Presence of type 1 hiatal hernia affects the clinical efficacy of per-oral endoscopic myotomy.

Abstract

Background: Per-oral endoscopic myotomy (POEM) is a valuable treatment option for achalasia and non-achalasia esophageal motility disorders, but little is known about the effect of type 1 hiatal hernias (T1HH) on POEM outcomes. We hypothesized there would be no difference in technical success or pre- or post-POEM Eckardt scores between those with and without T1HH.

Methods: This single-institution, retrospective review analyzed consecutive POEM cases from 6/10/2011-7/16/2024. T1HH were defined by esophagogastroduodenoscopy, manometry, contrast esophagram, or computed tomography imaging. Technical success included an 8 cm myotomy including the esophagogastric junction and extending 2 cm distal. Clinical success was defined as post-POEM Eckardt score ≤ 3. Demographics, T1HH, and pre- and post-procedural Eckardt scores were analyzed using descriptive, univariate, and multivariable logistic regression statistics.

Results: There were 173 POEM cases. Of these, 95(55%) were female, 34(20%) had T1HH, 148(86%) were performed for achalasia, median Eckardt scores were 7[IQR:5.3-9] pre-POEM and 0[IQR:0-1] post-POEM, with clinical success in 146(86%), length of myotomy was median 12[IQR:12-13]cm with technical success in 170(98%). There were no differences found between those with and without T1HH in terms of sex, achalasia diagnosis, previous interventions, pre-POEM Eckardt scores, length of myotomy, or technical success. Compared to those without T1HH, those with T1HH had higher median post-POEM Eckardt scores (median 0[IQR:0-1] vs. 0[IQR:0-0], p = 0.043), lower rates of clinical success (n = 26(76%) vs n = 120(86%), p = 0.01), and had a shorter distance from incisors to EGJ (40[IQR:38.3-41] vs 41[39-43]cm, p = 0.044). After adjustment, presence of T1HH was the only significant factor, conferring 0.13 odds (95%CI: 0.02-0.93, p = 0.042) of clinical success.

Conclusions: POEM produces excellent outcomes in patients with and without T1HH. T1HH did not affect technical success of POEM, but decreased clinical success rate and was associated with higher post-POEM Eckardt scores. POEM practitioners should be cognizant of T1HH and advise patients of its potential implications in their treatment plan.