By: Kenneth F Binmoeller, M.D.
Director, Interventional Endoscopy Services
Historically, patients with achalasia underwent a surgical Heller’s myotomy. The chest and abdominal cavities are entered from the skin and then the esophageal wall is cut open to relieve the spasm of the inner muscle layer. Over the past decade, an alternative endoscopic approach called POEM (peroral endoscopic myotomy) has emerged. What POEM enables is the ability to access the diseased inner muscle layer of the esophagus from the “inside” with an endoscope. We can thereby avoid cutting into and traumatizing the chest and abdominal cavities. We also avoid sacrificing the outer muscle layer of the esophagus since access is from the inside rather than the outside.
If the outcomes of the endoscopic and surgical approaches are equal, then it should be a “no-brainer” that a POEM procedure – performed from the inside with an endoscope – is preferable to surgery from the outside. But are the outcomes equal?
A randomized, controlled trial – the gold standard in evidence-based medicine – was recently published (Werner et al, N Engl J Med 2019; 381:2219-2229). In this multicenter trial, conducted in 8 European centers, achalasia patients were randomly assigned in a 1:1 ratio to undergo either POEM or laparoscopic Heller myotomy. The primary endpoint was a clinical success (defined by symptom score, high-resolution manometry testing, and quality of life testing). At the 2-year follow-up, 93 of 112 patients (83.0%) in the POEM group and 89 of 109 patients (81.7%) in the surgery group had clinical success. None of the patients who had POEM went to surgery. Serious adverse events were numerically higher in the surgery group (7.3% versus 2.7%), but this did not reach statistical significance. Importantly, none of the POEM patients had a complication that required conversion to surgery. The incidence of reflux esophagitis was significantly higher in the POEM group compared to the surgery group at 24 months (44% vs 29%), but it must be noted that all patients in the surgery group had also undergone an anti-reflux operation (fundoplication) to prevent reflux, whereas none of the POEM patients had this operation.
The upshot? We now have proof that POEM and surgery have equivalent outcomes. Yes, there is a potential trade-off of a higher risk of reflux esophagitis, but even if this occurs, we can treat esophagitis very effectively with acid-suppressive medication. Even for the very rare patient that does not respond to medication, we have the ability to perform an endoscopic anti-reflux procedure and avoid surgery.
If you would like more information on the POEM procedure, please contact us at 415-600-1151.