Peroral Endoscopic Myotomy provides effective palliation in type III achalasia

ABSTRACT Background Type III achalasia outcomes have historically been met with limited success after conventional laparoscopic Heller myotomy and pneumatic dilation. Peroral endoscopic myotomy (POEM) has emerged as a promising alterative due to multitude of reasons. Our objective is to investigate POEM outcomes in palliating type III achalasia.
 Methods A retrospective analysis of a prospectively maintained database was conducted in a tertiary care institution between April 2014 and July 2019. Primary outcome was post-operative Eckardt scores. We also explored lower esophageal spincter (LES) integrated resting pressure (IRP) on manometry, barium column height and width and complications. Standard statistical methods were applied using R.
 Results 
A total of 518 patients in the achalasia database were identified with 308 patients receiving a Heller myotomy and 210 receiving a POEM during the study time period. POEM was used for Type III achalasia in 36 patients (median age 60 years, 61.7% male) with a median operative time of 85mins [interquartile range IQR 71-115 mins] and follow-up period of 1 year [IQR 0.16-2.25yrs]. Within the POEM cohort, 11 patients (33%) had previous interventions including botox injections to LES (7), pneumatic dilation(1) and laparoscopic Heller myotomy (3). Significant decrease in Eckhart scores were observed (7 pre-operatively [IQR 6-8.75] vs. 0 post- operatively [IQR 0-1], p Conclusions POEM provides effective and durable palliation for type III achalasia as demonstrated by symptom relief, esophageal manometry and radiographic measurement. Considering its low morbidity profile, POEM should be considered as first line therapy in this challenging disease subtype.