The Utilization and Safety of Per Oral Endoscopic Myotomy (POEM) for Achalasia in the US

Background: Clinical trials show that per oral endoscopic myotomy (POEM) has similar efficacy to pneumatic dilation (PD) and laparoscopic heller myotomy (LHM) for relief of achalasia symptoms. We describe the diffusion of POEM into clinical practice and evaluate unanswered questions regarding safety and the burden of healthcare utilization after POEM.
Methods: Retrospective cohort study of achalasia patients (18-63 years) initially treated with POEM, PD, or LHM (2010-2017) using the MarketScan® claims databases. Administrative codes used to measure POEM were validated in an institutional cohort using gold standard chart abstraction. We compared frequencies of perforation requiring intervention and healthcare utilization in the year following intervention.
Results: Among 1,921 patients (mean age 46 years, 49% women), 75.7%, 16.9%, and 7.4% underwent LHM, PD, and POEM, respectively. POEM increased from 1.1% of cases in 2010 to 18.9% in 2017. Perforation occurred in 0.3% (95% confidence interval [CI]: 0.1-0.7%) undergoing LHM vs 0.9% (95%CI 0.2-2.7%) undergoing PD vs 0.0% (95%CI 0.0-2.6%)
undergoing POEM. After POEM, 88.0% (95%CI 82.6-93.4) of patients underwent achalasia-related diagnostic testing, compared to 74.3% (95%CI 72.1-76.5) and 78.5% (95%CI 74.0-83.0) after LHM and PD, respectively. Reintervention was performed in 16.9% (95%CI 11.1-24.1) of patients after POEM, compared to 7.8% (95%CI 6.4-9.3) and 45.5% (95%CI 40.0-51.1) after LHM and PD, respectively.
Conclusions: Utilization of POEM has increased over time in the US, and comprised nearly a fifth of definitive procedures performed for achalasia in 2017. Perforation requiring intervention was rare for all procedures. POEM was associated with greater post-procedure diagnostic testing and reintervention compared to LHM. Compared to PD, POEM was associated with greater post-procedure diagnostic testing but less frequent reintervention.