Peroral endoscopic myotomy as salvation technique post‐Heller: International experience

Abstract

Background Treatment for achalasia has traditionally been Heller myotomy (HM). Despite its excellent efficacy rate, a number of patients remain symptomatic post‐procedure. Limited data exist as to the best management for recurrence of symptoms post‐HM. We present an international, multicenter experience evaluating the efficacy and safety of post‐HM peroral endoscopic myotomy (POEM). Methods Patients who underwent POEM post‐HM from 13 centers from January 2012 to January 2017 were included as part of a prospective registry. Technical success was defined as successful completion of the myotomy. Clinical success was defined as an Eckardt score of ≤3 on 12‐month follow up. Adverse events (AE) including anesthesia‐related, operative, and postoperative complications were recorded. Results Fifty‐one patients were included in the study (mean age 54.2, 47% male). Technical success was achieved in 100% of patients. Clinical success on long‐term follow up was achieved in 48 patients (94%), with a mean change in Eckardt score of 6.25. Seven patients (13%) had AE: six experienced periprocedural mucosal defect treated endoscopically and two patients developed mediastinitis treated conservatively. Conclusion For patients with persistent symptoms after HM, POEM is a safe salvation technique with good short‐term efficacy. As a result of the challenge associated with repeat HM, POEM might become the preferred technique in this patient population. Further studies with longer follow up are needed.

Clinical practice guidelines for peroral endoscopic myotomy

“…Another prospective multicenter study ( n = 51) reported that a clinical response (defined as a decrease in ES ≤3) was achieved in 94% of the cases …”

2019 Seoul Consensus on Esophageal Achalasia Guidelines

“…Clinical studies have reported success rates of 92.0-98.0%. [124][125][126] Thus, POEM could be a feasible salvage treatment for patients with persistent symptoms after LHM. However, additional large studies with longer follow-up periods are necessary.…”

“An Odyssey of Third Space Endoscopy”—from Entry into the Tunnel to Entry into the Peritoneal Cavity

“…11,12 A recent randomized trial in treatment naïve patients has shown the efficacy of POEM to be >90% at 2 years when compared with 54% for PD. 13 Moreover, patients with failed LHM and PD and those with end-stage burnt out disease (sigmoid esophagus) also show a good technical and clinical success with POEM [14][15][16] (►Table 1). Taken together, POEM appears to be the panacea for complete spectrum of presentations of achalasia from naïve to treatment failures and also burnt out disease.…”