Response.

Abstract

We appreciate the interest shown by Estevinho et al1Estevinho M.M. Freitas T. Pinho R. Endoscopic treatment of achalasia: dim past, brighter future?.Gastrointest Endosc. 2023; 98: 139-140Google Scholar in our study comparing the short-term outcomes of the most common endoscopic and surgical modalities used to treat achalasia: pneumatic dilation (PD), peroral endoscopic myotomy (POEM), and laparoscopic Heller myotomy (LHM).2Haseeb 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 We share their enthusiasm for broader availability, increased awareness, and reimbursement for minimally invasive endoscopic procedures like POEM.3Hasan 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,4Attaar 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 The authors raise some important points that merit further consideration. Regarding the primary outcome of interest, it is possible that routine outpatient appointments may be scheduled for re-assessment of achalasia after a procedure; however, a planned inpatient admission for such appointments would be rare in our experience. Given the scarcity of such planned inpatient admissions, we believe they would not have changed the overall results. We acknowledge in our study the limitations of the database highlighted by the authors, including the lack of granular data about the severity or type of achalasia. Secondary outcomes, such as adverse event rates, were reported as incidence rates during hospitalization and were not analyzed on multivariate analysis. We extracted them through diagnosis and procedure codes and can only presume that some of the adverse events (eg, sepsis or hemorrhage) are related to the procedures performed and were not the result of the disease process. Therefore, we believe that a multivariate analysis of secondary outcomes would not have hampered the distortion effect. We also reported the need for achalasia-related intervention (PD, POEM, or LHM) within 30 days of the initial procedure. We believe it was insightful inasmuch as it provided information about the need for revision or lack of response to the initial intervention. Last, we agree that selection bias is one of the limitations of an observational study design. However, we decreased its impact by using a large nationally representative sample and multivariate regression for our primary outcome of interest.5Haneuse S. Distinguishing selection bias and confounding bias in comparative effectiveness research.Med Care. 2016; 54: e23-e29Google Scholar Dr Thompson is a consultant for, and recipient of research support from, Apollo Endosurgery, Boston Scientific, Fujifilm, GI Dynamics, Lumendi, Olympus, and USGI Medical; a consultant for Medtronic and Fractyl; the recipient of institutional research grants from Aspire Bariatrics and ERBE; a general partner for BlueFlame Healthcare; and a founder/consultant/board member for Envision Endoscopy, Enterasense, and GI Windows. The other author disclosed no financial relationships.