POEM more successful than pneumatic dilatation as initial treatment for achalasia

CHICAGO — Per-oral endoscopic myotomy, or POEM, showed a significantly higher success rate at 1 year compared with the gold standard pneumatic dilatation in achalasia patients who have not received prior treatment, according to the results of a randomized controlled trial presented at Digestive Disease Week.

However, reflux esophagitis developed much more frequently in patients who were treated with POEM, the researchers noted.

POEM “is a new treatment for achalasia [and] case series suggest excellent short term results, but data comparing POEM with the gold standard treatment pneumatic dilatation are lacking,” Albert Jan Bredenoord, MD, of the department of gastroenterology and hepatology at the Academic Medical Center in Amsterdam, said during his presentation.

Therefore, to compare the efficacy of POEM with pneumatic dilatation as an initial therapy in patients with achalasia, Bredenoord and colleagues randomly assigned 133 patients recently diagnosed with idiopathic achalasia by high-resolution manometry to undergo POEM or pneumatic dilatation with a 30 mm to 35 mm dilatation protocol.

Three patients were never treated with POEM, one because of a health insurance issue, one because of complications of an unrelated orthopedic surgery unrelated, and one who emigrated to Australia, Bredenoord noted.

Overall, 98.4% of the POEM group achieved treatment success compared with 78.8% of the pneumatic dilatation group at 3 months (P < .01). A small subgroup of patients with type 3 achalasia also had higher treatment success with POEM, Bredenoord said.

One patient who underwent pneumatic dilatation was hospitalized for a perforation, and another was hospitalized for severe chest pain. No severe adverse events related to POEM occurred.

At 1 year, patients in both groups who were still in clinical remission showed comparable integrated relaxation pressure, barium column height and symptoms as assessed by the Eckardt score, including weight loss, dysphagia, retrosternal pain and regurgitation.

However, at 1 year, patients underwent endoscopy after discontinuing PPIs for at least a week, and findings showed significantly more patients treated with POEM had reflux esophagitis (40% grade A/B; 8.3% grade C/D) compared with patients treated with pneumatic dilatation (13.1% grade A/B; 0% grade C/D; P < .02).

“POEM results in a significantly higher 1-year therapeutic success rate compared to pneumatic dilatation and development of reflux esophagitis off PPIs is seen much more frequently after POEM than after pneumatic dilatation.” Bredenoord said. “I can conclude that POEM is safe, effective, and may be considered as a first-line treatment in idiopathic achalasia, and after POEM, follow-up screening for reflux esophagitis is certainly recommended.” – by Adam Leitenberger

Reference:

Ponds FAM, et al. Abstract #637. Presented at: Digestive Disease Week; May 6-9, 2017; Chicago.

Disclosures: Bredenoord reports financial relationships with Nutricia, Medical Measurement Systems, Bayer, Allergan, Astellas, AstraZeneca and Almirall.