Baylor University Medical Center Proceedings October 2017 - 419

Comparison of outcomes of laparoscopic Heller myotomy
versus per-oral endoscopic myotomy for management
of achalasia
Steven G. Leeds, MD, J. S. Burdick, MD, Gerald O. Ogola, PhD, and Estrellita Ontiveros, MA

Achalasia is a rare disorder that has several treatment options. The gold
standard of treatment is a surgical myotomy called a laparoscopic Heller
myotomy (LHM). More recently, an endoscopic myotomy has become an
option as well, called per-oral endoscopic myotomy (POEM). An achalasia
registry was queried for patients undergoing either LHM or POEM at
Baylor University Medical Center at Dallas. Patient demographics, preoperative and postoperative data points, and Eckardt scores were collected.
The patients were further stratified into their follow-up intervals, immediate postoperative and long-term follow-up, to assess surgical success. A
subset analysis was done for success of treatment for patients who had
redo surgery versus those undergoing the procedure for the first time.
There were 12 patients in the POEM group and 11 patients in the LHM
group. Both groups demonstrated mean lower esophageal sphincter
pressures with failure to relax. Procedure length and hospital length of
stay were similar between the two groups. There were three adverse
events in each group, but none altered the patient's postoperative clinical course. Eckardt scores, used to assess success of the surgery, were
82% for POEM patients and 66% for LHM patients after 6 months. The
outcomes for POEM and LHM in our early experience are similar to those
reported in the literature for high-volume centers managing achalasia.

chalasia is a rare disorder of the esophagus that results
in aperistalsis and incomplete, or failed, relaxation of
the lower esophageal sphincter (LES) muscle (1). The
treatments for achalasia consist of disruption of the LES
muscle ﬁbers, relieving the outﬂow obstruction, which include
laparoscopic Heller myotomy (LHM), per-oral endoscopic myotomy (POEM), pneumatic dilation, and temporary relief using
botulinum toxin injection (2). It has been shown that LHM and
pneumatic dilation have similar outcomes at 2 years with regard
to symptom relief (3, 4), but meta-analyses and systematic reviews
favor LHM as the procedure of choice for its superior response
rates long term (5-7). The introduction of POEM has provided
another option for management of achalasia; with POEM, an
endoscopic submucosal tunnel is created in the wall of the esophagus to access the LES muscle ﬁbers without making incisions for
laparoscopic instruments. The endoscopic approach to the LES
muscle ﬁbers was originally characterized with a full thickness endoscopic exit of the lumen (8), but was reﬁned with a submucosal
tunnel to prevent full thickness leak in a porcine model (9). Inuoe
Proc (Bayl Univ Med Cent) 2017;30(4):419-423

et al had the ﬁrst successful treatment for clinical application
published in 2010 (10). POEM has become a reasonable option
for patients because of its minimal pain scores (11), sparing use of
narcotics (11), ability to create longer myotomies (12), versatility
with other disorders such as jackhammer esophagus (12), and
ability to be repeated for recurrence of symptoms (13), and it has
become the treatment of choice in some centers (2). Despite the
robust data supporting POEM's long-term use to treat achalasia
(14-18), early experience integrating this procedure into clinical practice needs to be carefully monitored to ensure adequate
results (19) and must take into account the learning curve (16,
20, 21). We report here our early experience integrating POEM
into clinical practice, comparing its outcomes to those of LHM.
METHODS
A prospectively gathered, and institutional review board
approved, registry for achalasia patients at Baylor University
Medical Center at Dallas was queried. A total of 48 patients
were enrolled in the database from September 2014 to February
2017. Twenty-two patients were eliminated from the study. Of
these, 12 patients were pending surgery, 4 patients were lost to
follow-up, and 6 patients were screen failures. The remaining
26 patients underwent operative treatment. Thirteen patients
underwent POEM, but only 12 patients had surgery for achalasia. One patient was a screen failure for jackhammer esophagus,
not achalasia. Thirteen patients underwent LHM, but only 11
patients were available for follow-up. Inclusion criteria for the
study included patients with a preoperative Eckardt score, at
least one postoperative visit with an Eckardt score, and completion of either LHM or POEM. Each category of surgery was further divided into primary surgery for achalasia and redo surgery.
In the POEM category, one patient had a prior LHM, and in
the LHM category, three patients had a prior LHM (Figure 1).
Data on patient characteristics were collected, including
gender, age, body mass index, LES basal pressure, LES residual
From the Division of Minimally Invasive Surgery (Leeds, Ontiveros) and Division of
Gastroenterology (Burdick), Baylor University Medical Center at Dallas; and Center
for Clinical Effectiveness, Baylor Scott & White Health, Dallas, Texas (Ogola).
Corresponding author: Steven G. Leeds, MD, Department of Surgery, Baylor
University Medical Center at Dallas, 3500 Gaston Avenue, 1st Floor Roberts
Hospital, Dallas, TX 75246 (e-mail: Steven.Leeds@BSWHealth.org).
419

Table of Contents for the Digital Edition of Baylor University Medical Center Proceedings October 2017