COMPARING COST AND OUTCOMES BETWEEN PERORAL ENDOSCOPIC MYOTOMY AND LAPAROSCOPIC HELLER MYOTOMY
Mikhail Attaar*1,2, Bailey Su1,2, Harry Wong1,2, Kristine Kuchta3, Woody Denham1, John G. Linn1, Michael Ujiki1
1NorthShore University Health System, Evanston, IL; 2University of Chicago Medical Center, Chicago, IL; 3NorthShore University Research Institute, Evanston, IL
Background and Aims: Peroral endoscopic myotomy (POEM) is an endoscopic treatment for achalasia and other esophageal motility disorders. Multiple studies have established its efficacy and safety compared to laparoscopic Heller myotomy (LHM), the gold standard treatment. However, most cost analysis studies have shown POEM to be equally if not more expensive than LHM when performed in the operating room. We aim to compare outcomes and charges between POEM and LHM at a single institution.
Methods: A retrospective review of a prospectively maintained gastroesophageal database was performed. Outcomes and charge data of 31 patients who underwent LHM and 101 patients who underwent POEM between March 2010 and September 2019 were analyzed. All procedures were performed by a single surgeon. Patients in either group who had significant perioperative complications or who did not present electively were excluded to reflect standard patient charges. Cohorts were compared using the t-test and multivariable linear regression.
Results: There was no difference in age, sex, BMI, preoperative Eckardt score or achalasia type between groups. Patients who underwent POEM had a significantly longer mean length of myotomy (12.9±4.6 vs 10.2±1.3 cm, p<0.01), shorter mean operative time (83±43 vs 141±36 minutes, p<0.01), lower median estimated blood loss (0 vs 25 mL, p<0.01), and shorter median length of stay (1 vs 2 days, p<0.01). Additionally, patients who underwent POEM had less pain at discharge (p=0.03), stopped narcotic medications earlier (p=0.01), and had a faster return to activities of daily living (p<0.01). The mean charges of POEM (25.7 ± 5.6 in thousands) and LHM (28.0 ± 6.7 in thousands) during the index admission were not significantly different (p=0.06). However, on multivariable analysis, when adjusting for age, sex, BMI, smoking status and achalasia type, POEM was found to incur $2,625±$1,201 less in charges than LHM (p=0.03). LHM mean charges were significantly higher in the categories of operating room services, anesthesia, pharmacy, room and board, laboratory and respiratory services; POEM had higher mean charges in the categories of medical/surgical supplies and recovery room (Figure 1). In specifically analyzing the medical/surgical supplies, 46.1% of the charges in the POEM cohort were due to the endoscopic clips that were used to close the mucosotomy.
Conclusion: In our cohort, patients who underwent POEM compared to LHM have significantly better perioperative outcomes in terms of operative time, blood loss, length of stay and pain. Additionally, when controlling for patient factors, we found that POEM incurs lower charges than LHM. In the category of medical/surgical supplies, the main driver of charges in the POEM cohort are the endoscopic clips.
Figure 1
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