Tu1513 PerOral Endoscopic Myotomy (POEM) Achieves Similar Clinical Response but Incurs Lesser Charges Compared to Heller Myotomy (HM) for the Treatment of Achalasia Vivek Kumbhari*, Alan H. Tieu, Mohamad H. El Zein, Saowanee Ngamruengphong, Ahmed Abdelgelil, Sepideh Besharati, Ellen M. Stein, Sameer Dhalla, Monica Nandwani, Anthony N. Kalloo, John O. Clarke, Mouen Khashab Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD Background: None of the gastrointestinal or surgical societies have incorporated peroral endoscopic myotomy (POEM) into their treatment algorithm for achalasia. Laparoscopic Heller myotomy (HM) remains the current gold standard therapy. Several uncontrolled studies comparing POEM and HM revealed equivalent short- term efficacy and safety. However, no data exists on the cost of POEM and how it compares to that of HM. Aims: To compare 1) the efficacy and safety and 2) the inpatient charges incurred in patients who underwent POEM or HM for the treat- ment of achalasia. Methods: A retrospective single center review was conducted of 52 consecutive POEM patients (2012-2014) and 52 consecutive HM patients (2009- 2014). All HM included a Toupet fundoplication and were performed robotically via a transabdominal approach. All POEM were performed by a gastroenterologist in the endoscopy unit. Endoscopic and surgical procedural data were abstracted and pre- and post-procedural symptoms (e.g. Eckardt stage) were recorded. Clinical response was defined by improvement of symptoms and decrease in Eckardt stage to % I. Adverse events were graded according to the ASGE lexicon’s severity grading sys- tem. All procedural and facility charges were obtained from review of the hospital finance records. Results: There was no difference between POEM and HM with re- gards to age, gender, symptom duration, achalasia subtype, HREM findings or Eck- ardt symptom stage (stage III: 82% vs. 84%, pZ1) at baseline. Patients in the POEM cohort were less likely to have a sigmoid esophagus (2.8% vs. 20%, pZ0.02). With regards to intraprocedural characteristics, patients in the POEM cohort had a significantly longer length of myotomy (11.6cm vs. 8.6cm, p !0.0001) despite a significantly shorter procedure time (106mins vs. 263 mins, p !0.0001). There was no significant difference in the rate of adverse events (9.6% vs 9.6%, pZ1) or the length of stay (1.9 vs. 2.3, pZ0.18) between both groups. Clinical response rate of patients in the POEM groups was similar to that in the HM group (94.3% vs. 88.5%, pZ0.48), though the duration of follow up (months) was significantly shorter (4.3 vs. 8.9, pZ0.01). POEM incurred significantly less total charges compared to HM ($14,481 vs. $17,782, pZ0.02). In detail, POEM in-room charges were significantly less ($5,070 vs. $7,616, p !0.001) though that of supplies were more ($4,394 vs $3,240, p !0.001). When the charges incurred due to the procedure itself (in-room, supplies, drugs) were compared, POEM was associated with cost savings ($9,756 vs. $11,136, pZ0.015). In addition, the charges incurred due to the inpatient hospital stay was significantly less with POEM ($2,771 vs. $5,206, pZ0.006). Conclusions: POEM when performed in an endoscopy unit was similar in efficacy and safety to HM. However, POEM was associated with significant cost savings ($3301/proce- dure). Tu1514 The Nuts and Bolts of Starting a Successful Per-Oral Endoscopic Myotomy (POEM) Program: a Practical Approach Madhusudhan R. Sanaka* 1 , Prashanthi N. Thota 1 , Murthy C. Sudish 2 , Siva Raja 2 1 Gastroenterology, Cleveland Clinic, Cleveland, OH; 2 Thoracic surgery, Cleveland Clinic, Cleveland, OH Introduction: Per-oral endoscopic myotomy (POEM) is an incisionless treatment mo- dality for Achalasia with efficacy comparable to Heller’s myotomy. We describe the essential steps involved in starting a POEM program. Endoscopic Training: Obser- vation of several live human cases and adequate training in animal models before performing POEM is a must. Training and experience in endoscopic submucosal dissection (ESD) is helpful. Porcine esophagus has similar anatomy to humans and is a good model to practice. We suggest practicing at least 15 POEMs in porcine esophagus before performing an actual case. Proctoring of initial couple of human cases by an experienced operator is recommended. Patient Selection and Preparation: Pre-operative workup should include a detailed clinical evaluation, high resolution esophageal manometry (HREM), timed barium swallow study (TBS) and an upper endoscopy (EGD) to confirm the diagnosis of Achalasia. Patient should be on clear liquid diet for a couple of days before POEM. We administer a broad spectrum antibiotic and Fluconazole just before POEM. Multidisciplinary Collaboration: Performing POEM requires superior endoscopic skills and thorough knowledge of surgical anatomy. Hence we suggest a two person technique- advanced endoscopist and thoracic surgeon with complementary skills to perform the procedure together. POEM should be performed in an operating room (at least initially) under general anesthesia and CO2 insufflation is mandatory. Anesthesiol- ogists should be adept in dealing with potential complications. Standardization of Procedure: The standard steps involved are mucosotomy in mid esophagus, creation of submucosal tunnel, division of inner circular muscle for 4-6cm in lower esophagus and for 2-4cm on the gastric side and closure of mucosotomy with endoscopic clips. Post-procedure care: Patients should be kept NPO and observed overnight on IV fluids and antibiotics. Water soluble contrast swallow study should be done next day and if there is no leak, patient can be started on a clear liquid diet and dis- charged home with gradual advancement of diet. Broad spectrum oral antibiotic should be given for 3-5 days and proton pump inhibitor for 2 months. Follow-up care: Patients should be followed up and evaluated at 2-3 months after POEM with TBS, pH study and HREM. EGD for surveillance of esophageal cancer is suggested every 1-2 years. Institutional support: It is ideal to perform POEM under the approval of Institutional Review Board. Limited number of operators should perform POEM to gain expertise and for better patient outcomes. Due to lack of a billing code in the US, it is billed as unlisted esophageal procedure and coordination between billing departments and insurance carriers is required. Tu1515 Predictors of Outcomes and Learning Curve Following Per Oral Endoscopic Myotomy for Achalasia Cardia Amit P. Maydeo, Nitin Joshi, Suryaprakash Bhandari, Mukta Bapat, Vinay K. Dhir* Endoscpy, Baldota Institute of digestive sciences, Mumbai, India Background: Per Oral Endoscopic Myotomy (POEM) is an effective treatment for achalasia cardia. There are no studies evaluating predictors of POEM outcome and the impact of learning curve. Objective: To evaluate predictors of POEM outcomes and assess the impact of learning curve on POEM. Design: Retrospective single centre study. Setting: Tertiary referral centrePatients: 268 patients with achalasia cardiaIntervention: POEM was done by posterior approach in first 208 patients, and anterior approachin the next 60 patients. Hybrid knife was used in 200 and triangular tip knife in 68 patients. Main Outcome measures: Primary outcome measure was treatment success defined by Eckardt’s score. Secondary measures were adverse events. Multivariate analysis was done for factors affecting outcome and learning curve determination was done. Results: Technical success was achieved in all pa- tients. There were 9(3.35%) treatment failures. Six failures occurred in the first 40 patients, while 3 occurred in the next 228 patients (15% vs. 1.3%, pZ0.0005). There were 12 adverse events (AE) in the first 40 patients (30%), and 26 (11.4%) in the next 228 patients (pZ0.005). On multivariate analysis, the factors adversely affecting treatment success were male gender (p Z 0.017) and prolonged operative time (pZ 0.030). Prolonged operative time (p Z 0.006) and type of achalasia (pZ0.034) were found to be independent predictors of AE. Limitations: Single center study. Conclusions: Male gender, type of achalasia and prolonged operative time are important predictors of adverse POEM outcome. The treatment success improves, and the rate of adverse events declines significantly after first 40 procedures. Tu1516 Meticulous Technique of Per-Oral Endoscopic Myotomy (POEM) for Achalasia Is Associated With Low Risk of Complications Siva Raja 2 , Ramprasad Jegadeesan 1 , Prashanthi N. Thota 1 , Scott L. Gabbard 1 , Monica Ray 1 , Neha Wadhwa 1 , Murthy C. Sudish 2 , Madhusudhan R. Sanaka* 1 1 Gastroenterology, Cleveland Clinic, Cleveland, OH; 2 Thoracic surgery, Cleveland Clinic, Cleveland, OH Background/Aims: Per-Oral Endoscopic Myotomy (POEM) is a novel treatment mo- dality for Achalasia derived from Natural Orifice Transluminal Endoscopic Surgery (NOTES). POEM is a technically demanding procedure with potential for rare but serious complications. Our POEMs are performed by a two member team comprising an experienced advanced endoscopist and a thoracic surgeon with meticulous technique and cross verification of crucial steps by both. The aim of this study was to evaluate the complications of POEM by this approach. Methods: Chart review of patients who underwent POEM during April - October 2014 from our Institutional Review Board approved prospective registry. Demographics, indica- tions, immediate and within 30 day complications reviewed. POEMs are performed in an operative room under general anesthesia with CO2 insufflation through endoscope. POEM is performed in standard steps including mucosotomy in mid esophagus, creation of submucosal tunnel extending 3-4 cm onto the gastric side, dividing the inner circular muscle, and closure of mucosotomy with endoscopic clips. During POEM, thorough hemostasis with coagulation of all vessels is achieved and extreme care is taken to avoid mucosal flap injury and repaired if any. Adequacy of myotomy is confirmed by patency of gastroesophageal junction (GEJ) and mu- cosotomy is closed water tight with clips. All the crucial steps are verified for ade- quacy and agreed upon by both operators. All patients were prescribed a proton pump inhibitor (PPI) for 2 months post-POEM. Data are presented as Mean Æ SD, Median (P25, P75) or N (%). Results: POEM was successfully performed in all 20 patients(100%) with a mean procedure time of 140.1Æ32.9 min. Median duration of hospital stay was 1.0 day (1.0, 2.5). Patient details are shown in Table. Five patients (20%) required venting needle placement for capnoperitoneum with resolution during the procedure. Two patients (10%) had mucosal perforation each near GEJ, one was closed with an endoscopic clip. Mucosal perforation in second patient was not amenable to clipping due to large size, but it was contained without a leak and discharged within 3 days. This patient was non-compliant with PPI and presented on AB492 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015 www.giejournal.org Abstracts