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

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.

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.

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.

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.