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683 Comparison of Perioperative Outcomes

After Per-Oral Esophageal Myotomy (POEM)
and Laparoscopic Heller...

Article in Journal of Gastrointestinal Surgery September 2012

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J Gastrointest Surg (2013) 17:228235
DOI 10.1007/s11605-012-2030-3

2012 SSAT QUICK SHOT PRESENTATION

Comparison of Perioperative Outcomes Between Peroral

Esophageal Myotomy (POEM) and Laparoscopic
Heller Myotomy
Eric S. Hungness & Ezra N. Teitelbaum &
Byron F. Santos & Fahd O. Arafat & John E. Pandolfino &
Peter J. Kahrilas & Nathaniel J. Soper

Received: 24 July 2012 / Accepted: 27 August 2012 / Published online: 28 September 2012
# 2012 The Society for Surgery of the Alimentary Tract

Abstract
Background Peroral esophageal myotomy (POEM) is a novel endoscopic operation for the treatment of achalasia. Few
POEM outcome data exist, and no study has compared POEM with the surgical standard, laparoscopic Heller myotomy
(LHM).
Methods Perioperative outcomes were compared between POEM and LHM performed in a nonrandomized fashion. Patients
in both groups met the following eligibility criteria: diagnosis of achalasia, age 1885, and absence of prior achalasia
treatment.
Results Eighteen patients underwent POEM, and 55 patients underwent LHM. Operative times were shorter for POEM (113
vs. 125 min, p<.05), and estimated blood loss was less (10 ml in all cases vs. 50 ml, p<.001). Myotomy lengths,
complication rates, and length of stay were similar. Pain scores were similar upon post-anesthesia care unit arrival and on
postoperative day 1 but were higher at 2 h for POEM patients (3.5 vs. 2, p0.03). Narcotic requirements were similar, although
fewer POEM patients received ketorolac. POEM patients Eckardt scores decreased (median 1 postop vs. 7 preop, p<.001), and
16 (89 %) patients had a treatment success (score 3) at median 6-month follow-up. Six weeks after POEM, routine follow-up
manometry and esophagram showed normalization of esophagogastric junction pressures and contrast column heights.
Conclusions POEM and LHM appear to have similar perioperative outcomes. Further investigation is needed regarding
long-term results after POEM.

Keywords Achalasia . Peroral endoscopic myotomy . Introduction

Laparoscopic Heller myotomy . Natural orifice transluminal
endoscopic surgery Achalasia is an idiopathic disease of esophageal physiology,
characterized by the manometric findings of absent peristal-
This study was presented at DDW: SSAT Quick Shots Session I on sis and a failure of esophagogastric junction (EGJ) relaxa-
May 21, 2012. tion upon swallowing. Achalasia results in progressively
E. S. Hungness (*) : E. N. Teitelbaum : B. F. Santos : severe dysphagia for solids and liquids, and can additionally
F. O. Arafat : N. J. Soper cause regurgitation, aspiration, chest pain, weight loss, and
Department of Surgery, Northwestern University
eventually an irreversible dilatation of the esophageal body.1
Feinberg School of Medicine,
676 North Saint Clair Street, Suite 650, Current primary treatment options include surgical myot-
Chicago, IL 60611, USA omy across the EGJ [laparoscopic Heller myotomy (LHM)]
e-mail: ehungnes@nmh.org and endoscopic pneumatic dilation of the EGJ, with a recent
randomized trial suggesting similar efficacy between the
E. N. Teitelbaum
Department of Surgery, George Washington University, two procedures at 2-year follow-up.2 However, substantial
Washington, DC, USA evidence suggests that LHM provides the most durable
symptom relief, without the need for repeat interventions,
J. E. Pandolfino : P. J. Kahrilas
as is often necessary with endoscopic dilation.35
Division of Gastroenterology and Hepatology, Northwestern
University Feinberg School of Medicine, Peroral esophageal myotomy (POEM) has recently been
Chicago, IL, USA introduced as a novel endoscopic operation for the treatment
J Gastrointest Surg (2013) 17:228235
of achalasia. POEM incorporates concepts of natural orifice
transluminal endoscopic surgery6 and expands upon techniques
used in endoscopic submucosal dissection7 in order to achieve
a division of the esophageal circular muscle fibers across the
EGJ and onto the stomach. As a result, POEM incorporates the
theoretical advantages of both endoscopic dilation (no skin
incisions, decreased pain, and less blood loss) and LHM
(durable surgical myotomy and single procedure).
A submucosal esophageal myotomy was first described
in an animal model by Pasricha and colleagues,8 and POEM
was first translated into clinical practice by Dr. Haru Inoue,
reported with colleagues in their landmark paper in 2010.9
Since that time, several small, single-institution POEM case
series have shown perioperative safety and excellent short-
term outcomes in terms of symptom resolution and improve-
ment in EGJ physiology.1012 However to date, no study has
directly compared POEM with the surgical standard of care,
LHM. In this study, we compare perioperative outcomes
between POEM and LHM performed at a single institution
in a nonrandomized fashion. Additionally, we present short-
term symptom and physiologic outcomes from our initial
POEM experience.
Methods
Patient Eligibility and Preoperative Evaluation
POEM procedures were performed at a single institution
under a Northwestern Institutional Review Board (IRB)-
approved study protocol. Patients referred for treatment of
achalasia were counseled regarding the existing treatment
options (endoscopic botulinum toxin injection, endoscopic
pneumatic dilation, LHM, and POEM) and elected to undergo
POEM. Patients undergoing POEM in this study met the
following eligibility criteria: diagnosis of achalasia confirmed
by manometry, age 1885, absence of prior treatment (either
endoscopic or surgical) for achalasia, and absence of sigmoid
esophagus. POEM procedures were performed conjointly by
the primary and senior authors. All POEM cases performed up
until the time of data analysis were included, so this series
represents the initial learning curve of the authors. All patients
signed a written consent for the procedure and outcomes data
collection.
The control group for this study was comprised of
patients who had undergone LHM at the same institution
by the same two surgeons, and who had enrolled in a
prospective outcomes database begun in 2004 under an
IRB-approved study protocol. Only LHM patients meeting
the same eligibility criteria preoperatively as the POEM
patients (diagnosis of achalasia, age 1885, no prior acha-
lasia treatment, and absence of sigmoid esophagus) were
included for comparison.
229
Preoperatively, patients in both groups were evaluated
with a history and physical examination, upper endoscopy,
timed barium esophagram (TBE), and high-resolution ma-
nometry (HRM). TBE was performed using a 200-ml oral
bolus of low-density barium, with radiographs taken at 1, 2,
and 5 min after swallowing. HRM was performed using a
previously described technique13 and interpreted according
to the Chicago Classification of esophageal pressure
topography.14 The following patient demographics were
also recorded prospectively: age, body mass index (BMI),
and American Society of Anesthesiologists (ASA) Physical
Classification status. An Eckardt symptom score15 (which
measures frequency of dysphagia, regurgitation and chest
pain, and amount of weight loss, each on a scale of 03
resulting in a total scale of 012 with higher scores indicat-
ing more severe disease) was recorded preoperatively for
POEM patients, but was not included in the symptom sur-
veys given to LHM patients.
POEM Operative Technique
POEM was performed in a fashion similar to that described
by Inoue and colleagues.9 Patients are kept on a clear liquid
diet for 48 h preoperatively and complete a 5-day course of
oral liquid nystatin for candida prophylaxis (added to our
protocol starting with patient #9). POEM is performed under
general anesthesia with endotracheal intubation and muscle
paralysis. Patients are positioned supine with the left arm
tucked at the side and the right arm abducted. The patients
systolic blood pressure is kept below 100 mmHg throughout
the procedure if possible.
An initial upper endoscopy is performed using a single-
channel, high-definition flexible gastroscope (GIF-H180
gastroscope; Olympus America, Inc., Center Valley, PA)
with carbon dioxide (CO2) insufflation. The esophagus
and stomach are aspirated of any residual fluid, and the
stomach is desufflated. The endoscope is then fitted with a
transparent oblique dissecting cap, and the distance from the
incisors to EGJ is measured on the scope shaft. Approxi-
mately 10 ml of solution containing indigo carmine (0.2 mg/
ml), epinephrine (5 mcg/ml), and 0.9 % saline is then
injected into the anterior esophageal wall 14 cm proximal
to the EGJ to form a submucosal bleb. A triangle-tip (TT)
endoscopic cautery knife (Triangle Tip Knife; Olympus) is
used to make a longitudinal mucosotomy over the site of the
fluid bleb, and the scope is maneuvered into the submucosal
space. A combination of blunt dissection and electrocautery
with the TT knife is then used to create an anterior submu-
cosal tunnel extending at least 3 cm caudal to the EGJ.
Additional indigo carmine solution is sequentially injected
to mark progression of the tunnel, as well as to aid in
hydrodissection and hemostasis. Once the submucosal tun-
nel is completed, the endoscope is withdrawn from the
230
tunnel and advanced into the gastric lumen to ensure that
indigo carmine dye is visible in the stomach submucosa, at
least 3 cm distal to the EGJ. If it is not, the submucosal
dissection is extended caudally.
A selective myotomy of only the inner, circular muscle
layer is then begun using the TT knife to lift and divide
individual fibers. A starting point is chosen several centi-
meters distal to the caudal extent of the mucosotomy, and
the myotomy is carried past the EGJ to the distal end of the
submucosal tunnel. After completing the myotomy, the
scope is reintroduced into the true esophageal lumen to
evaluate the effect of the myotomy on EGJ patency. After
the myotomy is deemed to be satisfactory, the submucosal
tunnel is irrigated with bacitracin solution, and the
mucosotomy is closed with endoscopic clips (QuickClip;
Olympus).
Postoperatively, patients are extubated and transferred to
the post-anesthesia care unit (PACU). Patients are kept nil
per os (NPO) on the night of surgery and receive standing
intravenous (IV) antiemetics and pain medication as needed.
On the morning of postoperative day (POD) 1, patients
undergo a contrast esophagram. If there is no evidence of
leak and adequate passage of contrast past the EGJ, patients
are started on a clear liquid diet for breakfast and, if toler-
ated, advanced to full liquids for lunch. If progressing as
expected, patients are discharged home on the afternoon of
POD #1. A full liquid diet is maintained for 2 weeks and
then gradually liberalized to include soft and solid foods.
LHM Operative Technique
Our technique for LHM has previously been described in
detail.16 Briefly, after establishing a pneumoperitoneum,
five trocars are placed. The phrenoesophageal ligament is
divided, and the diaphragmatic crura are opened. The ante-
rior mediastinal esophagus is dissected free from the sur-
rounding structures, and the short gastric vessels are divided
to mobilize the fundus. The anterior gastric fat pad and
anterior vagus nerve are dissected free from the stomach
and esophagus, and a myotomy of both muscle layers is
performed using a combination of blunt and electrocautery
dissection to at least 6 cm proximal and 2 cm distal to the
EGJ. After endoscopic visualization of the EGJ to confirm
adequacy of the myotomy and check for leak, an antireflux
procedure is performed. We prefer a posterior Toupet fun-
doplication, unless an excessive anterior angulation of the
EGJ results or if there is concern for esophageal perforation,
in which case an anterior Dor fundoplication is performed.
Postoperatively, patients are given standing IV antiemetics
and pain medication as needed. They are allowed clear liquids
on the day of surgery and advanced to soft diet the morning
after if progressing as expected. An esophagram is not rou-
tinely performed, and patients are typically discharged home
J Gastrointest Surg (2013) 17:228235
on the afternoon of POD #1 and maintained on a soft diet for
2 weeks.
Perioperative Data Collection
For both groups, the following intraoperative data were
collected prospectively: operative time (from initial endo-
scope insertion to final endoscope withdrawal for POEM,
and initial skin incision to final skin closure for LHM),
estimated blood loss (EBL), myotomy length, and compli-
cations. POEM myotomy lengths were measured by sub-
tracting the length on the endoscope shaft from the incisors
to the proximal myotomy edge from the shaft length from
incisors to the distal myotomy edge. LMH myotomy lengths
were measured using the distance between the open jaws of
a Hunter grasper (2.5 cm) as a ruler. Postoperatively, hospital
length of stay and 30-day mortality and complications were
recorded prospectively. Pain scores (scale 010) at PACU
arrival, 2-h postoperatively, and on the morning (8 am) of
POD #1 were obtained from nursing assessment records.
Narcotic administration was derived from the medication
administration record and converted into IV morphine equiv-
alents for comparison.
Follow-up Physiologic Studies and Symptom Scores
At 6 weeks postoperatively, POEM patients underwent per-
protocol HRM and TBE. Follow-up upper endoscopy was
performed at the discretion of each patients gastroentero-
logist at variable time intervals, or as indicated by postop-
erative symptoms. POEM patients were contacted via
telephone every 3 months postoperatively to assess for
complications and to obtain a current Eckardt score. An
Eckardt score 3 was considered a therapeutic success.2
Symptomatic gastroesophageal reflux (GER) was assessed
in POEM patients every 3 months postoperatively using the
GerdQ questionnaire.17 A score 7 (scale 018) was con-
sidered positive for GER, in line with established usage of
the questionnaire. LHM patients did not have routine short-
term physiologic follow-up studies, postoperative Eckardt,
or GerdQ scores.
Statistical Analysis
SPSS software (version 20; IBM, Armonk, NY) was used
for data analysis. Continuous and ordinal variables were
compared between groups using a MannWhitney U test.
Paired variables in the same patient before and after surgery
were compared using a Wilcoxon signed-rank test. Categorical
variables were compared using a Fisher exact test. A two-tailed
p value <.05 was considered statistically significant in all
cases. Data are presented throughout as median (minimum
maximum).
J Gastrointest Surg (2013) 17:228235 231

Results
From August 2010 to May 2012, 18 patients underwent
POEM and from March 2004 to May 2012, 55 patients
meeting the same eligibility criteria underwent LHM (60
patients who underwent LHM during the same time period
were excluded because they had received prior treatment,
had a sigmoid esophagus, or were <18 or >85 years old).
Gender distribution, BMI, ASA classification, and duration
of symptoms were all similar between groups (Table 1).
POEM patients were younger [38 (2269) vs. 49 (2279)
years, p0.03]. On preoperative HRM, 4-s integrated relaxa-
tion pressures (IRP), nadir relaxation pressures, and achalasia
subtype distribution were similar between groups, but POEM
patients had lower expiratory EGJ resting pressures [19 (751)
vs. 30 (860), p0.02].
Operative times were slightly shorter for POEM [113
(88220) vs. 125 (90195)min, p<.05), and EBL was less
[10 ml in all cases vs. 50 (10250)ml, p<.001). Myotomy
lengths were similar between groups (Table 2). In the PO-
EM cases, nine (717) clips were required to close the
mucosotomy, and Veress needle decompression of the pneu-
moperitoneum was required intraoperatively in seven
(39 %) cases. Two POEM cases were initially aborted after
endoscopy revealed esophageal candidiasis. These patients
completed a course of oral nystatin and had a subsequent
upper endoscopy to confirm resolution of candidiasis prior
to undergoing POEM.
No mortalities and one major complication (Clavien
Dindo18 grade IIIb) occurred in both groups. A POEM
patient had a contained perforation at the level of the EGJ.
The patient was non-compliant with NPO orders and ate
solid food on the night of her operation. She developed
retching and abdominal pain on postoperative day 1, and
an esophagram revealed a contained perforation at the EGJ.
She was taken back to the operating room where endoscopy
and laparoscopy failed to demonstrate a discrete esophageal
defect, and drains were placed. She initially recovered well,
but went on to develop recurrent dysphagia over the next
several months, potentially due to scarring as a result of the
perforation. A LHM patient had an esophageal perforation
that required bilateral thoractomy for drainage and repair.
He complained of dyspnea on POD #2, and a CT scan of the
chest showed a right lung consolidation and pneumomedias-
tinum but no esophageal leak. He was treated for presumed
aspiration pneumonia, but his symptoms persisted, and a
repeat CT scan revealed extravasation of contrast from the
distal esophagus and large right-sided pleural effusion. The
patient was taken to the operating room, and a right-sided
thoracotomy was performed to debride the right chest and
repair the leak. However, an anterior perforation was found
that was not entirely accessible from the right chest, so a left
thoracotomy was then performed for primary esophageal
repair with a reinforcing intercostal muscle flap. The patient
recovered after a 19-day hospitalization. Three (17 %) minor
complications (ClavienDindo grade I) occurred in the PO-
EM group and seven (13 %) in the LHM group (p0ns; listed
in Table 2). The median length of stay was 1 day in both
groups.
Pain scores were similar upon PACU arrival and on the
morning of POD #1 but were higher at 2 h in POEM patients
[3.5 (08) vs. 2 (010), scale 010, p 0.03). Narcotic

Table 1 Preoperative patient

demographics POEM LHM p value

Number 18 55
Female 5 (28 %) 26 (47 %) .18
Median (range) age 38 (2269) 49 (2279) .03
BMI (kg/m2) 25 (1945) 27 (1748) .86
ASA classification .95
I 2 (11 %) 4 (7 %)
II 12 (67 %) 39 (71 %)
III 4 (22 %) 12 (22 %)
Duration of symptoms (years) 1 (0.1330) 1.25 (0.2515) .54
Preoperative HRM
Basal expiratory pressure (mmHg) 19 (751) 30 (860) .02
4-s IRP (mmHg) 23 (1059) 26 (1070) .84
Nadir relaxation pressure (mmHg) 19 (952) 19 (962) .87
Achalasia subtype .48
I 33 % 20 %
II 61 % 77 %
The bolded value represents III 6% 3%
statistical significance
232 J Gastrointest Surg (2013) 17:228235

Table 2 Perioperative outcomes

POEM LHM p value

Median (range) operative time (min) 113 (88220) 125 (90195) <.05
Myotomy length (cm) 9 (614) 8.5 (710) .18
EBL (ml) 10 in all cases 50 (10250) <.001
Clips required to close mucosotomy 9 (717)
Veress needle decompression 7 (39 %)
of pneumoperitoneum
Major complications (grade IIIb) 1 (6 %) 1 (2 %) .45
- Esophageal perforation - Esophageal perforation
Minor complications (grade I) 3 (17 %) 7 (13 %) .71
- Subcutaneous - Anterior vagus nerve
emphysema division
- Atrial fibrillation - Splenic capsule tear
- Urinary retention - Aspiration
- Atrial fibrillation
- Urinary retention 2
- Readmission for chest pain
The bolded value represents Length of stay (days) 1 (113) 1 (119) .63
statistical significance

requirements were similar between groups, although fewer
POEM patients received IV ketorolac (28 vs. 80 %, p<.001;
Table 3).
Sixteen POEM patients had per-protocol HRM at 6 weeks
postoperatively. Resting expiratory EGJ pressures decreased
to normal median values [pre 19 (751)mmHg vs. post 9
(023)mmHg, p<.001) as did IRP [pre 21 (1059)mmHg
vs. post 12 (618)mmHg, p<.001; Fig. 1]. Thirteen POEM
patients completed follow-up TBE at 6 weeks, with signif-
icantly decreased column heights at 1, 2, and 5 min on their
postoperative studies [pre 17 (931), 16 (931), and 14 (031)
cm vs. post 7 (015), 5 (013), and 0 (09) cm, p.001; Fig. 2].
Postoperative upper endoscopy was performed on 15 POEM
patients at a median follow-up interval of 1.5 (1.512)months.
Esophagitis was present in five (33 %) patients (Los Angeles
class A, 2; B, 2; C, 1).
Among POEM patients, Eckardt scores (scale 012) de-
creased from 7 (512) preoperatively to 1 (09; p<.001) at
median 6 (range, 118) month follow-up. Symptomatic
recurrence (defined as an Eckardt score 4 at any time
point) occurred in two (11 %) POEM patients: the patient
in whom the contained leak occurred and the first patient in
our series. Both patients were subsequently successfully
salvaged with a LHM.
Four (22 %) POEM patients had a GerdQ score 7,
indicating symptomatic GER, at the same follow-up inter-
val. Seven (39 %) patients had either esophagitis on endos-
copy or a GerdQ score 7: two patients had both esophagitis
on EGD and a GerdQ 7, two patients had a GerdQ 7 but
EGDs negative for esophagitis, and three patients were
asymptomatic (i.e., GerdQ06) but had esophagitis on EGD.
Discussion
This study adds to the existing evidence that POEM is a
feasible and safe procedure for creating an endoscopic
myotomy in patients with treatment-nave achalasia. Addi-
tionally, POEM appears to have perioperative outcomes on
par with those of the surgical standard of care, LHM. During
this, our initial learning curve, the POEM procedure created
myotomies of similar length with slightly shorter operative
times when compared with LHM. Shorter operative times,
along with markedly reduced EBL and the absence of skin

Table 3 Postoperative pain

scores and pain medication POEM LHM p value
usage
Median (range) pain score on PACU arrival (scale 010) 2.5 (09) 2 (09) .76
Pain score at 2 h 3.5 (08) 2 (010) .03
Pain score on POD #1 1.5 (08) 2 (010) .71
Narcotics on day of surgery (mg morphine equivalents) 8.5 (036) 6.7 (031.4) .18
Narcotics on POD #1 2.5 (021) 3.3 (018) .85
The bolded value represents Number of patients receiving ketorolac 5 (28 %) 44 (80 %) <.001
statistical significance
J Gastrointest Surg (2013) 17:228235
Fig. 1 POEM patients pre- and 6-week postoperative high-resolution
manometry results (n016)
incisions, all reinforce the concept that POEM is a less
invasive procedure than LMH. However, the advantages of
POEM in terms of operative time and EBL were small, and
it is unknown whether these differences will translate into
any concrete clinical benefits for patients.
We found similar intra- and perioperative complication
rates between the two procedures, providing initial evidence
Fig. 2 POEM patients pre- and 6-week postoperative timed barium
esophagram results (n013)
233
that POEM has a safety profile comparable with LHM. One
contained esophageal perforation occurred at the level of the
EGJ in a patient who was non-compliant with NPO orders
and ate solid food on the night of her operation. It is unclear
whether this perforation was the result of food impaction or
if it would have manifested radiographically and/or clinically
regardless of adherence to postoperative protocol. Although
we have had no radiographic or clinically apparent leaks at the
site of the mucosotomy clip closure, we are still extremely
cautious when advancing a patients diet after POEM. All
patients are kept strictly NPO on the night of surgery and are
only given liquids after a contrast esophagram is negative for
leak. While postoperative care of these patients may liberalize
after a large enough collective experience demonstrates the
security of mucosotomy clip closure, at present, we do not
envision POEM being safely performed as an outpatient, or
same-day, procedure.
One other complication specific to POEM occurred in a
patient who developed subcutaneous emphysema postoper-
atively. This resolved spontaneously without sequelae, but
the patient required an additional day of hospitalization for
pain control and observation. Although the aim during PO-
EM is to leave the layer of longitudinal muscle fibers intact,
some degree of pneumomediastinum, and potentially pneu-
moperitoneum, pneumothorax, and/or subcutaneous emphy-
sema, will likely result regardless of technique. The largest
published POEM series to date, by Ren and colleagues,
highlights some of these POEM-specific complications.19
In their series of 119 cases, 23 % of patients developed
subcutaneous emphysema intraoperatively and an additional
56 % postoperatively. Three of these patients required treat-
ment with subcutaneous needle decompression.
Additionally, 3 % of their patients developed a pneumo-
thorax intraoperatively and another 25 % postoperatively. A
routine chest CT scan was performed on POD #1 which may
have detected some clinically insignificant pneumothoraces;
however, 17 patients (14 % of the total series) required chest
tube decompression, bilaterally in 4 cases. These data un-
derscore the points that CO2 (as opposed to room air) scope
insufflation should be used throughout POEM and that any
intra- or postoperative hemodynamic decompensation
should be treated as a tension pneumothorax until proven
otherwise.
Interestingly, no patients in the above series required
intraoperative decompression for pneumoperitoneum, as op-
posed to our experience in which seven (39 %) patients
required abdominal Veress needle placement, but no pneu-
mothoraces occurred at any time point. We hypothesize that
this may be due to the fact that Ren et. al. perform their
submucosal dissection in the posterior wall of the esopha-
gus, which may predispose to pneumothorax, whereas an
anterior tunnel (our approach) may result in a relatively
increased incidence of pneumoperitoneum.
234
In the immediate postoperative period, POEM appears to
result in levels of pain comparable with LHM. In fact, pain
scores were slightly higher in POEM patients at the 2-h time
point. Inpatient narcotic usage was similar on both the day
of surgery and POD #1, although fewer POEM patients
received ketorolac postoperatively (28 vs. 80 %, p<.001)
due to concern for bleeding in the submucosal tunnel. We
hypothesize that this discrepancy was partially responsible
for their higher 2-h pain scores. The first several patients in
our series were given standing ketorolac, but we discontinued
its usage in subsequent patients after encountering bleeding
during submucosal dissection in early cases and based on an
anecdotal report from another institution that a submucosal
hematoma had caused dysphagia in a POEM patient postop-
eratively. The safety of postoperative ketorolac in POEM
patients has yet to be conclusively determined.
In terms of symptomatic efficacy, POEM patients had
significantly decreased Eckardt scores to a median score of
1, and our therapeutic success rate (i.e., Eckardt score 3)
was 89 % at median 6-month follow-up. This is in line with
previously published POEM outcomes,9,10,12 as well as
historic data from well-designed LHM trials.2,20 The two
patients with symptomatic recurrences both underwent sub-
sequent LHM. During these operations, an anterior myot-
omy was performed, in a similar fashion to which we would
approach a reoperation after a failed Heller myotomy. In
both cases, some mild adhesions were encountered when
initially establishing the plane between esophageal muscu-
laris and submucosa. However, there was no mediastinal
inflammation, and once the correct plane was entered, the
myotomies proceeded as normal. Both of these reoperations
resulted in symptom resolution, providing initial evidence
that LHM can be used as a salvage procedure in patients
who develop recurrent dysphagia after POEM. Successful
endoscopic dilation after failed POEM has also been
reported10 and may serve as an alternative treatment modality
to salvage these patients.
On short-term follow-up HRM, POEM appears to result
in a normalization of EGJ pressures. Both IRP and resting
expiratory EGJ pressures were significantly reduced at
6 weeks postoperatively (Fig. 1). This mirrors the findings
of prior series, which have shown significant improvements
in EGJ physiology after POEM.9,10,12 TBE contrast column
heights also normalized on postoperative studies, further
supporting the concept that POEM results in improved
functional bolus passage through the EGJ (Fig. 2).
As opposed to LHM, POEM does not include an antire-
flux procedure, which could potentially result in increased
rates of GER postoperatively. Conversely, preservation of
the longitudinal muscle fibers and avoidance of dissection
and repair of the diaphragmatic crura may help prevent GER
after POEM. In our series, 33 % of patients who had post-
operative upper endoscopies had evidence of esophagitis;
J Gastrointest Surg (2013) 17:228235
however, only four patients (22 % of the overall series) had
symptomatic GER, as defined by a GerdQ score 7. All
were started on a proton pump inhibitor (PPI), and their
long-term outcomes in terms of symptoms, resolution of
esophagitis, and PPI dependence have yet to be determined.
The LMH literature is extremely variable in terms of post-
operative GER, with incidences of abnormal acid exposure
on 24-h pH studies ranging from 3 to 42 %,2,2022 which
may be a function of differences in fundoplication construc-
tion and operator experience. An important research objec-
tive in our, and other, POEM series going forward will be
the systematic administration of 24-h pH studies at longer
follow-up intervals as no such data after POEM have been
published to date.
Our study has several limitations. Most importantly,
patients were not randomized to treatment modality. This
may have resulted in differences in baseline characteristics
between groups, as is evidenced by the fact that LHM were
older and had higher baseline resting expiratory EGJ pres-
sures on preoperative HRM. Beginning in August 2010, all
patients who met the eligibility criteria were offered pneu-
matic dilation, LHM, or POEM as treatment options. LHM
was described to patients as the surgical standard of care and
POEM as a novel procedure under investigation with limited
outcomes data. Anecdotally, approximately 75 % of patients
who qualified for both operations chose POEM. As a result,
patient selection bias may have created additional unrecog-
nized differences between the treatment groups.
Additionally, PACU and ward nurses were not blinded to
treatment group, which could potentially introduce bias into
recorded pain scores and the amount of pain medication
administered as needed. All patients in this series were
treatment nave, and although POEM after endoscopic ther-
apy (botulinum toxin injection and/or dilation) has been
described,1012,19 further investigation is needed regarding
the effects of prior treatment on POEM safety and efficacy.
Additionally, this study represents our initial experience
with POEM in a clinical setting, and post-learning curve
results may differ significantly. Ideally, a multi-institution
randomized trial comparing POEM and LHM should be
conducted to more conclusively address these research
questions.
In conclusion, this study adds to the existing evidence
that POEM is a feasible and safe procedure for primary
treatment of achalasia. POEM results in an equally long
myotomy as LHM, but with slightly shorter operative times
and lower EBL. POEM does not appear to result in less pain
postoperatively than LHM, and narcotic requirements are
similar. At short-term follow-up, POEM results in signifi-
cant improvement of EGJ physiologic function as measured
by HRM and TBE. Further data are required regarding long-
term symptomatic and physiologic outcomes in terms of
both esophageal function and GER after POEM.
J Gastrointest Surg (2013) 17:228235
Acknowledgments The authors would like to acknowledge Remedios
Manuel, R.N., Colleen Krantz, R.N., and Meghan Thompson for their
help coordinating the clinical aspects of the study.
Disclosures Olympus America, Inc. granted instruments used during
the POEM procedures, but was not involved in the study design, data
collection, analysis, or manuscript preparation. John E. Pandolfino has
consulting agreements with Given Imaging and Crospon. Nathaniel J.
Soper is on the scientific advisory boards of TransEnterix and Miret
Surgical. Eric S. Hungness, Ezra N. Teitelbaum, Byron S. Santos, Fahd
O. Arafat, and Peter J. Kahrilas have no conflicts of interest or financial
ties to disclose.
References
1. Francis DL, Katzka DA. Achalasia: update on the disease and its
treatment. Gastroenterology 2010;139:36974.
2. Boeckxstaens GE, Annese V, des Varannes SB, et al. Pneumatic
dilation versus laparoscopic Hellers myotomy for idiopathic achalasia.
The New England journal of medicine 2011;364:180716.
3. Patti MG, Pellegrini CA. Esophageal achalasia 2011: pneumatic
dilatation or laparoscopic myotomy? Journal of gastrointestinal
surgery : official journal of the Society for Surgery of the Alimen-
tary Tract 2012;16:8703.
4. Kostic S, Kjellin A, Ruth M, et al. Pneumatic dilatation or laparo-
scopic cardiomyotomy in the management of newly diagnosed
idiopathic achalasia. Results of a randomized controlled trial.
World journal of surgery 2007;31:4708.
5. Campos GM, Vittinghoff E, Rabl C, et al. Endoscopic and surgical
treatments for achalasia: a systematic review and meta-analysis.
Annals of surgery 2009;249:4557.
6. Rattner D, Kalloo A, Group ASW. ASGE/SAGES Working Group
on Natural Orifice Translumenal Endoscopic Surgery. October
2005. Surgical endoscopy 2006;20:32933.
7. Othman MO, Wallace MB. Endoscopic mucosal resection (EMR)
and endoscopic submucosal dissection (ESD) in 2011, a Western
perspective. Clinics and research in hepatology and gastroenterology
2011;35:28894.
8. Pasricha PJ, Hawari R, Ahmed I, et al. Submucosal endoscopic
esophageal myotomy: a novel experimental approach for the treatment
of achalasia. Endoscopy 2007;39:7614.
9. Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy
(POEM) for esophageal achalasia. Endoscopy 2010;42:26571.
10. von Renteln D, Inoue H, Minami H, et al. Peroral endoscopic
myotomy for the treatment of achalasia: a prospective single center
study. The American journal of gastroenterology 2012;107:4117.
View publication stats
235
11. Swanstrom LL, Rieder E, Dunst CM. A stepwise approach and
early clinical experience in peroral endoscopic myotomy for the
treatment of achalasia and esophageal motility disorders. Journal of
the American College of Surgeons 2011;213:7516.
12. Costamagna G, Marchese M, Familiari P, Tringali A, Inoue H,
Perri V. Peroral endoscopic myotomy (POEM) for oesophageal
achalasia: Preliminary results in humans. Digestive and Liver
Disease 2012;44(10):827-32.
13. Pandolfino JE, Kwiatek MA, Nealis T, Bulsiewicz W, Post J,
Kahrilas PJ. Achalasia: a new clinically relevant classification by
high-resolution manometry. Gastroenterology 2008;135:152633.
14. Bredenoord AJ, Fox M, Kahrilas PJ, et al. Chicago classification
criteria of esophageal motility disorders defined in high resolution
esophageal pressure topography. Neurogastroenterology and mo-
tility : the official journal of the European Gastrointestinal Motility
Society 2012;24 Suppl 1:5765.
15. Eckardt VF. Clinical presentations and complications of achalasia.
Gastrointestinal Endoscopy Clinics of North America 2001; 11:
28192, vi.
16. Vaziri K, Soper NJ. Laparoscopic Heller myotomy: technical
aspects and operative pitfalls. Journal of gastrointestinal surgery :
official journal of the Society for Surgery of the Alimentary Tract
2008;12:158691.
17. Jones R, Junghard O, Dent J, et al. Development of the GerdQ, a
tool for the diagnosis and management of gastro-oesophageal
reflux disease in primary care. Alimentary pharmacology &
therapeutics 2009;30:10308.
18. Dindo D, Demartines N, Clavien PA. Classification of surgical
complications: a new proposal with evaluation in a cohort of
6336 patients and results of a survey. Annals of surgery
2004;240:20513.
19. Ren Z, Zhong Y, Zhou P, et al. Perioperative management and
treatment for complications during and after peroral endoscop-
ic myotomy (POEM) for esophageal achalasia (EA) (data
from 119 cases). Surgical Endoscopy 2012. doi:10.1007/
s00464-012-2336-y
20. Rawlings A, Soper NJ, Oelschlager B, et al. Laparoscopic Dor
versus Toupet fundoplication following Heller myotomy for achalasia:
results of a multicenter, prospective, randomized-controlled trial.
Surgical endoscopy 2012;26:1826.
21. Rebecchi F, Giaccone C, Farinella E, Campaci R, Morino M.
Randomized controlled trial of laparoscopic Heller myotomy plus
Dor fundoplication versus Nissen fundoplication for achalasia:
long-term results. Annals of surgery 2008;248:102330.
22. Novais PA, Lemme EM. 24-h pH monitoring patterns and clinical
response after achalasia treatment with pneumatic dilation or
laparoscopic Heller myotomy. Alimentary pharmacology &
therapeutics 2010;32:125765.