Worse Long-Term Outcomes of Peroral Endoscopic Myotomy in Patients with Prior Treatments: A Retrospective Survival Analysis in a High-Volume Western Center

Aims Peroral Endoscopic Myotomy (POEM) is an effective treatment for esophageal motility disorders, particularly achalasia. POEM also demonstrated a good safety and efficacy profile in patients with prior treatment failure (PTF). However, long-term data of POEM for this selective group have been underexplored. This study aims to compare long-term outcomes of POEM in patients with and without PTF

Methods This is a retrospective analysis of a prospectively maintained cohort of patients who underwent POEM for esophageal motility disorders at a single high-volume center between March 2012 and March 2024. Patients who had completed at least 6 months of follow-up were included. Baseline data included demographics, type of esophageal motility disorder, esophageal shape, and pre-POEM Eckardt score (ES). Procedural data included procedural time, adverse events and length of hospitalization. Follow-up data included clinical failure (defined as ES≥4), gastroesophageal reflux disease (GERD) symptoms and objective evidence of GERD (esophagitis > B, pH-impedance monitoring). Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression to identify factors associated with clinical failure.

Results 595 patients underwent POEM during the study period. A total of 564 patients (mean age 55.8 years, 57.3% male) with at least 6 months of follow-up after POEM for esophageal motility disorders (12.7% achalasia I, 76.6% achalasia II, 6.4% achalasia III, 4.2% other non-achalasia disorders) were included in the analysis. One-hundred eight (19.5%) patients had undergone previous treatments (37% Heller myotomy, 39% pneumatic balloon dilation, 15% POEM, 9% Botulinum toxin injection). No significant difference was observed in terms of procedural time (71.28±23.36 min vs 71.79±23.58), adverse events (4.6% vs 1.8%), and length of hospitalization (2.12±2.09 days vs 2.20±2.09 days) between primary POEM patients and those with PTF (P=ns). Globally, over a median follow-up of 36 months (range 6-60), 72 (12.7%) clinical failures were reported. Patients with PTF had a significantly higher rate of clinical failure (21.2% vs. 10.7%) (P<0.01). Cox regression analysis identified PTF (Hazard Ratio (HR)=2.10, p=0.005) and Achalasia I (HR=2.10, p=0.03) as independent risk factors for clinical failure. At 36 months follow-up, clinical reflux, esophagitis grade > B and acid exposure time (AET)>6% were found in 26.1%, 19% and 35.8% of patients, respectively, without significant differences between the two groups (P=ns).

Conclusions POEM appeared as a highly effective, safe and durable treatment option for esophageal motility disorders with optimal long-term outcomes. However, patients with PTF undergoing POEM had a significantly higher risk of clinical failure. Achalasia type I was shown as the other independent risk factor for clinical failure. These findings highlight the need for closer monitoring and potential enhanced interventions for these patients [1] [2].

Publikationsverlauf

Artikel online veröffentlicht:
27. März 2025

• References

• 1 an S, Zhong C, Ren Y. et al. Efficacy and Safety of Peroral Endoscopic Myotomy in Achalasia Patients with Failed Previous Intervention: A Systematic Review and Meta-Analysis. Gut Liver 2021; 15 (02): 153-167
• 2 Vackova Z, Mares J, Simkova D. et al. Long-term clinical evaluation of a decade with peroral endoscopic myotomy at a single European tertiary center. Gastrointest Endosc. Published online September 23, 2024