Per-oral endoscopic myotomy for achalasia cardia: outcomes in over 400 consecutive patients

Abstract

Background and study aims Per-oral endoscopic myotomy (POEM) has emerged as an efficacious treatment modality for the management of achalasia cardia (AC) and non-achalasia spastic esophageal motility disorders. Initial results are encouraging. We analyzed the safety and efficacy of POEM in a large cohort of patients with AC. Patients and methods The data from patients who underwent POEM (from January 2013 to June 2016) was prospectively collected and analyzed. Clinical success was defined as Eckardt score ≤ 3 after POEM procedure. Objective parameters including high-resolution manometry (HRM) and timed barium swallow (TBS) were analyzed and compared before and after the procedure. Gastroesophageal reflux was analyzed using 24-hour pH impedance study and esophagogastro-duodenoscopy. Results A total of 408 patients (mean age 40 years, range 4 – 77 years) underwent POEM during the specified period. POEM could be successfully completed in 396 (97 %) patients. Clinical success rates at 1, 2 and 3 years were 94 %, 91 % and 90 %, respectively. Mean Eckardt score was 7.07 ± 1.6 prior to POEM and 1.27 ± 1.06 after POEM (P = 0.001) at 1 year. Significant improvement in esophageal emptying on TBE (> 50 %) was documented in 93.8 % patients who completed 1-year follow up. Pre-procedure and post-procedure mean lower esophageal sphincter pressure was 45 ± 16.5 mmHg and 15.6 ± 6.1 mmHg, respectively (P = 0.001). Technical and clinical success were comparable in naïve vs prior treated cases (97.3 % vs 96.8 %, P = 0.795) (95.7 % vs 92.6 %, P = 0.275). GERD was documented in 28.3 % patients with 24-hour pH-impedance study and erosive esophagitis was seen in 18.5 % of patients who underwent POEM. Conclusions POEM is safe, effective and has a durable response in patients with achalasia cardia. Prior treatment does not influence the outcomes of POEM.

Management of achalasia cardia: Expert consensus statements

“…The mean length of myotomy in this study was 16.4 cm (range 7–26 cm) . Similar conclusion was drawn in a study where the response of type III AC to POEM was 87.5% at 1 year and was not significantly different from that of types I (91.3%) and II AC (96.3%) …”

“…as an endoscopic alternative to Heller's myotomy . Since then, numerous studies have been published demonstrating the safety and efficacy of POEM for AC in short‐term . The literature regarding long‐term efficacy of POEM is limited.…”

“…Endoscopic myotomy may be especially useful in patients with spastic achalasia, where a long myotomy is often required, which may not possible via a laparoscopic transhiatal approach. Limited data suggest that POEM may be effective across the spectrum of AC . There is only one study comparing the outcomes of LHM and POEM for type III AC.…”

“…Per‐oral endoscopic myotomy has emerged as a less invasive treatment options for naïve as well as for prior treatment failure patients. The published literature suggests that POEM is a safe and efficacious alternative to LHM or PD for treatment of failed cases of AC . Vigneswarwan et al .…”

Results of pneumatic dilation in treating achalasia: predictive factors

“…Good results have been obtained in the control of dysphagia, but pathological reflux rate reaches 46% of the cases in a 6‐month pH study . In a series of 396 patients submitted successfully to POEM, erosive esophagitis emerged in 18.5% of them 1 year after the procedure . No direct comparison of dilation and POEM has been published so far.…”