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

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

Prateek Sharma, MD, FASGE, reviewing Huang Z, et al. Gastrointest Endosc 2020 Jun 6.

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.

Prateek Sharma, MD, FASGE


Persistent and recurrent symptoms of achalasia after Heller myotomy surgery can be safely and effectively treated with POEM. The posterior wall is the preferred approach for POEM, with procedure times that are longer than POEM performed on treatment-naïve patients.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.


Huang Z, Cui Y, Li Y, Chen M, Xing X. Peroral endoscopic myotomy for achalasia patients with prior Heller myotomy: a systematic review and meta-analysis. Gastrointest Endosc 2020 Jun 6. (Epub ahead of print) (

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