Five-year clinical outcomes after per oral endoscopy myotomy (POEM) for achalasia

Aims Per oral endoscopic myotomy (POEM) is a well-established treatment for achalasia with clinical success exceeding 90%. However, the durability of this response is unknown. We sought to evaluate the long-term outcomes of POEM for achalasia 5 years and beyond in a multi-centre setting.

Methods Patients who underwent POEM for achalasia types 1, 2, and 3 were prospectively enrolled in a multi-centre observational study with data collected on technical aspects and short-term outcomes. Eckardt scores were calculated before treatment and at 6 months and 2 years after POEM. Among this cohort, patients who underwent POEM before June 2019 were contacted to assess long-term outcomes. The primary outcome was to evaluate the long-term clinical success at 5 years or beyond defined by an Eckart score≤3without the need for re-intervention. Secondary outcomes included identifying the factors associated with re-intervention and subsequent management strategies.

Results A total of 237 patients underwent POEM for achalasia in four Australian tertiary centres between January 2014 to June 2019. Median follow up was 6.3 years, (IQR 5.4 – 7.2 years). 27.6% of patients had Type 1, 56.4% had Type 2 and 15.8% had Type 3 achalasia. Previous treatments prior to POEM included Hellers myotomy; 10.0%, pneumatic balloon dilatation; 44.1% and botulinum toxin injection; 20.0%. The median Eckardt score prior to POEM was 8.0 (IQR 6.0 – 10.0) and at 6 months post-POEM was 0.0 (IQR 0.0 – 1.0, p<0.001). At 2 and 5 years follow up scores were 1.0 (IQR 0.00 – 2.00, p<0.001) and 2.0 (IQR 0.0 – 3.0, p<0.001) respectively. Five-year freedom from intervention and persistent Eckardt score≤3 was 84.7%. 6.2% required a re-do POEM at a median of 14 months post-POEM (IQR13.0 – 24.0) and 8.9% required a pneumatic dilatation at a median of 18 months post-POEM IQR (9.0 – 24.0). Higher pre-POEM Eckardt scores was a risk factor for re-intervention and persistently higher Eckardt scores at 5 years (p=0.016). Type of achalasia was not risk factor long term POEM failure, relative risk (RR) 1.18 (95% CI 0.95 – 1.41, p=0.14). Previous treatment prior (ie either Heller’s or pneumatic dilatation) to POEM was not a risk factor for long term POEM failure RR 1.09 (95%CI 0.81 – 1.40, p=0.63). Intra-procedural complications (such as major bleeding) were not risk factors for re-intervention, RR 0.97 95% CI (0.16 – 5.35).

Conclusions POEM provides highly effective long-term symptom relief for achalasia Type 1 and 2 in long term follow-up to 5 years and beyond. Patients with higher pre-POEM Eckardt scores had poorer outcomes in long term follow up.

Publication History

Article published online:
27 March 2025