Perioperative care and relevance of programmed postoperative endoscopy after peroral endoscopic myotomy – a risk-factor adapted stratification of patients?

Background: POEM has emerged as a valuable treatment option for achalasia and other esophageal motility disorders. Although its efficacy have been proven, certain concerns remain regarding its learning curve and the optimal protocol for perioperative care.

Objective: To identify factors impacting on perioperative safety of POEM and to evaluate whether programmed postoperative endoscopy constitutes a valuable tool in this context.

Methods: This retrospective study was performed at the University Hospital Würzburg. Data were extracted from medical records of all patients who underwent POEM from 01/2013 to 12/2022. Primary outcomes include the incidence and identification of risk factors for intra- and postoperative adverse events (AEs), as well as clinically relevant complications following POEM. The number needed to screen is calculated in relation to the efficacy of programmed re-endoscopy identifying postoperative abnormalities.

Results: POEM was performed in 336 patients by two endoscopic-experienced surgeons. 116 patients (34.5%) received either surgical (2.1%) or endoscopic pre-treatment (32.4%). Intraoperative AEs occurred in 11.0%, of which 11 (3.3%) were attributed to mucosal lesions and 10 (3.0%) to submucosal bleeding. Multivariate analysis revealed patient-associated factors (obesity and comorbidity with autoimmune disease), technical factors (myotomy length and speed) and the level of expertise (<50 POEMs performed) as independent risk factors. AEs dropped from 13% to 4.1% after 100 procedures performed by the individual surgeon while operation times plateaued by 5.3 min/cm myotomy. Postoperative endoscopy revealed any abnormal findings in 6.8%, with 1.2% requiring intervention. Multivariate analysis identified intraoperative AEs, especially mucosal lesions/bleeding, as well as speed of myotomy as independent risk factors for postoperative abnormalities. 12 patients (3.6%) had postoperative complications≥Clavien Dindo IIIa.

Conclusion: POEM is safe but entails a relevant learning curve and can be associated with serious complications. To optimise postoperative care, a risk-stratified approach appears to be a rational strategy. Intraoperative AEs, especially (sub)mucosal lesions/bleeding, were identified as independent risk factors for postoperative conspicuousness. Consequently, implementing a programmed re-endoscopy in this subgroup of patients may be justified to prevent severe complications and facilitate early intervention.

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Artikel online veröffentlicht:
04. September 2025