Su1514 Novel Technique of Auto-Tunneling During PerOral Endoscopic Myotomy (POEM)

Abstracts

[range 9-75 years]) underwent an attempt at POEM between May 2011 and November 2012. Data on the clinical history, the procedures, outcomes and complications were collected and analyzed. Clinical evaluation was performed by using the Eckardt score. Patients underwent telephonic follow-up at 3 months, and esophageal manometry at 6- and 12-months. The primary outcome was symptom relief (Eckardt score ⱕ 3) at 6- and 12-months and drop of resting LES pressure. Secondary outcomes were evaluation of adverse events and incidence of GERD. Results: Forty-seven patients had a classic type achalasia, 5 a vigorous type. Preoperative mean resting LES pressure was 42.1 mmHg (18.9-97.4 mmHg); mean Eckardt score was 7.8 (4-11). POEM was completed in 48 (92.3%) patients. In four patients the procedure aborted because of the inability of creating the submucosal tunnel. Mean procedure time was 83.4 min (49-140 min); submucosal tunnel mean length was 16.4 cm (12-20 cm) and mean length of myotomy 11.3cm (7-16 cm). During the procedure, 17 (32.7%) patients had a pneumoperitoneum requiring evacuation by Veress needle; 4 patients had a perforation of the mucosal flap at the cardia, treated with clips. No other adverse events occurred. Patients were fed on the 2nd post-operative day. Mean post-operative hospital stay was 4 days. Thirty-one patients completed the 3 months follow-up, 20 patients the 6-month follow-up, and 9 the 12-month follow-up. Symptoms relief was documented in 30 patients at 3month, 19 at 6-month, and 8 at 12-month follow-up. Eckardt score significantly dropped from 7.8 at baseline, to 1.0, 0.9, 1.7, respectively at 3-, 6- and 12-month follow-up. Esophageal manometry demonstrated a significant drop of median resting LES pressure, from 40.8 mmHg to 16.1 mmHg, 17.3 mmHg and 19.2 mmHg at 3-, 6and 12-months, respectively. No complications occurred during follow-up. Two patient experienced GERD symptoms requiring daily PPI, 3 and 6 months after POEM. Conclusions: POEM procedure is associated with good mid-term outcomes and excellent safety profile. Further studies with a longer follow-up, and RCTs are necessary to confirm its role in the treatment of esophageal achalasia.

Su1513 Early Results of PerOral Endoscopic Myotomy Using Hybrid Knife TM vs Laparoscopic Heller’s Myotomy for Achalasia Cardia Amit P. Maydeo*, Suryaprakash Bhandari, Nitin Joshi, Mukta Bapat, Rajan Y. Daftary, Abhay Upasani, Prashant Rao, Bhakti Thakkar, Vinay K. Dhir Baldota Institute of Digestive Sciences, Mumbai, India Background: Laparoscopic Hellers’s cardiomyotomy (LHM) is an established treatment for achalasia cardia. Recently endoscopic myotomy (POEM) has been described as a promising technique with good short term results. Hybrid knife is supposed to shorten the procedure time of POEM. We compared the technical and early functional results of the POEM and LHM. Methods: Data was collected prospectively for all patients of achalasia cardia. Endoscopy, high resolution manometry and barium swallow was done in all patients to confirm the diagnosis of achalasia cardia. POEM was performed under general anaesthesia using C02 insuffilation . Both the creation of submucosal tunnel and myotomy was done using hybrid knife (ERBE Elektromedizin, GmbH, Germany) capable of injecting and cutting with the same instrument. LHM was done using 4 ports along with anterior Dorr fundoplication. Technical results of both the procedures are given in table. Results: There were 12 POEM and 20 LHM procedures done in the period 2009 to 2012. The technical and functional results are shown in the table. There was no significant difference in the technical and functional success rates in the two groups. Two patients in the POEM group developed reflux symptoms while one patient in the LHM group developed severe reflux following removal of wrap (due to dysphagia). Two patients in the LHM group required reintervention, one for severe chest pain and other for severe dysphagia. One patient in the POEM developed pneumoperitomeum and pneumomediastinum after the procedure and was treated conservatively. Procedure time and length of hospital stay were significant longer for LHM group (Table). Conclusions: Both POEM and LHM have excellent short term results. However, the procedure time and length of stay were significantly longer for LHM group in our study. It is possible that the use of Hybrid knife reduces the procedure time of POEM. POEM Numbers M:F Mean age Mean Dysphagia score Pre-treatment Post treatment Technical success rate Functional success rate LES Pressure (mean, mm Hg) Pre-treatment Posttreatment Mean Length of myotomy(cm) Mean procedure time(min)

LHM

12 20 2:10 12:8 42 46 8.1 9.2 1.8 1.6 12/12 19/20 (95%) 12/12 17/20 (85%) 50.73 52 16.18 10 65

18 8 111.5

p value

0.274

0.0006

Complications Mucosal tear Significant bleed Pneumo-peritoneum/mediastinum Death

Re-interventions mean duration of hospital stay (days)

POEM

LHM

p value

1

2

1.000

0 1 0 0 2

0 0 0 2 4

0.375 0.516 0.0004

Su1514 Novel Technique of Auto-Tunneling During PerOral Endoscopic Myotomy (POEM) Payal Saxena*, Reem Z. Sharaiha, Ali Kord Valeshabad, Vikesh K. Singh, Anne Marie Lennon, Eun Ji Shin, Gerard L. Aguila, Marcia I. Canto, Pankaj J. Pasricha, Anthony N. Kalloo, Mouen Khashab Johns Hopkins Medical Institute, Baltimore, MD Background: Peroral endoscopic myotomy (POEM) was developed to reduce lower esophageal sphincter pressure in patients with achalasia. POEM is technically challenging and time consuming. The creation of an esophageal submucosal tunnel is a major and integral part of the procedure. Dissection of the submucosal fibers is a lengthy task. We have previously shown that a novel viscous gel (Cook Medical) has submucosal dissecting properties and can facilitate submucosal dissection. Aims: To present our initial experience with the use of the novel gel with dissecting properties for facilitating submucosal tunneling during POEM. Methods: A submucosal injection of 5ml of saline with 0.3% indigo carmine was performed to create a mucosal bleb. The mucosal entry point was 15cm above the gastroesophageal junction (GEJ). Subsequently, 1015ml of the gel was injected into the submucosal bleb using a 19-gauge needle and a custom-made injector apparatus. An approximately 2-cm longitudinal incision in the 2-o’clock position was created with a triangle-tip knife. The gastroscope was then advanced into the submucosal space. This esophageal submucosal space was noted to be already formed in all five pigs and there was no need to perform any esophageal submucosal dissection. A 15cm tunnel was noted to be formed in all pigs. The distal end of the formed tunnel was at the level of the GEJ in all pigs. The submucosal tunnel was then extended 2 to 3cm into the gastric cardia. The dissection of the circular muscle bundle was initiated 2 cm distal to the mucosal entry point. The division of the sphincter muscle was continued until the endoscope passed through the narrowed segment at the level of GEJ. The myotomy was extended for a distance of 2 to 3 cm into the gastric cardia. The mucosal entry site was not closed since the experiments were nonsurvival by intention. The esophageal and gastric mucosa (lumenal side) was then carefully examined for signs of mucosal injury. Results: The gastroscope was successfully introduced into the submucosal space in all pigs. The gel in the submucosal space was easily suctioned through the working channel of the gastroscope and did not interfere with endoscopic visualization. The esophageal submucosal tunnel was noted to be already formed upon entry into the submucosal space in all five pigs. Esophageal submucosal dissection was not required in any case. “Auto-tunneling” by the dissecting gel stopped at the level of the lower esophageal sphincter. Further tunneling into the gastric cardia was needed in all pigs. The average procedure (including myotomy) time was 28 minutes. Conclusions: We have described our initial experience with the use of a novel gel to facilitate submucosal tunneling during POEM. The gel allowed for safe and efficient POEM in all pigs.

Su1515 Safety and Efficacy of Biodegradable Stents (BS) in Elderly Patients (EP) With Achalasia Oscar V. HernáNdez MondragóN*, Oscar E. Diaz De Leon Salazar, Juan M. Blancas Valencia Endoscopy, National Institute of Social Security Centro Mexico Nacional Siglo XXI, Mexico city, Mexico Background: Achalasia is a rare esophagus disorder characterized by an incomplete relaxation of the lower esophageal sphincter (LES) and esophageal aperistalsis, with normal or high basal LES pressure. Dysphagia, chest pain, regurgitation and weight loss are the principal symptoms. The objective of treatment is to reduce the LES pressure. Surgery is the most effective in young but risky in elderly people in whom pneumatic dilation although effective, has high risk of perforation. Botulinum toxin injection (BTI) is safe but with a temporary effect. Placement of stent gets a continue dilation of the LES but they need to be removed in a second procedure with possible complications. Biodegradable stents (BS) are new stents made of polilactic acid that degrades in continuous contact with gastric chlorhydric acid in a mean of 10-14 weeks and the advantage of a conventional stent but without the need of removing it. The aim of this study is to evaluate the safety and efficacy of BS in elderly patients with achalasia. Methods: This was a prospective study conducted in a tertiary

AB352 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013

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