Introduction: Per Oral Endoscopic Myotomy (POEM) is a relatively novel technique to address achalasia, however little is known about potential variation in efficacy of POEM across the different achalasia types. We hypothesize that patients with type three achalasia will be more recalcitrant to POEM than patients with type one or type two achalasia.

Methods: We performed a retrospective analysis of patients with achalasia who received a POEM at a single tertiary care academic institution from 2011 – 2023. Patients were included if they had a documented diagnosis of achalasia and had a POEM at our institution. Patients were excluded if they were missing data on diagnosis of achalasia, time frame for duration prior to intervention, or missing pre- and post-operative Eckart score. Patients were grouped into cohorts based on achalasia type (Type I, II, III). POEM failure was defined as need for repeat intervention, symptom recurrence, and a high post-operative Eckart score. Demographic, preoperative, and post-operative outcomes were compared between cohorts. Measures of failure were assessed by multivariable logistic regression.

Results: During the study period, 189 patients met inclusion criteria. 41 patients had type I achalasia, 114 patients had type II achalasia, and 34 patients had type III achalasia. Patient age at surgery, sex, BMI, Charleston-Deyo Comorbidity Index, patients with diabetes with and without end organ complications, patients with connective tissue diseases, and patients with ulcer diseases did not differ amongst cohorts. Pre-operative Eckart scores were between 4.5 – 5 across groups (p = 0.50). Patients with type III achalasia were more likely to experience dysphagia with every meal (28% vs 37%, p = 0.05). Median IRP, LES residual pressure, and Basal LES pressure did not differ amongst groups. Post procedure mean Eckart scores ranged from .85 – .97 for all cohorts with no significant differences. Manometric measurements did not vary across cohorts after POEM. Symptom recurrence, need for repeat endoscopic intervention, repeat surgical intervention, or repeat POEM also did not vary across cohorts. Achalasia type did not increase the odds of having a higher post-operative Eckart score, worse dysphagia, regurgitation, or weight loss on multivariable logistical regression.

Conclusions: This data suggests that achalasia type is not associated with increased rates of POEM failure. This is promising as clinicians should not exclude patients for POEM eligibility based achalasia type as these patients all had similar outcomes in our cohort.

Patrick Wieland

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