title: Peroral endoscopic myotomy (POEM) leads to similar results in patients with and without prior endoscopic or surgical therapy.
abstract: BACKGROUND
  Traditional treatment for the esophageal motility disorder, achalasia, ranges from endoscopic botulinum toxin (Botox) injections or balloon dilatation, to laparoscopic or open surgical myotomy. Recent advances in endoscopic therapy have led to peroral endoscopic myotomy (POEM) as a viable alternative to traditional techniques for myotomy. Uncertainty exists as to whether the procedure is feasible for patients who have already received prior endoscopic or surgical procedures for therapy, as these groups experience higher failure rates as well as intraoperative mucosal perforations and technical difficulty during Heller myotomy. We describe our first 40 patients who have undergone POEM and compare outcomes between patients who have or have not received previous treatment for achalasia.
  
  
  METHODS
  We evaluated our prospectively collected database of POEM procedures performed by two surgeons (JLP and JMM) at a single institution. Perioperative data was collected for operative and hospital outcomes. Patients completed pre- and postoperative GERD-Health-Related Quality of Life Questionnaires (GERD-HRQL) and SF-12 surveys for symptom scoring.
  
  
  RESULTS
  Forty patients received a POEM procedure between 2011 and 2013. Of these, 40% (n = 16) had had at least one prior endoscopic or surgical procedure. Nine had prior Botox injections, 7 had balloon dilations, 3 had both Botox and dilations, and 3 received prior laparoscopic Heller myotomy (two with Dor fundoplication). Mean operative time was 102 min for patients with prior procedures (Prior Tx) and 118 min for patients without any prior procedure (No Tx) (p = 0.07). Intraoperative complication rates for the Prior Tx group were 12.5 versus 16.7% for the No Tx group. Mean follow-up was 10 months. Both groups independently demonstrated clinical improvement in both the GERD-HRQL and SF-12 scores following POEM. There were no statistical differences between the two groups for GERD-HRQL reflux and dysphagia subset scores, or SF-12 mental component summary.
  
  
  CONCLUSIONS
  We found favorable outcomes following POEM in patients who have had prior endoscopic or surgical treatments for achalasia, as well as for patients without prior intervention. There were no significant differences between these two groups with regards to operative times, GERD-HRQL scores, and mental component SF-12 scores. One complication requiring intervention occurred in a patient that had received multiple prior Botox injections and balloon dilatations. POEM appears to be a viable alternative for treatment of achalasia compared to traditional techniques, however, long-term data are needed to establish the durability of this technique and to determine whether symptoms will recur necessitating re-intervention.
authors.affiliation: Department of Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
authors.forename: Sean B
authors.initials: SB
authors.lastname: Orenstein
authors.forename: Siavash
authors.initials: S
authors.lastname: Raigani
authors.forename: Yuhsin V
authors.initials: YV
authors.lastname: Wu
authors.forename: Eric M
authors.initials: EM
authors.lastname: Pauli
authors.forename: Melissa S
authors.initials: MS
authors.lastname: Phillips
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Ponsky
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Marks
mesh_terms: D000368:Aged; D015154:Esophageal Motility Disorders / Q000601:surgery*; D005260:Female; D018662:Fundoplication / Q000379:methods*; D006801:Humans; D015994:Incidence; D007431:Intraoperative Complications / Q000453:epidemiology / Q000517:prevention & control*; D008297:Male; D009055:Mouth; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology / Q000517:prevention & control*; D011795:Surveys and Questionnaires; D014481:United States / Q000453:epidemiology