Is Heller myotomy feasible after percutaneous endoscopic gastrostomy (PEG) tube placement?

From the Guidelines

A Heller myotomy can be safely performed after a PEG tube placement, but the decision should be based on shared decision making between the patient and physician, taking into account patient and disease characteristics, patient preferences, and local expertise, as recommended by the AGA clinical practice update 1. When considering a Heller myotomy after PEG tube placement, several factors should be taken into account, including the timing of the procedure, the approach, and the potential risks and benefits.

• Ideally, the procedure should be performed by experienced physicians in high-volume centers, as recommended by the AGA clinical practice update 1.
• The patient should undergo a comprehensive diagnostic workup, including clinical history, upper endoscopy, timed barium esophagram, and high-resolution manometry, to determine the best course of treatment 1.
• The decision to perform a Heller myotomy after PEG tube placement should be based on the patient's individual needs and circumstances, including the severity of their achalasia, their overall health, and their preferences.
• The presence of a PEG tube may actually be beneficial for some patients undergoing Heller myotomy, as it provides a reliable feeding route during the immediate recovery period when swallowing might be uncomfortable.
• Postoperatively, the PEG tube can typically be used within 24-48 hours following the myotomy, though this should be confirmed with the surgical team.
• The surgical team should coordinate with the gastroenterology team that placed the PEG to ensure optimal management throughout the perioperative period.
• It is also important to consider the potential risks of the procedure, including the risk of postprocedural reflux and esophagitis, and to take steps to mitigate these risks, such as administering pharmacologic acid suppression and monitoring for gastroesophageal reflux disease after the procedure 1.

From the Research

Heller Myotomy After Peg Tube

• The decision to perform a Heller myotomy after a peg tube placement is complex and depends on various factors, including the patient's overall health, the severity of their achalasia, and their response to previous treatments 2, 3, 4.
• Studies have shown that laparoscopic Heller myotomy with partial fundoplication is a effective treatment for achalasia, with a high success rate and low complication rate 2, 5.
• However, the success of Heller myotomy may be lower in patients who have previously undergone a peg tube placement or other treatments for achalasia 3, 4.
• Pneumatic dilation is another treatment option for achalasia, and it may be considered for patients who are not good candidates for Heller myotomy or who have failed previous treatments 3, 4, 5.
• The choice between Heller myotomy and pneumatic dilation depends on various factors, including the patient's age, overall health, and preferences, as well as the expertise and experience of the treating physician 2, 3, 4, 5.

Comparison of Treatment Options

• A systematic review and meta-analysis of randomized controlled trials found that laparoscopic Heller myotomy and pneumatic dilation have similar long-term efficacy and safety profiles for the treatment of achalasia 5.
• Another study found that peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy have similar short-term outcomes and safety profiles, while pneumatic dilation has a higher risk of readmission and resource utilization 6.
• The choice of treatment should be individualized based on the patient's specific needs and circumstances, and should take into account the potential benefits and risks of each option 2, 3, 4, 5, 6.

Considerations for Patients with Peg Tubes

• Patients who have undergone a peg tube placement may require special consideration when evaluating treatment options for achalasia 3, 4.
• The presence of a peg tube may affect the success of Heller myotomy or pneumatic dilation, and alternative treatments may need to be considered 3, 4.
• Further research is needed to determine the optimal treatment approach for patients with achalasia who have undergone a peg tube placement 2, 3, 4, 5, 6.