Ashwin A. Kurian

Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure.

Background:Esophageal achalasia is most commonly treated with laparoscopic myotomy or endoscopic dilation. Per-oral endoscopic myotomy (POEM), an incisionless selective myotomy, has been described as a less invasive surgical treatment. This study presents 6-month physiological and symptomatic outcomes after POEM for achalasia. Methods:Data on single-institution POEMs were collected prospectively. Pre- and postoperative symptoms were quantified with Eckardt scores. Objective testing (manometry, endoscopy, timed-barium swallow) was performed preoperatively and 6 months postoperatively. At 6 months, gastroesophageal reflux was evaluated by 24-hour pH testing. Pre-/postmyotomy data were compared using paired nonparametric statistics. Results:Eighteen achalasia patients underwent POEMs between October 2010 and October 2011. The mean age was 59 ± 20 years and mean body mass index was 26 ± 5 kg/m2. Six patients had prior dilations or Botox injections. Myotomy length was 9 cm (7–12 cm), and the median operating time was 135 minutes (90–260). There were 3 intraoperative complications: 2 gastric mucosotomies and 1 full-thickness esophagotomy, all repaired endoscopically with no sequelae. The median hospital stay was 1 day and median return to normal activity was 3 days (3–9 days). All patients had relief of dysphagia [dysphagia score ⩽ 1 (“rare”)]. Only 2 patients had Eckardt scores greater than 1, due to persistent noncardiac chest pain. At a mean follow-up of 11.4 months, dysphagia relief persisted for all patients. Postoperative manometry and timed barium swallows showed significant improvements in lower esophageal relaxation characteristics and esophageal emptying, respectively. Objective evidence of gastroesophageal reflux was seen in 46% patients postoperatively. Conclusions:POEM is safe and effective. All patients had dysphagia relief, 83% having relief of noncardiac chest pain. There is significant though mild gastroesophageal reflux postoperatively in 46% of patients in 6-month pH studies. The lower esophageal sphincter shows normalized pressures and relaxation.

A Comparative Study on Comprehensive, Objective Outcomes of Laparoscopic Heller Myotomy With Per-Oral Endoscopic Myotomy (POEM) for Achalasia

Objective:To compare symptomatic and objective outcomes between HM and POEM. Background:The surgical gold standard for achalasia is laparoscopic Heller myotomy (HM) and partial fundoplication. Per-oral endoscopic myotomy (POEM) is a less invasive flexible endoscopic alternative. We compare their safety and efficacy. Methods:Data on consecutive HMs and POEMs for achalasia from 2007 to 2012 were collected. Primary outcomes: swallowing function—1 and 6 months after surgery. Secondary outcomes: operative time, complications, postoperative gastro-esophageal reflux disease (GERD). Results:There were 101 patients: 64 HMs (42% Toupet and 58% Dor fundoplications) and 37 POEMs. Presenting symptoms were comparable. Median operative time (149 vs 120 min, P < 0.001) and mean hospitalization (2.2 vs 1.1 days, P < 0.0001) were significantly higher for HMs. Postoperative morbidity was comparable. One-month Eckardt scores were significantly better for POEMs (1.8 vs 0.8, P < 0.0001). At 6 months, both groups had sustained similar improvements in their Eckardt scores (1.7 vs 1.2, P = 0.1).Both groups had significant improvements in postmyotomy lower esophageal sphincter profiles. Postmyotomy resting pressures were higher for POEMs than for HMs (16 vs 7.1 mm Hg, P = 0.006). Postmyotomy relaxation pressures and distal esophageal contraction amplitudes were not significantly different between groups. Routine postoperative 24-hour pH testing was obtained in 48% Hellers and 76% POEMs. Postoperatively, 39% of POEMs and 32% of HM had abnormal acid exposure (P = 0.7). Conclusions:POEM is an endoscopic therapy for achalasia with a shorter hospitalization than HM. Patient symptoms and esophageal physiology are improved equally with both procedures. Postoperative esophageal acid exposure is the same for both. The POEM is comparable with laparoscopic HM for safe and effective treatment of achalasia.

Peroral endoscopic esophageal myotomy: defining the learning curve

BACKGROUND Peroral endoscopic myotomy (POEM) is an endoscopic alternative to laparoscopic esophageal myotomy. It requires a demanding skill set that involves both advanced endoscopic skills and knowledge of surgical anatomy and complication management. OBJECTIVE Determine the learning curve for POEM. DESIGN Prospective cohort study. SETTING Tertiary-care teaching hospital. PATIENTS The study involved the first 40 consecutive patients undergoing the POEM procedure under a prospective institutional review board protocol (research.gov #NCT01399476, 1056). INTERVENTION Peroral endoscopic myotomy for esophageal motility disorders. MAIN OUTCOME MEASUREMENTS Length of procedure (LOP) and technical errors (inadvertent mucosotomy). RESULTS A total of 40 patients underwent POEM. The mean LOP was 126 ± 41 minutes. The mean myotomy length was 9 cm (range, 6-20 cm). The LOP per centimeter myotomy and variability decreased as our experience progressed. The means (± standard deviation) of the LOP per centimeter myotomy were as follows: first cohort, 16 ± 4 minutes; second, 17 ± 5 minutes; third, 13 ± 3 minutes; fourth, 15 ± 2 minutes; and fifth, 13 ± 4 minutes. The incidence of inadvertent mucosotomy also decreased with increasing experience, to 8, 6, 4, 0, and 1, respectively. These minor complications were repaired intraoperatively with clips. There were 7 patients with capnoperitonium and another with bilateral capnothoraces that were associated with hemodynamic instability but resolved by Veress needle decompression. Two patients required endoscopy in the early postoperative period: self-limited hematemesis in one and radiologic evidence of leakage at the mucosotomy site in another. LIMITATIONS Nonrandomized study. CONCLUSION Mastery of operative technique in POEM is evidenced by a decrease in LOP, variability of minutes per centimeter of myotomy, and incidence of inadvertent mucosotomies and plateaus in about 20 cases for experienced endoscopists. The learning curve can be shortened with very close supervision and/or proctoring.

Laparoscopic Colectomy In Octogenarians and Nonagenarians: A Preferable Option to Open Surgery?

OBJECTIVES To determine if laparoscopic colectomy is safer and more effective than open colectomy in patients older than 80 years of age. METHODS An operating room database of all colectomies performed on patients >or=80 years, from January 2002 to September 2007, was analyzed retrospectively. Data reviewed included type of operation, type of resection, length of procedure, length of stay (LOS), estimated blood loss, American Society of Anesthesiologists (ASA) grade, diagnosis, complications, mortality rates, and discharge destination, with p-values <0.05 considered significant. RESULTS One hundred thirty-nine patients underwent open procedures (Open group) during the study period versus 150 patients who underwent laparoscopic procedures (Lap group). Of the Lap group, 15 patients were converted to open cases. Forty-four patients from the Open group were excluded from the analysis as they were treated emergently, leaving 95 patients in the Open group. The mortality for open procedures was significantly higher at 9/95 (9.4%), compared with 3/150 (2%) following laparoscopic procedures (p = 0.0132). LOS was significantly longer for open procedures (11.16 days) versus laparoscopic procedures (7.11 days), p = 0.0001. Open procedures were associated with an increased risk of postoperative ileus (p < 0.02). The Open group had a higher likelihood of discharge to a nursing facility (43/87) than the Lap group (33/147), p < 0.0001. There were no significant differences in the length of procedure, estimated blood loss and postoperative complications. CONCLUSIONS Laparoscopic colectomy is a safer option that offers an improved outcome compared with open colectomy in elderly patients. Significant improvements in LOS, mortality rates, and discharge destination were observed.

In-hospital and 6-month mortality rates after open elective vs open emergent colectomy in patients older than 80 years.

BACKGROUND: There are few reports of long-term outcomes in elderly patients after open colectomy. OBJECTIVE: This study aimed to determine the in-hospital and 6-month outcomes and identify the variables associated with mortality after colectomy in patients ≥80 years of age. DESIGN: The charts of patients ≥80 years of age, who underwent open colectomy, were analyzed. Data included indications for operation, underlying diagnoses, preoperative functional status, type of procedure, length of procedure, length of stay, ASA grade, complications, and in-hospital and 6-month mortality rates. Univariate and multivariate logistic regression analyses were conducted to ascertain risk factors for mortality. P values of <.05 were considered significant. MAIN OUTCOME MEASURES: The main outcome measures were in-hospital and 6-month mortality. RESULTS: One hundred sixty-two patients ≥80 years of age underwent colectomy: 99 patients emergently; 63, electively. Postoperative acute renal failure (3% vs 19%, P = .0032) and in-hospital deaths were significantly higher (4.7% vs 28%, P = .0002) among the patients undergoing emergent colectomies. The mortality rate among emergent cases rose from 28% in-hospital to 52% at 6 months. Mortality among the elective cases increased similarly from 4.7% to 28.5%. Admission from a nursing facility was associated with higher in-hospital mortality (47.6% vs 14.9%, P = .0005). Discharge to a skilled nursing facility was associated with a higher 6-month mortality rate compared with discharge to home (40% vs 17%). Length of procedure, postoperative complications, perioperative blood transfusion, and emergent indications for operation independently predicted in-hospital mortality. Postoperative complications and emergent diagnosis independently predicted 6-month mortality. The 6-month mortality rate varied according to the underlying diagnosis as follows: fulminant Clostridium difficile colitis (86%); ischemic colitis (60%); gastrointestinal bleeding (37%), and volvulus (40%). LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: Emergent open colectomy in elderly patients is associated with a high morbidity and mortality rate. The mortality rate rises by >20% in both elective and emergent cases at discharge to 6 months. Length of procedure, postoperative complications, and colectomy for emergent indications predicted mortality.

Partial Anterior vs Partial Posterior Fundoplication Following Transabdominal Esophagocardiomyotomy for Achalasia of the Esophagus Meta-regression of Objective Postoperative Gastroesophageal Reflux and Dysphagia

OBJECTIVES To review transabdominal esophagocardiomyotomy (surgical treatment of achalasia) of the esophagus and to compare outcomes of partial anterior vs partial posterior fundoplication. DATA SOURCES An electronic search was conducted among studies published between January 1976 and September 2011 using the keywords achalasia, myotomy, antireflux surgery, and fundoplication. STUDY SELECTION Prospective studies of transabdominal esophagocardiomyotomy were selected. DATA EXTRACTION Outcomes selected were recurrent or persistent postoperative dysphagia and an abnormal 24-hour pH test result. Studies were divided into the following 3 groups: myotomy only, myotomy with anterior fundoplication, and myotomy with posterior fundoplication. Studies were weighted by the number of patients and by the follow-up duration. Event rates were calculated using meta-regression of the log-odds with the inverse variance method. DATA SYNTHESIS Thirty-nine studies with a total of 2998 patients were identified. The odds of postoperative dysphagia were 0.06 (95% CI, 0.03-0.12) for myotomy only, 0.11 (95% CI, 0.09-0.14) for myotomy with anterior fundoplication, and 0.06 (95% CI, 0.04-0.08) for myotomy with posterior fundoplication. The odds of a postoperative abnormal 24-hour pH test result were 0.37 (95% CI, 0.12-1.08) for myotomy only, 0.16 (95% CI, 0.11-0.24) for myotomy with anterior fundoplication, and 0.18 (95% CI, 0.13-0.25) for myotomy with posterior fundoplication. The increased odds of postoperative dysphagia in the group undergoing myotomy with anterior fundoplication compared with the group undergoing myotomy with posterior fundoplication were statistically significant (P < .001). However, the incidence of a postoperative abnormal 24-hour pH test result was statistically similar. CONCLUSION Partial posterior fundoplication when combined with an esophagocardiomyotomy may be associated with significantly lower reintervention rates for postoperative dysphagia, while providing similar reflux control compared with partial anterior fundoplication.

End of the Road for a Dysfunctional End Organ: Laparoscopic Gastrectomy for Refractory Gastroparesis

IntroductionGastroparesis is a functional disorder resulting in debilitating nausea, esophageal reflux, and abdominal pain and is frequently refractory to medical treatment. Therapies such as pyloroplasty and neurostimulators can improve symptoms. When medical and surgical treatments fail, palliative gastrectomy is an option. We examined outcomes after gastrectomy for postoperative, diabetic, and idiopathic gastroparesis.MethodsA prospective database was queried for gastrectomies performed for gastroparesis from 1999 to 2013. Primary outcomes were improvements in pre- versus postoperative symptoms at last follow-up, measured on a five-point scale. Secondary outcome was operative morbidity.ResultsThirty-five patients underwent laparoscopic total or near-total gastrectomies for postoperative (43 %), diabetic (34 %), or idiopathic (23 %) gastroparesis. Antiemetics and prokinetics afforded minimal relief for one third of patients. There were no mortalities. Six patients suffered a leak, all treated with surgical reintervention. With a median follow-up of 6 months, nausea improved or resolved in 69 %. Chronic abdominal pain improved or resolved in 70 %. Belching and bloating resolved for 79 and 89 %, respectively (p < 0.01).ConclusionsRegardless of etiology, medically refractory gastroparesis can be a devastating disease. Near-total gastrectomy can ameliorate or relieve nausea, belching, and bloating. Chronic abdominal pain commonly resolved or improved with resection. Despite attendant morbidity, gastrectomy can effectively palliate symptoms of gastroparesis.

Does Morbid Obesity Worsen Outcomes After Esophagectomy

BACKGROUND With worldwide increases in esophageal cancer and obesity, esophagectomies in the morbidly obese (MO) will only increase. Risk stratification and patient counseling require more information on the morbidity associated with esophagectomy in the obese. METHODS We studied nonemergent subtotal or total esophagectomies with reconstruction in the National Surgical Quality Improvement Project (NSQIP) database from 2005 to 2010. After excluding patients with disseminated disease and body mass index (BMI) less than 18.5, we compared outcomes of patients with normal BMI (18.5-25) to those of MO patients (BMI ≥ 35). Outcomes were mortality and morbidity. Multivariable regression controlled for age and comorbidities differing between groups. RESULTS Of 794 patients, 578 (73%) had a normal BMI and 216 (27%) patients were morbidly obese (MO). The population was 75% men, with a mean age of 62 years. Patients with a normal BMI were older and more likely to smoke (p < 0.001). MO patients had a higher incidence of hypertension (65% versus 41%) and diabetes (20% versus 10%), and fewer had preoperative weight loss greater than 10% (9% versus 31%) (p < 0.001). Overall, morbidity was 48.5% and mortality was 3%; there was no difference between the groups. On multivariable analysis, all outcomes were the same between groups except deep space infections and pulmonary embolism (PE), for which the obese were at 52% and 48% higher risk, respectively (p = 0.02). CONCLUSIONS In our study, postoperative mortality and pulmonary, cardiac, and thromboembolic morbidity were similar between MO patients and patients with a normal BMI. MO increased the odds of deep wound infections. Overall, BMI greater than 35 does not confer significant morbidity after esophagectomy. Patients with esophageal pathologic conditions should not be denied resection based on MO alone.

Esophagectomies with thoracic incisions carry increased pulmonary morbidity.

IMPORTANCE Thoracic incisions are not required for all esophagectomies and may increase pulmonary morbidity. OBJECTIVE To compare the pulmonary and overall morbidity of esophagectomies with and without thoracic incisions. DESIGN Observational study. SETTING Hospitals participating in the National Surgical Quality Improvement Project. PARTICIPANTS Patients without metastatic cancer undergoing nonemergency total esophagectomies with reconstruction from 2005 through 2010. Patients who underwent transhiatal esophagectomy (THE) were compared with a THORACIC group (Ivor Lewis and McKeown techniques). MAIN OUTCOMES AND MEASURES Pulmonary and overall morbidity, infection, and thromboembolic complications. RESULTS Of 1568 patients, 717 (45.7%) underwent THE, and 851 (54.3%) were in the THORACIC group (Ivor Lewis technique in 487 [31.1%] and McKeown technique in 364 [23.2%]). The population was 80.5% male, with a mean age of 62.9 years. Patients undergoing THE were older (P = .02). Diabetes mellitus was less common in the THORACIC group (11.2% vs 15.9% for THE; P = .02), and cancer was more common (91.0% vs 87.0%; P = .01). Morbidity was 49.2% and mortality was 3.3%, without differences between groups. The mean length of stay was 1.6 days shorter (P = .009) in the THE group. Multivariable analysis showed that thoracic incisions increased rates of pneumonia (odds ratio [OR], 1.47; P = .007), ventilator dependence (OR, 1.35; P = .04), and septic shock (OR, 1.86; P = .001) but not mortality. Compared with the Ivor Lewis technique, the McKeown technique worsened the odds of superficial wound infections (OR, 1.71; P = .02) but not septic shock (OR, 0.84; P = .47). CONCLUSIONS AND RELEVANCE Esophagectomies have an acceptable mortality rate but a significant morbidity rate. We demonstrated that rates of pneumonia, ventilator dependence, and septic shock are increased with the use of thoracic incision. Avoiding thoracic incisions may therefore decrease the risk of pulmonary morbidity and septic shock.

Technique of per-oral endoscopic myotomy (POEM) of the esophagus (with video)

BackgroundPer-Oral Endoscopic Myotomy (POEM) is becoming an acceptable alternative to laparoscopic cardiomyotomy for esophageal motility disorders. The aim of this video is to provide key technical steps to completing this procedure.MethodEach patient underwent diagnostic investigations including high resolution manometry (HRM), esophageogastroduodenoscopy (EGD), and timed-barium swallow for primary esophageal motility disorders preoperatively. Patients undergoing POEM procedures are preoperatively prepared by taking Nystatin swish-and-swallow for 3 days, 24 h of clear liquid diet, and 12 h of NPO. Preoperative antibiotics are given. Under general anesthesia and with the patient in the supine position, endoscopy with CO2 insufflation is prepared. Special endoscopic instruments and electrocautery settings are required to perform the POEM procedure, as illustrated in the slides. POEM is performed in six key/critical steps: (1) diagnostic endoscopy; (2) taking measurements; (3) esophageal mucosotomy creation; (4) submucosal tunneling; (5) selective circular myotomy of the anterior lower esophageal sphincter; and (6) closure of the mucosotomy. According to our protocol, all patients get an esophogram the next morning after surgery prior to discharge. The patient receives objective testing (HRM with 24 PH Impedance test, EGD, and timed-barium swallow) 6 months postoperatively.ConclusionIn six key steps, POEM can be accomplished as described in the video.