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


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.
Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
Quan-Lin
QL
Li
Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
Li-Qing
LQ
Yao
Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
Xiao-Yue
XY
Xu
Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
Jun-Yu
JY
Zhu
Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
Mei-Dong
MD
Xu
Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
Yi-Qun
YQ
Zhang
Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
Wei-Feng
WF
Chen
Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
Ping-Hong
PH
Zhou
D000328:Adult; D004931:Esophageal Achalasia / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D004943:Esophagogastric Junction / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008365:Manometry; D008875:Middle Aged; D009055:Mouth; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D011312:Pressure; D012008:Recurrence; D012086:Reoperation; D012189:Retrospective Studies; D016879:Salvage Therapy / Q000379:methods*; D016896:Treatment Outcome