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

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Abstract

Introduction

Many centers have reported excellent short-term efficacy of per-oral endoscopic myotomy (POEM) for the treatment of achalasia. However, long-term data are limited and there are few studies comparing the efficacy of POEM versus Heller Myotomy (HM).

Aims

To compare the long-term clinical efficacy of POEM versus HM.

Methods

Using a retrospective, parallel cohort design, all cases of POEM or HM for achalasia between 2010 and 2015 were assessed. Clinical failure was defined as (a) Eckardt Score > 3 for at least 4 weeks, (b) achalasia-related hospitalization, or (c) repeat intervention. All index manometries were classified via Chicago Classification v3. Pre-procedural clinical, manometric, radiographic data, and procedural data were reviewed.

Results

98 patients were identified (55 POEM, 43 Heller) with mean follow-up of 3.94 years, and 5.44 years, respectively. 83.7% of HM patients underwent associated anti-reflux wrap (Toupet or Dor). Baseline clinical, demographic, radiographic, and manometric data were similar between the groups. There was no statistical difference in overall long-term success (POEM 72.7%, HM 65.1% p = 0.417, although higher rates of success were seen in Type III Achalasia in POEM vs Heller (53.3% vs 44.4%, p < 0.05). Type III Achalasia was the only variable associated with failure on a univariate COX analysis and no covariants were identified on a multivariate Cox regression. There was no statistical difference in GERD symptoms, esophagitis, or major procedural complications.

Conclusion

POEM and HM have similar long-term (4-year) efficacy with similar adverse event and reflux rates. POEM was associated with greater efficacy in Type III Achalasia.

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Authors and Affiliations

  1. Division of Gastroenterology & Hepatology, Stanford University Hospital, GI Suite, 430 Broadway, Pavilion C-3rd Floor, Redwood City, CA, 94063, USA

    Alexander J. Podboy, Joo Ha Hwang, Afrin Kamal, Shai Friedland, George Triadafilopoulos, Thomas Zikos & John O. Clarke

  2. Division of General Surgery, Stanford University Hospital, Stanford, CA, USA

    Homero Rivas, Dan Azagury, Mary Hawn & James Lau

  3. Veterans Affairs Palo Alto Health Care System, Palo Alto, USA

    Shai Friedland

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  1. Alexander J. Podboy
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Contributions

Dr. Podboy is a gastroenterology and hepatology fellow at Stanford University Hospital in Stanford, California. He was instrumental in the design and conduct of the study, data collection, analysis and writing of the manuscript. Drs. Hwang and Triadafilopoulos are gastroenterologists in the department of Gastroenterology and Hepatology at Stanford University Hospital in Stanford, California. They were instrumental in the design and conduct of the study, analysis and writing of the manuscript. Drs. Rivas, Azagury, Hawn and Lau are surgeons in the department of surgery at Stanford University Hospital in Stanford, California. They contributed to the analysis and critical appraisal of the manuscript. Dr. Friedland is a gastroenterologist in the department of Gastroenterology and Hepatology at the Stanford University Hospital and at the Veterans Affairs Palo Alto Health Care System in Palo Alto. He was instrumental in the critical appraisal and writing of the manuscript. Drs. Kamal and Zikos are gastroenterology fellows in the department of Gastroenterology and Hepatology at Stanford University Hospital in Stanford, California. They were instrumental in the critical appraisal and analysis of the manuscript. Dr. Clarke is a gastroenterologist in the department Gastroenterology and Hepatology at Stanford University Hospital in Stanford, California. He was instrumental in the design and conduct of the study, data collection, analysis and writing of the manuscript.

Corresponding author

Correspondence to John O. Clarke.

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Authors Alexander J. Podboy, Joo Ha Hwang, Homero Rivas, Dan Azagury, Mary Hawn, James Lau, Afrin Kamal, Shai Friedland, George Triadafilopoulos, Thomas Zikos, and John O. Clarke have no conflicts of interest or financial ties to disclose.

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464_2020_7450_MOESM1_ESM.tiff

Supplementary file1 (TIFF 55 kb)—Supplementary Figure 1: Visual reference for the Barium variants identified. “Bird’s Beak” imaging variant describes the classic description of achalasia with proximal dilatation with gradual tapering (a). The “J- Shaped” imaging variant was defined as any sharp angulation (approx. 90 degrees) in the distal esophagus (b), Corkscrew defined as multiple short small positional turns in the esophagus (c).

Supplementary file2 (DOCX 37 kb)—Supplementary Figure 2: Inclusion Flow Chart

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Podboy, A.J., Hwang, J.H., Rivas, H. et al. Long-term outcomes of per-oral endoscopic myotomy compared to laparoscopic Heller myotomy for achalasia: a single-center experience. Surg Endosc 35, 792–801 (2021). https://doi.org/10.1007/s00464-020-07450-6

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