A Comparative Study on Comprehensive, Objective Outcomes of Laparoscopic Heller Myotomy With Per-Oral Endoscopic Myotomy (POEM) for Achalasia

Objective: To compare symptomatic and objective outcomes between HM and POEM. Background: The surgical gold standard for achalasia is laparoscopic Heller myotomy (HM) and partial fundoplication. Per-oral endoscopic myotomy (POEM) is a less invasive flexible endoscopic alternative. We compare their safety and efficacy. Methods: Data on consecutive HMs and POEMs for achalasia from 2007 to 2012 were collected. Primary outcomes: swallowing function-1 and 6 months after surgery. Secondary outcomes: operative time, complications, postoperative gastro-esophageal reflux disease (GERD). Results: There were 101 patients: 64 HMs (42% Toupet and 58% Dor fundoplications) and 37 POEMs. Presenting symptoms were comparable. Median operative time (149 vs 120 min, P < 0.001) and mean hospitalization (2.2 vs 1.1 days, P < 0.0001) were significantly higher for HMs. Postoperative morbidity was comparable. One-month Eckardt scores were significantly better for POEMs (1.8 vs 0.8, P < 0.0001). At 6 months, both groups had sustained similar improvements in their Eckardt scores (1.7 vs 1.2, P = 0.1). Both groups had significant improvements in postmyotomy lower esophageal sphincter profiles. Postmyotomy resting pressures were higher for POEMs than for HMs (16 vs 7.1 mm Hg, P = 0.006). Postmyotomy relaxation pressures and distal esophageal contraction amplitudes were not significantly different between groups. Routine postoperative 24-hour pH testing was obtained in 48% Hellers and 76% POEMs. Postoperatively, 39% of POEMs and 32% of HM had abnormal acid exposure (P = 0.7). Conclusions: POEM is an endoscopic therapy for achalasia with a shorter hospitalization than HM. Patient symptoms and esophageal physiology are improved equally with both procedures. Postoperative esophageal acid exposure is the same for both. The POEM is comparable with laparoscopic HM for safe and effective treatment of achalasia.