400 Utility of the Over-the-Scope-Clip As Endoscopic Monotherapy for Severe Acute Upper, Middle and Lower Gastrointestinal Bleeding (original) (raw)

2016, Gastrointestinal Endoscopy

Background: Unlike Laparoscopic myotomy, POEM affords freedom in selecting the myotomy orientation with some centers favoring anterior (A) and some posterior (P) orientation. It has been postulated that posterior POEM by cutting the sling fibers of the LES that maintain the angle of His (rather than the shorter clasp fibers cut in anterior POEM), may result in a more patulous LES with greater relief of dysphagia at the expense of more reflux. Some have also postulated that posterior POEM can be performed more rapidly and easily due to the location of the incision along the axis of the therapeutic channel of the endoscope. Finally, some authorities have suggested that in anterior POEM there may be more dense vascularity in the cardia and higher risk of intraprocedural hemorrhage as well as more escape of CO2 that may increase the incidence of capnoperitoneum/capnothorax. No data exist to date in support of any of these contentions. Aim: To assess outcomes in anterior vs posterior POEM in our single operator series of 248 POEMs (120 A, 128 P) performed from 10/2009 to 10/2015. Results: No learning curve bias expected as we performed a similar percentage of anterior POEMs in the first 3 years of our series (48/ 91, 53%), as in the last 2 years (vs 72/157 46%). Data were analyzed from a prospectively maintained database. There were no difference in the Eckardt score, including failures (post POEM Eckardt score>3, 5/110 AP vs 4/117 P, NS)., accidental mucosal injuriesincluding non-transmural minor blanching (29% vs 23%), prolonged stay of >5 days (1/ 119 A, 1/128 P). There was no difference in significant AEs but it should be noted that there was paucity of such events in our series with no leaks, no tunnel bleeds and no surgical/IR interventions. Posterior POEM was significantly faster overall (97 min A, 79 min P, PZ0.0007) including a faster closure (Suturing 177, clips 71) (9.6 min A, 7.9 min P, PZ0.02). More pts had pain requiring narcotics in posterior POEM (17% A vs 27% P, PZ0.007). There was a trend for less acid reflux in anterior POEM: +BRAVO studies (21/58 A, 29/58, PZ0.13), reflux esophagitis (22/57A, 33/60 P, PZ0.076). Based on these results we calculated a sample size of 120 (including 20% dropout) for an Anterior vs Posterior randomized trial to demonstrate that posterior POEM is faster. However, a larger number may be required to demonstrate a difference in incidence of reflux at 95% confidence. We have currently enrolled 94 pts in this RCT to be reported separately. Conclusion: Based on our analysis of our 248 single operator POEM series, anterior POEM is slower but results in less pain and less acid exposure and reflux esophagitis (90% confidence level). We are close to completing enrollment in a single operator anterior/posterior randomized trial.