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

Quan-Lin Li, Li-Qing Yao, Xiao-Yue Xu, Jun-Yu Zhu, Mei-Dong Xu, Yi-Qun Zhang, Wei-Feng Chen, Ping-Hong Zhou
Endoscopy 2016, 48 (2): 134-40

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.

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