The effect of prior treatment on clinical outcomes in patients with achalasia undergoing peroral endoscopic myotomy

Abstract

Background Peroral endoscopic myotomy (POEM) is a treatment option for patients with previous surgical or endoscopic treatment. We aimed to evaluate the influence of prior treatment on perioperative and follow-up outcomes in patients undergoing POEM.

Methods From August 2010 to December 2014, a total of 1384 patients with achalasia underwent POEM at our center. We retrospectively reviewed 849 patients who completed follow-up. Patients with an Eckardt score ≥ 4 after POEM were considered to have a clinical failure. We compared variables between patients with and without prior treatment. We analyzed risk factors for perioperative major adverse events, and clinical reflux and failure during follow-up. 

Results 245 patients (28.9 %) had undergone prior treatment, and 34 patients (4.0 %) experienced a major adverse event associated with the POEM procedure. During a median follow-up of 23 months (range 1 – 71), clinical reflux occurred in 203 patients (23.9 %) and clinical failure was recorded for 94 patients (11.1 %). Patients with prior treatment had a longer procedure duration (P = 0.001) and longer hospital stay after POEM (P = 0.001). Prior treatment was not an independent risk factor for major adverse events or clinical reflux (odds ratio [OR] 1.19, P = 0.65; OR 1.26, P = 0.19; logistic regression), but it did increase the rate of clinical failure during follow-up (hazard ratio 1.90, P = 0.002; Cox regression).

Conclusions POEM was performed safely with a low rate of major adverse events in patients with achalasia who had undergone prior surgical or endoscopic treatment. However, prior treatment increased the risk of clinical failure after POEM.

^* These authors contributed equally to this work.

• References

• 1 Bechara R, Ikeda H, Inoue H. Peroral endoscopic myotomy: an evolving treatment for achalasia. Nat Rev Gastroenterol Hepatol 2015; 12: 410-426
• 2 Bechara R, Onimaru M, Ikeda H. et al. Per-oral endoscopic myotomy, 1000 cases later: pearls, pitfalls, and practical considerations. Gastrointest Endosc 2016; 84: 330-338
• 3 Li QL, Zhou PH. Perspective on peroral endoscopic myotomy for achalasia: Zhongshan experience. Gut Liver 2015; 9: 152-158
• 4 Ngamruengphong S, Inoue H, Chiu PW. et al. Long-term outcomes of per-oral endoscopic myotomy in patients with achalasia with a minimum follow-up of 2 years: an international multicenter study. Gastrointest Endosc 2017; 85: 927-933
• 5 Familiari P, Gigante G, Marchese M. et al. Peroral endoscopic myotomy for esophageal achalasia: outcomes of the first 100 patients with short-term follow-up. Ann Surg 2016; 263: 82-87
• 6 Von Renteln D, Fuchs KH, Fockens P. et al. Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study. Gastroenterology 2013; 145: 309-311
• 7 Orenstein SB, Raigani S, Wu YV. et al. Peroral endoscopic myotomy (POEM) leads to similar results in patients with and without prior endoscopic or surgical therapy. Surg Endosc 2015; 29: 1064-1070
• 8 Zhou PH, Li QL, Yao LQ. et al. Peroral endoscopic remyotomy for failed Heller myotomy: a prospective single-center study. Endoscopy 2013; 45: 161-166
• 9 Jones EL, Meara MP, Pittman MR. et al. Prior treatment does not influence the performance or early outcome of per-oral endoscopic myotomy for achalasia. Surg Endosc 2016; 30: 1282-1286
• 10 Sharata A, Kurian AA, Dunst CM. et al. Peroral endoscopic myotomy (POEM) is safe and effective in the setting of prior endoscopic intervention. J Gastrointest Surg 2013; 17: 1188-1192
• 11 Kristensen HO, Kirkegard J, Kjaer DW. et al. Long-term outcome of peroral endoscopic myotomy for esophageal achalasia in patients with previous Heller myotomy. Surg Endosc 2017; 31: 2596-2601
• 12 Ngamruengphong S, Inoue H, Ujiki MB. et al. Efficacy and safety of peroral endoscopic myotomy for treatment of achalasia after failed Heller myotomy. Clin Gastroenterol Hepatol 2017; 15: 1531-1537
• 13 Nabi Z, Ramchandani M, Chavan R. et al. Peroral endoscopic myotomy in treatment-naive achalasia patients versus prior treatment failure cases. Endoscopy 2018; 50: 358-370
• 14 Zhang X, Modayil RJ, Friedel D. et al. Per-oral endoscopic myotomy in patients with or without prior Heller’s myotomy: comparing long-term outcomes in a large US. single-center cohort (with videos). Gastrointest Endosc 2018; 87: 972-985
• 15 Ren Y, Tang X, Chen Y. et al. Pre-treatment Eckardt score is a simple factor for predicting one-year peroral endoscopic myotomy failure in patients with achalasia. Surg Endosc 2017; 31: 3234-3241
• 16 Zhang XC, Li QL, Xu MD. et al. Major perioperative adverse events of peroral endoscopic myotomy: a systematic 5-year analysis. Endoscopy 2016; 48: 967-978
• 17 Li QL, Wu QN, Zhang XC. et al. Outcomes of per-oral endoscopic myotomy for treatment of esophageal achalasia with a median follow-up of 49 months. Gastrointest Endosc 2018; 87: 1405-1412
• 18 Jones R, Junghard O, Dent J. et al. Development of the GerdQ, a tool for the diagnosis and management of gastro-oesophageal reflux disease in primary care. Aliment Pharmacol Ther 2009; 30: 1030-1038
• 19 Emami MH, Raisi M, Amini J. et al. Pneumatic balloon dilation therapy is as effective as esophagomyotomy for achalasia. Dysphagia 2008; 23: 155-160
• 20 Boeckxstaens GE, Annese V, des VarannesSB. et al. Pneumatic dilation versus laparoscopic Heller’s myotomy for idiopathic achalasia. N Engl J Med 2011; 364: 1807-1816
• 21 Borges AA, Lemme EM, Abrahao LJ. et al. Pneumatic dilation versus laparoscopic Heller myotomy for the treatment of achalasia: variables related to a good response. Dis Esophagus 2014; 27: 18-23
• 22 Inoue H, Sato H, Ikeda H. et al. Per-oral endoscopic myotomy: a series of 500 patients. J Am Coll Surg 2015; 221: 256-264
• 23 Veenstra BR, Goldberg RF, Bowers SP. et al. Revisional surgery after failed esophagogastric myotomy for achalasia: successful esophageal preservation. Surg Endosc 2016; 30: 1754-1761
• 24 Kilic A, Schuchert MJ, Pennathur A. et al. Long-term outcomes of laparoscopic Heller myotomy for achalasia. Surgery 2009; 146: 826-833
• 25 Nau P, Rattner D. Laparoscopic Heller myotomy as the gold standard for treatment of achalasia. J Gastrointest Surg 2014; 18: 2201-2207