Peroral endoscopic myotomy in opioid-induced esophageal dysfunction: recommend caution

We read with interest the article by Jacobs et al1Jacobs C.C. Al-Haddad M. Stainko S. et al.Prevalence and impact of opioid use in patients undergoing peroral endoscopic myotomy.Gastrointest Endosc. 2023; 97: 655-663.e2Google Scholar evaluating the prevalence and impact of opioid use in patients who had undergone peroral endoscopic myotomy (POEM). This study adds to the limited body of literature for the management of opioid-induced esophageal dysfunction (OIED). The authors concluded that POEM may be considered in patients with motility disorders and chronic opioid use but that further research is required. We agree with this statement, and we highlight that POEM should be reserved for carefully selected patients after comprehensive evaluation and after conservative measures have failed. This study contrasts to a 2016 study that noted an inferior treatment response in patients with achalasia taking opioids compared with patients with idiopathic achalasia.2Ravi K. Murray J.A. Geno D.M. et al.Achalasia and chronic opiate use: innocent bystanders or associated conditions?.Dis Esophagus. 2016; 29: 15-21Google Scholar Opioids are hypothesized to cause esophageal motor dysfunction by interfering with inhibitory signaling. To our knowledge, there are no clinical trials evaluating OIED management. Based on larger retrospective studies, the preferred approach is opioid cessation or reduction, which may lead to symptom improvement and/or reversal of manometric findings, although further prospective studies are needed.3Snyder D.L. Vela M.F. Impact of opioids on esophageal motility.Neurogastroenterol Motil. 2023; 35e14587Google Scholar This potential reversibility with cessation supports caution before irreversible procedure such as POEM is recommended.3Snyder D.L. Vela M.F. Impact of opioids on esophageal motility.Neurogastroenterol Motil. 2023; 35e14587Google Scholar, 4Babaei A. Szabo A. Shad S. et al.Chronic daily opioid exposure is associated with dysphagia, esophageal outflow obstruction, and disordered peristalsis.Neurogastroenterol Motil. 2019; 31e13601Google Scholar, 5Ratuapli S.K. Crowell M.D. DiBaise J.K. et al.Opioid-induced esophageal dysfunction (OIED) in patients on chronic opioids.Am J Gastroenterol. 2015; 110: 979-984Google Scholar Furthermore, symptoms in spastic esophageal disorders, particularly chest pain, may not always correlate with manometric findings and rather represent visceral hypersensitivity, which may worsen after POEM.6Mujica V.R. Mudipalli R.S. Rao S.S. Pathophysiology of chest pain in patients with nutcracker esophagus.Am J Gastroenterol. 2001; 96: 1371-1377Google Scholar Esophageal motor disorders assessed in this study, including esophagogastric junction outflow obstruction, type III achalasia, distal esophageal spasm, and hypercontractile esophagus are clinically heterogeneous, and a one-size-fits-all treatment approach is not ideal.1Jacobs C.C. Al-Haddad M. Stainko S. et al.Prevalence and impact of opioid use in patients undergoing peroral endoscopic myotomy.Gastrointest Endosc. 2023; 97: 655-663.e2Google Scholar Finally, opioids have widespread effects in the GI tract and are associated with greater long-term symptom burden,3Snyder D.L. Vela M.F. Impact of opioids on esophageal motility.Neurogastroenterol Motil. 2023; 35e14587Google Scholar,7Patel D.A. Goss J. Hayat M. et al.Opioid exposure differentially impacts esophageal body contraction over the lower esophageal sphincter.Gastroenterology. 2022; 163: 403-410Google Scholar,8Werner Y.B. Hakanson B. Martinek J. et al.Endoscopic or surgical myotomy in patients with idiopathic achalasia.N Engl J Med. 2019; 381: 2219-2229Google Scholar as evidenced by increased heartburn in the current study.1Jacobs C.C. Al-Haddad M. Stainko S. et al.Prevalence and impact of opioid use in patients undergoing peroral endoscopic myotomy.Gastrointest Endosc. 2023; 97: 655-663.e2Google Scholar We congratulate the authors on this study. Although POEM was effective in OIED, we believe that POEM should be considered only in carefully selected patients not responding to more conservative treatment. Both authors disclosed no financial relationships.