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PERORAL ENDOSCOPIC MYOTOMY AND LAPAROSCOPIC HELLER MYOTOMY SHOW SIMILAR OUTCOMES IN TYPE III ACHALASIA
Archana Jeeji
*, Alexander S. Farivar, Emily M. Mackay, Adam J. Bograd, Peter T. White, Brian E. Louie
Thoracic Surgery, Swedish Medical Center, Seattle, WA
BACKGROUND
Achalasia is a neurodegenerative esophageal motility disorder classified into three manometric subtypes with variable treatment response. Studies have shown less favorable response to myotomy in patients with Type III compared to types I and II. Guidelines recommend peroral endoscopic myotomy (POEM) over laparoscopic Heller myotomy (HM) for the treatment of achalasia Type III due its ability to achieve a longer tailored proximal myotomy to treat the distal esophageal spasm characteristic of this subtype. However, there is limited evidence directly comparing these operations. Recent discussions have questioned the need for a longer myotomy. We aim to compare the treatment response to POEM vs HM in patients with Type III achalasia.
METHODS
We conducted a retrospective review of all consecutive patients undergoing primary myotomy for achalasia classified as Type III or achalasia variants with Type III features. The primary outcome was symptomatic response assessed using the Eckardt score (ES) with a score of ? 3 classified as success. The secondary outcome was need for re-intervention at 3 years.
RESULTS
There were 48 patients including Type III (38) and achalasia variants (9). Eighteen of 48 had POEM vs 30 who underwent HM. The groups were similar in age, sex and BMI (table 1).
Patients who underwent POEM and HM had similar pre-operative Eckardt scores (6 (5-7) POEM vs 6(4-8) HM, p=0.41). Myotomy lengths were similar between the groups (table 1).
After myotomy, both groups had similar rates of success defined as ES ? 3 (12/14 POEM vs 26/29 HM, p=0.70). The majority of patients had mild symptoms with an ES 0 or 1. The primary persisting symptom was dysphagia in patients who underwent both POEM and HM (table 2).
Re-interventions occurred in 4/18 (22.2%) of patients who underwent POEM compared to 5/30 (16.7%) who underwent HM, p=0.63. The majority of patients in both groups had symptomatic improvement after their last reintervention (table 2). One patient who underwent POEM had persistence of dysphagia and required an esophagectomy after which ES improved from 5 to 0. Another who underwent HM had persistent dysphagia despite balloon dilation, but symptoms remained mild with an ES of 4. They opted for no further interventions.
CONCLUSION
Patients with Type III achalasia who underwent HM had similar response to myotomy at 3 years compared to those who underwent POEM when treated with a standard 6cm (4cm esophageal and 2cm gastric) myotomy. There was no difference in re-interventions between the groups.
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