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POEM effective in spastic esophageal disorders
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SAN DIEGO — Per-oral endoscopic myotomy is a safe and effective treatment for esophagogastric junction outflow obstruction and spastic esophageal disorders, like jackhammer esophagus and type 3 achalasia, according to research presented at Digestive Disease Week.
Saurabh Chandan, MD, of the department of gastroenterology and hepatology at the University of Nebraska Medical Center, said current guidelines recommend that POEM should be considered for treating any of the achalasia syndromes, as long as the appropriate expertise is available, and recent reports have shown successful outcomes with POEM in patients with spastic esophageal disorders.
“Management of these disorders with standard pharmacologic and endoscopic therapy is challenging with failure being reported as high as 74%,” he said in his presentation. “It remains unclear if patients with prior endoscopic or pharmacological intervention do better or worse when compared to treatment-naive patients.”
The researchers performed a systematic review and meta-analysis to determine the overall efficacy of POEM in spastic esophageal disorders and esophagogastric junction outflow obstruction (EGJOO). They also explored whether variation in total average myotomy length and total operative time had any link to clinical outcomes.
Chandan and colleagues searched the literature for studies that included the outcome of pooled rate of clinical success with POEM, defined by an Eckhardt score 3 or less at follow up. They included myotomy length and operative time as secondary outcomes. They identified 11 studies comprising 290 patients that fit their criteria.
Investigators found that the overall pooled rate of clinical success for POEM was 85.5% (95% CI, 80.2%–89.6%). They found no significant difference in clinical success based on myotomy length, with lengths of less than 10 cm, 10 cm to 15 cm and greater than 15 cm having success rates of 91.1%, 84% and 88.6%, respectively. The same was true for operative time. The success rate was 88.9% for procedures that took less than 60 minutes, 88.7% for procedures that took 60 to 120 minutes and 84.4% for procedures that took longer than 120 minutes.
Looking at each individual disorder, Chandan and colleagues found that POEM was successful in 93.7% of patients with type 3 achalasia, 96.1% of patients with diffuse esophageal spasm, 71.4% of patients with jackhammer esophagus and 93.3% of patients with EGJOO. The pooled rate of adverse events was 14.2%.
“POEM is a safe and effective treatment modality for patients with spastic esophageal disorders and EGJ outflow obstruction,” Chandan concluded. “Based on our analysis, variation in total myotomy length or operative time had no correlation to clinical success.” – by Alex Young
Reference:
Chandan S, et al. Abstract 469. Presented at: Digestive Disease Week; May 18-21, 2019; San Diego.
Disclosures: Chandan reports no relevant financial disclosures. Please see the meeting disclosure index for all other authors’ relevant financial disclosures.
Perspective
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Kenneth DeVault, MD, FACG
The treatment of achalasia concentrates on endoscopic or surgical methods to relieve the muscular obstruction caused by a poorly relaxing lower esophageal sphincter (LES). Per-oral endoscopic myotomy (POEM) is a new endoscopic technique that achieves that goal using an endoscope to incise the muscle of the LES rather than laparoscopic surgery or balloon-based dilation. It is becoming the treatment of choice in many centers.
There are patients with dysphagia who have spastic esophageal disorders that produce symptoms but are not classic achalasia. This includes type III achalasia, which was formerly known as “vigorous achalasia” as well other less well-defined disorders such as distal spasm and jackhammer (high-pressure) esophagus.
This study is a systematic review and meta-analysis of the outcomes of POEM therapy on patients with spastic esophageal disorders other than type I or II achalasia. They found a success rate of 85% that did not vary depending on the length of the myotomy or the operative time.
The esophageal abnormalities treated in this analysis have recently been redefined by high-resolution manometry, but this patient population has been present for many years. Surgery has rarely been offered in the past (either open or using less invasive approaches). Why are these data so good when the non-POEM approach to myotomy was rarely offered and of questionable efficacy? First, the patients may be different or at a different place in their disease, although this does not seem that likely. It is also possible that the technique is better (maybe provides a longer or more complete myotomy and has a lower morbidity). Finally, the lack of placebo control in many of these studies raises the concern of false-positive findings. Referring well-selected patients to centers with expertise in these techniques is reasonable. Because even classic achalasia tends to recur after definitive, surgical or endoscopic therapy, ensuring patients understand that some of the conditions are likely not “curable” and ongoing follow-up is important. Further, POEM certainly predisposes to acid reflux and patients need to be followed and treated for this expected side effect of the surgery.
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