A novel strategy to initiate a peroral endoscopic myotomy program.
OBJECTIVES
The standard of care for achalasia remains laparoscopic Heller myotomy with partial fundoplication. Peroral endoscopic myotomy (POEM) has been introduced as an alternative, but safety and long-term comparative efficacy are not yet established. We report our experience in developing a POEM program using a novel hybrid approach.


METHODS
We developed a hybrid approach to POEM with a POEM followed by laparoscopic evaluation, extension of the myotomy, if necessary, and partial fundoplication. We reviewed the results of the programme from April 2012 until May 2015. Starting in 2014, we began offering patients stand-alone POEM. Patient data were collected. Preoperative and postoperative Eckardt scores were compared.


RESULTS
A total of 28 patients underwent POEM or POEM plus laparoscopic evaluation with partial fundoplication. Patient characteristics and perioperative and postoperative data were recorded. The median preoperative Eckardt score was 6 (range 4-11). The mean follow-up period was 136 days (range 41-330) and the median postoperative Eckardt score was 0 (range 0-6) at 6 weeks. Of our initial 10 patients, 6 required laparoscopic extension of the myotomy; 7 subsequent patients did not require an additional myotomy. Three patients who underwent POEM without laparoscopy continued to have dysphagia postoperatively. One patient had an attempted POEM that was aborted secondary to bleeding, and a standard laparoscopic modified Heller myotomy with partial fundoplication was performed.


CONCLUSIONS
The excellent results of laparoscopic myotomy with partial fundoplication are challenging to duplicate during the initial adoption of a POEM approach. We present a program developed to steepen the learning curve and enhance patient safety while implementing this new procedure.
['Reinersman|J Matthew|JM|', 'Wigle|Dennis A|DA|', 'Gostout|Christopher J|CJ|', 'Song|Louis M Wong Kee|LMWK|', 'Blackmon|Shanda H|SH|']
D000293:Adolescent D000328:Adult D000368:Aged D000369:Aged, 80 and over D004931:Esophageal Achalasia D049630:Esophageal Sphincter, Lower D004945:Esophagoscopy D005260:Female D018662:Fundoplication D006801:Humans D010535:Laparoscopy D008297:Male D008875:Middle Aged D000074433:Myotomy D057605:Natural Orifice Endoscopic Surgery D017410:Practice Guidelines as Topic D016896:Treatment Outcome D055815:Young Adult
Achalasia Minimally invasive Oesophageal surgery