PERORAL ENDOSCOPIC MYOTOMY (POEM) AND LAPAROSCOPIC HELLER MYOTOMY WITH DOR FUNDOPLICATION FOR ESOPHAGOGASTRIC JUNCTION OUTFLOW OBSTRUCTION (EGJOO): A COMPARISON OF OUTCOMES AND IMPACT ON PHYSIOLOGY
Inanc Sarici*1, Sven Eriksson1, Mohamad Rassoul Abu-Nuwar1, Ping Zheng1, Toshitaka Hoppo1,2, Ali H. Zaidi1,2, Blair Jobe1,2, Shahin Ayazi1,2
1Esophageal Institute, Allegheny Health Network, Pittsburgh, PA; 2Department of Surgery, Drexel University, Philadelphia, PA
Introduction: Esophagogastric junction outflow obstruction (EGJOO) is a motility disorder characterized by elevated lower esophageal sphincter (LES) integrated relaxation pressure with preserved esophageal peristalsis. Studies have shown that Heller myotomy with Dor fundoplication (HMD) and per oral endoscopic myotomy (POEM) are effective treatments for EGJOO. However, there is paucity of data comparing the efficacy and impact of these two procedures. Therefore, the aim of this study was to compare outcomes and impact on esophageal physiology in patients undergoing HMD or POEM for primary EGJOO.
Methods: This was a retrospective review of patients who underwent either HMD or POEM for primary functional EGJOO at our institution between 2013 and 2021. Favorable outcome was defined as a postoperative Eckardt score ≤ 3 at one year. Gastroesophageal reflux disease-health-related quality of life (GERD–HRQL) questionnaire, endoscopy, 48-hour Bravo pH monitoring, and high-resolution manometry (HRM) results at baseline and 1-year after surgery were compared between groups. Objective GERD was defined as DeMeester score >14.7 or LA grade C/D esophagitis.
Results: The final study population consisted of 52 patients who underwent HMD (n=35) or POEM (n=17) for EGJOO. At a mean (SD) follow-up of 13.2 (2.9) months, clinical success was achieved by 30 (85.7%) patients after HMD and 14 (82.4%) after POEM (p=0.753). Esophageal myotomy length was longer in the POEM group [11 (7-15) vs. 5 (5-6) cm, p=0.001]. The POEM group had a shorter median (IQR) hospital stay [1 (1-1) vs. 2 (1-2) day, p=0.001]. Need for additional procedures (p=1.000), perioperative complications (p=0.327) and readmissions (p=1.000) were similar between groups.
Preoperatively, the HMD group had higher median (IQR) GERD-HRQL total scores [31.0 (21.5-45.0) vs. 16.5 (10.0-26.0); p= 0.019]. However, postoperative GERD-HRQL scores were similar [4.0 (0.0-19.0) vs. 11.0 (2.0-18.0), p=0.370]. There were no patients who had preoperative objective GERD in the POEM group, but there were 19 (54.2%) in the HMD group (p=0.001). By contrast, the POEM group had the higher rate of objective GERD, postoperatively (61.5% vs. 25.9%, p=0.041).
Preoperative manometry findings were similar between groups. Postoperatively, the POEM group had significantly higher rates of median (IQR) ineffective swallows [100 (60-100) vs. 10 (0-20), p=0.006] and incomplete bolus clearance [90 (90-100) vs. 10 (0-40), p=0.004], and lower median (IQR) percent peristalsis [10 (0-80) vs. 90 (60-100), p=0.014] and mean wave amplitude [26.8 (11.8-33.0) vs. 79.9 (66.3-130.2) mmHg, p=0.003]. All other HRM findings were comparable.
Conclusion: Peroral endoscopic myotomy and Heller myotomy with Dor fundoplication are equally effective at relieving EGJOO. However, in POEM relief comes at the cost of the reflux barrier and esophageal body function.
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