Impact of prior endoscopic or surgical interventions on clinical outcomes after peroral endoscopic myotomy for achalasia.

BACKGROUND

The aim of this study is to compare outcomes of POEM for achalasia between those with (PI) or without (NPI) previous disease intervention.

METHODS

Single-center retrospective study of consecutive achalasia patients with or without ≥ 1 prior intervention with pneumatic dilation (PD), Heller myotomy (LHM), and/or Botox injection (BTI) who underwent POEM and had ≥ 6-month follow-up. Baseline testing: Eckardt Score (ES), high-resolution manometry (HRM), and functional lumen imaging probe (FLIP) of the esophagogastric junction (EGJ) at 50-mL distention. Between 6 and 12 months after POEM, patients were questioned about daily PPI use and HRM, ES, FLIP, EGD, and pH testing off anti-secretory medications were repeated when possible. Clinical response was defined as follows: ES ≥ 3, EGJ-DI > 2.8 mm2/mmHg, and integrated relaxation pressure (IRP) < 15 mmHg. GERD was defined as acid exposure time (AET) > 6%. Outcomes were compared between the PI and NPI groups.

RESULTS

471 patients (mean: 55 ± 19 yrs; 60% M) with type 1 (17%), 2 (72%) or 3 (11%) achalasia with no prior (n = 325) or a prior (n = 126) intervention were identified. The PI group was older (p < 0.001), had a lower baseline ES (p = 0.03), lower IRP (p = 0.001), higher EGJ-DI (p = 0.001), and a longer POEM procedure time (p = 0.001) compared to the NPI group. Mean overall clinical response by ES (95.3%), IRP (86.7%), and EGJ-DI (86.2%), and daily PPI use (30%), esophagitis (65%), and AET > 6% (49%) were similar between the two groups.

CONCLUSION

Achalasia patients with previous LES-directed interventions undergoing POEM are older, have lower ES, lower LES pressure/tone, and require longer POEM times compared to those without previous interventions. Prior intervention does not impact the frequency of clinical response, daily PPI use, esophagitis or post-POEM GERD (ClinicalTrials.gov NCT02770859).