POEM vs laparoscopic Heller-Dor in the treatment for esophageal achalasia: long term results (> 5 years) of a comparative study using propensity score

Aims A recent RCT comparing POEM and laparoscopic Heller-Dor fundoplication (LHD) showed similar outcome results but with both techniques. This was also shown by a previous case-control study with propensity score (PS) by our group. However, both studies were limited by a short follow-up. The aim of the present study was therefore to reassess our patients at a minimum 5-year follow-up.

Methods Two groups of consecutive patients undergoing treatment for primary achalasia from January 2014 to November 2017 were recruited in two high-volume centers, one with extensive experience with POEM and one with LHD. Patients with previous endoscopic treatment were included, whereas patients with previous LHD or POEM were excluded. One-hundred and forty patients for each center were matched with PS (Caliper 0.2). The patients were followed with clinical (Eckardt score), endoscopic, and pH-manometry evaluations. Failure was defined as an Eckardt score<3 or the need for further treatment. Only those patients who reached a minimum 5-year follow-up were considered in this study.

Results A total of 68 patients in the POEM group and 118 in the LHD had at least 5 years of follow-up and formed the study population. One patient in both groups died during the follow-up for causes unrelated to achalasia. At a median follow-up of 79.6 months [IQR 42.1-103.95], 87.3% of the POEM patients and 90.1% of the LHD patients showed an Eckardt score≤3 (p=n.s.). The need for PPIs was higher in the POEM group than in the LHD group (45.6% vs 24.6%, p 0.03) and esophagitis was found in 34% of the POEM and 10.4% of LHD patients (p<0.002) (Table 1). None of the patients developed esophageal cancer.

Conclusions POEM provides the same long-term results as LHD. This study confirms, however, a higher incidence of post-operative GERD with the former, even if its real significance needs to be further evaluated.

Publication History

Article published online:
27 March 2025