Peroral endoscopic myotomy (POEM)—a relatively new technique in therapeutic flexible gastrointestinal endoscopy—has enabled those performing endoscopy to create a new working space outside the lumen, an accomplishment previously considered to be a surgical complication, explains Thomas Rösch. Patients with achalasia can benefit from this treatment, as it cuts the obstructing muscle from inside the body as opposed to transcutaneously. However, despite being introduced nearly 10 years ago, randomized trials confirming patient results following POEM and encouraging its use by clinicians have been limited.

For a study published in the New England Journal of Medicine, Dr. Rösch and colleagues sought to compare outcomes following POEM with those of laparoscopic Heller’s myotomy (LHM) plus Dor’s fundoplication in patients with symptomatic achalasia.

Relief of dysphagia was similar in both groups (POEM, 83% vs. LHM, 81.7%). “Initially, POEM performed better, with the same high success rates seen in previous retrospective case series,” notes Dr. Rösch. “However, after 6 months, both groups were performing similarly. The 5-year results, a secondary outcome, are still pending but will be available in 2021.”

Whereas an antireflux procedure is an integral part of LHM, this was presumed unnecessary with POEM. “Initially there was hope that because POEM leaves the peri-esophageal space intact, unlike with LHM, patients would experience less reflux,” says Dr. Rösch. “However, we confirmed this to not be true. Patients in the POEM group had higher rates of, mostly minimal, reflux signs on endoscopy at 3 months (57% vs. 20%); at 2 years, this difference was less pronounced (44% vs. 29%). Whether this difference will be further decreased at the 5 year follow-up is yet to be determined.”

Dr. Rösch is focusing future research in this area on the clinical relevance of post-procedural reflux with POEM and LHM. “We know that reflux can lead to the development of Barrett’s esophagus and ultimately cancer, but the magnitude of this problem following these procedures for patients with achalasia remains unknown.”

References

Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia

https://www.nejm.org/doi/full/10.1056/NEJMoa1905380