A More Effective Treatment for Achalasia

A specialized endoscopic procedure called peroral endoscopic myotomy (POEM) is a safe and effective treatment for esophageal achalasia, according to the August issue of Gastroenterology.

Achalasia is an esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter, increased sphincter tone, and disrupted peristalsis. It causes dysphagia, regurgitation, and chest pain. Achalasia can be treated with endoscopic balloon dilatation or injections of botulinum toxin, which have 1 y rates of remission of 68% and 41%, respectively. Or it can be treated surgically, by laparoscopic Heller myotomy (LHM), which relieves the disorder in 90% of patients. However, researchers have been investigating a less-invasive endoscopic technique, known as POEM.

Daniel Von Renteln et al. tested POEM in 70 patients at 5 different medical centers in North America and Europe. POEM was performed without technical difficulties under general anesthesia. The mean procedure time was 105 minutes and the mean length of the myotomy was 13 cm. The authors followed the patients for an average of 10 months.

They found that 3 months after POEM, 97% of patients were in symptom remission. Symptom scores were reduced from 7 to 1, and lower esophageal sphincter pressures were reduced from 28 to 9 mm Hg. After 6 months, 89% of patients were in symptom remission, and after 1 y, 82% still had few or no symptoms (see below figure).

Patients in remission 3 months to 1-year after POEM, with 95% confidence intervals.

Patients in remission 3 months to 1-year after POEM, with 95% confidence intervals.

In an editorial that accompanies the article, Lee Swanstrom states that these outcomes are far better than those of surgery, balloon dilation, or botulinum toxin, which all have a period of intervention trauma that must be overcome before patients receive the full effects of the treatment. Swanstrom says that POEM has the efficacy of surgery with the recovery profile of endoscopy.

The POEM procedure is safe—Von Renteln et al. reported no major morbidities, although about a third of patients had occasional gastroesophageal reflux. Interestingly, approximately half of the patients had received previous endotherapies, such as balloon dilation or botulinum toxin injections, before POEM, so it appears to be safe and efficient after previous treatments.

The authors state that one potential benefit of POEM is the option to extend the myotomy into the proximal esophagus, so this procedure might be used to treat type III achalasia or spastic disorders such as nutcracker esophagus. Patients with these disorders were not included in the current study, so further studies are needed.

Von Renteln et al. conclude that POEM produces similar effects as LHM, without the need for skin incisions, and reduces procedural trauma. However, the efficacy of POEM decreased moderately over the year after the procedure, so in the long term, it could be slightly less effective than LHM. The authors say that this can only be determined in trial that directly compares the procedures.

More Information on Achalasia

Read the article online.
Von Renteln D, Fuchs K-H, Fockens P, et al. Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study. Gastroenterology 2013;145: 309–311.e3.

Read the accompanying editorial.
Swanstrom LL. Poetry is in the air: first multi-institutional results of the per-oral endoscopic myotomy procedure for achalasia. Gastroenterology 2013;145: 272–273.

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