Skip to main content
SpringerLink
Log in

A Matched Comparison of Per Oral Endoscopic Myotomy to Laparoscopic Heller Myotomy in the Treatment of Achalasia

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Per oral endoscopic myotomy (POEM) is increasingly utilized to treat patients with achalasia. Early results have demonstrated significant improvement of symptoms, but there are concerns about postoperative reflux. With only limited comparative data available, we sought to compare POEM to laparoscopic Heller myotomy (LHM) with partial fundoplication.

Methods

This is a retrospective review of 42 POEM and 84 LHM patients undergoing primary myotomy for achalasia. Patients were matched by achalasia type, by Eckardt and dysphagia scores, and by quality of life (QOL) metrics. Analysis at 6–12-month follow-up evaluated these metrics, PPI use, pH, manometric, and endoscopic data.

Results

We matched 25 patients with achalasia types I (6), II (13), and III (6). Follow-up was longer for LHM at 158.1 (36.5–272.9) weeks versus 36.2 (22.2–41.2) weeks (p = 0.001). Eckardt scores, QOL metrics, and dysphagia significantly improved in both groups. DeMeester scores and total percent time less than 4 were abnormal in both groups and comparable (p = 0.925 and p = 0.838). Esophagitis was seen in 53.4 % (POEM) and 31.6 % (LHM) (Yates’ p = 0.91), and PPI use was equivalent at 36 %.

Conclusion

Early clinical outcomes are excellent with POEM and comparable to the standard of care LHM. Long-term follow-up is required as concerns for reflux persist.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Park W, Vaezi MF. Etiology and pathogenesis of achalasia: The current understanding. Am J Gastroenterol. 2005;100(6):1404–14.

    Article  PubMed  Google Scholar 

  2. Boeckxstaens GE, Annese V, Varannes SB des, Chaussade S, Costantini M, Cuttitta A, et al. Pneumatic Dilation versus Laparoscopic Heller’s Myotomy for Idiopathic Achalasia. N Engl J Med [Internet]. 2011;364(19):1807–16. Available from: http://www.nejm.org/doi/abs/10.1056/NEJMoa1010502

  3. Inoue, Haruhiro, Minami H SH. First clinical experience of submucosal endoscopic myotomy for esophageal achalasia with no skin incision. Gastrointest Endosc. 2009;69:AB122.

  4. von Renteln D, Inoue H, Minami H, Werner YB, Pace A, Kersten JF, et al. Peroral endoscopic myotomy for the treatment of achalasia: a prospective single center study. Am J Gastroenterol [Internet]. 2012;107(3):411–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22068665

  5. Stavropoulos SN, Desilets DJ, Fuchs KH, Gostout CJ, Haber G, Inoue H, et al. Per-oral endoscopic myotomy white paper summary. Surg Endosc Other Interv Tech. 2014;28(7):2005–19.

    Article  Google Scholar 

  6. Kurian AA, Dunst CM, Sharata A, Bhayani NH, Reavis KM, Swanström LL. Peroral endoscopic esophageal myotomy: Defining the learning curve. Gastrointest Endosc [Internet]. Elsevier Inc.; 2013;77(5):719–25. Available from: http://dx.doi.org/10.1016/j.gie.2012.12.006

  7. Teitelbaum EN, Soper NJ, Santos BF, Arafat FO, Pandolfino JE, Kahrilas PJ, et al. Symptomatic and physiologic outcomes one year after peroral esophageal myotomy (POEM) for treatment of achalasia. Surg Endosc. 2014;3359–65.

  8. Inoue H. Peroral Endoscopic Myotomy (POEM) for Esophageal Achalasia. Endoscopy [Internet]. 2010;42:265–71. Available from: /www.youtube.com/watch?v=1iG-eC113IM

  9. Inoue H, Sato H, Ikeda H, Onimaru M, Sato C, Minami H, et al. Per-Oral Endoscopic Myotomy: A Series of 500 Patients. J Am Coll Surg [Internet]. American College of Surgeons; 2015;221(2):256–64. Available from: http://dx.doi.org/10.1016/j.jamcollsurg.2015.03.057

  10. Bhayani NH, Kurian A a, Dunst CM, Sharata AM, Rieder E, Swanstrom LL. A comparative study on comprehensive, objective outcomes of laparoscopic Heller myotomy with per-oral endoscopic myotomy (POEM) for achalasia. Ann Surg [Internet]. 2014;259(6):1098–103. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24169175

  11. Chan SM, Wu JCY, Teoh AYB, Yip HC, Ng EKW, Lau JYW, et al. Comparison of early outcomes and quality of life after laparoscopic Heller’s cardiomyotomy to peroral endoscopic myotomy for treatment of achalasia. Dig Endosc [Internet]. 2015;27–32. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26108140

  12. Wiklund IK, Junghard O, Grace E, Talley NJ, Kamm M, Veldhuyzen van Zanten S, Pare P. Chiba N, Leddin DS, Bigard MA, Colin R SP. Quality of Life in Reflux and Dyspepsia patients. Psychometric documentation of a new disease-specific questionnaire (QOLRAD). Eur J Surg Suppl. 1998;583:41–9.

  13. V V. The development of the GERD-HRQL symptom severity instrument. Dis Esophagus. 2007;20(2):130–4.

  14. Dakkak M BJ. A new dysphagia score with objective validation. J Clin Gastroenterol. 1992;14(2):99–100.

  15. Swanström, Lee L.Rieder Erwin DC. A Stepwise Approach and Early Clinical Experience in Peroral Endoscopic Myotomy for the Treatment of Achalasia and Esophageal Motility Disorders. J AM Coll Surg. 2011;213(6):751–6.

  16. Teitelbaum EN, Soper NJ, Pandolfino JE, Kahrilas PJ, Hirano I, Boris L, et al. Esophagogastric junction distensibility measurements during Heller myotomy and POEM for achalasia predict postoperative symptomatic outcomes. Surg Endosc. 2014;(2015):522–8.

    Article  Google Scholar 

  17. Marano L, Pallabazzer G, Solito B, Santi S, Pigazzi A, De Luca R, et al. Surgery or Peroral Esophageal Myotomy for Achalasia. Medicine (Baltimore) [Internet]. 2016;95(10):e3001. Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00005792-201603080-00050

  18. Swanstrom LL, Kurian A, Dunst CM, Sharata A, Bhayani N, Rieder E. Long-Term Outcomes of an Endoscopic Myotomy for Achalasia. Ann Surg. 2012;256(4):659–67.

    Article  PubMed  Google Scholar 

  19. Richards W. Heller Myotomy Versus Heller Myotomy With Dor Fundoplication for Achalasia. Ann Surg [Internet]. 2006;243(3):427–8. Available from: http://dx.doi.org/10.1016/B978-1-4160-4696-7/00012-5

  20. Marco G. Patti, MD,* Carlos A. Pellegrini, MD,† Santiago Horgan, MD,† Massimo Arcerito, MD,* Pablo Omelanczuk M, Andrea Tamburini, MD,* Urs Diener, MD,* Thomas R. Eubanks, MD,† and Lawrence W. Way M. Minimally Invasive Surgery for Achalasia An 8-Year Experience With 168 Patients. Ann Surg. 1999;230(4):587–94.

  21. Sharata AM, Dunst CM, Pescarus R, Shlomovitz E, Wille AJT, Reavis KM, et al. Peroral Endoscopic Myotomy (POEM) for Esophageal Primary Motility Disorders: Analysis of 100 Consecutive Patients. J Gastrointest Surg [Internet]. 2014;19(1):161–70. Available from: http://link.springer.com/10.1007/s11605-014-2610-5

  22. Weisz G, Smilowitz NR, Kirtane AJ, Rinaldi MJ, Parvataneni R, Xu K, et al. Proton Pump Inhibitors, Platelet Reactivity, and Cardiovascular Outcomes after Drug-Eluting Stents in Clopidogrel-Treated Patients: The ADAPT-DES Study. Circ Cardiovasc Interv. 2015;8(10):1–8.

    Google Scholar 

  23. Lazarus B, Chen Y, Wilson FP, Sang Y, Chang AR, Coresh J, et al. Proton Pump Inhibitor Use and the Risk of Chronic Kidney Disease. JAMA Intern Med [Internet]. 2016;176(2):238. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26752337

  24. Abrahamsen B, Vestergaard P. Proton pump inhibitor use and fracture risk - effect modification by histamine H1 receptor blockade. Observational case–control study using National Prescription Data. Bone [Internet]. Elsevier B.V.; 2013;57(1):269–71. Available from: http://dx.doi.org/10.1016/j.bone.2013.08.013

  25. Ro Y, Eun CS, Kim HS, Kim JY, Byun YJ, Yoo K-S, et al. Risk of Clostridium difficile Infection with the Use of a Proton Pump Inhibitor for Stress Ulcer Prophylaxis in Critically Ill Patients. Gut Liver [Internet]. 2016;10(4):581–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27021503

  26. Weisz G, Smilowitz NR, Kirtane AJ, Rinaldi MJ, Parvataneni R, Xu K, et al. and Cardiovascular Outcomes After Drug-Eluting Stents The ADAPT-DES Study. 2016;1–8.

  27. Gomm W, von Holt K, Thomé F, Broich K, Maier W, Fink A, et al. Association of Proton Pump Inhibitors With Risk of Dementia. JAMA Neurol [Internet]. 2016;73(4):410–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26882076

  28. Csendes A, Braghetto I, Burdiles P, Korn O, Csendes P, Henríquez A. Very Late Results of Esophagomyotomy for Patients With Achalasia. Ann Surg. 2006;243(2):196–203.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgments

Dr. Schneider’s fellowship is supported by the Ryan Hill Foundation and the Foundation for Surgical Fellowships.

Drs. Schneider, Louie, Warren, Farivar, Schembre, and Aye have substantially contributed towards, reviewed, and approved this paper. They agree to be accountable towards ensuring accuracy and integrity of this work.

Author information

Authors and Affiliations

  1. Division of Thoracic Surgery, Swedish Cancer Institute, 1101 Madison Street, Suite 900, Seattle, WA, 98104, USA

    Andreas M. Schneider, Brian E. Louie, Heather F. Warren, Alexander S. Farivar & Ralph W. Aye

  2. Division of Gastroenterology, Swedish Medical Center, Seattle, WA, USA

    Drew B. Schembre

Authors
  1. Andreas M. Schneider
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Brian E. Louie
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Heather F. Warren
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Alexander S. Farivar
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Drew B. Schembre
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ralph W. Aye
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Brian E. Louie.

Additional information

Oral Presentation

Digestive Disease Week/SSAT

May 24, 2016, San Diego, CA, USA

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Schneider, A.M., Louie, B.E., Warren, H.F. et al. A Matched Comparison of Per Oral Endoscopic Myotomy to Laparoscopic Heller Myotomy in the Treatment of Achalasia. J Gastrointest Surg 20, 1789–1796 (2016). https://doi.org/10.1007/s11605-016-3232-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-016-3232-x

Keywords

Search

Navigation