for the Treatment of Achalasia: a Single Center Experience Vivek Kumbhari*, Alan Tieu, Alba Azola, Mohamad H. El Zein, Eun Ji Shin, Ellen M. Stein, Bani Chander Roland, Monica Nandwani, Sameer Dhalla, Anne Marie Lennon, Vikesh K. Singh, Marcia I. Canto, Ahmed A. Messallam, Payal Saxena, Colin M. Gilmore, William J. Ravich, Anthony N. Kalloo, Pankaj J. Pasricha, John O. Clarke, Mouen Khashab AB220 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014 Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, MD Background: Patients who suffer from symptomatic idiopathic achalasia have a variety of therapeutic options. Pneumatic dilatation (PD), laparoscopic Heller myotomy (LHM) and Peroral Endoscopic Myotomy (POEM) are currently the three most attractive. PD is the least invasive but symptom recurrence appears common, often necessitating repeated dilatation or an alternative therapy such as LHM. POEM may be a potential alternative to LHM in those who have relapsed after PD or in those who have not undergone prior therapy. There is no available evidence comparing outcomes of these three procedures to help guide the clinician as to which of these therapies has the highest efficacy and safety. Aims: To review the efficacy and safety of PD, LHM and POEM in patients presenting to a single tertiary-care center. Methods: A retrospective single center review was performed of consecutive patients who underwent POEM, LHM or PD between 2008 to 2013. Sequential, graded PD (30-35-40mm) and LHM have been offered to patients throughout the duration of the study. POEM has been offered at our institution since 2012. Patients that underwent PD and then subsequently either POEM or LHM were included in the PD cohort as well as their respective POEM or LHM cohort. Endoscopic and surgical procedural data were abstracted and preand post-procedural symptoms (e.g. Eckardt stage) were recorded. Clinical remission was defined by improvement of symptoms and decrease in Eckardt stage to %I and the absence of subsequent therapy at any point in time for LHM and POEM and within 1 year for the PD cohort. Adverse events were graded according to the ASGE lexicon’s severity grading system. Results: In total, there were 118 patients that had undergone PD (nZ73), LHM (nZ66) or POEM (nZ21) for their management of achalasia. There were 42 patients in the PD group that had subsequently undergone LHM (nZ33) or POEM (nZ9). The pre-procedure characteristics were similar amongst all three groups (table 1). A total of 34 patients in the PD group required LHM or POEM within 12 months of dilation. Clinical remission for PD vs. LHM vs. POEM was 45% vs. 74% vs. 95% respectively, p!0.001. The mean duration of follow up was 10 and 3 months for LHM and POEM, respectively. There was no statistically significant difference in the rate and severity of complications amongst the three groups (table 2). In particular, there was only one severe complication (perforation) which occurred in the PD group. Conclusions: This is the first study to compare the main three currently available therapies for achalasia. Our data confirms frequent early symptom recurrence in patients undergoing PD. As achalasia is a chronic relapsing condition, suitable patients should consider LHM or POEM early in their management. Table 1. Pre procedural Characteristics PD (n[73) LHM (n[66)