POEM Beats Pneumatic Dilation for Achalasia Treatment

Prateek Sharma, MD, FASGE reviewing Ponds FA, et al. JAMA 2019 July 9.

The current treatment options for patients with achalasia include pneumatic dilation, laparoscopic Heller myotomy, or peroral endoscopic myotomy (POEM). Treatment success rates of up to 80% to 90% have been reported with all these procedures, but no randomized controlled trials (RCT) have been conducted since the introduction of the POEM procedure.  

In this multicenter RCT, treatment-naive achalasia patients (n=133) were randomized to either POEM or pneumatic dilation. Treatment success was defined as a reduction in a patient’s symptom score (using the Eckardt scale) to <3 and the absence of severe complications and/or need for re-intervention. Pneumatic dilation was initially performed using a 30-mm balloon; if at 3 weeks post-dilation the Eckardt score was >3, a subsequent pneumatic dilation with a 35-mm balloon was performed. POEM was performed by expert endoscopists (each of whom had previously performed at least 20 POEMs) with patients under general anesthesia. Treatment success was 92% in the POEM group compared to 54% in the dilation group, a difference of 38% (95% CI, 22%-52%; p <.001). Post-treatment, there were no significant differences between the groups of the median integrated relaxation pressure or median barium column height. Reflux esophagitis occurred significantly more often in the POEM group (41%) compared to the dilation group (7%). There was 1 perforation after pneumatic dilation, but no serious adverse events occurred in the POEM group.


Comment:
Results from this randomized clinical trial comparing POEM with pneumatic dilation as the initial treatment for achalasia demonstrate a significantly higher treatment success rate at 2 years for patients who underwent POEM. GERD symptoms and reflux esophagitis are higher with POEM. Overall, POEM appears to be better than dilation as first-line treatment.

Prateek Sharma, MD, FASGE
Bio and Disclosures

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Citation(s):
Ponds FA, Fockens P, Lei A, et al. Effect of peroral endoscopic myotomy vs pneumatic dilation on symptom severity and treatment outcomes among treatment-naive patients with achalasia: a randomized clinical trial. JAMA. 2019;322:134-144. (https://doi.org/10.1001/jama.2019.8859)