At Digestive Disease Week 2022, John M. DeWitt, MD, professor of medicine, Indiana University Health, explains his findings on the diagnosis and management of achalasia in 2022 and how the COVID-19 pandemic affected these trends.
There are higher rates of achalasia diagnosis and peroral endoscopic myotomy (POEM) use for the management of patients with achalasia, said John M. DeWitt, MD, Professor of Medicine, Indiana University Health, at Digestive Disease Week 2022.
The American Journal of Managed Care® (AJMC®): What trends are we seeing with diagnosis and management of achalasia in 2022?
DeWitt: There are several trends that we're seeing. First, there's an increase in the diagnosis of achalasia, and that may reflect first use of high resolution manometry—which is a more sensitive test for a diagnosis compared to conventional manometry—and more practices that are not associated with academic medical centers using this technology to investigate patients with typical symptoms, which may include dysphasia, regurgitation, and weight loss. There's also new technology improving the stiffness or compliance of the lower esophageal sphincter; so some patients who may have a normal manometry who still have acids or peristalsis on manometry are being diagnosed if they have a stiff or noncompliant lower esophageal sphincter by a test called impedance planimetry.
The second trend which I think is important is the increased use of peroral endoscopic myotomy (POEM) for the management of these patients. The traditional surgery that's performed for this disease is Heller myotomy, and now that is performed laparoscopically. A recent study in JAMA Surgery1 has shown us that, while laparoscopic Heller myotomy is still performed in about three quarters of patients nationwide for this disease, the incidence of POEM has increased about 20-fold between the years 2010 and 2017 and likely over the subsequent 4 or 5 years after that study was published, that trend has only increased. I think those are the 2 most noticeable trends now for this disease.
AJMC®: Did COVID-19 impact either of these trends?
DeWitt: Great question. I think the impact of the pandemic has decreased [the trends]—probably some patients who may have presented for diagnosis stayed home because, unless there's severe weight loss associated with this disease, most of the symptoms are bothersome but not life-threatening. So, if someone had some of these symptoms, they may have postponed their trip to the physician or the hospital to undergo testing to have a diagnosis made.
The more important trend, which we did observe at our center, was a decrease in the therapy for the diagnosis. The pandemic caused most elective procedures such as treatment for achalasia to be postponed in order to decrease the utilization of operating room staff or endoscopy or surgeons who perform these procedures to do them. For instance, the diagnosis of cancer or certain urgent traumas would be getting preference over elective procedures, so we did notice a down trend in the number of patients coming in for these elective procedures during the latter half of the 2 years of the pandemic.
Fortunately, over the last 6 to 12 months, we've seen near normalization of the numbers of patients we were seeing coming in for testing and treatment that we encountered in 2018 and 2019 before the pandemic started.
1. Lois AW, Oelschlager BK, Wright AS, Templeton AW, Flum DR, Farjah F. Use and safety of per-oral endoscopic myotomy for achalasia in the US. JAMA Surg. Published online April 20, 2022. doi:10.1001/jamasurg.2022.0807.