Esophagus to Small Intestine
The efficacy of peroral endoscopic myotomy versus pneumatic dilation as treatment for patients with achalasia suffering from persistent or recurrent symptoms after laparoscopic Heller myotomy: A randomized clinical trial
Background and aims: For patients with achalasia experiencing persistent or recurrent symptoms after laparoscopic Heller myotomy (LHM), pneumatic dilation (PD) is the most frequently used treatment. Peroral endoscopic myotomy (POEM) is increasingly being investigated as rescue therapy. This study aimed to determine the efficacy of POEM versus PD for patients with persistent or recurrent symptoms after LHM.
Methods: This randomized multicenter controlled trial included patients after LHM with an Eckardt score > 3 and substantial stasis (≥ 2 cm) on timed barium esophagogram and randomized to POEM or PD. The primary outcome was treatment success, defined as an Eckardt score of ≤ 3 and without unscheduled retreatment. Secondary outcomes included the presence of reflux esophagitis, high-resolution manometry, and timed barium esophagogram findings. Follow-up duration was 1 year after initial treatment.
Results: 90 patients were included. POEM had a higher success rate (28/45 patients [62.2%]) than PD (12/45 patients [26.7%]; absolute differ-ence, 35.6%; 95% confidence interval [CI]: 16.4−54.7%; p = 0.001; odds ratio = 0.22; 95% CI: 0.09−0.54; relative risk for success = 2.33; 95% CI: 1.37−3.99). Reflux esophagitis was not significantly different between POEM (12/35 [34.3%]) and PD (6/40 [15%]). Basal lower esophageal sphincter pressure and integrated relaxation pressure (IRP-4) were significantly lower in the POEM group (p = 0.034; p = 0.002). Barium column height after 2 and 5 minutes was significantly less in patients treated with POEM (p = 0.005; p = 0.015).
Conclusions: Among patients with achalasia experiencing persistent or recurrent symptoms after laparoscopic Heller myotomy, peroral endo-scopic myotomy resulted in a significantly higher success rate than pneumatic dilation, with a numerically higher incidence of grade A−B reflux esophagitis.