Gut and Liver, Vol. 11, No. 5, September 2017, pp.

642-647

ORiginal Article

Comparison of the Outcomes of Peroral Endoscopic Myotomy for Achalasia

According to Manometric Subtype

Won Hee Kim1, Joo Young Cho1, Weon Jin Ko1, Sung Pyo Hong1, Ki Baik Hahm1, Jun-Hyung Cho2, Tae Hee Lee2, and
Su Jin Hong3
1
Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, 2Digestive Disease Center, Soonchunhyang University
Hospital, Seoul, and 3Digestive Disease Center, Soonchunhyang University Bucheon Hospital, Bucheon, Korea

Background/Aims: We evaluated whether manometric sub- dence between the ages of 30 and 60 years.1
type is associated with treatment outcome in patients with Available treatment options for achalasia are oral pharmaco-
achalasia treated by peroral endoscopic myotomy (POEM). logic therapy, endoscopic injection of botulinum toxin, pneu-
Methods: High-resolution manometry data and Eckardt matic dilatation, or laparoscopic myotomy. Of these, pneumatic
scores were collected from 83 cases at two tertiary referral dilatation and myotomy are considered the most effective treat-
centers where POEM is performed. Manometric tracings ment,2 with a favorable short-term outcome. However, the ben-
were classified according to the three Chicago subtypes. eficial effect declines over time, and repeat intervention may be
Results: Among the 83 cases, 48 type I, 24 type II, and 11 required.3
type III achalasia cases were identified. No difference was When compared with surgical myotomy, peroral endoscopic
found in pre-POEM Eckardt score, basal lower esophageal myotomy (POEM) is known to be a safe and effective form of
sphincter (LES) pressure, or integrated relaxation pressure endoscopic surgery for achalasia patients. Inoue and colleagues
(IRP) among the type I, type II, and type III groups. All three introduced POEM as an alternative treatment for achalasia pa-
patient groups showed a significant improvement in post- tients in 2010.4,5 POEM has been performed worldwide in more
POEM Eckardt score (6.1±2.1 to 1.5±1.5, p=0.001; 6.8±2.2 than 7,000 cases, there is growing evidence that POEM can be a
to 1.2±0.9, p=0.001; 6.6±2.0 to 1.6±1.4, p=0.011), LES standard treatment for achalasia patients.
pressure (26.1±13.8 to 15.4±6.8, p=0.018; 32.3±19.0 to Recent studies have reported excellent outcomes for POEM in
19.2±10.4, p=0.003; 36.8±19.2 to 17.5±9.7, p=0.041), terms of both symptom resolution and improvement in esopha-
and 4s IRP (21.5±11.7 to 12.0±8.7, p=0.007; 24.5±14.8 to gogastric junction (EGJ) physiology and esophageal emptying.
12.0±7.6, p=0.002; 24.0±15.7 to 11.8±7.1, p=0.019) at a The treatment success rate of 89% to 100%4,6-9 have been re-
median follow-up of 16 months. Conclusions: POEM resulted ported for the treatment.
in a good clinical outcome for all manometric subtypes. (Gut Response to botulinum toxin injection or pneumatic dilata-
Liver 2017;11:642-647) tion was best in type II achalasia and somewhat lower in type I;
patients with type III achalasia had a poor response to all forms
Key Words: Esophageal achalasia; Peroral endoscopic my- of therapy, which is similar in laparoscopic Heller’s myotomy.9-11
otomy; High resolution manometry; Treatment outcome However, the treatment outcomes for POEM, divided accord-
ing to achalasia subtype as defined by high resolution manom-
INTRODUCTION etry (HRM) have rarely been studied to the best of our knowl-
edge. We therefore evaluated whether manometric subtype was
Achalasia is an esophageal motility disorder of unknown associated with the treatment outcome in patients treated with
cause. Achalasia is characterized by impaired relaxation of the POEM.
lower esophageal sphincter (LES) and absent esophageal peri-
stalsis, due to neuronal degeneration of the myenteric plexus.
Estimated incidence is 1 per 100,000 per-year with a peak inci-

Correspondence to: Joo Young Cho

Digestive Disease Center, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam 13496, Korea
Tel: +82-31-780-5641, Fax: +82-31-780-5219, E-mail: [email protected]
Received on November 8, 2016. Revised on January 3, 2017. Accepted on January 3, 2017. Published online June 27, 2017
pISSN 1976-2283 eISSN 2005-1212 https://doi.org/10.5009/gnl16545
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0)
which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
 Kim WH, et al: Peroral Endoscopic Myotomy for Achalasia 643

MATERIALS AND METHODS (0, absent; 1, occasional; 2, daily; and 3, each meal) and weight
loss (0, no weight loss; 1, <5 kg; 2, 5 to 10 kg; and 3, >10 kg).
1. Patients
Patients were followed postoperatively, every 3 months periods.
This retrospective cohort study was conducted from Novem-
2. High resolution manometry
ber 2011 to December 2014 in two tertiary referral centers.
This study was approved by the Institutional Review Board of The manometric data were collected pretreatment and at 12
Soonchunhyang University Hospital and CHA Bundang Medical months postoperatively. An HRM with 32 solid-state sensors
Center, CHA University. Informed consent was obtained from all spaced at 1 cm intervals (InSIGHTTMHRiM· system; Sandhill
subjects. A total of 83 achalasia patients who underwent POEM Scientific, Highlands Ranch, CO, USA) was used. Studies were
were enrolled in our study. The diagnosis of achalasia was performed with the patient in the sitting position after at least 6
based on HRM. In addition, patients were required to have an hours of fasting. The manometric protocol included a 5-minute
Eckardt score of more than 3.12 The Eckardt score is the sum of period to assess basal sphincter pressure and ten 5 mL-saline
the symptom scores for dysphagia, regurgitation, and chest pain swallows.

A B C

Fig. 1. High-resolution manometry tracings of the three subtypes of achalasia. (A) Type I achalasia, (B) type II achalasia, and (C) type III achalasia.

A B C

D E F

Fig. 2. Peroral endoscopic myotomy (POEM) procedure. (A) Mucosal incision, (B) creation of a submucosal tunnel, (C) myotomy, (D, E) submucosal
space difference between the esophageal and gastric side, and (F) closure.
644 Gut and Liver, Vol. 11, No. 5, September 2017

Manometric data were analyzed using the BioView software RESULTS

(Sandhill Scientific Inc.). Manometric tracings were classified
1. Patient characteristics
according to the three Chicago subtypes:13 type I with impaired
LES relaxation during swallow and aperistalsis of esophageal In total, 83 achalasia patients with a mean age of 45.2 years
body, type II with pan-esophageal pressurization, type III with (range, 12 to 75 years) and 35 male patients (42.2%) were en-
no normal peristalsis, but evidence of esophageal spasm (Fig. 1). rolled in the study. The mean duration of symptoms was 6.4
The manometries were interpreted by experienced gastroenter- years, and 40 patients had received prior treatment for achala-
ologists (T.H.L. and W.H.K.). sia. Of them, 18 patients had 30 mm balloon dilatation, 12 had
botulinum toxin injection, two had both balloon dilatation and
3. POEM procedures
botulinum toxin injection, two had laparoscopic Heller my-
POEM was performed under general anesthesia by expert otomy, and six had POEM (Table 1).
endoscopists (J.Y.C. and S.J.H.). The procedure consisted of four In total, 48 patients had achalasia type I (57.8%), 24 patients
consecutive steps: (1) mucosal incision: after 5 mL submucosal had achalasia type II (28.9%), and 11 patients had achalasia
injection (mixture of sodium hyaluronate, normal saline, and type III (13.3%). There was no difference in the pre-POEM Eck-
indigo carmine), about 2 cm length vertical mucosal incision is ardt score, basal LES pressure, and IRP between type I, type II,
made at 10 to 15 cm above the EGJ to allow entry into the sub- and type III groups (6.1±2.1 mm Hg vs 6.8±2.2 mm Hg vs 6.6±2.0
mucosa; (2) creation of a submucosal tunnel: submucosal tunnel mm Hg, p=0.557; 26.1±13.8 mm Hg vs 32.3±19.0 mm Hg vs
was made using spray coagulation until the LES was reached; 36.8±19.2 mm Hg, p=0.137; 21.5±11.7 mm Hg vs 24.5±14.8
(3) myotomy: dissection of the inner circular muscle bundle was mm Hg vs 24.0±15.5 mm Hg, p=0.618).
started inside the submucosal tunnel, 2 cm distal to the mucosal
2. Outcomes of POEM
entry site and more than 10 cm proximal to the EGJ. The my-
otomy should be extended 2 cm to the stomach cardia; and (4) All of the POEMs were successfully performed without any
closure: the mucosal entry was closed with multiple endoscopic serious complications. There was no significant difference in
clips (Fig. 2). therapeutic success between the previously treated and treat-
ment naive patients (97.4% vs 100%, p=0.433). Also, treatment
4. Outcomes measurements
success rate was similar in two independent endoscopists (67/69
Eckardt score was recorded every 3 months periods. HRM [97.1%] vs 14/14 [100%], p=0.519) (Supplement Table 1).
and Endoscopy was performed 6 months and 12 months after Capnoperitoneum occurred in 12.5% of patients, and was
POEM. The primary outcome was therapeutic success, defined resolved with conservative treatment in all patients. Mucosal
by a reduction in the Eckardt score to ≤3. The secondary out- perforation was occurred in one patient. The mean procedure
comes were LES pressure and integrated relaxation pressure (IRP) time of 83 patients was 91.1±35.8 minutes, mean length of the
measured by HRM and other procedure related parameters. submucosal tunnel created was 12.2±3.3 cm, and the average
length of myotomy was 9.0±2.8 cm. The procedure time, my-
5. Statistical analysis
otomy length, nil per os time, and hospital stay were no signifi-
Statistical analysis was performed using SPSS 21.0 software cantly different between the groups (Table 2).
(IBM Corp., Armonk, NY, USA). The mean values between base- Treatment success, defined as an Eckardt score of <3, was
line and follow-up were compared using Wilcoxon signed rank achieved in all the three groups, 97.9% in type I, 100% in II pa-
test for paired samples. Statistical significance between groups tients, and 90.9% in type III. The success rate was not different
was evaluated using analysis of variance. A p-values of less between groups (p=0.179). All three groups of patients showed a
than 0.05 was considered statistically significant. significant improvement in post-POEM Eckardt score at the me-

Table 1. Previous Treatment Modalities

Type 1 (n=48) Type 2 (n=24) Type 3 (n=11) p-value
Previous treatment 0.902
Botulinum toxin injection 7 (16.7) 4 (14.8) 1 (7.1)
Pneumatic balloon dilatation 10 (23.8) 4 (14.8) 4 (28.6)
Both toxin and balloon 2 (4.8) 0 0
Laparoscopic Heller’s myotomy 1 (2.4) 1 (3.7) 0
POEM 3 (7.1) 2 (7.4) 1 (7.1)
Data are presented as number (%).
POEM, peroral endoscopic myotomy.
 Kim WH, et al: Peroral Endoscopic Myotomy for Achalasia 645

Table 2. Comparison of Perioperative Details among Groups

Variable Type 1 (n=48) Type 2 (n=24) Type 3 (n=11) p-value
Time of procedure, min 103.7±44.2 86.0±25.5 82.5±33.3 0.212
NPO time, day 5.1±2.3 5.5±1.8 4.6±2.0 0.634
Length of myotomy, cm 0.787
Total 9.0±3.0 8.5±1.6 9.3±2.8 0.889
Esophageal 7.2±2.6 6.6±1.6 7.8±2.4 0.417
Gastric 1.8±0.9 2.0±0.4 1.6±0.8 0.293
Data are presented as mean±SD.
NPO, nil per os.

Table 3. Treatment Outcomes after Peroral Endoscopic Myotomy

Variable Type 1 (n=48) Type 2 (n=24) Type 3 (n=11) p-value
Treatment success (Eckardt score ≤3) 47 (97.9) 24 (100) 10 (90.9) 0.179
Eckardt score
Before POEM 6.1±2.1 6.8±2.2 6.6±2.0 0.557
After POEM 1.5±1.5 1.2±0.9 1.6±1.4 0.838
Before and after-POEM difference 4.8±2.5 5.4±2.8 5.0±2.1 0.793
LES pressure, mm Hg
Before POEM 26.1±13.8 32.3±19.0 36.8±19.2 0.137
After POEM 15.4±6.8 19.2±10.4 17.5±9.7 0.670
Before and after-POEM difference 8.7±16.5 17.1±17.9 20.6±26.4 0.366
IRP, mm Hg
Before POEM 21.5±11.7 24.5±14.8 24.0±15.7 0.618
After POEM 12.0±8.7 12.0±7.6 11.8±7.1 0.969
Before and after-POEM difference 7.8±13.0 14.7±16.1 12.8±16.0 0.553
Data are presented as number (%) or mean±SD.
POEM, peroral endoscopic myotomy; LES, lower esophageal sphincter; IRP, integrated relaxation pressure.

* Type I achalasia patients (Table 3).

Type II
LES pressure (26.1±13.8 to 15.4±6.8, p=0.018; 32.3±19.0 to
Type III
10 19.2±10.4, p=0.003; 36.8±19.2 to 17.5±9.7, p=0.041), and 4s
9 IRP (21.5±11.7 to 12.0±8.7, p=0.007; 24.5±14.8 to 12.0±7.6,
8 p=0.002; 24.0±15.7 to 11.8±7.1, p=0.019) decreased after POEM
7 in all three groups of patients. IRP decreased the most in type II
6 achalasia patients (Table 3).
5 A total of 18 patients had endoscopic reflux esophagitis:
4 16.7% (8/48) of patients with achalasia type I, 33.3% (8/24)
3 of type II, and 18.2% (2/11) of type III. The incidence of re-
2 flux esophagitis was not different between the subtype groups
1 (p=0.553).
0
Before POEM After POEM
DISCUSSION
Fig. 3. Eckardt score before and after peroral endoscopic myotomy
(POEM). *p=0.001; †p=0.001; ‡p=0.011.
POEM is suggested as an effective treatment option for acha-
lasia, however, it remains controversial due to a paucity of data
dian follow-up of 16 months (Fig. 3). There was no significant from randomized controlled trial,5 and the use of relatively short
difference in mean post-POEM Eckardt score between groups, follow-up periods. There is also a shortage of studies on the pre-
but decreased degree of Eckardt score was most high in type II dictors of therapeutic success and prognosis of POEM.
646 Gut and Liver, Vol. 11, No. 5, September 2017

Since the introduction of HRM, achalasia has been divided the surgical literature, the basal LES pressures are expected to
into three subtypes. The treatment outcome was different on approach 10 mm Hg after myotomy. In out study, basal LES
achalasia subtypes and suggests that the subtyping of achalasia pressure after POEM are from 15.4 to 19.2 mm Hg. Relatively
allows the clinician to direct therapy and improve predicted shorter lengths of myotomy on the gastric side may account for
outcomes.9-11,14 this, and the low rate of reflux.
In studies of pneumatic dilatation, achalasia subtype clas- Our study has several limitations. This includes the small
sified by HRM was found to be an important predictor of the sample size, with only 11 type III patients enrolled. Data on the
treatment success and prognosis.11 The type II achalasia subtype postprocedure incidence of reflux esophagitis, or medication for
was most frequent in Western,11,14,15 Asian,16,17 and Korean6,18,19 RE, were not always available. Our study also included only one
studies and was found to be more responsive to treatment (95.3% patient with sigmoid type achalasia.
to 100%). The same is true in the case of laparoscopic Heller’s Nevertheless, this study is useful as the first study to deter-
myotomy (LHM).9,10,14 Most studies reported that the type III mine the therapeutic outcome of POEM by manometric sub-
patients had the lowest response rate to pneumatic dilatation types, and the predictors of treatment outcome and the precise
and LHM, and reported treatment success rate was 29% to indications of POEM.
86%.2,9,10,14 Of special note is that the type III achalasia subtype, that
In our study, treatment success was achieved in all three sub- showed poor response to any other treatment modality, had a
types, and all parameters improved after POEM. In the patients high success rate of 90.9% with POEM. Therefore, POEM should
with type II achalasia, treatment success was achieved 100%, be a particularly useful treatment modality in type III achalasia
and the difference between the pre- and post-POEM Eckardt patients.
score and IRP was highest of the three groups. In conclusion, POEM is an endoscopic procedure of relatively
Even as type III, 10 out of 11 of those belonging to the type low invasiveness and shows good clinical outcomes for esopha-
III group (90.9%) achieved treatment success; postoperative Eck- geal achalasia without serious complications. POEM appears to
ardt score ≤3 and improved chest pain. Although the number be a very effective treatment for achalasia patients, regardless of
of patients was not many, the treatment success rate of POEM the manometric subtype. POEM may be of the most effective-
was much higher than pneumatic dilatation or LHM.20,21 Type III ness in type II patients like other studies, and it is particularly
achalasia has spastic contractions in the mid and distal esopha- useful treatment modality in type III achalasia subtype.
gus. Therefore, reducing the pressure of LES as well as the One concern is that, there was some difference in the success
segment affected spastic motility is also required. Unlike LHM, rate according to the practitioner, experienced professionals or
POEM allows access to the entire length of the esophageal body, trainees under the guidance of professionals are needed to per-
therefore long myotomy can be performed.21 The higher success form POEM. A large prospective study with long-term follow-up
rate of POEM in type III achalasia may be due to long myotomy is needed to confirm that POEM can be considered as a standard
of esophageal body. There are few data about the role of POEM treatment in any subtype of achalasia patients.
in the management of patients with type III achalasia, and this
study can be an additional evidence for POEM as effective treat- CONFLICTS OF INTEREST
ment modality for type III achalasia.
Unlike other studies, the type I subtype was most common No potential conflict of interest relevant to this article was
in our study (57.8%). Till date, POEM was not been widely ac- reported.
cepted in Korea. Therefore, POEM was frequently performed as
a second line therapy after the failure of the first line therapy ACKNOWLEDGEMENTS
such as medication, pneumatic balloon dilatation, and Botox in-
jection. In our study, 40 out of 83 patients (48.2%) had received The abstract of this manuscript has been a poster presentation
prior treatment. It is possible that achalasia type II responded at United European Gastroenterology Week 2015. Neither the
relatively well to other treatments; therefore, many of these submitted manuscript nor portions thereof have been published
patients were excluded from our study. There may have been a previously or are under consideration for publication elsewhere.
bias towards recruiting patients with type I achalasia, as sug-
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