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DECISION REGRET FOR PATIENTS UNDEROING PER ORAL ENDOSCOPIC MYOTOMY AND LAPAROSCOPIC HELLER MYOTOMY
Sullivan A. Ayuso
*, Miracle Burt, Kristine Kuchta, Jean-Christophe Rwigema, Derrius Anderson, Jonathan Chao, Joann Carbray, Natalie Liu, H. Mason Hedberg, Michael Ujiki
Surgery, NorthShore University HealthSystem, Evanston, IL
Background: Per oral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM) are the main endoscopic and surgical options for patients with achalasia and other motility disorders disrupting esophagogastric outflow. When comparing the procedures, LHM with fundoplication has lower rates of postoperative reflux while POEM has decreased morbidity. Decision Regret (DR) aims to elicit whether a patient feels remorse about some aspect of their decision. The objective of this study is to assess and compare rates of DR for patients undergoing LHM and POEM.
Methods: A prospectively maintained single-institution database was queried for all patients undergoing LHM and POEM from 2011-2024. Basic demographic and procedural information were obtained. The primary outcome of the study was DR, which was measured using the validated Brehaut Decision Regret Scale. Scores from a Likert scale were dichotomized to "no regret" (score of 5) or "some regret" (score 1-4). Secondary outcomes included reasons for regret. Standard statistical methods were used, and a multivariable analysis (MVA) was performed to identify predictors of DR.
Results: Of the 270 patients (225 POEM, 45 LHM) in this time period, 135 responded to the survey. There were 104 who underwent POEM and 31 who underwent LHM (48.2% Dor, 48.2% Toupet, 3.6% Roux-en-Y). The mean age for all patients was 57.0±20.0 years with mean BMI of 27.4±6.3 and median Eckhardt Score of 6.0 (IQR 4.5-8.0). The most common pre-procedure diagnoses were Type 2 achalasia (60.7%), Type 1 achalasia (15.6%), Type 3 achalasia (8.2%), esophagogastric junction outflow obstruction (EGJOO) (6.7%), and achalasia with unknown subtype (5.2%).
For all patients, 81.5% did not endorse any DR. Patients who underwent POEM had a higher rate of DR (22.1% vs 6.5%, p=0.04). Of the two LHM with reported DR, reasons for regret included perforation, prolonged hospital stay, and need for subsequent procedure. The most common reasons for DR in the POEM group were postprocedure reflux (65.3%), persistent symptoms (26.1%), myotomy blowout (4.3%), and perforation (4.3%). On MVA, type 1 achalasia (95% CI 1.58-15.00; p=0.01) and EJGOO (95% CI 1.62-35.9; p-0.01) were predictors of DR but POEM was not a predictor of DR. All but nine (6.7%) patients would undergo the procedure again; all these patients were in the POEM group.
Conclusions: Over 80% of patients undergoing LHM and POEM did not exhibit DR following their procedure and would choose to undergo the procedure again. Compared to patients undergoing LHM, POEM patients exhibited more DR, which was most strongly linked to post-procedure reflux. POEM did not remain an independent predictor of DR on MVA.
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