Using either posterior or anterior myotomy during peroral endoscopic myotomy can provide clinical success in the treatment of achalasia, according to study results.
Mouen A. Khashab , MD, from the division of gastroenterology and hepatology at Johns Hopkins Medical Institutions, and colleagues wrote that while finding the optimal clinical approach to peroral endoscopic myotomy (POEM) is crucial, data comparing these techniques are limited.
“Theoretically, the anterior approach could be associated with decreased risk of reflux as it preserves the oblique muscle fibers of the lower esophageal sphincter,” they wrote in Gastrointestinal Endoscopy. “On the other hand, the posterior approach could lead to decreased risk of intra and postprocedural bleeding because it avoids tunneling through the anterior submucosal layer that harbor direct arterial branches off the left gastric artery.”
Researchers performed a single-blind, randomized, non-inferiority clinical trial comprising 138 patients who underwent POEM and completed 1 year of follow-up. They included adult patients diagnosed with achalasia and randomly assigned them to undergo anterior (n = 73) or posterior (n = 77) POEM. The primary outcome of the study was to compare the efficacy of the different approaches based on clinical success, defined as an Eckardt score greater than 3.
Khashab and colleagues found that 90% of patients in the anterior group achieved clinical success and 97.3% achieved technical success compared with 89% and 100%, respectively, in the posterior group. Researchers detected abnormal esophageal acid exposure in 49% of patients in the anterior group and 42% of the posterior group. Both groups also had similar GERD questionnaire scores.
Both groups had a median length of hospital stay of 2 days (interquartile range, 1–3). Researchers observed 15 total adverse events across both groups, with eight in the anterior group and seven in the posterior group.
“Posterior POEM is not inferior to anterior POEM in terms of clinical success,” Khashab and colleagues wrote. “Both approaches are equivalently safe when performed by experienced operators. Abnormal esophageal acid exposure occurs at equal rates after either approach.” – by Alex Young
Disclosures: Khashab reports consulting for Boston Scientific, Medtronic and Olympus. He also reports serving on advisory boards for Boston Scientific and Olympus. Please see the full study for all other authors’ relevant financial disclosures.