乌鸦传媒

Use of per-oral endoscopic myotomy (POEM) for esophageal achalasia increased dramatically during the past decade, a retrospective study found, and while the procedure appears just as safe as laparoscopic Heller myotomy (LHM), it led to greater healthcare utilization.

From 2010 to 2017, the proportion of achalasia procedures using POEM in a commercial claims database increased from 1.1% to 18.9%, reported Alex Lois, MD, MS, of the University of Washington in Seattle, and colleagues.

"Achalasia is a rare, chronic esophageal motility disorder that leads to dysphagia, often with chest pain, regurgitation, and weight loss. Definitive treatment requires mechanical disruption of the lower esophageal sphincter," the group explained in .

This has been most frequently achieved with LHM, and less often with pneumatic dilation (PD), but randomized trials have demonstrated similar short-term efficacy with POEM, though with a greater risk for future reflux.

During the study period, shifts in use of LHM and PD were far less dramatic:

• LHM: 75% in 2010 and 71% in 2017
• PD: 23% in 2010 and 10% in 2017

"Payers have been hesitant to reimburse for POEM, stating it remains an investigational procedure," noted Lois and coauthors. "However, these results suggest that use of POEM is increasing despite the lack of a billing code. This increase may be explained by variability in payer coverage of POEM, patient demand for POEM, clinician willingness to adopt this procedure, or shifting practice guidelines recommending POEM alongside LHM as first-line therapy for achalasia."

Average total costs associated with the procedures at 1 year were higher with POEM ($35,143) and LHM ($31,451) than with PD ($22,975), while mean out-of-pockets costs were no different (under $2,000 for all three).

While adverse events were rare with the three procedures -- with no between-group differences -- POEM was associated with more subsequent diagnostic tests (incidence rate ratio [IRR] 2.2, 95% CI 1.9-2.6) and reinterventions (IRR 1.9, 95% CI 1.1-3.3) compared to LHM.

This finding was "probably because of the higher rate of pathologic reflux after this procedure," Marco Patti, MD, of the University of Virginia in Charlottesville, and colleagues, stated in an .

"Use of POEM should be carefully considered," the editorialists said. "While it seems more effective than LHM for type III achalasia and for treating recurrent symptoms after LHM, its use as primary treatment is questionable for patients with type I and II achalasia. In fact, it has been observed that severe gastroesophageal reflux disease develops in many patients, who then require lifelong proton pump inhibitors or even a laparoscopic fundoplication."

Compared with PD, POEM was also associated with more subsequent diagnostic tests (IRR 1.5, 95% CI 1.3-1.8) but fewer reinterventions (IRR 0.4, 95% CI 0.2-0.6).

For their study, Lois and colleagues examined national commercial claims data on 1,921 adults (ages 18 to 63) who underwent an index intervention for achalasia from July 2010 to December 2017. Of these, 1,454 received LHM, 325 received PD, and 142 received POEM.

For inclusion, patients needed to be enrolled for at least 6 months before their procedure and at least 12 months thereafter. Those with an esophageal or gastric malignancy or who had prior esophageal or gastric surgeries were excluded, among others.

A little more than half of the cohort were men, with median ages ranging from 48 to 51 across groups, with most having an Elixhauser comorbidity index score of 0 (35-37%) or 1 (24-31%). More than two-thirds had a prior diagnostic evaluation with an esophagram/upper gastrointestinal series and 58% to 78% had a prior manometry.

Nineteen total severe adverse events occurred within 1 year of the index procedure: 11 in the LHM group, five in the PD group, and three in the POEM group. Procedure-related adverse events included pneumothorax, hemorrhage, esophageal perforation, and death in six patients.

Average length of hospital stay following the procedure was similar with POEM and LHM (1.03 and 1.48 days, respectively), and shorter with PD (0.36 days).

"As experience accumulates, POEM could be transitioned to an outpatient procedure, as could LHM, avoiding the burden of a hospitalization," the study authors noted.

The authors acknowledged limitations to the data, including the insufficient power to identify minimal differences in rare adverse events due to the rare nature of achalasia. Also, residual confounding may have occurred.

Comment