Feasibility and safety of peroral endoscopic myotomy for achalasia after failed endoscopic interventions

Abstract

With advances in natural orifice transluminal endoscopic surgery, peroral endoscopic myotomy (POEM) has become a novel treatment for esophageal achalasia. In this study, we investigated the feasibility and safety of POEM in patients with achalasia after failed endoscopic interventions. Data on all patients undergoing POEM treatment of achalasia were collected prospectively. We enrolled 61 patients who underwent POEM for achalasia between July 2011 and January 2014. The preoperative intervention group included patients who had undergone botulinum toxin injection or pneumatic balloon dilation before POEM. The preoperative, operative, and short-term outcome data between the groups were compared. Among preoperative intervention group, 22 patients received endoscopic therapy before being referred for operation (18 dilation only, 2 botulinum toxin only, and 2 both treatments). Procedure time in the preoperative intervention group was similar to the nonpreoperative intervention group (60.8 ± 30.9 vs. 62.0 ± 21.0 minutes, P = 0.863). Both groups demonstrated significant improvement in Eckardt scores and manometric outcomes at 1-year follow-up. There were no significant differences in pretreatment and posttreatment D-values of symptom scores and lower esophageal sphincter pressures between groups (6.2 ± 2.2 vs. 6.1 ± 1.8, P = 0.840; 27.9 ± 17.6 vs. 24.9 ± 15.2; P = 0.569). There was also no significant difference in the incidence of intraoperative complications (P = 0.958) and gastroesophageal reflux rate (23.5% vs. 20.0%, P = 0.771) between the two groups. Our study demonstrated that POEM is safe and effective, even for treating achalasia in the setting of failed endoscopic interventions.

Per oral endoscopic myotomy as salvage therapy in patients with achalasia refractory to endoscopic or surgical therapy is technically feasible and safe: Systematic review and meta‐analysis

“…The other systematic reviews showed that POEM is more effective than HM in terms of relieving dysphagia with short‐time follow‐up, though POEM is associated with a much higher incidence of postoperative gastroesophageal reflux disease (GERD) 15,16. Recently, some studies have shown that POEM was effective even in patients who previously failed endoscopic procedures or HM 17-31. However, the number of patients who had POEM after failed conventional endoscopic treatment or HM was limited in each study and the therapeutic yield of POEM as salvage therapy has not been well evaluated.…”

2019 Seoul Consensus on Esophageal Achalasia Guidelines

“…[113][114] POEM is a treatment option in cases for which PBD failed, as well as an initial treatment for achalasia (Table 7). 77,109,[115][116][117][118][119][120][121][122] Large-scale observational studies including patients in whom PBD failed have reported that POEM is a safe and effective treatment option. 96,117,120 Prior treatment did not increase the risk of POEM-related adverse events.…”

Peroral (Poem) or Surgical Myotomy for the Treatment of Achalasia: A Systematic Review and Meta-Analysis

“…Unfortunately, most of the major adverse events were related to unrecognized intraoperative mucosal perforation. Some recent studies (7,37,38) found no difference in adverse events or efficacy after treatment with POEM vs Heller in patients treated with different previous therapies (dilation, Botox, and surgery) (4,7,21,(38)(39)(40)(41) . However, a separate prior study by Ren et al (42) showed a higher complication rate in POEM, perhaps related to the learning curve.…”