title: Prior treatment does not influence the performance or early outcome of per-oral endoscopic myotomy for achalasia.
abstract: BACKGROUND
  Per-oral endoscopic myotomy (POEM) is an emerging treatment for achalasia. Pneumatic dilation, botulinum toxin injection, and previous myotomy increase the difficulty of subsequent Heller myotomy, but their impact on POEM remains unknown. The purpose of this study was to compare patients who had undergone prior treatment for their achalasia to those undergoing POEM as an initial therapy.
  
  
  METHODS
  All patients undergoing POEM were entered into a prospective database from August 2012 to October 2014. Data collected included demographics, dysphagia and symptom survey scores, operative time, clips required for mucosotomy closure, perioperative complications and length of hospital stay.
  
  
  RESULTS
  Forty-five patients underwent POEM during the study period. Fifteen (30%) had undergone previous treatment (seven Botox injection, five pneumatic dilation and three Heller myotomy). Primary POEM patients were younger than those who had had prior treatment (mean age 46 ± 17 vs. 64 ± 12 years, p < 0.001), but gender, body mass index and ASA class were not significantly different. There were no conversions to Heller myotomy or perioperative complications in either group. Operative time for primary POEM was 103 ± 27 versus 102 ± 29 min following prior treatment (p = 0.84). Mucosotomy closure required a median 7 (4-16) and 8 (5-16) clips, respectively (p = 0.08). Length of stay was 1 day in each group. Median dysphagia scores decreased from 4 (0-5) to 1 (0-4) following primary POEM and 4 (0-5) to 0 (0-4) in the prior treatment group (p = 0.45) during a median follow-up of 10 months (5-17 months). All patients in each group expressed satisfaction with their procedure and would undergo the procedure again given the benefit of hindsight.
  
  
  CONCLUSIONS
  Per-oral endoscopic myotomy is a safe and effective treatment for achalasia which improves dysphagia and disease-specific quality of life. Previous endoscopic or laparoscopic treatment of achalasia does not affect the performance or early outcome of POEM.
authors.affiliation: Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA. Edward.Jones@UCDenver.edu.
authors.forename: Edward L
authors.initials: EL
authors.lastname: Jones
authors.affiliation: Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Meara
authors.affiliation: Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA.
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Pittman
authors.affiliation: Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA.
authors.forename: Jeffrey W
authors.initials: JW
authors.lastname: Hazey
authors.affiliation: Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA.
authors.forename: Kyle A
authors.initials: KA
authors.lastname: Perry
mesh_terms: D003680:Deglutition Disorders / Q000601:surgery; D004931:Esophageal Achalasia / Q000601:surgery*; D004945:Esophagoscopy / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery; D061646:Operative Time; D017060:Patient Satisfaction; D011446:Prospective Studies; D011788:Quality of Life
keywords: Achalasia; Dysphagia; Outcome; POEM; Per-oral endoscopic myotomy; Prior treatment