Failed Peroral Endoscopic Myotomy? What Next…?

Peroral endoscopic myotomy (POEM) is a minimally invasive procedure increasingly utilized to treat achalasia and other esophageal motility disorders. Despite its high efficacy, studies show that POEM has a clinical failure rate (Eckardt score [ES] >3) ranging from 2% to 20%. The authors of this study conducted a retrospective multicenter study (16 centers across North America, Europe, and Asia) to evaluate the clinical efficacy of pneumatic dilation (PD), laparoscopic Heller myotomy (LHM), redo POEM, and conservative management in the setting of failed POEM. 

Of 3144 patients included in the study, 99 (51% men; mean age, 51.4 years; mean ES, 7.8) experienced clinical failure (ES>3, 3.1%) after a POEM procedure (mean esophageal/gastric myotomy lengths, 6.7/2.8 cm) during a mean follow-up of 12.7 (standard deviation, 17.9) months. These patients were then managed with one of the following modalities: conservative management (n=29; 45% men; mean age, 54.7 years; mean ES, 5.1), redo POEM (n=33; 58% men; mean age, 48.7 years; mean ES, 6.1), PD (n=30; 47% men; mean age, 46.4 years; mean ES, 5.5), or LHM (n=7; 57% men; mean age, 49 years; mean ES, 6.9). Clinical success (ES ≤3) was highest with redo POEM (76%) compared to PD (60%), LHM (29%), and conservative management (37.9%) during a median follow-up of 10 months (3-20 months). There were 4 adverse events (pneumoperitoneum, subcutaneous emphysema, inadvertent mucosotomy, and esophageal leak) in the redo-POEM group, but none noted in the LHM and PD groups.