S602 Per-Oral Endoscopic Myotomy (POEM) Results in Improvement in an Endoscopic Score for Achalasia (the CARS Score)

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Introduction: We recently reported development of the CARS score, an endoscopic scoring system for achalasia that is based on abnormalities in 4 esophageal features of the disease (i.e., esophageal Contents, Anatomy, Resistance at the lower esophageal sphincter (LES), and Stasis) (Figure 1). We have shown that the CARS score performs well in predicting the presence of achalasia. Now, we aimed to find whether the CARS score improves after treatment with peroral endoscopic myotomy (POEM). Methods: We reviewed our Center for Esophageal Diseases patient database for patients who had POEM for a disorder of outflow obstruction performed between January 2020 and December 2022 and continued care in our esophageal medical-surgical clinic. Such patients typically underwent a comprehensive work up including endoscopy with calculation of CARS score before POEM and a surveillance protocol including an endoscopy 3 months after POEM. Patients with suspected or known achalasia were prescribed a 1-5 day liquid diet prior to their endoscopic procedures. Results: Among 96 patients treated with POEM during this time period, 66 (mean age 56.2, 55% female) had both pre- and post-POEM endoscopies; 56 patients had achalasia (8 type 1, 32 type 2, 16 type 3), and 10 had EGJOO. Median time to the first endoscopy after POEM was 3 months (IQR: 3-4). Compared to the mean pre-POEM CARS score (3.5, SD 1.8), the mean post-POEM CARS score was significantly lower (1.9, SD 1.4) (P < 0.01). Subset analyses of the 4 individual components of the CARS score revealed significant reductions in the Resistance-LES score (mean reduction 1.3, P < 0.01) and Stasis score (mean reduction 0.2, P = 0.01); see Table 1. Among the subset of patients with symptom scores post-POEM, a CARS score ≥4 during the short-term period had higher symptom scores in follow up, but this did not reach statistical significance (BEDQ 10 vs 3.6, NS; Eckhardt 4.1 vs 3.4, NS). Ongoing studies are examining CARS during a longer surveillance period. Conclusion: We found significant reductions in the endoscopic CARS score in patients treated with POEM. These reductions were driven primarily by improvements in the endoscopic assessment of Resistance-LES and Stasis changes. Further studies are needed to determine whether improvement in the CARS score can predict symptomatic improvement after POEM.Figure 1.: CARS endoscopic scoring system. The CARS score for the prediction of achalasia includes 4 components. Each component is scored 0 – 2 with the exception of stasis of the esophageal lining, which is given 1 point each for chronic stasis changes or candida esophagitis. Table 1. - CARS score and subscore comparing pre– and post– POEM Contents Anatomy Resistance Stasis Total Score Pre-POEM 1.0 0.8 1.3 0.4 3.5 Post-POEM 0.8 0.8 0.1 0.2 1.9 P value 0.07 0.68 < 0.01 0.01 P< 0.01

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