Repeat peroral endoscopic myotomy: a salvage option for persistent/recurrent symptoms

Background and study aims: Although peroral endoscopic myotomy (POEM) is credited with high success rates in the treatment of achalasia, persistent/recurrent symptoms may occasionally develop afterwards. Our purpose was to evaluate the feasibility, safety, and efficacy of repeat peroral endoscopic myotomy (Re-POEM) as salvage therapy after initial POEM failure.

Patients and methods: Fifteen patients with persistence/recurrence of symptoms after previous POEM (Eckardt symptom score ≥ 4) were retrospectively selected from a prospectively maintained database housing a total of 1454 consecutive patients with achalasia. The primary endpoint was symptom relief during follow-up, defined by an Eckardt score of ≤ 3. Secondary outcome measures were procedure-related adverse events, change in manometric lower esophageal sphincter (LES) pressure, and reflux symptoms before and after Re-POEM.

Results: All patients underwent successful Re-POEM a mean of 13.5 months (range 4 – 37 months) after execution of their primary POEM procedures. Mean operative time was 41.5 minutes (range 28 – 62 minutes). One instance of submucosal tunnel infection was successfully managed with conservative treatment. During a mean follow-up period of 11.3 months (range 3 – 18 months), therapeutic success was achieved in all patients. The mean symptom score pretreatment was 5.6 (range 4 – 8), compared with a post-treatment mean of 1.2 (range 0 – 3; P < 0.001). Mean LES pressure also declined from 25.0 mmHg to 9.5 mmHg after Re-POEM (P < 0.001). The overall clinical reflux complication rate of Re-POEM was 33.3 %.

Conclusions: Re-POEM appears safe and effective as a salvage option after initial POEM failure, conferring short-term symptom relief and being free of serious complications in all patients.

• References

• 1 Boeckxstaens GE, Zaninotto G, Richter JE. Achalasia. Lancet 2014; 383: 83-93
• 2 Eckardt AJ, Eckardt VF. Treatment and surveillance strategies in achalasia: an update. Nat Rev Gastroenterol Hepatol 2011; 8: 311-319
• 3 Inoue H, Minami H, Kobayashi Y et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
• 4 Stavropoulos SN, Desilets DJ et al. NOSCAR POEM White Paper Committee Per-oral endoscopic myotomy white paper summary. Gastrointest Endosc 2014; 80: 1-15
• 5 von Renteln D, Fuchs KH, Fockens P et al. Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study. Gastroenterology 2013; 145: 309-311
• 6 Familiari P, Gigante G, Marchese M et al. Peroral endoscopic myotomy for esophageal achalasia: outcomes of the first 100 patients with short-term follow-up. Ann Surg 30.10.2014; [Epub ahead of print]
• 7 Swanstrom LL, Kurian A, Dunst CM et al. Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure. Ann Surg 2012; 256: 659-667
• 8 von Renteln D, Inoue H, Minami H et al. Peroral endoscopic myotomy for the treatment of achalasia: a prospective single center study. Am J Gastroenterol 2012; 107: 411-417
• 9 Li QL, Chen WF, Zhou PH et al. Peroral endoscopic myotomy for the treatment of achalasia: a clinical comparative study of endoscopic full-thickness and circular muscle myotomy. J Am Coll Surg 2013; 217: 442-451
• 10 Chen WF, Li QL, Zhou PH et al. Long-term outcomes of peroral endoscopic myotomy for achalasia in pediatric patients: a prospective, single-center study. Gastrointest Endosc 2015; 81: 91-100
• 11 Chiu PW, Wu JC, Teoh AY et al. Peroral endoscopic myotomy for treatment of achalasia: from bench to bedside (with video). Gastrointest Endosc 2013; 77: 29-38
• 12 Lee BH, Shim KY, Hong SJ et al. Peroral endoscopic myotomy for treatment of achalasia: initial results of a Korean study. Clin Endosc 2013; 46: 161-167
• 13 Pandolfino JE, Kwiatek MA, Nealis T et al. Achalasia: a new clinically relevant classification by high-resolution manometry. Gastroenterology 2008; 135: 1526-1533
• 14 Zhou PH, Li QL, Yao LQ et al. Peroral endoscopic remyotomy for failed Heller myotomy: a prospective single-center study. Endoscopy 2013; 45: 161-166
• 15 Miller DL, Allen MS, Trastek VF et al. Esophageal resection for recurrent achalasia. Ann Thorac Surg 1995; 60: 922-925
• 16 Zaninotto G, Costantini M, Portale G et al. Etiology, diagnosis, and treatment of failures after laparoscopic Heller myotomy for achalasia. Ann Surg 2002; 235: 186-192
• 17 Campos GM, Vittinghoff E, Rabl C et al. Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis. Ann Surg 2009; 249: 45-57
• 18 Petersen RP, Pellegrini CA. Revisional surgery after Heller myotomy for esophageal achalasia. Surg Laparosc Endosc Percutan Tech 2010; 20: 321-325
• 19 Oelschlager BK, Chang L, Pellegrini CA. Improved outcome after extended gastric myotomy for achalasia. Arch Surg 2003; 138: 490-495; discussion 495-497
• 20 Kurian AA, Dunst CM, Sharata A et al. Peroral endoscopic esophageal myotomy: defining the learning curve. Gastrointest Endosc 2013; 77: 719-725
• 21 Werner YB, Costamagna G, Swanström LL et al. Clinical response to peroral endoscopic myotomy in patients with idiopathic achalasia at a minimum follow-up of 2 years. Gut 2015; [Epub ahead of print]
• 22 Rohof WO, Salvador R, Annese V et al. Outcomes of treatment for achalasia depend on manometric subtype. Gastroenterology 2013; 144: 718-725
• 23 Li QL, Zhou PH. Perspective on peroral endoscopic myotomy for achalasia: Zhongshan experience. Gut Liver 2015; 9: 152-158
• 24 Ren Z, Zhong Y, Zhou P et al. Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases). Surg Endosc 2012; 26: 3267-3272
• 25 Saxena P, Chavez YH, Kord Valeshabad A et al. An alternative method for mucosal flap closure during peroral endoscopic myotomy using an over-the-scope clipping device. Endoscopy 2013; 45: 579-581
• 26 Modayil R, Friedel D, Stavropoulos SN. Endoscopic suture repair of a large mucosal perforation during peroral endoscopic myotomy for treatment of achalasia. Gastrointest Endosc 2014; 80: 1169-1170
• 27 Ling T, Pei Q, Pan J et al. Successful use of a covered, retrievable stent to seal a ruptured mucosal flap safety valve during peroral endoscopic myotomy in a child with achalasia. Endoscopy 2013; 45: E63-E64
• 28 Li H, Linghu E, Wang X. Fibrin sealant for closure of mucosal penetration at the cardia during peroral endoscopic myotomy (POEM). Endoscopy 2012; 44: E215-E216