Heller Myotomy Versus Peroral Endoscopic Myotomy

Heller Myotomy Versus Peroral Endoscopic Myotomy (POEM)

“Laparoscopic Heller Myotomy Versus Peroral Endoscopic Myotomy (POEM) for Achalasia: A Systematic Review and Meta-analysis” is a new article published by Patti el al in the Annals of Surgery. The authors conducted a Medline literature search for achalasia treatment. 53 Heller myotomy studies included 5834 patients were compared to 21 POEM studies that covered 1958 patients. The two main outcomes examined were improvement of dysphagia and postoperative GERD. Mean follow-up time was 41 months for Heller myotomy and 16 months for POEM. At 12 and 24 months after intervention for achalasia treatment dysphagia improved in more than 90% of patients in both groups. However, patients undergoing POEM were significantly more likely to develop symptomatic GERD (gastroesophageal reflux disease).

The study is quite relevant to our practice at Houston Heartburn and Reflux Center as it gives us more evidence based information about the long-term outcome of POEM. Most importantly however, this study highlights the phenomenon of rapid early adoption of endoscopic techniques despite several significant limitations. I remember attending SAGES conference few months ago here in Houston and several authorities in the field of laparoscopic foregut surgery were confirming that POEM is currently the gold standard treatment for achalasia. The assumption was that as long as the phreno-esophageal membrane is not disturbed the incidence of post-POEM GERD should remain low. This article disproves this assumption and highlights the importance of an anti-reflux procedure following lower esophageal sphincter myotomy to prevent acid reflux. Indeed, GERD is a multifactorial disease and esophageal dysmotility is a contributing factor. In the case of achalasia, the addition of lower esophageal sphincter myotomy significantly increases the risk of acid reflux. Accordingly, an anti-reflux barrier in the form of fundoplication is particularly needed in achalasia cases following lower esophageal sphincter myotomy.

There is no doubt that POEM and other forms of natural orifice transluminal endoscopic surgery (NOTES) are quite appealing to both patient and surgeon. However, such approaches are limited by their own nature and in some cases like achalasia treatment half the surgery is not possible to complete using POEM. Consequently, achalasia patients undergoing POEM are at higher risk of GERD and this meta-analysis proves it.