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 55.717.7 years. Mean BMI was 29.5 +/- 9.2. Median OR time was 133.5 minutes (range 70-462); average myotomy was 13.1 +/- 2.3cm. 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.