Comparable risk of Barrett’s esophagus with dysplasia between peroral endoscopic myotomy (POEM) and Heller’s myotomy in achalasia: A propensity-matched analysis

Aims Barrett’s esophagus (BE), a known precursor to esophageal adenocarcinoma, is a potential long-term complication of esophageal motility disorders, particularly achalasia. Interventions like peroral endoscopic myotomy (POEM) and Heller’s myotomy aim to alleviate symptoms by addressing esophageal outflow obstruction, yet they may predispose patients to gastroesophageal reflux disease (GERD), a key risk factor for BE. While POEM has gained traction as a minimally invasive alternative with comparable efficacy to Heller’s myotomy, concerns persist about its higher propensity to induce GERD due to the absence of an anti-reflux mechanism. This raises critical questions regarding the relative risk of BE development post-intervention in POEM versus Heller’s myotomy, necessitating a comparative evaluation of their long-term impacts on risk of dysplasia.

Methods The study involved a cohort of patients that had achalasia with POEM based on international classification of disease (ICD) code and current procedural terminology (CPT) code in the national TriNetX database. Our POEM cohort was compared to a propensity-matched cohort of patients with Heller’s myotomy for achalasia. The risk of esophageal cancer and Barrett’s esophagus with dysplasia based on ICD code was analyzed.

Results 1,836 patients were identified to have had a POEM procedure performed for achalasia between January 2015 to October 2024 in a national database amongst 68 health care organisations in the United States. The mean age of patients in the POEM cohort was 58.3 years and 44.7% were female. The median follow up following POEM was 188.0 days (IQR 0.0 – 604.0) compared to Heller’s myotomy 869.0days (IQR 0.0 – 2861.0days). Compared to a propensity score matched cohort of patients that had a Heller’s myotomy for achalasia the absolute risk was 0.005 for both groups with the risk ratio being 1.0 (95%CI 0.42 – 2.40).

Conclusions Despite the shorter median follow-up for POEM, being a more recent procedure compared to Heller’s myotomy, our data suggest that the risk of Barrett’s esophagus with dysplasia is comparable between the two interventions. These findings indicate that while POEM which is known to have a higher propensity for GERD, its long-term impact on the development of Barrett’s esophagus appears similar to Heller’s myotomy. Further studies with extended follow-up are warranted to confirm these results and assess the progression of reflux-related complications in post-intervention achalasia patients.

Publication History

Article published online:
27 March 2025