Clinical and financial outcomes of per-oral endoscopic myotomy compared to laparoscopic heller myotomy for treatment of achalasia

Lena Shally; Kashif Saeed; Derek Berglund; Mark Dudash; Katie Frank; Vladan N Obradovic; Anthony T Petrick; David L Diehl; Jon D Gabrielsen; David M Parker

doi:10.1007/s00464-022-09652-6

Clinical and financial outcomes of per-oral endoscopic myotomy compared to laparoscopic heller myotomy for treatment of achalasia

Surg Endosc. 2023 Jul;37(7):5526-5537. doi: 10.1007/s00464-022-09652-6. Epub 2022 Oct 11.

Authors

Affiliations

¹ Geisinger Commonwealth School of Medicine, 525 Pine St, Scranton, PA, 18510, USA. lshally@som.geisinger.edu.
² Department of Bariatric and Foregut Surgery, Geisinger Medical Center, 100 N Academy Ave, Danville, PA, 17822, USA.
³ Department of Population Health and Sciences, Geisinger Medical Center, 100 N Academy Ave, Danville, PA, 17822, USA.
⁴ Department of Gastroenterology and Nutrition, Geisinger Medical Center, 100 N Academy Ave, Danville, PA, 17822, USA.

PMID: 36220985
DOI: 10.1007/s00464-022-09652-6

Abstract

Background: Previous studies analyzing short-term outcomes for per-oral endoscopic myotomy (POEM) have shown excellent clinical response rates and shorter operative times compared to laparoscopic Heller myotomy (LHM). Despite this, many payors have been slow to recognize POEM as a valid treatment option. Furthermore, comparative studies analyzing long-term outcomes are limited. This study compares perioperative and long-term outcomes, cost-effectiveness, and reimbursement for POEM and LHM at a single institution.

Methods: Adult patients who underwent POEM or LHM between 2014 and 2021 and had complete preoperative data with at least one complete follow up, were retrospectively analyzed. Demographic data, success rate, operative time, myotomy length, length of stay, pre- and postoperative symptom scores, anti-reflux medication use, cost and reimbursement were compared.

Results: 58 patients met inclusion with 25 undergoing LHM and 33 undergoing POEM. There were no significant differences in preoperative characteristics. Treatment success (Eckardt ≤ 3) for POEM and LHM was achieved by 88% and 76% of patients, respectively (p = 0.302). POEM patients had a shorter median operative time (106 min. vs. 145 min., p = 0.003) and longer median myotomy length (11 cm vs. 8 cm, p < 0.001). All LHM patients had a length of stay (LOS) ≥ 1 day vs. 51.5% for POEM patients (p < 0.001). Both groups showed improvements in dysphagia, heartburn, regurgitation, Eckardt score, GERD HRQL, RSI, and anti-reflux medication use. The improvement in dysphagia score was greater in patients undergoing POEM (2.30 vs 1.12, p = 0.003). Median hospital reimbursement was dramatically less for POEM ($3,658 vs. $14,152, p = 0.002), despite median hospital costs being significantly lower compared to LHM ($2,420 vs. $3,132, p = 0.029).

Results: POEM is associated with a shorter operative time and LOS, longer myotomy length, and greater resolution of dysphagia compared to LHM. POEM costs are significantly less than LHM but is poorly reimbursed.

Keywords: Achalasia; Dysphagia; Laparoscopic Heller myotomy; Per-oral endoscopic myotomy; Symptomatic treatment.

MeSH terms

Adult
Deglutition Disorders* / surgery
Esophageal Achalasia* / complications
Esophageal Achalasia* / surgery
Esophageal Sphincter, Lower / surgery
Gastroesophageal Reflux* / surgery
Heller Myotomy*
Humans
Laparoscopy*
Myotomy*
Natural Orifice Endoscopic Surgery*
Retrospective Studies
Treatment Outcome