Outcomes of anterior versus posterior peroral endoscopic myotomy 2 years post-procedure: prospective follow-up results from a randomized clinical trial

Abstract

Background Peroral endoscopic myotomy (POEM) is considered a primary treatment modality for achalasia. It can be performed using either the anterior or posterior approach. A previous randomized clinical trial (RCT) showed that the posterior approach was noninferior to the anterior approach at 1 year post-POEM in terms of clinical success, rate of adverse event, and risk of gastroesophageal reflux disease (GERD). The aim of this post-RCT study was to compare outcomes at ≥ 2 years post-POEM. Methods Patients who previously completed the 1-year follow-up were contacted and their Eckardt, dysphagia, and GERD questionnaire (GERDQ) scores and frequency of proton pump inhibitor use were recorded. Clinical success was defined as an Eckardt score < 3. Results 150 patients were initially randomized and 138 completed the 1-year follow-up. Of the 138, 111 (anterior group 54, posterior group 57) also completed ≥ 2 years of follow-up, with an overall clinical success decrease from 89 % to 82 %. At ≥ 2 years post-POEM, clinical success was achieved in 46/54 (85 %) and 45/57 (79 %) in the anterior and posterior groups, respectively (P = 0.43). A similar decrease in clinical success was noted in both groups at ≥ 2 years (anterior: 90 % to 85 %; posterior 89 % to 79 %; P = 0.47). GERDQ score was 6 (interquartile range 6 – 8; P = 0.08) in both treatment groups. Conclusions The anterior and posterior POEM techniques remained equally effective at 2 years and decreases in efficacy were similar between the two approaches over time. GERD outcomes were also similar in both groups during medium-term follow-up.

An Updated Meta-analysis: Similar Clinical Efficacy of Anterior and Posterior Approaches in Peroral Endoscopic Myotomy (POEM) for Achalasia

“…These studies were published between 2016 and 2020. Six studies only reported the outcomes of POEM in the anterior approach [ 26 – 31 ], and nine studies only reported the outcomes of POEM in the posterior approach [ 32 – 40 ], while four studies compared outcomes of POEM via the anterior approach and posterior approach [ 41 – 44 ]. This meta-analysis included ten studies reporting outcomes with POEM via anterior myotomy and thirteen studies reporting outcomes with POEM via posterior myotomy.…”

“…Thus, further analysis was conducted in studies with a direct comparison between anterior and posterior approaches. Among all the included studies, 3 studies met the conditions of direct comparison because the patients were divided into anterior and posterior groups for comparison in these studies (including two RCTs [ 41 , 43 ] and one cohort [ 44 ]). The analysis after balancing baseline showed that the pooled weighted mean difference (WMD) was -1.56 mmHg (95% CI -3.09 to 0.78 mmHg; I 2 0.00%; n = 3; P = 0.19) ( Figure 2(b) ), which still showed no significant difference between these two groups, and the significant heterogeneity disappeared.…”

Achalasia in the Elderly: Diagnostic Approach and a Proposed Treatment Algorithm Based on a Comprehensive Literature Review

“…Adverse events were comparable between the two groups [ 38 ]. A recent report on two-years follow ups showed that both techniques remained equally effective and GERD outcomes were also similar [ 39 ]. An RCT reported on 63 patients who were randomized to either anterior (31 patients) or posterior (33 patients) groups.…”

Advances and caveats in modern achalasia management

“… 17 Nonetheless, a prospective randomized controlled study showed that at a 2-year follow up, neither showed superiority in terms of efficacy or post-operative GERD. 18 Regardless of the initial technique employed, if POEM needs to be repeated, the alternative approach should be considered. Advantages of POEM over LHM include the avoidance of the abdominal cavity structures as well as the opportunity to tailor the length of the myotomy along the esophageal axis in order to target the proximal end of a spastic contraction.…”

“…As the most recent treatment option for achalasia, comparative studies have shown POEM to be on par with both graded PD and LHM in terms of outcomes and complication rates. 15 , 16 – 32 POEM also is durable over time, but there is a clear learning curve associated with success and reduction in complication rate. 33 , 34 A pooled analysis of three cohort studies comparing POEM and LHM showed similar outcomes.…”