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Comparative Effectiveness Review of Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia

August 5, 2019

Health Problem: Esophageal achalasia (EA) is an uncommon motility disorder of unknown etiology that is characterized by increased lower esophageal sphincter (LES) pressure and esophageal aperistalsis. Treatment for EA includes both conservative treatment options, such as pharmaceutical therapies or botulinum toxin injection and invasive options, such as pneumatic dilation or surgery.

Technology Description: Peroral endoscopic myotomy (POEM) is a natural orifice transluminal endoscopic surgery technique. The technique involves guiding an endoscope through the esophagus, making an incision in the mucosa, creating a submucosal tunnel for access to the lower esophagus and gastroesophageal junction, and cutting the muscle fibers in the lower esophagus and proximal stomach. Internal incisions are closed with clips after myotomy is complete. Natural orifice surgery, such as POEM, aims to reduce procedure-related pain and return patients to regular activities sooner than surgeries requiring external incisions.

Controversy: Controversies associated with POEM include those related to details about where and how to make the myotomy in order to maximize effectiveness for reducing dysphagia and minimize the potential for gastroesophageal reflux disease. Other controversies include concerns over learning curves and many people have cited a dearth of comparative and long-term data to definitively show the safety and effectiveness of POEM vis-à-vis conventional treatments.

Key Questions:

  • How does POEM compare with laparoscopic Heller myotomy (LHM) or pneumatic dilation (PD) for the treatment of EA?
  • How does POEM compare with LHM or PD with respect to safety in patients with EA?
  • Have definitive patient selection criteria been established for POEM as a treatment for EA?