Peroral endoscopic myotomy for opioid-induced esophageal dysfunction: proceed with caution.

Abstract

Chronic opioid use is prevalent in the United States, and opioid-induced esophageal dysfunction (OIED) has become increasingly recognized.1Parsells J. Cook S.F. Kaufman D.W. et al.Prevalence and characteristics of opioid use in the US adult population.Pain. 2008; 138: 507-513Google Scholar, 2Snyder D.L. Crowell M.D. Horsley-Silva J. et al.Opioid-induced esophageal dysfunction: differential effects of type and dose.Am J Gastroenterol. 2019; 114: 1464-1469Google Scholar, 3Snyder D.L. Vela M.F. Opioid-induced esophageal dysfunction.Curr Opin Gastroenterol. 2020; 36: 344-350Google Scholar Jacobs et al4Jacobs C.C. Al-Haddad M. Stainko S. Perkins A. DeWitt J.M. Prevalence and impact of opioid use in patients undergoing peroral endoscopic myotomy.Gastrointest Endosc. 2023; 97: 655-663.e2Google Scholar report the outcomes of peroral endoscopic myotomy (POEM) in opioid users with spastic esophageal disorders and esophagogastric outflow obstruction. This was a single-center retrospective study of 89 patients, of whom 18 were using daily opioids. The short-term response at 6 to 12 months, based on Eckardt scores ≤3, was similar between opioid and nonopioid users (83.3% vs 85.9%, respectively; P = .72). Besides heartburn being reported more frequently among opioid versus nonopioid users (82.4% vs 38.6%, P = .002), there were no differences in post-POEM esophagitis, impedance planimetry, or manometric findings. On the basis of these results, the authors concluded that POEM could be considered for motility disorders among opioid users when narcotics cannot be discontinued. The authors should be commended for conducting the first reported study to evaluate the frequency of opioid use in patients undergoing POEM and for using several metrics (ie, symptoms, manometry, impedance planimetry) to assess response. This is an important topic with clinical implications. In all, the study did not identify any associations between opioid use and response to POEM, but this should be interpreted with caution. As highlighted by the authors, the small sample size of 18 patients using opioids may have precluded the detection of other significant findings, such as the effect of opioid type and dosing on clinical response and degree of OIED.2Snyder D.L. Crowell M.D. Horsley-Silva J. et al.Opioid-induced esophageal dysfunction: differential effects of type and dose.Am J Gastroenterol. 2019; 114: 1464-1469Google Scholar Additional research is needed to better stratify patients with OIED who may benefit from POEM as compared with other measures, given the rare but sometimes serious adverse effects, including postprocedural reflux and blown-out myotomy.5Triggs J.R. Krause A.J. Carlson D.A. et al.Blown-out myotomy: an adverse event of laparoscopic Heller myotomy and peroral endoscopic myotomy for achalasia.Gastrointest Endosc. 2021; 93: 861-868Google Scholar,6The J.L. Tham H.Y. Sen Soh A.Y. et al.Gastro-esophageal reflux disease (GERD) after peroral endoscopic myotomy (POEM).Surg Endosc. 2022; 36: 3308-3316Google Scholar Multicenter studies with larger sample sizes may help to better define the role of POEM for OIED and to determine the most appropriate treatment pathway for this patient population. Dr Yang is a consultant for Olympus, Fujifilm, Apollo Endosurgery, Medtronic and Microtech and the recipient of research support from Microtech and 3D-Matrix. Dr Draganov is a consultant for Olympus, Boston Scientific, Fujifilm, Cook Medical, and Medtronic. The other author disclosed no financial relationships.