Achalasia cardia (AC) is a neurodegenerative disease characterised by the absence of normal peristalsis and relaxation of the lower oesophageal sphincter (LOS). The motility of the oesophageal body cannot be restored using the currently available treatment options, like pneumatic balloon dilatation, Heller myotomy, botulinum toxin injections, and peroral endoscopic myotomy (POEM). Therefore, we offer the optimum palliative care to these patients, mainly by disrupting the LOS. POEM has emerged as an efficient endoscopic treatment option for AC, and multiple studies with short-to-medium-term follow-up have confirmed the utility of POEM in these patients. However, most of these studies have evaluated the efficacy of POEM in treatment-naïve cases of AC, whereas there are limited data from studies that assessed the outcome of POEM in prior treatment failure cases. Previous treatment has been shown to induce submucosal inflammation and fibrosis, and can therefore influence the technical and clinical outcomes of subsequent treatment. With this aim, we evaluated and compared the outcome of POEM in treatment-naïve and prior treatment failure cases of AC in approximately 500 patients using a retrospective analysis of a prospectively maintained database.
The baseline characteristics were similar in both patient groups, except for the age and proportion of patients with sigmoid achalasia. The prior treated achalasia group consisted of older participants and included more patients with sigmoid achalasia than the treatment-naïve group. Besides these characteristics, the other baseline characteristics, such as the type of achalasia and basal LOS pressure, were similar in both groups. In addition, pneumatic balloon dilatation was the most common treatment type in the prior treated group (84%), followed by Heller myotomy (10%). POEM could be successfully completed in the majority of patients in both the groups; however, severe submucosal fibrosis was the most common reason for premature termination of POEM procedure, although it was found in only 1.8% of patients. Severe submucosal fibrosis was encountered in equal numbers of patients in both the groups, and therefore prior treatment may not be the only factor leading to submucosal fibrosis, and other factors like long disease duration and mucosal oedema may also play an important role. The occurrence of major and minor adverse events was similar in both groups, which implies that POEM can be safely accomplished in previously treated patients. The procedure duration was longer in the prior treatment group, but this was not significant when taking other factors into account, such as dilatation of the oesophagus (>6 cm), type of knife used (with or without water jet), occurrence of an adverse event, type of AC, and disease duration. The clinical success was identical in both of the groups at short-term (6 months: ˜90%) and long-term (3 years: ˜80%) follow-up.
We also evaluated and compared gastro-oesophageal reflux disease (GORD) between these groups with symptom analysis, oesophagogastroduodenoscopy, and 24-hour pH analysis. GORD was detected in approximately a quarter of patients in the treatment-naïve group and one-third of patients in the prior treatment failure group. There was a poor correlation between symptoms, erosive oesophagitis, and 24-hour pH results; only half of the patients with positive 24-hour pH results had symptoms suggestive of GORD, meaning that symptoms alone may not be a reliable indicator of GORD and objective documentation of GORD by pH study is required to guide therapeutic decisions.
To conclude, POEM is equally effective for treatment- naïve and prior treatment failure patients with achalasia and has the potential to be the first-line treatment modality in prior treatment failure patients with achalasia. Randomised trials are required to compare the effectiveness of POEM with other established treatment options, such as pneumatic dilatation and Heller myotomy.