FROM PROSE TO POEM? CHALLENGES IN THE TREATMENT OF ACHALASIA - Tiberiu Hershcovici M.D.

FROM PROSE TO POEM?
CHALLENGES IN THE
TREATMENT OF ACHALASIA

    Tiberiu Hershcovici M.D.

CLINICAL PRESENTATION
   S.Y.,, 38 yyear old,, generally
                          g       y healthyy
   8 months of relatively abrupt onset of dysphagia for liquids
    and solids with progressive worsening
   Daily food regurgitation and heartburn predominantly during
    night
   Chest pain after meals
   Weight loss of 20 kilogram
   Normal physical examination
   Normal CBC, full biochemistry panel and TSH

INVESTIGATIONS

   Endoscopy:
     mild pan-esophageal dilatation with food retention
      despite 12 hours fasting
     closed EGJ easily passed with the scope
     normal stomach and duodenum

HIGH RESOLUTION ESOPHAGEAL
             MANOMETRY

LES: Increased resting
pressure (50 mm Hg)

HIGH RESOLUTION ESOPHAGEAL
            MANOMETRY
Impaired    relaxation of
  LES (IRP=25 mm Hg).
 Panesopahgeal
  pressurization with all
  the swallows.
Incomplete bolus transit
  with all the swallows on
  impedance study.

BARIUM SWALLOW

 Esophageal
           g   dilatation
  with delayed emptying
  of the esophagus.
             p g
 Narrowing of the distal
  esophagus
      p g with a typical
                      yp
  “bird’s beak” appearance.

CLINICAL STAGING
 ECKARDT SCORE

 ECKARDT SCORE =11

DIAGNOSIS

   Achalasia type II
   Eckardt stage 3

WHAT IS THE TREATMENT

What is the relationship between
    achalasia subtype
                   yp and treatment modality?
                                           y
   Individualized therapy in achalasia?
     Pneumatic  balloon dilatation (PD)
     Heller myotomy + fundoplication (HM)
     POEM (per-oral endoscopic myotomy)

PNEUMATIC DILATATION vs.
              HELLER MYOTOMY
   There were no significant differences in success rates between the
    treatment groups:
       PD (95 patients):
                   ti t ) 90% and   d 86% att 1 and
                                                  d 2 years
       HM (106 patients) : 93% and 90% at 1 and 2 years
   Complications
         p          included esophageal
                                  p g     p
                                          perforation in 4% of the PD g
                                                                      group.
                                                                          p
    Up to 3 PD were allowed in a 2 years period.
   At 1 year: no significant differences between the groups in the frequency
    of abnormal acid exposure or in the frequency of reflux esophagitis.
   The relationship between acahalasia type and treatment results was not
    analyzed.

                          Boeckxstaens GE et al N Engl J Med 2011; 364:1807

PNEUMATIC DILATATION vs
                               vs.
             HELLER MYOTOMY
   In patients treated with PD, redilation is more often
    needed in:
      younger (age

RELATIONSHIP BETWEEN TREATMENT
     SUCCESS RATE AND ACHALASIA SUBTYPE

   A higher percentage of
    patients with type II
    achalasia are treated
    successfully with PD or
    HM than patients with
    t
    types I and
              d III achalasia.
                      h l i

                                 Rohof et al, Gastroenterology, 2013, 144, 718

COMPARISON BETWEEN PD AND HM FOR
         THE 3 ACHALASIA SUBTYPES

   Type I and II patients had an excellent response to both
    HM and
         d PD
           PD.
   In type II patients, success rate was higher for PD than
    HM (100% vs. 93%, respectively) but with a higher rate
    of complications (esophageal perforation)
                                 perforation).
   Patients with type III have an impaired response rate to
    PD.

                           Rohof et al, Gastroenterology, 2013, 144, 718

WHY POEM?

   Inoue et al (2010) reported the first series of per-oral
    endoscopic myotomies (POEM) for the treatment of
    achalasia in 17 patients.
                    patients
   POEM is based on NOTE and EDS principles and
    allows to hone in on precisely the tissue affected by the
    disease: the circular and sling fibers of the lower
    esophageal sphincter (LES).
   On paper, POEM would seem to be the perfect
    compromise treatment:
     minimally invasive nature of the endoscopic approach
     permanent and complete resection comparable with surgical
      myotomy
     hiatal anatomy leaved intact

Back to the patient…..

   The patient underwent POEM

Back to the patient…..

   3 months after POEM:
     Significant improvement in dysphagia and food
      regurgitation
     Weight
      W i ht increase
              i
     No reflux symptoms

Long-Term
    Long Term Outcomes of an Endoscopic
           Myotomy for Achalasia
   Prospectively collected data on 18 patients treated with POEM in a
    single institution and followed for 6 months (The Oregon Clinic,
    Portland, US).
   Persistent relief of dysphagia in all the patients.
   Incomplete relief of chest pain.
   Normalization of IRP (integrated residual pressure) in all the
    patients.
   Objective evidences of gastroesophageal reflux (esophagitis or
    increased esophageal acid exposure) were present in 50% of
    patients.

POEM vs. HELLER MYOTOMY

POEM vs. HELLER MYOTOMY
                        POEM   HM    P value

Number of patients       37    64

Median operative        120    149   < 0.001
time (min)
Mean                     11
                         1.1   22
                               2.2   < 0.0001
hospitalization (day)
Eckardt score at 6       1.2   1.7       NS
months
LES resting              16    7.1

Unanswered questions
   Who is the “ideal” patient for POEM?

   Who will perform it: surgeon or gastroenterologist?

   What is the “real”
                 real long term prognosis of POEM and how it compare
    with HM and PD?

   What is the significance of the increased rate of gastroesophageal
    reflux after POEM?

   What is the treatment of failed POEM: POEM redo, PD or HM?

   Is it POEM the treatment of failed PD or HM?