title: Efficacy and Safety of Peroral Endoscopic Myotomy for Treatment of Achalasia After Failed Heller Myotomy.
abstract: OBJECTIVE
  In patients with persistent symptoms after Heller myotomy (HM), treatment options include repeat HM, pneumatic dilation, or peroral endoscopic myotomy (POEM). We evaluated the efficacy and safety of POEM in patients with achalasia with prior HM vs without prior HM.
  
  
  METHODS
  We conducted a retrospective cohort study of 180 patients with achalasia who underwent POEM at 13 tertiary centers worldwide, from December 2009 through September 2015. Patients were divided into 2 groups: those with prior HM (HM group, exposure; n = 90) and those without prior HM (non-HM group; n = 90). Clinical response was defined by a decrease in Eckardt scores to 3 or less. Adverse events were graded according to criteria set by the American Society for Gastrointestinal Endoscopy. Technical success, clinical success, and rates of adverse events were compared between groups. Patients were followed up for a median of 8.5 months.
  
  
  RESULTS
  POEM was technically successful in 98% of patients in the HM group and in 100% of patients in the non-HM group (P = .49). A significantly lower proportion of patients in the HM group had a clinical response to POEM (81%) than in the non-HM group (94%; P = .01). There were no significant differences in rates of adverse events between the groups (8% in the HM group vs 13% in the non-HM group; P = .23). Symptomatic reflux and reflux esophagitis after POEM were comparable between groups.
  
  
  CONCLUSIONS
  POEM is safe and effective for patients with achalasia who were not treated successfully by prior HM. Although the rate of clinical success in patients with prior HM is lower than in those without prior HM, the safety profile of POEM is comparable between groups.
authors.affiliation: Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Saowanee
authors.initials: S
authors.lastname: Ngamruengphong
authors.affiliation: Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan.
authors.forename: Haruhiro
authors.initials: H
authors.lastname: Inoue
authors.affiliation: Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois.
authors.forename: Michael B
authors.initials: MB
authors.lastname: Ujiki
authors.affiliation: Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois.
authors.forename: Lava Y
authors.initials: LY
authors.lastname: Patel
authors.affiliation: Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India.
authors.forename: Amol
authors.initials: A
authors.lastname: Bapaye
authors.affiliation: Surat Institute of Digestive Sciences, Surat, India.
authors.forename: Pankaj N
authors.initials: PN
authors.lastname: Desai
authors.affiliation: Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India.
authors.forename: Shivangi
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authors.lastname: Dorwat
authors.affiliation: Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan.
authors.forename: Jun
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authors.lastname: Nakamura
authors.affiliation: Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan.
authors.forename: Yoshitaka
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authors.affiliation: Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan.
authors.forename: Valerio
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authors.affiliation: Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan.
authors.forename: Manabu
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authors.lastname: Onimaru
authors.affiliation: Gastroenterology and Endoscopy Unit, Digestive Disease Department, L Pavillon-Edouard Herriot Hospital, Lyon, France.
authors.forename: Thierry
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authors.lastname: Ponchon
authors.affiliation: Gastroenterology and Endoscopy Unit, Digestive Disease Department, L Pavillon-Edouard Herriot Hospital, Lyon, France.
authors.forename: Mathieu
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authors.lastname: Pioche
authors.affiliation: Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France; INSERM U1032, Lyon, France.
authors.forename: Sabine
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authors.affiliation: Gastroenterology and Endoscopy Unit, Digestive Disease Department, L Pavillon-Edouard Herriot Hospital, Lyon, France.
authors.forename: Jérôme
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authors.lastname: Rivory
authors.affiliation: Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France; INSERM U1032, Lyon, France.
authors.forename: François
authors.initials: F
authors.lastname: Mion
authors.affiliation: Université de Lyon and Hospices Civils de Lyon, Digestive Physiology, E Herriot Hospital, Lyon, France; INSERM U1032, Lyon, France.
authors.forename: Aurélien
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authors.affiliation: Division of Gastroenterology and Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, Florida.
authors.forename: Peter V
authors.initials: PV
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authors.affiliation: Division of Gastroenterology and Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, Florida.
authors.forename: Yaseen
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authors.affiliation: Division of Gastroenterology and Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, Florida.
authors.forename: Ali
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authors.lastname: Abbas
authors.affiliation: Division of Gastroenterology and Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, Florida.
authors.forename: Davinderbir
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authors.affiliation: Division of Gastroenterology and Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, Florida.
authors.forename: Dennis
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authors.affiliation: Department of Gastrointestinal and Endocrine Surgery, University of Strasbourg, Strasbourg, France.
authors.forename: Silvana
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authors.affiliation: Department of Surgery, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts.
authors.forename: John
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authors.affiliation: Division of Gastroenterology, Department of Medicine, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts.
authors.forename: David
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authors.lastname: Desilets
authors.affiliation: Department of Gastroenterology, King's College Hospital NHS Foundation Trust, London, United Kingdom.
authors.forename: Bu
authors.initials: B
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authors.affiliation: Department of Gastroenterology, King's College Hospital NHS Foundation Trust, London, United Kingdom.
authors.forename: Amyn
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authors.affiliation: Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Gulara
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authors.lastname: Hajiyeva
authors.affiliation: Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Amr
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authors.affiliation: Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Yen-I
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authors.affiliation: Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Majidah
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authors.lastname: Bukhari
authors.affiliation: Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Yamile
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authors.affiliation: Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Vivek
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authors.lastname: Kumbhari
authors.affiliation: Department of Gastroenterology, Royal Prince Alfred Hospital, Camperdown, Australia.
authors.forename: Payal
authors.initials: P
authors.lastname: Saxena
authors.affiliation: University of New South Wales, Sydney, New South Wales, Australia.
authors.forename: Michael
authors.initials: M
authors.lastname: Talbot
authors.affiliation: Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.
authors.forename: Philip Wai-Yan
authors.initials: PW
authors.lastname: Chiu
authors.affiliation: Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.
authors.forename: Hon-Chi
authors.initials: HC
authors.lastname: Yip
authors.affiliation: Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.
authors.forename: Vivien Wai-Yin
authors.initials: VW
authors.lastname: Wong
authors.affiliation: Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas.
authors.forename: Ruben
authors.initials: R
authors.lastname: Hernaez
authors.affiliation: Digestive Endoscopy Unit, Humanitas Research Hospital, Milan, Italy Digestive Endoscopy Unit, Humanitas Unversity, Milan, Italy.
authors.forename: Roberta
authors.initials: R
authors.lastname: Maselli
authors.affiliation: Digestive Endoscopy Unit, Humanitas Research Hospital, Milan, Italy Digestive Endoscopy Unit, Humanitas Unversity, Milan, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Repici
authors.affiliation: Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland. Electronic address: mkhasha1@jhmi.edu.
authors.forename: Mouen A
authors.initials: MA
authors.lastname: Khashab
mesh_terms: D000328:Adult; D000368:Aged; D004724:Endoscopy / Q000009:adverse effects* / Q000379:methods*; D004931:Esophageal Achalasia / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D000074433:Myotomy / Q000009:adverse effects* / Q000379:methods*; D012189:Retrospective Studies; D062606:Tertiary Care Centers; D016896:Treatment Outcome
keywords: Achalasia; Heller Myotomy; Outcome; Peroral Endoscopic Myotomy; Recurrence; Surgery; Therapy