Arnon Lambroza

Peroral endoscopic myotomy: establishing a new program.

Achalasia is an esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter (LES) and aperistalsis of the esophageal body. Treatment of achalasia is aimed at decreasing the resting pressure in the LES. Peroral endoscopic myotomy (POEM), derived from natural orifice transluminal endoscopic surgery (NOTES) and advances in endoscopic submucosal dissection (ESD), presents a novel, minimally invasive, and curative endoscopic treatment for achalasia. POEM involves an esophageal mucosal incision followed by creation of a submucosal tunnel crossing the esophagogastric junction and myotomy before closure of the mucosal incision. Although the procedure is technically demanding and requires a certain degree of skill and competency, treatment success is high (90%) with low complication rates. Since the first described POEM in humans in 2010, it has been used increasingly at centers worldwide. This article reviews available published clinical studies demonstrating POEM efficacy and safety in order to present a proposal on how to establish a dedicated POEM program and reach base proficiency for the procedure.

Tu1229 Endoluminal Functional Lumen Imaging Probe (EndoFLIP) During Peroral Endoscopic Myotomy (POEM) for Achalasia Predicts Postoperative Clinical Success: A Multicenter Case-Control Study

Background: Anorectal manometry is useful in evaluating and planning treatment in patients with fecal incontinence (FI) and other disorders of defecation. Traditional water perfusion techniques are limited to 4 to 8 radial measurements obtained via a pullback technique. Three-dimensional high resolution anorectal manometry (3D HRAM) employs solid state micro transducers and can obtain 257 data points during resting, squeeze, and bear down (simulated defecation) sequences. Data are then reconstructed into a 3D format showing functional anatomy. While differences are known to exist between patients with FI and obstruction, patients with mixed disorders (of FI and obstruction) are less well described Objective: To determine physiologic differences between groups of female patients with FI, obstructed defecation, and mixed disorders. In addition to known parameters of mean resting pressure and maximal squeeze pressure, relationships between rectoanal pressure differential and percent anal relaxation were sought among the groups. Methods Retrospective chart review of 50 female patients undergoing 3D HRAM between 1/1/ 13 and 6/1/14. Physiologic values including mean resting, and maximal squeeze pressures, percent anal relaxation, and rectoanal pressure differential were recorded. Analysis of variance test, and linear regression analysis was performed as appropriate. Results:Women with mixed defecatory disorders had sphincter pressure profiles that were significantly different from patients with pure FI or obstruction (table). While rectoanal pressure differential was not different among the groups, patients with mixed disorders had a significant linear relationship between rectoanal pressure differential and percent anal relaxation that was not seen among the pure FI or obstructed groups (figure). Conclusion: Mixed defecatory disorders are associated with a unique physiologic profile that can be characterized using 3D HRAM. The mixed defecatory group demonstrates relationships between physiologic parameters that are not seen the incontinent or obstructed groups. This data will be helpful in the planning treatment regimens.