Dataset Information

Per-oral endoscopic myotomy for palliation of achalasia: A video atlas.

ABSTRACT: Video 1Video available at: https://www.jtcvs.org/article/S2666-2507(21)00513-7/fulltext.Video 2Video available at: https://www.jtcvs.org/article/S2666-2507(21)00513-7/fulltext.Video 3Video available at: https://www.jtcvs.org/article/S2666-2507(21)00513-7/fulltext.Video 4Video available at: https://www.jtcvs.org/article/S2666-2507(21)00513-7/fulltext.Video 5Video available at: https://www.jtcvs.org/article/S2666-2507(21)00513-7/fulltext.Video 6Video available at: https://www.jtcvs.org/article/S2666-2507(21)00513-7/fulltext.Video 7Video available at: https://www.jtcvs.org/article/S2666-2507(21)00513-7/fulltext.

SUBMITTER: Raja S

PROVIDER: S-EPMC8690962 | biostudies-literature | 2021 Dec

REPOSITORIES: biostudies-literature

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Per-oral endoscopic myotomy for palliation of achalasia: A video atlas.

Raja Siva S Adhikari Saurav S Sanaka Madhu R MR

JTCVS techniques 20210805

Video 1Video available at: https://www.jtcvs.org/article/S2666-2507(21)00513-7/fulltext.Video 2Video available at: https://www.jtcvs.org/article/S2666-2507(21)00513-7/fulltext.Video 3Video available at: https://www.jtcvs.org/article/S2666-2507(21)00513-7/fulltext.Video 4Video available at: https://www.jtcvs.org/article/S2666-2507(21)00513-7/fulltext.Video 5Video available at: https://www.jtcvs.org/article/S2666-2507(21)00513-7/fulltext.Video 6Video available at: https://www.jtcvs.org/article/S26 ...[more]

PMID: 34977797

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Project description:ImportanceSeveral professional practice guidelines recommend per-oral endoscopic myotomy (POEM) as a potential first-line therapy for the management of achalasia, yet payers remain hesitant to reimburse for the procedure owing to unanswered questions regarding safety.ObjectiveTo evaluate the use, safety, health care utilization, and costs associated with the use of POEM for treatment of achalasia relative to laparoscopic Heller myotomy (LHM) and pneumatic dilation (PD).Design, setting, and participantsThis was a retrospective national cohort study of commercially insured patients, aged 18 to 63 years, who underwent index intervention for achalasia with either LHM, PD, or POEM in the US between July 1, 2010, and December 31, 2017. Patient data were obtained from a national commercial claims database. Included in the study were patients with at least 12 months of enrollment after index treatment and a minimum of 6 months of continuous enrollment before their index procedure. Patients 64 years or older were excluded to avoid underestimation of health care claims from enrollment in Medicare supplemental insurance. Data were analyzed from July 1, 2019, to July 1, 2021.Main outcomes and measuresChanges in the proportion of annual procedures performed for achalasia were evaluated over time. The frequency of severe procedure-related adverse events, including perforation, pneumothorax, bleeding, and death, were compared. Negative binomial regression was used to compare the incidence rates of subsequent diagnostic testing, reintervention, and unplanned hospitalization. Generalized linear models were used to compare differences in 1-year health-related expenditures across procedures.ResultsThis cohort study included a total of 1921 patients (median [IQR] age: LHM group, 48 [37-56] years; 737 men [51%]; PD group, 51 [41-58] years; 168 men [52%]; POEM group, 50 [40-57] years; 80 men [56%]). The use of POEM increased 19-fold over the study period, from 1.1% (95% CI, 0.2%-3.2%) of procedures in 2010 to 18.9% in 2017 (95% CI, 13.6%-25.3%; P = .01). Adverse events were rare and did not differ between procedures. Compared with LHM, POEM was associated with more subsequent diagnostic testing (incidence rate ratio [IRR], 2.2; 95% CI, 1.9-2.6) and reinterventions (IRR, 1.9; 95% CI, 1.1-3.3). When compared with PD, POEM was associated with more subsequent diagnostic testing (IRR, 1.5; 95% CI, 1.3-1.8) but fewer reinterventions (IRR, 0.4; 95% CI, 0.2-0.6). The total 1-year health care costs were similar between POEM and LHM, but significantly lower for PD (mean cost difference, $7674; 95% CI, $657-$14 692).Conclusions and relevanceResults of this cohort study suggest that POEM was associated with higher health care utilization compared with LHM and lower subsequent health care utilization but higher costs compared with PD. The use of POEM is increasing rapidly; payers should recognize the totality of evidence and current treatment guidelines as they consider reimbursement for POEM. Patients should be informed of the trade-offs between approaches when considering treatment.

Project description:IntroductionPeroral endoscopic myotomy (POEM) is the standard treatment for achalasia. Functional luminal imaging probe (FLIP) technology enables objective measurement of lower esophageal sphincter (LES) geometry, with literature linking specific values to improved post-POEM outcomes. Our study assesses FLIP's intraoperative use in evaluating myotomy extent in real-time.MethodsRetrospective data from all patients undergoing POEM with intraoperative FLIP measurements were extracted from June 2020 to January 2023. The primary endpoint was intraoperative FLIP measurements, management changes, and symptom improvement (Eckardt score).ResultsFourteen patients (age 56 ± 14 years, BMI 28 ± 7 kg/m2) were identified. Most patients were female (64%). Predominantly, patients presented with type II achalasia (50%). FLIP measurements were taken before and after myotomy, demonstrating increases in mean distensibility index (DI) 1.6 ± 1. 4 to 5.4 ± 2.1 mm2/mmHg (p < 0.05) and mean diameter (Dmin) 6 ± 1.8 to 10.9 ± 2.3 mm (p < 0.05) at 50 ml balloon fill. Additional myotomy was performed in one patient when an inadequate increase in FLIP values were noted. Mean operative time was 98 ± 28 min, and there were no intraoperative complications. At the 30-day follow-up, median Eckardt score decreased from mean a preoperative score of 7 ± 2 to a post-operative mean of 2 ± 3, with 10 patients (78%) having a score ≤ 2. In total, four patients experienced symptom recurrence, with repeat FLIP values revealing a significant decrease in DI from 7 ± 2.2 post-POEM to 2.5 ± 1.5 at recurrence. FLIP technology identified LES pathology in 3 out of 4 (75%) patients, facilitating referral to LES-directed therapy.ConclusionOur study adds to the literature supporting the use of FLIP technology during the POEM procedure, with most patients achieving ideal values after a standard-length myotomy. This suggests the potential benefits of shorter myotomies guided by FLIP to achieve comparable outcomes and reduce postoperative GERD risk. Collaborative standardization of study designs and outcome measures is crucial for facilitating prospective trials and cross-setting outcome comparisons.

Dataset Information

Per-oral endoscopic myotomy for palliation of achalasia: A video atlas.

Publications

Per-oral endoscopic myotomy for palliation of achalasia: A video atlas.

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