Endoscopic treatment of achalasia: Dim past, brighter future?

Abstract

We read with great interest the study by Haseeb et al,1Haseeb M. Khan Z. Kamal M.U. Jirapinyo P. Thompson C.C. Short-term outcomes after peroral endoscopic myotomy, Heller myotomy, and pneumatic dilation in patients with achalasia: a nationwide analysis.Gastrointest Endosc. 2023; 97: 871-879.e2Google Scholar who performed the largest head-to-head comparison between the mainstay therapies for achalasia2Hasan A. Low E.E. Fehmi S.A. et al.Evolution and evidence-based adaptations in techniques for peroral endoscopic myotomy for achalasia.Gastrointest Endosc. 2022; 96: 189-196Google Scholar: laparoscopic heller myotomy (LHM), endoscopic pneumatic dilation (PD), and peroral endoscopic myotomy (POEM). The primary outcome was admission for any diagnosis within 30 days and aimed at estimating efficacy, and the secondary endpoints concerned safety. The outcomes after POEM and LHM were similar, whereas PD was associated with a significantly higher need for blood transfusion (2.3% vs 0.7%), mortality (1.1% vs 0.0%), and longer hospital stay, in the index episode. Besides that, this study highlights the importance of improving access to advanced endoscopic techniques. Indeed, only 44.9% of the patients underwent PD or POEM. Considering that POEM and LHM were similar regarding costs (mean costs per patient, including readmissions, were $65,737 and $64,736, respectively), it is pertinent to expand the availability of POEM, practitioners’ awareness, and reimbursement policies, as previously stated.3Shah E.D. Chang A.C. Law R. Valuing innovative endoscopic techniques: per-oral endoscopic myotomy for the management of achalasia.Gastrointest Endosc. 2019; 89: 264-273.e3Google Scholar, 4Shally L, Saeed K, Berglund D, et al. Clinical and financial outcomes of per-oral endoscopic myotomy compared to laparoscopic heller myotomy for treatment of achalasia. Surg Endosc. Epub 2022 Oct 11.Google Scholar, 5Lois A.W. Oelschlager B.K. Wright A.S. et al.Use and safety of per-oral endoscopic myotomy for achalasia in the US.JAMA Surg. 2022; 157: 490-497Google Scholar, 6Attaar M. Su B. Wong H.J. et al.Comparing cost and outcomes between peroral endoscopic myotomy and laparoscopic Heller myotomy.Am J Surg. 2021; 222: 208-213Google Scholar Notwithstanding, this study has some pitfalls. First, it is unclear whether planned admissions were included in the primary outcome. Indeed, routine appointments may have been scheduled for achalasia reassessment and for other comorbidities. Second, there is no information regarding the severity of the intercurrences or the need for recurrent admissions. Third, the endpoint “repeated interventions” is elusive because it is uncertain whether such procedures were done because of a lack of response or because of adverse events. Fourth, even though the worse safety profile of PD may be associated with patient-related factors (individuals were significantly older and had more comorbidities), the lack of multivariable analysis of the secondary endpoints hampers the estimation of such a distortion effect. Fifth, POEM was performed in large teaching hospitals, potentially leading to selection bias. Last, the short follow-up time and the lack of information on the resolution of symptoms are noteworthy. All authors disclosed no financial relationships.