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FRIDAY, MAY 21, 2021Esophagus 2Poster

ID: 3517554ESTABLISHMENT OF A POEM SERVICE IN A LARGEINTEGRATED HEALTHCARE SYSTEMLawrence J. Leung*, Gene K. Ma, Howard Y. Chang,Jonathan Svahn, Norio Fukami, Ming-Ming Xu, Steven Lam,Amita Risbud, Jeffrey K. Lee, Terry L. JueBackground and Aim: Currently, no standardized training and credentialing criteriafor competency in Per Oral Endoscopic Myotomy (POEM) have been established.The ideal clinical care model is also undefined. The aim of this study is to provide adescriptive retrospective study of the establishment and outcomes of a tertiaryPOEM service in a large integrated community health system. Methods: We outlinedthe steps taken at Kaiser Permanente Northern California to establish a POEM ser-vice. We catalogued patients who underwent POEM at our facility from January 29,2019 to November 4, 2020. Pertinent information including achalasia subtype andprior treatments were recorded. Primary outcome measures include technical suc-cess (successful tunneling into the gastric cardia and myotomy of LES muscle fibers),clinical success (post-procedure Eckardt score �3) at 3-6 months and 12 monthspost-procedure, adverse events, and esophageal distensibility index changes beforeand after myotomy. Results: Establishing a POEM service involved: 1) designating ahospital facility with thoracic and foregut surgical expertise as the POEM site; 2)establishing competency training, proctorship criteria, and resource allocation withhospital leadership; 3) observation and education of POEM by experts; 4) skillsdevelopment using ex-plant and live animal models; 5) engaging anesthesia, radi-ology, surgery, nursing, and referring gastroenterologists to design a comprehensivecare model; 6) onsite technical support by industry with initial cases; 7) creden-tialing proctorship; 8) pre- and post- POEM telehealth encounters given a largegeographic referral base (Figure 1). The POEM providers were gastroenterologists.One had performed nearly 100 endoscopic submucosal dissection (ESD) and over200 endoscopic mucosal resection (EMR) procedures. The other had performedapproximately 100 esophageal EMR procedures. There were 39 patients (Figure 2)who underwent POEM since the start of service including 6 with prior surgicaltreatment. Average Eckardt score pre-POEM was 6.33 (standard deviation [SD] Z1.63). Technical success was 100%. Clinical success at 3-6 months was 92% (n Z 25,mean Eckardt Z 1.24 [SD Z 1.42]). Clinical success at 12 months was 94.7% (n Z19, mean Eckardt Z 1.74 [SD Z 1.55]). One adverse event occurred (2.56%). Ourfirst patient had a mucosotomy requiring closure by clips, and EGD reassessmentshowed a submucosal hematoma. The patient recovered uneventfully and re-sponded to POEM. The severity of the event was moderate per the ASGE Lexicon.Conclusion: In this study, we outlined the steps involved to establish a POEM servicein a large integrated healthcare system. Prior competency in interventional endos-copy, procedural training models, POEM observation and education, proctorship,and interdisciplinary patient care are recommended.

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Figure 1. POEM Service Establishment Timeline

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Figure 2. Demographics and Characteristics


ID: 3520144ENDOSCOPIC SUBMUCOSAL DISSECTION FOR GERD(ESD-G) FOR PROTON PUMP INHIBITOR-REFRACTORYGASTROESOPHAGEAL REFLUX DISEASE (GERD)Kazuhiro Ota*, Shinya Nishida, Taro Iwatsubo, Shinpei Kawaguchi,Yuichi Kojima, Toshihisa Takeuchi, Kazuhide HiguchiBackground and aims: Medications, such as proton-pump inhibitors (PPIs), havebeen recommended first line therapy for gastroesophageal reflux disease (GERD),but not all patients receive satisfactory relief with drug therapy, alone. We developedthe endoluminal fundoplication by applying ESD (endoscopic submucosaldissection), and named ESD-G (ESD for GERD). We previously reported aboutefficacy of ESD-G (Scand J Gastroenterol. 2014, 49: 1409-13). We will herein reportof novel result including the added patients undergone ESD-G. Methods: The pur-pose of ESD-G is to narrow the space of hiatus hernia by performing ESD to themucosa in the esophago-gastric junction (EGJ). In addition, ESD-G also might havethe effects of the decrease in a part of the GERD symptom by ablating the sensorynerves. We decided for safety that the range of the mucosa to resect surgically was 1/2 (or 1/4 +1/4) circles of the EGJ lumen, because it is reported that resecting themembrane of the lumen of 2/3 circles or more is going to make esophageal stricturein cases of ESD for esophageal cancer. The efficacy of ESD-G was evaluated using theobjective findings (upper gastrointestinal endoscopy and 24-hour multichannel in-traluminal impedance-pH monitoring) and the subjective item (FSSG (FrequencyScale for the Symptoms of GERD) and PPI doses to control the GERD symptoms).The patients with histories of gastrectomy or endoscopic treatment were excludedfrom the investigation. Results: The 42 patients with PPI-refractory GERD underwentESD-G and the 16 patients were excluded this investigation because of abovecriteria. We calculated in 26 patients. ESD-G improved significantly the FSSG(Acid reflux score: 16[7-27]/6.5[0-22], p＝0.0004; Dysmotility score: 10.5[0-19]/5[0-16], pZ0.0023). ESD-G reduced significantly the dosage of PPI for suppressingsymptoms associated with GERD (pZ0.0003). ESD-G did not decrease the numberof reflux episodes. Conclusion: This novel endoscopic treatment “ESD-G” couldimprove the GERD symptoms in PPI-refractory GERD patients.

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ID: 3524032HOSPITAL ADMISSION CHARACTERISTICS ANDTREATMENT COST OF ACHALASIA: A TIME-TRENDANALYSIS OF THE LAST TWO DECADES IN UNITEDSTATESMuhammad Hashim Hayat*, Rishi D. Naik, Michael F. Vaezi,Dhyanesh A. PatelObjectives: Achalasia, a neurodegenerative motility disorder of esophagus, has hadadvances in manometric diagnosis and interventional therapy, but the impact onpatient morbidity is unknown. The aim of this study was to assess admissions trends,cost, length of stay, and rates of myotomy in US population with achalasia.Methods: We reviewed the National Inpatient Sample Database for all hospitaliza-tions with principal discharge diagnosis for achalasia and cardiospasm using theICD-9 code: 530.0 and ICD-10 code K22.0 between years 1993–2017. Trends indischarge rates, costs, length of stay, and rates of myotomy (heller or per-oralendoscopic myotomy - ICD-9 code 42.7, ICD-10 codes 0D840ZZ- 0D848ZZ) wereanalyzed via JMP 14 software. Results: In the year 2017, the total number of age-sexstandardized admissions for achalasia was 5,855 which is a twofold increase from2,759 admissions in 1993. Rate of discharge (per 100,000 persons) also increasedfrom 1.1 in 1993 to 1.8 in 2017 (p < 0.01). The mean age of admitted patientpopulation ranged between 55.6 – 57.8 years. Approximately 25 to 30% of theadmitted patients were admitted via emergency department. The mean length ofhospitalization saw a steady decline from 5.9 days to 4.3 days in 2017 however themean charges saw a significant increase from $11,228 in 1993 to $64,884 in 2017(adjusted for inflation, p< 0.01) (Figure 1). This rise in cost paralleled a rise inincidence of myotomy for both Heller and per-oral endoscopic myotomy (Figure 2).Conclusions: The incidence of achalasia is on the rise and we found a twofold in-crease in admissions related to achalasia during the last two decades. Further-more, despite the decrease in length of hospitalization over the years, there was asignificant increase in cost of hospitalizations likely related to rise in incidence ofmyotomy.

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Figure 1: Mean charges per admission from year 1993 to 2017 related toprimary diagnosis of achalasia

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Figure 2: Total number of discharges related to primary diagnosis of acha-lasia parallel rise in myotomy from 1993 to 2017

SATURDAY, MAY 22, 2021Esophagus 2Poster

ID: 3525327THE EFFICACY AND LONG-TERM OUTCOMES OFENDOSCOPIC FULL-THICKNESS SUTURING FORCHRONIC GASTROINTESTINAL FISTULAS WITHOVERSTITCH DEVICE: IS IT A DURABLE CLOSURE?Duochen Jin*, Guoxin ZhangBackground and aim: Endoscopic closure of a chronic gastrointestinal fistula (CGF)is challenging for its epithelialized surfaces. The aim was to assess the efficacy andlong-term closure rate of endosuturing for CGFs with Apollo Overstitch device.Patients and methods: Consecutive CGF patients undergoing endosuturing for fis-tula closure from April 2018 to January 2020 at the First Affiliated Hospital of NanjingMedical University were enrolled for retrospective review. Demographics, fistulacharacteristics, details of the suturing procedures and outcomes were collected foranalysis. Results: Twenty patients (mean age 59.8 � 9.1 years; 85% males) with atotal of 23 CGFs underwent sutured fistula closure. Esophagotracheal fistulas werethe most common CGFs (12/23, 52.2%) and prior cancer surgery was the mostcommon fistulation etiology (14/20, 70%). Twelve patients (12/20, 60%) had un-dergone failed endoscopic attempts at fistula closure before suturing. Additionalendoscopic therapies used during suturing were 100% in argon plasma coagulation,50% in clip fixation, and 10% in stent placement. Although all patients undergoingsuturing achieved immediate technical success of fistula closure, sustained fistulaclosure was observed in only 5 patients (5/20, 25.0%) on surveillance endoscopy 3months after suturing with a mean follow-up of 19.5 months. Esophagotrachealfistula patients predisposed to a shorter dehiscence-free survival than those withother fistulas (HR 3.378; 95% CI 1.127 - 10.13). Conclusions: Endosuturing is safeand considerable applied as the first-line or salvage therapy for CGF closure. How-ever, long-term healing of CGFs by suturing is challenging and CGF patients mightnot benefit from repeated suturing.

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Fig. 1. Endoscopic views showing chronic esophagotracheal fistulas andesophagomediastinal fistulas. (a1) patient No. 2 with a congenital esoph-agotracheal fistula, 6 � 6 mm; (a2) patient No. 11 with a traumatic esoph-agotracheal fistula, 15 � 10 mm; (a3) patient No.14 with anesophagotracheal fistula caused by radical resection for esophageal can-cer, 8 � 8 mm; (b1) patient No. 8 with an esophagomediastinal fistulacaused by swallowing a fishbone, 5 � 5 mm; (b2) patient No. 10 withan esophagomediastinal fistula caused by radical resection for esophagealcancer, 10 � 10 mm; (b3) patient No. 17 with an esophagomediastinal fis-tula caused by radical resection for esophageal cancer, 5 � 8 mm.

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AB296 GASTROINTESTINAL ENDOSCOPY Volume 93, No. 6S : 2021 www.giejournal.org


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Fig. 2. Flow chart of interventions and outcomes of the enrolled 20 pa-tients with CGFs undergoing endoscopic suturing. & Patient No. 8 diedof aortic dissection following ingestion of a fishbone; # The gastric fistulaof patient No. 9 was clinically cured after the secondary endoscopic sutur-ing, but the other esophagotracheal fistula still existed.


ID: 3523454SUBMUCOSAL TUNNELLIING TECHNIQUES FORZENKER’S DIVERTICULUM: A SYSTEMATIC REVIEW OFEARLY OUTCOMES WITH POOLED ANALYSIS.Marco Spadaccini*, Maselli Roberta,Viveksandeep Thoguluva Chandrasekar, Harsh K. Patel,Alessandro Fugazza, Piera Alessia Galtieri, Gaia Pellegatta, Simona Attardo,Silvia Carrara, Andrea A. Anderloni, Asma A. Alkandari, Prateek Sharma,Mouen A. Khashab, Alessandro RepiciBackground and aim: In the last decade, flexible endoscopic septotomy has been re-ported as a safe and effective treatment for Zenker’s diverticulum (ZD). Morerecently, novel endoscopic submucosal tunneling techniques, namely standard Z-POEM (Zenker PerOral Endoscopic Myotomy) and POES (PerOral EndoscopicSeptotomy), have been proposed in order to obtain complete muscular septumexposure and deeper myotomy. The aim of this study is to provide a systematicreview with meta-analysis of the first experiences of third space approaches for ZD.Methods: Electronic databases (Medline, Scopus, EMBASE) were searched up toOctober 2020. Studies including patients with symptomatic ZD who underwentendoscopic treatment by submucosal tunneling technique were eligible. Procedural,clinical, and safety outcomes were assessed by pooling data with a random-effectmodel to obtain a proportion with a 95% confidence interval. Results: Ten retro-spective studies were eligible for inclusion (229 patients). Six studies were per-formed in the United States, 2 in Europe, and 2 in Asia. Most of the studies (nZ7)were single-center experiences, and three studies involved multiple centers. Endo-scopic pyloromyotomy was feasible in the 97.3%(I 2 Z0%) of patients. In most ofthe studies (nZ7, 166 patients) authors used the standard Z-POEM technique re-porting a technical success of 97.5% (I 2 Z0%), in a mean procedural time of 44.3 �7.5 minutes. In the remaining 3 studies including POES approach performed on 63patients, the technical success rate was 96.5% (I 2 Z0%), in a mean procedural timeof 20.4 � 9.3 minutes. Clinical success was achieved after 93.4%(I 2 Z0%) of pro-cedures with comparable rates between standard Z-POEM and POES (93,7% vs91.1%, respectively). The overall adverse events rate was 5.3%(I 2 Z0%) withcomparable rates between standard Z-POEM and POES (5.2% vs 7.7%, respectively).Conclusions: Flexible endoscopic treatment of ZD performed by a submucosaltunnelling technique appears to be a feasible option, with convincing data interms of safety and promising clinical results in the short term.


ID: 3522401EVOLUTION OF THE PERORAL ENDOSCOPIC MYOTOMYTECHNIQUE FOR ACHALASIA: A SINGLE-CENTEREXPERIENCEAlyssa Y. Choi*, Samuel S. Ji, Spencer Kozik, Jennifer M. Kolb,Zain Moosvi, Anastasia Chahine, Emily Bernal, Rochelle Simoni,Jason B. Samarasena, Kenneth J. ChangIntroduction: Peroral endoscopic myotomy (POEM) is emerging as a safe and effec-tive treatment option of achalasia. In this study our aim to was to evaluate post-POEM outcomes of safety and efficacy with a special focus on our recently describednavigational pocket technique. Methods: A retrospective chart review was per-formed in patients who had undergone POEM at a tertiary referral medical centerfrom 3/11/2014 to 9/18/2020. Eckardt score was assessed pre- and post- POEM. Thelengths of the total myotomy and extension into the cardia were collected from theprocedure note. Follow up endoscopic data included degree of esophagitis. Safetywas assessed through adverse events involving hospitalizations, ER visits, and phoneappointments. Results: A total of 145 patients had POEM with 132 having adequatefollow up to be included in this study (mean age 58.2, 54.5% female). Of those,87.1% of patients had achalasia (32.6% Type 1, 46.2% Type 2, 8.3% Type 3). Otherdiagnoses included jackhammer (5.3%), esophageal spasm (1.5%), and unspecified(6.1%). The average length of total myotomy was 10.9 cm (range 4-23 cm) andextension of myotomy into the cardia 1.8 cm (0-3 cm). The mean Eckardt scoreimproved from 7.3 (1-12) pre-POEM to 1.2 (0-5) post-POEM (p<0.001). There was apositive correlation between pre-POEM Eckardt score and total myotomy length(rZ0.182, pZ0.048). Eighteen (12.4%) patients had adverse events requiring ERvisit or hospitalization, with the most common adverse events being incompletelyclosed tunnel, dysphagia, and chest pain (3 patients each). Sixty-two (47%) patientsunderwent an EGD post-POEM. Of 62, 33 (59%) had no esophagitis, 12 (21.4%) LAclass A, 4 (7.1%) class B, 5 (9.0%) class C, 2 (3.5%) class D. Patients who had anyform of esophagitis had a longer extension of myotomy into the cardia compared topatients without esophagitis (pZ0.001). A navigational pocket technique was im-plemented in the 34 most recent POEMs. This technique demonstrated a shorterextension of myotomy into the cardia. (1.9 cm vs 1.4 cm, pZ0.015). Patients thatunderwent navigational pocket technique, demonstrated lower post-POEM Eckardtscores as compared to patients without navigational pocket technique (0.60 vs. 1.41,pZ0.039). Conclusion: Our single center experience continues to build on thesafety and efficacy of POEM for the treatment of achalasia. Post-POEM, there was adecrease in Eckardt scores with the majority of patients developing no esophagitis.These benefits of POEM were augmented post-implementation of the navigationalpocket technique with shorter lengths of myotomy extension into the cardia andlower post-POEM Eckardt scores.


ID: 3523846LONG TERM OUTCOMES OF REDO POEMS IN PATIENTSWITH REFRACTORY OR RECURRENT ACHALASIA: ASINGLE CENTER EXPERIENCELucie F. Calderon*, Hima Veeramachaneni, Salih Samo,Ahmed A. Messallam, Rushikesh Shah, Steven Keilin, Qiang CaiBackground and Aims: There are few studies exploring therapeutic options for pa-tients with refractory or recurrent achalasia after per-oral endoscopic myotomy(POEM). Redo POEM is an option for management of these patients; however, thereis limited data on its clinical success. This study aims to identify the efficacy andsafety of redo POEM in patients who have refractory or recurrent symptoms to initialmyotomy. Additionally, we seek to qualify which patients would benefit from redoPOEM based off underlying presenting characteristics. Methods: This was a retro-spective study of patients from August 2014 to February 2020 with refractory orrecurrent achalasia after initial POEM who elected to undergo redo POEM. All pa-tients were assessed for their eligibility for POEM based off diagnosis of achalasiafrom clinical presentation and confirmation by manometry studies. Initial severitywas classified into mild, moderate, and severe achalasia according to the Eckardtscore (mild 0-4, moderate 5-8, severe 9-12). Patients included in this study werethose who failed initial POEM as defined by Eckardt score > 6 at follow up visits.Clinical success was defined as post POEM Eckardt score of � 3. Demographic,disease and procedure-related data were extracted from chart review. Redo POEMswere performed with posterior myotomy at the same orientation as the initial my-otomy. Patients were followed at 6-52 months following redo POEM to assess clinicalsuccess. Results: 15 patients with refractory achalasia elected to undergo repeatPOEM (age 25-79, 53.3% female) and 1 was lost to follow up. Included patients had


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achalasia type I (20%), type II (53.3%), type III (0%), or were unspecified (26.7%).Their initial Eckardt scores ranged from 3-11 with an average of 7.1 +/-2.37 (95% CI5.87-8.27), and they were assigned to mild (nZ3), moderate (nZ7), and severeachalasia (nZ4) based off symptom severity (mild 0-4, moderate 5-8, severe 9-12).Initial procedure times were 61.9 +/- 21.1 minutes and repeat procedure times were62.2 +/- 14.4 minutes (pZ0.9601). After redo POEM, clinical success, defined byEckardt score < 3, was achieved in 9/15 patients (60%) (mild 66.7%, moderate 71%,and severe 50%). Of these 9 patients, 4 (44.4%) reported limited relief (4.25 months+/- 2.36), 3 (33.3%) reported continued relief (7-31+ months), and 2 were lost tolong term follow-up. Adverse events in redo POEMs were limited to capnoperito-neum (nZ1) requiring needle decompression, without significant increase in timeof hospitalization (2.67 vs 2.24 days, p Z 0.89). Conclusion: This is the first studyobserving the long-term results of redo POEM greater than 6 months. Overall, redoPOEM offers a safe and effective option for patients with achalasia who have re-fractory or recurrence of symptoms after initial myotomy and can offer long-termclinical success for indicated patients.

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ID: 3523123ESOPHAGEAL STENT PLACEMENT FOR MANAGEMENTOF MALIGNANT DYSPHAGIAFiras Bahdi*, Abraham Yu, Ikenna K. Emelogu, Martin Coronel,Phillip S. Ge, Emmanuel Coronel, Brian R. Weston,Patrick M. Lynch, William A. Ross, Shria Kumar, Jeffrey LeeIntroduction: Esophageal stents (ES) have been increasingly used to treat esopha-geal obstruction associated with malignancies. We evaluate outcomes of ES place-ment for malignant esophageal obstruction at our tertiary care, cancer-focusedcenter. Methods: We identified patients who underwent placement of ES foresophageal obstruction, dysphagia, odynophagia, between 1/1/2001-7/31/2020.Exclusion criteria included ES placed for benign stricture, fistulae, or post-surgicalindications. No ES was placed for proximal pathology. Patient charts were reviewedfor demographics, procedure and stent characteristics, complications, and follow up.Standard statistical analyses were performed. Results: We identified 242 ES placedfor malignant dysphagia. Among the 242, 123 (50.8%) were fully covered, 65 (26.9%)partially covered, 5 (2.1%) uncovered, 8 (3.3%) plastic, and 41 (16.9%) of unknowntype. The median age at stent placement was 64 years, the majority of patients(79.8%) were male, and the majority (204, 84.3%) had esophageal cancer. Of the242, 84 (34.7%) had radiation therapy prior to ES placement. Patients and stentcharacteristics are described further in Table 1. Table 2 depicts complications andoutcomes after placement of ES. The most frequent early complications (within 30days of ES placement) included pain in 69 (28.1%) and migration in 21 (8.7%),though there was no significant difference in the rates of complications among stenttype subgroups. When evaluating delayed complications (after 30 days), recurrentsymptoms (46, 19.0%) and migration (26, 10.7%) were most common. The sub-group with the highest rate of migration was the plastic stent group (4, 50%),(pZ0.004 for difference among groups). In follow-up, 92 (38.0%) patients requiredother enteral nutrition modalities. This included endoscopic gastrostomy tube in 44(18.2%), interventional radiology placed feeding tube in 14 (5.8%), and surgicallyplaced feeding tube in 14 (5.8%). Exploratory analyses were conducted using uni-variable logistic regression to identify factors associated with early complication,delayed complication, and need for other modalities of enteral nutritional accessduring follow-up. No patient or stent characteristics were significantly associatedwith ES complication or need for alternative enteral access. Discussion: ES place-

ment has become a mainstream therapeutic option when evaluating malignantdysphagia. Fully covered stents in particular are most frequently used. Complicationsare relatively frequent, both early and delayed, and include pain, migration, andrecurrence of symptoms. A high proportion of patients require alternative enteralnutrition modalities despite ES placement. Future studies should attempt to identifyfactors that are associated with successful palliation of malignant dysphagia after ESplacement, in order to best tailor therapy.

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Table 1. Patients and Stents Characteristics (NZ242)

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Table 2. Complications & Outcomes


ID: 3524397DO ADMISSION AND DEMOGRAPHICCHARACTERISTICS DIFFER IN PATIENTS ADMITTEDFOR ACHALASIA UNDERGOING PNEUMATIC DILATIONVERSUS MYOTOMYAnmol Mittal*, Dayna Panchal, Sushil AhlawatIntroduction: Achalasia, an esophageal motility disorder, has an unknown etiologyand does not have curative treatment. Current techniques for disease modificationinclude pneumatic dilation and laparoscopic Heller’s myotomy (LHM), as well asnew emerging techniques including peroral endoscopic myotomy (POEM). Thecurrent accepted gold standard for treatment is an LHM, however, there have notbeen any established guidelines to decide between the treatment options fordifferent types of patients with achalasia. Our aim was to understand the


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characteristics of admissions and patient demographics that may influence treat-ment decisions. Methods: The Nationwide Inpatient Sample (NIS) 2001-2013 data-base was queried for patients with an admission diagnosis of Achalasia usingInternational Classification of Diseases, Ninth Revision (ICD-9) codes. Esophago-myotomy (E) and Esophagus Dilation (ED) were isolated based on ICD-9 procedurecodes. A chi-square analysis was performed to determine variables to be included ina multivariable analysis. A binary logistic regression analysis was used to examinedemographic and other important variables, with a significance level of p < 0.001.Results: A total of 83,710 patients were identified who had been admitted for acha-lasia, of which 30,865 (36.9%) received a myotomy and 10,855 (13.0%) receivedpneumatic dilation. After incorporating complications including pneumonia, urinarytract infections, myocardial infarctions, and acute renal failures, it was found pneu-matic dilation was performed more for adults aged 80 or greater (OR 12.07), thosewith Medicare, Medicaid or uninsured status (OR 2.36, OR 2.08, OR 4.54), and thoseadmitted on a weekend (OR 10.56). Discussion: Pneumatic dilation and LHM areboth effective treatments for achalasia. Our data shows that LHM was performedmore frequently in younger patients possibly because dilation is associated withhigher relapse rates and the need for repeat dilations, which may not be preferablein a younger patient. Younger patients are more often surgical candidates and maytolerate LHM better than older. LHM was performed less frequently on patientsadmitted during the weekend probably due to lack of ancillary support. We alsonoted that pneumatic dilation was preferred in patients that were uninsured or hadMedicare, or Medicaid as compared to private insurance payors. Pneumatic dilationis more cost-effective and can be done routinely as an outpatient procedure, helpingreduce health care costs for both insurance providers and patients. Resolution ofsome of these barriers may help shift the paradigm of performing dilations topreferring LHM or POEM.

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Table 1. Predictors of Pneumatic Dilation over Myotomy in the StudyPopulation


ID: 3523193MIGRATION OF ESOPHAGEAL STENTS PLACED FORMALIGNANT OBSTRUCTIONIkenna K. Emelogu*, Firas Bahdi, Abraham Yu, Martin Coronel,Emmanuel Coronel, Phillip S. Ge, Brian R. Weston,William A. Ross, Patrick M. Lynch, Shria Kumar, Jeffrey LeeIntroduction: Esophageal stents (ES) are a widely used therapeutic option for themanagement of malignant esophageal obstruction. However, there is a high rateof complications after ES placement, particularly migration. We evaluate rates ofmigration after ES placement for malignant esophageal obstruction at our tertiary

care, cancer-focused center. Methods: We identified patients who underwentplacement of ES for malignancy-related esophageal obstruction, between 1/1/2001-7/31/2020. Exclusion criteria included ES placed for benign stricture, fistulae, or post-surgical indications. No ES was placed for proximal pathology. If patients underwentmultiple ES placement, only the index placement at our center was included. Patientcharts were reviewed for demographics, procedure and stent characteristics, com-plications, and follow up. Results: We identified 242 patients with ES placed formalignant dysphagia. The median age at stent placement was 64 years and 79.8%were male. Etiology of obstruction was most commonly esophageal (204, 84.3%) andpulmonary (12, 5.0%) cancers. Migration occurred in 45 (18.6%) of patients. Amongthese 45, early migration (within 30 days of placement) occurred in 21 (46.7%),while delayed migration occurred in 24 (53.3%). Table 1 compares patients whoexperienced documented migration of their ES versus those who did not. In thenon-migration group, esophageal cancer was more frequently the cause ofobstruction (85.3% vs 80.0%, pZ0.01). Fully covered stents were more frequent inthe migration group (60.0% vs 48.7%), as were plastic stents (11.1% vs 1.5%), whilepartially covered stents were less frequent in the migration group (20.0% vs 28.4%),pZ0.004. Logistic regression analyses revealed no significant associations betweenmigration and stent type, size, use of a securing method, or cancer type. There wasno significant difference in migration rates based on having resection, chemo-therapy, or radiation therapy before ES placement, or resection after placement.Table 2 depicts management after migration of ES. Fully covered and plastic stentswere often directly removed. For partially covered stents, placement of another stentprior to removal of both was often used. This technique was less effective in partiallycovered stents, which were often unable to be removed. Discussion: ES placement isbecoming a mainstay in the management of malignant dysphagia. Migration remainsan issue, occurring in almost 20% of patients. Despite novel stent technology andstent securing techniques, migration can still occur, and pose problems in removal.Contrary to perception, post-placement chemotherapy did not impact migrationrates. Partially covered stents, in particular, have issues during removal if migrated.While fully covered stents can migrate, their relative ease in removability highlightstheir use in malignant dysphagia.

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ID: 3523410THIRD-SPACE APPROACH VS FLEXIBLE ENDOSCOPICSEPTOTOMY FOR THE TREATMENT OF SHORT-SEPTUMZENKER’S DIVERTICULUMRoberta Maselli, Marco Spadaccini*, Alessandro Fugazza,Edoardo Vespa, Piera Alessia Galtieri, Gaia Pellegatta,Elisa Chiara Ferrara, Silvia Carrara, Andrea A. Anderloni,Alessandro RepiciBackground and Aim: The definitive treatment of Zenker’s diverticulum (ZD) is totransect the cricopharyngeal muscle to eliminate the septum between the divertic-ulum and the upper oesophagus. Flexible endoscopic septotomy (FES) has beenreported as a safe and effective treatment. However, patients with short septum (ss;�20mm) ZD still represent a difficult-to-treat subgroup of patients because of theanatomical limitation leading to reduced operating space for both rigid and flexibleendoscopic treatments. Recently, third space tunneling approaches, namely Z-POEMand POES, have been developed to allow a safer, more complete myotomy; how-ever, comparison data the standard flexible septotomy are still lacking. Methods:This is a retrospective analysis, comparing efficacy and safety between septotomyperformed by a luminal or a third space approach (POES) for treating ssZD. Allpatients with ZD who were referred for flexible endoscopic septotomy wereincluded in a prospectively maintained database. Exclusion criteria consisted ofseptum>20 mm and follow up time shorter than 12 months. Persistent complete ornear-complete resolution of dysphagia (Dakkak and Bennett: 0 or 1) was defined asclinical success. Adverse events according to ASGE lexicon and procedure time werealso recorded. Follow up was carried out by patient visits or via telephone calls by adedicated nurse. Efficacy and safety outcomes were assessed at two different follow-up time points (12-months and 24-months), and then compared between standardflexible endoscopic septotomy (FES group) and third space tunnelling technique(POES group). Results: From February 2011 to December 2019, 142 patients havebeen treated for ssZD by FES (nZ107) and POES (nZ35). The two groups did notdiffer in terms of demographics (FES group: 68.9�12.0, M/F: 66/41, ASA: 1.8�0.6.POES group: 68.9�14.1, M/F 19/16, ASA 2.1�0.6) and baseline clinical features (FESgroup: mean septum size: 17.5�11.1; mean dysphagia score: 2.6�0.6. POES group:septum size: 1.4�6.8; mean dysphagia score 2.5�0.5). Mean procedural time was19.7�7.3 and 13.6�6.3, respectively. Two perforations and one case of post pro-cedural fever occurred in the FES Group. One case of intra-procedural bleedingoccurred in the POES Group. The 86.9% (93/107) and 94.3% (33/35) of patients wereasymptomatic at 12 months follow-up time point after FES and POES respectively (pvalue: 0.23). A persistent clinical success was reported for the 80.3% (86/107) and91.5% (32/35) of patients at the 24 months follow-up time point after FES and POESrespectively (p value: 0.13). Patients with symptoms recurrence were all treated byrepeating a flexible endoscopic approach. Conclusions: A novel third-spaceapproach appears to be at least comparable to standard flexible endoscopic sep-totomy in terms of mid-term efficacy and safety for treating short septum ZD.


ID: 3525627PREDICTIVE VALUE OF INTRAOPERATIVE ESOPHAGEALFUNCTIONAL LUMINAL IMAGING PROBE(FLIP)PANOMETRY IN PATIENTS WITH ACHALASIAUNDERGOING PERORAL ENDOSCOPIC MYOTOMY: ASINGLE-CENTER EXPERIENCELi-Chang Hsing, Kee Wook Jung*, Ga Hee Kim, Hee Kyong Na,Jeong Hoon Lee, Ji Yong Ahn, Do Hoon Kim, Kee Don Choi,Ho June Song, Gin Hyug Lee, Hwoon-Yong JungBackground: Esophageal functional luminal imaging probe (FLIP) panometry is usedto evaluate the clinical characteristics of esophageal motility disorders. However, thepredictive value of FLIP panometry in patients with achalasia undergoing peroralendoscopic myotomy (POEM) remains unclear. Moreover, it is not clear which pa-rameters can predict symptom improvement and partial recovery of peristalsis (PRP)after POEM treatment. This study aimed to evaluate the clinical significance ofpanometry and determine the parameters that predict symptom improvement andPRP after POEM. Methods: We reviewed the clinical records of patients with acha-lasia who underwent FLIP panometry after induction of general anesthesia andPOEM at a tertiary referral center in Seoul, Korea, from October 2017 to March 2020.Follow-up included esophageal manometry and symptom questionnaires. FLIP datawas analyzed after interpolating with the cubic spine method using MATLAB.Results: Sixty-eight patients (M:FZ33:35, ageZ52�17) were analyzed prospectively.Manometric diagnoses were achalasia type 1 (NZ14), type 2 (NZ39), and type 3(NZ15). FLIP panometry diagnoses were reduced esophagogastric junction opening(REO) with retrograde contractile response (NZ43), REO with absent contractility(NZ5), REO with a normal contractile response (NZ11), and retrograde contractileresponse (NZ9). All the patients with achalasia showed improvement after POEM(Eckardt score from 6.48�2.20 to 1.16�1.15, P<0.01). None of parameters includingpanometry diagnoses showed a significant correlation with symptomatic improve-ment after POEM. However, the presence of repetitive antegrade contractions (RAC)(24 RACs with 24 PRPs vs. 8 RACs without 12 PRPs, P<0.01) and subtypes of achalasia(2 PRPs in type 1 vs. 16 PRPs in type 2 vs. 6 PRPs in type 3, P<0.01) could predict thePRP after POEM. Conclusions: FLIP panometry showed the potential to predict theclinical course after POEM. FLIP may be a useful complementary tool during high-resolution manometry in evaluating esophageal motility disorders. Keywords:Achalasia, peroral endoscopic myomectomy (POEM), esophageal flip panometry


ID: 3522484LONG-TERM OUTCOMES OF PER ORAL ENDOSCOPICMYOTOMY VERSUS LAPAROSCOPIC HELLERMYOTOMY: A SYSTEMATIC REVIEW ANDMETA-ANALYSISAhmed Eltelbany*, Abdul Mohammed, Sushrut Trakroo,George Khoudari, Osama Hamid, Prashanthi N. Thota, Siva Raja,Madhusudhan R. SanakaBackground & Aims: Laparoscopic Heller myotomy (LHM) and peroral endoscopicmyotomy (POEM) have both reported good outcomes in the treatment of acha-lasia. While LHM is the preferred surgical approach, POEM is being increasinglyadopted as a preferred therapeutic option. However, gastroesophageal reflux dis-ease (GERD) could be a significant issue after POEM since it is not combined with ananti-reflux fundoplication unlike LHM. We performed a systematic review and meta-analysis studying the long-term outcomes of safety and efficacy of POEM and LHM inachalasia patients. Methods: A comprehensive and systematic Medline literaturesearch (through November 2020) was performed on reported outcomes of LHM andPOEM for the treatment of achalasia. The outcomes measured were improvement ofdysphagia symptoms and gastroesophageal reflux disease (GERD), at least 2 years ormore following each intervention. Linear regression was used to model the effect ofeach procedure on the different outcomes. All analyses were performed usingSTATA 16 software. Results: A total of 3141 patients, 1027 patients who underwentPOEM and 2114 patients who underwent LHR were included from 36 studies. Therate of clinical success evidenced by absence of dysphagia was significantly better inPOEM, 87.4% (95% confidence interval [CI], 79.3-94.1) when compared with LHM,81.34% (95% CI, 70.0-90.4), respectively (p <0.001). Conversely, presence of GERDsymptoms was significantly lower in LHM, 18.2% (95% CI, 12.2-23.1) whencompared with POEM, 28.4% (95% CI, 13.6-46.0), p<0.001.


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Forest plot showing proportion of patients with improvement ofdysphagia after POEM

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Forest plot showing proportion of patients with improvement ofdysphagia after LHR


ID: 3520807A RANDOMIZED CONTROLLED TRIAL OF ROPIVACAINEFOR POST-OPERATIVE PAIN IN POEMMandip Rai*, Amir Nazarian, Robert BecharaIntroduction: Though usually mild to moderate in severity, postoperative pain afterperoral endoscopic myotomy (POEM) is common. Ropivacaine is a commonly usedlocal anesthetic in other minimally invasive surgeries. There are no studies that haveaddressed minimizing postoperative pain in patients undergoing POEM for acha-lasia. We currently use a multimodal approach to pain management with topicallidocaine, ketorolac and liquid acetaminophen. We hypothesized that intraoperativetopical intra-tunnel irrigation with ropivacaine would result in a significant reductionin pain scores and decreased requirements of additional analgesics in the postop-erative period. Methods: A double-blind, randomized, placebo-controlled trial wasconducted at the Kingston Health Sciences Center. Patients received either 30mL of0.2% ropivacaine or 30mL of placebo (saline) irrigated topically into the POEMtunnel after completing the myotomy and prior to closing the mucosal incision. Theprimary outcome was pain post-POEM at 6 hours assessed by the Numeric RatingScale (NRS). Secondary objectives included assessing pain score at 0.5, 1, 2, 4 hourspost-POEM and on discharge, Quality of Recovery (QoR-15) scores at discharge,narcotic requirement, adverse events, and patients’ willingness to have the pro-cedure done on an outpatient basis. Results: A total of 20 patients were enrolled, 10in each group. Baseline patient characteristics are presented in Table 1. No differ-ence was seen in the intra-procedural fentanyl use between the two groups. A meanof 87.5 mg of fentanyl in the placebo group (SD 46.0 mg) and a mean of 110.0 mg in

the ropivacaine group (SD 62.6 mg) (p Z 0.372) was used. No statistical differencewas seen in the pain scores (Table 2). For the primary outcome of pain post-POEMat 6 hours, the NRS was 11.0 in the placebo group and 24.0 in the ropivacaine group(95% C.I. of the difference: -32.2 to 6.2). No adverse events occurred and no dif-ferences were seen in QoR-15 scores at discharge. Overall usage of post-proceduralnarcotics was low with no differences between the two groups. 0.5 hours postpro-cedural, 1 patient in the placebo group used 1mg of morphine. 1 hour postproce-dural 2 patients in the placebo group used 1 mg of morphine each and 1 patient inthe ropivacaine group used 1 mg of morphine. 2 and 4 hours postprocedural 1patient in each group used 1mg of morphine. No patients used narcotics after 4hours post procedure. 50% of patients in both groups were willing to have theprocedure done as an outpatient. Conclusions/Implications: The addition of intra-operative tunnel irrigation with ropivacaine did not lead to reduced pain post-POEM.Narcotics were seldom used. Half of the patients in this study were willing to havethe procedure done as an outpatient. Future research should explore in whom asame-day discharge may be a safe and effective strategy.

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ID: 3520717EARLY ADVERSE EVENTS FOLLOWING POEM AND THEROLE OF POST-PROCEDURAL IMAGING ANDENDOSCOPYSara Nullens*, Renske Anne Berndien Oude Nijhuis, Jac Oors,Barbara A. Bastiaansen, Paul Fockens,Arjan BredenoordPeroral Endoscopic Myotomy (POEM) is an endoscopicprocedure that has earned its place in the treatment of achalasia andhypercontractile esophageal disorders. Early adverse events (AEs) ofPOEM include insufflation-related events, bleeding, leakage andinfections. In most centers measures are taken in order to rapidly detectimmediate post-operative AEs, including repeat endoscopy or a watersoluble contrast esophagogram. It is currently not well known to whatextent these investigations will influence clinical outcome or guide ourtherapeutic decision making. The goal of this retrospective, single-centercohort study was to determine the prevalence of early AEs following


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POEM (within 14 days) and to assess whether early AEs following POEMcan be predicted by investigations performed post-procedure.Methods: Between August 2011 and October 2020, a total of 352 consecutive POEM-procedures were performed by two experienced endoscopists in our center. Allpatients were contacted 14 days following POEM to inquire about the possibleoccurrence of AEs (according to the Clavien-Dindo classification). Clinical and pro-cedure-related characteristics along with endoscopic and radiological information24h post-POEM were collected. Results: Eleven of the 352 performed procedureswere technical failures (3.13%), 8 due to the presence of extensive submucosalfibrosis, 2 due to loss of orientation in the submucosal tunnel and 1 extensivesubmucosal hemorrhage who underwent a successful POEM in a second attempt.Fibrosis was present in subjects that underwent radiotherapy for other indicationsprior to POEM or following long standing disease (> 10 years). Between August 2011and August 2016 a barium esophagogram was routinely made the following day. Inthree out of 162 patients (1.85%) a contrast leakage judged by the radiologist assignificant was visualized, resulting in endoscopic treatment. After August 2016,esophagograms were no longer performed, and in none of these 190 patients arepeat early endoscopy was needed. Repeat gastroscopy was performed 48h later inthe first 14 consecutive subjects - no repeat interventions were performed based onthese findings and therefore aborted as well. Intra-procedural events were observedin 19.89%, with drainage of a capnoperitoneum (22/352, 6.25%) and closure of adistal mucosal perforation (17/352, 4.82%) by additional clipping being the mostprevalent ones. One patient was readmitted 2 days later with retrosternal pain(negative CT). No deaths or severe AEs were observed. Conclusion: POEM is a safeprocedure with a technical success rate of 97%. No severe AE were reported in thisretrospective cohort study. Performing an esophagogram post-POEM done byskilled endoscopists may trigger obsolete repeat procedures, as none of the patientswithout routinely performed imaging following POEM necessitated repeat inter-vention.


ID: 3522464CRICOPHARYNGEAL PERORAL ENDOSCOPICMYOTOMY (C-POEM) FOR DYSPHAGIC PARKINSON’SDISEASE PATIENTS WITH IMPAIREDCRICOPHARYNGEAL RELAXATIONPeter I. Wu*, Michal Szczesniak, Marc Wong, Taher Omari, Vincent Mok,Ian J. Cook, Charles Cock, Joseph J. Sung, Philip Wai Yan W. ChiuBackground and Aim: Oropharyngeal dysphagia (OPD) is a highly prevalent symp-tom in patients with Parkinson’s disease (PD), and upper oesophageal sphincter(UOS) dysfunction is an important factor underpinning the pathophysiology of OPDin this population. Cricopharyngeus (CP) is the main component of UOS. We as-sessed the feasibility and preliminary efficacy of cricopharyngeal peroral endoscopicmyotomy (C-POEM) as a treatment for OPD associated with UOS dysfunction in PD.Methodology: PD patients with OPD underwent high-resolution pharyngealimpedance-manometry (HRPIM). Data were analysed using Swallow Gateway(swallowgateway.com). Impaired UOS relaxation, increased trans-sphincteric resis-tance and reduced UOS opening during 10ml thin-liquid bolus swallows definedUOS dysfunction (Figure 1). We performed C-POEM in 6 of eight consecutive pa-tients with demonstrable UOS dysfunction, one declined and one was excluded forhigh anaesthetic risk. An initial submucosal bleb in the posterior hypopharyngealwall was followed by a 1-2cm length mucosotomy commencing at 2-3cm cranial tothe endoscopically identified upper margin of the CP. Next, a 5-6cm submucosaltunnel was created extending into the proximal oesophagus and full-thickness CPmyotomy (3-4cm long) was completed as per standard POEM technique. SydneySwallow Questionnaire (SSQ) and Swallowing Quality of Life Questionnaire (Swal-Qol) at pre- and 1-month post-C-POEM measured symptomatic improvement.HRPIM was repeated at 1-month follow-up. Results: C-POEM was performed withoutcomplications in all (nZ6) patients. Intra-procedural neck surgical emphysema wasobserved in all. At 1-month, SSQ score dropped (improved) in all patients by anaverage of 54% from 672 (range 413, 1034) to 308 (range 158, 444); and SwalQolincreased (improved) in all patients by an average of 20% from 54.3 (range 40.5,62.9) to 65.2 (range 57.8, 74.5). HRPIM confirmed a reduction in both mean restingUOS tone [from 61.2mmHg (range 30.0, 85.96) to 8.7mmHg (range 1.1, 17.4)] andintegrated relaxation pressure (IRP) [from 12.6mmHg (range 6.8, 16.5) to -0.3mmHg(range -4.5, 2.8)]. Mean hypopharyngeal intrabolus pressure (IBP) also decreasedfrom 28.0mmHg (range 15.6, 47.1) to 13.7mmHg (range 5.0, 31.2). Conclusion: Indysphagic PD patients with UOS dysfunction, C-POEM is feasible and inducesobjective improvements in symptomatic and manometric indices of swallowfunction.

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Figure 1. HRPIM example of a 10ml thin liquid swallow in a dysphagic PDpatient who underwent C-POEM. (A) Before C-POEM, UOS can be easilyidentified as a horizontal pressure band that relaxes at the onset of swal-low. (B) After C-POEM, the UOS basal tone became harder to identify, thepharyngeal contractility was preserved. (C) Three key swallow metricsderived from HRPIM. We defined UOS dysfunction as raised IRP and atleast one of the functional consequences: raised IBP and reduced MaxAd. (D) Bar chart illustrating the normalisation of all three metricsfollowing C-POEM.

SATURDAY, MAY 22, 2021Esophagus 2Lecture

ID: 3525907SHORT TERM OUTCOMES OF TRANSORALINCISIONLESS FUNDOPLICATION (TIF) 2.0 FORTREATING GERD: A MULTICENTER PROSPECTIVECOHORT STUDY (THE TIF REGISTRY)Marcia I. Canto*, Kenneth J. Chang, Peter G. Janu, Michael J. Murray,Amit Sohagia, Hany Eskarous, Mohamad Dbouk, Alyssa Y. Choi,Jennifer M. Kolb, Jason Samarasena, Ninh T. Nguyen, Nirav Thosani,Erik B. Wilson, David L. Diehl, Harshit S. Khara, Jon Gabrielsen,Barham K. Abu Dayyeh, Reem Z. Sharaiha, Cheguevara Afaneh,Rasa Zarnegar, Christy M. Dunst, Olaya I. Brewer Gutierrez,Michael R. Marohn, Glenn IhdeBackground: Published studies report variable efficacy of transoral incisionless fun-doplication (TIF) for the management of GERD in selected patients with no/smallhiatal hernias and BMI<35. Over the years, the TIF technology and technique havebeen enhanced but data on the impact on clinical outcomes are limited.AIM: We aimed to track the patient-reported and clinical outcomes of GERD patientsafter TIF 2.0 using >30 fasteners to create a >3 cm long, >300 degree circumfer-ential valve. Methods: Patients with GERD and extra-esophageal symptoms from 10academic and community medical centers (TIF Registry), elevated GERD-HQRLscore +/- Reflux Symptom Index (RSI)>13 and pathologic reflux by esophageal pH-metry or erosive esophagitis/Barrett’s esophagus were evaluated before and after aminimum 6 months post TIF performed by gastroenterologists and surgeons. Weexcluded post-POEM and dysplastic BE patients. The primary outcome was GERDsymptom improvement (>50% decrease in standardized GERD-HQRL). Secondaryoutcomes were: 1) normalization of RSI, 2) normalization of acid exposure time(AET), 3) discontinuation of proton pump inhibitor (PPI), and 4) overall patientsatisfaction. We used Fisher’s exact, Wilcoxon signed-rank test, or McNemar’s test,where appropriate. We performed univariate and multivariate analysis to assessfactors associated with clinical success (at least 2 of the above 5 outcomes achieved).Results: To date, 70 patients have had TIF (Table 1) with median follow-up of 13months (IQR 9-24). TIF was technically successful in all cases. Symptom improve-ment was achieved in 92%, with decrease of GERD-HQRL scores from a mean 24.1(SD 18.1) to 7.3 (SD 8.7), p <.0001. 89% of 28 patients with elevated baseline RSInormalized their scores (Figure 1A). Overall, patient satisfaction improved from abaseline of 11% to 81% (p <0.0001) (Figure 1B). To date, pH testing post-TIF wasavailable in 42 patients; esophageal acid exposure time was normal in 74%, but this


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increased to 84% when a TIF valve circumference of >270 degrees was achieved.Prior to TIF, 56(80%) of all patients were taking daily or twice daily PPI; post TIF,80% of all TIF patients were off PPI (Figure 1B). Using stepwise logistic regression,the only factor associated with clinical success (symptom and pH improvement) wasa TIF valve circumference of >270 degrees (pZ0.037), after considering hiatalhernia length, Hill grade, valve length, and number of TIF fasteners. Median TIFprocedure time was 43 minutes (IQR 33-48). All TIFs were completed as ambulatoryprocedures with no serious adverse events. Conclusion: TIF 2.0 with enhancedtechnique is a safe and effective endoscopic outpatient treatment for selected GERDpatients. Studies of TIF durability, re-intervention rate, and impact of concomitanthiatal hernia repair are ongoing.

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Baseline Patients’ and Procedural Characteristics

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Clinical Outcomes


ID: 3525506WIDE AREA TRANSEPITHELIAL SAMPLE BIOPSY WITH3-DIMENSIONAL COMPUTER-ASSISTED ANALYSIS(WATS3D) NEARLY DOUBLES THE DETECTION OFDISEASE RECURRENCE IN POST-ABLATIONSURVEILLANCE OF BARRETT’S ESOPHAGUSSwathi Eluri*, Cary C. Cotton, Ariel E. Watts, David M. Chaletsky,Brian Moloney, Zubair A. Malik, Arvind J. Trindade, Stuart R. Gordon,Patrick Yachimski, Abraham R. Khan, Felice Schnoll-Sussman,Michael S. Smith, Shervin Shafa, Nicholas J. ShaheenBackground: Little is known about the additive yield of wide-area transepithelialsampling with computer-assisted three-dimensional analysis (WATS3D) in detect-ing recurrent disease in post-ablation surveillance of Barrett’s esophagus (BE) aftercomplete eradication of intestinal metaplasia (CEIM). Aim: To assess the incrementalyield of WATS3D in conjunction with forceps biopsy (FB) for detection of intestinalmetaplasia (IM) or dysplasia recurrence in post-ablation BE after CEIM. Methods: Weanalyzed data from a prospective multicenter registry of patients from 15 U.S. sitesundergoing EGD with WATS3D and FB for BE. Patients aged 18-80 years had eitherGERD symptoms being screened for BE, known BE undergoing surveillance, or post-ablation BE undergoing surveillance. For this analysis, we included BE participantsundergoing post-ablation surveillance after CEIM. Enrolled subjects underwent EGDwith biopsies and WATS3D per routine care. WATS3D samples were analyzed perstandard protocol and routine biopsies by the pathologist at the enrolling institution.Clinical and pathology data are collected at baseline and at subsequent EGDs for upto 10 years following enrollment. Recurrence was defined as IM or dysplasia in theesophagus or dysplasia in the cardia. IM of the cardia was not considered recur-rence. We fit Kaplan-Meier estimates of cumulative incidence of recurrence with andwithout WATS3D. We described the yield of FB and WATS3D for various histologicgrades of recurrence. Results: Of 397 participants undergoing post-CEIM surveil-lance, mean age was 65.4 years, 97% were white, and 73% were men (Table). Forbaseline (pre-ablation) histology, 74 (18.6%) had non-dysplastic BE (NDBE), 25(6.3%) indefinite for dysplasia (IND), 104 (26.2%) low-grade dysplasia (LGD), 142(35.8%) high-grade dysplasia (HGD), and 52 (13.1%) had intramucosal adenocarci-noma (IMC). Mean segment length before treatment was 3.5 � 2.9 cm. A majority(85%) underwent radiofrequency ablation, 13% had cryoablation, and 67% endo-scopic mucosal resection (EMR). The overall prevalence of recurrence was 21.8%:19.7% IM (nZ104), 0.4% IND (nZ2), 0.8% crypt dysplasia (nZ4), 0.8% LGD (nZ4),0.2% HGD (nZ1), 0.0% IMC. Adjunctive use of WATS3D to FB resulted in a 1.9-foldincrease in the rate of identifying any recurrence (Figure). Increasing baseline BEsegment length was a significant predictor of IM detection on WATS3D (OR [95%CI]: 1.80 [1.14 - 3.22]. WATS3D detected 2 cases of recurrence with LGD and 1 withHGD, while missing 2 cases of LGD detected on FB. Conclusions: In a multicenterregistry, adjunctive use of WATS3D in a post-CEIM BE population resulted in a nearlytwo-fold increase in detection of disease recurrence. The odds of WATS3D findingrecurrence over FB was more common in those with longer baseline BE segmentlengths.

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ID: 3522402CONCOMITANT HIATAL HERNIA REPAIR ANDTRANSORAL INCISIONLESS FUNDOPLICATIONIMPROVES SUBJECTIVE AND OBJECTIVE MEASURES OFGERD: A SINGLE CENTER SERIESMary Kathryn Roccato*, Alyssa Y. Choi, Jennifer M. Kolb, Sagar Shah,Anastasia Chahine, Rochelle Simoni, Jason B. Samarasena,Ninh T. Nguyen, Kenneth J. ChangIntroduction: Concomitant hiatal hernia repair and transoral incisionless fundoplica-tion (cTIF) is an anti-reflux procedure for gastroesophageal reflux disease (GERD)that consists of a hiatal hernia repair followed by TIF. In addition to tightening thelower esophageal sphincter and restoring the gastroesophageal flap valve, a hiatalhernia repair repairs the diaphragmatic crural defect. Although TIF has demon-strated improvement in the number of reflux episodes, total acid exposure time(AET), and DeMeester scores, similar data does not exist for cTIF. The purpose ofthis study was to evaluate the effectiveness of cTIF using wireless 48-hour pHmonitoring in addition to quality of life measures. Methods: Patients with refluxrefractory to PPI therapy received wireless 48-hour pH monitoring as a part of pre-operative testing for cTIF. Patients were eligible for cTIF if they had hiatal hernia >2cm, DeMeester score >50, LA class C esophagitis or Hill Grade 3 or above. Patientsreceived repeat pH monitoring at 6 months or greater, off proton pump inhibitor(PPI). GERD-HRQL was used to assess quality of life in association with refluxsymptoms. Results: Of the 34 patients who received cTIF (100% completion), 5(14.7%) underwent wireless 48-hour pH monitoring off PPI therapy both pre andpost-cTIF. Mean age was 59.8 (range 27-77), 17 (50%) were male, mean BMI was 27.7kg/m2, mean HH measurement was 2.7 (� 11.5, 0-8 cm), 8 (23.5%) had Barrett’sesophagus, 4 (11.8%) had LA class C or D esophagitis. The mean follow up was 26.3weeks (�21.4, 1-84). Post-cTIF, there was an improvement in reflux episodes (meandifference 130, 81.4% decrease, 95% CI 49.7-210.3), AET (mean difference 14.3,91.8% decrease, 95% CI 3.16-25.4), and DeMeester scores (mean difference 47.5,91.0% decrease, 95% CI 12.2-82.7) (Table 1). Mean scores by GERD-HRQL decreasedby 51.6% at 6 months and 68.3% at 12 months for heartburn and decreased by 83%at 6 months and 100% at 12 months for regurgitation. One patient had more reflux-type symptoms post-cTIF but normalized AET and DeMeester score, as a result likelyhad functional heartburn. Discussion: cTIF successfully strengthens the anti-refluxbarrier and reduces pathologic GERD. Patients who underwent pH studies after cTIFdemonstrated decreased reflux episodes and improvement in AET and DeMeesterscore. Additionally, patients perceived less bothersome GERD symptoms includingheartburn and regurgitation. cTIF is effective in decreasing objective and subjectivemeasures of reflux activity. Larger prospective studies are currently underway.

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ID: 3522385A NOVEL ANTI-REFLUX RAP: RESECTION ANDPLICATION FOR PATIENTS WITH ALTERED GEJANATOMYPiotr Sowa*, Ronald D. Ortizo, Jennifer M. Kolb,Deanna Orozco, Jason B. Samarasena, Kenneth J. ChangBackground: The Resection and Plication (RAP) procedure is a viable endoscopictreatment option for gastroesophageal reflux disease (GERD) in patients withaltered gastroesophageal junction (GEJ) anatomy who otherwise have limitedtreatment options. RAP is a unique strategy for this challenging group who may havemedication refractory GERD or troublesome regurgitation. Methods: This is a single-center retrospective study of patients with altered GEJ anatomy and GERD that havebeen deemed poor or unsuitable candidates for standard anti-reflux therapy. GERDdiagnosis was made by BRAVO pH testing, evidence or erosive esophagitis, orpresence of Barrett’s esophagus. The RAP procedure consists of mucosectomy at thegastric side of the GEJ utilizing band mucosal resection followed by full thicknessgastro-gastric plications using the suturing device. Clinical success was measured bysymptom response according to GERD-Health Related Quality of Life (GERD-HRQL)and Reflux Disease Questionnaire (RDQ) and change in PPI usage. Results: 25 pa-tients underwent the RAP procedure between 2017-2020. 16 patients (64%) hadaltered anatomy from previous surgeries: gastric bypass (3), sleeve gastrectomy (4),esophagectomy (2), Nissen fundoplication (3), G-POEM + esophagectomy (1), G-POEM + gastroplasty (1), Heller myotomy + esophagectomy + partial gastrectomy(1), and Nissen fundoplication + gastric bypass (1). Technical success was 100%.Average procedure time was 30-40 minutes and all patients were sent home. Meanfollow up was 11.12 months. 11 patients (44%) were able to stop or decrease PPIuse. RDQ for symptom severity improved from 13.6 pre-RAP to 8.4 post-RAP(p<0.01). RDQ for symptom frequency improved from 15.2 to 6.4 post-RAP(p<0.01). GERD-HRQL also improved 23.2 pre-RAP and 10 post-RAP (p<0.01). Allprocedures were done as outpatient. There were no procedure related adverseevents. Conclusions: The RAP procedure represents a novel endoscopic treatmentoption for the management of refractory GERD in patients who are not candidatesfor traditional surgical or endoscopic therapies due to altered anatomy. RAP is safe,well-tolerated and results in a high degree of patient satisfaction.


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Pre and Post RAP RDQ and GERD HRQL averages


ID: 3524127LIQUID NITROGEN SPRAY CRYOTHERAPY IS EFFECTIVEAND SAFE WHEN USE IN THE MANAGEMENT OF EARLYESOPHAGEAL ADENOCARCINOMA: SYSTEMIC REVIEWAND META-ANALYSISMengdan Xie*, Michael S. SmithBackground: Liquid nitrogen spray cryotherapy (LNC) is an effective therapy forendoscopic ablation of Barrett’s esophagus (BE) and related neoplasia. Multiplestudies have demonstrated efficacy, safety and tolerability for treating BE and su-perficial (T1) esophageal adenocarcinoma (EAC). The aim of this study was to sys-tematically review the efficacy and safety of LNC in treating T1 EAC. Methods:Relevant articles and abstracts were searched in Pubmed, Web of Science, Embase,and Scopus. Studies were included if T1 EAC patients were treated with LNC andrates of complete eradication of intraluminal cancer (CE-C), dysplasia (CE-D), orintestinal metaplasia (CE-IM) were reported after at least two LNC sessions. Studiesthat evaluated squamous cell cancer, used non-LNC cryotherapy, lacked CE rates,were not original research or were not in English were excluded. A random effectsmodel was used to calculate pool proportions for CE rates. Rates of serious adverseevents (SAEs), defined as stricture, hemorrhage, perforation and/or severe painrequiring endoscopic intervention, transfusion or hospitalization, were used toevaluate LNC safety. Results: A total of 16 studies with 359 patients met criteria,including 13 studies with 271 patients which qualified for the efficacy evaluation. Amajority (58%) of these cases had persistent T1 EAC despite prior endoscopicresection (ER), radiofrequency ablation (RFA) or other ablative therapy. ConcurrentER was performed in 35% of these patients. The pooled CE-C rate for all T1 EAC was74% (95% CI 66-81%). For the 208 cases with EAC confined to the mucosa (T1a),pooled rates were 82% for CE-C (74-90%), 76% for CE-D (65-87%) and 65% for CE-IM(49-81%). A somewhat lower pooled CE-C rate of 53% (40-65%) was found for the 63cases with EAC involving submucosa (T1b). SAEs occurred in 9.7% of LNC cases,most commonly strictures (8.8%), GI bleeding (0.6%) and perforation (0.3%).Discussion: ER combined with ablative therapy is the standard of care for BE withassociated T1a EAC. This meta-analysis shows at least 82% of these patients canachieve CE-C when LNC is selected as the ablative modality. While CE-C rates wereas high as 97% in some included studies, the pooled rate in this meta-analysis likelyis lower due to a majority of patients having failed ER or other eradication methods.Therefore, the CE-C rate for LNC in treatment naïve T1a EAC may be even higher.RFA for BE with high grade dysplasia or intramucosal carcinoma has published ratesof 87% (83-91%) for CE-D and 74% (59-89%) for CE-IM, which are non-inferior to theLNC pooled rates in this study. Even T1b tumors, where esophagectomy is thepreferred intervention, achieved CE-C after LNC in about half of patients. Thisimpressive efficacy, combined with low SAE rates, suggests LNC should be apreferred option in treating early EAC and associated BE.

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Table. Study and Patient Characteristics for Efficacy of LNC in Treating T1Esophageal Adenocarcinoma (EAC)

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Figure. Complete Eradication of Intraluminal Cancer (CE-C) in T1aEsophageal Adenocarcinoma

SUNDAY, MAY 23, 2021Esophagus 2Poster

ID: 3521961SHORT VS STANDARD ESOPHAGEAL MYOTOMY INACHALASIA - A SYSTEMATIC REVIEW AND META-ANALYSIS OF COMPARATIVE TRIALSSaurabh Chandan*, Antonio Facciorusso, Shahab R. Khan,Daryl Ramai, Babu P. Mohan, Mohammad Bilal, Banreet S. Dhindsa,Lena Kassab, Hemant Goyal, Abhilash Perisetti, Ishfaq Bhat,Shailender Singh, Douglas G. AdlerBACKGROUND & AIMS: Despite the clinical efficacy of POEM, post-operativesymptomatic gastroesophageal reflux disease (GERD) remains a major concern.While it is known that length of the gastric myotomy affects post-operative GERD,the clinical relevance of variation in esophageal myotomy length is not well known.We performed a systematic review and meta-analysis of studies comparingoutcomesof short vs standard myotomy length in patients with achalasia. Methods: Wesearched multiple databases from inception through November 2020 to identifystudies that reported on outcomes of Achalasia patients who underwent shortesophageal myotomy (SM) as compared to standard esophageal myotomy (STM).Meta-analysis was performed to determine pooled odds ratio of clinical success,GERD outcomes and adverse events with the two techniques. Results: Five studies,with 450 patients were included in the final analysis. SM group had 205 patientswhile STM group had 245 patients. cm. Across all the studies, the gastric myotomylength was kept the same in both the SM and STM groups, ranging from 2-3.2 cm.The etiology was Type I Achalasia in 88 patients, Type II in 309 patients and Type IIIin 4 patients. Mean age ranged from 37.7 years to 49.3 years. Length of stay (LOS)


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ranged from 2.81 to 9.9 days. Median follow up time ranged from 6 to 26.8 month inthe short myotomy group and 6 to 29.5 months in the standard myotomy group.There was no difference in clinical success, OR 1.29 (95% CI 0.57-2.91,I2 0%);pZ0.53, post-operative symptomatic GERD, OR 0.87 (95% CI 0.44-1.74, I2 29%);pZ0.7, mucosal injuries, OR 0.74 (95% CI 0.25-2.17, I2 0%), pZ0.58, length of stay,pZ0.21, and overall adverse events, OR 0.52 (95% CI 0.19-1.38, I2 40%); pZ0.19,between the two groups. Incidence of post-operative erosive esophagitis as deter-mined by endoscopy was lesser in SM group, OR 0.50 (95% CI 0.24-1.03, I2 0%);pZ0.06. Conclusion: Our analysis shows that performing peroral endoscopic my-otomy with a shorter length esophageal myotomy in patients with Achalasia is noninferior to standard length myotomy. While the incidence of post-operative symp-tomatic gastroesophageal reflux was similar between the two groups, patients withshorter myotomies were statistically less likely to have endoscopic evidence oferosive esophagitis. The overall rates of adverse events, risk of mucosal injuries andlength of hospital stay were similar between the two groups of patients.

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Forest Plot - Clinical Success

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Forest Plot - Erosive Esophagitis


ID: 3522314EXCESSIVE BIOPSIES IN PATIENTS WITH ANIRREGULAR Z LINE AND NO HISTORY OF BARRETT’SESOPHAGUSThomas J. Kaminsky*, Keegan Colletier, John C. Fang, Kathryn R. Byrne,Andrew J. GawronIntroduction: Barrett’s esophagus (BE) is a known risk factor for esophageal adeno-carcinoma (EAC) and consensus guidelines recommend a standardized approach toendoscopic screening and surveillance. Segments less than one centimeter are oftendescribed as an irregular Z line. These segments are low risk lesions and arefrequently encountered during endoscopy for indications other than BE. Biopsy isnot recommended as this leads to unnecessary procedures, patient anxiety andadditional expenditures. We aimed to characterize the rate of biopsy in patients withan irregular Z line and no history of BE at a large tertiary care center.Objectives: 1) Define the biopsy rate of the irregular Z line in patients with noknown history of Barrett’s esophagus. 2) Characterize histopathologic findings inirregular Z line biopsies. 3) Describe surveillance recommendations at the time ofendoscopy for patients with an irregular Z line. Methods: The study sample includedadult patients undergoing EGD at the University of Utah Medical Center from 2011to 2016. Data was obtained from a set of 16,505 distinct patients who underwent atotal of 23,404 procedures. A validated rules-based natural language processing(NLP) tool was applied to the data set using a keyword review of EGD reports toaccurately identify 2,340 cases describing an irregular Z line. We manually reviewed948 cases as a representative sample and excluded those with an indication of BEand/or prior history of BE within the medical record. A total of 154 cases wereexcluded due to BE. A total of 794 cases were performed for other indications andwere included in our analysis (Figure 1). Results: Of 794 cases describing an irregularZ line, 612 (77.08%) included biopsies and 182 (22.92%) did not. Histological anal-ysis of the biopsy specimens showed 260 (41.27%) with esophagitis, 223 (35.40%)with normal mucosa, 104 (16.51%) with SIM, 34 (5.40%) with increased eosinophils,1 (0.15%) with SIM and dysplasia and 8 (1.27%) with other findings (Table 1). No

esophageal cancer was detected. At the time of endoscopy, no surveillance EGD wasrecommended in 701 (88.29%) cases, while repeat EGD was recommended in 93(11.71%) cases (Table 2). Conclusion: This study represents a large retrospectivereview of patients undergoing biopsy of an irregular Z line without a BE indication orhistory. The majority of patients received biopsies despite having no history of BE orindication for screening. The majority of biopsy results were benign and would notwarrant surveillance. At the time of procedure, most surveillance recommendationswere absent. Our data shows significant discordance between clinical practice andcurrent guideline recommendations. Future research should focus on barriers toguidelines adherence and emphasize quality improvement to minimize low valueendoscopy with biopsies of the irregular Z line.

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ID: 3526903UNLIKE HELLER MYOTOMY (HM), PER ORALENDOSCOPIC MYOTOMY (POEM) IS ASSOCIATED WITHIMPROVEMENT IN OBJECTIVE GASTROESOPHAGEALREFLUX DISEASE METRICS ON LONG TERM FOLLOW-UPStavros N. Stavropoulos*, Nasim Parsa, Laleh Omrani, Maria Kollarus,Hallie Peller, Jessica L. Widmer, Rani J. ModayilBackground: POEM has evolved to become a first-line treatment for achalasia. InWestern series post-POEM objective GERD rates based on endoscopy/pH studyare in the range of 30-50%. The scant published data on objective GERD after HMwith fundoplication suggest that GERD rates rise over time possibly due to loss ofefficacy of the fundoplication. We hypothesized that the opposite trend may bepresent in POEM as the myotomy fully heals with contraction and remodeling of thescar. Methods: From a large prospective database including all POEMs performed atour center from 10/09 to 11/20 (704 POEMs) we extracted patients with pairedBRAVO data: an initial post-POEM study followed by a long-term (LT) study at least 2years after the initial study. We offer patients repeat pH studies at 2 years from theirinitial study to assess for possible improvement in GERD that may allow a step-downin antacids or, conversely, new/worsening GERD that may require step-up. All pHstudies were performed off-proton pump inhibitors (PPIs) for 2 weeks and manuallyreviewed by a motility expert. The main outcome was comparison of GERD in short-term vs. LT pH studies. Secondary outcomes included esophagitis, GERD symptoms,clinical success (CS) and clinically significant Adverse Events (csAEs). CS was definedas Eckardt score �3 and no need for salvage treatment. Results: 21 patients hadpaired BRAVO data. All had post-POEM follow up 2.5 years (median 6.3). See table 1for baseline characteristics and Table 2 for outcomes. There were no aborted POEMsor csAEs. The early GERD assessment was completed at a median of 4.7 [2.8-22.3]months and the LT assessment, at a median of 56.7 [28.2-89.7] months. On LTassessment, patients had a far lower proportion of positive pH studies (42.8% vs66.6%, pZ0.003), total number of refluxes (22.5 vs 66.0, pZ0.001), and DeMeesterscore (20.9 vs 38.1, pZ0.03). There was also less overall esophagitis (47.6% vs. 33%).71% of pts noted to have symptom score reduction and 57% of pts were on lowerPPI dosages. Of patients with a positive early pH study, 35% normalized their studyon long-term follow up. Clinical success endured in all patients at median follow upof 76.2 [31-103] months. Conclusion: Post-POEM GERD appears to decrease overtime as healing and scar contraction occur, unlike GERD after HM/fundoplicationwhich has been reported to increase with time. Post-POEM GERD appearsmanageable with PPIs without long-term sequelae and GERD symptoms appear todecrease over time with lower PPI dosage requirements. Our findings suggest that asignificantly lower number of POEM patients may require PPIs after the initial post-operative period and support shifting GERD assessment with pH studies from 3-6months to 6-12 months to avoid over-estimating GERD.

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Baseline characteristics

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outcomes


ID: 3522391THE RISK OF NEEDING AN ANTIREFLUX PROCEDUREAFTER PER ORAL ENDOSCOPIC MYOTOMY ANDSALVAGE WITH TRANSORAL INCISIONLESSFUNDOPLICATIONJennifer M. Kolb*, Peter H. Nguyen, Samuel S. Ji, Jason B. Samarasena,Kenneth J. ChangBackground: Gastroesophageal reflux (GERD) is the main potential limitation of per-oral endoscopic myotomy (POEM) whereas a surgical Heller myotomy has thebenefit of an anti-reflux wrap. Transoral incisionless fundoplication (TIF) is anendoscopic anti-reflux procedure that can be used as rescue therapy for post POEMGERD. However, prognostic indicators to predict which patients are most at risk forpost POEM GERD are lacking. This study aims to evaluate management of postPOEM GERD and the risk for needing an anti-reflux procedure. Methods: This is asingle center retrospective cohort study of all patients who underwent POEM be-tween March 2014 to September 2020 and had clinical follow up. Post POEM clinicalsymptoms and endoscopic information was collected and patients were followed forthe development of GERD and need for intervention. Results: There were 145 pa-tients of whom 132 were included in this study. There were 115 patients (87%) whohad achalasia (43 type I, 61 type II, and 11 type III), 9 patients had spastic disordersincluding jackhammer esophagus and diffuse esophageal spasm, and 8 unknowntype. There were no patients who had severe GERD that required anti reflux surgery.There were 12 patients who had PPI refractory GERD and subsequently had TIF(66.7% female, mean age 52.5, mean BMI 25.34 + 6.18). The mean distensibilityindex on EndoFLIP at 60cc at the completion of POEM was 3.87 + 1.52. Eight of the12 patients underwent ambulatory pH monitoring and had mean DeMeester scorewas 53.85. The majority had type I achalasia (nZ7) and one patient each had type II,type III, achalasia subtype unknown, jackhammer esophagus, and diffuse esophagealspasm. The risk of significant post POEM reflux requiring TIF was highest for spasticdisorders (22.2%), followed by achalasia type I (16%), type III (10%), and achalasiatype II (1.6%). All patients underwent TIF at mean 339 days since POEM (range 149-548). The mean number of fasteners for TIF was 32.17 + 5.36 and the mean valvelength 3.92 + 1.16. At 6 months and 12 months post TIF, 4 (33%) patients were ableto stop or decrease their PPI. One adverse event occurred where a patient devel-oped non-sustained ventricular tachycardia post procedure and underwent left heartcatheterization Conclusions: Significant post POEM GERD requiring endoscopicintervention occurred most commonly in individuals with spastic disorders; theseare also the individuals who benefit most from POEM compared to surgical Hellermyotomy. Type I achalasia patients have the second highest likelihood for requiringanti reflux intervention, likely due to redundant esophagus, and may benefit fromstraightening the esophagus during TIF. These results can help risk stratify indi-viduals for GERD at the time of POEM and tailor post procedure anti-reflux man-agement.


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ID: 3520465ESOPHAGEAL STENT PLACEMENT FOR BENIGNESOPHAGEAL INDICATIONS IS ASSOCIATED WITHHIGH RATES OF EARLY READMISSIONFarah S. Hussain*, Gokulakrishnan Balasubramanian,Alice Hinton, Georgios Papachristou, Samuel Han, Thomas M. Runge,Jeffery R. Groce, Sajid Jalil, Luis F. Lara, Somashekar G. KrishnaBackground: Other than malignant stricture, esophageal stents (ES) are increasinglyused to manage a host of non-malignant (benign) esophageal conditions includingstrictures, fistulas, leaks, perforations, and gastrointestinal (GI) bleeding. However,stent technology has not evolved to meet the increasing demand and ES are asso-ciated with high rates of complications including migration, pain, reflux, and rarelybleeding and perforation. There is a paucity of outcomes data for esophageal stentplacements for benign etiologies. We sought to evaluate predictors of early read-mission following ES placement in hospitalized patients. Methods: Using appropriateICD-10-CM codes, the National Readmission Database (NRD, 2016-2017) wasqueried to include all inpatient adults (�18 years of age) with endoscopy-guided ESplacement. A multivariable model was used to evaluate the study outcome of early(� 30 days) readmission. Results: Among a total of 823 subjects who underwentindex placement of ES, the early readmission rate was 26.9% (nZ221). A majority(69.5%, nZ572) of the ES were placed for non-malignant etiology. The early read-mission rate following ES placement for non-malignant etiology was 30.24% whilethat for malignant obstruction was 19.44% (pZ0.02). Multivariable analysis (Table 1)revealed that ES placement for benign indication was independently associated withearly readmission (OR 1.84, 95% CI 1.08-3.13). Notably, the other variables includingtiming of stent placement, hospital demographics, and patient demographics andcomorbidities did not impact early readmission. Conclusion: In this national analysis,nearly one third of patients who underwent esophageal stent placement for non-malignant etiology were readmitted within 30 days. While we need to further assesswhy esophageal stenting for benign indications were associated with higher read-mission rates, efforts are necessary to define appropriate indications and improvethe device (stent) and endoscopy technology.


ID: 3524080ENDOFLIP DISTENSIBILITY INDEX AS A TOOL AFTERPERORAL ENDOSCOPIC MYOTOMY FOR ASSESSMENTOF CLINICAL OUTCOMESRobert Dorrell*, Swati Pawa, Nyree Thorne, Gregory B. Russell,Kelly Hammoudi, Michael F. Fina, Richard S. Bloomfeld, Rishi PawaBackground: Peroral endoscopicmyotomy(POEM) isaminimally invasive approachusedto treat spastic esophagealmotility disorders includingachalasia. It has shown comparableoutcomes to Laparoscopic Heller’s myotomy with a significant reduction in patientmorbidity. We present our experience starting a POEM program at a tertiary care centerand combining subjective and objective data using Eckardt score (ES) and Endoluminalfunctional imaging probe (EndoFLIP) distensibility index (DI) to demonstrate clinicalsuccess. Methods: This is a retrospective study of patients undergoing POEM at ourinstitution over an 18-month period. Data on demographics, disease course, high-res-olution esophageal manometry (HRM), and clinical outcomes were recorded. Technicalsuccess was defined as successful creation of a submucosal tunnel followed by a fullthickness myotomy. Clinical success was defined as a post-procedure ES � 3. Patientswere scheduled for an EndoFLIP post-procedure using an 8-cm, EndoFLIP-325N ballooncatheter. A DI � 2.8 mm2/mmHg at 50mL was used to define adequate myotomy.Change in ES was assessed using a paired t-test and compared against a hypothesis ofno change; Wilcoxon Two-Sample Test was used to assess differences in DI. Results: Atotal of 28 patients underwent POEM with a median follow-up of 178 days. The averagepatient age was 58.1 (standard deviation: 15.4) and 64% were female. There were 27patients with achalasia (96%) and 1 patient with jackhammer esophagus (4%), alldiagnosed on HRM pre-POEM. Prior interventions included: Botox injections (8, 29%),pneumatic dilation (2, 7%), and Heller myotomy (3, 11%). The average ES decreasedfrom 8.1 (SD 1.9) pre-procedure to 0.9 (SD 1.3) post-procedure (p<0.0001). Clinicalsuccess was achieved in 26 patients (93%). In the two patients with clinical failure, theES decreased from 8 to 5 in one patient and 10 to 4 in the other; however the goal ES�3 was not achieved. Post-procedure EndoFLIP data was obtained in 21 of the 28 pa-tients. The remaining 7 patients including 2 clinical failures are still awaiting post-POEMEndoFLIP due to COVID-19 related precautions. In the 21 patients with clinical successundergoing post-procedure EndoFLIP, the DI at 50cc was � 2.8 in all patients, with amean DI of 6.1 mm2/mmHg (SD 2.6). During EndoFLIP, reflux esophagitis wasobserved in 5 patients (24%). The mean DI for patients with and without esophagitiswas 6.2 (SD 3.3) versus 6 (SD 2.4) respectively (p>0.99). There were 2 adverse eventsincluding a tunnel leak and a small pneumothorax that were managed conservatively.Conclusion: POEM is a highly effective treatment for achalasia and spastic esophagealmotility disorders. Our study demonstrates that EndoFLIP is a valuable tool to provideobjective data regarding patients’ response to POEM as it correlates well with the ES.

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Table 1. Demographics, Procedure Details and Outcomes in Patients un-dergoing POEM


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ID: 3526523A MULTIDISCIPLINARY APPROACH EXPEDITED THELEARNING CURVE AND MINIMIZED COMPLICATIONSOF PERORAL ENDOSCOPIC MYOTOMYMohamed O. Othman*, Shaleen Vasavada, Salmaan Jawaid,Nihanth Palivela, Michael Oliver M. Mercado, Yan Liu, Shawn GrothBackground: Peroral endoscopic myotomy (POEM) is a minimally invasivealternative for the treatment of achalasia. The technical skills required toperform POEM encompasses both surgical and endoscopic expertise withboth specialties performing them worldwide. Our team of a gastroenterolo-gist and cardiothoracic (CT) surgeon sought to create a multidisciplinaryapproach to expedite the learning curve and minimize complications ofPOEM. The aim of our study is to determine the learning curve of POEMwhen performed by two providers from two different disciplines. Methods:This is a retrospective study of the first 116 patients who underwent POEMat our institution from 03/2016 till 03/2019. One gastroenterologist and oneCT surgeon performed all the procedures together in a collaborative fashionensuring that both will do an equal part of the tunnel creation and themyotomy. Demographics and operative variables were collected. Technicalsuccess was defined as the ability to perform the entire procedure. Thera-peutic success was defined as an Eckardt score of < 3 six months afterPOEM. To define the “learning curve,” nonlinear regression was used to fitan inverse curve, with case number used as the independent variable andoperating time as the dependent variable to yield an estimate of “a”(asymptote) and “b” (slope) according to a method described by Feldman etal. to characterize the learning curve for laparascopy. This asymptote sig-nifies the level at which the performance flattens (“learning plateau”) whilethe slope represents how quickly a level of performance is reached(“learning rate”). Results: A total of 116 individuals who received POEM wereincluded. Mean age was 53.7 + 18 years and 52% of the patients were female.Baseline Eckardt scores were greater than 3 for 77% of patients. The overallmean procedure time was 96 (+ 43 minutes). Technical and therapeutic successrates were 99.1% and 94%, respectively. There was a significant difference be-tween Eckardt score prior to POEM and at 6 months following the procedurewith and without adjusting for age, gender, and PPI use (p <0.05). No majoradverse events occurred while minor adverse event rate was only 10.2%. Thetotal operative time (median 106 minutes, range 34–324) decreased significantlyover consecutive procedures when tested by nonlinear curve regression (R2 Z0.16, PZ0.000), with a learning plateau at 103 minutes and a learning rate of 18cases. Conclusion: A multidisciplinary approach in performing POEM allowedhigh technical and therapeutic success rates, low adverse event rate, and fastlearning curve with a reasonable operating time.

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ID: 3523506TRENDS IN THE PERFORMANCE AND USE OFESOPHAGEAL STENTS FOR MALIGNANT DYSPHAGIAOVER TIMEShria Kumar*, Firas Bahdi, Abraham Yu, Ikenna K. Emelogu,Martin Coronel, Emmanuel Coronel, Phillip S. Ge, Brian R. Weston,Patrick M. Lynch, Jeffrey LeeIntroduction: Esophageal stents (ES) have been increasingly used to treat esopha-geal obstruction, dysphagia, and odynophagia associated with malignancies. Weaim to analyze our management practice of malignant esophageal obstruction overthe last two decades. Methods: We identified patients who underwent placement of


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ES for esophageal obstruction, dysphagia, odynophagia, between 1/1/2001-12/31/2019. Exclusion criteria included ES placed for benign stricture, fistulae, or post-surgical indications. No ES was placed for proximal pathology. Patient charts werereviewed for procedure characteristics, complications, and follow up. Non-para-metric test for trend was performed to evaluate trends over time. Results: From2001-19, we placed 241 ES for malignant dysphagia. ES have been placed in highernumbers from 2001 to 2019 (Figure 1A). From 2001-2006, a mean of 9 ES wereplaced each year, from 2007-2012, mean of 10 placed annually, and from 2013-2019,mean of 19 ES placed each year. The choice of stent type varied significantly overtime (Figure 1B). After 2007, no plastic stents were placed. Since 2013, fully coveredstents are most frequently placed. While partially covered stents were initiallyincreasing in frequency, their use has since decreased. Uncovered stents remaininfrequently utilized. The rate of complications related to ES placement has notsignificantly changed over time (Figure 2A). Complications were defined as docu-mented migration, stent ingrowth or tumor recurrence causing recurrent orpersistent symptoms, bleeding, perforation, infection, and severe pain clearly due toES placement. Median 60% of patients developed some complication post-ESplacement, and this did not vary significantly over time (pZ0.94 for trend). Despiteevolution of stent choice, migration rates did not vary significantly over time (me-dian 17% migration rate, pZ0.38 for trend). Despite the increased use and place-ment of ES, patients continue to require other modalities for enteral feeding,including endoscopically placed gastrostomy tube and interventional radiology orsurgery placed feeding tubes (Figure 2B). This occurred at a mean rate of 36% be-tween 2001-2006, 40% between 2007-2012, and 41% between 2013-2019 (pZ0.57for trend). Discussion: The placement of ES to treat malignant dysphagia hasincreased significantly over the past 2 decades. As stent technology improves, thechoice of stent type has evolved, and fully covered stents have become frequentlyutilized. Despite the availability of ES and advent of removable, fully covered stents,complication rates remain high, in keeping what has been reported in publishedstudies as well. ES placement provides promise of palliation of malignant dysphagia,but with relatively high complication rates and the need for other potential nutri-tional modalities.

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FIGURE 1

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FIGURE 2


ID: 3524656DIVERTICULAR PER ORAL ENDOSCOPIC MYOTOMY(D-POEM) FOR ESOPHAGEAL DIVERTICULARDISEASE- A SYSTEMATIC REVIEW AND METANALYSISHarshal S. Mandavdhare*, Praveen Kumar-M, Dayakrishna Jha,Antriksh Kumar, Vishal Sharma, Pankaj N. Desai, Lada Shumkina,Pankaj Gupta, Harjeet Singh, Usha DuttaBackground: The traditional way to tackle Zenkers diverticulum (ZD) has been flex-ible endoscopic septum division (FESD). Although, a technically easy procedure,FESD has high rates of recurrence due to the inherent fear of perforation leading topremature termination of the procedure leaving behind residual septum. Recently,the concept of per oral endoscopic myotomy (POEM) has been found useful formanaging diverticular diseases of esophagus and has been termed DiverticularPOEM (D-POEM). Preliminary studies have shown promising results for D-POEM.Methods: We systematically searched for the literature on PubMed and Embase, forstudies reporting clinical success, technical success and adverse events in D-POEMalone. For the comparison of D-POEM vs FESD/rigid endoscopy the outcomesincluded were: Technical success; Clinical success; Procedure time; Length of hos-pital stay and Adverse event rate. The definitions of outcomes were: Technicalsuccess - defined by completion of all steps of D-POEM/FESD including septotomy;Clinical success - defined by decrease in the dysphagia score post procedure(Dakkak Bennett score to 0/1) or modified Eckhart score<3; Adverse event ratedefined as per the American Society of Gastrointestinal Endoscopy (ASGE) lexicon;Length of hospital stay- in days post procedure; Procedure time - time needed to


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complete the procedure in minutes. For the missing data we contacted the authorsthrough electronic mail (e-mail). We selected published studies/abstracts in Englishlanguage that included � 5 cases reporting D-POEM alone or D-POEM compared toFESD/rigid endoscopy. We excluded case reports <5 cases, review articles, letter toeditor not containing original data, commentary, articles published in non-Englishlanguage and, unrelated articles on diverticular diseases of oesophagus that have notmentioned the use of D-POEM. We computed pooled prevalence for D-POEM aloneand summary risk ratio for D-POEM vs FESD using random effect method with in-verse variance approach. Subgroup analysis for ZD, non-ZD and mixed diverticulumwere conducted. Results: Total 14 studies were identified that reported on either D-POEM or D-POEM compared with FESD. The pooled clinical, technical success andadverse event rate for D-POEM were 85.84%, 95.11% and 8.8% respectively. Theclinical success was significantly better than FESD while the technical success,adverse event rate, procedure time and length of hospital stay were comparable withFESD. The recurrence rate was negligible for D-POEM compared to FESD. Onsubgroup analysis by dividing into 3 groups of ZD, non-ZD and mixed, there was nodifference between clinical, technical success and adverse event rate among the 3groups. Conclusion: D-POEM is an effective and safe technique among both ZD andnon-ZD patients and has better clinical success than FESD.


ID: 3526796REPEAT GASTRIC PERI-ORAL ENDOSCOPIC MYOTOMYFOR TREATMENT OF GASTROPARESIS: A CASE SERIES.Sara Welinsky*, Javelle Wynter, Daniela Jodorkovsky,Amrita SethiBackground: Gastroparesis (GP), a condition of delayed emptying of the stomach,commonly presents with symptoms of abdominal pain, nausea, and vomiting. His-torical treatment options include medical management, pyloric botox injection (BI),pyloric balloon dilation/stenting, gastric stimulator placement and surgical pyloricsphincteroplasty. Recently, Gastric Peroral Endoscopic Myotomy (G-POEM), inwhich a submucosal tunnel is created in the distal stomach for identification of thepyloric muscle followed by myotomy, has been accepted as a safe and effectivemanagement for GP although symptoms are known to recur. When performed inthe esophagus for achalasia, repeat POEM is offered for recurrent symptoms. Thegoal of this case series is to describe our experience with repeat G-POEM. Methods:A retrospective review was performed at a single center of patients who underwentrepeat GPOEM procedure for the management of GP. Electronic medical recordswere reviewed for indications, pre-procedure treatments, procedural techniques,adverse events (AEs) and clinical response. Procedure-related complications weredefined as bleeding not responsive to standard hemostasis methods, capnoperito-neum or perforation requiring intervention, post procedure pain, nausea, vomitingabove baseline, or post-procedure infection. Results: Between 8/2020 and 11/2020,three patients were identified. The patients’ ages, gender, etiology of gastroparesis,and symptom indices are described in Table 1. Pre-G POEM treatment includedmedical management with anti-emetic therapy and prokinetic agents (nZ3), andmedicinal marijuana (nZ1). Pyloric BI was performed in all 3 patients. For the initialprocedure, a greater curve (GC) approach was taken in 2 patients and a lesser curve(LC) approach in the third. There were no AEs associated with the initial G-POEMs.The duration of clinical response for each patient is provided in Table 1. Patientspresented for repeat G-POEMS due to recurrent symptoms (see Table 1) at 14, 15,and 18 months. Myotomies were performed on the LC in the patients with prior GCapproach, and in a posterior approach in the one LC patient. Suturing was used formucosotomy closure for all procedures. Two associated AEs occurred with repeat G-POEMs including incision site mucosal oozing due to suturing requiring a hemo-static clip. In one patient, mucostomy dehiscence, closed with clips, was seen inrepeat endoscopy performed to evaluate prolonged abdominal pain. Conclusion:While further follow-up is required to determine clinical efficacy, repeat G-POEMappears to be feasible and safe in this case series. While overall efficacy of G-POEMas well as effects of variations in technique, such as approach or use of doublemyotomy, are currently being studied, repeat G-POEM should also now be consid-ered in the algorithm of treatment for gastroparesis.

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ID: 3520453PERORAL ENDOSCOPIC MYOTOMY (POEM) VERSUSLAPAROSCOPIC HELLER MYOTOMY (LHM) FORESOPHAGEAL ACHALASIA – A SYSTEMATIC REVIEW ANDMETA-ANALYSISSami Ghazaleh*, Azizullah Beran, Dipen Patel, Sehrish Malik,Jordan Burlen, Yaseen Alastal, Ali NawrasBackground: Esophageal achalasia results from progressive degeneration of ganglioncells in the myenteric plexus in the esophageal wall. Current treatment options forachalasia include pneumatic dilation, laparoscopic Heller myotomy (LHM), andperoral endoscopic myotomy (POEM). The aim of this meta-analysis is to comparethe efficacy and safety of POEM and LHM. Patients and methods: We conducted asystematic review and meta-analysis of studies that compared POEM and LHM inpatients with achalasia. We performed a comprehensive search in the databases ofPubMed/MEDLINE, Embase, and the Cochrane Central Register of Controlled Trialsfrom inception through October 28, 2020. We considered randomized controlledtrials, cohort studies, case-control studies, and case series. We excluded abstracts,animal studies, case reports, reviews, editorials, and letters to editors. From eachstudy, we collected the number of patients who underwent PEOM or LHM. Primaryoutcome was clinical success (i.e. postoperative Eckardt score 3 or lower). Sec-ondary outcomes were postoperative reflux symptoms, perioperative adverseevents, operation time, and length of hospital stay. The random-effects model wasused to calculate the odds ratios (OR), mean differences (MD), and confidence in-tervals (CI). A p value <0.05 was considered statistically significant. Heterogeneitywas assessed using the Higgins I2 index. Results: Nineteen studies, one randomizedcontrolled trial and eighteen cohorts, involving 1799 patients were included in themeta-analysis. POEM was superior to LHM in terms of clinical success (OR 1.65, 95%CI 1.18 – 2.32, p Z 0.004, I2 Z 0%), operation time (MD -23.25 mins, 95% CI -37.86– -8.64, p Z 0.002, I2 Z 91%) and length of hospital stay (MD -0.44 days, 95% CI-0.87 – -0.01, p Z 0.04, I2 Z 63%). Perioperative adverse events were similar be-tween patients who underwent POEM or LHM (OR 0.76, 95% CI 0.50 – 1.15, p Z0.20, I2 Z 18%). Postoperative reflux symptoms were more likely to occur in POEMcompared with LHM (OR 1.76, 95% CI 1.03 – 3.00, p Z 0.04, I2 Z 15%).Conclusions: Our meta-analysis demonstrated that POEM was more effective thanLHM in achieving clinical success in patients with esophageal achalasia. Both pro-cedures resulted in comparable perioperative adverse events. POEM was superior to


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LHM in terms of operation time and length of stay, but it resulted in an increasedrisk of postoperative reflux symptoms. Further randomized controlled trials withlarge sample sizes are needed to confirm our findings.

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Forest plots of clinical success, postoperative reflux symptoms, and peri-operative adverse events

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Forest plots of operation time and length of hospital stay


ID: 3526919COST EFFECTIVENESS ANALYSIS OF PARTIALLYCOVERED, FULLY COVERED, AND SUTURED FULLYCOVERED SELF EXPANDING METAL STENTS FORPALLIATION OF MALIGNANT ESOPHAGEAL DYSPHAGIAMartin H. Gregory*, Vinay Chandrasekhara, Thomas Hollander,Gabriel Lang, Vladimir Kushnir, Daniel Mullady, Koushik K. DasBackground: Self-expanding metal stents (SEMS) are routinely used to palliate malig-nant dysphagia. We recently demonstrated in a large, multicenter, retrospectiveseries that partially covered stents (pcSEMS) had a lower rate of migration than fullycovered stents (fcSEMS) or fcSEMS with antimigration fins (fcSEMS-AF) (10.9% vs25.3% vs 19.3%) with a similar rate of epithelial hyperplasia amongst all three(12.6%). Adjunctive techniques such as anchoring sutures (fcSEMS-S) have beenstudied to reduce the rate of migration with fcSEMS (18.0%). Given the increasedcost associated with strategies other than pcSEMS, we aimed to examine the cost-effectiveness of these options of SEMS in malignant dysphagia. Aim: Determine thecost-effectiveness of fcSEMS, fcSEMS-AF, fcSEMS-S compared to pcSEMS. Methods:A Markov model was constructed using TreeAge Pro Healthcare 2020 comparing the4 treatment strategies in patients undergoing palliative esophageal stent placement.The model included rates of stent migration, obstruction from overgrowth anddeath and frequency of need for EGD for stent removal/replacement based on ourand other’s previously reported data. Other complications such as GI bleeding, foodimpaction and cancer progression were assumed to be similar across the arms.Utility for terminal esophageal cancer was obtained from the literature. Model pa-rameters were tested in 1-way sensitivity analysis across clinically plausible valuesfrom the literature. Two-way sensitivity analyses were performed between the costof fcSEMS and risk of obstruction/migration. The model was estimated with micro-simulation of 18,000 patients. Results: Each of the fcSEMS arms was more costly thanpcSEMS. Mean effectiveness was 0.3 quality-adjusted life-years for each arm. ThepcSEMS arm was least costly with the same utility and thus dominated the otherstrategies. Median survival in the population was 93 days, similar to our prior un-derlying study population. The decision was robust to all 1-way sensitivity analyses.No combination of fcSEMS stent price and risk of obstruction would make thefcSEMS strategy cost-effective. Conclusion: Based on our Markov modeling, giventhe significantly lower rate of migration with pcSEMS with similar rates of epithelialhyperplasia in comparison to fcSEMS, fcSEMS-AF, and fcSEMS-S, the dominant cost-effective strategy is to use pcSEMS for malignant dysphagia. Future stent designsshould aim to reduce stent migration and epithelial hyperplasia to be cost-effective.

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SEMS, self-expandable metal stent; pc, partially-covered; S, suture; AF,anti-migration fins; QALY, quality-adjusted life-years; ICER, incrementalcost-effectiveness ratio


ID: 3525909COMPARISON OF ZENKER’S PER-ORAL ENDOSCOPICMYOTOMY (Z-POEM) WITH TRADITIONAL FLEXIBLEENDOSCOPIC SEPTOTOMYEric Swei*, Mihir S. WaghBackground: Flexible endoscopic therapy of Zenker’s diverticulum (ZD) using sub-mucosal tunneling, similar to per-oral endoscopic myotomy (Z-POEM) is becomingincreasingly common. However, data comparing Z-POEM with traditional flexibleendoscopic septotomy (FES) for ZD are sparse. The purpose of this study was tocompare outcomes of Z-POEM with traditional FES. Methods: This was prospectivestudy of patients who underwent flexible endoscopic treatment of Zenker’s


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diverticulum at a tertiary academic medical center. The study was approved by theIRB. Patients who underwent Z-POEM between 2019-2020 were compared to priorpatients with ZD who underwent traditional FES from 2018-2019. Patient demo-graphics and outcomes including procedure time, technical success, clinical successand adverse events were compared using two-sample t-testing. Clinical success wasdefined as improvement in Eckardt score < 3. Adverse events (AE) were recordedper published ASGE criteria. Results: 10 patients (median age 70 years, 70% male)underwent Z-POEM during the study period and 20 patients (median age 73 years;80% male) underwent traditional FES. The two groups were similar in pre-proce-dural demographics including age, gender, size of ZD, pre-procedural Eckardt score,and ASA score (Table 1). The Hybrid Knife was used in all patients undergoing Z-POEM (nZ10). Knife usage in patients undergoing traditional FES was as follows:hybrid knife Z2, hook knife Z7, Clutch-Cutter Z 8, hook knife and insulated tip(IT) knife Z2, hook knife and dual knife Z1. Total procedure time was similarbetween groups: 45.6 minutes (range 26-54) in the Z-POEM group and 56.7 minutes(range 25-92) in the traditional FES group (p Z0.153). Procedure time improved inthe last four Z-POEM cases (mean 33.2 minutes) likely reflecting a learning curveeffect.Technical success was 100% in both groups. There was no statistically significantdifference in average post-procedure Eckardt scores between the two groups (0.2for Z-POEM group vs 1.0 for traditional FES, pZ0.257). There were no serious AE ineither group. One patient (10% minor AE) in the Z-POEM group had ER visit forchills and altered taste due to side-effect of perioperative antibiotic which resolvedupon stopping the offending agent. Two patients (10% minor AE) presented to theER after traditional FES (one with syncope due to dehydration requiring hospitali-zation for IV fluids; and another with chest pain, discharged from ER after negativeevaluation). Conclusions: Initial data suggests that Z-POEM is an effective techniqueto treat Zenker’s diverticulum with no significant differences in clinical outcomes oradverse event rate when compared to traditional FES. However, comparison islimited due to the recent introduction of the Z-POEM technique and relative rarity ofZD which leads small number of patients and lack of long-term data.

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ID: 3527043INCREASED UPTAKE OF PERORAL ENDOSCOPICMYOTOMY (POEM) FOR ACHALASIA AMONGPROVIDERS IN THE PHILADELPHIA REGIONFOLLOWING ESTABLISHMENT OF A REGIONAL POEMCENTERIan Holmes*, Rebecca Loh, Benjamin Chipkin, Muhammad Bashir,Christopher Adkins, Alexander SchlachtermanIntroduction: Peroral endoscopic myotomy (POEM) is a recently introduced endo-scopic technique for the treatment of achalasia. Although studies have supportedPOEM’s effectiveness as a minimally invasive therapy, surgical myotomy remainsmore widely implemented than POEM. POEM requires additional training beyondstandard gastroenterology fellowship and is currently limited to specialized centers.Our objective was to explore regional uptake of POEM among local providers beforeand after establishment of a local POEM center. Methods: The Institutional ReviewBoard (IRB) at our institution approved a 21-question multiple-choice survey thatwas developed by a panel of specialists that included a POEM trained advancedendoscopist. The survey was sent via email to 208 physicians in the Philadelphia areaprior to the intervention (establishment of the POEM center,) then a follow upsurvey was sent 22 months after the first POEM had been performed. Some ques-tions allowed for responders to select all answers that applied. An initial email andtwo reminder emails were sent for the first survey, and one email was sent for thesecond survey. Results: During the study period from 1/1/2019 to 12/3/2020, 82patients underwent POEM. Prior to the establishment of the POEM center, 45 pro-viders completed the online survey (response rate of 21.6%.) 72.7% preferred torecommend surgical myotomy (laparoscopic or open) for achalasia while only 27.3%prescribed POEM. 69.8% of providers had never prescribed POEM, although 95.6%believed POEM would gain acceptance as a main form of therapy. 75.6% were awareof a POEM program in the area. After the POEM program was established, 18 pro-viders completed the survey (8.7%). 72.2% of respondents reported that they pre-scribed POEM and all respondents said they would consider POEM for treatment ofachalasia. 22.2% believed POEM was superior to surgical myotomy. 18/18 (100%)were aware that there was a POEM program in the area. Conclusion: After estab-lishment of a regional POEM center at a tertiary medical center, the percentage oflocal gastroenterologists who had prescribed POEM for achalasia rose from 27.3% to72.2%. Awareness of a local POEM program rose from 75.6% to 100% of survey re-spondents. Local availability of POEM led to increased prescription of POEM forachalasia among area gastroenterologists.

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Table 1. Survey demographics pre- and post-establishment of POEMcenter.

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Figure 1. Changes in awareness of POEM availability and prescription ofPOEM pre- and post-establishment of POEM center.


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ID: 3526685POSTERIOR ESOPHAGEAL PERORAL ENDOSCOPICMYOTOMY (POEM) AFTER FAILED HELLER MYOTOMYIN ACHALASIABenjamin Chipkin*, Rebecca Loh, Brianna Shinn,Nishi K. Pandey, Kaushal Desai, Christopher Adkins,Anthony Dimarino, Sidney Cohen, Alexander SchlachtermanIntroduction: Laparoscopic anterior Heller myotomy has been widely used to treatachalasia. For patients with failed anterior myotomy, secondary treatment withposterior esophageal peroral endoscopic myotomy (POEM) provides an efficacioustherapy option; however, there is a paucity of literature on these patients. In patientswith prior interventions, submucosal fibrosis may prevent tunneling and lead topremature POEM termination. While early research showed longer POEM proceduretimes for patients with prior treatments, more recent data showed no difference.This study aims to examine the safety and efficacy of posterior POEM for treatmentof achalasia in patients with failed anterior myotomy. Methods: This retrospectivestudy conducted at a single tertiary care center reviewed consecutive patients whounderwent POEM by a single endoscopist from 1/2019-10/2020. Diagnosis, treatmenthistory, Eckardt scores, proton pump inhibitor (PPI) use, procedure metrics, com-plications, and length of stay were collected via chart review. Pre-POEM Eckardtscores were recorded 1 month prior, and post-POEM Eckardt scores were recordedat 3-, 6-, and 12-month follow-up. T-tests assessed for differences in Eckardt scores,submucosal tunnel length, time for tunneling, myotomy length, time for myotomy,and length of stay. Linear regression assessed for correlation between myotomylength and procedure duration. Results: We identified 8 patients with failed anteriormyotomy and 18 with no history of intervention who underwent POEM. Priorintervention did not increase POEM duration or myotomy length. Pre- and post-POEM Eckardt scores did not differ between patients with and without prior treat-ment. For patients with failed anterior myotomy, there was a significant difference inpre- versus post-POEM Eckardt scores (Figure 1); 2 required long-term PPI (panto-prazole 40 mg BID > 6 months post-POEM); 1 is continuing PPI at 3 months; 5stopped PPI within 6 months; 0 developed erosive esophageal disease or strictureafter POEM; 0 required transoral incisionless fundoplication; and 0 had majorcomplications from bleeding, infection, or perforation. There was no significantdifference in length of stay between patients with and without prior treatment.Conclusion: Given the posterior approach, secondary POEM in failed anterior myot-omy patients is no more complex than primary POEM. There was no difference inmyotomy length or procedure duration between patients with and without priortreatment. Clinical response to POEM was robust, with Eckardt scores significantlydecreased pre- versus post-POEM, and 7 of 8 had Eckardt score � 2 at most recentfollow-up. Only 2 of 8 required long-term PPI to date. There were no major com-plications and no difference in length of stay. In patients with failed anterior myot-omy, secondary posterior POEM is a safe and effective treatment for achalasia.

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Figure 1. Eckardt score pre- and post-posterior POEM for patients withfailed anterior Heller myotomy. Each trend line shows changes in Eckardtscores pre- and post-POEM for individual patients (n Z 8). Gray boxesrepresent mean Eckardt scores at 1 month pre-POEM (mean Z 8.9), 3months post-POEM (mean Z 3.2), 6 months post-POEM (mean Z 1.2),and 12 months post-POEM (mean Z 0.2). Paired t-tests showed a statisti-cally significant difference in Eckardt scores for 1 month pre-POEM versus3 months post-POEM (p Z 0.0132), 6 months post-POEM (p Z 0.0033),and 12 months post-POEM (p Z 0.0011). Seven of 8 patients had Eckardtscore � 2 at most recent follow-up.


ID: 3524192INCREASING PREVALENCE OF REFLUX ESOPHAGITIS ASA CAUSE OF SEVERE UPPER GASTROINTESTINALHEMORRHAGEPeerapol Wangrattanapranee*, Usah Khrucharoen,Dennis M. Jensen, Thongsak Wongpongsalee, Mary Ellen JensenBackground and Aims: Reflux esophagitis (RE) causing severe upper gastrointestinalbleeding (UGIB) and RE endoscopic treatment are infrequently reported on. Ourstudy aims were to evaluate 1) changes in prevalence of RE as a cause of UGIB over 3decades in our 2 academic medical centers; 2) 30-day outcomes of RE patients withUGIB; and 3) 30-day outcome comparisons of RE patients with and without focalesophageal ulcers and stigmata of recent hemorrhage (SRH). Methods: Prospectivelycollected data from CURE Hemostasis databases of patients hospitalized with severeUGIB from endoscopic diagnosed RE at two academic centers from March 1992 toApril 2020 were retrospectively reviewed. Prevalence, demographics, and 30-dayoutcomes were analyzed. Patients with RE, focal ulcers, and SRH were treated withendoscopic hemostasis, similar to patients with peptic ulcer bleeding (PUB). Results:Among 2,703 patients with severe UGIB, the prevalence of RE increased from 1.6%between 1992-2006 to 7.7% between 2007-2020, p<0.001. 114 patients had RE - 23(20.2%) had focal esophageal ulcers and SRH. 76.3% of all RE patients were malewith a mean age of 61.1 years old. 38.6% had prior gastroesophageal reflux disease(GERD) symptoms. 36% were on acid suppressants. 30-day rebleeding, readmission,and all-cause mortality rates were 11.4%, 12.3%, and 6.1%. 20.2% of RE patients hadfocal ulcers and SRH and most of them were treated endoscopically. None of thosepatients rebled from the focal ulcers nor had any complications of the endoscopictreatment. Although there were different rates of SRH and endoscopic hemostasis,there were no significant differences in demographics or major 30-day clinical out-comes for RE patients with or without SRH and ulcers [Table 1-2]. Conclusion: Theprevalence of RE as a cause of severe UGIB has increased significantly over the last 3decades. Most RE patients had no prior GERD symptoms and did not take acidsuppressants prior to severe UGIB. Endoscopic treatment of RE patients with SRHwas safe and is recommended, utilizing techniques similar to PUB. Further researchstudies on potential causes of the increase in RE prevalence and in earlier diagnosisand treatment are warranted to prevent development of severe UGIB.

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SUNDAY, MAY 23, 2021Esophagus 2Lecture

ID: 3524065ENDOSCOPIC THERAPY VERSUS SURGICALINTERVENTION IN MANAGING T1AN0M0 AND T1BN0M0ESOPHAGEAL CANCER: A MORTALITY ANALYSISMengdan Xie*, Michael S. SmithBackground: Endoscopic therapy is gaining more acceptance as a preferred inter-vention for superficial node-negative esophageal cancer, avoiding the morbidityand mortality of esophagectomy. Since 2010, guidelines have subdivided theseneoplasms into T1a (mucosal only involvement) and T1b (submucosal involvement),with corresponding differences in treatment guidance. The aim of this study was tocompare long-term survival in patients with T1a/T1b esophageal cancer managedwith either endoscopic therapy or surgery. Methods: The Surveillance, Epidemi-ology, and End Results (SEER) database from 2010 to 2017 was searched to identifypatients with T1aN0M0 or T1bN0M0 esophageal cancer who underwent eitherendoscopic therapy or surgery. Those with unknown TNM stage or no/unknownintervention performed were excluded. Clinicopathological information includingage, gender, race, cancer site, histology and grade were compared between theendoscopic and surgery cohorts. All-cause mortality and esophageal cancer-specificmortality were analyzed. Multivariate regression was used to adjust for possibleconfounders. Kaplan-Meier and Cox proportional hazard modeling were used forsurvival analysis. Results: Data was available for analysis in 2,460 patients, amongwhich there were 1,643 T1a lesions and 817 T1b cancers (Table 1). For both tumorstages, the endoscopic therapy group was older (p < 0.05) and had a higher tumorgrade level (p < 0.05) than the surgery group. With a median of survival time 35months, all-cause mortality rates for T1a and T1b tumors were 20.2% and 31.2%,respectively. There were no significant differences in all-cause mortality between theendoscopic therapy and surgery groups for either T1a or T1b cancer. For T1a le-sions, patients undergoing surgery had a significantly higher esophageal cancer-specific mortality rate (HR 2.15, p < 0.01) and decreased cancer-free survivalcompared to the endoscopic therapy group. This difference in cancer-specificmortality was not found for T1b tumors (HR 1.34, p Z 0.259), though the non-esophageal cancer-related mortality rate was significantly higher in the endoscopictherapy group compared to the surgery group (19.66% vs 12.76%, p < 0.05).Discussion: These results suggested a greater mortality benefit for endoscopic ther-

apy over surgery in T1aN0M0 esophageal cancers. As for T1bN0M0 cancer, the SEERdata did not show a clear mortality benefit of endoscopic therapy. However, asincluded patients were relatively older and more likely to die from other diseases,endoscopic therapy may have been underused for at least some of these patients. Ifthis were the case, a similar mortality benefit may have been found for these moreinvasive tumors.

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Table: Characteristics of T1a/T1b esophageal cancer patients underwentendoscopic therapy or surgery

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Figure: A: Multivariate analysis of outcomes in T1a/T1b patients under-went endoscopic therapy or surgery. B: Cancer-specific survival in T1acancer with endoscopic therapy or surgery


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ID: 3520455SHORT VERSUS STANDARD PERORAL ENDOSCOPICMYOTOMY (POEM) FOR ESOPHAGEAL ACHALASIA – ASYSTEMATIC REVIEW AND META-ANALYSISSami Ghazaleh*, Azizullah Beran, Yasmin Khader,Christian Nehme, Justin Chuang, Muhammad Aziz, Sachit Sharma,Ahmed M. Elzanaty, Zubair Khan, Jordan Burlen, Ali NawrasBackground: Peroral endoscopic myotomy (POEM) is increasingly being used totreat esophageal achalasia, but it is associated with a high rate of gastroesophagealreflux disease (GERD). The aim of our meta-analysis is to examine if a modifiedPOEM with a shorter myotomy length could reduce the incidence of post-operativeGERD while achieving the same clinical efficacy as a standard myotomy. Patients andmethods: We conducted a systematic review and meta-analysis of studies thatcompared POEM using short myotomy with standard myotomy. We performed acomprehensive search in the databases of PubMed/MEDLINE, Embase, the Co-chrane Central Register of Controlled Trials, and Web of Science Core Collectionfrom inception through October 30, 2020. We considered randomized controlledtrials, cohort studies, case-control studies, and case series. We excluded animalstudies, case reports, reviews, editorials, and letters to editors. From each study, wecollected the number of patients who underwent short or standard POEM. Primaryoutcome was clinical success (i.e. postoperative Eckardt score 3 or lower). Sec-ondary outcomes were post-operative GERD and operation time. The random-ef-fects model was used to calculate the risk ratios (RR), mean differences (MD), andconfidence intervals (CI). A p value <0.05 was considered statistically significant.Heterogeneity was assessed using the Higgins I2 index. Results: Seven studies, fiverandomized controlled trial and two retrospective cohorts, involving 638 patientswere included in the meta-analysis. Short myotomy was as effective as standardmyotomy in achieving clinical success (RR 1.00, 95% CI 0.95 – 1.05, p Z 0.86, I2 Z14%). Operation time was shorter in short myotomy compared with standard my-otomy (MD -14.63 mins, 95% CI -18.55 – -10.71, p < 0.00001, I2 Z 45%). Althoughreflux symptoms were similar between the two myotomy lengths (RR 0.94, 95% CI0.58 – 1.54, pZ 0.82, I2Z 32%), short myotomy had lower risk of reflux esophagitison endoscopy (RR 0.61, 95% CI 0.39 – 0.98, p Z 0.04, I2 Z 0%) and pathologic acidexposure on pH monitoring (RR 0.58, 95% CI 0.36 – 0.94, p Z 0.03, I2 Z 0%).Conclusions: Our meta-analysis demonstrated that POEM using a shorter myotomyis comparable with standard myotomy in terms of clinical success. A shorter myot-omy requires a shorter operation time and reduces the occurrence of post-operativeGERD. Further randomized controlled trials with large sample sizes are needed toconfirm our findings.

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Forest plots of clinical success and operation time

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Forest plots of post-operative gastroesophageal reflux disease (GERD)


ID: 3525824UNDERWATER PERORAL ENDOSCOPIC MYOTOMY(UPOEM) FOR ZENKER’S DIVERTICULUM USING ASTANDARDIZED PROTOCOLKenneth F. Binmoeller*, Andrew Nett, Chris M. Hamerski,Rabindra R. Watson, Morgan Rigopoulos, Jona C. BernabeBackground: We have previously reported on the feasibility of underwater peroralendoscopic myotomy (UPOEM) for achalasia, substituting conventional gas insuf-flation with water submersion [GIE 2016; 83; 454]. Potential advantages of UPOEMinclude avoidance of pneumomediastinum, heat-sink effect, and optical enhance-ments. This study aimed to evaluate the clinical outcomes of UPOEM for Zenker’sdiverticulum. Methods: Retrospective review of a prospectively collected database ofconsecutive patients with Zenker’s diverticulum treated with UPOEM for dysphagiausing a standardized protocol over a 26-month period (September 2018 toNovember 2020). Equipment: 1) High definition gastroscope with near focus; 2)Small-caliber transparent cap attachment ;3 ) T-type hybrid submucosal dissectionknife; Standard through-the-scope clips. Procedure: 1) Submucosal injection withdilute indigocarmine through the hybrid knife; 2) 2 cm mucosal incision over thelong axis of the septum ; 3) Both sides of the cricopharyngeal muscle along thediverticulum and esophageal walls dissected free; 4) Incision of the cricopharyngealmuscle up to longitudinal muscle fibers of the eophagus. Endocut I current wasused, alternating with soft coagulation for hemostasis of bleeding vessels. 2-5 clips toclose the mucosal incision opening to the septomyotomy tunnel. Results: 31consecutive patients (76.24+10.77yrs, 14M:17F) with dysphagia from a Zenker’sdiverticulum were treated with UPOEM by a single operator (KFB). Nine (29%)patients had previous Zenker’s treatment, including dilation (4), septomyotomy (4)and surgery (1 ). Median Eckhardt score of 9. Procedural time was 40 + 17min with100% technical success, no intra-procedural adverse events and all proceduralbleeding successfully controlled. Follow up: 41 + 38 weeks in 15 patients; all had noadverse events, no bleeding, and were asymptomatic after a median of 7.25 months[range 0.25 to 26.5]. Post UPOEM Eckhardt score of 0. One patient required 3 di-lations for management of a post UPOEM stricture that resolved with Eckhardt score0. Follow up pending in 16 patients. Limitation: Single center, single operator,


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limited follow-up, retrospective study Conclusions: UPOEM for Zenker’s divertic-ulum using a standardized protocol resulted in high clinical success rates with noserious adverse effects.


ID: 3526803PER ORAL ENDOSCOPIC MYOTOMY (POEM): 11-YEAROUTCOME FROM A LARGE US REFERRAL CENTERStavros N. Stavropoulos*, Xiaocen Zhang, Laleh Omrani,Collin E. Brathwaite, Maria Kollarus, Sharon Taylor, Iosif Galibov,James H. Grendell, Rani J. ModayilBackground: Per oral endoscopic myotomy (POEM) is the prototype and most suc-cessful form of transluminal endoscopic surgery and is becoming the treatment ofchoice for achalasia. In 2009 we performed the first POEM outside Japan. We hereinreport our 11-year POEM experience, focusing on long-term efficacy and GERD data.Method: This is a single-center prospective cohort study. Result: A total of 704 pa-tients received POEM at our center between 10/2009-11/2020. There were 317(45%) females and the median age was 55. Seventy-four (10.5%) patients were� 80years-old and 219 (31.1%) were ASA class III/IV. The Chicago Classification diagnosiswas type I achalasia in 193 (28%), type II in 352 (52%) and type III in 108 (16%)patients, and EGJ outflow obstruction, DES or jackhammer esophagus in 26 (3.8%).The disease was stage I in 124 (17.6%), II in 407 (57.8%), III in 42 (6%) and IV in 131(18.6%) patients. A total of 335 (47.6%) patients received one or more prior treat-ments, including 153 (21.7%) botulinum toxin injection, 123 (17.5%) dilation, and102 (14.5%) Heller. There were no aborted POEMs. Median POEM operative timewas 54 min. Clinically significant adverse events (csAEs) occurred in 21 patients,including 2 dehiscence of tunnel os without leak, 8 delayed bleeds and 11 others.There was no mortality. Median hospital stay was 2 days. After a median follow up of23 months, 29 failures occurred, defined as postoperative Eckardt score>3 oradditional treatment. Using Kaplan Meier estimates, annual POEM success rates from1-8 years were 98%, 97%, 97%, 95%, 94%, 93%, 93%, 93%. After POEM, 111 (15.9%)patients had grade 2-3 reflux symptoms (�twice/week). In the 664 patients at least 6months out of their POEM, 446 (67%) completed 48-hour Bravo study, of which 261(58%) were positive. 490 (73.8%) patients received follow up endoscopy, of which201 (49.3%) had esophagitis. Barrett’s esophagus was present in 16 patients beforePOEM. Post POEM, Barrett’s and peptic strictures responsive to dilation developedin 8 pts each, all due to PPI non-compliance. None of these led to POEM “failure”.Conclusion: POEM is highly effective, with>90% success extending to >10 yearspost-POEM rivalling Heller myotomy outcomes from expert centers. Our serieshas the most extensive and well documented objective GERD data and long-termfollow-up published to date. Objective GERD is seen in w50% of patients but iseminently manageable by PPIs with manageable GERD sequelae seen in a smallminority of PPI non-compliant patients.

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Baseline characteristics and Clinical Outcomes

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Kaplan Meier Curve


ID: 3523433PER ORAL ENDOSCOPIC MYOTOMY FOR ZENKER’SDIVERTICULUM: A NOVEL AND SUPERIOR TECHNIQUECOMPARED TO SEPTOTOMY ?Michel Kahaleh*, Noah Y. Mahpour, Amy Tyberg, Romy Bareket,Haroon M. Shahid, Avik Sarkar, Abdelhai Abdelqader,Mihajlo Gjeorgjievski, Daniel Marino, Daniel Kats, Monica Gaidhane,Ian Greenberg, David P. Lee, Bryce Bushe, Chiemeziem Eke, Hojin Sun,Prashant Kedia, Ana L. Madrigal Méndez, Maximilien Barret, Rachel Hallit,Nikolas P. Eleftheriadis, Jose Nieto, Roberto Oleas,Carlos Robles-Medranda, Amol BapayeIntroduction: Zenker’s Diverticulum carries significant risk for dysphagia, weightloss, and aspiration events due to pooling of food and oral secretions into thepseudo-diverticulum. Endoscopic tunneling for Zenker’s Diverticulum has beenshown to have promising data in regards to symptom alleviation and reducedmorbidity and mortality. We report our data from a multicenter study comparing peroral endoscopic myotomy (Z-POEM) versus traditional septotomy for the treatmentof Zenker’s Diverticulum. Methods: Patients with a Zenker’s Diverticulum treatedeither by Z-POEM or Septotomy from 7 international centers between March 2016through November 2019 were included. Patient demographics, pre interventionfunctional markers and scores (Functional Oral Intake Scale Score {FOIS Score},Eckardt Score), size of the diverticulum, procedural data, adverse events, and hos-pital length of stay (LOS) were collected. Independent and paired T-test analyses andchi-square analyses were conducted to compare means and proportions respec-tively. Results: A total of 101 cases were analyzed: 49 Septotomy, 52 Z-POEM (Table1). For the Septotomy cohort, mean age was 73, average pre-intervention FOIS scorewas 5.3, and average pre-intervention Eckardt score was 5.4. The average proceduretime was 44 minutes, the average length of myotomy was 3.51 cm. Technical successwas achieved in 100% of cases. There were 15 adverse events (21%): bleeding(nZ5), leak (nZ4), nausea/vomiting (nZ3), or other (nZ3). 7 patients experiencedrecurrence, both required an additional procedure. The average LOS was 1.9 days.Post procedurally, the FOIS score was 6.6, the Eckardt score was 1.6, and overallclinical success was reported in 84% of cases. For the Z-POEM cohort, mean age was75, average pre-intervention FOIS score was 5.9, and the average pre-interventionEckardt score was 5.15. The average procedure time was 42 minutes, the averagelength of myotomy was 3.32 cm. Technical success was achieved in 98% of cases.There were no adverse events. Three cases required an additional procedure. Theaverage LOS was 1.5 days. Post procedurally, the FOIS score was 6.82, the Eckardtscore was 1.3, and overall clinical success was reported in 92% of cases. The Z-POEMgroup had significantly less adverse events than the septotomy group (p Z.016548). All other outcomes were not statistically different. Conclusions: In thetreatment of Zenker’s Diverticulum, multiple therapeutic modalities exist; however,our experience and data reveal an important and significant advantage of Z-POEMover traditional septotomy in a statistically significant difference in terms of adverseevents. We believe that Z-POEM will shift towards becoming a standard of care in theendoscopic treatment of Zenker’s Diverticulum, and Endoscopists should familiarizethemselves with the technique.


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RESULTS COMPARING ZPOEM vs SEPTOTOMY


ID: 3523395THE IMPACT OF OBESITY ON PERORAL ENDOSCOPICMYOTOMY IN ACHALASIA: AN INTERNATIONALMULTICENTER REGISTRYMichel Kahaleh*, Lauren Pioppo, Amy Tyberg, Avik Sarkar,Haroon M. Shahid, Romy Bareket, Samuel Jo, Maria G. Porfilio,Juan C. Carames, Monica Gaidhane, Mihajlo Gjeorgjievski,Abdelhai Abdelqader, Ma Guadalupe Martínez, Hojin Sun,Chiemeziem Eke, David P. Lee, Bryce Bushe, Iman Andalib,Nikolas P. Eleftheriadis, Prashant Kedia, Ana L. Madrigal Méndez,Jose Nieto, Hannah P. Lukashok, Carlos Robles-MedrandaBackground and aims: Achalasia often presents with significant dysphagia that isaccompanied by weight loss. However, a significant portion of patients withachalasia are obese. Per-oral endoscopic myotomy (POEM) is an established therapyfor achalasia. Limited data exists on the outcomes of obese patients undergoingPOEM. We aim to analyze the safety and efficacy of POEM in obese patientscompared to nonobese patients. Methods: A multicenter registry was utilized tocapture and identify retrospectively all patients who underwent an esophagealPOEM between February 1, 2014 and November 20, 2020. Patients were split intotwo groups: nonobese (body mass index <30 kg/m2) and obese (body mass index�30 kg/m2). Patient demographics, Eckhardt scores, procedural data, and post-procedural follow-up data were extracted. High resolution manometry and disten-sibility index were measured before and after POEM for comparison. The primaryoutcomes were safety and efficacy of POEM in obese vs non-obese patients. Results:A total of 155 patients from 6 centers were included: 108 in the nonobese group and47 in the obese group. Baseline demographics, Eckhardt scores, and prior treatmentwere similar in both groups (Table 1). The most common type of achalasia was type2 in the nonobese and type 1 in the obese group. The obese group had morebaseline reflux, higher esophageal sphincter pressures, and lower distensibilityindices. Both groups had a statistically significant reduction (6.15 units) in post-POEM Eckhardt scores (p < .00001). The obese group had more symptomatic refluxpost-POEM and higher intra-procedural adverse events (3/47, 28% vs 9/108, 8%) (pvalue Z 0.03514) (Table 1). Length of hospital stay was similar between the twogroups. Conclusions: The efficacy of POEM for achalasia in nonobese and obese

patients appears to be similar in short-term follow up. Intraprocedural complicationsand post-procedure reflux were relatively higher in obese group.

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ID: 3522152CLINICAL AND TECHNICAL OUTCOMES OF POEM FORMANAGEMENT OF CRICOPHARYNGEAL BARS (CP-POEM): A MULTICENTER INTERNATIONAL STUDYSarah S. Al Ghamdi*, Oscar V. Hernández Mondragón,Nasim Parsa, Jose Nieto, Michael Bejjani, Mohamad Aghaie Meybodi,Muhammad N. Yousaf, Bachir Ghandour, Chonlada Krutsri,Chainarong Phalanusi, Saowanee Ngamruengphong,Mouen A. KhashabBackground: Cricopharyngeal bars (CPBs) are a unique etiology of oropharyngealdysphagia resulting from fibrous replacement of the cricopharyngeal muscle(CPM) due to acid reflux or mechanical injury. Dysphagia due to CPBs mimicsmanifestations of Zenker’s diverticula (ZD). While no medical therapy is required inasymptomatic patients, symptomatic patients are managed with endoscopic dilationor open surgical myotomy of the CPM. Cricopharyngeal peroral endoscopic myot-omy (CP-POEM) is an emerging technique utilized in the management of dysphagiadue to CPBs. No prior studies have assessed the outcomes of CP-POEM. Aims: Toevaluate technical success, clinical success, adverse events (AEs), and long-termrecurrence of CP-POEM. Methods: Consecutive patients who underwent POEM forthe management of CPBs between 05/2011-12/2020 at 4 tertiary care centers (2 US, 1South America, 1 Asia) were included. The primary outcome was clinical success(defined as improvement of dysphagia score to � 1 or complete resolution of othersymptoms if dysphagia score was � 1 at baseline). Secondary outcomes were


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technical success (defined as successful completion of all procedural steps), the rateof AEs (severity graded as per ASGE lexicon), total procedure duration and symptomrecurrence during follow-up (defined as dysphagia score > 1 or recurrence of othersymptoms). Results: A total of 27 patients (mean age 69 yr, F 10) underwent CP-POEM during the study period. The most common presenting symptoms at the timeof the index procedure were dysphagia (nZ26, 96.3%) and regurgitation (nZ20,74%) (Table 1). A total of 6 patients had prior CPB treatment (3 (11%) surgicalmyotomy, 2 (7.4%) endoscopic dilation, 1 (3.7%) botulinum toxin injection).Technical success was achieved in 27 (100%) patients. The mean procedure timewas 45.63min. Number of clips used for mucosal closure was 5.16 � 1.21. Overall,AEs occurred in 2 (7.4%) patients, both of which were rated as moderate. Bothpatients had inadvertent mucosotomies, which were managed endoscopically (Table2). One of those patients subsequently developed a leak which was successfullymanaged endoscopically. There were no other post-procedure AEs, including in-fections, hematoma, or mediastinitis. Post-procedure, the mean length of hospitalstay was 2.63d. Clinical success was achieved in 100% of patients. CP-POEM signifi-cantly reduced the median dysphagia score of patients by 2 (from 3 to 1). During amedian (IQR) duration of follow up of 1269 (439-2083) days, one patient developedrecurrence of regurgitation without dysphagia. Conclusion: CP-POEM is a safe andeffective treatment option for symptomatic CPBs. Although symptom recurrencewas low during 3.5yr follow-up, longer term outcomes should be further evaluated.CP-POEM should be considered as a management option for symptomatic CPBs atcenters with expertise in POEM.

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Baseline Patient Characteristics

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Outcomes of CP-POEM


ID: 3521433COMPARISON OF HYPOPHARYNGEAL AND SEPTALMUCOSOTOMY APPROACHES FOR ZENKER’S PER-ORALENDOSCOPIC MYOTOMY (Z-POEM): ANINTERNATIONAL MULTICENTER STUDYSarah S. Al Ghamdi*, Oscar V. Hernández Mondragón, Alessandro Repici,Marco Spadaccini, Jennifer M. Kolb, Kenneth J. Chang, Monica Saumoy,Gregory G. Ginsberg, Nikhil A. Kumta, Nasim Parsa, Jose Nieto,Alina Tantau, Chonlada Krutsri, Chainarong Phalanusi, Konstantinos Delis,Michael Lajin, Michael Bejjani, Omid Sanaei, Bachir Ghandour,Mohamad Aghaie Meybodi, Mouen A. KhashabBackground: Z-POEM is a a safe and effective technique in the treatment of Zenker’sdiverticulum (ZD). Traditionally, Z-POEM is performed using a hypopharyngealmucosotomy (HM); however, closure is anatomically cumbersome and tunnelingtowards the septum can be challenging. To address this issue, a septal mucosotomy(SM) approach has been successfully utilized. Aims: To compare HM and SM ap-proaches for Z-POEM with regards to technical success, clinical success, adverseevents (AEs), and long-term recurrence. Methods: Consecutive patients who un-derwent Z-POEM for the management of ZD between 10/2018-12/2020 at 11 tertiarycare centers (6 US, 3 Europe, 1 Mexico, 1 Asia) were included. The primary outcome


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was clinical success (improvement of dysphagia score to � 1 or resolution of allsymptoms if dysphagia score was � 1 at baseline). Secondary outcomes weretechnical success (successful completion of all procedural steps), rate/severity of AEs(per ASGE lexicon), total procedure duration and symptom recurrence (dysphagiascore > 1 or recurrence of other symptoms at follow-up). Results: A total of 174patients (mean age 71.37yr, F 77) were included, 53 (30.5%) of whom underwent Z-POEM using the HM technique and 121 (69.5%) using the SM technique. There wereno significant differences in baseline patient characteristics between the two groups.Most common presenting symptoms were dysphagia (nZ170, 97%) and regurgita-tion (nZ120, 68.9%) (Table 1). Technical success was achieved in 48 (90.6%) and115 (95%) patients in the HM and SM groups, respectively (pZ0.26). Technicalfailure was due severe submucosal fibrosis in all patients, occurring in 5 (9.4%) and 6(5%) patients, respectively. The mean procedure time was significantly longer in HMgroup (49.63min vs 41.92min, pZ0.04). Overall, AEs occurred in 7 (13.2%) patientsin the HM arm and 6 patients (5%) in the SM arm (pZ0.02). The most common AEswere inadvertent mucosotomies (4 in the SM group) and esophageal leaks (3 in SMand 1 in HM group). All AEs were rated as mild to moderate and were successfullymanaged conservatively or endoscopically (Table 2). Post-procedure, the meanlength of hospital stay was similar between the two groups (2.02d vs 1.70d, pZ0.28).Clinical success was equivalent in both groups (HM 93.5% vs SM 94.1%, pZ0.88). Z-POEM significantly reduced the mean dysphagia score of patients by 2.14�0.79 and2.21�0.81, respectively (pZ0.67). Among 92 (53%) patients with long-term follow-up, symptom recurrence occurred in 2 patients in the HM group and 1 patient in theSM group (pZ0.07) during a median (IQR) duration of follow-up of 349 and 608days, respectively (pZ0.86). Conclusion: Hypopharyngeal and septal approaches toZ-POEM are equally highly effective in the treatment of ZD. However, the SMapproach is safer and more efficient. We recommend SM as the preferred Z-POEMtechnique.

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