Per-oral endoscopic myotomy is better than pneumatic dilation for post-laparoscopic heller myotomy achalasia

The finding implies that Per-oral endoscopic myotomy can be considered the initial treatment option for achalasia patients experiencing persistent or recurrent symptoms after laparoscopic Heller myotomy.

Achalasia is a rare oesophagal motility disorder with dysfunctional or absent oesophagal body motility and inadequate lower oesophagal sphincter (LES) relaxation. Treatment options for achalasia patients include PD, LHM, and POEM. The authors noted that LHM and POEM yield longer-lasting symptomatic responses in treatment-naïve achalasia patients than a single series of PDs. Persistent or recurrent symptoms occur in 10%–20% of patients treated with LHM, despite the high LHM and POEM efficacy rates.

Per-oral endoscopic myotomy is increasingly being investigated as rescue therapy. Pneumatic dilation is said to be the most frequently used treatment for achalasia patients experiencing persistent or recurrent symptoms following laparoscopic Heller myotomy. Caroline M G Saleh, University of Amsterdam, Amsterdam, The Netherlands, and colleagues aimed to determine the efficacy of POEM versus PD for patients with persistent or recurrent symptoms after LHM in a randomized multicenter controlled trial.

The trial included 90 patients after laparoscopic Heller myotomy with an Eckardt score >3 and substantial stasis (≥2 cm) on a timed barium esophagogram. They were randomized to per-oral endoscopic myotomy or pneumatic dilation. The study's primary outcome was treatment success, defined as an Eckardt score of ≤3 and without unscheduled re-treatment. Secondary outcomes were the presence of reflux esophagitis, timed barium esophagogram findings, and high-resolution manometry. The patients were followed one year after the initial treatment.

The authors reported the following findings:

• POEM had a higher success rate (62.2%) than PD (26.7%; absolute difference, 35.6%; odds ratio, 0.22; relative risk for success, 2.33).
• There was no significant difference in reflux esophagitis between POEM (34.3%) and PD (15%).
• Integrated relaxation pressure (IRP-4) and basal lower oesophagal sphincter pressure were significantly lower in the POEM group.
• Barium column height following 2 and 5 minutes was remarkably less in patients treated with POEM.

"Findings from the randomized controlled trial revealed that per-oral endoscopic myotomy results in remarkably lower Eckardt scores than pneumatic dilation for achalasia patients experiencing persistent or recurrent symptoms after laparoscopic Heller myotomy," the researchers concluded.

Reference:

Saleh CMG, Familiari P, Bastiaansen BAJ, Fockens P, Tack J, Boeckxstaens G, Bisschops R, Lei A, Schijven MP, Costamagna JG, Bredenoord AJ. The Efficacy of Peroral Endoscopic Myotomy vs Pneumatic Dilation as Treatment for Patients With Achalasia Suffering From Persistent or Recurrent Symptoms After Laparoscopic Heller Myotomy: A Randomized Clinical Trial. Gastroenterology. 2023 Mar 11:S0016-5085(23)00258-5. doi: 10.1053/j.gastro.2023.02.048. Epub ahead of print. PMID: 36907524.