Outcomes of anterior versus posterior peroral endoscopic myotomy 2 years post-procedure: prospective follow-up results from a randomized clinical trial

Abstract

Background Peroral endoscopic myotomy (POEM) is considered a primary treatment modality for achalasia. It can be performed using either the anterior or posterior approach. A previous randomized clinical trial (RCT) showed that the posterior approach was noninferior to the anterior approach at 1 year post-POEM in terms of clinical success, rate of adverse event, and risk of gastroesophageal reflux disease (GERD). The aim of this post-RCT study was to compare outcomes at ≥ 2 years post-POEM.

Methods Patients who previously completed the 1-year follow-up were contacted and their Eckardt, dysphagia, and GERD questionnaire (GERDQ) scores and frequency of proton pump inhibitor use were recorded. Clinical success was defined as an Eckardt score < 3.

Results 150 patients were initially randomized and 138 completed the 1-year follow-up. Of the 138, 111 (anterior group 54, posterior group 57) also completed ≥ 2 years of follow-up, with an overall clinical success decrease from 89 % to 82 %. At ≥ 2 years post-POEM, clinical success was achieved in 46/54 (85 %) and 45/57 (79 %) in the anterior and posterior groups, respectively (P = 0.43). A similar decrease in clinical success was noted in both groups at ≥ 2 years (anterior: 90 % to 85 %; posterior 89 % to 79 %; P = 0.47). GERDQ score was 6 (interquartile range 6 – 8; P = 0.08) in both treatment groups.

Conclusions The anterior and posterior POEM techniques remained equally effective at 2 years and decreases in efficacy were similar between the two approaches over time. GERD outcomes were also similar in both groups during medium-term follow-up.

• References

• 1 Kahrilas PJ, Katzka D, Richter JE. Clinical practice update: the use of per-oral endoscopic myotomy in achalasia: expert review and best practice advice from the AGA Institute. Gastroenterology 2017; 153: 1205-1211
• 2 Zaninotto G, Bennett C, Boeckxstaens G. et al. The 2018 ISDE achalasia guidelines. Dis Esophagus 2018; 31
• 3 Khashab MA, Vela MF, Thosani N. et al. ASGE guideline on the management of achalasia. Gastrointest Endosc 2020; 91: 213-227.e6
• 4 Werner YB, Hakanson B, Martinek J. et al. Endoscopic or surgical myotomy in patients with idiopathic achalasia. N Engl J Med 2019; 381: 2219-2229
• 5 Rodriguez de Santiago E, Mohammed N, Manolakis A. et al. Anterior versus posterior myotomy during poem for the treatment of achalasia: systematic review and meta-analysis of randomized clinical trials. J Gastrointestin Liver Dis 2019; 28: 107-115
• 6 Mohan BP, Ofosu A, Chandan S. et al. Anterior versus posterior approach in peroral endoscopic myotomy (POEM): a systematic review and meta-analysis. Endoscopy 2020; 52: 251-258
• 7 Khashab MA, Sanaei O, Rivory J. et al. Peroral endoscopic myotomy: anterior versus posterior approach: a randomized single-blinded clinical trial. Gastrointest Endosc 2020; 91: 288-297.e7
• 8 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
• 9 Ramchandani M, Nabi Z, Reddy DN. et al. Outcomes of anterior myotomy versus posterior myotomy during POEM: a randomized pilot study. Endosc Int Open 2018; 6: E190-198
• 10 Tan Y, Lv L, Wang X. et al. Efficacy of anterior versus posterior per-oral endoscopic myotomy for treating achalasia: a randomized, prospective study. Gastrointest Endosc 2018; 88: 46-54
• 11 Rösch T, Repici A, Boeckxstaens G. Will reflux kill POEM?. Endoscopy 2017; 49: 625-628
• 12 Ichkhanian Y, Benias P, Khashab MA. Case of early Barrett cancer following peroral endoscopic myotomy. Gut 2019; 68: 2107-2110
• 13 Werner YB, Costamagna G, Swanstrom LL. et al. Clinical response to peroral endoscopic myotomy in patients with idiopathic achalasia at a minimum follow-up of 2 years. Gut 2016; 65: 899-906
• 14 Taft TH, Carlson DA, Triggs J. et al. Evaluating the reliability and construct validity of the Eckardt Symptom Score as a measure of achalasia severity. Neurogastroenterol Motil 2018; 30: e13287
• 15 Kumbhari V, Familiari P, Bjerregaard NC. et al. Gastroesophageal reflux after peroral endoscopic myotomy: a multicenter case–control study. Endoscopy 2017; 49: 634-642