Long-term outcomes of per-oral endoscopic myotomy compared to laparoscopic Heller myotomy for achalasia: a single-center experience

Podboy, Alexander; Hwang, Joo Ha; Rivas, Homero; Azagury, Dan E.; Hawn, Mary T.; Lau, James Y.; Kamal, A. N.; Friedland, Shai; Triadafilopoulos, George; Zikos, Thomas; Clarke, John O.

doi:10.1007/s00464-020-07450-6

Cited by 42 publications

(68 citation statements)

References 62 publications

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“…Of the 43 patients, 25 (58.1%) went on to develop esophagitis as noted on follow-up EGD (Table 2). Median (Q1-Q3) time to EGD was 21 months in patients that did not go on to develop esophagitis compared to 24 (13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31) months in patients that did develope esophagitis (p = 0.951). Four patients (16%) were found to have Grade A esophagitis, five patients (20%) had Grade B esophagitis, 11 patients (44%) had Grade C esophagitis and two patients (8%) had grade D esophagitis.…”

Section: Severity Of Esophagitis On Egdmentioning

confidence: 96%

“…Peroral endoscopic myotomy (POEM) is an endoscopic procedure developed by Inoue and colleagues that has become an attractive option in recent years as a treatment for achalasia due to its minimally invasive approach and similar efficacy and safety when compared to laparoscopic Heller myotomy [13][14][15][16][17][18][19][20][21][22]. However, a primary area of concern has been an increased incidence of gastroesophageal reflux disease (GERD) after POEM due to the inability to perform a concurrent fundoplication [23].…”

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confidence: 99%

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Intraoperative impedance planimetry (EndoFLIP™) results and development of esophagitis in patients undergoing peroral endoscopic myotomy (POEM)

Attaar

Wong

et al. 2020

Surg Endosc

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Introduction Peroral endoscopic myotomy (POEM) is a minimally invasive treatment for achalasia. Considerable evidence demonstrates a high incidence of gastroesophageal reflux disease (GERD) after POEM. The endoluminal functional lumen imaging probe (FLIP) uses impedance planimetry to obtain objective measurements of the gastroesophageal junction. This study aims to determine whether FLIP measurements collected at the time of POEM are associated with the development of reflux esophagitis postoperatively. Methods Patients who underwent POEM between 2012 and 2019 who subsequently had esophagogastroduodenoscopy (EGD) were included. Intraoperative FLIP measurements before and after myotomy, clinical data from EGD, and reflux specific quality of life questionnaires were collected. Comparisons between groups were made using the Wilcoxon rank-sum and Fisher's exact tests. Receiver operating characteristic (ROC) curves were used to determine optimal cutoffs of measurements to classify patients into those with high risk of postoperative esophagitis and those with lower risk. Results A total of 43 patients were included. Of those, 25 (58.1%) were found to have esophagitis on postoperative EGD: four patients (16%) with LA Grade A, five (20%) with LA Grade B, 11 (44%) with LA Grade C and two (8%) with LA grade D esophagitis. Patients with a final distensibility index ≥ 2.7 and a final cross-sectional area ≥ 83 were significantly more likely to develop esophagitis on postoperative EGD (p = 0.016 and p = 0.008, respectively). Gastroesophageal reflux disease health-related quality of life (GERD-HRQL) and reflux symptom index (RSI) scores were not significantly different in patients who developed esophagitis and those who did not. Conclusion Reflux affects some patients after POEM. We show that FLIP measurements collected during POEM may help predict which patients are more likely to develop reflux esophagitis postoperatively. Subjective symptoms on quality of life questionnaires are not reliable in determining which patients are at risk for esophagitis.

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Section: Severity Of Esophagitis On Egdmentioning

confidence: 96%

mentioning

confidence: 99%

Intraoperative impedance planimetry (EndoFLIP™) results and development of esophagitis in patients undergoing peroral endoscopic myotomy (POEM)

Attaar

Wong

et al. 2020

Surg Endosc

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“…Endoscopic and surgical myotomy appear comparable with regard to efficacy at least in short-term follow-up (►Table 2). [80][81][82][83][84][85][86][87][88][89] In the randomized study by Werner and colleagues, POEM was noninferior to laparoscopic Heller's myotomy with Dor's fundoplication at 2 years (83% vs. 81.7%). However, the downside of POEM was a higher incidence of reflux esophagitis (44% vs. 29%).…”

Section: Pneumatic Dilatation Versus Myotomy (Poem and Heller's)mentioning

confidence: 97%

“…80 POEM may be superior to Heller's myotomy in cases with type III achalasia and other nonachalasia spastic esophageal motility disorders like hypercontractile esophagus and distal esophageal spasm. 89,90 In a retrospective cohort study, the clinical success after POEM was significantly better than Heller's myotomy in selected cases with type III achalasia. 90 Subsequent studies have also confirmed excellent outcomes with POEM in spastic motility disorders of esophagus.…”

Section: Pneumatic Dilatation Versus Myotomy (Poem and Heller's)mentioning

confidence: 98%

Optional Management of Achalasia in 2021: Dilatation or Myotomy

Nabi

Ramchandani

Reddy

2021

Journal of Digestive Endoscopy

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Achalasia cardia is a primary motility disorder of the esophagus, defined by lack of normal esophageal peristalsis along with inadequate relaxation of lower esophageal sphincter . The mainstay of management in achalasia includes pneumatic dilatation, Heller’s myotomy and peroral endoscopic myotomy (POEM). Pneumatic dilatation and Heller’s myotomy have gained maturity over several decades. The current best practice with regard to pneumatic dilatation is graded and on-demand dilatation in appropriately selected cases with type I and II achalasia. Laparoscopic Heller’s myotomy plus partial fundoplication is minimally invasive with reduced postoperative reflux and has virtually replaced open Heller’s myotomy with or without fundoplication. The subtyping of achalasia using high-resolution manometry bears prognostic significance and may help in choosing appropriate therapeutic modality in these patients. Since all the three modalities are effective for type I and II achalasia, the choice among these depends on the availability, expertise, and patient’s preferences. On the other hand, POEM is more effective than pneumatic dilatation and Heller’s myotomy and, therefore, preferred in type III achalasia. Although POEM is effective across the spectrum of esophageal motility disorders, the incidence of gastroesophageal reflux is high and needs to be considered while choosing among various options in these patients. In cases with failed POEM, redo POEM appears to be effective in alleviating symptoms.

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“…Podboy et al reported on a large retrospective cohort study comparing long-term outcomes between POEM and LHM for achalasia. 7 A total of 98 patients were included with 55 POEM and 43 LHM. Mean follow-up for the POEM group was 3.94 AE 1.15 years and that for the LHM group was 5.44 AE 1.81 years.…”

Section: Long-term Outcomes Efficacymentioning

confidence: 99%

Long-Term Outcomes of POEM for Primary Esophageal Motility Disorders

Tat

Kroh²

2021

Digestive Disease Interventions

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Since peroral endoscopic myotomy (POEM) emerged in 2010 as a treatment for achalasia, more than 7,000 procedures have been performed in the world. The main indication for POEM continues to be achalasia, which is a rare esophageal motility disorder characterized by impaired lower esophageal sphincter relaxation and aperistalsis. POEM has also been applied in other types of primary esophageal motility disorders. Short-term outcomes indicate that POEM has comparable results to laparoscopic Heller myotomy in terms of efficacy and safety. Studies show decrease in Eckardt scores after POEM as a reflection of symptomatic relief. Now, a decade after its introduction, long-term data have emerged for POEM and demonstrates that POEM remains effective and safe. Both POEM and laparoscopic Heller myotomy are associated with postinterventional gastroesophageal reflux disease (GERD). Antireflux mechanisms are disrupted during the procedures. However, the rate of GERD is higher after POEM than with laparoscopic Heller myotomy. Laparoscopic Heller myotomy is commonly performed with a partial fundoplication to reduce antireflux, but POEM is not typically combined with an antireflux procedure. Further studies should examine the long-term effects of postinterventional GERD.

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Long-term outcomes of per-oral endoscopic myotomy compared to laparoscopic Heller myotomy for achalasia: a single-center experience

Cited by 42 publications

References 62 publications

Intraoperative impedance planimetry (EndoFLIP™) results and development of esophagitis in patients undergoing peroral endoscopic myotomy (POEM)

Intraoperative impedance planimetry (EndoFLIP™) results and development of esophagitis in patients undergoing peroral endoscopic myotomy (POEM)

Optional Management of Achalasia in 2021: Dilatation or Myotomy

Long-Term Outcomes of POEM for Primary Esophageal Motility Disorders

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