294. DOES CHOICE OF INITIAL SURGICAL OR ENDOSCOPIC MYOTOMY IN ACHALASIA AFFECT THE EVENTUAL LIKELIHOOD OF ESOPHAGEAL CANCER DEVELOPMENT?

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Abstract Background Achalasia is associated with an increased risk of esophageal cancer development. Heller’s myotomy with partial fundoplication (HM) is the current gold standard for the treatment of achalasia. Peroral endoscopic myotomy (POEM) has shown similar outcomes in terms of dysphagia resolution, but with a higher risk of postoperative gastroesophageal reflux disease (GERD). Long-standing GERD however, is also a risk factor for the development of esophageal adenocarcinoma. This study aimed to determine via a probabilistic approach, the likelihood of esophageal cancer development in patients who underwent either HM or POEM as the initial myotomy of choice for achalasia. Methods A systematic review and meta-analysis of studies reporting the outcomes of HM or POEM, outcomes of revisional procedures, and cancer incidences in achalasia, from 2015–2024 were included. A Markov decision tree analysis was developed, with input probabilities based on the systematic review. The model allowed for 1 revisional myotomy procedure (either revisional HM or revisional POEM) after a failed initial surgical or endoscopic myotomy, and 1 additional salvage pneumatic balloon dilation after subsequent failed interventions. Primary outcome was the eventual probability of developing esophageal cancer. Results Sixteen studies were included in the Markov model. Overall risk of esophageal cancer development was low. The probability of esophageal cancer was 1.0% in achalasia patients with dysphagia resolution after myotomy without GERD; 1.1% in achalasia patients with dysphagia resolution after myotomy but with postoperative GERD; and 2.0% in achalasia patients with no symptom resolution despite myotomy and revisional procedures. Based on 10,000 simulations in each arm, the likelihood of esophageal cancer development in a patient who underwent initial HM compared to initial POEM were similar, at 1.2% and 1.1% (p = 0.551) respectively. Conclusion Though POEM resulted in a higher risk of GERD, the overall likelihood of esophageal cancer in achalasia patients treated with an initial HM or POEM appeared similar. This may be explained by the overall low, albeit elevated, risk of developing esophageal cancer in achalasia patients.

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