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Recurrent dysphagia after myotomy for achalasia: pneumatic dilation or POEM?

Which modality offers superior outcomes?

  • 2022 SAGES Oral
  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Introduction

Myotomy is the gold standard treatment for achalasia, yet long-term failure rates approach 15%. Treatment options for recurrent dysphagia include pneumatic dilation (PD), laparoscopic redo myotomy, per oral endoscopic myotomy (POEM), or esophagectomy. We employ both PD and POEM as first-line treatment for these patients. We evaluated operative success and patient reported outcomes for patients who underwent PD or POEM for recurrent dysphagia after myotomy.

Methods

We identified patients with achalasia who underwent PD or POEM for recurrent dysphagia after previous myotomy within a foregut database at our institution between 2013 and 2021. Gastroesophageal Reflux Disease-Health-Related quality of Life (GERD-HRQL) and Eckardt scores, and overall change in each were compared across PD and POEM groups. Successful treatment of dysphagia was defined by Eckardt scores ≤ 3.

Results

103 patients underwent myotomy for achalasia. Of these, 19 (18%) had either PD or POEM for recurrent dysphagia. Nine were treated with PD and 10 with POEM. The mean change in Eckardt and GERD-HRQL scores did not differ between groups. 50% of the PD group and 67% of the POEM group had resolution of their dysphagia symptoms (p = 0.65). Mean procedure length was greater in the POEM group (267 vs 72 min, p < 0.01) as was mean length of stay (1.56 vs 0.3 days, p < 0.01). There was one adverse event after PD and three adverse events after POEM. After PD, 7 patients (70%) required additional procedures compared to four patients (44%) in the POEM group, consisting mostly of repeat PD.

Conclusion

Patients undergoing PD or POEM for recurrent dysphagia after myotomy have similar rates of dysphagia resolution and reflux symptoms. Patients undergoing PD enjoy a shorter length of stay and shorter procedure time but may require more subsequent procedures.

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Acknowledgements

We would like to thank Glen Leverson, PhD for his insightful comments and feedback.

Funding

Effort on this study and manuscript was made possible by a George H. A. Clowes, Jr., MD, FACS, Memorial Research Career Development Award from the American College of Surgeons and a VA Career Development Award to Dr. Funk (CDA 015-060). The views represented in this article represent those of the authors and not those of the DVA or the US Government.

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Authors and Affiliations

  1. Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA

    Christopher Zimmermann, Nate Torell, Anne Lidor, Luke Funk & Amber Shada

  2. Division of Minimally Invasive Surgery, Department of Surgery, University of Wisconsin-Madison, 4602 Eastpark Blvd, Suite 3525, Madison, WI, 53718, USA

    Amber Shada

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Contributions

CZ, NT, AS contributed to the study design and data collection. All coauthors participated in the data interpretation and revisions. All coauthors approved the version to be published and agree to be accountable for all aspects of the work and ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Correspondence to Amber Shada.

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Disclosures

Luke Funk received funding for this study through a George H. A. Clowes, Jr., MD, FACS, Memorial Research Career Development Award from the American College of Surgeons and a VA Career Development Award. Christopher Zimmermann, Nate Torell, Anne Lidor, and Amber Shada have no disclosures.

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Zimmermann, C., Torell, N., Lidor, A. et al. Recurrent dysphagia after myotomy for achalasia: pneumatic dilation or POEM?. Surg Endosc 37, 4812–4817 (2023). https://doi.org/10.1007/s00464-022-09556-5

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