Peroral endoscopic myotomy versus pneumatic dilation – result from a retrospective study with 1-year follow-up

 

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Abstract

Background and aims On the basis of lesser rates of major adverse events and a short-term efficacy as Heller’s myotomy, there is a growing enthusiasm in favor of peroral endoscopic myotomy (POEM), whereas study comparing POEM and pneumatic dilatation (PD) is quite rare. The aim of this study was to evaluate the efficacy of POEM and PD in Chinese achalasia patients in a retrospectively designed study.

Methods Patients with achalasia, who underwent either PD (n = 26) or POEM (n = 40) were retrospectively recruited from September 2010 through March 2016 at a single tertiary center. During the 1-year follow-up, clinical outcome and functional data of lower esophageal sphincter (LES) were recruited. Clinical symptoms were assessed by use of the Eckardt score. The primary outcome was therapeutic success (Eckardt score ≤ 3). Functional data of LES (4-second integrated relaxation pressure [4s-IRP], LES relax rate, and LESP) at baseline and 1 month after treatment were also evaluated. Data was analyzed by SPSS 13.0 version using a significance level of p < 0.05.

Results The success rates were 24/26 (92.31 %), 25/26 (96.15 %), and 24/26 (92.31 %), respectively, with POEM, as compared with 35/40 (87.50 %), 29/40 (72.50 %), and 23/40 (57.50 %), respectively, with PD, 1 month, 3 months, and 1 year after treatment. Statistically significant difference was observed between the 2 therapies (at 3 months, Fisher’s exact test, p = 0.01; at 1 year, Fisher’s exact test, p < 0.0001). Compared with PD, the Eckardt score was lower with POEM 1 month, 3 months, and 1 year after treatment. More patients in POEM group reported gastroesophageal reflux symptoms (after 3 months 7/26 (26.92 %) vs. 2/40 (5.00 %), Fisher’s exact test, p = 0.01; after 1 year 6/26 (19.23 %) vs. 1/35 (2.86 %), Fisher’s exact test, p = 0.02). The postoperative 4s-IRP and LESP were both lower with POEM than with PD, respectively. Type I achalasia had a better response with POEM than with PD.

Conclusion In this retrospective analysis with 1-year follow-up, POEM presents with a higher success rate and more reflux symptoms compared with PD. Change on LES function after treatment may explain the outcome in part. Type I achalasia may respond better to therapies compared with type II.

Zusammenfassung

Hintergrund und Ziele Aufgrund des geringeren Risikos schwerer unerwünschter Ereignisse und der kurzfristigen Wirksamkeit im Vergleich zur Myotomie nach Heller, wird die perorale endoskopische Myotomie (POEM) in letzter Zeit immer beliebter. Dagegen liegen kaum Studien vor, in denen POEM mit Ballon­dilatation verglichen wurde. Ziel der vorliegenden retrospektiven Studie war die Evaluation der Effizienz von POEM und Ballondilatation bei Achalasie-Patienten in China.

Methoden Von September 2010 bis März 2016 wurden Achalasie-Patienten, die entweder mittels Ballondilatation(n = 26) oder POEM (n = 40) behandelt worden waren, retrospektiv in einem Tertiärzentrum rekrutiert. Während des einjährigen Follow-ups wurden klinisches Outcome und Funktionsdaten des unteren Ösophagussphinkters erhoben. Klinische Symptome wurden mithilfe des Eckardt Scores bewertet. Primäres Outcome war der therapeutische Erfolg (Eckardt Score ≤ 3). Ebenso wurden die Funktionsdaten des unteren Ösophagussphinkters (4s-IRP, LESRR und LESP) an der Baseline und einen Monat nach der Behandlung evaluiert. Die Daten wurden mit dem Statistical Package for Social Sciences (SPSS) Version 13.0 unter Anwendung eines Signifikanzniveaus von P < 0,05 analysiert.

Ergebnisse Die Erfolgsraten betrugen 24/26 (92,31 %), 25/26 (96,15 %) und 24/26 (92,31 %) jeweils bei POEM, im Vergleich zu 35/40 (87,50 %), 29/40 (72,50 %) und 23/40 (57,50 %) jeweils bei Ballondilatation, einen Monat, drei Monate und ein Jahr nach der Behandlung. Es konnte ein statistisch signifikanter Unterschied zwischen den beiden Therapien festgestellt werden (nach drei Monaten, exakter Test nach Fisher, P = 0.01; nach einem Jahr, exakter Test nach Fisher, P < 0.0001）. Im Vergleich zur Ballondilatation war der Eckardt Score bei POEM einen Monat, drei Monate und ein Jahr nach der Behandlung niedriger. In der POEM-Gruppe gaben mehr Patienten gastro-ösophageale Refluxsymptome an (nach drei Monaten 7/26 (26.92 %) versus 2/40 (5.00 %), exakter Test nach Fisher, P = 0.01; nach einem Jahr 6/26 (19.23 %) versus 1/35 (2.86 %), exakter Test nach Fisher, P = 0.02). Der postoperative 4s-IRP und LESP waren beide bei POEM niedriger im Vergleich zu den entsprechenden Werten bei Ballondilatation. Typ II Achalasie hatte bei POEM eine bessere Responserate als bei Ballondilatation.

Schlussfolgerung In dieser retrospektiven Studie mit einem einjährigen Follow-up zeigte POEM eine höhere Erfolgsrate und mehr Refluxsymptome im Vergleich zur Ballondilatation. Eine veränderte Funktionsweise des unteren Ösophagussphinkters könnte dieses Ergebnis teilweise erklären. Typ I Achalasie spricht möglicherweise besser auf Therapien an als Typ II.

^* Co-first authors.

• References

• 1 Boeckxstaens GE, Zaninotto G, Richter JE. Achalasia. Lancet 2014; 383: 83-93
  CrossrefPubMedGoogle Scholar
• 2 Moonen A, Annese V, Belmans A. et al. Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut 2016; 65: 732-739
  CrossrefPubMedGoogle Scholar
• 3 Yaghoobi M, Mayrand S, Martel M. et al. Laparoscopic Heller’s myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized, controlled trials. Gastrointest Endosc 2013; 78: 468-475
  CrossrefPubMedGoogle Scholar
• 4 Inoue H, Tianle KM, Ikeda H. et al. Peroral endoscopic myotomy for esophageal achalasia: technique, indication, and outcomes. Thoracic Surg Clin 2011; 21: 519-525
  PubMedGoogle Scholar
• 5 Kumagai K, Tsai JA, Thorell A. et al. Per-oral endoscopic myotomy for achalasia. Are results comparable to laparoscopic Heller myotomy?. Scand J Gastroenterol 2015; 50: 505-512
  CrossrefPubMedGoogle Scholar
• 6 Marano L, Pallabazzer G, Solito B. et al. Surgery or peroral esophageal myotomy for achalasia: a systematic review and meta-analysis. Medicine (Baltimore) 2016; 95: e3001
  PubMedGoogle Scholar
• 7 Sanaka MR, Hayat U, Thota PN. et al. Efficacy of peroral endoscopic myotomy vs other achalasia treatments in improving esophageal function. World J Gastroenterol 2016; 22: 4918-4925
  CrossrefPubMedGoogle Scholar
• 8 Bredenoord AJ, Smout AJ. High-resolution manometry. Dig Liver Dis 2008; 40: 174-181
  CrossrefPubMedGoogle Scholar
• 9 Kahrilas PJ, Sifrim D. High-resolution manometry and impedance pH/manometry: valuable tools in clinical and investigational esophagology. Gastroenterology 2008; 135: 756-769
  CrossrefPubMedGoogle Scholar
• 10 Pandolfino JE, Kwiatek MA, Nealis T. et al. Achalasia: a new clinically relevant classification by high-resolution manometry. Gastroenterology 2008; 135: 1526-1533
  CrossrefPubMedGoogle Scholar
• 11 Sharata AM, Dunst CM, Pescarus R. et al. Peroral endoscopic myotomy (POEM) for esophageal primary motility disorders: analysis of 100 consecutive patients. J Gastrointest Surg 2015; 19: 161-170
  CrossrefPubMedGoogle Scholar
• 12 Costamagna G, Marchese M, Familiari P. et al. Peroral endoscopic myotomy (POEM) for oesophageal achalasia: preliminary results in humans. Dig Liver Dis 2012; 44: 827-832
  CrossrefPubMedGoogle Scholar
• 13 Boeckxstaens GE, Annese V, des Varannes SB. et al. Pneumatic dilation versus laparoscopic Heller’s myotomy for idiopathic achalasia. N Engl J Med 2011; 364: 1807-1816
  CrossrefPubMedGoogle Scholar
• 14 Eleftheriadis N, Inoue H, Ikeda H. et al. Training in peroral endoscopic myotomy (POEM) for esophageal achalasia. Ther Clin Risk Manag 2012; 8: 329-342
  PubMedGoogle Scholar
• 15 Kahrilas PJ, Bredenoord AJ, Fox M. et al. The Chicago Classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil 2015; 27: 160-174
  CrossrefPubMedGoogle Scholar
• 16 Werner YB, Costamagna G, Swanström LL. et al. Clinical response to peroral endoscopic myotomy in patients with idiopathic achalasia at a minimum follow-up of 2 years. Gut 2015 Apr 30 [Epub ahead of print]
  PubMedGoogle Scholar
• 17 Aljebreen AM, Samarkandi S, Al-Harbi T. et al. Efficacy of pneumatic dilatation in Saudi achalasia patients. Saudi J Gastroenterol 2014; 20: 43-47
  CrossrefPubMedGoogle Scholar
• 18 Yaghoobi M, Mayrand S, Martel M. et al. Laparoscopic Heller’s myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized, controlled trials. Gastrointest Endosc 2013; 78: 468-475
  CrossrefPubMedGoogle Scholar
• 19 Rohof WO, Salvador R, Annese V. et al. Outcomes of treatment for achalasia depend on manometric subtype. Gastroenterology 2013; 144: 718-725
  CrossrefPubMedGoogle Scholar
• 20 Patel A, Patel A, Mirza FA. et al. Achalasia symptom response after Heller myotomy segregated by high-resolution manometry subtypes. J Gastroenterol 2016; 51: 112-118
  CrossrefPubMedGoogle Scholar
• 21 Borges AA, Lemme EM, Abrahao Jr LJ. et al. Pneumatic dilation versus laparoscopic Heller myotomy for the treatment of achalasia: variables related to a good response. Dis Esophagus 2014; 27: 18-23
  CrossrefPubMedGoogle Scholar
• 22 Familiari P, Greco S, Gigante G. et al. Gastroesophageal reflux disease after peroral endoscopic myotomy: analysis of clinical, procedural and functional factors, associated with gastroesophageal reflux disease and esophagitis. Dig Endosc 2015 Jul 14 [Epub ahead of print]
  PubMedGoogle Scholar
• 23 Verlaan T, Rohof WO, Bredenoord AJ. et al. Effect of peroral endoscopic myotomy on esophagogastric junction physiology in patients with achalasia. Gastrointest Endosc 2013; 78: 39-44
  CrossrefPubMedGoogle Scholar