Peroral endoscopic myotomy (POEM): a comparative study between Chagasic and idiopathic achalasia

Abstract

Background and study aims Achalasia can be classified as either primary (idiopathic) achalasia or secondary achalasia, which is a consequence of another systemic disease. Peroral endoscopic myotomy (POEM) is an effective and safe treatment for achalasia. We evaluated the efficacy and safety of POEM in patients with Chagasic achalasia compared to idiopathic achalasia.

Patients and methods We evaluated POEM procedures performed at a single institution from November 2016 to January 2018. Demographic data, Eckardt score, lower esophageal sphincter (LES) pressure, body mass index, post-operative erosive esophagitis, adverse events, length of hospital stay, and procedure-related parameters were analyzed.

Results Fifty-one patients underwent POEM as a treatment for achalasia in this period (20 patients with Chagasic and 31 with Idiopathic etiology). The overall clinical success rate was 92.1 %, with no statistical difference between groups (90 % in the Chagasic group vs. 93.5 % in the Idiopathic group, P = 0.640). Both groups had significant reduction in Eckardt score and in LES pressure, and increase in bodey mass index (BMI) at 1-year follow-up. There was no statistical difference between groups regarding Eckardt score (P = 0.439), LES pressure (p = 0.507), BMI (P = 0.254), post erosive esophagitis (35 % vs. 38.7 %, P = 0.789), adverse events (30 % vs. 12 %, P = 0.163,) length of hospital stay (3.75 days vs. 3.58 days, P = 0.622), and operative time (101.3 min vs. 99.1 min, P = 0.840).

Conclusion POEM is an effective and safe treatment for patients with achalasia. There is no difference in POEM outcomes for those patients with Chagasic or Idiopathic achalasia.

• References

• 1 Vaezi MF, Pandolfino JE, Vela MF. ACG clinical guideline: diagnosis and management of achalasia. Am J Gastroenterol 2013; 108: 1238-1249
• 2 Yu L, Li J, Wang T. et al. Functional analysis of long-term outcome after Heller’s myotomy for achalasia. Dis Esophagus 2010; 23: 277-283
• 3 Reynolds JC, Parkman HP. Achalasia. Gastroenterol Clin North Am 1989; 18: 223
• 4 de Oliveira RB, Rezende Filho J, Dantas RO. et al. The spectrum of esophageal motor disorders in Chagas' disease. Am J Gastroenterol 1995; 90: 1119-1124
• 5 Mayberry JF. Epidemiology and demographics of achalasia. Gastrointest Endosc Clin N Am 2001; 11: 235-248
• 6 Winter H, Shukla R, Elshaer M. et al. Current management of achalasia – a review. Br J Med Pract 2015; 8: a810
• 7 Eckardt DF. Clinical presentations and complications of achalasia. Gastrointest Endosc Clin N Am 2001; 11: 281-292
• 8 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
• 9 Ramchandani M, Nageshwar Reddy D, Nabi Z. et al. Management of achalasia cardia: Expert consensus statements. J Gastroenterol Hepatol 2018; 33: 1436-1444
• 10 Bonifácio P, de Moura DTH, Bernardo WM. et al. Pneumatic dilation versus laparoscopic Heller's myotomy in the treatment of achalasia: systematic review and meta-analysis based on randomized controlled trials. Dis Esophagus 2019; 32
• 11 Kahaleh M, Xu MM, Zamarripa F. et al. POEM in Latin America: the rise of a new standard. J Clin Gastroenterol 2019; 53: e352-e355
• 12 Rezende JM. Classificação radiológica do megaesôfago. Res Goiana Med 1982; 28: 187-191
• 13 Eckardt VF, Aignherr C, Bernhard G. Predictors of outcome in patients with achalasia treated by pneumatic dilatation. Gastroenterol 1992; 103: 1732-1738
• 14 Lundell LR, Dent J, Bennett JR. et al. Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut 1999; 45: 172-180
• 15 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
• 16 Rosner B. Fundamentals of Biostatistics. 2. Boston: PWS Publishers; 1986: 584-585
• 17 Timm NH. Multivariate Analysis with Applications in Education and Psychology. Monterrey, CA: Brooks/Cole; 1975: 687-688
• 18 Boeckxstaens GE. Achalasia: virus-induced euthanasia of neurons?. Am J Gastroenterol 2008; 103: 1610-1612
• 19 Troncon LE, Oliveira RB, Romanello LM. et al. Abnormal progression of a liquid meal through the stomach and small intestine in patients with Chagasʼ disease. Dig Dis Sci 1993; 38: 1511-1517
• 20 Spiess AE, Kahrilas PJ. Treating achalasia: from whalebone to laparoscope. JAMA 1998; 280: 638-642
• 21 Boeckxstaens GE, Zaninotto G, Richter JE. Achalasia. Lancet 2014; 383: 83-93
• 22 Zaninotto G, Bennett C, Boeckxstaens G. et al. The 2018 ISDE achalasia guidelines. Dis Esophagus 2018; 31: 1-29
• 23 Barbieri LA, Hassan C, Rosati R. et al. Systematic review and meta-analysis: Efficacy and safety of POEM for achalasia. United European Gastroenterol J 2015; 3: 325-334
• 24 Wu QN, Xu XY, Zhang XC. et al. Submucosal fibrosis in achalasia patients is a rare cause of aborted peroral endoscopic myotomy procedures. Endoscopy 2017; 49: 736-744
• 25 Ngamruengphong S, Inoue H, Chiu PW. et al. Long-term outcomes of per-oral endoscopic myotomy in patients with achalasia with a minimum follow-up of 2 years: an international multicenter study. Gastrointest Endosc 2017; 85: 927-933
• 26 Martinek J, Svecova H, Vackova Z. et al. Per-oral endoscopic myotomy (POEM): mid-term efficacy and safety. Surg Endosc 2018; 32: 1293-1302
• 27 Nabi Z, Reddy DN, Ramchandani M. Adverse events during and after per-oral endoscopic myotomy: prevention, diagnosis, and management. Gastrointest Endosc 2018; 87: 4-17
• 28 Gao Q, Tu S, Tang X. et al. Mid-term outcomes of a single center randomized controlled trial comparing peroral endoscopic short versus long myotomy for achalasia in China. Am J Gastroenterol 2017; 112: S173-S174