Efficacy of peroral endoscopic myotomy vs other achalasia treatments in improving esophageal function

Table 1 Patient characteristics n (%)

	PD (n = 22)		LHM (n =142)		POEM (n =36)
Factor	n	Summary	n	Summary	n	Summary	P value
Age at diagnosis (yr)	22	47.5 ± 17.0	142	45.8 ± 15.6	36	52.6 ± 17.2	0.078a
Age at current treatment (yr)	22	50.3 ± 17.9	142	46.5 ± 15.73	36	55.4 ± 16.82	0.013a
Gender	22		142		36		0.19c
Female		11 (50.0)		71 (50.0)		12 (33.3)
Male		11 (50.0)		71 (50.0)		24 (66.7)
Ethnicity	22		141		36		0.85d
White		17 (77.3)		118 (83.7)		31 (86.1)
Black		4 (18.2)		19 (13.5)		4 (11.1)
Other		1 (4.5)		4 (2.8)		1 (2.8)
BMI (kg/m2)	22	27.1 ± 6.9	142	26.0 ± 5.13	36	29.1 ± 5.92	0.012a
Achalasia sub-type	14		120		34		0.023d
Subtype 1		5 (35.7)		30 (25.0)		13 (38.2)
Subtype 2		6 (42.9)		82 (68.3)		18 (52.9)
Subtype 3		2 (14.3)		1 (0.83)		3 (8.8)
Achalasia variant		1 (7.1)		7 (5.8)		0 (0.0)
Prior treatments
Received any prior treatment	22	15 (68.2)	140	62 (44.3)3	36	26 (72.2)2	0.003c
Months from last to current treatment	14	17.7 [2.3, 87.5]	54	6.3 [3.2,28.5]	25	14.7 [6.4,20.2]	0.29b
Botulinium toxin injection	22	1 (4.5)	140	16 (11.4)	36	8 (22.2)	0.11c
PD	22	9 (40.9)2	140	19 (13.6)13	36	11 (30.6)2	0.002c
LHM	22	7 (31.8)2	140	1 (0.71)13	36	10 (27.8)2	< 0.001c
Botulinum toxin injection and regular endoscopic balloon dilation	22	2 (9.1)	140	1 (0.71)	36	0 (0.0)	0.050d
Regular endoscopic balloon dilation	22	3 (13.6)	140	34 (24.3)3	36	2 (5.6)2	0.031c

¹Significantly different from PD;

²Significantly different from LHM;

³Significantly different from POEM. Values presented as Mean ± SD, Median [P25, P75] or N (column %). P-value: a = ANOVA, b = Kruskal-Wallis test, c = Pearson's χ² test, d = Fisher's Exact test. PD: Pneumatic dilation; LHM: Laparoscopic Heller myotomy; POEM: Peroral endoscopic myotomy.

Table 2 High-resolution esophageal manometry and timed barium swallow findings: Univariable analysis

	PD (n = 22)		LHM (n = 142)		POEM (n = 36)
Factor	n	Summary	n	Summary	n	Summary	P value
Pre-treatment
Eckardt score	2	7.0 (7.0, 7.0)	9	6.0 (5.0, 7.0)	36	6.5 (5.0, 8.0)	0.77
HREM
Basal mean pressure (mmHg)	2	31.9 (10.6, 53.2)	86	40.5 (27.2, 51.7)	24	38.7 (27.0, 48.7)	0.89
LES-IRP pressure (mmHg)	3	29.1 (12.0, 34.5)	92	24.0 (17.5, 34.4)	26	23.6 (20.2, 33.4)	0.92
TBE
Height in 1 min (cm)	22	10.2 (7.0, 13.6)	133	9.5 (7.2, 15.0)	34	9.8 (4.0, 14.5)	0.43
Width in 1 min (cm)	22	3.4 (2.5, 4.0)	133	3.0 (2.5, 4.0)	34	3.4 (2.0, 4.4)	0.93
Volume remaining at 1 min (cc)	22	67.3 (44.0, 126.2)	133	71.6 (41.1, 131.9)	34	52.8 (37.7, 119.2)	0.44
Height in 5 min (cm)	20	6.5 (4.0, 10.5)	131	8.0 (5.0, 12.5)	34	5.3 (2.5, 10.0)	0.063
Width at 5 min (cm)	20	2.7 (2.0, 3.6)	131	2.5 (2.0, 3.7)	34	2.5 (1.5, 4.0)	0.83
Volume remaining at 5 min (cc)	20	40.8 (15.5, 73.1)	131	49.1 (15.7, 91.6)	34	25.4 (11.3, 62.8)	0.12
2-mo post-treatment
Eckardt score	4	4.5 (2.0, 6.0)	50	1.00 (0.00, 2.0)	36	1.00 (0.00, 2.0)	0.073
HREM
Basal mean pressure (mmHg)	2	22.0 (18.8, 25.1)	86	14.5 (7.6, 22.7)	24	11.4 (8.2, 20.2)	0.32
LES-IRP pressure (mmHg)	3	10.8 (10.5, 19.4)	92	7.1 (3.9, 10.7)	26	6.6 (3.3, 11.1)	0.18
TBE
Height in 1 min (cm)	22	8.0 (5.8, 11.0)	133	6.7 (4.5, 10.2)	34	6.3 (2.1, 9.5)	0.39
Width in 1 min (cm)	22	2.0 (1.5, 2.5)	133	2.0 (1.2, 2.5)	34	1.6 (0.50, 2.5)	0.28
Volume remaining at 1 min (cc)	22	25.4 (14.1, 41.7)	133	20.4 (6.0, 49.8)	34	12.8 (0.79, 47.7)	0.31
Height in 5 min (cm)	20	2.2 (0.00, 6.5)	131	2.5 (0.00, 6.2)	34	2.3 (0.00, 6.9)	0.94
Width at 5 min (cm)	20	1.05 (0.00, 2.6)	131	1.00 (0.00, 2.1)	34	0.50 (0.00, 2.0)	0.97
Volume remaining at 5 min (cc)	20	4.1 (0.00, 30.2)	131	2.7 (0.00, 21.2)	34	0.54 (0.00, 18.8)	0.98
Post - pre treatment difference
Eckardt score	-	-	7	-6.0 (-8.0, -2.0)	36	-6.0 (-7.0, -4.0)	0.75
HREM
Post-Pre basal mean pressure (mmHg)	2	-10.0 (-34.4, 14.5)	86	-25.1 (-36.8, -12.1)	24	-19.6 (-43.1, -11.9)	0.78
Post-Pre LES-IRP pressure (mmHg)	3	-9.7 (-23.7, -1.5)	92	-15.2 (-26.4, -8.3)	26	-14.2 (-24.5, -7.8)	0.60
TBE
Post-Pre height at 1 min (cm)	22	-0.90 (-5.5, 1.9)	133	-2.5 (-7.0, 0.30)	34	-2.8 (-8.5, 1.5)	0.73
Post-Pre width at 1 min (cm)	22	-1.4 (-2.0, -0.30)	133	-1.00 (-2.0, -0.20)	34	-1.5 (-2.1, 0.00)	0.79
Post-Pre volume at 1 min (cc)	22	-40.2 (-81.2, -14.1)	133	-35.8 (-101.8, -10.4)	34	-29.5 (-100.7, -0.29)	0.74
Post-Pre height at 5 min (cm)	20	-0.75 (-5.4, 0.05)	131	-4.7 (-10.0, 0.00)	34	-2.0 (-7.5, 1.9)	0.069
Post-Pre width at 5 min (cm)	20	-0.90 (-2.3, 0.00)	131	-1.5 (-2.2, -0.20)	34	-1.00 (-2.4, 0.00)	0.86
Post-Pre volume at 5 min (cc)	20	-14.0 (-45.9, -2.6)	131	-31.3 (-66.1, -5.5)	34	-17.0 (-37.7, 0.00)	0.14

Values presented as Median (P25, P75) with Kruskal-Wallis tests. PD: Pneumatic dilation; LHM: Laparoscopic Heller myotomy: POEM: Peroral endoscopic myotomy; HREM: High resolution esophageal manometry; TBE: Timed barium esophagram; LES: Lower esophageal sphincter; IRP: Integrated relaxation pressure.

Table 3 Improvement in high resolution esophageal manomtery and timed barium esophagram parameters in each treatment group

	PD (n = 22)
Factor	n	Pre-Treatment	Post-treatment	P value
HREM1
TBE
Height at 1 min (cm)	22	10.2 (7.0, 13.6)	8.0 (5.8, 11.0)	0.11
Width at 1 min (cm)	22	3.4 (2.5, 4.0)	2.0 (1.5, 2.5)	< 0.001
Volume at 1 min (cc)	22	67.3 (44.0, 126.2)	25.4 (14.1, 41.7)	< 0.001
Height at 5 min (cm)	20	6.5 (4.0, 10.5)	2.2 (0.00, 6.5)	0.026
Width at 5 min (cm)	20	2.7 (2.0, 3.6)	1.05 (0.00, 2.6)	< 0.001
Volume at 5 min (cc)	20	40.8 (15.5, 73.1)	4.1 (0.00, 30.2)	0.001
	LHM (n = 142)
Factor
HREM
Basal mean pressure (mmHg)	86	40.5 (27.2, 51.7)	14.5 (7.6, 22.7)	< 0.001
LES-IRP pressure (mmHg)	92	24.0 (17.5, 34.4)	7.1 (3.9, 10.7)	< 0.001
TBE
Height at 1 min (cm)	133	9.5 (7.2, 15.0)	6.7 (4.5, 10.2)	< 0.001
Width at 1 min (cm)	133	3.0 (2.5, 4.0)	2.0 (1.2, 2.5)	< 0.001
Volume at 1 min (cc)	133	71.6 (41.1, 131.9)	20.4 (6.0, 49.8)	< 0.001
Height at 5 min (cm)	131	8.0 (5.0, 12.5)	2.5 (0.00, 6.2)	< 0.001
Width at 5 min (cm)	131	2.5 (2.0, 3.7)	1.00 (0.00, 2.1)	< 0.001
Volume at 5 min (cc)	131	49.1 (15.7, 91.6)	2.7 (0.00, 21.2)	< 0.001
	POEM (n = 36)
Factor
Eckardt score	36	6.5 (5.0, 8.0)	1.00 (0.00, 2.0)	< 0.001
HREM
Basal mean pressure (mmHg)	24	38.7 (27.0, 48.7)	11.4 (8.2, 20.2)	< 0.001
LES-IRP pressure (mmHg)	26	23.6 (20.2, 33.4)	6.6 (3.3, 11.1)	< 0.001
TBE
Height at 1 min (cm)	34	9.8 (4.0, 14.5)	6.3 (2.1, 9.5)	0.01
Width at 1 min (cm)	34	3.4 (2.0, 4.4)	1.6 (0.50, 2.5)	< 0.001
Volume at 1 min (cc)	34	52.8 (37.7, 119.2)	12.8 (0.79, 47.7)	< 0.001
Height at 5 min (cm)	34	5.3 (2.5, 10.0)	2.3 (0.00, 6.9)	0.017
Width at 5 min (cm)	34	2.5 (1.5, 4.0)	0.50 (0.00, 2.0)	< 0.001
Volume at 5 min (cc)	34	25.4 (11.3, 62.8)	0.54 (0.00, 18.8)	0.003

¹HREM data not available in PD group. Values presented as Median (P25, P75) with Wilcoxon signed rank test. PD: Pneumatic dilation; LHM: Laparoscopic Heller myotomy; POEM: Peroral endoscopic myotomy; HREM: High resolution esophageal manometry; TBE: Timed barium esophagram; LES: Lower esophageal sphincter; IRP: Integrated relaxation pressure.

Table 4 High resolution esophageal manomtery and Timed barium esophagram findings: Adjusted analysis¹

Outcome	PD	LHM	POEM	P value
Eckardt score	2	-5.7 (-6.7, -4.5)	-5.6 (-6.1, -5.2)	0.94
HREM
Post-Pre basal mean pressure (mm Hg)	2	-27.5 (-30.3, -24.5)	-33.1 (-38.0, -27.6)	0.084
Post-Pre LES-IRP pressure (mm Hg)	2	-20.1 (-22.2, -17.9)	-20.9 (-24.7, -16.5)	0.76
TBE
Post-Pre height at 1 min (cm)	-2.7 (-5.1, -0.05)	-4.6 (-5.5, -3.7)	-5.4 (-7.1, -3.5)	0.21
Post-Pre width at 1 min (cm)	-1.4 (-1.9, -0.77)	-1.3 (-1.5, -1.03)	-1.7 (-2.2, -1.2)	0.28
Post-Pre volume at 1 min (cc)	-81.8 (-112.4, -44.3)	-79.3 (-92.7, -64.8)	-95.6 (-119.4, -67.6)	0.58
Post-Pre height at 5 min (cm)	-5.8 (-7.7, -3.7)	-6.0 (-6.8, -5.2)	-5.8 (-7.3, -4.1)	0.95
Post-Pre width at 5 min (cm)	-1.6 (-2.4, -0.74)	-1.5 (-1.8, -1.1)	-1.9 (-2.5, -1.3)	0.47
Post-Pre volume at 5 min (cc)	-68.2 (-89.9, -43.5)	-51.2 (-60.9, -41.0)	-64.6 (-82.0, -45.3)	0.28

¹ANOVA analysis was used to obtain adjusted means. A logarithm transformation of each outcome [ln(y -1 + min(y)] was modeled as the outcome variable with age at time of treatment, BMI and having had previous treatments as the independent variables. 2Data not available Only 3 patients in PD group had HREM testing done both pre- and post-treatment, hence this group was not included in the models. Values presented as mean (95%CI). PD: Pneumatic dilation; LHM: Laparoscopic Heller myotomy; POEM: Peroral endoscopic myotomy; HREM: High resolution esophageal manomtery; TBE: Timed barium esophagram; LES: Lower esophageal sphincter; IRP: Integrated relaxation pressure.