Per oral endoscopic myotomy: Another tool in the toolbox

Abstract

ObjectiveUse of per oral endoscopic myotomy is increasing for the treatment of achalasia, with potential for rapid recovery and less invasiveness. We report our experience with per oral endoscopic myotomy to better understand how it fits into a modern paradigm of achalasia management. MethodsA total of 152 patients with achalasia underwent per oral endoscopic myotomy from April 2014 to March 2018. Type II achalasia was the most prominent subtype in 69 patients (49%), and 33 patients (21.5%) had a prior Heller myotomy. Postoperative Eckardt scores, integrated relaxation pressure, and timed barium esophagram column height and width at 2 months were compared with preoperative measurements. ResultsPer oral endoscopic myotomy was completed in 149 patients (98%). Median operative time was 96 minutes (75 minutes for the last 30 cases), and length of stay was 1 day (interquartile range, 1-2). The most common morbidities were mucosal perforation in 2 patients (1.3%) and bleeding in 3 patients (2.0%), although no nonendoscopic intervention was required. Mortality was zero. Postoperatively, the median Eckardt score decreased from 6 to 0 (P < .001), residual lower esophageal sphincter pressure decreased from 22 mm Hg to 6 mm Hg (P < .001), and timed barium esophagram column height and width at 5 minutes decreased from 8 and 2.5 cm to 1.5 and 0.8 cm (P < .001), respectively. Median time to return to daily activity was 7 days; 49 patients (49.5%) had abnormal acid reflux on 24-hour pH testing postprocedure. ConclusionsPer oral endoscopic myotomy is a safe and effective intervention that provides clear subjective and objective improvement in patients with achalasia. High postprocedure acid reflux raises concern about future sequelae if used in a nonselective fashion.