Superior clinical outcomes of peroral endoscopic myotomy compared with balloon dilation in all achalasia subtypes

Abstract

Background and Aim Optimal treatment modalities for each of the three subtypes of achalasia are still under debate. Differences in prognosis and long‐term outcomes between peroral endoscopic myotomy (POEM) and balloon dilation (BD) are also unclear. We aimed to compare the treatment outcomes of BD and POEM in each subtype of achalasia by using information from the manometry database of a tertiary referral center in Korea. Methods Data from 5207 esophageal manometry procedures performed between 1989 and 2016 were analyzed. The medical records and results of esophagography and esophagogastroduodenoscopy were also reviewed. Results We identified 264 patients (116 men and 148 women) with diagnosis of achalasia during the study period. POEM and BD were carried out on 64 and 177 patients, respectively. There was a significant difference in the time to relapse between the POEM group and the BD group (P = 0.002). At the 24‐month follow‐up, the clinical success rates of POEM and BD were 91.8% and 68.0%, respectively. The hazard ratio of symptom return was 6.54 for BD compared with POEM (95% confidence interval 2.12–20.22, P = 0.001). After a follow‐up period of 24 months, the success rate of POEM was significantly higher than that of BD for all subtypes of achalasia. However, only that of types I and II was statistically significant (type 1: 92.0% vs 51.1%, P = 0.004; type 2: 92.3% vs 59.8%, P = 0.007; and type3: 91.7% vs 55.6%, P = 0.051). Conclusions Peroral endoscopic myotomy was more effective than BD in providing mid‐long‐term remission in patients with all manometric subtypes of achalasia.

Esophageal POEM: the new standard of care

“…A recent comparative study identified 64 and 177 patients who underwent POEM and PD, respectively. At the 24 months follow-up period, the clinical success rate of POEM was much higher than PD across all subtypes, although only type I and type II were statistically significant (type 1: 92.0% vs. 51.1%, P=0.004; type 2: 92.3% vs. 59.8%, P=0.007; and type 3: 91.7% vs. 55.6%, P=0.051) (58). A recent meta-analysis comparing outcomes of treatment for achalasia for all manometric subtypes, evaluated 1,575 patients and found that POEM was more likely to be successful than LHM for both type I (OR, 2.97; 95% CI, 1.09 to 8.03; P=0.032) and type III (OR, 3.50; 95% CI, 1.39 to 8.77; P=0.007) achalasia.…”

Achalasia: what to do in the face of failures of Heller myotomy

“…In a recent retrospective study, POEM appears to be more effective than PD after 2 years of treatment in patients with all manometric subtypes of achalasia, but the incidence of postprocedure reflux remains a concern. 16 Similarly, a systematic review of postprocedure GERD after POEM compared with LHM reported significantly more reflux symptoms (19.0% versus 8.8%), abnormal acid exposure (39.0% versus 16.8%), and esophagitis (29.4% versus 7.6%) after POEM. 17 Selecting a treatment option Although endoscopic BTI is an established treatment modality for achalasia, a meta-analysis comparing BTI with both single PD and HM showed BTI to be less durable than both.…”

Management of achalasia in 2020: Per-oral endoscopic myotomy, Heller’s or dilatation?

“…The efficacy of POEM vs PD was 92% vs 51% in type I (P = 0.004), 92.3% vs 59.8% in type II (P = 0.007), and 91.7% vs 55.6% (P = 0.051) in type III achalasia. 76 In a multi-center randomized trial comparing POEM with PD, treatment success was achieved in 92% of patients in POEM group as compared to 54% of patients in the PD group at twoyears follow-up. On the other hand, reflux esophagitis was significantly more frequent after POEM as compared to PD (41% vs 7%).…”