Early outcomes of peroral endoscopic myotomy with fundoplication for achalasia cardia – Is it here to stay?

Abstract

Background: Peroral endoscopic myotomy with fundoplication (POEM-F) has garnered widespread attention since it tries to achieve an appropriate antireflux procedure during the same setting. The outcomes of POEM-F are currently unexplored.Methods: Patients who underwent POEM-F at our center were retrospectively studied to assess its safety and early outcomes.Results: Twenty patients [70% male; median age 32 years (range 25-41)], with a median symptom duration of 2.1 years (range 1.5-3.7) with achalasia were included. POEM-F procedure was completed in a median of 118 min (range 90-160), with 17/20 (85%) technical success. The median hospitalization was 4 days (range 2-7). Capnothorax (n = 3), resolved spontaneously (n = 2) in 4-6 h, while in one patient (n = 1) the endoscope inadvertently entered into the thoracic cavity for which prophylactic intercostal drain was required.Capnoperitoneum was seen in 17/17 (100%) patients who underwent fundoplication, subcutaneous emphysema in 8/17 (47%) patients. At 1-month follow-up endoscopy, 5/17 (29.4%) patients had loosening of the fundal wrap, 3/17 (17.6%) patients had ulceration in fundus and in gastroesophageal junction due to underlying hemoclips. At 3 months, loosening of the fundal wrap was seen in 7/17 (41.2%) patients. A 24-h pH-metry revealed abnormal esophageal acid exposure in 7/17 (41.2%) patients, while it was normal in those patients in whom the fundal wrap was maintained. 10/17 (58.8%) patients were off proton pump inhibitors. Conclusion:POEM-F is technically feasible with reasonable short term success. However, the durability, early success and safety of POEM-F need reassessment in long-term studies before being applied in clinical practice.

Endoscopic Treatment of Reflux

“…No dysphagia was reported after the procedure. 78 Recently another series reported results in 20 patients, followed at 1 and 3 months. Fundoplication was maintained in 85% at 1 month and GERD-HRQL scores were normal in 95%.…”

“…Although the procedure can be performed simultaneous to POEM, only 50% of the patients have abnormal AET after POEM, and doing a fundoplication in all the patients is possibly overtreating the other 50%. 78 Conversely, if the procedure is performed only after GERD has developed, the technique requires an anterior approach and could be challenging in patients with a prior anterior myotomy due to fibrosis. Only short-term results from highly specialized centers are available, but the procedure may have drawbacks similar to a Dor fundoplication, where the anti-reflux properties of the wrap decrease with time with subsequent recurrence of reflux.…”

“…The hemoclips were also seen to penetrate later into the stomach mucosa in some patients during endoscopic follow-up. 78…”

Achalasia Cardia: Balloon, Tunnel, or Knife?

“…However, the results of POEM þ F from another center were not convincing. 51 Twenty patients underwent the POEM þ F procedure, with 17/20 (85%) technical success. At 1-month follow-up endoscopy, 5/17 (29.4%) patients had loosening of the fundal wrap and 3/17 (17.6%) patients had ulceration in the fundus and gastroesophageal junction due to underlying hemoclips.…”

Insights into the endoscopic management of esophageal achalasia

“…There are limited data on these novel therapeutic approaches with small patient cohorts and short follow-up intervals. In a recent study by Patil and colleagues, 39 20 patients underwent POEM-F at a single center with an 85% technical success rate. These patients were followed for 3 months.…”