Need for Reinterventions After Per Oral Endoscopic Myotomy in Achalasia

Introduction: Per oral endoscopic myotomy (POEM) is a highly effective treatment for the palliation of symptoms in achalasia. Since achalasia is an incurable, progressive disorder, some of these patients would need reinterventions due to recurrent symptoms. There is a paucity of data on the need for reinterventions after POEM. Hence, our study aimed to assess the patient factors and type and number of reinterventions needed after POEM during long-term follow-up. Methods: Chart review of our institution’s POEM registry of all achalasia patients who underwent POEM between May 2014 and May 2023 and had a mean follow-up of 4 years. Primary endpoints were types of endoscopic or surgical reinterventions after index POEM, based on recurrent symptoms or abnormal imaging. Reinterventions were categorized as (1) botulinum toxin injections, (2) pneumatic dilation, (3) through-the-scope controlled radial expansion balloon dilatation (TTS/CRE), and (4) Heller myotomy. Results: There were 199 patients with a mean f/u of 4 years (Table 1), of which 23 (11.6%) required reinterventions after POEM. Freedom from reintervention after POEM was 95% (190/199) at one year, 92% (184/199) at 2 years, 89% (178/199) at 3 years, and 88.4% (176/199) at 4 years. Endoscopic interventions were performed in 21 patients, while 2 underwent surgical interventions only. The maximum number of reinterventions were TTS/CRE balloon dilations (47%, 16/34). Most reinterventions occurred within 2 years after POEM (Figure 1). Reintervention rates based on type of achalasia were 11.7% (6/51) in type 1, 13.5% (12/89) in type 2, 5% (2/35) in type 3 and 11.7% (2/25) in unclassified type (P = 0.67). The rate of reinterventions among patients who had other treatments prior to index POEM versus those who did not have any treatment prior to index POEM were 69.5% (16/23) vs 35.2% (62/176), P = 0.028. There was no significant difference in other patient factors between those who required reinterventions vs those who did not require. Conclusion: POEM was highly effective treatment for achalasia and only a small proportion of patients required reinterventions during a long-term f/u of 4 years. There was no difference in the rate reinterventions among patients with different achalasia subtypes. Interestingly, patients who underwent other treatments prior to index POEM were also more likely to require reinterventions after the POEM. Further studies are warranted to confirm these findings. Table 1. - Comparative Analysis of the Baseline Characteristics of 199 Patients No reintervention (n = 176) Reintervention (n = 23) P value Age, mean (SD), years 59.4 (14.7) 60.02 (18.1) 0.85 Sex, n (%) Female 83 (47.2%) 11 (47.8%) 0.95 BMI, mean (SD) 29.5 (7.1) 30.1 (6.6) 0.69 Ethnicity, n (%) White 132 (75%) 16 (10.8%) African-American 16 (9.1%) 6 (26.1%) Asian 2 (1.1%) 0 Others 26 (14.8%) 1 (4.3%) Disease, n (%) 0.67 Achalasia type I 45 (25.6%) 6 (26.1%) Achalasia type II 76 (43.2%) 12 (52.2%) Achalasia type III 33 (18.8%) 2 (8.7%) Achalasia type unclassified 22 (12.5%) 3 (13%) Duration of symptoms, mean (SD), year 5.0 (5.6) 4.9 (4.4) 0.93 Sigmoid esophagus, n (%) 22 (12.9%) 1 (4.5%) 0.48 Total Eckardt score, mean (SD) 6.7 (2.5) 6.6 (2.6) 0.81 Dysphagia 2.3 (0.8) 2.4 (0.9) 0.75 Regurgitation 1.75 (1.04) 1.78 (1.04) 0.89 Chest pain 1.19 (1.05) 1.3 (1.1) 0.63 Weight loss 1.41 (1.28) 1.04 (1.02) 0.19 Lower esophageal sphincter basal integrated relaxation pressure, mean (SD), mm Hg 23.8 (14.1) 22.4 (13.6) 0.65 Column height at 1 min, mean (SD), cm 11.1 (5.6) 9.2 (5.2) 0.12 Column width at 1 min, mean (SD), cm 3.34 (1.83) 3.52 (2.19) 0.66 Column height at 5 min, mean (SD), cm 8.13 (5.76) 8.16 (5.6) 0.98 Column width at 5 min, mean (SD), cm 2.68 (1.93) 2.88 (1.58) 0.65 Figure 1.: Rate of reintervention after successful POEM for achalasia.