Population trends in achalasia diagnosis and management: a changing paradigm

Abstract

Summary The Chicago Classification of esophageal motility disorders improved the differentiation of achalasia subtypes and tailored treatment. Heller myotomy (HM) and pneumatic dilation are two established treatments for achalasia. Peroral endoscopic myotomy (POEM) has become a third definitive option and is on the rise. Using the National Inpatient Sample (NIS) database, we evaluated patients hospitalized with achalasia and associated surgical and endoscopic interventions from 2013 to 2017 and compared patients undergoing HM versus POEM. The NIS database was queried to include patients with achalasia. Patients who underwent HM, POEM (only 2017 due to lack of distinct procedure code in 2013), pneumatic dilation, or esophagectomy were identified. Adverse events during the hospitalization were also queried using diagnosis codes. From 2013 to 2017, patients hospitalized with achalasia increased from 16 850 to 19 485. There were reductions in the number of esophageal dilations (10.6–5.4%, P < 0.001) and HM (18.7–13.1%, P < 0.001). In 2017, 580 POEMs were performed. Compared with patients undergoing HM in 2017, patients who had POEM had higher mean age > 64 (P = 0.004), Charlson comorbidity index (P < 0.001), disease severity (P < 0.001), and likelihood of mortality (P < 0.001). There were no differences in length of stay, mortality, or total costs between the HM and POEM groups. Patients hospitalized with achlasia increased from 2013 to 2017, possibly due to the growth and accessibility of high-resolution esophageal manometry. As expertise in POEM increases, the number of POEM performed is anticipated to rise with possible further reductions in other treatment modalities for achalasia.

Healthcare Utilization, Costs and Other Outcomes of Peroral Endoscopic Myotomy (POEM) Versus Heller Myotomy in the Inpatient Management of Achalasia in The United States: A 2016 to 2020 Nationwide Study

“…A prior nationwide retrospective study from 2013 to 2017 showed that the prevalence of high-resolution esophageal manometry laboratories is the highest in the Northeast, thus explaining the highest percentage of POEMs performed was in the Northeast. 24 However, this study showed that the Southern U.S. region had the fewest centers, which might indicate a recent change in the number of POEM centers in the U.S.…”

“…In contrast, a downward trend was observed in discharges following HM from 2016 (49%) to 2020 (41%). Trieu et al described similar results in a previous nationwide retrospective analysis of achalasia hospitalizations in the U.S. 24 POEM is still considered a new procedure and requires high endoscopic skills and an in-depth understanding and knowledge of the complexity of performing such a procedure including any complication that may arise either during the procedure or postoperatively. This trend is expected to continue as more providers, whether gastroenterologists or surgeons are trained to perform POEM and patients seem to prefer POEM as a non-surgical intervention.…”

“…The ICD-10 codes used for this study are provided in the Supplemental Materials and were extracted from a previous study using the NIS. 24…”

Gastroesophageal Reflux Waning Over Time in Endoscopic Versus Surgical Myotomy for the Treatment of Achalasia: A Systematic Review and Meta-Analysis

“…The initial search identified 14,540 articles, resulting in 33 systematic reviews, composed of 30 observational studies (Table 1) and three RCTs [6,46,47] (Table 2). The study by Trieu et al [41] was excluded from the meta-analysis by evaluating the same database already included in Khoraki et al [29]. The same occurred for the study by Conte et al [46], which was replaced by de Moura et al [47], who published updated data from the same sample.…”

“…The study by Trieu et al [ 41 ] was excluded from the meta-analysis by evaluating the same database already included in Khoraki et al [ 29 ]. The same occurred for the study by Conte et al [ 46 ], which was replaced by de Moura et al [ 47 ], who published updated data from the same sample.…”