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Peroral endoscopic myotomy is equally safe and highly effective treatment option in achalasia patients with both lower and higher ASA classification status

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Abstract

Introduction

The American Society of Anesthesiologists (ASA) physical status classification system was developed as a simple categorization of patients’ physiological status that predicts the operative risk. Peroral endoscopic myotomy (POEM) is a less invasive alternative to surgical myotomy in achalasia. As such, POEM seems to be an appealing option for high-risk patients with achalasia. However, there are no studies which systematically analyzed the outcomes of POEM among patients with different ASA classes. Hence, we aimed to compare the safety and efficacy of POEM in patients with lower and higher ASA classes.

Methods

Medical records of all achalasia patients who underwent POEM at our institution between April 2014 and May 2019 were reviewed. Patients were categorized arbitrarily into two groups, lower ASA class (ASA I and II combined) and higher ASA class (ASA class III and IV combined). Demographic and procedural details, timed barium swallow (TBE), high-resolution esophageal manometry (HREM), pH study findings and Eckardt scores were compared between the two groups. Baseline characteristics were compared using Chi-square test and two-sample t-test for categorical and continuous variables, respectively.

Results

A total of 144 patients met our study criteria (lower ASA class, n = 44; and higher ASA class, n = 100). Patients in higher ASA class were significantly more obese and older. More patients in lower ASA class had prior Heller myotomy and more patients in higher ASA Class had prior botulinum toxin injections. Procedural parameters were similar in both groups. Procedural complications were infrequent and were also similar in the two groups. The length of stay, 30-day readmission rate, reflux symptoms and esophageal pH study findings were also comparable between the two groups. Treatment success was similar in both groups, 97.7% in lower ASA class versus 92% in higher ASA class (p = 0.19). At 2-month follow-up, both groups had significant improvement in HREM and TBE parameters.

Conclusion

POEM is a very safe and highly effective treatment option for achalasia patients with advanced ASA class similar to lower ASA class patients. POEM may be considered as the preferred choice for myotomy in these high-risk achalasia patients due to its low morbidity and high efficacy.

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Author notes

  1. Madhusudhan R. Sanaka and Pravallika Chadalavada are co-first authors.

Authors and Affiliations

  1. Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA

    Madhusudhan R. Sanaka, Prashanthi N. Thota & Scott Gabbard

  2. Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA

    Pravallika Chadalavada, Fahrettin Covut, Rajat Garg & Mohammad Alomari

  3. Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA

    Sudish Murthy & Siva Raja

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  1. Madhusudhan R. Sanaka
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Correspondence to Madhusudhan R. Sanaka.

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Conflict of interest

Dr. Madhusudhan R Sanaka, Dr. Pravallika Chadalavada, Dr. Fahrettin Covut, Dr. Rajat Garg, Dr. Prashanthi Thota, Dr. Scott Gabbard, Dr. Mohammad Alomari, Dr. Sudish Murthy, and Dr. Siva Raja have no conflicts of interest or financial ties to disclose pertinent to this article.

Ethical Statement

All procedures followed were in accordance with the ethical standards of the responsible committee on Human experimentation and with the Helsinki declaration of 1964 and later versions. This retrospective study was approved by the Institutional Board Review of Cleveland Clinic.

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This manuscript has not been published and is not under consideration for publication elsewhere. However, the preliminary data was accepted in abstract form for a poster presentation at the Digestive Disease Week, DDW 2020 conference (May 2nd–5th, 2020 | Chicago, Illinois).

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Sanaka, M.R., Chadalavada, P., Covut, F. et al. Peroral endoscopic myotomy is equally safe and highly effective treatment option in achalasia patients with both lower and higher ASA classification status. Esophagus 18, 932–940 (2021). https://doi.org/10.1007/s10388-021-00840-2

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