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www.worldwidejournals.com 47 Dr. Kalpesh Patil Assistant Professor Department of Surgery MIMER Medical College Talegaon Dabhade Pune. Score Dysphagia Regurgita tion Retro-sternal pain Weight loss in kg 0 None None None None 1 Occasional Occasional Occasional < 5 2 Daily Daily Daily 5-10 3 Each meal Each meal Each meal > 10 PARIPEX INDIAN JOURNAL F RESEARCH | O November 2020 Volume 9 | Issue 11 | | PRINT ISSN No. 2250 1991 | DOI : 10.36106/paripex Pre procedure gastroscopy showing cardio spasm with fluid residue in esophagus aSubmucous bleb b-Mucosal incision a-Submucous tunneling bcoagulation of large vs a-Gastric extension bComplete Myotomy aloss of spasm, bClosure of mucosal incision about 3cm above the gastro-esophageal (GE) junction and was extended till gastric end of tunnel. Step5: Closure of mucosal incision Haemostatis achieved metaculisaly inspecting the tunnel and edges of myotomy. Inadverant mucosal injuries to esophagus and stomach where also looked for. After confirmation these two, mucosal incision was closed by using endoclip (Ez Olympus). Post-operative management -Patient was kept nil by mouth for 24 hours post procedure. After 24 hours water soluble radio-opaque dye study was done to rule out any leakage at the mucosal incision. Oral liquids started on 2nd postoperative day and the patient was discharged on same day. All intraoperative results including operative time and complications were recorded. Follow up:Patient called for follow up visits on 7th day, 1 month, 3 months and yearly up to 3 years. During follow up visits all patients evaluated. th 7 day :Only clinical assessment was done 1 month:Clinical assessment and follow up gastroscopy was done 6 month:Clinical assessment by Eckardt score and gastroscopy and High resolution myotomy (HRM) were done. For symptomatic patients 24 hours PH impedence was done at 6 months interval. DeMeester's score above 14.7 was considered as indicator of GERD. Adverse events (AE) – AE were defined as those events that required specific intervention or modification of the procedural technique. Both early and late AEs were recorded. RESULTS Total 50 patients underwent POEM in our center. M: F 28 : 22, mean age 43.04 years, (range 22-65 years) Type of AC according to Chicago classification-Type II-47, Type III-3. Prior treatment history was noted in 6 patients PBD-3, LHM2, POEM-1. Anterior approach was used in majority of patients 47 (94%) whereas 3(6%) patients underwent posterior approach. The median operative time of POEM procedure was 83.4 min (range70mins to 160mins) median length of myotomy was 13cm (range 6-21cm) Table 1: Demographics of study patients Technical success rate was 98% as in one patient procedure could not be completed due to dense submucous fibrosis. There was no significant difference in clinical success rate among subtype II and III upto follow up for 3 years. One patient having failure at one year underwent Re-POEM. Adverse effects-esophageal mucosal perforation was seen in 2 patients and gastric mucosal perforation in 1 patient which was identified on operation table and closed with endoclips. Insufflation related complication-surgical emphysema was seen in 4 patients which was managed by temporarily stopping procedure for some time. In 1 patient pneumothorax was developed and managed by inserting ICD tube. Capnoperitonium was seen in 6 patients which was drained using standard Verres needle. One patient developed chest pain after 5 days for which patient was readmitted and medical management was done. There were no major bleeding episodes during or after the procedure. Symptomatic GERD was seen in 10 (20%) patients and erosive esophagitis was seen in 14 (28%) patients. They needed medicines for a short period only. None of these patients needed a long-term medical management and no patient developed any reflux related complications. DISCUSSION Achalasia cardia is progressive irreversible disease of esophageal musculature. It is idiopathic in most cases but can be secondary as seen in after Chagas disease and herpes virus (4,5) . AC has been treated with pharmacological agents like calcium channel blockers and with botulinum toxin but long term success rate has been low with them and there have been few poorly tolerated side effects (5,6) Surgical 48 www.worldwidejournals.com No. of Patients 50 Mean age, years(range) 43.04 (22 -65 yrs)

PERORAL ENDOSCOPIC MYOTOMY (POEM) FOR ACHALASIA CARDIA: PROSPECTIVE CASE SERIES OF 50 PATIENTS.