SIX YEARS OF SINGLE CENTER EXPERIENCE WITH PERORAL ENDOSCOPIC MYOTOMY (POEM)

Aims:

POEM has proved excellent mid-term efficacy even when compared with other standard methods for treatment of achalasia, but the long-term durability still needs to be confirmed. Nevertheless, the high risk of post-POEM reflux tempers the enthusiasm. The aim of our study was to assess the long-term clinical outcome of POEM and a thorough analysis of post-POEM reflux.

Methods:

A retrospective analysis of prospectively collected data of patients undergoing POEM (December 2012-November 2018). All patients were scheduled for follow up at 3, 6, 12 M and every year after POEM. Upper GI endoscopy, HRM and 24-hour pH monitoring were performed 3 M after POEM; endoscopy was then repeated between 24 – 36 M. Main outcomes were treatment success defined as ES < 3, recurrence rate and reflux parameters evaluated by 24h pH-metry, presence of reflux esophagitis, reflux symptoms and use of PPIs.

Results:

A total of 295 patients with achalasia underwent 308 POEMs. Follow- up visits at 3, 12, 24, 36 and 48 M were completed in 238, 167, 122, 66 and 25 patients At 3, 12, 24, 36 and 48 M treatment success was achieved in 97% (CI 95 – 100), 95% (91 – 98), 90% (84 – 95), 83% (74 – 92) and 83% (74 – 92) of patients. A total of 24 patients experienced treatment failure (n = 6) or recurrence (n = 18). At 3 M, RE was observed in 101/238 (42.4%, LA C/D in 11 patients). Abnormal acid exposure was detected in 89/208 (42.8%) patients. At 24 – 36 M, endoscopy was performed in 82 patients and RE was present in 25 patients (30.5%). PPIs were administered to 38.4% and 40.1% of patients at 3 and 24 M, respectively.

Conclusions:

POEM is a highly effective endoscopic treatment for achalasia with sustained treatment success of more than 80% at 24 and 36 M. Post-POEM reflux is present in almost 40% of patients, thus remaining a crucial clinical challenge in safety profile of the procedure.