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POEM VS LAPAROSCOPIC HELLER-DOR IN THE TREATMENT FOR ESOPHAGEAL ACHALASIA: LONG TERM RESULTS (> 5 YEARS) OF A COMPARATIVE STUDY USING PROPENSITY SCORE
Andrea Costantini
*1, Francesca Mangiola
2, Giovanni Capovilla
1, Rosario Landi
2, Luca Provenzano
1, Loredana Nicoletti
1, Michele Valmasoni
1, Cristiano Spada
2, Mario Costantini
1, Pietro Familiari
2, Renato Salvador
11Azienda Ospedale Universita Padova, Padova, Veneto, Italy; 2Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Lazio, Italy
Background: A recent RCT comparing POEM and Laparoscopic Heller-Dor (LHD) showed similar outcome results with both techniques. This was also shown in 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 > 5-year follow-up.
Methods: Two groups of consecutive patients undergoing treatment for primary achalasia from 2014 to 2017 were recruited in two high-volume centers, one with extensive experience with POEM and one with LHD. Patients with previous "traditional" endoscopic treatments were included, whereas patients with previous POEM or LHD 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 manometry-pH evaluations. Survival curves (as freedom from symptoms) were calculated with the Kaplan-Meier method and compared with the log-rank test for the whole population. Only those patients who reached more than 5-year follow-up were particularly 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.) (Figure 1). 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. One patient in the POEM group and 6 patients in the LHD one recurred within 3 years of follow-up. At a longer follow-up (> 5 years), 8 additional patients in the POEM group and 6 in the LHD group showed recurrence of symptoms, leading to 12.7% and 9.9% of failures, respectively (p = n.s., Figure 1).
Conclusion: At > 5-year follow-up POEM provides similar symptom relief to LHD in achalasia patients. This study confirms, however, a higher incidence of post-operative GERD with the former, even if its real significance needs to be further evaluated.
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