Endoscopy 2018; 50(04): 358-370
DOI: 10.1055/s-0043-121632
Original article
© Georg Thieme Verlag KG Stuttgart · New York

Peroral endoscopic myotomy in treatment-naïve achalasia patients versus prior treatment failure cases

Zaheer Nabi
Asian institute of Gastroenterology, Hyderabad, India
,
Mohan Ramchandani
Asian institute of Gastroenterology, Hyderabad, India
,
Radhika Chavan
Asian institute of Gastroenterology, Hyderabad, India
,
Manu Tandan
Asian institute of Gastroenterology, Hyderabad, India
,
Rakesh Kalapala
Asian institute of Gastroenterology, Hyderabad, India
,
Santosh Darisetty
Asian institute of Gastroenterology, Hyderabad, India
,
Sundeep Lakhtakia
Asian institute of Gastroenterology, Hyderabad, India
,
G. Venkat Rao
Asian institute of Gastroenterology, Hyderabad, India
,
D. Nageshwar Reddy
Asian institute of Gastroenterology, Hyderabad, India
› Author Affiliations
Further Information

Publication History

submitted 03 May 2017

accepted after revision 21 September 2017

Publication Date:
23 November 2017 (online)

Abstract

Background and study aim Peroral endoscopic myotomy (POEM) has emerged as an effective treatment modality for achalasia. Prior treatment may affect the outcomes of subsequent management. In this study, we aimed to compare the safety and efficacy of POEM in treatment-naïve patients vs. those with prior treatment failure (PTF).

Patients and methods The data of consecutive patients with achalasia who underwent POEM at a single tertiary care center from January 2013 to November 2016 were analyzed retrospectively. A comparative analysis was performed between treatment-naïve and PTF cases. Technical and clinical success, adverse events, and operative time for POEM were compared between the two groups.

Results Overall, 502 patients with achalasia underwent POEM during the study period: 260 patients (51.8 %) in the treatment-naïve group and 242 patients (48.2 %) in the PTF group. The mean operative time was significantly longer in the PTF group compared with the treatment-naïve group (74.9 ± 30.6 vs. 67.0 ± 27.1 minutes; P  = 0.002). On multivariate analysis, type of achalasia, dilated esophagus ( > 6 cm), disease duration, prior treatment, occurrence of adverse events, and type of knife used were significant predictors of operative time. Technical success (98.1 % vs. 97.1 %; P = 0.56) and clinical success (92.4 % vs. 92.5 %; P  = 0.95) were comparable in the treatment-naïve and PTF cases, respectively. Occurrence of gas-related events and mucosotomy were similar in both groups. Elevated DeMeester score was found in 17 /53 patients (32.1 %) in the PTF group and in 11 /44 patients (25.0 %) in the treatment-naïve group (P = 0.50).

Conclusion POEM is safe and equally effective for treatment-naïve patients and for those in whom prior treatment has failed. POEM should be considered the treatment of choice in patients in whom prior treatment has failed.

 
  • References

  • 1 Vaezi MF, Pandolfino JE, Vela MF. ACG clinical guideline: diagnosis and management of achalasia. Am J Gastroenterol 2013; 108: 1238-1249
  • 2 Hungness ES, Teitelbaum EN, Santos BF. et al. Comparison of perioperative outcomes between peroral esophageal myotomy (POEM) and laparoscopic Heller myotomy. J Gastrointest Surg 2013; 17: 228-235
  • 3 Docimo Jr. S, Mathew A, Shope AJ. et al. Reduced postoperative pain scores and narcotic use favor per-oral endoscopic myotomy over laparoscopic Heller myotomy. Surg Endosc 2017; 31: 795-800
  • 4 Teitelbaum EN, Rajeswaran S, Zhang R. et al. Peroral esophageal myotomy (POEM) and laparoscopic Heller myotomy produce a similar short-term anatomic and functional effect. Surgery 2013; 154: 885-891
  • 5 Ujiki MB, Yetasook AK, Zapf M. et al. Peroral endoscopic myotomy: a short-term comparison with the standard laparoscopic approach. Surgery 2013; 154: 893-900
  • 6 Bhayani NH, Kurian AA, Dunst CM. et al. A comparative study on comprehensive, objective outcomes of laparoscopic Heller myotomy with per-oral endoscopic myotomy (POEM) for achalasia. Ann Surg 2014; 259: 1098-1103
  • 7 Marano L, Pallabazzer G, Solito B. et al. Surgery or peroral esophageal myotomy for achalasia: a systematic review and meta-analysis. Medicine 2016; 95: e3001
  • 8 Miller HJ, Neupane R, Fayezizadeh M. et al. POEM is a cost-effective procedure: cost-utility analysis of endoscopic and surgical treatment options in the management of achalasia. Surg Endosc 2017; 31: 1636-1642
  • 9 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
  • 10 Smith CD, Stival A, Howell DL. et al. Endoscopic therapy for achalasia before Heller myotomy results in worse outcomes than Heller myotomy alone. Ann Surg 2006; 243: 579-586
  • 11 Jones EL, Meara MP, Pittman MR. et al. Prior treatment does not influence the performance or early outcome of per-oral endoscopic myotomy for achalasia. Surg Endosc 2016; 30: 1282-1286
  • 12 Kristensen HO, Kirkegard J, Kjaer DW. et al. Long-term outcome of peroral endoscopic myotomy for esophageal achalasia in patients with previous Heller myotomy. Surg Endosc 2017; 31: 2596-2601
  • 13 Louie BE, Schneider AM, Schembre DB. et al. Impact of prior interventions on outcomes during per oral endoscopic myotomy. Surg Endosc 2017; 31: 1841-1848
  • 14 Ramchandani M, Nageshwar ReddyD, Darisetty S. et al. Peroral endoscopic myotomy for achalasia cardia: treatment analysis and follow up of over 200 consecutive patients at a single center. Dig Endosc 2016; 28: 19-26
  • 15 Ramchandani M, Nageshwar ReddyD. Peroral endoscopic myotomy: technique of mucosal incision. Clin Gastroenterol Hepatol 2014; 12: 900-901
  • 16 Nabi Z, Ramchandani M, Reddy DN. et al. Per oral endoscopic myotomy in children with achalasia cardia. J Neurogastroenterol Motil 2016; 22: 613-619
  • 17 Souma Y, Nakajima K, Taniguchi E. et al. Mucosal perforation during laparoscopic surgery for achalasia: impact of preoperative pneumatic balloon dilation. Surg Endosc 2017; 31: 1427-1435
  • 18 Richardson WS, Willis GW, Smith JW. Evaluation of scar formation after botulinum toxin injection or forced balloon dilation to the lower esophageal sphincter. Surg Endosc 2003; 17: 696-698
  • 19 Onimaru M, Inoue H, Ikeda H. et al. Peroral endoscopic myotomy is a viable option for failed surgical esophagocardiomyotomy instead of redo surgical Heller myotomy: a single center prospective study. J Am Coll Surg 2013; 217: 598-605
  • 20 Orenstein SB, Raigani S, Wu YV. et al. Peroral endoscopic myotomy (POEM) leads to similar results in patients with and without prior endoscopic or surgical therapy. Surg Endosc 2015; 29: 1064-1070
  • 21 Sharata A, Kurian AA, Dunst CM. et al. Peroral endoscopic myotomy (POEM) is safe and effective in the setting of prior endoscopic intervention. J Gastrointest Surg 2013; 17: 1188-1192
  • 22 Ngamruengphong S, Inoue H, Ujiki MB. et al. Efficacy and safety of peroral endoscopic myotomy for treatment of achalasia after failed Heller myotomy. Clin Gastroenterol Hepatol 2017; 15: 1531-1537
  • 23 Hungness ES, Sternbach JM, Teitelbaum EN. et al. Per-oral endoscopic myotomy (POEM) after the learning curve: durable long-term results with a low complication rate. Ann Surg 2016; 264: 508-517
  • 24 Miles LF, Frelich MJ, Gould JC. et al. Per-oral endoscopic myotomy (POEM) after previous laparoscopic Heller myotomy is feasible and safe in a porcine model. Surg Laparosc Endosc Percutan Tech 2015; 25: 408-411
  • 25 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. Ann Surg 2016; 263: 82-87
  • 26 Werner YB, von Renteln D, Noder T. et al. Early adverse events of per-oral endoscopic myotomy. Gastrointest Endosc 2017; 85: 708-718.e2
  • 27 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
  • 28 Burt BM. The ascent of POEM: Double-tunnel per oral endoscopic re-myotomy. J Thorac Cardiovasc Surg 2016; 151: e103-e104
  • 29 Teitelbaum EN, Soper NJ, Arafat FO. et al. Analysis of a learning curve and predictors of intraoperative difficulty for peroral esophageal myotomy (POEM). J Gastrointest Surg 2014; 18: 92-99
  • 30 Vigneswaran Y, Yetasook AK, Zhao JC. et al. Peroral endoscopic myotomy (POEM): feasible as reoperation following Heller myotomy. J Gastrointest Surg 2014; 18: 1071-1076
  • 31 Fumagalli U, Rosati R, De Pascale S. et al. Repeated surgical or endoscopic myotomy for recurrent dysphagia in patients after previous myotomy for achalasia. J Gastrointest Surg 2016; 20: 494-499
  • 32 Tyberg A, Seewald S, Sharaiha RZ. et al. A multicenter international registry of redo per-oral endoscopic myotomy (POEM) after failed POEM. Gastrointest Endosc 2017; 85: 1208-1211
  • 33 van Hoeij FB, Ponds FA, Werner Y. et al. Management of recurrent symptoms after per-oral endoscopic myotomy in achalasia. Gastrointest Endosc 2017; DOI: 10.1016/j.gie.2017.04.036.
  • 34 Haito-Chavez Y, Inoue H, Beard KW. et al. Comprehensive analysis of adverse events associated with per oral endoscopic myotomy in 1826 patients: an international multicenter study. Am J Gastroenterol 2017; 112: 1267-1276
  • 35 Zhang XC, Li QL, Xu MD. et al. Major perioperative adverse events of peroral endoscopic myotomy: a systematic 5-year analysis. Endoscopy 2016; 48: 967-978
  • 36 Familiari P, Greco S, Gigante G. et al. Gastroesophageal reflux disease after peroral endoscopic myotomy: analysis of clinical, procedural and functional factors, associated with gastroesophageal reflux disease and esophagitis. Dig Endosc 2016; 28: 33-41
  • 37 Kumbhari V, Familiari P, Bjerregaard NC. et al. Gastroesophageal reflux after peroral endoscopic myotomy: a multicenter case–control study. Endoscopy 2017; 49: 634-642