Per-Oral Endoscopic Myotomy is Less Painful than Laparoscopic Heller Myotomy and Permits Earlier Hospital Discharge

Salvatore Docimo, Jr., DO, Abraham Mathew, Alexander J Shope, Joshua S Winder, Randy S Haluck, Eric M Pauli. Penn State Hershey Medical Center

INTRODUCTION: Per-oral endoscopic myotomy (POEM) is a flexible endoscopic therapy for achalasia with similar outcomes to the gold-standard laparoscopic Heller myotomy (LHM). Previous literature has demonstrated POEM to have similar post-operative morbidity, dysphagia and esophageal reflux scores to LHM.  While considered less invasive than LHM because of a lack of abdominal incisions, little is known about pain following POEM. This study compares post-operative pain scores between POEM and LHM.

 METHODS: A retrospective review of all patients undergoing POEM or LHM from 2006-2015 was performed. Patient demographics, co-morbidities, hospital length of stay (LOS) and analgesic medication usage data were collected.  Pain scores were evaluated on a visual-analog scale (1-10) upon arrival to the recovery room, one hour postoperatively and at discharge. The average pain score for the first 24 hours of hospitalization was also calculated.

 RESULTS: Thirty-four POEM patients and 105 LHM patients were identified.  The average age, body mass index and ASA scores were not statistically different between the groups. There were also no differences in smoking, diabetes, cardiac disease or pulmonary disease between groups. When compared to LHM, POEM patients had significantly less pain upon arrival to the recovery room (1.7 vs 3.61, p=0.0025), one hour post-operatively (2.2 vs 3.46, p=0.042), and during the first day of hospitalization (24 hour average 1.6 vs 3.29, p=0.037).  The average LOS for POEM was 31.2 hours and 55.79 hours for LHM (p=0.00001). The mean pain score at discharge was 1.6 for the POEM group and 2.09 for the LHM group (p=0.0657).   The time from the last dose of narcotic analgesic to discharge was not statistically different between the groups (p=0.1773). At discharge, 8.82% (3/34) of POEM patients required a prescription for narcotic, compared to 82.8% (87/105) of LHM patients (p<0.0001).

CONCLUSIONS: Patients undergoing POEM for achalasia demonstrated significantly less postoperative pain upon arrival to the recovery room, one hour postoperatively, and during the first 24 hours of hospitalization when compared to LHM patients. Despite the fact that POEM patients were discharged an average of 24 hours before LHM patients, only 8.82% of them required a prescription for narcotic analgesics, compared to 82.8% of LHM patients.  Our findings suggest POEM not only provides similar outcomes but at a less costly pain burden to the patient. Earlier hospital discharge coupled with little need for narcotic usage likely permits patients to return to normal activity sooner.  

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