Peroral Endoscopic Myotomy Can Be Safe and Effective for Persistent Symptoms After Heller Myotomy

Persistent and recurrent symptoms have been reported in up to 20% of patients with achalasia after surgical treatment with Heller myotomy. The aim of this systematic review and meta-analysis was to analyze the efficacy and safety of peroral endoscopic myotomy (POEM) for the management of persistent achalasia in patients treated with a previous surgical myotomy. 

The authors identified 272 patients from 9 studies (3 prospective, 3 retrospective, and 3 case series) who underwent POEM after prior Heller myotomy. This included patients with a mean age of 54 years, follow-up duration of 15.6 months, mean disease duration of 9.3 years, and mean interval between surgery and POEM of 8.2 years. A significant reduction of 5.14 (95% confidence interval [CI], 4.19-6.09; I^2=86.4%) in the Eckardt score was noted after POEM. Clinical success (post-POEM Eckardt score, ≤3) was noted in 90% of the patients (95% CI, 83.1%-96.8%; I^2=51.2%). Manometry findings of lower esophageal sphincter pressure and integrated relaxation pressure were also significantly lower by 12.01 mm Hg (95% CI, 6.74-17.27; I^2=85.1%) and 10.02 mm Hg (95% CI, 4.95-15.09; I^2=85.7%), respectively. The pooled rates of post-POEM symptomatic gastroesophageal reflux, esophagitis, and abnormal acid exposure by pH monitoring were 36.9% (95% CI, 20.7%-53.1%), 33.0% (95% CI, 9.6%-56.4%), and 47.8% (95% CI, 33.4%-62.2%), respectively. An analysis of the technical aspects showed a mean procedure time of 93.8 minutes (95% CI, 90.9-96.6), a mean endoscopic myotomy length of 11.8 cm (95% CI, 11.6-12.00), and a preference for posterior wall myotomy in the majority (93.7%) of POEM procedures. Adverse events included mucosal injury (11), pneumothorax (5), pneumomediastinum (4), pneumoperitoneum (3), mediastinitis (3), delayed bleeding (1), submucosal hematoma (1), and pneumonia (1). There was no mortality in the reviewed studies.