title: Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure.
abstract: BACKGROUND
  Esophageal achalasia is most commonly treated with laparoscopic myotomy or endoscopic dilation. Per-oral endoscopic myotomy (POEM), an incisionless selective myotomy, has been described as a less invasive surgical treatment. This study presents 6-month physiological and symptomatic outcomes after POEM for achalasia.
  
  
  METHODS
  Data on single-institution POEMs were collected prospectively. Pre- and postoperative symptoms were quantified with Eckardt scores. Objective testing (manometry, endoscopy, timed-barium swallow) was performed preoperatively and 6 months postoperatively. At 6 months, gastroesophageal reflux was evaluated by 24-hour pH testing. Pre-/postmyotomy data were compared using paired nonparametric statistics.
  
  
  RESULTS
  Eighteen achalasia patients underwent POEMs between October 2010 and October 2011. The mean age was 59 ± 20 years and mean body mass index was 26 ± 5 kg/m. Six patients had prior dilations or Botox injections. Myotomy length was 9 cm (7-12 cm), and the median operating time was 135 minutes (90-260). There were 3 intraoperative complications: 2 gastric mucosotomies and 1 full-thickness esophagotomy, all repaired endoscopically with no sequelae. The median hospital stay was 1 day and median return to normal activity was 3 days (3-9 days). All patients had relief of dysphagia [dysphagia score ≤ 1 ("rare")]. Only 2 patients had Eckardt scores greater than 1, due to persistent noncardiac chest pain. At a mean follow-up of 11.4 months, dysphagia relief persisted for all patients. Postoperative manometry and timed barium swallows showed significant improvements in lower esophageal relaxation characteristics and esophageal emptying, respectively. Objective evidence of gastroesophageal reflux was seen in 46% patients postoperatively.
  
  
  CONCLUSIONS
  POEM is safe and effective. All patients had dysphagia relief, 83% having relief of noncardiac chest pain. There is significant though mild gastroesophageal reflux postoperatively in 46% of patients in 6-month pH studies. The lower esophageal sphincter shows normalized pressures and relaxation.
authors.affiliation: Division of GI and MIS, The Oregon Clinic, Portland, OR 97213, USA. lswanstrom@orclinic.com
authors.forename: Lee L
authors.initials: LL
authors.lastname: Swanstrom
authors.forename: Ashwin
authors.initials: A
authors.lastname: Kurian
authors.forename: Christy M
authors.initials: CM
authors.lastname: Dunst
authors.forename: Ahmed
authors.initials: A
authors.lastname: Sharata
authors.forename: Neil
authors.initials: N
authors.lastname: Bhayani
authors.forename: Erwin
authors.initials: E
authors.lastname: Rieder
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003680:Deglutition Disorders / Q000209:etiology / Q000601:surgery; D004931:Esophageal Achalasia / Q000150:complications / Q000601:surgery*; D049630:Esophageal Sphincter, Lower / Q000601:surgery*; D004945:Esophagoscopy; D005260:Female; D005500:Follow-Up Studies; D005764:Gastroesophageal Reflux / Q000453:epidemiology / Q000209:etiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D016896:Treatment Outcome