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.