In Type III Achalasia, POEM Reliably Delivers Excellent Sustained Palliation

Per oral endoscopic myotomy (POEM) should be considered as first-line therapy for patients with type III achalasia. So concludes a new retrospective analysis that found the minimally invasive procedure yielded symptom relief and improved esophageal manometry, radiograph measurements and drainage studies, all with low associated morbidity.

The single-center investigation from Cleveland Clinic — one of the largest studies devoted exclusively to type III achalasia, a rare and difficult-to-treat subtype of the condition — was recently published online in the Journal of Thoracic and Cardiovascular Surgery.

“We had excellent perioperative outcomes and sustained postoperative palliation with POEM for type III achalasia at one year,” says Cleveland Clinic thoracic surgeon Monisha Sudarshan, MD, who shared first authorship of the study with Siva Raja, MD, PhD, Surgical Director of the Center for Esophageal Diseases. “Outcomes were superior to those historically reported after laparoscopic Heller myotomy, botulinum toxin injection and pneumatic dilation, suggesting a paradigm shift in initial management.”

A rare and challenging condition

Type III achalasia is the most severe of the three Chicago classification subtypes, defined as having premature contractions in at least 20% of swallows. It is also the rarest, with fewer than 10% of achalasia patients thus classified. Its rarity makes studies assessing optimal interventions especially difficult.

Challenges in treating this entity are compounded by the fact that spasms extend much higher than the esophagogastric junction (often to the mid-esophagus), making conventional therapies for type II achalasia, which target the lower esophageal sphincter (LES), more likely to fail.

Compared with laparoscopic Heller myotomy, POEM provides a longer proximal myotomy (7-10 cm starting in the mid-esophagus), potentially making it a better intervention for type III achalasia.

Study design and findings

Using Cleveland Clinic’s prospectively maintained achalasia database, the researchers identified 504 patients treated for achalasia from April 2014 to July 2019. Of these, 217 patients (43%) underwent POEM, and 36 of those had type III achalasia, representing the study cohort.

Of the 36 patients who underwent POEM for type III achalasia (mean age, 62 years; 61% male), 11 had undergone previous interventions: botulinum toxin injections to the LES (n = 7), laparoscopic Heller myotomy (n = 3) and pneumatic dilation (n = 1).

Median operative time was 85 minutes, and median hospital stay was 1 day. Patients reported a return to activities of daily living in a median of 7 days and were followed for a median of 1 year.

The primary outcome measure was postoperative Eckardt score; 94% of patients achieved the threshold for treatment success — defined as a score ≤ 3 — at their two-week postoperative visit and through a year of follow-up.

Patients’ preoperative-to-postoperative changes in overall Eckardt score and various components of the score were as follows:

• Median Eckardt score, from 7 preoperatively to 0 postoperatively (P < 0.01)
• Median LES integrated resting pressure, from 25.5 to 4.5 mmHg (P < 0.01)
• 1-minute barium column height, from 10 to 0 cm (P < 0.01)
• 1-minute barium column width, from 2 to 0 cm (P < 0.01)

Complications occurred in three patients, as follows:

• One mucosal perforation, which resolved with conservative management
• One readmission for bleeding duodenal ulcer, which responded to proton pump inhibitor therapy
• One readmission for dysphagia and rehydration

Esophageal pH studies were conducted about three months postoperatively in 23 patients; 14 of these (61%) had an abnormal DeMeester score (> 14.72).

Comparisons with Heller myotomy

Type III achalasia patients in the database who underwent laparoscopic Heller myotomy between January 2006 and July 2019 were also assessed. Thirty-five patients were identified, though the authors note that they were more similar to patients with type II achalasia since they had limited esophageal spasms.

Comparisons between the Heller myotomy and POEM cohorts were as follows:

• No significant differences were found in Eckardt score at one year or in postoperative timed barium esophagography height and width.
• Integrated resting pressure at one year was significantly higher in the Heller group versus the POEM group (7.3 mmHg vs. 4.3 mmHg).
• Incidence of an abnormal pH study (DeMeester score > 14.72 mmHg) was higher in the POEM group than in the Heller group (61% vs. 24%).

Subsequent therapy was required by zero of 36 patients in the POEM cohort as compared with two of 35 patients in the laparoscopic Heller myotomy cohort.

Key takeaways

The authors emphasize the following points from this study:

• POEM is best suited for type III achalasia. The longer myotomy better addresses the spasms extending to the mid-esophagus, leading to excellent perioperative and sustained postoperative outcomes. Botulinum toxin injection and pneumatic dilation have high failure rates in this population and should not be considered in patients who are candidates for POEM.
• Comparison of interventions among achalasia patients remains difficult. Achalasia is a complex motility disorder with a wide range of esophageal morphology, symptoms and manometry results. Although a randomized study comparing POEM with laparoscopic Heller myotomy in similar patients would be ideal, it is unlikely to be undertaken due to the rarity of the disease and physician bias in treatment.
• Long-term implications of increased reflux after POEM are still unknown. It is likely that some patients will ultimately need a partial fundoplication following POEM, the authors note. “Increased acid exposure is the greatest Achilles’ heel of POEM,” observes Dr. Raja. “Longer follow-up is needed to assess its impact in these patients.”