TP6.2.14 Outcome of POEM (Per-oral endoscopic myotomy) for achalasia

Aims Laparoscopic Heller’s myotomy (LHM) has been the surgical gold standard for treatment of oesophageal achalasia. Peroral endoscopic myotomy (POEM) has been proposed as an alternative technique. The aim of this study was to assess the safety and efficacy of POEM for achalasia in our unit. Methods We have operated on 202 patients for oesophageal achalasia since 2005: 107 had LHM, 86 had POEM, and 9 had an oesophagectomy. We assessed the clinical outcome of POEM comparing pre- and postoperative endoscopic, radiologic and manometric findings, as well as Eckardt-, GERD- and DsQoL score for achalasia. All follow-up patients were offered endoscopy. Results Data were completed for the first 45 POEM patients. The average age was 45 years. 18 patients (40%) had prior achalasia treatment. The median hospital stay was 2 days (2-5). There was no mortality, but 4 patients (9%) had post-operative complications. The median follow-up was 24 months (12-49). Clinical success (Eckardt score ≤ 3) was achieved in 39 patients (87%). Thirteen patients (29%) were taking PPIs for chest symptoms. Eleven of these underwent pH studies of whom only 1 had a DeMeester score > 14.5. Of the 24 patients who had post-operative endoscopy, 40% was diagnosed with oesophagitis grade A, yet only 5 of them were symptomatic. Conclusions POEM appears to be safe and effective and warrants consideration as first-line therapy in expert achalasia centres. Longer term randomized studies comparing the outcomes of POEM with LHM and pneumatic dilatation will determine its place in the treatment of achalasia.

A Case of Peroral Endoscopic Myotomy for Paediatric Oesophageal Achalasia

Objective of the Paper: To present a case of successful use of Peroral Endoscopic Myotomy (POEM) in oesophageal achalasia in a 6-year-old child at the Scientific and Research Institute of Emergency Paediatric Surgery and Traumatology. Key Points. Being highly efficient and minimally invasive, POEM has been gaining in popularity in management of oesophageal achalasia in adult patients. However, in paediatrics, clinicians remain wary of the method. POEM was used to treat grade 3 oesophageal achalasia in a 6-year-old girl. No intraoperative complications were recorded. The postoperative period was uncomplicated: feeding with strained food started the next day after surgery; the child was discharged from the hospital on day 3. During follow-up visits (3, 12, 24 months) the child did not have any complaints; symptoms of dysphagia regressed completely; 3-month weight gain was 4kg; endoscopic examination showed an unobstructed oesophagus without inflammation. Conclusion. POEM is a promising method for management of oesophageal achalasia in children; still, controlled randomised studies should be conducted in order to assess the efficiency of the method in comparison with the efficiency of laparoscopy and balloon dilatation. Keywords: endoscopy, children, oesophageal achalasia, peroral endoscopic myotomy.

Laparoscopic repair of late perforation following Heller myotomy due to overeating

Laparoscopic Heller myotomy is the mainstay surgical treatment of oesophageal achalasia and has proven to be safe and effective over the course of time. Oesophageal perforation after myotomy can be a serious complication with devastating outcomes. Most commonly, mucosal perforation are detected intraoperatively or early postoperatively. We present an extremely rare case of late oesophageal perforation in a 28-year-old man treated with laparoscopic Heller myotomy for type II oesophageal achalasia, and its successful minimally invasive repair with laparoscopic primary suturing.

Surgical treatment of an oesophageal achalasia in a small breed dog

A 6-year-old, male Yorkshire Terrier dog presented with persistent regurgitation and severe weight loss. Based on the clinical signs, physical and other various diagnostic examinations, including fluoroscopy, were performed. Myasthenia gravis was ruled out through a serum acetylcholine receptor antibody titre measurement and a negative response to neostigmine bromide (0.02 mg/kg) within 4 hours of injection. The dog was diagnosed with idiopathic oesophageal achalasia. As a treatment, a modified Heller’s oesophagomyotomy was performed, and the dog recovered well with no signs of recurrence for 18 months.