Role of prehabilitative gastrostomy tube feeding to bridge severely malnourished surgically unfit achalasia patients to per-oral endoscopic myotomy.

Background and aim: Achalasia cardia may be associated with a risk of severe malnutrition, causing unique challenges in nutritional and definitive management. This study aims to evaluate a novel nutrition strategy in severely malnourished, surgically unfit patients, using percutaneous endoscopic gastrostomy (PEG) tube feeding to improve nutrition followed by per-oral endoscopic myotomy (POEM).

Methods: We conducted a prospective study of achalasia cardia patients from September 2023 to September 2024 at a tertiary care centre. Patients with severe malnutrition (body mass index [BMI] < 16.0 kg/m²) and hypoalbuminemia (< 3.0 g/dL) deemed surgically unfit by multidisciplinary team were included. They received PEG feeding to improve nutritional status before undergoing POEM. Serial anthropometric and biochemical parameters before PEG and before POEM were compared and technical and clinical success of both procedures was assessed.

Results: Among 45 achalasia patients, eight (17.77%) met the inclusion criteria. The median Eckardt score was 10 (range 9-11), with a median symptom duration of 3.5 years (range 2-10). Six patients had type-I and two had type- II achalasia, including two with prior treatment failures. Two patients died even before PEG placement due to severe infections at presentation. The remaining six patients underwent PEG feeding, gaining an average of 11.96 (± 2.68) kg over 11.33 (± 0.94) weeks. This was associated with significant improvement in BMI (13.9 to 19.15; p < 0.00001), albumin (2.8 to 4.2; p < 0.0001), mid-arm circumference (17.27 vs. 22.64; p < 0.001), biceps skin fold thickness (2.15 vs. 3.61; p < 0.001) and triceps skin fold thickness (3.25 vs. 5.84; p < 0.001). All patients then successfully underwent POEM, achieving 100% technical and clinical success.

Conclusion: Patients with severe malnutrition (based on BMI and serum albumin) with achalasia considered unfit for POEM or surgery can be managed safely and effectively by using PEG tube feeding as bridge to successful POEM treatment.