When the gold standard fails: Propensity-matched comparison of peroral endoscopic myotomy after Heller myotomy versus index peroral endoscopic myotomy.

Abstract

Symptoms of achalasia can recur after Heller myotomy (HM), which is considered the gold standard therapy. Although peroral endoscopic myotomy (POEM) has been used as salvage therapy after failed HM, limited data exist comparing long-term outcomes of POEM after HM versus POEM as index myotomy. We compared physiologic and patient-reported outcomes of salvage versus initial POEM for achalasia. From April 2014 to January 2023, 381 patients underwent POEM for achalasia at Cleveland Clinic; 84 had previous HM (POEM-after-HM group) and 297 had not (index-POEM group). Propensity-score matching generated 62 pairs with median follow-up of 3 years. Longitudinal trends in symptom palliation (Eckardt score), esophageal emptying (timed barium esophagram), esophagitis, and reinterventions were evaluated. Operative time, length of stay, and complications were comparable between groups. Longitudinal symptom palliation differed: 67% in the POEM-after-HM group and 80% in the index-POEM group had Eckardt score ≤3 at 5 years (P = .028). Complete esophageal emptying at 5 years was 20% in the POEM-after-HM group versus 24% in the index-POEM group (P = .61). Longitudinal esophagitis trends and postoperative pH testing were similar between groups, despite fundoplication in 89% of the POEM-after-HM group. By 5 years, 10 reinterventions were performed after POEM-after-HM versus 4 after index-POEM (P = .24). Salvage POEM provides durable palliation for recurrent achalasia symptoms after HM but with less favorable outcomes than index POEM. Factors inherent to previous HM (fibrosis, narrow crural closure, tight fundoplication) may limit the effectiveness of salvage POEM. Previous fundoplication does not protect against post-POEM reflux esophagitis. We recommend closer follow-up for patients undergoing POEM after failed HM.