title: Reduced postoperative pain scores and narcotic use favor per-oral endoscopic myotomy over laparoscopic Heller myotomy.
abstract: Per-oral endoscopic myotomy (POEM) is a less invasive therapy for achalasia with a shorter hospitalization but with similar short- and long-term outcomes as a laparoscopic Heller myotomy (LHM). Previous literature comparing POEM to LHM has focused primarily on postoperative outcome parameters such as complications, dysphagia scores and gastro-esophageal reflux severity. This study specifically compares postoperative pain following POEM to pain following LHM, the current gold-standard operation.
  
  
  
  A retrospective review of all patients undergoing POEM or LHM for achalasia was performed from 2006 to 2015. Data collection included demographics, comorbidities, length of stay (LOS) and pain scores (arrival to the recovery room, 1 h postoperative, average first 24 h and upon discharge). Statistical analysis was performed using Student's t test and Chi-square test.
  
  
  
  Forty-four POEM patients and 122 LHM patients were identified. The average age (52.2 ± 20.75 vs 50.9 ± 17.89 years, p = 0.306) and BMI (28.1 ± 7.62 vs 27.6 ± 7.07 kg/m2, p = 0.824) did not differ between the POEM and LHM groups, respectively; however, the American Society of Anesthesiology scores were higher in the POEM patients (2.43 ± 0.62 vs 2.11 ± 0.71, p = 0.011). There were no differences in rates of smoking, diabetes, cardiac disease or pulmonary disease. The average pain scores upon arrival to the recovery room and 1 h postoperatively were lower in the POEM group (2.3 ± 3.014 vs 3.61 ± 3 0.418, p = 0.025 and 2.2 ± 2.579 vs 3.46 ± 3.063, p = 0.034, respectively). There was no difference in the average pain score over the first 24 h (2.7 ± 2.067 vs 3.29 ± 1.980, p = 0.472) or at the time of discharge (1.6 ± 2.420 vs 2.09 ± 2.157, p = 0.0657) between the POEM and LHM groups. After standardizing opioid administration against 10 mg of oral morphine, the POEM group used significantly less narcotics that the LHM group (35.8 vs 101.8 mg, p < 0.001) while hospitalized. The average LOS for the POEM group was 31.2 h and 55.79 for the LHM group (p < 0.0001). At discharge, fewer POEM patients required a prescription for a narcotic analgesic (6.81 vs 92.4 %, p < 0.0001).
  
  
  
  POEM demonstrated significantly less postoperative pain upon arrival to the recovery room and 1 h postoperatively. To achieve similar pain scores during the first 24 h and at discharge, LHM patients required more narcotic analgesic administration. Despite a significantly shorter LOS, fewer POEM patients require a prescription for narcotic analgesics compared to LHM. POEM is a less painful procedure for achalasia than LHM, permitting earlier hospital discharge with little need for home narcotic use.
authors.affiliation: Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Hershey Medical Center, 500 University Drive, H149, Hershey, PA, 17036, USA. sdocimo@gmail.com.
authors.forename: Salvatore
authors.initials: S
authors.lastname: Docimo
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Medicine, Penn State Hershey Medical Center, Hershey, PA, USA.
authors.forename: Abraham
authors.initials: A
authors.lastname: Mathew
authors.affiliation: Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Hershey Medical Center, 500 University Drive, H149, Hershey, PA, 17036, USA.
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: Shope
authors.affiliation: Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Hershey Medical Center, 500 University Drive, H149, Hershey, PA, 17036, USA.
authors.forename: Joshua S
authors.initials: JS
authors.lastname: Winder
authors.affiliation: Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Hershey Medical Center, 500 University Drive, H149, Hershey, PA, 17036, USA.
authors.forename: Randy S
authors.initials: RS
authors.lastname: Haluck
authors.affiliation: Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Penn State Hershey Medical Center, 500 University Drive, H149, Hershey, PA, 17036, USA.
authors.forename: Eric M
authors.initials: EM
authors.lastname: Pauli
mesh_terms: D000284:Administration, Oral; D000328:Adult; D000368:Aged; D000701:Analgesics, Opioid / Q000627:therapeutic use; D016009:Chi-Square Distribution; D003680:Deglutition Disorders / Q000209:etiology / Q000601:surgery*; D004931:Esophageal Achalasia / Q000150:complications / Q000601:surgery*; D049630:Esophageal Sphincter, Lower / Q000601:surgery*; D004945:Esophagoscopy / Q000379:methods*; D005260:Female; D005764:Gastroesophageal Reflux / Q000453:epidemiology; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement; D010149:Postoperative Pain / Q000188:drug therapy / Q000503:physiopathology*; D011184:Postoperative Period; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D000701:Analgesics, Opioid
keywords: Achalasia; Laparoscopic Heller myotomy; POEM; Per-oral endoscopic myotomy