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Matched Comparison of Per Oral Endoscopic Myotomy to Laparoscopic Heller Myotomy for the Treatment of Achalasia - Early Subjective and Objective Outcomes
Andreas M. Schneider^*1, Brian E. Louie¹, Heather F. Warren¹, Alexander S. Farivar ¹, Drew B. Schembre², Ralph W. Aye^1
1Thoracic Surgery, Swedish Medical Center, Seattle, WA; ²Gastrointestinal, Swedish Medical Center, Seattle, WA

Background: Per Oral Endoscopic Myotomy (POEM) is a novel treatment for achalasia that is being increasingly utilized. Early results have demonstrated significant improvements in the patient’s ability to swallow, but there is concern and evidence that patients undergoing POEM may have significant reflux postoperatively. Currently, there is only limited comparative data to laparoscopic Heller myotomy (LHM) to provide context to these concerns. We sought to compare our short term outcomes with POEM to laparoscopic Heller myotomy with partial fundoplication.
Methods: We retrospectively reviewed outcomes from a prospectively maintained database of consecutive patients with achalasia undergoing primary myotomy. Data on 32 POEM (2014-2015) and 120 LHM (2003-2015) patients was reviewed and matched based on the Chicago classification subtype, Eckardt score, QOLRAD, GERD-HRQL and Dysphagia scores. Analyses were conducted at the 6-12 month follow up using the outcomes of quality of life, Eckardt scores, PPI use, pH scores and endoscopic esophagitis.
Results: We matched 25 POEM patients to 25 LHM patients according to achalasia subtypes I (5/5), II (14/14), and III (6/6). Gender distribution (M/F), mean age and BMI for POEM was 14/11, 54.8 years and 27.8 and for LHM was 10/15, 51.7 years and 24.6, these were comparable. In the LHM group 20 Dor and 5 Toupet fundoplications were performed.
Compared to preoperative values the postoperative Eckhardt scores, QOL metrics and swallowing ability significantly improved in both groups (Table 1). The postoperative values were also comparable between the groups (Table 1). However in the POEM group, DeMeester scores were numerically higher, EGD revealed esophagitis in 53.3% of POEM patients and 26.7% LHM patients and PPI use was 36.9% (POEM) and 21.7% (LHM).
Conclusion: Patients with achalasia undergoing POEM or LHM achieve significant improvement in quality of life and Eckhardt scores along with palliation of their swallowing function in early clinical follow up. Although objective testing appears similar between the groups, the presence of esophagitis and higher PPI use in the POEM group suggests that ongoing and longer term follow up is required.
Table 1

Subjective
MEAN	POEM			LAP HELLER MYOTOMY			Post Operative Comparison
	Pre	Post	p-value	Pre	Post	p-value	p-value
Eckhardt Score	6.38	1.01	<0.001	6.5	1.22	<0.001	0.77
QOLRAD	4.19	6.24	<0.001	3.62	6.55	<0.001	0.36
GERD HRQL	16.06	5.95	0.002	20.68	5.62	0.003	0.9
Swallowing	13.72	30.8	<0.001	12.62	35.29	<0.001	0.27
Objective
Mean	POEM			LAP HELLER MYOTOMY			Post Operative Comparison
	Post operative			Post Operative			p-value
DeMeester Score	23.06			16.07			0.66
Total time <4%	6.18			11.15			0.55

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