Peroral Endoscopic Myotomy (POEM) and Laparoscopic Heller Myotomy with Dor Fundoplication for Esophagogastric Junction Outflow Obstruction (EGJOO): a Comparison of Outcomes and Impact on Physiology

Journal of Gastrointestinal Surgery https://doi.org/10.1007/s11605-023-05844-0 SSAT QUICK SHOT PRESENTATION Peroral Endoscopic Myotomy (POEM) and Laparoscopic Heller Myotomy with Dor Fundoplication for Esophagogastric Junction Outflow Obstruction (EGJOO): a Comparison of Outcomes and Impact on Physiology Inanc S. Sarici1,2 · Sven Eriksson1,2 · Mohamad Rassoul Abu‑Nuwar1 · Jacob Kuzy1 · Margaret Gardner1 · Ping Zheng1,2 · Blair Jobe1,2,3 · Shahin Ayazi1,2,3 Received: 5 May 2023 / Accepted: 16 September 2023 © The Author(s) 2023 Abstract Introduction Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility disorder characterized by failure of lower esophageal sphincter (LES) relaxation with preserved peristalsis. Studies have shown that Heller myotomy with Dor fundoplication (HMD) and per oral endoscopic myotomy (POEM) are effective treatments for EGJOO. However, there is paucity of data comparing the efficacy and impact of these two procedures. Therefore, the aim of this study was to compare outcomes and impact on esophageal physiology in patients undergoing HMD or POEM for primary EGJOO. Methods This was a retrospective review of patients who underwent either HMD or POEM for primary EGJOO at our institution between 2013 and 2021. Favorable outcome was defined as an Eckardt score ≤ 3 at 1 year after surgery. GERD– HRQL questionnaire, endoscopy, pH monitoring, and high-resolution manometry (HRM) results at baseline and 1 year after surgery were compared pre- and post-surgery and between groups. Objective GERD was defined as DeMeester score > 14.7 or LA grade C/D esophagitis. Results The final study population consisted of 52 patients who underwent HMD (n = 35) or POEM (n = 17) for EGJOO. At a mean (SD) follow-up of 24.6 (15.3) months, favorable outcome was achieved by 30 (85.7%) patients after HMD and 14 (82.4%) after POEM (p = 0.753). After HMD, there was a decrease GERD-HRQL total score (31 (22–45) to 4 (0–19); p < 0.001), and objective reflux (54.2 to 25.9%; p = 0.033). On manometry, there was a decrease in LES resting pressure (48 (34–59) to 13 (8–17); p < 0.001) and IRP (22 (17–28) to 8 (3–11); p < 0.001), but esophageal body characteristics did not change (p > 0.05). Incomplete bolus clearance improved (70% (10–90) to 10% (0–40); p = 0.010). After POEM, there was no change in the GERD-HRQL total score (p = 0.854), but objective reflux significantly increased (0 to 62%; p < 0.001). On manometry, there was a decrease in LES resting pressure (43 (30–68) to 31 (5–34); p = 0.042) and IRP (23 (18–33) to 12 (10–32); p = 0.048), DCI (1920 (1600–5500) to 0 (0–814); p = 0.035), with increased failed swallows (0% (0–30) to 100% (10–100); p = 0.032). Bolus clearance did not improve (p = 0.539). Compared to HMD, POEM had a longer esophageal myotomy length (11 (7–15)-vs-5 (5–6); p = 0.001), more objective reflux (p = 0.041), lower DCI (0 (0–814)-vs-1695 (929–3101); p = 0.004), and intact swallows (90 (70–100)-vs-0 (0–40); p = 0.006), but more failed swallows (100 (10–100); p = 0.018) and incomplete bolus clearance (90 (90–100)-vs-10 (0–40); p = 0.004). Conclusion Peroral endoscopic myotomy and Heller myotomy with Dor fundoplication are equally effective at relieving EGJOO symptoms. However, POEM causes worse reflux and near complete loss of esophageal body function. Keywords Esophagogastric junction outflow obstruction (EGJOO) · Lower esophageal sphincter (LES) · Heller myotomy · Per oral endoscopic myotomy (POEM) · GERD Extended author information available on the last page of the article 13 Vol.:(0123456789) Journal of Gastrointestinal Surgery Introduction Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) with preserved peristalsis of the esophageal body.[1] The etiology of EGJOO can be primary or secondary and is found in 3–24% of patients who undergo high resolution manometry (HRM).[2, 3] Secondary EGJOO can be due to structural, postsurgical or a malignant process, and is best managed by addressing the underlying pathology.[4] Conversely, primary EGJOO is an idiopathic disease process and is mainly managed through symptom palliation. Patients with mild symptoms may respond to pharmacotherapy, pneumatic dilation, or botulinum toxin injection.[4] However, patients with refractory or severe symptoms may require surgical myotomy.[5, 6] The goal of surgical myotomy is to disrupt the muscle fibers responsible for the hypertensive LES, thereby decreasing resistance and relieving symptoms. This can be done via a transabdominal approach with the Heller myotomy or an endoscopic approach known as peroral endoscopic myotomy (POEM). The advantage of the transabdominal approach is that it grants access to the hiatus, allowing hiatal hernia repair if needed, and can be performed in conjunction with a partial fundoplication to assist with reflux control after myotomy. The endoscopic approach eliminates the risks of laparoscopic surgery and enables the surgeon to extend the myotomy more proximally on to the esophageal body muscles so that myotomy length can be tailored to diseased segment length. Limited studies have demonstrated that both Heller myotomy and POEM can effectively palliate dysphagia in patients with EGJOO with success rates of 96 and 94%, respectfully.[6, 7] Heller myotomy with Dor fundoplication (HMD) and POEM are well-established surgical procedures for esophageal motility disorders such as achalasia and its subtypes, and many studies have shown the safety and efficacy of both procedures.[8, 9] However, studies of HMD and POEM for the management of EGJOO are limited with small sample size, shortterm follow-up, and lack of complete postoperative objective data.[5, 6] Additionally, no studies have compared the efficacy of these two surgical procedures. Therefore, this study aims to compare the outcomes and impact on esophageal physiology between HMD and POEM in patients with primary EGJOO. evaluated and approved by the Institutional Review Board of the Allegheny Health Network (IRB Number 2021–239). Patients with a diagnosis of primary EGJOO who were 18 years or older and had at least 1-year follow-up after surgery were included in this study. Patients diagnosed with secondary EGJOO (e.g., hiatal hernia, stricture), achalasia, jackhammer esophagus, diffuse esophageal spasm, and other esophageal motility disorders were not included in this study. Disease‑Related Quality of Life Measures All patients were asked to complete validated questionnaires preoperatively and 1-year postoperatively, including Eckardt symptom score and Gastroesophageal Reflux DiseaseHealth-Related Quality of Life (GERD-HRQL). The Eckardt score was used to grade the severity of esophageal motility disorders and assess four symptoms: weight loss, dysphagia, retrosternal pain, and regurgitation. Each symptom was scored from 0 to 3 with an aggregate score between (...truncated)