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Background and Aims The safety and efficacy of peroral endoscopic myotomy (POEM) when performed by gastroenterologists in the endoscopy unit are currently unknown. The aims of this study were to assess (1) the safety and efficacy of POEM in which all procedures were performed by 1 gastroenterologist in the endoscopy unit, and (2) the predictors of adverse events and nonresponse. Methods All consecutive patients who underwent POEM at 1 tertiary center were included. Clinical response was defined by a decrease in the Eckardt score to 3 or lower. Adverse events were graded according to the American Society for Gastrointestinal Endoscopy lexicon's severity grading system. Results A total of 60 consecutive patients underwent POEM in the endoscopy suite with a mean procedure length of 99 minutes. The mean length of submucosal tunnel was 14 cm and the mean myotomy length was 11 cm. The median length of hospital stay was 1 day. Among 52 patients with a mean follow-up period of 118 days (range 30-750), clinical response was observed in 48 patients (92.3%). There was a significant decrease in Eckardt score after POEM (8 vs 1.19, P P P = .01). pH impedance testing was completed in 25 patients, and 22 (88%) had abnormal acid exposure, but positive symptom correlation was present in only 6 patients. All patients with symptomatic reflux were successfully treated with proton pump inhibitors. Conclusions POEM can be effectively and safely performed by experienced gastroenterologists at a tertiary care endoscopy unit. Adverse events are infrequent, and most can be managed intraprocedurally. Post-POEM reflux is frequent but can be successfully managed medically.

Background and Aims Medical treatment options for gastroparesis are limited. Data from studies of botulinum toxin and surgical pyloroplasty suggest that disruption of the pylorus can result in symptomatic improvement in some patients with refractory gastroparetic symptoms. The aim of this study was to determine the clinical response to transpyloric stent (TPS) placement in patients with gastroparetic symptoms refractory to standard therapy. Methods Patients with gastroparesis refractory to medical treatment were referred for TPS placement for salvage therapy. Self-reported symptom improvement, stent migration rate, and pre– and post–stent gastric-emptying study results were collected. Results A total of 30 patients with refractory gastroparesis underwent 48 TPS procedures. Of these, 25 of 48 (52.1%) were performed in patients admitted to the hospital with intractable gastroparetic symptoms. Successful stent placement in the desired location across the pylorus (technical success) was achieved during 47 procedures (98%). Most (n = 24) stents were anchored to the gastric wall by using endoscopic suturing with a mean number of sutures of 2 (range 1-3) per procedure. Clinical response was observed in 75% of patients, and all inpatients were successfully discharged. Clinical success in patients with the predominant symptoms of nausea and vomiting was higher than in those patients with a predominant symptom of pain (79% vs 21%, P = .12). A repeat gastric-emptying study was performed in 16 patients, and the mean 4-hour gastric emptying normalized in 6 patients and significantly improved in 5 patients. Stent migration was least common (48%) when stents were sutured. Conclusion TPS placement is a feasible novel endoscopic treatment modality for gastroparesis and improves both symptoms and gastric emptying in patients who are refractory to medical treatment, especially those with nausea and vomiting. TPS placement may be considered as salvage therapy for inpatients with intractable symptoms or potentially as a method to select patients who may respond to more permanent therapies directed at the pylorus.

The tip of currently available percutaneous endoscopic gastrojejunostomy (PEGJ) tubes frequently migrates back into the stomach.To study the safety of a novel, ballooned-tip, PEGJ tube and assess the risk of retrograde migration into the stomach within 3 weeks of placement.Prospective clinical study (NCT01551095).Tertiary-care center.Seven patients who required post-pyloric feeding were included.Placement of PEGJ feeding tubes.Position of the PEGJ, abdominal radiograph findings, adverse events.Seven patients underwent placement of self-propelled PEGJ tubes during the study period. Technical success was achieved in all patients (100%). All procedures were rated as technically simple, and jejunostomy tubes were placed in 5 minutes during all procedures. Abdominal radiographs showed that the jejunostomy tubes were in the jejunum in all 7 patients at both 1 and 3 weeks after tube placement.Small number of patients and short follow-up.Ballooned-tip PEGJ feeding tubes were safe and easy to place. The presence of the balloon prevented migration into the stomach. Ballooned-tip PEGJ tubes have the potential to eliminate the need for hospital readmission and repeat endoscopies for retrograde tube migration, and this may result in large systemic cost savings.

Sa1456 Per-Oral Endoscopic Myotomy (POEM) for Non-Achlasia Neuromuscular Disorders of the Esophagus Ahmed M. Sharata*, Christy M. Dunst, Radu Pescarus, Eran Shlomovitz, Kevin M. Reavis, Lee L. Swanstrom GMIS, Oregon Clinic, Portland, OR; GMIS, Providence Portland Medical Center, Portland, OR Background: Per-Oral Endoscopic Myotomy (POEM) has recently been described as an alternative to conventional myotomy for neuromuscular disorders of the esophagus. While efficacy and outcomes in achalasia are good, there is a paucity of literature in Non-Achalasia Neuromuscular Disorders (NAND). Historically, laparoscopic myotomies are followed by unpredictable and generally poor outcomes for NAND. The aim of this study is to review our experience with POEM in NAND patients. Methods: Comprehensive data was collected prospectively on all patients undergoing POEM for NAND between 11/2010 and 11/2013. Patients were classified as having diffuse esophageal spasm (DES), hypertensive nonrelaxing lower esophageal sphincter (LES), nutcracker esophagus with/without-relaxing LES based on manometry. Pre/postoperative symptom scores and high resolution manometry data were collected. Operative data was compared to a separate cohort of achalasia POEM patients. Results: Twenty-five patients underwent POEM for NAND with a median age was 64 years (range, 36-83 years). Twelve had nutcracker esophagus with/without nonrelaxing LES, eight had hypertensive nonrelaxing LES and five patients had DES. There was no mortality. There were no conversions to laparoscopy or thoracoscopy, no mediastinitis. Mean operative time was 128 mins. The incidence of inadvertent mucosotomy was 8% (2/25 patients) and capnoperitoneum requiring Veress decompression was 12% (3/25 patients). These were not different from POEM for achalasia despite the increased length of myotomy ( 11 cm NAND, 8 cm achalasia). Patients with DES had longer myotomies (12-23). Median follow up was 20 months (range, 7-36months). Complete resolution of dysphagia was obtained in 70% (pre/post median score 3/0) and chest pain in 71.5% (pre/post median score 1/ 0). Two patients (one nutcracker esophagus and one DES) underwent unremarkable laparoscopic Heller myotomy for refractory symptoms. Five patients underwent endoscopic dilations (1-2 episodes) for occasional dysphagia or chest pain and two other patients underwent multiple dilatations. Average LES resting pressure decreased from 44.2 to 26.6mmHg (pZ0.01). Average DECA decreased from 126.7mmHg to 53.7mmHg (pZ0.0009). Heartburn and regurgitation scores were unchanged by POEM (pZ0.94; pZ0.12). Conclusion: The POEM approach provides an avenue for long esophageal myotomies which avoids the traditional mediastinal exposure required for the treatment of patients with Non-Achalasia Neuromuscular Disorders (NAND) such as diffuse esophageal spasm and nutcracker esophagus. This early experience suggests POEM is a safe and effective treatment option for a majority of NAND patients. Sa1457 Pneumatic Dilatation (PD) Versus Laparoscopic Heller Myotomy (Lhm) Versus PerOral Endoscopic Myotomy (POEM) for the Treatment of Achalasia: a Single Center Experience Vivek Kumbhari*, Alan Tieu, Alba Azola, Mohamad H. El Zein, Eun Ji Shin, Ellen M. Stein, Bani Chander Roland, Monica Nandwani, Sameer Dhalla, Anne Marie Lennon, Vikesh K. Singh, Marcia I. Canto, Ahmed A. Messallam, Payal Saxena, Colin M. Gilmore, William J. Ravich, Anthony N. Kalloo, Pankaj J. Pasricha, John O. Clarke, Mouen Khashab AB220 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014 Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, MD Background: Patients who suffer from symptomatic idiopathic achalasia have a variety of therapeutic options. Pneumatic dilatation (PD), laparoscopic Heller myotomy (LHM) and Peroral Endoscopic Myotomy (POEM) are currently the three most attractive. PD is the least invasive but symptom recurrence appears common, often necessitating repeated dilatation or an alternative therapy such as LHM. POEM may be a potential alternative to LHM in those who have relapsed after PD or in those who have not undergone prior therapy. There is no available evidence comparing outcomes of these three procedures to help guide the clinician as to which of these therapies has the highest efficacy and safety. Aims: To review the efficacy and safety of PD, LHM and POEM in patients presenting to a single tertiary-care center. Methods: A retrospective single center review was performed of consecutive patients who underwent POEM, LHM or PD between 2008 to 2013. Sequential, graded PD (30-35-40mm) and LHM have been offered to patients throughout the duration of the study. POEM has been offered at our institution since 2012. Patients that underwent PD and then subsequently either POEM or LHM were included in the PD cohort as well as their respective POEM or LHM cohort. Endoscopic and surgical procedural data were abstracted and preand post-procedural symptoms (e.g. Eckardt stage) were recorded. Clinical remission was defined by improvement of symptoms and decrease in Eckardt stage to %I and the absence of subsequent therapy at any point in time for LHM and POEM and within 1 year for the PD cohort. Adverse events were graded according to the ASGE lexicon’s severity grading system. Results: In total, there were 118 patients that had undergone PD (nZ73), LHM (nZ66) or POEM (nZ21) for their management of achalasia. There were 42 patients in the PD group that had subsequently undergone LHM (nZ33) or POEM (nZ9). The pre-procedure characteristics were similar amongst all three groups (table 1). A total of 34 patients in the PD group required LHM or POEM within 12 months of dilation. Clinical remission for PD vs. LHM vs. POEM was 45% vs. 74% vs. 95% respectively, p!0.001. The mean duration of follow up was 10 and 3 months for LHM and POEM, respectively. There was no statistically significant difference in the rate and severity of complications amongst the three groups (table 2). In particular, there was only one severe complication (perforation) which occurred in the PD group. Conclusions: This is the first study to compare the main three currently available therapies for achalasia. Our data confirms frequent early symptom recurrence in patients undergoing PD. As achalasia is a chronic relapsing condition, suitable patients should consider LHM or POEM early in their management. Table 1. Pre procedural Characteristics PD (n[73) LHM (n[66)