Per-oral endoscopic myotomy may benefit most patients with achalasia: experts

Last Updated: 2017-10-13

By Will Boggs MD

NEW YORK (Reuters Health) - Most patients with achalasia, particularly those with type III, can benefit from treatment with per-oral endoscopic myotomy (POEM), according to an expert review and commentary from the American Gastroenterological Association (AGA).

"The decision of POEM versus pneumatic dilation or laparoscopic myotomy is controversial, which is why we formatted this as a commentary and not a guideline," Dr. David Katzka from Northwestern University Feinberg School of Medicine, in Chicago, told Reuters Health by email. "Until we have longer-term outcomes of randomized trials (only 1 year follow-up so far other than retrospective data), it is still considered a new therapy."

In their report, online October 6 in Gastroenterology, Dr. Katzka and colleagues make recommendations for when clinicians should consider POEM among the therapies currently available for achalasia.

Before embarking on treatment, they note, it is important to establish the diagnosis and ascertain the achalasia subtype using high-resolution manometry. Type I - "classic" achalasia - is associated with negligible pressurization within the esophagus; type II - the most common presenting subtype - has uniform simultaneous pressurization bands from the upper esophageal sphincter to the lower esophageal sphincter; and type III has premature (spastic) contractions.

The reported success rate of POEM has been >90% in multiple uncontrolled studies, but reflux follows the procedure in up to 58% of patients, the authors note.

There are insufficient data to compare POEM with either laparoscopic myotomy or pneumatic dilatation, they find.

The commentary proposes the following best practices:

- Patient-specific parameters and published efficacy data should be used to determine the need for achalasia therapy.

- POEM should be performed by experienced physicians in high-volume centers, because an estimated 20 to 40 procedures are needed to achieve competence.

- Where expertise is available, POEM should be considered as primary therapy for type III achalasia.

- Where expertise is available, POEM should be considered as a treatment option comparable to laparoscopic Heller myotomy for any of the achalasia subtypes.

- Patients face a high risk of developing post-POEM reflux esophagitis, so they should be advised before undergoing the procedure of the management considerations, including potentially indefinite proton-pump-inhibitor therapy and/or surveillance endoscopy.

"If patients consider undergoing POEM, they have to consider that we do not have retrospective data much beyond 5 years and randomized data beyond 1 year when considering this as a treatment for a lifelong disease," Dr. Katzka said. "Patients also have to consider what appears to be a high incidence of gastroesophageal reflux that develops, including erosive esophagitis that will require lifelong PPI use at least. This is not to say, this does not happen with other therapies, though the incidence appears to be less with the others."

"It is also important for patients and physicians to realize that recurrence and/or complications of achalasia treatment are not uncommon and patients need to continue to be followed regularly by their physicians," he said. "It is not a safe assumption that any of these procedures are automatically curative."

Dr. Jan Martinek from the Institute for Clinical and Experimental Medicine in Prague, Czech Republic, who recently reviewed the midterm efficacy and safety of POEM for achalasia, told Reuters Health by email, "I think that it is too early to say that POEM is comparable to laparoscopic Heller myotomy - there is a randomized trial underway, and we will have data of the highest quality."

"POEM is now a valid and accepted alternative (and probably the least invasive) to treat achalasia," said Dr. Martinek, who was not involved in the review. "The issue of reflux is unsolved, and about a third of patients will need antireflux drugs for the long term."

Dr. Martinek added, "I fully agree it is a difficult procedure and should be centralized."

Dr. Steven Leeds from Baylor University Medical Center at Dallas, Texas, has compared outcomes of laparoscopic Heller myotomy versus POEM for managing achalasia. He told Reuters Health by email, "I think it is important to understand that these are recommendations based on the body of literature currently available."

"Most of the recommendations can be considered controversial in that sense," he said. "However, the present data supports that an endoscopic myotomy provides at least equal results to the gold-standard laparoscopic myotomy (Heller)."

"The data are very promising, and we are starting to recognize this as first-line therapy," noted Dr. Leeds, who was not part of the review. "It is important for all physicians to know this exists and that they will be referring patients for a new procedure that has displaced an outdated one."

"Despite POEM being accepted so broadly, so much more investigation needs to be done," Dr. Leeds said. "This includes randomized controlled studies, studying particular types of achalasia outcomes, further use of the endoscopic tunneled approach to myotomy in the case of the pylorus, the use for GI-wall tumors, and for potential diagnostic or staging procedures in the peritoneal cavity or mediastinum. The use of POEM can go beyond its use for achalasia."

SOURCE: http://bit.ly/2g74HGK

Gastroenterology 2017.