Long-term outcomes of per-oral endoscopic myotomy in achalasia patients with a minimum follow-up of 4 years: a multicenter study

Abstract

Background and study aims Per-oral endoscopic myotomy (POEM) is associated with a short-term clinical response of 82 % to 100 % in treatment of patients with achalasia. Data are limited on the long-term durability of the clinical response in these patients. The aim of this study was to determine the long-term outcomes of patients undergoing POEM for management of achalasia.

Methods This was a retrospective multicenter cohort study of consecutive patients who underwent POEM for management of achalasia. Patients had a minimum of 4 years follow-up. Clinical response was defined by an Eckardt score ≤ 3.

Results A total of 146 patients were included from 11 academic medical centers. Mean (± SD) age was 49.8 (± 16) years and 79 (54 %) were female. The most common type of achalasia was type II, seen in 70 (47.9 %) patients, followed by type I seen in 41 (28.1 %) patients. Prior treatments included: pneumatic dilation in 29 (19.9 %), botulinum toxin injection in 13 (8.9 %) and Heller myotomy in seven patients (4.8 %). Eight adverse events occurred (6 mucosotomies, 2 pneumothorax) in eight patients (5.5 %). Median follow-up duration was 55 months (IQR 49.9–60.6). Clinical response was observed in 139 (95.2 %) patients at follow-up of ≥ 48 months. Symptomatic reflux after POEM was seen in 45 (32.1 %) patients, while 35.3 % of patients were using daily PPI at 48 months post POEM. Reflux esophagitis was noted in 16.8 % of patients who underwent endoscopy.

Conclusion POEM is a durable and safe procedure with an acceptably low adverse event rate and an excellent long-term clinical response.

• References

• 1 Khashab MA, El Zein M, Kumbhari V. et al. Comprehensive analysis of efficacy and safety of peroral endoscopic myotomy performed by a gastroenterologist in the endoscopy unit: a single-center experience. Gastrointestinal endoscopy 2016; 83: 117-125
• 2 Parsa N, Khashab MA. POEM in the Treatment of esophageal disorders. Curr Treatment Options Gastroenterol 2018;
• 3 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
• 4 Von Renteln D, Fuchs KH, Fockens P. et al. Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study. Gastroenterology 2013; 145: 309-311
• 5 Inoue H, Sato H, Ikeda H. et al. Per-oral endoscopic myotomy: a series of 500 patients. J Am Coll Surg 2015; 221: 256-264
• 6 Swanstrom LL, Kurian A, Dunst CM. et al. Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure. Annals Surgery 2012; 256: 659-667
• 7 Familiari P, Gigante G, Marchese M. et al. Peroral endoscopic myotomy for esophageal achalasia: outcomes of the first 100 patients with short-term follow-up. Annals Surg 2016; 263: 82-87
• 8 Schlottmann F, Luckett DJ, Fine J. et al. Laparoscopic Heller myotomy versus peroral endoscopic myotomy (POEM) for achalasia: A systematic review and meta-analysis. Annals Surg 2018; 267: 451-460
• 9 Werner YB, Costamagna G, Swanstrom LL. et al. Clinical response to peroral endoscopic myotomy in patients with idiopathic achalasia at a minimum follow-up of 2 years. Gut 2016; 65: 899-906
• 10 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 e922
• 11 Akintoye E, Kumar N, Obaitan I. et al. Peroral endoscopic myotomy: a meta-analysis. Endoscopy 2016; 48: 1059-1068
• 12 Li QL, Wu QN, Zhang XC. et al. Outcomes of per-oral endoscopic myotomy for treatment of esophageal achalasia with a median follow-up of 49 months. Gastrointest Endosc 2018; 87: 1405-1412
• 13 Teitelbaum EN, Dunst CM, Reavis KM. et al. Clinical outcomes five years after POEM for treatment of primary esophageal motility disorders. Surg Endosc 2018; 32: 421-427
• 14 Weber CE, Davis CS, Kramer HJ. et al. Medium and long-term outcomes after pneumatic dilation or laparoscopic Heller myotomy for achalasia: a meta-analysis. Surg Laparosc Endosc Percutan Tech 2012; 22: 289-296
• 15 Kumbhari V, Familiari P, Bjerregaard NC. et al. Gastroesophageal reflux after peroral endoscopic myotomy: a multicenter case-control study. Endoscopy 2017; 49: 634-642
• 16 Eckardt VF, Aignherr C, Bernhard G. Predictors of outcome in patients with achalasia treated by pneumatic dilation. Gastroenterology 1992; 103: 1732-1738
• 17 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
• 18 Li H, Peng W, Huang S. et al. The 2 years’ long-term efficacy and safety of peroral endoscopic myotomy for the treatment of achalasia: a systematic review. In J Cardiothorac Surg 2019; 14: 1
• 19 He C, Li M, Lu B. et al. Long-term efficacy of peroral endoscopic myotomy for patients with achalasia: outcomes with a median follow-up of 36 months. Dig Dis Sci 2019; 64: 803-810
• 20 Zhang X, Modayil RJ, Friedel D. et al. Per-oral endoscopic myotomy in patients with or without prior Hellerʼs myotomy: comparing long-term outcomes in a large U.S. single-center cohort (with videos). Gastrointest Endosc 2018; 87: 972-985
• 21 Martinek J, Svecova H, Vackova Z. et al. Per-oral endoscopic myotomy (POEM): mid-term efficacy and safety. Surg Endosc 2018; 32: 1293-1302
• 22 Werner YB, Hakanson B, Martinek J. et al. Endoscopic or surgical myotomy in patients with idiopathic achalasia. N Engl J Med 2019; 381: 2219-2229
• 23 Moonen A, Annese V, Belmans A. et al. Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut 2016; 65: 732-739
• 24 Ramchandani M, Nageshwar ReddyD, Nabi Z. et al. Management of achalasia cardia: expert consensus statements. J Gastroenterol Hepatol 2018;
• 25 Khashab MA, Sanaei O, Rivory J. et al. Peroral endoscopic myotomy: anterior versus posterior approach: a randomized single-blinded clinical trial. Gastrointest Endosc 2019;
• 26 Kim WH, Cho JY, Ko WJ. et al. Comparison of the outcomes of peroral endoscopic myotomy for achalasia according to manometric subtype. Gut Liver 2017; 642-647
• 27 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
• 28 Rosch T, Repici A, Boeckxstaens G. Will Reflux Kill POEM?. Endoscopy 2017; 49: 625-628
• 29 Repici A, Fuccio L, Maselli R. et al. GERD after per-oral endoscopic myotomy as compared with Hellerʼs myotomy with fundoplication: a systematic review with meta-analysis. Gastrointest Endosc 2018; 87: 934-943
• 30 Richards WO, Torquati A, Holzman MD. et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg 2004; 240: 405-412
• 31 Tyberg A, Choi A, Gaidhane M. et al. Transoral Incisionless fundoplication for reflux after peroral endoscopic myotomy: a crucial addition to our arsenal. Endosc Int Open 2018; 6: E549-552
• 32 Inoue H, Ueno A, Shimamura Y. et al. Peroral endoscopic myotomy and fundoplication: a novel NOTES procedure. Endoscopy 2019; 51: 161-164
• 33 Nabi Z, Ramchandani M, Darisetty S. et al. Peroral endoscopic myotomy with endoscopic fundoplication in a patient with idiopathic achalasia. Endoscopy 2020; 52: 74-75
• 34 Brewer Gutierrez OI, Benias PC, Khashab MA. et al. Same-Session Per-Oral Endoscopic Myotomy Followed by Transoral Incisionless Fundoplication in Achalasia: Are We There Yet?. Am J Gastroenterol 2020; 115: 162