Peroral endoscopic myotomy for the treatment of achalasia and other esophageal motor disorders: Short-term and medium-term results at a Mexican tertiary care center

Abstract

Introduction and aims: Achalasia is characterized by the absence of lower esophageal sphincter relaxation and esophageal aperistalsis. Diagnosis is confirmed through high-resolution esophageal manometry. Laparoscopic myotomy is the standard treatment, but peroral endoscopic myotomy (POEM) is a safe and effective alternative, with good short-term and medium-term results. Our aim was to describe the short-term and medium-term experience with POEM at a tertiary care center. Materials and methods: The study was conducted within the time frame of November 2014 and February 2017. Treatment-naïve achalasia patients and previously-treated achalasia patients that were candidates for POEM were included. A protocolized 24-month follow-up was carried out. Results: Fifty procedures were included and 31 (68%) were performed on women. Forty-one (82%) of the procedures were carried out on previously untreated patients, 7 (14%) were performed on previously treated patients, and 2 (4%) of the patients had redo-POEM. The mean age of the patients was 48.8 ± 14.1 years. The pre-POEM Eckardt score was 9 and the integrated relaxation pressure was 24.4 mmHg. Sixty-eight percent of the patients had type ii achalasia. Procedure time was 80 min and myotomy length was 12.6 cm. Hospital stay was 3 days and subcutaneous emphysema was the most common adverse event (30%). A total of 22/50 (44%) patients reached the 24-month follow-up, maintaining the Eckardt score and the decrease in the integrated relaxation pressure. There were no deaths. A total of 47.5% of the patients had a positive pH-study at 6 months, 15% had clinical reflux, and 35% presented with mild esophagitis. All the patients were adequately controlled with proton pump inhibitors. Conclusion: POEM is safe and effective in the short term and medium term for the treatment of achalasia and other esophageal motor disorders in Mexican patients. Resumen: Introducción y objetivos: La acalasia se caracteriza por una ausencia de relajación del esfínter esofágico inferior y aperistalsis esofágica. La manometría esofágica de alta resolución) confirma el diagnóstico. La miotomía laparoscópica es el estándar de tratamiento, pero la miotomía endoscópica peroral (POEM) representa una alternativa segura, efectiva y con buenos resultados a corto y mediano plazo. Nuestro objetivo es describir la experiencia de la POEM en un centro de referencia de tercer nivel en México a corto y mediano plazo. Material y métodos: Estudio realizado entre noviembre 2014 y febrero 2017. Se incluyeron pacientes con acalasia vírgenes y postratados, candidatos a POEM. Se realizó un seguimiento hasta 24 meses de forma protocolizada. Resultados: Se incluyeron 50 procedimientos, edad de 48.8 ± 14.1 años, mujeres 31 (68%), vírgenes 41 (82%), postratados 7 (14%) y redo-POEM 2 (4%). El puntaje Eckardt y la presión de relajación integrada pre-POEM fueron 9 y 24.4 mmHg respectivamente. La acalasia fue tipo ii en el 68%. Tiempo del procedimiento 80 min y miotomía de 12.6 cm. Estancia intrahospitalaria de 3 días, el enfisema subcutáneo fue el evento adverso más común (30%). Veintidós de 50 (44%) alcanzaron 24 meses, observando un mantenimiento del Eckardt y disminución en la presión de relajación integrada. No se presentó ninguna muerte. La pHmetría fue positiva en el 47.5% a los 6 meses, hubo reflujo clínico en el 15% y esofagitis leve en el 35%, que fueron adecuadamente controlados con inhibidor de bomba de protones. Conclusión: La POEM es una técnica segura y efectiva para el tratamiento de pacientes mexicanos con acalasia y otros trastornos motores del esófago a corto y mediano plazo. Keywords: Achalasia, POEM, Mexican population, Safety and efficacy, Palabras clave: Acalasia, Miotomía endoscópica peroral, Población mexicana, Seguridad y eficacia